A randomized controlled trial on the efficacy of intermittent and continuous traction for patients with knee osteoarthritis.

OBJECTIVE: To investigate the efficacy of intermittent and continuous traction in the treatment of knee osteoarthritis. DESIGN: A randomized, controlled, observer-blind seven-week trial. SETTING: Hospital-based outpatient practice. SUBJECTS: Ninety-eight patients with stage 3 knee osteoarthritis according to Kellgren-Lawrence radiological rating scale. INTERVENTIONS: All 98 patients were randomly assigned to three treatment groups, for three weeks (weekends excluded). The control group (n=30, mean age: 59.30±8.16) received hot pack and short wave diathermy; the intermittent group (n=30, mean age: 58.20±7.78) received hot pack, short wave diathermy and intermittent traction; and the continuous group (n=30, mean age: 57.97±9.53) received hot pack, short wave diathermy and continuous traction. OUTCOME MEASUREMENTS: The values of the Turkish version of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale, and knee passive range of motion were measured at baseline, three-week and seven-week follow-up. RESULTS: Compared with baseline at weeks 3 and 7, all the outcome measures, except range of motion, were significantly reduced in all groups (all P≤0.001). In terms of the change data from baseline to week 3, both traction groups were significantly superior to the control in the WOMAC physical function scores. Considering the change data from baseline to week 7, both traction groups were significantly superior to the control in the pain scores, physical function and total scores, while only the continuous group was significantly better than the control in the stiffness scores (control: 1.17 ± 1.64; continuous: 2.38 ± 1.44) (P=0.014). Compared with baseline at weeks 3 and 7, range of motion values significantly increased in both traction groups (P<0.05) but not in the control (P>0.05). However, there were no significant differences among the three groups considering the change data from baseline to week 7 in range of motion values (P=0.300). CONCLUSIONS: Joint traction was found to be beneficial for the improvement of pain and physical function loss related to knee osteoarthritis.

A randomized controlled trial of electrostimulation effects on effussion, swelling and pain recovery after anterior cruciate ligament reconstruction: a pilot study.

OBJECTIVE: To evaluate rehabilitation results of electrostimulation especially on joint effusion, swelling and pain recovery after anterior cruciate ligament reconstruction. DESIGN: A randomized controlled trial; the assessor was not blinded to the group allocation. SETTING: Orthopaedics-traumatology and physical medicine-rehabilitation departments. SUBJECTS: Twenty-nine consecutive patients underwent anterior cruciate ligament reconstruction. INTERVENTIONS: Both groups began the voluntary exercise protocol one day post-surgery. The intervention group (n = 15) also received 30 sessions electrostimulation treatment protocol started four days after the operation. MAIN MEASURES: Numerical bulge-dancing patella signs for effusion assessment; differences in circumferences of the mid-centre of the patella between operated and non-operated knees for swelling assessment. A self-report of average daily resting pain assessed by visual analogue scale; Intenational Knee Documentation Committee scoring system and Tegner Activity Scale for subjective response assessment. RESULTS: Twenty-six subjects including 13 patients from the intervention group completed the study. Significantly less effusion and swelling were determined in the intervention group after seven days (1.8 ± 1.3 versus 2.4 ± 1.7 for effusion and 1.7 ± 1.2 versus 3.4 ± 1.5 for swelling) to 12 weeks (0.2 ± 0.7 versus 0.6 ± 0.8 for effusion and 0.2 ± 0.8 versus 0.8 ± 0.9 for swelling) postoperative (P < 0.05). Patients treated with electrostimulation had significantly lower pain scores from seven days up to 12 weeks after the operation (P < 0.05). CONCLUSION: Electrostimulation along with exercise therapy appears superior to exercise alone regarding knee effusion, swelling and pain recovery after anterior cruciate ligament reconstruction. Still, there is need for further clinical studies using a radiologic method to demonstrate this effect of electrostimulation.

Effects of Behçet's disease on sexual function and psychological status of male patients.

