Egyptian Rheumatology and Rehabilitation (Egypt Rheumatol Rehabil) 2019 | January-March | Volume 46 | Issue 1

Intra-articular injection of platelet-rich plasma and therapeutic exercise in knee osteoarthritis Mona E. M Badr, Eman A. R Hafez, Atif I El-Ghaweet, Heba M El-Sayed Egyptian Rheumatology and Rehabilitation 2019 46(1):1-10 Context There is no definite treatment strategy capable of decreasing destruction of cartilage and enhancing its healing. Intra-articular injection of platelet-rich plasma (PRP) provides a lot of growth factors that are capable of stimulating regeneration of cartilage and is supposed to be a future solution to patients with osteoarthritis (OA). Aim To detect the efficacy of intra-articular injection of PRP or therapeutic exercise (Ex) alone as well as a combination of both in the treatment of idiopathic knee OA. Settings and design A prospective randomized controlled clinical study was conducted. Patients and methods A total of 60 patients, 44 to 65 years of age, having idiopathic unilateral knee OA were included in the study and were divided into three groups: PRP group included 20 patients and were treated with intra-articular PRP injection, Ex group included 20 patients and were treated with only therapeutic Ex, and PRP and Ex group included 20 patients who were treated with both PRP intra-articular injection and therapeutic Ex. Evaluation of all patients was done by visual analogue scale, tenderness, range of motion, thigh circumference, and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores at baseline and 1 and 6 months later. Objective evaluation was done through MRI of osteoarthritic knee at baseline and 6 months later. Statistical analysis Statistical analyses were performed using SPSS for windows, version 20.0. Results Baseline WOMAC score differences among the three groups were not statistically significant but were significant 6 months after treatment. In PRP and Ex groups, there was a significant improvement after treatment, whereas a highly significant improvement in PRP+Ex group. MRI grading differences among the three groups were not significant before or after treatment, with no improvement in all three groups after treatment. Conclusion A combination of intra-articular injection of PRP and therapeutic Ex resulted in significantly lesser visual analogue scale, WOMAC score, and joint tenderness compared with PRP or Ex alone.

Association of rheumatoid arthritis disease activity, severity with electrocardiographic findings, and carotid artery atherosclerosis Samia M Abd El-Monem, Ahmed Y Ali, Nashwa I Hashaad, Ahmed M Bendary, Hend A.F Abd El-Aziz Egyptian Rheumatology and Rehabilitation 2019 46(1):11-20 Aim The aim was to detect specific ECG changes in rheumatoid arthritis (RA) patients as well as to study atherosclerotic changes of the carotid arteries as an indicator of cardiovascular system risk factors and to correlate findings with disease activity and severity parameters to elucidate possible associations between these variables. Patients and methods This study included 30 RA patients, 30 age-matched and sex-matched systemic lupus erythematosus patients and 30 age-matched and sex-matched healthy volunteers as control groups. The patients were subjected to clinical examination, assessment of disease activity score-28 (DAS28), functional disability Health Assessment Questionnaire, and laboratory and radiological assessments. ECG and measurement of the carotid intima media thickness (CIMT) by carotid ultrasound scan was also done. Results Ten (33.3%) RA patients had ECG abnormalities, with ST or T-wave abnormality being the most common abnormality present. RA patients had the highest frequencies of ECG abnormalities. Most ECG changes occurred in RA patients using steroids (90%). ST or T-wave abnormality in RA occurred more in patients with a higher swollen joint count, higher DAS28, and a higher patients’ global health assessment. RA patients had the highest mean. The mean CIMT was significantly higher in RA patients with ECG abnormalities. There were significant positive correlations of average CIMT with DAS28, Health Assessment Questionnaire, and Simple Erosion Narrowing Score. There were significant positive correlations of mean CIMT with the level of triglycerides, cholesterol, high-density lipoprotein, erythrocyte sedimentation rate, and a highly significant correlation between mean CIMT and C-reactive protein. CIMT at a cut-off point of 0.75 mm can predict ECG abnormalities with high sensitivity and specificity. Conclusion ECG changes were present in 33.3% of RA patients. Increased CIMT was observed in RA patients and correlated well with disease activity and severity parameters.

