NON-PHARMACOLOGICAL TREATMENT OF PSORIATIC ARTHRITIS

U ovome preglednom članku donosimo osvrt na postojeće kliničke dokaze i dostupne mogućnosti nefarmakološkog liječenja psorijatičnog artritisa. Iako posljednjih dvadeset godina interes za područje reumatološke rehabilitacije ubrzano raste, načela rehabilitacije psorijatičnog artritisa, zbog nedostatka relevantnih dokaza, „posuđena“ su i najčešće temeljena na spoznajama o nefarmakološkom liječenju ankilozantnog spondilitisa i reumatoidnog artritisa. Randomizirana kontrolirana istraživanja malobrojna su i loše kvalitete, a uglavnom su usmjerena na istraživanje učinkovitosti edukacije, terapijskih vježba i balneoterapije. Možemo zaključiti da je psorijatični artritis trenutačno djelomično „zanemarena“ bolest u rehabilitacijskom smislu u odnosu prema drugim reumatskim bolestima. Danas postoji imperativ ranog i usmjerenog početka te interdisciplinarnog pristupa rehabilitaciji psorijatičnog artritisa, utemeljenog na bolesnikovim željama i potrebama te provedbi kvalitetnih kliničkih istraživanja iz područja nefarmakološkog liječenja i rehabilitacije psorijatičnog artritisa.In this review article, we present an overview of existing clinical evidence and available non-pharmacological treatments of psoriatic artritis. Although interest in the rehabilitation of rheumatic diseases has been steadily increasing over the past 20 years, the principles of psoriatic arthritis rehabilitation are still mostly based on the non-pharmacological treatment options for ankylosing spondylitis and rheumatoid arthritis. Randomized controlled trials are small and of poor quality, and are mainly focused on the research of eff ectiveness of education, therapeutic exercises, and balneotherapy. It can be concluded that, as far as rehabilitation is concerned, psoriatic arthritis is currently “neglected” compared to other rheumatic diseases. Today, early and targeted treatment initiation is imperative, along with an interdisciplinary approach to the rehabilitation of psoriatic arthritis based on patient wishes and needs, as well as the implementation of quality clinical research in the non-pharmacological treatment

NON-PHARMACOLOGICAL PAIN MANAGEMENT OF RHEUMATIC DISEASES

Reumatske bolesti jedan su od vodećih uzroka kroničnih bolnih stanja, koja, ako se ne prepoznaju i pravodobno ne liječe, uzrokuju nesposobnost te posljedično smanjuju kvalitetu života pojedinca. Kronična bol kod reumatskih bolesnika ima multifaktorsku podlogu. Zbog toga je često praćena poremećajem spavanja i raspoloženja, umorom te smanjenjem funkcionalnog kapaciteta i zglobova i kralježnice. Novija istraživanja upućuju na činjenicu da reumatska bol nije samo nociceptivna, već kod velikog broja bolesnika može imati karakteristike i neuropatske i centralne boli. Upravo zbog navedenoga dosadašnji je pristup liječenju reumatske boli često davao vrlo skromne rezultate. Zato se reumatska bol više ne smije liječiti samo kao simptom, već kao zasebna bolest. Učinkovito liječenje reumatske boli zahtijeva multidisciplinarni, biopsihosocijalni pristup, uzimajući u obzir uzrok i karakter boli, obilježja bolesti, stil života te psihološku sposobnost pojedinca za nošenje s bolnim stanjima. Pažljiv odabir različitih modali teta nefarmakološkog liječenja trebao bi zato biti prvi korak u liječenju reumatske boli, uz primjenu dostupnih nam farmakoloških intervencija. Malen broj sustavnih pregleda, koji su obuhvatili samo manji broj uzroka i načina liječenja reumatske boli, uz upitnu kvalitetu dokaza, upućuje na potrebu izrade novih visokokvalitetnih randomiziranih kontroliranih studija, koje bi omogućile stvaran uvid u djelotvornost brojnih nefarmakoloških postupaka u liječenju reumatske boli.Rheumatic diseases are a leading cause of chronic painful conditions, which, if not recognized and treated in a timely manner, cause inability and consequently reduce the quality of life of individuals. Chronic pain in rheumatic patients has a multifactorial background. Th erefore, it is oft en accompanied by sleep and mood disturbances, fatigue, and reduced functional capacity of joints and the spine. Recent studies suggest that rheumatic pain is not exclusively nociceptive, and that in a large number of patients it may have the characteristics of neuropathic and central pain. Th us, the current approach to the treatment of rheumatic pain oft en had very modest results. For these reasons, rheumatic pain can no longer be treated only as a symptom, but should rather be viewed as a separate disease. Eff ective treatment of rheumatic pain requires a multidisciplinary, biopsychosocial approach taking into account the cause and nature of the pain, the disease characteristics, lifestyle, and psychological ability of an individual to deal with painful conditions. Careful selection of diff erent modes of non-pharmacological treatment should be the fi rst step in the treatment of rheumatic pain with the use of available pharmacological interventions. A small number of systematic reviews, which included only a small number of causes and treatments for rheumatic pain with questionable quality of evidence, indicates the need to develop new high-quality randomized controlled trials, in order to enable real insight into the eff ectiveness of non-pharmacological methods for the treatment of rheumatic pain

