Environmental characteristics of older people attending physical medicine and rehabilitation outpatient clinics.

OBJECTIVE: A residential environment refers to the physical and social characteristics in a neighbourhood. The physical characteristics include interior housing qualities, exterior neighbourhood characteristics, and the accessibility of essential facilities and services outside the neighbourhood. Older adults especially may be vulnerable to the negative impacts of the residential environment. The aim of this study is to elucidate the problems ageing people face in their neighbourhoods, buildings and public areas. METHODS: The study group consisted of a total of 1,001 people over the age of 65 who were admitted to physical medicine and rehabilitation clinics in Turkey and consented to participate. A questionnaire covering demographic, social and environmental information was used. RESULTS: Of the study group, 58.6% was living in an apartment building, but only 23.6% of these buildings had an elevator, and the stairs were inconvenient in 46.7% of the buildings. Only 49% of the elderly people went for a walk regularly. The most frequent complaint about the hospitals, community health centres and other public areas was the inappropriate restroom conditions. Eighty-six percent of the study group were not members of an organization, a foundation or a group, and 73.6% did not have personal hobbies. CONCLUSIONS: The layouts of buildings and surroundings are inappropriate for older people, and the opportunities for them to participate in social activities are limited. Health and social programmes and governmental and local policies for older people are needed, and public awareness about this issue should be raised.

Effects of Botulinum Toxin A Injection on Ambulation Capacity in Patients with Cerebral Palsy.

PURPOSE: The purpose of the study is to assess the change in their ambulatory capacity and spasticity in children with cerebral palsy (CP) who received botulinum toxin A (BoNT-A) injection and underwent rehabilitation therapy. METHODS: Thirty patients with CP, 3-13 years who had varied functional levels and lower extremity spasticity, were randomized in two groups. In Group 1(n = 15), BoNT-A was administered to the affected extremity and underwent rehabilitation. In Group 2 (n = 15), the patients underwent only rehabilitation protocol. The Visual Analogue Scale (VAS), Tardieu Scale (TS), Gross Motor Function Classification System (GMFCS), Selective Motor Control, and Goal Attainment Scale were evaluated 4 and 12 weeks after baseline. RESULTS: The mean scores of the TS (p < 0.001) GMFCS, GAS, and VAS (p < 0.05) significantly improved in Group 1. CONCLUSION: We think that implementation of rehabilitation protocols with BoNT-A injection is superior to alone rehabilitation therapy and increasing ambulatory capacity in patients with CP.

Prevalence of Rheumatoid Arthritis and Spondyloarthritis in Turkey: A Nationwide Study.

OBJECTIVES: This study aims to estimate the prevalence of rheumatoid arthritis (RA) and spondyloarthritis (SpA) in Turkey using the same telephone questionnaire developed for screening RA and SpA in France and used in Serbia and Lithuania. MATERIAL AND METHODS: The study was performed in two steps. In step I, the French questionnaire was translated into Turkish and validated through a group of 200 patients (80 males, 120 females; mean age 44.0±13.1 years; range 19 to 75 years) followed up at the rheumatology departments of University Hospitals in Antalya and Ankara. In step II, the validated Turkish questionnaire was administered face-to-face to randomly selected 4,012 subjects (1,670 males, 2,342 females; mean age 41.5±16.8 years; range 16 to 97 years) by trained general practitioners across the country, in 25 prov- inces for case detection. The subjects who were suspected of having RA or SpA in accordance with the questionnaire were invited to the nearest university hospital for rheumatologic examination in order to confirm the diagnosis. RESULTS: In step II, a total of 25 subjects (2 males, 23 females) were diagnosed as RA. The standardized RA prevalence for the general population of Turkey was calculated as 0.56% (95% confidence interval [CI]; 0.33-0.79), 0.10% (95% CI; -0.05-0.25) for males and 0.89% (95% CI; 0.51-1.27) for females. A total of 18 subjects (3 males, 15 females) were diagnosed as SpA. The standardized SpA prevalence for the general population of Turkey was 0.46% (95% CI; 0.25-0.67), 0.17% (95% CI; -0.03-0.37) for males and 0.65% (95% CI; 0.32-0.98) for females. The prevalence of RA was highest in the Northern region (2.00%) and the prevalence of SpA was highest in the Central region (1.49%). CONCLUSION: The prevalences of RA and SpA in Turkey are close to each other and there are significant inter-regional variations in prevalences of both RA and SpA.

