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Cilj: Analizirati učinkovitost primjene egzoskeletnog robotskog uređaja Armeo Power® (Hocoma, Švicarska) u rehabilitaciji ruke osoba s jednostranim motoričkim ispadom nakon moždanog udara. Ispitanici i metode: U istraživanje koje je provedeno na Zavodu za fizikalnu i rehabilitacijsku medicinu KBC-a Rijeka bilo je uključeno ukupno 20 ispitanika iz stacionarne rehabilitacije. Eksperimentalna skupina (n = 10) uz konvencionalnu terapiju tretirana je i na Armeo Power® uređaju (5 puta tjedno / 4 tjedna; 45 minuta po tretmanu). Istovremeno se kod kontrolne skupine (n = 10) provodila samo konvencionalna terapija. Konvencionalna terapija u objema skupinama bila je vremenski usklađena (5 puta tjedno / 4 tjedna; 45 minuta po tretmanu). Procjenjivale su se motorička funkcija, funkcionalna mjera neovisnosti te prosječno izvođenje i zadovoljstvo izvođenjem okupacije, a procjena se vršila kliničkim ocjenskim ljestvicama. Rezultati: Kod svih kliničkih parametara u ponovljenim mjerenjima zabilježeno je statistički značajno poboljšanje (P = 0,005). Usporedbom između skupina na kraju liječenja nije utvrđena statistički značajna razlika u mjerama motoričke funkcije na FMA (engl. Fugl-Meyer Assessment) skali (P = 0,120) niti funkcionalne neovisnosti na FIM (engl. Functional Independence Measure) skali (P = 0,762). Međutim, zbog značajno bolje motoričke funkcije eksperimentalne skupine na početku, teško je s velikim značajem promatrati usporedbu na kraju liječenja, barem kada je riječ o FMA. Statistički značajna razlika između skupina na kraju liječenja zabilježena je samo u rezultatima COPM-a (engl. Canadian Occupational Performance Measure) (prosječno izvođenje, P = 0,014; prosječno zadovoljstvo, P = 0,022). Zaključci: Dobiveni rezultati ukazuju da terapija uređajem Armeo Power u kombinaciji s konvencionalnom terapijom može poboljšati funkcionalni oporavak nakon moždanog udara, iako su potrebna daljnja istraživanja na većem broju bolesnika., Aim: To analyze the impact of exoskeletal robotic device Armeo Power® (Hocoma, Switzerland) on arm and hand post-stroke rehabilitation of patients with one side movement disability. Patients and methods: Among the patients who participated in the stationary rehabilitation program at Department of Physical and Rehabilitation Medicine in Clinical Hospital Centre Rijeka we formed experimental group of 10 patients, and corresponding control group. For experimental group, we combined conventional and robotic therapy (5 times a week for 4 weeks, 45 minutes per therapy), while in the control group we applied only conventional therapy. Conventional therapy in both groups was the same (5 times a week for 4 weeks, 45 minutes per therapy). Assessment of a motoric function, functional measurement of independence, average performance, satisfaction in the therapy and estimation was done by clinical scales. Results: Statistically significant improvement was noticed in both groups with all clinical parameters (P=0,005). Comparing the two groups at the end of treatment there was no significant statistic difference in measurements of motor function on FMA (Fugl-Meyer Assessment) scale (P=0,120), or functional independence on FIM (Functional Independence Measure) scale (P=0,762). Statistically significant difference between groups at the end of treatment was registered only in results of COPM (Canadian Occupational Performance Measure), average performance P=0,014; average satisfaction P=0,022. Conclusion: Obtained results show that Armeo Power therapy in combination with conventional therapy can improve functional recovery of patients after brain stroke, although further research is needed on a larger number of patients.