INTRODUCTION: There are no studies on the sexual function of male patients with Behçet's disease (BD), but it is probable that male sexual dysfunction may be seen in this chronic condition. AIM: The aim of this study was to assess the effect of BD on male sexual function and psychiatric status, and to examine the relationship between sexual function and depression in this population. METHODS: Patients with a diagnosis of BD for at least one year were included in the study. The patients' age, educational level, and duration of disease were recorded. A healthy control group was selected with highly similar characteristics to the patient group. The sexual functions of the patient and the control groups were assessed using the International Index of Erectile Functions (IIEF), and their emotional status was evaluated using the Beck Depression Inventory (BDI). MAIN OUTCOME MEASURES: The results of the questionnaires in patient and control groups were compared. The relationship between the clinical findings and questionnaire scores was assessed in the patient group. RESULTS: Forty-two patients with BD and 42 healthy individuals were included in the study. The mean subscale scores of the IIEF for erectile function were significantly lower in the patient group compared to the control group (P < 0.001). The IIEF score was not related to active skin findings, active oral ulcers, active genital ulcers, eye involvement, or medication for BD, but it was related with history of arthritis. The BDI and IIEF scores were negatively correlated in the patient group. CONCLUSION: BD has a negative impact on men's psychological state and sexual function. We recommend that depression and sexual dysfunction be investigated and treated while assessing patients with BD.

Relationship between anti-CCP antibodies and oxidant and anti-oxidant activity in patients with rheumatoid arthritis.

OBJECTIVE/AIM: A new group of autoantibodies in Rheumatoid Arthritis (RA), the anti-cyclic citrullinated peptide (anti-CCP) antibodies directed to citrulline-containing proteins, which are of value for the severity of RA. Up to date, the relationship between anti-CCP antibodies and oxidant, anti-oxidant activity in patients with RA has not been elucidated in the previous studies. In this study we aimed to investigate the effect of anti-CCP antibodies in the circulation on whole blood, serum and synovial fluid oxidant and anti-oxidant activity in patients with RA. MATERIALS AND METHODS: RA patients with anti-CCP (+) (n=25) and anti-CCP (-) (n=24) were recruited into the study. All patients had a positive rheumatoid factor (RF). The patients who were under treatment with only non-steroidal antiinflammatory drugs (NSAID) at the study time included in the study. Catalase (CAT), Glutathione peroxidase (GSHPx), Myeloperoxidase (MPO) activities and the levels of Malondialdehyde (MDA) were measured in whole blood, serum and synovial fluid in both groups. RESULTS: There were no significant differences in terms of the mean whole blood and serum antioxidative activity (CAT, GSHpx) and the mean blood and serum MDA and MPO values (oxidative activity), between the patients with anti-CCP(+) and those with anti-CCP(-). There was increased synovial oxidant activity (MDA and MPO levels) (p<0.05) in anti-CCP(+) RA patients with or without ESR negativity when compared with anti-CCP(-) RA patients. There was positive correlation between anti-CCP antibody levels and synovial MDA and MPO levels (r=0.435, p<0.05, r=0.563, p<0.05 respectively) in anti-CCP (+) group. CONCLUSIONS: In conclusion, anti-CCP antibody positivity seems to be associated with increased synovial fluid oxidant activity (increased MDA and MPO levels) in patients with RA. These conclusions need to be validated in a larger controlled study population.

The frequency and effect of fibromyalgia in patients with Behçet's disease.

OBJECTIVES: This study aims to investigate the scores of depression, anxiety, sleep and quality of life (QoL), to identify the prevalence of fibromyalgia (FM) in Behçet's disease (BD), and to evaluate whether there is a difference between BD patients with and without FM in these scores. PATIENTS AND METHODS: Between March 2008 and January 2009, 97 patients with BD and 95 age- and sex-matched healthy controls were included in the study. The patients with BD were divided into two groups according to the presence or absence of FM. All participants were evaluated by the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Pittsburgh Sleep Quality Index (PSQI), and Medical Outcomes Study Short Form-36 (SF-36). RESULTS: Compared to the controls, FM prevalence was higher (19.6% vs 3.2%) with increased BDI and BAI scores, while the subscores of SF-36 including physical function, physical role, pain, general health, social function, and emotional role decreased in BD patients (for all p<0.001). All BD patients with FM were females (n=19), while only 46% of BD patients without FM were females (n=36) (p<0.001). In BD patients with FM, compared to female BD patients without FM, the mean age (p=0.017), disease duration (p=0.028), and BDI scores (p=0.017) were significantly higher, while the PSQI scores (p=0.001) and SF-36 subscores, except general health (p=0.114), were significantly lower (for all p<0.05). CONCLUSION: Our study results suggest that patients with BD have an increased severity of depression and anxiety, higher frequency of FM, and worsened QoL than healthy individuals. In addition, the presence of FM seems to be related with female sex, longer disease duration, older age, depression, sleep disturbance, and poor QoL in BD patients.

