Radial shock-wave therapy for frozen shoulder patients with type 2 diabetes mellitus: a pilot trial comparing two different energy levels.

BACKGROUND: Extracorporeal shock-wave therapy (ESWT) is highly recommended for the management of orthopedic shoulder pathologies. Yet, the clinical relevance of the dose difference effect of radial ESWT approaches in the management of frozen shoulder patients with type 2 diabetes mellitus remains uncertain. AIM: The aim was to examine the short-term effects of medium-and high-energy levels of radial ESWT (rESWT) in the treatment of frozen shoulder patients with type 2 diabetes mellitus. DESIGN: Prospective clinical pilot study. SETTING: This study was conducted in an outpatient clinic. POPULATION: Thirty-nine patients who had frozen shoulder untreated for at least 3 months, diagnosed with type 2 diabetes mellitus for ≥3 years were included. METHODS: The patients were randomly allocated to receive either high-energy rESWT (hrESWT), or medium-energy rESWT (mrESWT) or placebo at 8 Hz twice a week for six weeks. The primary outcome measure was pain, evaluated by the Visual Analog Scale (VAS) Score. Secondary outcome measures were function evaluated by the Shoulder Pain and Disability Index (SPADI) Score, and shoulder active range of motion (AROM). The mechanical properties of the deltoid and trapezius muscles were assessed using the MyotonPRO (Myoton AS, Tallinn, Estonia). RESULTS: The mrESWT resulted in statistically significant reductions in night pain at 6 weeks (ηp2=0.27, P=0.003). Significantly improved function (SPADI scores: -35.42±21.29 vs.-29.59±22.60; ηp2=0.39, P˂0.001) was found in both hrESWT and mrESWT group by 6 weeks. Significantly higher mean shoulder AROM values were recorded for external rotation (ηp2=0.53, P<0.001), and internal rotation (ηp2=0.21, P=0.020), in the hrESWT group at the 6th week. A significantly improved resting tone (ηp2=0.58) and stiffness of deltoid muscle (ηp2=0.62) were found in the mrESWT group (P<0.001). The trapezius muscle resting tone reduced with hrESWT (ηp2=0.17, P=0.033). CONCLUSIONS: Regardless of the energy levels, rESWT appears to be an effective therapeutic intervention for frozen shoulder patients with type 2 diabetes mellitus in the short-term results. CLINICAL REHABILITATION IMPACT: Our results suggest that this rESWT can be a useful strategy for the rehabilitation of frozen shoulder patients with type 2 diabetes mellitus. This is the first study on dose difference effectiveness in terms of the clinical significance of rESWT which is key to transfer research evidence into practice.

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.

Obesity Associated With Active, but Preserved Joints in Rheumatoid Arthritis: Results From our National Registry.

OBJECTIVES: This study aims to investigate the prevalence of obesity in patients with rheumatoid arthritis (RA) and associations with disease outcomes. PATIENTS AND METHODS: The study population comprised of 1,038 patients with RA (198 males, 840 females; mean age 56.1±12.6 years; range 19 to 94 years) who had been included in National RA-Registry. RA disease activity measures, physical function, quality of life, joint destruction, laboratory tests, as well as pain, fatigue, general health, and patient and physician global health assessments on a visual analog scale were collected. RESULTS: Our patients had established RA with mean disease duration of 10.2±8.8 years and moderate disease activity (disease activity score in 28 joints: mean 3.7±1.6). According to the body mass index (BMI), 70% of the patients were overweight (n=362, 34.9%) or obese (n=364, 35.1%). These patients had higher disease activity scores in 28 joints, visual analog scale-pain and visual analog scale-patient global scores, and higher levels of fasting blood glucose; however, they had lower radiographic scores than normal-BMI patients (p<0.05). Regression analyses showed that the BMI was independently and inversely associated with disease activity scores in 28 joints and Sharp/van der Heijde scores after the adjustments for biologic and treatment-related factors (p<0.05). CONCLUSION: Our findings indicate that obesity is more common in patients with RA than the general population. High disease activity and low radiographic damage were associated with high BMI in this National RA-Registry.