A Multicenter Pilot Study of Burden Among Caregivers of Geriatric Rehabilitation Patients With Neuromusculoskeletal Diseases.

PURPOSE: In this study, we aimed to describe the sociodemographic characteristics of caregivers of patients in a geriatric unit and to clarify the relationship between caregiver burden and specific clinical variables in the patients and the characteristics of the caregivers. DESIGN: Cross-sectional multicenter study. METHODS: One hundred twenty-three patients and 123 caregiver dyads, with mean ages of 72.5 ± 7.7 years and 51 ± 14.7 years, respectively, were included. The functional, psychological, and cognitive statuses of the patients were determined, and the sociodemographic characteristics of the caregivers as well as the type and duration of caregiving were recorded. Caregivers completed the Caregiver Burden Inventory (CBI) to measure the perceived burden of care. Most patients were female and generally lived with their family. FINDINGS: Most of the caregivers were family members (90%), female (73.2%), primary school graduates (52.8%), and first-degree relatives (73.1%). The average CBI score was 33, and the highest CBI subscores were for time, developmental, and physical burdens. Caregiver burden correlated with the patient's ambulatory, psychological, and cognitive status and with the caregiver's age, gender, income level, and duration of caregiving. CONCLUSIONS: We have highlighted the relationship between caregiver and patient characteristics in a cohort of elderly Turkish patients with neurological and musculoskeletal disorders. In particular, we have highlighted the heavy caregiver burden in a developing country. CLINICAL RELEVANCE: Our results may guide the nurses to understand the requirements of caregivers and to help them find suitable resources that would meet their needs to cope with their burden.

Non-response to colchicine in familial Mediterranean fever should be identified accurately.

AIM: Colchicine prophylaxis is the single most important factor in ameliorating familial Mediterranean fever (FMF) for the prevention of both attacks and secondary amyloidosis. The aim of the present study was to evaluate the exact proportion of those patients who do not respond to colchicine and to characterize their demographic, sociodemographic and clinical aspects. METHODS: One hundred and eight patients with FMF were included in our study. The demographic (age, gender), socioeconomic (education level, employment status, economic income level) and clinical features (age at onset of FMF, age at FMF diagnosis, family history of FMF, mean duration of colchicine use and mean daily colchicine dose) of the patients were evaluated. The patients unresponsive to colchicine therapy, according to their statements, were recorded. Also with another question, patients' routine colchicine-consuming habits were elucidated in a self-answering format. 'Non-responders' were defined as patients who experienced FMF attacks at a frequency greater than once every 3 months despite treatment with 2 mg colchicine daily. Data were analyzed with the chi-square test and Fisher's exact test. RESULTS: There were 50 female and 58 male patients with a mean age of 42.4 ± 11.3 years. The mean age at FMF onset and at FMF diagnosis were 14.3 ± 10.5 and 19.1 ± 12.9 years, respectively. Sixteen percent of the patients defined themselves as 'suffering from attacks in spite of regular colchicine'. Irregular colchicine usage was determined in 11% of the patients who were considered as 'unresponsive to colchicine therapy' according to their statements. In spite of regular colchicine regimen, attacks were present in 5% of the patients in our study. Although there was no difference in demographic and clinical aspects, patients with irregular colchicine usage were found to be from lower socioeconomic backgrounds, had less education and more unemployment (P < 0.001). CONCLUSION: Regular colchicine usage anamnesis may be misleading in the first evaluation and this risk seems to be higher in patients from lower socioeconomic background. Routine colchicine-consuming habits should be detailed in patients with FMF before claiming its failure.

Relapsing polychondritis: inflamed joints and ears.

BACKGROUND: Relapsing polychondritis (RP) is an episodic and progressive inflammatory disease of the cartilaginous structures, including elastic cartilage of the ear and nose, hyaline cartilage of the peripheral joints, fibrocartilage at axial sites, and cartilage of the tracheo-bronchial tree. The spectrum of its presentations may vary from intermittent mild episodes of chondritis to occasional organ involvement or even life-threatening manifestations. CASE REPORT: We presented a 64 year-old male patient with bilaterally knee arthritis and discoloration of pinna. CONCLUSION: There is lack of awareness about this disease due to its rarity. With this case presentation, our goal was to draw attention to this disease, which could be delayed for the diagnosis.