Clinical and magnetic resonance imaging findings of the temporomandibular joint in patients with rheumatoid arthritis.

BACKGROUND: The aim of this study is to evaluate temporomandibular joint (TMJ) involvement in patients with rheumatoid arthritis by magnetic resonance imaging (MRI), jaw clenching force, mouth opening, and Fonseca's questionnaire, and to establish the relationship between these findings and clinical, radiologic, and laboratory activity parameters that are unique to rheumatoid arthritis. METHODS: Included in the study were 30 RA patients and 30 healthy volunteers. Jaw clenching force of the entire cases was measured with Istanbul Bite Force Recorder (kg) and the mouth opening was measured with a ruler (cm). Additionally, hand grip forces of patients with rheumatoid arthritis were measured with hand dynamometer (kg). Hand and feet graphs and TMJ MRIs of patients were obtained. MRI findings were classified as normal, mild, medium, and severe. DAS28 and sharp scores of patients were estimated. Sedimentation rate (ESR), C-Reactive protein (CRP) and rheumatoid factor (RF) were checked in the patient group and Fonseca's questionnaires were filled in. RESULTS: A significant difference was not observed between age, gender, and level of education of the groups. Jaw clenching force and mouth opening were established as significantly low in RA group compared to the control group (P < 0.001). A significant correlation was found between jaw clenching force, hand grip force, mouth opening, questionnaire, and MRI findings with the disease duration sharp score, DAS28, and hand grip force of the RA group (P < 0.05). However, a significant correlation was not established with ESR, CRP, and RF (P < 0.001). CONCLUSIONS: Jaw clenching force, mouth opening, and Fonseca's questionnaire can be used as parameters pointing to TMJ involvement in patients with RA. Yet, further studies in which TMJ involvement is followed up since the onset of the disease are of necessity.

The validity and reliability of the Turkish version of the Revised Fibromyalgia Impact Questionnaire.

The Revised Fibromyalgia Impact Questionnaire (FIQR) attempts to address the limitations of the Fibromyalgia Impact Questionnaire (FIQ). As there is no Turkish version of the FIQR available, we aimed to investigate the validity and reliability of a Turkish translation of the FIQR in Turkish female fibromyalgia (FM) patients. After translating the FIQR into Turkish, it was administered to 87 female patients with FM. All of the patients filled out the questionnaire together with a Turkish version of the FIQ, hospital anxiety and depression scales (HADS), short form-36 (SF-36). The tender-point count (TPC) was also calculated from tender points identified by thumb palpation. One week later, FM patients filled out the Turkish FIQR at their second visit. The test-retest reliability of the Turkish FIQR questions ranged from 0.714 to 0.898. The test and retest reliability of total FIQR score was 0.835. Cronbach's alpha was 0.89 for FIQR visit 1 (the first assessment) and 0.91 for FIQR visit 2 (the second assessment), indicating acceptable levels of internal consistency for both assessments. The total scores of the FIQR and FIQ were significantly correlated (r = 0.87, P < 0.01). Significant correlations for construct validity were also obtained between the FIQR total and domain scores and the FIQ, the HADS and the subscales of the SF-36 (FIQR total versus SF-36 physical component score and mental component score were r = -0.63, P < 0.01 and r = -0.51, P < 0.01, respectively). The Turkish FIQR is a reliable and valid instrument for measuring health status in FM, showing sufficient reliability and construct validity. It may be utilized for both clinical practice and research use in the Turkish-speaking population in place of FIQ, since its Turkish version has problems in the wording, omissions, concepts, and scoring from the original FIQ.

Complex regional pain syndrome: a vitamin K dependent entity?

