Publication: Romatoid Artritli Hastalarda Nöropatik Ağrı; Santral Sensitizasyon, Yorgunluk, Uyku ve Yaşam Kalitesi İle İlişkisi: Kontrollü Çalışma
Abstract
AMAÇ: Romatoid artrit (RA) sinoviyal eklemleri ve eklem dışı organları etkileyen, progresif ve inflamatuar bir hastalıktır. RA'da ağrı hastaların en çok düzelmesini istediği semptomdur. RA hastalarında güncel tedaviler ile inflamasyon yeteri kadar baskılansa bile ağrının devam edebildiği, bu nedenle inflamasyon haricinde ağrıya katkı sağlayabilecek farklı ağrı yolakları olabileceği düşünülmektedir. Nöropatik ağrı (NA) somatosensoriyel sistemi etkileyen bir lezyon veya hastalığın doğrudan bir sonucu olarak ortaya çıkan ağrıdır. Periferik ve/veya santral mekanizmalarla oluştuğu, santral sensitizasyon (SS)'nin ise santral mekanizmaların temelinde yer aldığı belirtilmektedir. RA hastalarındaki ağrının nöropatik komponentler içerdiğini gösteren bulgular mevcuttur ancak NA veya SS prevelansı için kesin bir veri yoktur. Bu çalışmada, RA'lı hastalarda NA ve SS varlığını belirlemeyi, NA'nın SS, demografik ve klinik bulgular, yorgunluk, uyku ve yaşam kalitesi ile olan ilişkisini saptamayı amaçladık. GEREÇ VE YÖNTEM: Çalışmaya Ondokuz Mayıs Üniversitesi Tıp Fakültesi Fiziksel Tıp ve Rehabilitasyon polikliniği tarafından takip edilen, American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) RA Klasifikasyon Kriterleri'ni karşılayan 100 RA hastası (K/E=62/38, yaş=50,31±10,37 yıl) ve 100 sağlıklı kontrol (K/E=64/36, yaş=48,12±9,29 yıl) dahil edildi. Katılımcıların sosyodemografik özellikleri kayıt edildi. Hastaların ağrı düzeyi ve sabah tutukluluğu vizüel analog skala (VAS), hastalık aktivitesi DAS-28 skoru ile değerlendirildi. Hassas ve şiş eklem sayısı, ESH (eritrosit sedimentasyon hızı) ve CRP (C-reaktif protein) düzeyleri kaydedildi. Hasta ve kontrol grubunda NA varlığı PainDetect ağrı anketi, SS varlığı Santral Sensitizasyon Ölçeği (SSÖ), yorgunluk düzeyi Yorgunluk Şiddet Skalası (YŞS), uyku kalitesi Pittsburg Uyku Kalite İndeksi (PUKİ), fonksiyonel durumları Sağlık Değerlendirme Anketi (HAQ), yaşam kalitesi Kısa Form-36 (SF-36) kullanılarak değerlendirildi. NA ve SS varlığının tespiti için kabul görmüş kesme skorları kullanıldı (sırasıyla PainDetect ≥19 ve SSÖ≥40). RA hastaları PainDetect ağrı skalası skoruna göre 'NA olası (≥19) ', 'NA belirsiz (13-18)' ve 'NA olası değil (≤12) ' şeklinde 3 alt gruba ayrılıp, alt gruplar tüm parametreler açısından karşılaştırıldı. İstatistiksel analizler için IBM SPSS Statistics 22 (IBM SPSS, Türkiye) programı kullanıldı. İstatistiksel anlamlılık düzeyi p<0,05 olarak kabul edildi. BULGULAR: RA hastalarında kontrol grubuna kıyasla PainDetect ve SSÖ skorları anlamlı düzeyde yüksek bulundu (p<0,05). Hastalık süresi ortalaması 11,19±7,19 olan RA'lı hastalarımızın çoğunluğu en az bir hastalığı modifiye edici ajan (%95) ve biyolojik ajan (%63) kullanmakta olup orta düzeyde hastalık aktivitesine (DAS-28 skoru 3,36±1,28) sahip idi. RA'lı hastaların %15'i NA olası, %26'sı NA belirsiz ve %40'ı SS var olarak bulundu. RA'lı hastalarda NA ve SS var olma oranı kontrollere kıyasla anlamlı düzeyde yüksek saptandı (p<0,05). 'NA olası veya NA belirsiz' olan RA hastalarında ağrı VAS, SSÖ, YŞS, HAQ ve PUKİ skorları 'NA olası değil' RA hastalarına kıyasla anlamlı düzeyde yüksek iken, SF-36 alt parametre skorları ise anlamlı düzeyde düşük bulundu (p<0,05). PainDetect skoru ile ağrı VAS, şiş eklem sayısı, sabah tutukluğu, DAS-28, HAQ, YŞS, PUKİ total ve SSÖ skorları arasında anlamlı pozitif korelasyon tespit edilirken, biyolojik ajan kullanım süresi ve SF-36 tüm alt parametre skorları ile arasında ise negatif korelasyon saptandı (p<0,05). SSÖ skorları ile ağrı VAS, HAQ, YŞS, PUKİ total skorları arasında pozitif korelasyon tespit edilirken, SF-36 tüm alt parametre skorları arasında negatif korelasyon saptandı (p<0,05). SONUÇ: RA'lı hastaların sağlıklı kontrollerden daha yüksek PainDetect ve SSÖ skorlarına sahip olduklarını bulduk. Dahası, RA hastalarında sağlıklı bireylere kıyasla daha yüksek oranda NA (%15) ve SS (%40) var olduğunu tespit ettik. RA'lı hastalarda NA semptomları ve SS arasındaki ilişki gözlemledik. Ayrıca, yüksek NA ve yüksek SS düzeyinin artmış yorgunluk, bozulmuş uyku, kötü fonksiyonel durum ve düşük yaşam kalitesi ile ilişkili olduğunu saptadık. RA hastalarında ağrı her zaman inflamasyondan kaynaklanmayabilir. Hastalar NA ve SS varlığı açısından da sorgulanmalı, gerekli durumda tedavi planı inflamatuar süreçler yanında nöropatik unsurları da içerecek şekilde olmalıdır. Böylece hastaların ağrı ve yorgunluk düzeylerinde azalma, fonksiyonel durumlarında iyileşme, uyku ve yaşam kalitelerinde düzelme sağlanabilir.
