Osteoporosis and polymorphisms of osteoprotegerin gene in postmenopausal women - a pilot study.

OBJECTIVES: Osteoprotegerin (OPG) has an important role in bone remodeling, and it has been proposed that the OPG gene might be a candidate gene for osteoporosis predisposition. Several studies have already assessed the connection between OPG gene polymorphism and bone mineral density (BMD). In this study we wanted to analyze the association of two polymorphisms in the OPG gene with BMD and bone turnover markers in women with and without osteoporosis. MATERIAL AND METHODS: In 22 postmenopausal women with osteoporosis (aged 65.6 ±12.6) and 59 women without osteoporosis (aged 60.8 ±8.7) we analyzed the association of two polymorphisms in the OPG gene with BMD, measured by dual energy absorptiometry and with bone turnover markers (crosslaps and osteoprotegerin). A163G, G209A, T245G and G1181C polymorphisms were determined. RESULTS: No significant differences in age, anthropometry, number of fractures, osteocalcin and cross-laps were found between women with and without osteoporosis. Women with osteoporosis were significantly longer in postmenopause. Significantly more women with osteoporosis had AG polymorphism (p = 0.038) compared to women without osteoporosis, while no significant difference was found in prevalence of TT and GG polymorphism between patients with and without osteoporosis. No relationship was found between investigated polymorphism and bone turnover markers. A significant negative correlation between total hip BMD and crosslaps (p = 0.046) as well as between total hip T score and crosslaps (p = 0.044) was found in women without osteoporosis. CONCLUSIONS: Postmenopausal women with osteoporosis had AG polymorphism more frequently than women without osteoporosis. Our results indicate that A163G polymorphism could have an impact on higher bone loss in postmenopausal women.

[Controlled-release oxycodone in the treatment of chronic musculoskeletal pain: A preliminary experience of rheumatology center].

In the etiology of non-malignant pain, a significant proportion is constituted by patients with pain originating in the musculoskeletal system. The use of strong opioids in the treatment of non-malignant pain is still controversial. Therefore, the aim of this study was to establish the efficacy and safety of oxycodone with a controlled release of the active substance (CR) in the treatment of patients with chronic, not well-controlled musculoskeletal pain. Here we present our preliminary results. In this prospective, open, single-center study conducted at a rheumatology center we enrolled consecutive patients with musculoskeletal pain due to a variety of musculoskeletal diseases (osteoarthritis, pain in the lower back, spondyloarthritis), who suffered from moderate to severe pain despite previous analgesic therapy (with NSAIDs, weak opioids, or a fixed combination of paracetamol and weak opioids). Patients were switched to therapy with oxycodone CR and followed for 14 days. The starting dose of oxycodone CR was 10 mg, and later the dose was adapted as necessary. The primary endpoint was to assess the effectiveness of oxycodone CR on pain intensity, and the secondary goal was to assess the efficiency on the general health of the patient (both on a horizontal visual analogue scale, VAS 0 = best, 10 = worst). Fifteen patients (12 women, 3 men), with a mean age of 61 ± 12 years and a diagnosis of osteoarthritis, pain in the lower back, or inflammatory arthritis, were included in the study. The duration of pain was 41 ± 12 months. The average intensity of pain before oxycodone CR treatment was 7.87 ± 2.28 (range 7-10), and at the end of the study it was 5.92 ± 2.43 (range 4-9) (p=0.069). General health was rated 7.27 ± 2.14 (range 3-10) before the start and 6.00 ± 1.53 (range 3-9) at the end of the study (p=0.028). In one patient the treatment was discontinued due to dizziness and nausea, and one patient voluntarily left the study because of fear and the subjective impression of no adequate pain control after 2 days of treatment. The oxycodone side-effect profile was as expected. Results of our preliminary study show that in patients with chronic non-malignant pain which is not well controlled by simple analgesics, NSAIDs, and weak opioids, treatment with oxycodone CR contributed to a significant reduction in the level of pain and improved the general health of the subjects.