Correlations among enthesitis, clinical, radiographic and quality of life parameters in patients with ankylosing spondylitis.

OBJECTIVES: To investigate the relationship between enthesitis and disease activity, functional status, fatigue, joint mobility, radiological damage, laboratory parameter and quality of life in patients with ankylosing spondylitis (AS). METHODS: A total of 421 patients with AS (323 male and 98 female) who were included in the Turkish League Against Rheumatism Registry were enrolled in the study. The Bath AS Disease Activity Index (BASDAI), fatigue, the Bath AS Functional Index (BASFI), the Bath AS Metrology Index (BASMI), the Maastricht AS Enthesitis Score (MASES), AS quality of life (ASQoL), the Bath AS Radiology Index (BASRI) and erythrocyte sedimentation rate (ESR) were evaluated. RESULTS: Enthesitis was detected in 27.3% of patients. There were positive correlations between MASES and BASDAI, BASFI and fatigue (p < 0.05). MASES was not correlated with BASRI, BASMI, ASQoL and ESR. The mean MASES score was 1.1 ± 2.4. The most frequent regions of enthesopathies were right iliac crest, spinous process of L5 and proximal to the insertion of left achilles tendon, respectively. CONCLUSIONS: Enthesitis was found to be associated with higher disease activity, higher fatigue, worse functional status and lower disease duration. As enthesitis was correlated with BASDAI, we conclude that enthesitis can reflect the disease activity in patients with AS.

Description of the registry of patients with ankylosing spondylitis in Turkey: TRASD-IP.

A web-based application patient follow-up program was developed to create a registry of patients with ankylosing spondylitis (AS) by the Turkiye Romatizma Arastirma Savas Dernegi (TRASD) AS Study Group. This study describes the methodological background and patient characteristics. The patient follow-up program is a web-based questionnaire, which contains sections on socio-demographic data, anamnesis, personal and family history, systemic and musculoskeletal examination, laboratory and imaging data and treatment. Between October 1, 2007 and February 28, 2009, 1,381 patients from 41 centers were included in the registry (1,038 males [75.2%]; mean age 39.5 ± 10.7 years). Mean disease duration was 12.1 ± 8.5 years, and mean time from initial symptom to diagnosis was 5 ± 6.8 years (median 2 years). HLA-B27 positivity was detected in 73.7% of 262 patients tested. Manifestations of extraarticular involvement were anterior uveitis (13.2%), psoriasis and other skin and mucous membrane lesions (6%) and inflammatory bowel disease (3.8%). The prevalence of peripheral arthritis was 11.2%. In 51.7% of patients, the Bath AS Disease Activity Index was ≥4. But since our patients consisted of the ones with more severe disease who referred to the tertiary centers and needed a regular follow-up, they may not represent the general AS population. Disease-modifying anti-rheumatic drugs were being used by 41.9% of patients, with 16.4% using anti-TNF agents. TRASD-IP (Izlem Programi: Follow-up program) is the first AS registry in Turkey. Such databases are very useful and provide a basis for data collection from large numbers of subjects. TRASD-IP gives information on the clinical and demographic profiles of patients, and the efficacy and safety of anti-TNF drugs, examines the impact on quality of life, and provides real-life data that may be used in cost-effectiveness analyses.

Carotid intima-media thickness and paraoxonase activity in patients with ankylosing spondylitis.