Efficacy of manual lymphatic drainage and intermittent pneumatic compression pump use in the treatment of lymphedema after mastectomy: a randomized controlled trial.

BACKGROUND: This study has two aims. The first was to investigate the efficacy and contribution of an intermittent pneumatic compression pump in the management of lymphedema, and the second was to evaluate the correlation of our measurement methods. METHODS: This study was designed as a controlled clinical trial at the Physical Medicine and Rehabilitation Department of Ataturk University Faculty of Medicine. Thirty-one patients with upper extremity lymphedema following mastectomy participated in the study. The patients were divided into two groups. The complex decongestive physical therapy (CDT) group (group 1, n = 15) received allocated treatment, including skin care, manual lymphatic drainage, compression bandages, compression garments, and exercises. The other group had CDT combined with an intermittent pneumatic compression pump (group 2, n = 16). Both groups were treated five times a week for 3 weeks (for a total of 15 sessions). Patients were assessed according to circumference measurements of landmarks, limb volume difference, dermal thickness with ultrasonography (USG), and pain. RESULTS: We observed significant difference in both groups when comparing them before and after therapy. The baseline median volume difference of group 1 was 630 (180-1,820), and after therapy it was 480 (0-1,410). In group 2, the beginning median volume difference was 840 (220-3,460), and after therapy it was 500 (60-2,160). However, no significant differences were observed between the two groups in terms of the above-mentioned parameters. CONCLUSION: We concluded that the pneumatic compression pump did not contribute to the reduction of lymphedema. In addition, gauging dermal thickness using USG may prove to be a useful measurement method in the evaluation of lymphedema.

Antioxidant profile in patients with complex regional pain syndrome type I.

OBJECTIVE: Complex regional pain syndrome (CRPS) type I is one of the most important problems with regard to physical medicine and rehabilitation. CRPS may cause not only higher therapeutic costs but also greater work time loss. The mechanism and pathogenesis of CRPS still remains unknown. Some findings indicating oxidative stress have been reported. This study was carried out to determine the role of oxidative stress in patients with CRPS. MATERIALS AND METHODS: Twenty patients (13 women and seven men) with CRPS and 20 age- and sex-matched healthy controls were enrolled in this study. Complex regional pain syndrome was diagnosed according to the modified International Association for the Study of Pain (IASP) criteria. We evaluated demographic, clinical and laboratory characteristics of the patients. Antioxidant enzymatic activities consisting of serum superoxide dismutase (SOD), glutathion peroxidase (GPX) and glutathione S-transferase (GST) activities were measured using appropriate methods and compared with healthy controls. RESULTS: The mean age of the patients was 39.5 years and the mean duration of symptoms was 5.5 months. Complex regional pain syndrome devoleped after a traumatic event in 90% of patients. In 10% of patients there were no traumatic events. SOD, GPX and GST levels were significantly higher in patients with CRPS than healthy controls (P = 0.012, P = 0.036 and P = 0.016, respectively). CONCLUSION: Our findings suggest a possible role of oxidative stress in the pathogenesis of CRPS.

Femoral cartilage thickness measurements in healthy individuals: learning, practicing and publishing with TURK-MUSCULUS.