NEFARMAKOLOŠKO LIJEČENJE BOLNOG RAMENA – KOMPARATIVNO ISTRAŽIVANJE

Non-pharmacological treatment is undeniably a significant part of painful shoulder syndrome treatment. Medical exercises are its most important segment, according to the results of evidence-based medicine. Due to the fact that exercises are rarely used as monotherapy, we were particularly interested in the data regarding other non-pharmacological methods of treatment found in the Cochrane library and PEDro database (Physiotherapy Evidence Database). Simultaneously, we conducted a research study of painful shoulder syndrome treatment with conventional methods of physical therapy. The study included 157 patients, which allowed us to compare our preliminary results with data found in the previously mentioned databases. The majority of quality studies that can be found in the literature database involve the use of modern technology, such as extracorporeal shock wave therapy and high-intensity laser therapy, because they have proven to be very effective in the reduction of pain intensity and the increase of functional capacity of the painful shoulder. These methods of treatment have shown to be effective even in patients with calcific tendinitis, a more severe form of the disease, as well as in patients who had no calcifications. Conventional methods of treatment, often referred to as standard physical therapy (low-level laser therapy, electrotherapy, therapeutic ultrasound) have proven to be effective, but less effective compared to the aforementioned methods. The results of our research also corroborate the previously mentioned fact, thus confirming that the use of conventional methods of physical medicine (therapeutic ultrasound, diclofenac sonophoresis, interferential current therapy, low-level laser therapy, cryotherapy) has been successful in reducing pain intensity and increasing the functional capacity of the painful shoulder. Among the conventional methods of treatment, electrotherapy (interferential current therapy) turned out to be the most efficient one. Non-pharmacological treatment have to be an integral part of all painful shoulder syndrome treatment protocols, and in the future, the use of modern technology in addition to conventional methods of treatment should be encouraged.Nedvojbeno je da u procesu liječenja sindroma bolnog ramena važnu ulogu ima nefarmakološko liječenje (NFL). Pritom, sukladno rezultatima medicine utemeljene na dokazima (EBM), najveću ulogu imaju medicinske vježbe. One se, pak, rijetko rabe samostalno, kao monoterapija, pa nas je zbog toga zanimalo kakve ćemo podatke pronaći u Cochraneovoj bazi i Fizioterapijskoj bazi podataka (engl. Physiotherapy Evidence Database – PEDro) za ostale oblike NFL-a. Istodobno, proveli smo istraživanje o liječenju sindroma bolnog ramena konvencionalnom terapijom, uključivši u istraživanje 157 bolesnika, kako bismo svoje preliminarne rezultate mogli usporediti s podatcima nađenima u rečenim bazama podataka. Najveći broj kvalitetnih studija, pronađenih u literaturi, vezan je za primjenu modernih tehnologija, primjerice, udarnog vala i lasera visokog intenziteta, koji su pokazali znatan učinak na smanjenje boli i povećanje funkcionalnog kapaciteta bolnog ramena. Ove metode liječenja pokazale su se uspješnima i u bolesnika s kalcificirajućim tendinitisom, kao težim oblikom bolesti, ali i kod onih bez te otegotne činjenice. Konvencionalne metode liječenja, često nazivane klasičnom fizikalnom terapijom (elektroterapija, laser niskog intenziteta i ultrazvuk) pokazale su svoju učinkovitost, iako su uvijek bile inferiorne prije navedenim metodama. Rezultati našeg istraživanja bili su u skladu sa spomenutom činjenicom, tako da se primjena konvencionalne fizikalne terapije (ultrazvuk, sonoforeza, interferentne struje, laser niskog intenziteta, krioterapija) pokazala učinkovitom u smanjenju boli i povećanju funkcionalnog kapaciteta bolnog ramena, pri čemu je primjena interferentnih struja bila nešto uspješnija od drugih metoda. NFL mora i nadalje ostati sastavni dio svih protokola liječenja sindroma bolnog ramena, pri čemu modernim tehnologijama treba ustupati sve više mjesta u odnosu prema konvencionalnim metodama liječenja