Osteoporosis, spinal mobility and chest expansion index in patients with ankylosing spondylitis.

To determine the correlation between the bone mineral density (BMD) and spinal mobility and chest expansion index in patients with ankylosing spondylitis. Eighty patients with confirmed diagnosis of ankylosing spondylitis were included in this study. In all of them physical examination was performed including assessment of spinal mobility and chest expansion index. Bone mineral density of the lumbar spine (L1-L4, anteroposterior view) and at the left hip was measured by dual X-ray absorptiometry (DXA) in standard manner According to the WHO classification of osteoporosis, patients were classified in three groups (normal, osteopenic or osteoporotic) depending on the osteoporotic status in lumbar spine, hip and femoral neck region. Eighty patients (46 men and 34 women; age 25-73 years) were included. Mean BMD for lumbar spine was 1.104 +/- 1.043 (T score: 0.67 +/- 2.15) and for total hip was 1.057 +/- 0.899 (T score: -0.28 +/- 2.34). Significant difference in the mobility of thoracic spine was observed in patients in regard to the WHO classification of osteoporosis in lumbar and femoral region (p = 0.031, Oneway Anova for osteoporosis of lumbar region; p = 0.022, Oneway Anova for osteoporosis of total hip region). Mean value for the chest expansion index was 3.07 +/- 1.66 cm. Chest expansion index was significantly reduced in patients having osteoporosis in lumbar and total hip region (p = 0.015, Oneway Anova for osteoporosis of lumbar region; p = 0.038, Oneway Anova for osteoporosis of total hip region). The observation that reduced mobility of thoracic and lumbar spine and chest expansion index occured in patients with low BMD in lumbar and total hip region suggest that osteoporosis should be monitored more frequently in patients with AS.

[Therapeutic exercise for patients with chronic low-back pain]. / Medicinske vjezbe za bolesnike s kronicnom krizoboljom.

Low Back Pain (LBP) is a major medical and socio-economical problem in the industrialized countries. Exercise therapy is the keystone of conservative treatment for chronic low back pain (CLBP). Numerous randomized trials and clinical practice guidelines have supported that exercise diminishes disability and pain severity while improving fitness and occupational status in patients with CLBP, as well as decrease its recurrence rate. However, there is no significant evidence that one particular type of exercise is clearly more effective than others. Here we present a descriptive review of different types of exercise for therapeutic or prevention purposes in patients with CLBP. Studies suggest that individually tailored, supervised exercise programs are associated with the best outcomes. High quality clinical trials are needed to determine the effectiveness of specific interventions (type, time, intensity and other characteristics) aimed at individuals and/or specific target groups.

Comparison of the effects of land-based and water-based therapeutic exercises on the range of motion and physical disability in patients with chronic low-back pain: single-blinded randomized study.

The aim of the study was to compare the effect ofwater-based exercise in thermal mineral water versus land-based exercise therapy on the lumbar spine range of motion and physical disability in adult patients with chronic low back pain. Out of 72 patients hospitalized for inpatient treatment in a special rehabilitation hospital, 36 patients performed a 3-week standardized program of group water-based exercises and the other 36 performed a program of group land-based exercises. All patients were also treated with electro analgesic therapy and underwater massage. The patients were assessed for lumbar spine motion using standardized measures with flexible tape, while physical disability was measured by the Physical Disability Index. Evaluations were performed at the beginning and at the end of treatment. Compared with baseline, a statistically significant improvement was detected in both groups regarding both primary outcome measures. At the end of treatment, there was no statistically significant difference between the two exercise treatments in any parameter of interest (p < 0.01). In conclusion, in our sample of patients with chronic low back pain, exercise treatment improved lumbar motion and decreased the level of physical disability. However, comparison of land-based exercises and water-based exercises in thermal mineral water did not demonstrate any significantly different result.

Relationship of bone mineral density with disease activity and functional ability in patients with ankylosing spondylitis: a cross-sectional study.