Cilj: Neurorehabilitacija bolesnika nakon moždanog udara predstavlja velik izazov, a robotski sustavi kao nadogradnja konvencionalne rehabilitacije predmet su brojnih istraživanja. Tako je pri Zavodu za fizikalnu i rehabilitacijsku medicinu KBC-a Rijeka provedeno istraživanje u kojem je korišten robotski uređaj Armeo Spring® (Hocoma, Švicarska) s ciljem procjene učinkovitosti njegove primjene. Ispitanici i metode: U istraživanje je uključeno 40 bolesnika koji su zadobili moždani udar s posljedičnom hemiparezom, a uključeni su u neurorehabilitaciju u subakutnoj fazi, prosječno 47,31 (± SD = 24,74) dana nakon moždanog udara. Bolesnici su podijeljeni u dvije skupine, od po 20 bolesnika i obje skupine provodile su vježbe dva puta dnevno. Ispitivana skupina bolesnika provela je konvencionalne postupke fizioterapije po Bobath konceptu uz dodatnu robotsku terapiju na uređaju Armeo Spring® (Hocoma, Švicarska), a dvadeset bolesnika kontrolne skupine provodilo je konvencionalnu fizioterapiju po Bobath konceptu dva puta dnevno. Procjena učinkovitosti mjerena je funkcijskim indeksom onesposobljenosti (engl. Functional Independent Measurement; FIM) i ocjenskom ljestvicom motoričke procjene (engl. Motor Assessment Scale; MAS), a procjena je vršena prije i poslije provedene neurorehabilitacije. Rezultati: Praćenjem triju varijabli, cjelokupni FIM test, cjelokupni MAS test (MAS U) te MAS test za funkciju ruke (engl. Motor Assessment Scale za funkciju ruke; MAS FR), uočena je statistički značajna razlika (P < 0,05) između ispitivane i kontrolne skupine. Zaključak: Istraživanje je pokazalo da pokreti potpomognuti uređajem Armeo Spring® poboljšavaju ishod rehabilitacije i nadopunjuju konvencionalnu terapiju. Posebno je ohrabrujući podatak da smo svoje rezultate postigli kod bolesnika u subakutnoj fazi rehabilitacije nakon moždanog udara., Aim: Neurorehabilitation of patients after stroke is a major challenge, and robotic systems as an upgrade to conventional rehabilitation have been the subject of numerous studies. Thus, a research was conducted at the Department of Physical and Rehabilitation Medicine of the University Hospital Center Rijeka in which an Armeo Spring® (Hocoma, Switzerland) robotic device was used in order to evaluate the effectiveness of its application. Subjects and methods: The study included 40 patients after stroke with consequent hemiparesis and were involved in subacute phase neurorehabilitation, averaging 47.31 (± SD = 24.74) days after stroke. Patients were divided into two groups of 20 patients and both groups performed exercises twice a day. The examined group of patients performed conventional physiotherapy procedures according to the Bobath concept with additional robotic therapy on the Armeo Spring® device (Hocoma, Switzerland) and twenty patients of the control group performed conventional physiotherapy according to the Bobath concept twice a day. Performance assessment was measured by the Functional Independent Measurement (FIM) and the Motor Assessment Scale (MAS) and the assessment was performed before and after neurorehabilitation. Results: Monitoring three variables, the overall FIM test, the overall MAS test (MAS U) and the MAS test for upper extremity function (Motor Assessment Scale for upper extremity function; MAS UE) showed a statistically significant difference (p

Uvod: Terapija udarnim valom (TUV) (od engl. shockwave therapy) je neinvazivna metoda temeljena na mehaničkim pulsovima koji se u obliku vala šire kroz ljudsko tijelo te izazivaju mikroskopske intersticijalne i ekstracelularne biološke učinke među kojima je i regeneracija tkiva. Cilj: Cilj ovog retrospektivnog istraživanja bio je ispitati učinkovitost i razlike u liječenju bola TUV-om u pacijenata s dijagnozama plantarni fascitis, kalcificirajući tendinitis ramena i lateralni epikondilitis lakta nakon upotrebe tri i pet uzastopnih tretmana. Ispitanici i metode: U radu su korišteni podatci pacijenata iz baze podataka Zavoda za fizikalnu i rehabilitacijsku medicinu Kliničkog bolničkog centra u Rijeci, a pri tome su u skladu s Helsinškom deklaracijom ostali anonimni: dob, spol, mjerenja intenziteta bola dobivena uz pomoć vizualno analogne skale (od engl. Visual Analogue Scale, VAS). Ispitanici su podijeljeni u dvije grupe za svaku dijagnozu (TUV3 i TUV5). Ispitivanje je sadržavalo ukupno 148 pacijenata: plantarni fascitis N = 50, kalcificirajući tendinitis ramena N = 50 i lateralni epikondilitis lakta N = 48. Rezultati: Primjena terapije udarnim valom kod pacijenata s dijagnozama plantarni fascitis, kalcificirajući tendinitis ramena i lateralni