PURPOSE: The risk of atherosclerosis is increased in several rheumatological disorders, but any such risk remains unproven for ankylosing spondylitis. Since carotid intima-media thickness is an indicator of early atherosclerosis, and the paraoxonase (PON1) enzyme has antioxidant activity to prevent LDL oxidation, we aimed to identify: 1) the relationship between carotid intima-media thickness (CIMT) and serum paraoxonase (PON1) activity in ankylosing spondylitis (AS) patients; and 2) the possible differences in CIMT in AS patients versus age-matched, healthy controls. METHODS: Forty-five AS patients (36.8±9.8 years, 36 males, 9 females) and 30 controls (35.9±10.2 years, 23 males, 7 females) were recruited consecutively. Serum PON1 activity and CIMT were measured. The Bath Ankylosing Spondylitis Metrology Index (BASMI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Radiologic Index (BASRI) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) were used to identify relationships between these clinical indices and levels of CIMT and PON1. RESULTS: Mean CIMT was significantly increased in AS patients relative to controls (0.49±0.06 mm vs. 0.59±0.07 mm; p < 0.0001). Conversely, serum PON1 activity was decreased (199.1±60.3 U/L vs. 96.7±29 U/L; p < 0.0001). PON1 activity was negatively correlated with CIMT (r = -0.557, p = 0.0001). Disease duration was positively correlated with CIMT (r = 0.542, p = 0.0001) and negatively correlated with PON1 (r = -0.649, p = 0.0001). On multivariate analysis, disease duration and serum PON1 activity were found to be independent predictors of CIMT (R2 = 0.687, p = 0.0001). CONCLUSIONS: In conclusion, significantly increased CIMT and decreased PON1 activity suggest a relationship between atherosclerosis and AS: a relationship that is strongly correlated with disease duration.

Quality of life and related variables in patients with ankylosing spondylitis.

OBJECTIVES: To evaluate quality of life (QoL) and related variables in patients with ankylosing spondylitis (AS), a chronic inflammatory disease of the spine. METHODS: Nine-hundred and sixty-two patients with AS from the Turkish League Against Rheumatism AS Registry, who fulfilled the modified New York criteria, were enrolled. The patients were evaluated using the Assessment of SpondyloArthritis International Society core outcome domains including Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), fatigue (BASDAI-question 1), pain (last week/spine/due to AS), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Bath Ankylosing Spondylitis Radiology Index (BASRI), Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) and two QoL questionnaires (the disease-specific ASQoL and generic the Short Form-36 [SF-36]). RESULTS: The mean ASQoL score was 7.1 ± 5.7. SF-36 subscales of general health, physical role and bodily pain had the poorest scores. ASQoL was strongly correlated with disease duration, BASDAI, fatigue, BASFI, BASMI, BASRI, MASES, pain and SF-36 subscales (P < 0.001). SF-36 subscales were also strongly correlated with BASDAI and BASFI. Advanced educational status and regular exercise habits positively affected QoL, while smoking negatively affected QoL. CONCLUSIONS: In patients with AS, the most significant variables associated with QoL were BASDAI, BASFI, fatigue and pain. ASQoL was noted to be a short, rapid and simple patient-reported outcome (PRO) instrument and strongly correlated with SF-36 subscales.

Third metatarsal brown tumor with secondary hyperparathyroidism: an atypical localization.

Brown tumors represent the terminal stage of the remodeling process during primary or secondary hyperparathyroidism. We report the first case of brown tumor on the third metatarsal associated with secondary hyperparathyroidism caused by vitamin D deficiency. Radiography showed an expansile tissue mass in the third metatarsal bone. The diagnosis was suggested by the clinical history and was confirmed by biochemical, radiologic, and histopathologic determinations. After intravenous therapy with calcidiol, 1g/d, her symptoms were relieved. The brown tumor showed regression and ossification during the 3 months after therapy.

Is joint hypermobility important in prepubertal children?

The purpose of this study was to investigate serum prolidase activity and its relationship with collagen metabolism and joint hypermobility, and to determine the prevalence and characteristics of joint hypermobility in prepubertal children. Serum prolidase activity was measured spectrophotometrically. Joint hypermobility was defined using Beighton criteria. The children underwent complete history and physical examination. Serum levels of prolidase were lower in the hypermobile group compared with controls and no statistical difference (1,598.61 +/- 54.99, 1,741.89 +/- 57.54; P > 0.05). However, there was significant negative correlation between prolidase level and Beighton score (r = -0.295, P = 0.002). The prevalence of hypermobility was distributed as follows: >or=4, 39.3%; >or=5, 22.7%; >or=6, 13.3%. There was correlation between joint hypermobility and pes planus (P = 0.006), arthralgia (P = 0.042), and musculoskeletal disorders in mother and/or father (P < 0.001). The decrease in prolidase activity may be related with collagen metabolism in joint hypermobility Therefore, joint hypermobility appeared to warrant further investigation due to concomitant signs and symptoms.