Complex regional pain syndrome (CRPS) is the complication of some injuries, such as a fracture, which affects the distal end of the injured extremity characterized by pain, allodynia, hyperalgesia, edema, abnormal vasomotor and sudomotor activity, movement disorders, joint stiffness, regional osteoporosis, and dystrophic changes in soft tissue. Exact pathogenic mechanism of CRPS is still unclear. Suggested pathogenic mechanisms of CRPS are evaluated in four major groups consist of classic inflammation, hypoxic changes and chronic ischemia, neurogenic inflammation and sympathetic dysregulation. All of these suggested pathogenic mechanisms produced by inflammatory cytokines mediated by nuclear factor kappaB. Vitamin K is a family of structurally similar, fat-soluble, 2-methyl-1,4-naphthoquinones. Vitamin K exerts a powerful influence on bone formation, especially in osteoporosis. Fat in bone stores some vitamin K. Gamma-carboxylation of the glutamic acid in osteocalcin is vitamin K dependent. Osteocalcin plays a role in calcium uptake and bone mineralization. Osteocalcin, the most abundant non-collagenous protein in bone, is produced by osteoblasts during bone matrix formation. Because osteocalcin is not carboxylated in case of vitamin K deficiency at the distal site of fracture or injury, it cannot bind to hydroxyapatite causing osteoporosis. Fracture starts a local inflammatory process in the fracture site and adjacent tissues as seen in CRPS. Vitamin K was shown to suppress the inflammatory cytokines and NF-kappaB and prevent oxidative, hypoxic, ischemic injury (which have key role in both initiation and progression of CRPS) to oligodendrocytes and neurons. We hypothesized that vitamin K has a key role and modulatory effect in CRPS pathogenesis. Vitamin K deficiency at the distal site of fracture occurs because of diminished and slowed circulation, local immobilization after extremity fracture or injury and use of vitamin K store at the distal site of the injured extremity and in the circulation for fracture healing and bone remodelling. In case of vitamin K deficiency at the distal site of fracture, classic inflammation starts with fracture at the distal tissues could not be restricted and classic inflammation, hypoxic changes, chronic ischemia, neurogenic inflammation, sympathetic dysregulation, which are the pathogenic mechanisms of CRPS, and patchy osteoporosis which occur due to high level of under-carboxylated osteocalcin could not be prevented. Briefly vitamin K level decreases in the distal site of the injured extremity consequently resulting in patchy osteoporosis due to high level of under-carboxylated osteocalcin and unrestricted inflammation which are the cause for both initiation and progression of CRPS.

A prospective randomised controlled clinical trial comparing the efficacy of different molecular weight hyaluronan solutions in the treatment of knee osteoarthritis.

Viscosupplementation consists of injecting exagenous hyaluronan (HA) into the synovial joints to restore the normal rheological environment which deteriorates severely in osteoarthritic (OA) joints. Efficacy might be related to the rheological properties and molecular weight (MW) of the hyaluronan preparations. This prospective, controlled, double-blind, randomised clinical trial was aimed at comparing the elastoviscous properties of a high molecular weight viscosupplement, hylan G-F 20, with that of a lower molecular weight hyaluronan product in order to determine the relationship of elastoviscosity to efficacy, alongside placebo, in the treatment of patients with knee OA. The results were analysed as a "completers" analysis with 59 patients. Primary outcome measures included the Western Ontario and Mc Master Universities' Osteoarthritis Index (WOMAC) for pain, stiffness and function scores, and patient and physician global assessments (0-100 scale). For patient (PGA) and physician global assessments (PhGA), the 0-100 scale was used, with 100 being the worst. Follow-up assessments were made at intervals of 1, 3 and 6 months after the first injection. Local adverse events, such as transient pain at the injection site or warm knee lasting for one night, were recorded in two patients (3%). In all groups, the WOMAC pain score exhibited a significant difference from the baseline value; neither treatment group was significantly different from the placebo group, but total pain score was significantly better than baseline for both of the HA groups at the end of 6 months (p < 0.05). Improvement in WOMAC physical function score favoured both sodium hyaluronate and hylan G-F 20 after the first month, and remained significant until the end of 6 months (p < 0.01). In the placebo group, the physical function scores became worse after the end of the 1st month; the scores at the end of 6 months were no different from those at the beginning. The WOMAC stiffness scores of both of the hyaluronic acid groups improved with the first injection, and remained significantly better than the placebo group until the end of the survey (p < 0.001). All groups expressed improvement with PGA scores after the first injection. At the end of 6 months all three groups were similar, but the treatment groups were significantly better than the placebo group (p < 0.05), and all were significantly better than at the beginning (p < 0.05). The PhGA scores were similar in all groups until after the third injection. The second group was slightly better in the controls at 1 and 3 months, but all the groups were similar at the end of 6 months. Although the placebo group seemed worse, it was not statistically significant. Compared with lower molecular weight HA, the higher molecular weight HA might be more efficacious in treating knee OA, but heterogeneity of previous studies limited definitive conclusions. Patients treated by injection of either of two hyaluronan preparations showed clinical improvement for pain, though no different from the placebo group; WOMAC stiffness scores were better than placebo in the HA groups, whereas PGA scores showed improvement in all groups but HA groups were better than placebo. PhGA scores were worse in the placebo group, but not to a statistically-significant extent. The HA groups did not differ in terms of clinical efficacy.