epikondilits lakta, s ciljem smanjenja intenziteta bola, pokazala se uspješnom. Dobivenim rezultatima utvrđeno je da primjena pet TUV tretmana dovodi do boljih rezultata smanjenja bola u sve tri dijagnoze negoli samo tri primijenjena tretmana (p < 0,001; p < 0,001; p < 0,001). Nadalje je utvrđeno da se nakon tri primijenjena tretmana postigao bolji učinak smanjenja bola kod plantarnog fascitisa negoli kod kalcificirajućeg tendinitisa ramena i lateralnog epikondilitisa lakta, dok nakon pet primijenjena tretmana nije bilo razlike u smanjenju bola među dijagnozama. Zaključak: Ova studija preporučuje primjenu pet tretmana kod sve tri dijagnoze kako bi pacijenti imali bolji učinak smanjenja bola., Introduction: Shock wave therapy (SWT) is a non-invasive method based on mechanical pulses widening through the human body and causing microscopic interstitial and extracellular biological effects, including tissue regeneration. Aim: The aim of this retrospective study was to analyze efficacy and differences in pain treatment with SWT in patients with plantar fasciitis, calcific tendinitis of the shoulder and lateral epicondylitis of the elbow after three and five consecutive treatments. Participants and methods: The patients data were taken from the database at the Departmentof Physical and Rehabilitation Medicine of the Clinical Hospital Center in Rijeka and used only in purpose of this work, and according to the Helsinki Declaration, stayed anonymous: age, sex, pain intensity measurements obtained using the Visual Analogue Scale. The participants were devided into two groups (TUV3 and TUV5). The data were taken from 148 patients: plantar fasciitis N = 50, calcific tendinitis of the shoulder N = 50 and lateral epicondylitis of the elbow N = 48. Results: The therapy with SWT proved to be successful in patients with diagnosis of plantar fasciitis, calcific tendinitis of the shoulder and lateral epicondylitis of the elbow. The analyzed results showed that three or five treatments both resulted in pain reduction in all three diagnosis, with five treatments being more efficient than just three applied treatments (p < 0,001; p < 0,001; p < 0,001). It has also been established that after three applied treatments a better effect of pain reduction is achieved in plantar fascitis than in calcific tendinitis of the shoulder and lateral epicondylitis of the elbow, and after five applied treatments there was no difference in pain reduction between diagnoses. Conclusion: Therefore, this study recommends the application of five treatments in all three diagnoses in order for patients to have better pain relief.

Cilj ovog presječnog istraživanja je utvrditi kvalitetu života (QOL) i razinu tjelesne aktivnosti djece mlađe školske dobi s juvenilnim idiopatskim artritisom (JIA) na lokaciji Primorsko-goranske županije u usporedbi sa zdravim vršnjacima te utvrditi koje su najizraženije razlike među njima vezane za kakvoću života. Metode: Istraživanje je provedeno na 13-ero djece s JIA-om s popisa liječene na Klinici za dječju reumatologiju i 17-ero zdrave djece iz osnovne škole. Djeca su bila u dobi između 8-14 godina. Svi sudionici, uključujući njihove roditelje, ispunili su upitnike za procjenu razine svoje tjelesne aktivnosti (Physical Activity Questionnaire for Children; PAQ-C) i kvalitetu života (Quality of life Pediatric Quality of Life InventoryTM Generic Core Scale; Rheumatology Module Scale). Rezultati su pokazali statistički značajne razlike u kakvoći života vezanoj za fizičko funkcioniranje/zdravlje (p =0,033), školske aktivnosti (p = 0,008) i psihosocijalno zdravlje (p = 0,033) između JIA i kontrolne skupine. Odgovori iz reumatološkog upitnika otkrili su statistički značajnu razliku u kakvoći života vezanoj za bol (p = 0,041), dnevne aktivnosti (p = 0,011), liječenje (p = 0,002), zabrinutost (p = 0,0006) i komunikaciju ( p = 0,0002) između JIA i kontrolne skupine. JIA skupina pokazala je značajno nižu razinu tjelesne aktivnosti (p = 0,008). Otkrivena je statistički značajna (p = 0,0000) povezanost između kakvoće života vezane za bol i one vezane za fizičko funkcioniranje/zdravlje (r = 0,94), emocionalno funkcioniranje (r = 0,71), socijalno funkcioniranje (r = 0,74) ), funkcioniranje u školi (r = 0,56) i psihosocijalno zdravlje (r = 0,80). Zaključci: Rezultati istraživanja sugeriraju da JIA utječe na kakvoću života u gotovo svim područjima oboljele djece mlađe školske dobi, te da su najveće razlike prema zdravim vršnjacima prisutne u kakvoći života vezanoj za brigu o svom zdravlju i komunikaciju o njihovoj bolesti., The aim of this cross