Intradural herniation of intervertebral disc at the level of Lumbar 1-Lumbar 2.

Intradural disc herniation is a serious and rare complication of intervertebral disc rupture. The preoperative diagnosis of intradural disc herniation is still difficult despite new neuroradiologic investigation possibilities including computerized tomography and magnetic resonance imaging and it is usually diagnosed by during surgery. Here we present an intradural disc herniation case at the level of L1-L2 with accompanying significant myelopathic neurologic deficits. A 50-year-old female patient was admitted to the hospital with pain and weakness in both legs. Her neurological examination revealed paraparesis. Magnetic resonance imaging showed an extruded disc hernia of central localization at the L1-L2 level. She underwent total laminectomy at the level of L1-L2 and her intradural disc fragment was extirpated by microsurgical methods.

Tuberculous sacro-ileitis: two cases and radiological findings.

Infective sacro-ileitis is due to common bacteria, 25% being tuberculosis and 10% brucellosis. Slow progression characterizes joint tuberculosis, an uncommon variant of this disease. The onset is usually insidious, and early diagnosis requires a high index of clinical suspicion. We report two cases with tuberculous sacro-ileitis which initially mimicked brucellosis infiltration. Diagnosis of tuberculosis of the sacroiliac joint was established by fine-needle aspiration of joint and radiological imaging methods such as computerized tomography, magnetic resonance and three-phase bone scan. The current diagnosis and treatment of this condition is discussed based on these cases and a literature review.

Paraoxonase-1 activity as a marker of atherosclerosis is not associated with low bone mineral density in healthy postmenopausal women.

The aging process is associated with an increasing prevalence of osteoporosis and atherosclerosis, but it is uncertain if these two conditions are interrelated. Serum paraoxonase-1 (PON1) is a high-density lipoprotein (HDL) associated enzyme that has been implicated in the pathogenesis of atherosclerosis. Our aims of the study were to investigate (1) serum paraoxonase and arylesterase activities and, lipid hydroperoxide (LOOH) levels in healthy postmenopausal women and (2) whether there were any associations between these enzyme activities and bone mineral density (BMD). A total of 97 generally healthy postmenopausal women were enrolled in the study. BMD was measured at lumbar spine (LS) and femoral neck (FN) with dual energy X-ray absorptiometry. Serum paraoxonase and arylesterase activities were measured spectrophotometrically. LOOH levels were measured by iodometric assay. In this population, 50 (51%) women had BMD T scores < -2.5 at the LS and/or FN defined as osteoporosis and 47 (49%) of them had normal BMDs. Serum paraoxonase, arylesterase, and LOOH activities were not significantly different between osteoporotic and nonosteoporotic postmenopausal women. There were also no correlations between paraoxonase, arylesterase, LOOH activities, and LS BMD and FN BMD. We conclude that there may be not good evidence to support a direct relationship between osteoporosis and atherosclerosis in these subjects. However, prospective studies with larger groups are needed to investigate this issue further.

[The efficacy of botulinum toxin-A in the treatment of hypersalivation in children with cerebral palsy]. / Serebral palsili çocuklarda hipersalivasyon tedavisinde botulinum toksin-A uygulamasi.