The therapeutic application of functional electrical stimulation and transcranial magnetic stimulation in rehabilitation of the hand function in incomplete cervical spinal cord injury Shereen Fawaz, Fatma Kamel, Ahmed El Yasaky, Heba El Shishtawy, Ahmed Genedy, Reda M Awad, Lobna El Nabil Egyptian Rheumatology and Rehabilitation 2019 46(1):21-26 Background Functional electrical stimulation (FES) therapy has a potential to improve voluntary grasping and induce plastic changes among individuals with tetraplegia secondary to traumatic spinal cord injury (SCI). Also, evidence suggests that the use of high frequency repetitive transcranial magnetic stimulation (rTMS) to increase corticomotor excitability improves hand function in persons with cervical SCI. Purpose Our randomized controlled trial was carried out to compare the two rehabilitation programs, the first applied to FES and real rTMS whereas the second applied to FES and sham rTMS, with repect to hand function in chronic traumatic incomplete cervical SCI patients, and also with respect to changes in cortical excitability, and its relation to hand function before and after the rehabilitation programs. Patients and methods Our study included 22 patients with chronic traumatic incomplete SCI. Patients were randomly assigned into two groups, 11 patients each. Group I patients received FES for 12 weeks with an additional real rTMS therapy for the last two weeks, at 10 Hz frequency, subthreshold intensity for a total of 1500 pulse per session for 10 sessions. Whereas group II patients received FES for 12 weeks with an additional sham rTMS therapy for the last two weeks. All were followed by an intensive hand training program. Patients were assessed: using hand function tests (action research arm test, modified Sollerman hand function test, nine-hole pegboard scale, and finger tapping test) and corticomotor excitability tests (using amplitude of motor evoked potential). Conclusion Our study showed statistically significant improvements in hand function tests in group I, who received FES in addition to real rTMS therapy in comparison with group II, who received FES in addition to sham rTMS at 12-week assessment. This could support the evidence of the additional benefit of real rTMS therapy for 10 sessions/2 weeks in improving hand function and motor recovery following SCI.

Electromyographic study to predict functional outcome of transforaminal epidural steroid injection in lumbosacral radiculopathy Hussein Sultan, Tamer H Shehata, Wafaa S El-Emary, Shehad M Fakhry Egyptian Rheumatology and Rehabilitation 2019 46(1):27-34 Context Epidural steriod injections (ESIs) are commonly used for managment of lumbosacral radiculopathy (LSR). Predicting outcomes after ESIs could be another valuable application of needle electromyography (EMG) in these patients. Aim The aim was to determine if EMG study can predict the functional outcome of transforaminal ESIs in patients with LSR. Materials and methods The study included 20 patients with clinical diagnosis of LSR. Peripheral nerve conduction study, late responses, somatomsensory evoked potentials, and needle EMG were performed in both lower limbs followed by transforaminal ESI under fluoroscopic guidance. The functional outcome was evaluated using visual analog scale for pain and Oswestry disability index (ODI) that were performed before and after injections. Results There were statistically significant decrease in pain severity (visual analog scale; P=0.022) and in ODI (improvement in functional score; P=0.029) after injection in patients with symptom duration less than 3 months compared with patients with longer duration of symptoms. In patients with negative EMG findings, there was a significantly greater reduction in pain severity (P<0.01) and ODI score (P<0.01) after injection compared with patients with positive findings. Regression analysis showed that negative needle EMG findings were significant predictors of pain reduction (P=0.001) and functional improvement (P=0.002) in patients with LSR after ESI. Conclusion This study supports the notion that EMG studies can be used for prediction of functional outcome in patients with LSR performing transforaminal ESI.