In ankylosing spondylitis, inflammatory activity probably plays a key role in the pathophysiology of bone loss. The aim of the study was to investigate the relationship of bone mineral density (BMD) at the lumbar spine and hip region with some measures of disease activity and functional ability in patients with ankylosing spondylitis. In 80 patients with established ankylosing spondylitis, disease activity and functional ability were determined by C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Functional Index (BASFI). Spinal pain and patient global health were assessed using horizontal visual analog scale. BMD was measured by dual-energy X-ray absorptiometry. There was a significant negative correlation of bone density T scores with acute-phase reactants (i.e., patients with lower T scores had higher level of CRP and ESR). That relationship was reflected more reliably at proximal femur sites than at the lumbar spine. There were also significant differences in ESR, BASDAI, BASFI, spinal pain and global health between three groups of patients according to WHO classification of osteoporosis (normal, osteopenic and osteoporotic). Significantly, more patients with osteopenia at the lumbar spine had lower BASDAI index than those with normal BMD (P = 0.030). Our results indicate an association of low BMD with high disease activity in patients with AS. Femoral BMD seems to be more associated with disease activity and functional ability than lumbar spine BMD.

[Diagnosis and conservative treatment of low back pain: review and guidelines of the Croatian Vertebrologic Society]. / Dijagnostika i konzervativno lijecenje krizobolje: pregled i smjernice Hrvatskog Vertebroloskog Drustva.

Low back pain (LBP) is a very common condition with high costs of patient care. Medical doctors of various specialties from Croatia have brought an up-to-date review and guidelines for diagnosis and conservative treatment of low back pain, which should result in the application of evidence-based care and eventually better outcomes. As LBP is a multifactorial disease, it is often not possible to identify which factors may be responsible for the onset of LBP and to what extent they aggravate the patient's symptoms. In the diagnostic algorithm, patient's history and clinical examination have the key role. Furthermore, most important is to classify patients into those with nonspecific back pain, LBP associated with radiculopathy (radicular syndrome) and LBP potentially associated with suspected or confirmed severe pathology. Not solely a physical problem, LBP should be considered through psychosocial factors too. In that case, early identification of patients who will develop chronic back pain will be helpful because it determines the choice of treatment. In order to make proper assessment of a patient with LBP (i.e. pain, function), we should use validated questionnaires. Useful approach to a patient with LBP is to apply the principles of content management. Generally, acute and chronic LBP cases are treated differently. Besides providing education, in patients with acute back pain, advice seems to be crucial (especially to remain active), along with the use of drugs (primarily in terms of pain control), while in some patients spinal manipulation (performed by educated professional) or/and short-term use of lumbosacral orthotic devices can also be considered. The main goal of treating patients with chronic LBP is renewal of function, even in case of persistent pain. For chronic LBP, along with education and medical treatment, therapeutic exercise, physical therapy and massage are recommended, while in patients with a high level of disability intensive multidisciplinary biopsychosocial approach has proved to be effective.

Osteoporosis in psoriatic arthritis: is there any?

AIMS: Although considered as a feature of inflammatory rheumatic diseases, there is a lot of controversy around low bone mass in patients with psoriatic arthritis. The aim of this cross-sectional study was to analyze bone mineral density in patients with psoriatic arthritis, as well as to investigate its possible association with some measures of disease activity and functional capacity. SUBJECTS AND METHODS: Sixty-nine patients with established psoriatic arthritis (mean age 56.20 ± 12.23 years) and who have not been treated with specific antiosteoporotic drugs were recruited from the out-patient clinic database. Bone mineral density was measured by dual-energy X-ray absorptiometry at the lumbar spine and at the left hip. Disease activity measures included: duration of morning stiffness, tender and swollen joint count, patient's and physician's global assessment, presence of dactylitis and enthesitis, ESR, CRP and Disease Activity Score 28. Health Assessment Questionnaire was used to assess functional status. RESULTS: According to WHO definition, spinal osteoporosis was found in 7.2% of patients, total hip osteoporosis in 1.4% of patients and femoral neck osteoporosis in 2.9% of patients. There was no significant association of any of the measures of disease activity with BMD at any site. Higher HAQ scores were associated with lower total hip BMD. CONCLUSIONS: In our sample of patients with psoriatic arthritis we did not find increased prevalence of osteoporosis. There was no association of BMD with indices of disease activity, while negative correlation was found between HAQ and total hip BMD.