sectional study was to assess the quality of life (QOL) and level of physical activity in primary school children with juvenile idiopathic arthritis (JIA) in the Primorje-Gorski Kotar County as compared to healthy peers, and to identify the most pronounced differences in QOL between them. The study included 13 children with JIA recruited from the paediatric rheumatology clinic and 17 healthy children from primary school. The children were aged 8-14 years. All participants, including their parents, completed questionnaires to assess the level of their physical activity (Physical Activity Questionnaire for Children; PAQ-C) and QOL (Pediatric Quality of Life Inventory (PedsQLTM) Generic Core and Rheumatology Module scales). Study results showed statistically significant differences in the QOL associated with physical functioning/health (p=0.033), school activities (p=0.008) and psychosocial health (p=0.033) between JIA and control groups. Responses in the rheumatologic questionnaire revealed a statistically significant difference in the QOL associated with pain (p=0.041), daily activities (p=0.011), treatment (p=0.002), concern (p=0.0006) and communication (p=0.0002) between JIA and control groups. The JIA group showed a significantly lower level of physical activity (p=0.008). There was a statistically significant (p=0.0000) correlation between the QOL associated with pain and the QOL associated with physical functioning/health (r=0.94), emotional functioning (r=0.71), social functioning (r=0.74), school functioning (r=0.56) and psychosocial health (r=0.80). In conclusion, study results suggested JIA to affect QOL in almost all domains in the affected primary school children, with the greatest differences from their healthy peers being recorded in the QOL associated with worrying and communicating about their illness.

Sacral stress fractures are divided into fatigue fractures and insufficiency fractures. Fatigue fractures occur in a normal bone exposed to abnormal or repetitive stresses, whereas insufficiency fractures occur in weakened bones under normal stress and with no underlying trauma. Sacral insufficiency fractures are often overlooked causes of nonspecific lumbosacral back pain, especially in elderly women with underlying osteoporosis. In addition to old age and postmenopausal osteoporosis, other conditions which reduce bone mineral density and present risk factors for the occurrence of insufficiency fractures include: long-term glucocorticoid and bisphosphonates therapy, long-term vitamin D insufficiency and osteomalacia, renal osteodystrophy, primary hyperparathyroidism, Paget’s disease, long-term immobilisation and radiotherapy for the treatment of malignant diseases. There are no typical clinical signs to suggest sacral stress fracture. These fractures are often associated with degenerative diseases of the spine and intervertebral disc, and they are often accompanied by pre-existing osteoporotic vertebral compression fractures. Plain radiographs of the spine and pelvis, which are the first step in diagnostic imaging, are usually non-diagnostic when it comes to sacral fractures. Due to radicular pain symptoms, magnetic resonance imaging of the lumbosacral spine is the next step in diagnosis, in which sacral fractures are often revealed as accidental findings. In this paper, we shall present a case of an elderly patient with multiple comorbidities and multiple risk factors, in whose case physical therapy did not prove to be effective. During diagnostic testing, a subsequent MRI showed an accidental finding confirming the sacral fracture. Furthermore, we shall highlight the importance of early detection of sacral stress fracture in high-risk patients, in order to avoid unnecessary, and sometimes invasive, diagnostic procedures and to reduce the possibility of possible complications. The imaging method of choice for the diagnosis of sacral stress fractures is MRI., Stresne prijelome (engl. stress fractures) možemo podijeliti na prijelome zamora ili stresne prijelome u užem smislu (engl. fatigue fractures) i na prijelome u oslabljenoj kosti (engl. insufficiency fractures). Prijelomi zamora nastaju u zdravoj kosti zbog dugotrajnog ponavljanja neprimjerenog opterećenja, dok prijelomi u oslabljenoj kosti nastaju spontano, odnosno bez prethodne traume. Prijelomi sakruma u oslabljenoj kosti često su neprepoznat uzrok križobolje i boli u zdjelici, posebice u žena starije dobi s osteoporozom. Osim starije dobi i postmenopauzalne osteoporoze, rizični čimbenici za prijelom u oslabljenoj kosti jesu dugotrajna terapija glukokortikoidima