Body, wrist, and hand anthropometric measurements as risk factors for carpal tunnel syndrome Mohamed H Imam, Marwa M Hasan, Rehab A ELnemr, Riham H El-Sayed Egyptian Rheumatology and Rehabilitation 2019 46(1):35-41 Aim The aim of this study was to identify cut-off values for body, hand, and wrist measurements in order to correctly identify individuals with increased risk of carpal tunnel syndrome (CTS). Patients and methods This study included 30 patients with clinically diagnosed and electrophysiologically confirmed idiopathic CTS and 30 age-matched and sex-matched healthy volunteers as the control group. Both groups performed sensory and motor conduction studies of the median nerve. Body, hand, and wrist anthropometric measurements were taken including weight, height, waist circumference, hip circumferences, wrist depth/width, third digit length, palm length/width, and hand length. Obesity indicators and hand/wrist ratios were calculated. Area under the ROC curve (AUC), confidence intervals, cut-off values, sensitivity, and specificity were calculated separately for each measured parameter. Results There were statistically significant differences among the studied participants regarding all measured anthropometric parameters (P<0.001). As a result, all studied patients had squarer wrists and shorter hands than healthy participants. The AUC values for all studied measurements showed high accuracy (AUC<95) except for hip circumference, waist-to-hip ratio, palm length, third digit length, and digit index which showed moderate accuracy. In the studied patients there were positive significant correlations between BMI, wrist depth, wrist ratio, and shape index with an electrophysiological severity grading of CTS of the studied patients; on the other hand, there were negative significant correlations between palm length, hand length, and hand ratio with electrophysiological severity grading of CTS. Conclusion The cut-off values for body, wrist, and hand anthropometric measurements are useful tools to assess the risk factors for CTS.

Importance of patient education in management of patients with rheumatoid arthritis: an intervention study Soha H Senara, Wafaa Y Abdel Wahed, Shimaa E Mabrouk Egyptian Rheumatology and Rehabilitation 2019 46(1):42-47 Background People living with chronic diseases such as rheumatoid arthritis (RA) are extremely in need of patient education (PE) to adapt and cope with the effects of the disease and treatments. PE comprises all educational activities provided for patients, including aspects of therapeutic education, health education, and health promotion. Objective The aim of this study was to evaluate the effect of PE program following the eight evidence-based EULAR-2015 recommendations in the management of patients with RA. Patients and methods A randomized controlled clinical trial with two parallel arms was carried out at the Department of Rheumatology and Rehabilitation, Faculty of Medicine, Fayoum University, Egypt. One hundred patients (both sexes) having RA were included in the study, and their mean age was 39.23±11.28 years, with range from 19 to 71 years. Patients were randomly allocated into two comparable groups: group I received health education through designed PE program and group II did not receive PE program. Disease activity and disability were assessed at the start of study and at two visits later, that is, after 3 months and 6 months, by using the 28 joint disease activity score 28 and the Health Assessment Questionnaire disability index. Results On comparing laboratory investigation and outcome scores at follow-up visits, although there were no significant differences between the two study groups regarding laboratory investigation, disease activity score 28 and Health Assessment Questionnaire scores at the start of the study, comparative differences were reported in the follow-up visits. Significant decreases in the laboratory values and scores were reported in group I, whereas no difference was reported in group II. Conclusion PE interventions in patients with RA documented significant improvements in behavior, pain, and disability among these patients.