AIM: Rheumatoid arthritis (RA) is a progressive and inflammatory disease affecting synovial joints and extra-articular organs. Pain is the symptom that patients want to improve the most in RA. It is thought that pain may continue in RA patients even if inflammation is sufficiently suppressed with current treatments, and therefore there may be different pain pathways that may contribute to pain other than inflammation. Neuropathic pain (NP) is pain that occurs as a direct result of a lesion or disease affecting the somatosensory system. It is stated that it occurs through peripheral and/or central mechanisms, and central sensitization (CS) is the basis of central mechanisms. There are findings indicating that pain in RA patients contains neuropathic components, but there is no definitive data for the prevalence of NP or CS. In this study, we aimed to determine the presence of NP and CS in RA patients and to determine the relationship between NP and CS, demographic and clinical findings, fatigue, sleep and quality of life. MATERIALS AND METHODS: The study included 100 RA patients (F/M=62/38, age=50.31±10.37 years) and 100 healthy controls (F/M=64/36, age=48.12±9.29 years) who were followed up by the Physical Medicine and Rehabilitation Polyclinic of Ondokuz Mayıs University Faculty of Medicine and who met the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) RA Classification Criteria. The sociodemographic characteristics of the participants were recorded. The pain level and morning stiffness of the patients were assessed with the visual analog scale (VAS), and the disease activity was assessed with the DAS-28 score. Tender and swollen joint count, ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein) levels were recorded. In the patient and control groups, the presence of NP was assessed using the PainDetect Pain Questionnaire, the presence of CS was assessed using the Central Sensitization Inventory (CSI), fatigue level was assessed using the Fatigue Severity Scale (FSS), sleep quality was assessed using the Pittsburg Sleep Quality Index (PSQI), functional status was assessed using the Health Assessment Questionnaire (HAQ), and quality of life was assessed using the Short Form-36 (SF-36). Accepted cut-off scores were used to determine the presence of NP and CS (PainDetect ≥19 and CSI≥40, respectively). RA patients were divided into 3 subgroups as 'NP probable (≥19)', 'NP uncertain (13-18)' and 'NP unlikely (≤12)' according to the PainDetect pain scale score, and the subgroups were compared in terms of all parameters. IBM SPSS Statistics 22 (IBM SPSS, Turkey) program was used for statistical analyses. Statistical significance level was accepted as p<0.05. RESULTS: PainDetect and CSI scores were significantly higher in RA patients compared to the control group (p<0.05). The majority of our RA patients with a mean disease duration of 11.19±7.19 were using at least one disease-modifying agent (95%) and biological agent (63%) and had moderate disease activity (DAS 28 score 3.36±1.28). 15% of RA patients were found to be 'NP probable', 26% were found to be 'NP uncertain' and 40% were found to be 'CS present'. The rate of NP and CS presence in RA patients was found to be significantly higher compared to controls (p<0.05). While pain VAS, CSI, FSS, HAQ and PSQI scores were significantly higher in RA patients with 'NA probable or NA uncertain' compared to 'NA unlikely' RA patients, SF-36 subparameter scores were found to be significantly lower (p<0.05). A significant positive correlation was found between the PainDetect score and pain VAS, swollen joint count, morning stiffness, DAS-28, HAQ, FSS, PSQI total and CSI scores, while a negative correlation was found between the duration of biological agent use and all SF-36 subparameter scores (p<0.05). A positive correlation was found between the CSI scores and pain VAS, HAQ, FSS, PSQI total scores, while a negative correlation was found between all SF-36 subparameter scores (p<0.05). CONCLUSIONS: We found that patients with RA had higher PainDetect and CSI scores than healthy controls. Furthermore, we found that RA patients had higher rates of NP (15%) and CS (40%) compared to healthy individuals. We observed a relationship between NA symptoms and SS in patients with RA. We also found that high NP and high CS levels were associated with increased fatigue, disrupted sleep, poor functional status, and poor quality of life. Pain in RA patients may not always be caused by inflammation. Patients should be questioned for the presence of NA and SS, and if necessary, the treatment plan should include neuropathic elements in addition to inflammatory processes. Thus, patients' pain and fatigue levels can be reduced, their functional status improved, and their sleep and quality of life improved.