BACKGROUND AND OBJECTIVES: Measurement of the femoral cartilage thickness by using in-vivo musculoskeletal ultrasonography (MSUS) has been previously shown to be a valid and reliable method in previous studies; however, to our best notice, normative data has not been provided before in the healthy population.The aim of our study was to provide normative data regarding femoral cartilage thicknesses of healthy individuals with collaborative use of MSUS. METHODS: This is across-sectional study run at Physical and Rehabilitation Medicine Departments of 18 Secondary and Tertiary Centers in Turkey. 1544 healthy volunteers (aged between 25-40 years) were recruited within the collaboration of TURK-MUSCULUS (Turkish Musculoskeletal Ultrasonography Study Group). Subjects who had a body mass index value of less than 30 and who did not have signs and symptoms of any degenerative/inflammatory arthritis or other rheumatic diseases, history of knee trauma and previous knee surgery were enrolled. Ultrasonographic measurements were performed axially from the suprapatellar window by using linear probes while subjects' knees were in maximum flexion. Three (mid-point) measurements were taken from both knees (lateral condyle, intercondylar area, medial condyle). RESULTS: A total of 2876 knees (of 817 M, 621 F subjects) were taken into analysis after exclusion of inappropriate images. Mean cartilage thicknesses were significantly lower in females than males (all p< 0.001). Thickness values negatively correlated with age; negatively (females) and positively (males) correlated with smoking. Men who regularly exercised had thicker cartilage than who did not exercise (all p < 0.05). Increased age (in both sexes) and absence of exercise (males) were found to be risk factors for decreased cartilage thicknesses. CONCLUSION: Further data pertaining to other countries would be interesting to uncover whether ethnic differences also affect cartilage thickness. Collaborative use of MSUS seems to be promising in this regard.

Circulating vascular endothelial growth factor concentrations in patients with postmenopausal osteoporosis.

INTRODUCTION: The role of vascular endothelial growth factor (VEGF) in osteoporosis has not yet been clearly established. Vascular endothelial growth factor is an important part of bone formation. In the literature, although the effects of VEGF on bone metabolism were investigated by different studies, there are very rare studies analysing the association between osteoporosis and VEGF. In the present study, our objective was to investigate serum VEGF concentrations in patients with postmenopausal osteoporosis (PMO) and the correlation of serum VEGF levels and bone mineral density (BMD). MATERIAL AND METHODS: This study was performed on 35 PMO patients, and 30 age-matched healthy controls. Serum VEGF concentrations were measured using a quantitative sandwich enzyme immunoassay technique according to the manufacturer's instructions. Bone mineral density values were determined by dual energy X-ray absorptiometry (DEXA). RESULTS: Serum VEGF concentrations were statistically significantly lower in PMO patients than in controls (150 ±65 pg/ml, 260 ±135 pg/ml respectively; p = 0.005). A positive correlation was found between serum VEGF concentrations and BMD values (r = 0.63, p = 0.001). CONCLUSIONS: Vascular endothelial growth factor concentrations were decreased in PMO patients and VEGF may play an important role in bone health.

Prevalence of atopic disorders in rheumatic diseases.

OBJECTIVES: The aim of this study was to assess the point prevalences of hay fever, asthma, and atopic dermatitis in OA, RA, and AS, and to compare with healthy controls. METHODS: A total of 935 patients and healthy controls were included. Demographic and clinical features were recorded, and a questionnaire assessing the existence of atopic disorders like asthma, hay fever, and atopic dermatitis in all groups was applied. "Either atopy" implied that an individual was either diagnosed with or had symptoms of one or more of these disorders, such as asthma, hay fever, or atopic dermatitis. RESULTS: When compared to the controls, only patients with AS had an increased risk for hay fever (OR 1.52, 95 % CI 1.00-2.41). Patients with RA had increased risks for hay fever, atopic dermatitis, and either atopy compared to the patients with OA (2.14, 95 % CI 1.18-3.89; 1.77, 95 % CI 1.00-3.18; and 3.45, 95 % CI 1.10-10.87, respectively). Steroid use had no effect on the prevalence of atopic disorders in patients with RA. CONCLUSIONS: Patients with OA, RA, and AS seem to have similar risks for asthma, atopic dermatitis, and either atopy to healthy controls. However, the prevalence of hay fever may increase in AS. Patients with RA have a higher risk of atopy than patients with OA.

Melatonin levels in premenopausal women with fibromyalgia syndrome.

The fibromyalgia syndrome (FMS) is a chronic, widespread pain disorder of unknown etiology. It has been suggest that familial component, environmental factors, endocrine and neurotransmitter alterations, and psychological factors may contribute to the development of FMS. The role of melatonin in FMS is unclear. Some studies describe a lower nocturnal peak and a decreased secretion of melatonin in women with FMS when compared with healthy matched controls. The aim of the present study was to determine the possible role of melatonin in FMS patients. We examined the characteristics and levels of melatonin in 25 consecutive premenopausal women with FMS. Serum blood samples were collected from 25 patients and 20 the age and gender matched healthy controls. Melatonin levels were measured by enzyme-linked immunosorbent assay. Then, the results were compared with those from healthy subjects. Serum melatonin levels of FMS patients were not statistically different from those of controls (P > 0.05). No association was observed between melatonin levels of patients with FMS and disease duration, sleep disturbances, fatigue, and pain scores. Our results demonstrate that melatonin levels were similar in patients with FMS and healthy controls. Further studies are needed to determine the possible role of melatonin.