OBJECTIVES: We evaluated the efficacy of botulinum toxin A (BTX-A) injection into the submandibular salivary gland to decrease hypersalivation in children with cerebral palsy (CP). PATIENTS AND METHODS: Three children (1 girl, 2 boys; mean age 10; range 7 to 13 years) with CP received BTX-A injections. Due to hypersalivation, two patients dirtied 50 napkins and 5-6 pieces of clothes daily, and one patient dirtied 100 napkins and 8-9 pieces of clothes. The severity of hypersalivation was assessed using the drool rating scale. Injections were performed in the submandibular gland under ultrasound localization and under local anesthesia. The amount of saliva flow at the mouth two hours after the meals and in a duration of 30 minutes was assessed seven times: before the first injection and at different intervals after injections up to 12 weeks. The dose of BTX-A was increased from 5 to 20 units per gland in two patients, while one patient received a standard dose of 20 units. At least 50% reduction in saliva secretion at the end of three months was accepted as a successful outcome. RESULTS: Lower doses of BTX-A were not effective to provide the desired amount of reduction in saliva in two patients. However, application of 20 units resulted in a satisfactory decrease in all the patients. CONCLUSION: In selected patients and with appropriate doses, ultrasound-guided BTX-A injections may improve hypersalivation in patients with CP.

Correlations of serum prolidase activity between bone turnover markers and mineral density in postmenopausal osteoporosis.

Prolidase is a specific imidodipeptidase involved in collagen degradation. The increase in the enzyme activity is believed to be correlated with the increased intensity of collagen degradation. The aim of this study was to evaluate the serum prolidase activity and its relationship between bone turnover markers and bone mineral density (BMD) in postmenopausal osteoporosis. The study included 45 postmenopausal osteoporotic, 55 postmenopausal nonosteoporotic and 38 premenopausal healthy women. BMD was measured at the femoral neck and lumbar spine with DEXA. T score was more than 2.5 SD below the normal at the lumbar spine or femoral neck in postmenopausal osteoporotic patients. Serum levels of prolidase, C-terminal telopeptide of type I collagen (C-telopeptide), total alkaline phosphatase (ALP), osteocalcin (OC), urinary deoxypyridinoline (Dpd) and urinary creatinine were also assayed. C-telopeptide, total ALP, OC, urinary Dpd levels were significantly higher in postmenopausal osteoporotic group compared with premenopausal women. However, there was no statistical difference in serum prolidase activity between the three groups. There were also no significant correlations between serum prolidase and any biomarkers of bone turnover as well as BMD. To conclude, in postmenopausal osteoporotic women with increased bone turnover, serum prolidase concentration was not correlated with the biomarkers of bone formation or bone resorption and with BMD.

Audiological findings in patients with ankylosing spondylitis.

Ankylosing spondylitis (AS) is a chronic inflammatory disease. The aim of this investigation was to study the relationship between AS and hearing loss. This study compared 28 patients with AS with 23 age-matched controls. All subjects underwent ENT examination, audiological and acoustic immittance measurements, and auditory brainstem response (ABR) tests. Sensorineural hearing loss was found in 28.6 per cent of the AS patients and in 4.35 per cent of the control group. For hearing levels at 250-500 Hz and 4000-8000 Hz, there was a statistically significant difference between the two groups. Acoustic reflex was not obtained in both ears of four patients and the left ear of one patient. There was a correlation between increase of tympanic volume and limitation in neck movement, between extension of 1-3 interpeak latency and limitation in the neck movement. In conclusion, AS affects the inner ear more than the middle ear.

[Macrodystrophia lipomatosa: a case report]. / Makrodistrofi lipomatoza: Olgu sunumu.

Macrodystrophia lipomatosa is a rare form of congenital localized gigantism. A forty-year-old male patient presented with complaints of swelling and deformity in the right toe and difficulty in wearing shoes. Conventional radiographic examination, ultrasonography, and computed tomography showed dorsal and medial deviations in the right toe, hypertrophy and degeneration in bone structure, increased density in the medullary bone, and a lipomatous mass with infiltration to the adjacent soft tissue muscles. Partial removal of the lipomatous tissues was performed. Microscopic examination of the specimen revealed fat deposits, ligamentous, and neural tissue elements in normal structure. The patient had no complaints and there was no change in the size of the lesion within a two-year follow-up period.