[Novelties in pathophysiology, radiology diagnostics and conservative treatment of painful spine conditions and deformities]. / Novosti u patofiziologiji, radioloskoj dijagnostici i konzervativnom lijecenju bolnih stanja i deformacija kraljeznice.

Spinal pain, especially chronic low-back pain is one of the most prominent health and healthcare problems. Better understanding of pain pathophysiology and more precise visualization using modern imaging techniques help us to focus our intervention and obtain better outcome. In most patients with spine conditions symptoms and function resolve with conservative treatment. In this article we report on novelties in pathophysiology of spinal pain, magnetic resonance imaging and conservative treatment options (medications, therapeutic exercise, physical therapy and orthoses) of painful spine conditions and scoliosis. Apart from being informative, together with the corresponding article about novelties in invasive/surgical treatment, this special focus article on recent developments in this area can be used as an aid in decision making when approaching these patients.

Muscle strength and bone density in patients with different rheumatic conditions: cross-sectional study.

AIM: To explore the relationship between muscle strength and bone density in patients with different rheumatic diseases and to examine whether inflammatory arthritis was more harmful for muscle strength and bone loss than degenerative joint diseases. METHODS: The study included 361 men and women with a mean±standard deviation age of 60.5±11.4 years and different rheumatic conditions: regional syndromes, osteoarthritis of the hands, shoulders, knees, and hips, and inflammatory arthritis. Maximum voluntary back strength was measured by isometric dynamometry. Bone mineral density (BMD; g/cm2) of the lumbar spine, femoral neck, and distal radius was measured by dual-energy x-ray absorptiometry. Anthropometry and lifestyle characteristics were also assessed. RESULTS: Back strength was lowest in patients with hand and shoulder osteoarthritis (20.0±17.9 kg), followed by patients with inflammatory arthritis (24.8±19.2 kg). Patients with inflammatory arthritis had the lowest BMD at the mid-radius (0.650±0.115 g/cm2) and femoral neck (0.873±0.137 g/cm2), while patients with hand and shoulder osteoarthritis had the lowest BMD at the mid-radius (0.660±0.101). In both sexes, muscle strength was significantly lower in patients who had lower BMD (T score<-1.0). Multiple regression analysis identified significant predictors of back strength to be spine BMD (P=0.024) and body mass index (P=0.004) in men and femoral neck BMD in women (P=0.004). CONCLUSION: Muscle strength decline may be connected to bone loss in patients with rheumatic conditions, especially those with inflammatory joint diseases.

[Ultrasonography of the hip, knee and ankle]. / Dijagnosticki ultrazvuk kuka, koljena i gleznja.

Hip ultrasonography (US), besides visualization of anatomic structures, provides precise puncture and aspiration of the joint content. The most often US findings in inflammatory rheumatic diseases are intra-articular effusion (pathologic finding>2 mm), hypertrophy ofsynovial membrane, cartilage damage and bone erosions. US characteristics ofosteoarthritis (OA) are small amount of effusion, lost of cartilage, osteophytes on the articular edges and possible mild hypertrophy of synovial membrane. Recently, US has been used in diagnostics of many knee disorders, including lesions of articular cartilage, tendons, ligaments, menisci, synovial joint and surrounding blood vessels and muscles. US could be used for measuring thickness of hyaline cartilage and for assessment of its integrity at the area of femoral condyles and intercondylar notch, but only if patients are enable to bend their knees. Numerous arthropathies that affect the knee could be evaluated by US too, so it is possible to document the presence of effusion, hypertrophy ofsynovial membrane, formation ofpannus, popliteal cysts, loose bodies, cartilage thinness and synovial plica. New technologic development of US diagnostics provides high-quality presentation of some smaller structures like ankle joint, calcaneal insertion of Achilles tendon and surrounding soft tissues. The most important achievement is demonstration ofpathologic changes of Achilles tendon within inflammatory and degenerative diseases.