AIM: Rheumatoid arthritis (RA) is a progressive and inflammatory disease affecting synovial joints and extra-articular organs. Pain is the symptom that patients want to improve the most in RA. It is thought that pain may continue in RA patients even if inflammation is sufficiently suppressed with current treatments, and therefore there may be different pain pathways that may contribute to pain other than inflammation. Neuropathic pain (NP) is pain that occurs as a direct result of a lesion or disease affecting the somatosensory system. It is stated that it occurs through peripheral and/or central mechanisms, and central sensitization (CS) is the basis of central mechanisms. There are findings indicating that pain in RA patients contains neuropathic components, but there is no definitive data for the prevalence of NP or CS. In this study, we aimed to determine the presence of NP and CS in RA patients and to determine the relationship between NP and CS, demographic and clinical findings, fatigue, sleep and quality of life. MATERIALS AND METHODS: The study included 100 RA patients (F/M=62/38, age=50.31±10.37 years) and 100 healthy controls (F/M=64/36, age=48.12±9.29 years) who were followed up by the Physical Medicine and Rehabilitation Polyclinic of Ondokuz Mayıs University Faculty of Medicine and who met the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) RA Classification Criteria. The sociodemographic characteristics of the participants were recorded. The pain level and morning stiffness of the patients were assessed with the visual analog scale (VAS), and the disease activity was assessed with the DAS-28 score. Tender and swollen joint count, ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein) levels were recorded. In the patient and control groups, the presence of NP was assessed using the PainDetect Pain Questionnaire, the presence of CS was assessed using the Central Sensitization Inventory (CSI), fatigue level was assessed using the Fatigue Severity Scale (FSS), sleep quality was assessed using the Pittsburg Sleep Quality Index (PSQI), functional status was assessed using the Health Assessment Questionnaire (HAQ), and quality of life was assessed using the Short Form-36 (SF-36). Accepted cut-off scores were used to determine the presence of NP and CS (PainDetect ≥19 and CSI≥40, respectively). RA patients were divided into 3 subgroups as 'NP probable (≥19)', 'NP uncertain (13-18)' and 'NP unlikely (≤12)' according to the PainDetect pain scale score, and the subgroups were compared in terms of all parameters. IBM SPSS Statistics 22 (IBM SPSS, Turkey) program was used for statistical analyses. Statistical significance level was accepted as p<0.05. RESULTS: PainDetect and CSI scores were significantly higher in RA patients compared to the control group (p<0.05). The majority of our RA patients with a mean disease duration of 11.19±7.19 were using at least one disease-modifying agent (95%) and biological agent (63%) and had moderate disease activity (DAS 28 score 3.36±1.28). 15% of RA patients were found to be 'NP probable', 26% were found to be 'NP uncertain' and 40% were found to be 'CS present'. The rate of NP and CS presence in RA patients was found to be significantly higher compared to controls (p<0.05). While pain VAS, CSI, FSS, HAQ and PSQI scores were significantly higher in RA patients with 'NA probable or NA uncertain' compared to 'NA unlikely' RA patients, SF-36 subparameter scores were found to be significantly lower (p<0.05). A significant positive correlation was found between the PainDetect score and pain VAS, swollen joint count, morning stiffness, DAS-28, HAQ, FSS, PSQI total and CSI scores, while a negative correlation was found between the duration of biological agent use and all SF-36 subparameter scores (p<0.05). A positive correlation was found between the CSI scores and pain VAS, HAQ, FSS, PSQI total scores, while a negative correlation was found between all SF-36 subparameter scores (p<0.05). CONCLUSIONS: We found that patients with RA had higher PainDetect and CSI scores than healthy controls. Furthermore, we found that RA patients had higher rates of NP (15%) and CS (40%) compared to healthy individuals. We observed a relationship between NA symptoms and SS in patients with RA. We also found that high NP and high CS levels were associated with increased fatigue, disrupted sleep, poor functional status, and poor quality of life. Pain in RA patients may not always be caused by inflammation. Patients should be questioned for the presence of NA and SS, and if necessary, the treatment plan should include neuropathic elements in addition to inflammatory processes. Thus, patients' pain and fatigue levels can be reduced, their functional status improved, and their sleep and quality of life improved.
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