Spastic paraparesis and sensorineural hearing loss in a patient with neurobrucellosis.

OBJECTIVE: Brucellosis is a zoonotic disease and still a major public health problem in many geographic areas including Mediterranean basin and Middle East. Brucellosis causes multisystemic involvement and although rare central nervous system involvement causes serious manifestations. Neurobrucellosis occurs less than 5% of patients and presents with meningitis,encephalitis, myelitis, myelopathy, stroke, paraplegia, radiculoneuritis, intracerebral abscess, epidural abscess, demyelination and cranial nerve involvement or any combination of these manifestations. Spastic paraparesis and the sensorineural involvement are rarely reported in the literature. METHODS: Herein we present a 28 years-old man with spastic paraparesis and sensorineural hearing loss due to neurobrucellosis. RESULTS: The patient was treated with antibiotics combination for 6 months and underwent rehabilitation program. CONCLUSIONS: Neurobrucellosis should be ruled out in patients with unexplained neurological symptoms and/or sensorineuralhearing loss particularly in those living in endemic areas.

Expert opinion and key recommendations for the physical therapy and rehabilitation of patients with ankylosing spondylitis.

AIM: Physiotherapy is an integral part of the management of ankylosing spondylitis (AS) and there is a need for recommendations which focus on the rehabilitation of patients with AS. We aimed to develop recommendations for the physical therapy and rehabilitation of patients with AS based on the evidence and expertise. METHODS: The Anatolian Group for the Assessment in Rheumatic Diseases (ANGARD) is a scientific group of Turkish academicians (physiatrists and rheumatologists) who are experts in the rehabilitation of patients with AS. A systematic literature search summarizing the current available physiotherapy and rehabilitation trials in AS were presented to the experts before a special 2-day meeting. Experts attending this meeting first defined a framework based on the main principles and thereafter collectively constructed six major recommendations on physiotherapy and rehabilitation in AS. After the meeting an email survey was conducted to rate the strength of the recommendations. RESULTS: Six key recommendations which cover the general principles of rehabilitation in AS in terms of early intervention, initial and follow-up assessments and monitoring, contraindications and precautions, key advice for physiotherapy methods and exercise were constructed. CONCLUSION: These recommendations were developed using evidence-based data and expert opinion. The implementation of these recommendations should encourage a more comprehensive and methodical approach in the rehabilitation of patients with AS. Regular lifelong exercise is the mainstay of rehabilitation and there is a considerable need for well-designed studies which will enlighten the role of physical therapy in the management of AS.

Agreement of Turkish physiatrists with the assessment in spondyloarthritis international society and the European league against rheumatism recommendations for the management of ankylosing spondylitis and rheumatoid arthritis.

BACKGROUND: New developments in the field of targeted therapies or biologic agents led more effective management of ankylosing spondylitis (AS) and rheumatoid arthritis (RA). Recommendations for the management of rheumatic diseases propose to reduce inappropriate use of medications, minimize variations among countries, and enable cost-effective use of health care resources. OBJECTIVE: The aim this study was to evaluate conceptual agreement of ASsessment in SpondyloArthritis International Society (ASAS) and the EUropean League Against Rheumatism (EULAR) recommendations for the management of AS and EULAR recommendations for RA and to assess the rate of application among Turkish physiatrists in daily clinical practice. METHODS: An online survey link has been sent to 1756 Turkish physiatrists with e-mails asking to rate agreement on 11-item ASAS/EULAR AS recommendations and 15-item EULAR RA recommendations with synthetic and biological disease-modifying anti-rheumatic drugs. Also barriers and difficulties for using biologic agents were assessed. RESULTS: Three hundred nine physiatrists (17.5%) completed the survey. The conceptual agreement with both recommendations was very high (Level of agreement; mean 8.35±0.82 and 8.90± 0.67 for RA and AS recommendations, respectively), and the self-declared application of overall recommendations in the clinical practice was also high for both RA and AS (72.42% and 75.71%, respectively). CONCLUSION: Turkish physiatrists are in good conceptual agreement with the evidence-based recommendations for the management of AS and RA. These efforts may serve to disseminate the knowledge and increase the current awareness among physicians who serve to these patients and also implementation of these recommendations is expected to increase as well.