Prikaz slučaja kasnog tipa primarnog limfedema – od dijagnoze do uspješne terapije

We present a case report of a 46-year-old nurse with lower limb, late onset, second degree primary lymphedema diagnosed thirty years after symptoms onset. Lack of specialised lymphedema clinics, lymphedema specialists, lymphedema management guidelines and lymphedema registry are main causes for prolonged diagnosis in Croatia. Primary lymphedema treatment was con-ducted through 45-minutes sessions three times a week in total 7 sessions. Treatment sessions consisted of limb circumference mea-surements and manual lymph drainage followed by Partsch compression therapy protocol and education. Instructions for physical activity were made likewise. Significant volume reduction was successful despite long primary lymphedema duration. Changes in quality of life and physical activity were noted by self-administered questionnaires. Compression garment specialist made measures for flat knitted stockings compression class III. that are indicated for lymphedema and have important role in the maintenance phase of limb volume. Despite the fact that primary lymphedema is chronic condition, and it has been left untreated for over thirty years in our patient. With proper lymphedema therapy management and teamwork it is possible to achieve and maintain satisfying treatment results especially if you have motivated and properly educated patientPrikaz slučaja 46 godišnje medicinske sestre koja ima drugi stupanj kasnog primarnog limfedema donjih ekstremiteta koji je dijagnosticiran 30 godina nakon pojave prvih simptoma. Nepostojanje ambulante za limfedem, liječnika specijalista koji se bavi limfedemom, smjernica za zbrinjavanje limfedema niti registra za limfedem glavni su uzroci kašnjenja postavljanja dijagnoze limfedema u Hrvatskoj. Terapija limfedema provedena je kroz sedam tretmana u trajanju od 45 minuta, tri puta tjedno. Korišteni su fizioterapijski postupci: ručna limfna drenaža u kombinaciji s kompresivnom terapijom po dr. Partch i edukacija. Dane su upute o provođenju tjelesne aktivnosti. Postignuto je smanjenje volumena unatoč dugotrajnom trajanju limfedema. Promjene u kvaliteti života i razini tjelesne aktivnosti zabilježili smo uz pomoć upitnika. Po završetku terapije pacijentica je upućena ortotičarki radi uzimanja mjera za ravno tkanu kompresivnu odjeću kompresijske klase III. koja je prikladna za fazu održavanja volumena limfedema. Unatoč činjenici da je primarni limfedem kronično stanje, koje je u slučaju naše pacijentice bilo neliječeno preko trideset godina, uz pomoć timskog rada i sveobuhvatnog terapijskog pristupa zbrinjavanju primarnog limfedema moguće je dobiti zadovoljavajuće rezultate terapije te iste održati, posebno ukoliko imate motiviranog i dobro educiranog pacijenta