i bisfosfonatima, dugotrajan teži nedostatak vitamina D i osteomalacija, renalna osteodistrofija, primarni hiperparatiroidizam, Pagetova bolest, dugotrajna nepokretnost i radioterapija zbog maligne bolesti. Specifični klinički znakovi stresnog prijeloma sakruma ne postoje. Ovakvi prijelomi često su udruženi s degenerativnim promjenama kralježnice i intervertebralnog diska, a često su prisutni i osteoporotični prijelomi kralježaka. Na standardnim radiogramima kralježnice i zdjelice, koji su prvi korak u slikovnoj dijagnostičkoj obradi, prijelomi sakruma najčešće se ne uočavaju. Zbog često prisutnih radikularnih simptoma sljedeći dijagnostički korak jest magnetska rezonancija lumbosakralne kralježnice na kojoj su prijelomi sakruma najčešće slučajan nalaz. Prikazujemo bolesnicu s multiplim komorbiditetima i višestrukim čimbenicima rizika kod koje je zbog prolongirane križobolje provedena fizikalna terapija s nezadovoljavajućim učinkom. Tijekom obrade učinjena je magnetska rezonancija gdje je kao slučajan nalaz potvrđen prijelom sakruma. Ističemo važnost ranog prepoznavanja rizičnih skupina pacijenata čime se postiže izbjegavanje suvišnih, katkad i invazivnih dijagnostičkih postupaka. Slikovna metoda izbora za dijagnozu stresnog prijeloma sakruma jest magnetska rezonancija.

We aimed to verify by Rasch analysis whether the Mini-BESTest, a balance measure, confirms its main psychometric properties in patients with subacute stroke undergoing rehabilitation in three different countries (Slovenia, Croatia, and Italy), and to examine the stability of item hierarchy and difficulty across the three national versions through a differential item functioning analysis. We investigated 159 patients with subacute stroke consecutively admitted to three rehabilitation facilities after screening for an intensive, tailored rehabilitation program. Balance function was tested within 36 h from admission and after ∼25 days. As no differential item functioning was found between admission and discharge data or among countries, all data were pooled. Rasch criteria for the functioning of rating scale categories were fulfilled. In terms of internal construct validity, all items except item #14 (Cognitive Get UpGo; infit value=1.42) showed an acceptable fit to the Rasch model. The patient ability-item difficulty matching was very good. Reliability indices were high. The Principal Component Analysis of standardized residuals confirmed the unidimensionality of the test. On the basis of the item calibration, raw scores of the Mini-BESTest were transformed into linear estimates of dynamic balance and six statistically detectable levels of balance ability were defined. Good psychometric features of the Mini-BESTest were confirmed. The three different national versions showed stability in item hierarchy, indicating equivalence of their cross-cultural adaptations. Problems with item #14 in these patients warrant further study.

The aim of this study was to assess the functional outcome of a population of lower limb amputees supplied with prosthesis. The research was conducted from June to September of 2010 at the Center for Physical and Rehabilitation Medicine, of the Clinical Hospital Center Rijeka, Croatia. The study included 50 adult subjects of both genders with a unilateral transtibial or transfemoral lower limb amputations. The 2-minute walk test (2MWT) was used to assess the functional outcome of these individuals. Data were statistically analyzed. Subjects were divided into groups according to age. The best results were obtained by subjects between the age of 45 and 59 years. The difference between groups was statistically significant (p0.001). Taking into account the cause of amputation, there was a statistically significant difference in the results of the 2 MWT between subjects in whom the cause of amputation was circulatory and those where the cause of the amputation was not due to circulatory problems. The best results were obtained in subjects in whom the cause of amputation was not circulatory (p = 0.009). Considering the level of amputation there was a statistically significant difference in the results of the 2MWT between subjects with transtibial and those with transfemoral amputations. Better results were obtained in transtibial amputees (p = 0.039). Considering the first prosthetic supply, better results were obtained in subjects using prosthetic devices over 9 years (p = 0.031). Our research confirmed that age, gender, level and cause of amputation, including the time from the first prosthetic supply have an effect on the 2MWT results.