[The reliability and validity of a Croatian version of the Bath Ankylosing Spondylitis Functional Index (BASFI) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) in patients with ankylosing spondylitis]. / Pouzdanost i valjanost hrvatske inacice Bath funkcijskog indeksa za ankilozantni spondilitis (BASFI) i Bath indeksa aktivnosti bolesti za ankilozantni spondilitis (BASDAI) u bolesnika s ankilozantnim spondilitisom.

The aim of the study was to investigate the reliability and the validity of the Croatian version of the Bath Ankylosing Spondylitis Functional Index (BASFI) and Bath Ankylosing Spondylitis Disease Activity index (BASDAI) in patients with ankylosing spondylitis (AS). Patients with established diagnosis of AS participated in the study. Fifty-two and 48 patients were included for the evaluation of BASFI and BASDAI, respectively. For translation international translation steps were followed. For reliability patients recompleted both indices on the following day. To assess validity following parameters were obtained: spinal mobility in sagittal plane, chest expansion index, erythrocyte sedimentation rate, serum C-reactive protein, level of pain and patient's global health. Apart from descriptive statistics Spearman's rho coefficient was used. Correlation between BASFI and BASDAI score was 0.621. The mean BASFI scores on two occasions (within 24 hours) were 4.82 +/- 2.67 versus 4.88 +/- 2.52 (r = 0.961; p < 0.01), and for BASDAI scores were 5.46 +/- 2.30 versus 5.32 +/- 2.19, respectively (r = 0.959; p < 0.01). Stability index for both indices was 0.98. High correlation was found for each repeated question of BASFI and BASDAI. For both indices congruent validity demonstrated the best correlation with cervical and thoracic mobility. Also, the correlation was observed for BASFI with spinal mobility in lumbar region and with chest expansion index, and for BASDAI with the level of pain. Our findings indicate that Croatian version ofBASFI and BASDAI is reliable and valid. Therefore, it can be used in clinical research as well as in clinical practice.

[Therapeutic ultrasound in chronic low back pain treatment]. / Terapijski ultrazvuk u lijecenju bolesnika s kronicnom krizoboljom.

The purpose was to determine the efficacy of therapeutic ultrasound in patients with chronic low back pain. Thirty-one patients, age 38-77, with low back pain lasting more than three months and the intensity of pain on visual analogue scale at least 50 mm, are randomly divided in two groups. Ultrasound is applied on the lumbar paravertebral muscle in 16 patients and in 15 patients the machine was not switched on. All patients also underwent kinesitherapy. Pharmacological treatment was not changed during the research (except the possibility of using paracetamol as the "rescue drug"). Following parameters were measured at the beginning and at the end of the research: pain intensity on the visual analogue scale/mm, modified Schober measure/cm, patient's and physician's global assessment of treatment efficacy (1-5 scale). The intensity of pain in the ultrasound group before the treatment was 82,7+/-14,0 and after the treatment 79,8+/-12,2 (p<0,05). The intensity of pain in the placebo group before the treatment was 81,7+/-12,1 and at the end of the treatment 78,9+/-12,1 (p>0,05). The value of the modified Schober measure for the ultrasound group were 5,7+0,8 cm vs. 5,8+/-0,9 cm (p>0,05) and in the placebo group were 5,4+/-0,9 cm vs. 5,6+/-1,0 cm (p>0,05). There was no significant statistical difference between ultrasound and placebo group regarding the efficacy of the treatment (patients p>0,05, physicians p>0,05). Therapeutic ultrasound was effective in decreasing the pain intensity in this research, but showed no improvement regarding the functional ability of the lumbar spine in patients with chronic low back pain.