Psychological status is associated with health related quality of life in patients with rheumatoid arthritis.

OBJECTIVE: Rheumatoid arthritis (RA) is a chronic and disabling disease frequently effects physical and psychological well being. The aim of the present study was to determine the impact of psychological status on health related quality of life in patients with RA and also to assess which quality of life (QoL) instrument - disease specific and generic - is more prone to this effect. METHODS: A total of 421 patients with RA recruited from joint database of five tertiary centers. Depression and anxiety risks were assessed by the Hospital Anxiety and Depression Scale (HADS); and quality of life assessed by Rheumatoid Arthritis Quality of Life (RAQoL), Nottingham Health Profile (NHP) and The Short Form 36 (SF 36) questionnaire. RESULTS: Patients with higher risk for depression or anxiety had poorer quality of life compared to the patients without risk for depression or anxiety. Depression and anxiety scores significantly correlated with quality of life questionnaires. There was significant association between anxiety and depression with worsening in both disease specific and generic health related quality of life. However, RAQoL showed more association with depression and anxiety levels. CONCLUSION: Higher depression and anxiety risks showed increased deterioration in quality of life. Compared to generic QoL scales, RAQoL scale, a disease specific QoL instrument, is much more influenced by depression and anxiety.

Serum melatonin levels in ankylosing spondilitis: correlation with disease activity.

This study was carried out to determine the serum levels of melatonin (MLT) in patients with ankylosing spondilitis (AS) and to evaluate its correlation with disease activity. We assessed clinical characteristics and labaratory parameters. Serum samples from 36 patients (25 males, 11 females) with active AS and 25 healthy subjects (18 males, 7 females) were collected. MLT levels were measured by enzyme-linked immunosorbent assay, and disease activity of AS was assessed according to the Bath AS disease activity index (BASDAI), the erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). Then, the results were compared with those from 25 healty controls. The serum levels of MLT were significantly increased in AS patients as compared to healthy controls (p < 0.05). MLT levels were correlated with BASDAI (r = 0.871, p < 0.001) and CRP levels (r = 0.691, p < 0.001), but not with ESR, in patients with AS. Our results suggest a possible role for this immunoregulatory hormone in the disease activity in AS patients.

Relationship between psychological status and disease activity and quality of life in ankylosing spondylitis.

Our aim in this study was to compare the depression and anxiety risk in patients with AS and healthy controls and also to determine the relationship between disease activity, quality of life and psychological well-being. Two hundred and forty-three patients with ankylosing spondylitis (AS) and 118 age-, sex- and education-matched healthy controls were enroled into the study. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and Functional Index, and Metrology Index, Health Assessment Questionnaire for Spondyloarthropathies (HAQ-S), Hospital Anxiety and Depression Scale (HADS) including depression subscale (HADS-D) and anxiety subscale (HADS-A), Ankylosing Spondylitis Quality of Life (ASQoL) Scale, duration of morning stiffness, pain-visual analogue scale (VAS), patient and physician's global assessment of disease activity (100 mm VAS) were used to assess clinical and psychological status. Patients had similar HADS-D but higher HADS-A than healthy controls. Patients with high risk for depression and anxiety had higher scores in BASDAI, BASFI and also poorer scores in VAS pain, patient global assessment, physician global assessment, HAQ-S and ASQoL. There was a negative correlation of HADS-D and HADS-A scores with educational level of the patients. Higher scores in HADS-D and HADS-A indicated poorer functional outcome and quality of life. Multivariate logistic regression analysis revealed that the HADS-D (OR=6.84), HAQ-S (OR=1.76), VAS pain score (OR=1.03) and ESR (OR=1.02) were independent risk factors for higher anxiety scores whereas HADS-A (OR=1.36) and ASQoL (OR=1.24) were independent risk factors for higher depression scores. The psychological status had close interaction with disease activity and quality of life in patients with AS.