The aim of the study was to analyze the senior population when deciding to choose either going to the private or public physical medicine practice in Croatia. 240 patients (public and private group, 120 participants each) from the Croatian medium large county Primorje–Gorski kotar, were enrolled from 6 physical medicine practices (3 public and 3 private). Between December 1st 2009 and January 31st 2010, in the public and private practices seniors aged 65 to 85 years were 64.17%, 52.40% respectively, of all interviewed participants in single group. The results showed that in Croatia majority of seniors visiting the physical medicine were females in revisit and dependents of government health insurance. Study suggested the great influence of: general practitioner, closeness to home and time of the appointment for patients going to public physical medicine, while in private peers and sooner appointment outweigh. In either practice seniors were satisfied with the overall quality of health services and graded the best average-higher in favor for the private. Elderly Croatian residents showed to be the important feature in physical medicine and rehabilitation and to participate actively in their health issues. Following those results, we will perform the study in the rest of the country and compare it to this data. That could enable the specific improvement for the health care of seniors in Croatia.

Psorijatični artritis (PsA) je kronična upalna artropatija koja može zahvatiti periferne zglobove i aksijalni skelet. Registrira se u 7 % do 42 % pacijenata s kožnom psorijazom. Promjene na zglobovima mogu godinama prethoditi pojavi kožnih promjena. Bolest se manifestira bolom i zakočenošću u zahvaćenim zglobovima. Važnu ulogu ima genetska predispozicija (prisutnost B27 udružena je s aksijalnim oblikom bolesti, a DR4 sa simetričnim poliartikularnim oblikom koji podsjeća na reumatoidni artritis). Entenzitisi su upalne promjene na hvatištu tetiva i ligamenata za kost. Navedene su promjene svojstvene spondiloartritisima, tj. skupini upalnih reumatskih bolesti kojima pripada i PsA. Za PsA, kao i za ostale spondiloartritise, tipična je pojava određenih ekstraartikulanih zglobnih manifestacija, kao npr. očne promjene (konjunktivitis i uveitis se viđaju u 1/3 bolesnika s PsA), srčane smetnje, upalne bolesti crijeva, te upale genitourinarnog sustava. U liječenju zglobnih promjena koriste se NSAR (nesteroidni antireumatici), DMARD (Disease-Modifying Antirheumatic Drugs), tj. lijekovi koji modiiciraju bolest kao što su metotreksat (MTX), lelunomid i sulfasalazin. U novije vrijeme sve se više koriste i biološki agensi. Fizikalna terapija je, u pravilu, nadopuna medikamentnoj terapiji. U težim oblicima PsA nameće se potreba i rekonstruktivnih kirurških zahvata. U liječenju PsA preporuča se istodobno liječenje kožnih i zglobnih promjena. Da bi se postiglo optimalne rezultate potrebno je naglasiti kolika je važnost zajedničkog pristupa reumatologa i dermatologa u liječenju bolesnika s PsA., Psoriatic arthritis (PsA) is chronic inlammatory arthropathy of peripheral joints and axial sceleton, occurring in 7% to 42% of patients with psoriasis. Arthritis might precede skin psoriatic lesion lesion in 13% to 17% cases. Patients present with pain and stiffness of the affected joins. A genetic factors play an important role (B27 has been associated with axial form, and DR4 with peripheral polyarticular form of PsA). Enthesopathy is a hallmark feature of PsA. It is an inlammation at the sites where tendons and ligaments attach to the bone. Extra-articular manifestations of disease are conjuctivitis and uveitis (occur in up to 1/3 of patients with PsA), heart disorder (aortic insuficiency), gut inlammation, urogenital inlammation.Treatment of PsA includes therapies for boths the skin and the joint disease. The treatment for the joint disease includes using NSAR (nonsteroidal anti-inlammatory drugs), DMARDs (Disease-Modifying Antirheumatic Drugs) such as methotrexat (MTX), lelunomid, sulfasalasin and biological agents. Second-line therapy are: systemic glucocorticoids, retinoic acid derivatives/etretinate, photochemoterapy with MTX, physical therapy as an adjunct to drug therapy, and reconstructive surgery. The most important is that rheumatologist and dermatologist need to have some approach in management of PsA for optimal results.