Depression in patients with chronic low back pain N Nassar, N Assaf, D Farrag, D Ibrahim, A Al-Sheekh Egyptian Rheumatology and Rehabilitation 2019 46(1):48-54 Background Low back pain is a common health issue affecting at least 80% of individuals during their lifetime. It is usually recurrent and develops into chronic low back pain (CLBP). In chronic pain, psychosocial risk factors become relevant, and may explain how individuals respond to pain. CLBP is often comorbid with depression. Aim The aim of this study was to detect if there is an association between depression and functional disability in patients with CLBP. Patients and methods This cross-sectional, descriptive preliminary study included 50 patients with CLBP. Pain intensity was measured using visual analogue scale (VAS), functional disability was measured using the Oswestry Disability Index (ODI), and depression assessment was done using Beck depression inventory (BDI) questionnaire II. Results The mean age of the patients was 43.66±13.96 years. Mean scores for VAS, ODI, and BDI were 5.38±2.42, 18.66±7.26, and 22.40±9.20, respectively. A strong positive correlation was found between VAS and each of ODI and BDI (r=0.797 and 0.515, respectively; P=0.000). Similarly, a positive significant linear relation was detected between degree of disability by ODI and severity of depression by BDI (P=0.039). Conclusion Depression strongly influences pain intensity and degree of disability in patients with CLBP. Screening and early management of depression is essential for reducing pain and disability associated with CLBP.

Comparative study between platelet-rich plasma injection and steroid injection in mild–moderate shoulder osteoarthritis and their relation to quality of life Dalia Salah Saif, Deena Mamdouh Serag, Mohamed Ahmed El Tabl Egyptian Rheumatology and Rehabilitation 2019 46(1):55-61 Context Osteoarthritis (OA) is a degenerative joint disorder that causes joint pain and stiffness. Platelet-rich plasma (PRP) is considered a recent effective line of management of OA. Aims To compare the effect of local injection of PRP versus steroid in shoulder OA and their relation to quality of life. Patients and methods This study included 50 patients with mild–moderate OA shoulder diagnosed according to Samilson and Prieto grading system of shoulder OA and were recruited from the outpatient clinic of physical medicine, and rehabilitation, Faculty of Medicine, Menoufia University Hospital, in the period between 2017 and 2018. The study included both sexes. Group I included 25 patients who were injected intra-articularly with PRP in the affected shoulder, and group II included 25 patients who were injected with triamcinolone acetate. They were evaluated by Western Ontario Osteoarthritis Shoulder index and visual analogue scale before and after injection. Statistical analysis A descriptive and analytic study by SPSS, version 16, on IBM compatible computer was done. Results There was a highly statistical significant difference between preinjection and postinjection parameters regarding Western Ontario Osteoarthritis Shoulder score and visual analogue scale in both groups, with more improvement in the PRP group. Conclusion Intra-articular injections with PRP and steroids are effective less-invasive lines of shoulder OA treatment, with superiority to PRP owing to more persistence of its effects.

Comparison between the roles of musculoskeletal ultrasound and magnetic resonance imaging in detection of joint inflammation and destruction in rheumatoid arthritis Sherihan M Salama Egyptian Rheumatology and Rehabilitation 2019 46(1):62-69 Background Detection of early signs of synovitis and bone erosions by modern radiological techniques such as musculoskeletal ultrasound (US) and MRI has gained a great interest, as early diagnosis and treatment to target for patients of rheumatoid arthritis (RA) has its impact on disease control. Aim The aim of the following study is to detect the ability of US compared with MRI for the early detection of joint synovitis and bone erosion in RA patients. Patients and methods Six hundred joints (second to fifth metacarpophalangeal joints and second to fifth proximal interphalangeal joints) were examined in 50 patients with RA diagnosis. Clinical assessment, noncontrast MRI, US, and conventional radiography were performed for synovitis and bone erosion evaluation. Results and conclusion We concluded that both US and MRI had high ability to detect inflamed joints with close agreement but favoring the US, especially with the added value of power Doppler US where it can reflect increased vascularity associated with inflammation and also with higher scores for these affected joints than that shown by MRI. On the other hand, the study has found that although both US and MRI had high ability to detect erosions with close agreement, the MRI favorably had higher scores for joint erosions compared with the scores shown by US.