Rheumatology Flashcards
what is ankylosis?
abnormal stiffening and immobility of a joint due to fusion of bones
What HLA is Ankylosing spondylitis associated with? main population affected?
HLA B27 (+ve in 90-95%)
affects young males 20-30 / 15-40
Modified Schober’s test - how?
The modified Schober’s test should be used for serial measurement
To perform this test, mark two points on the back (one 5 cm below and one 10 cm above a line drawn between the dimples of Venus)
On forward flexion, the distance between the two points should be >5 cm
If the distance is <5 cm, this indicates restricted forward flexion
-> tests lumbar spine in ankylosing spondylitis
what is ankylosing spondylitis?
A seronegative spondyloarthropathy and a chronic inflammatory disease of the axial skeleton that leads to partial or complete fusion and rigidity of the spine.
- a seronegative spondyloarthropathy
- features include pain, morning stiffness and reduced range of motion
- mainly affects young men
Aetiology of ankylosing spondylitis
Genetic predisposition (90-95% patients are +ve for HLA B27)
Most commonly affects young males 20-30yo / 15-40yo
symptoms of ankylosing spondylitis
- inflammatory back pain
- morning stiffness (improves with movement)
- peripheral enthesitis
- peripheral arthritis may occur in up to 1/3 pts with hips and shoulders being most commonly affected.
- tenderness of SI joints
Extra-articular
- anterior uveitis (20-30%)
- aortitis -> AR
- upper lobe pulmonary fibrosis
- IgA nephropathy (5%)
- may also have IBD
examination findings in ankylosing spondylitis
- limited spinal motion
- tenderness of the SI-joints (e.g. on FABER test)
Specific tests of the spine:
- lumbar: modified Schober’s test
- thoracic: reduced chest expansion in some (<5cm), dorsal kyphosis can develop as the disease progresses
- cervical: globally reduced movements, measure occiput to wall distance
ankylosing spondylitis management
Non-pharmacological:
- exercise and PT -> critical to maintain posture, flexibility and motility
Pharmacological:
-NSAIDs with PPI are first line
- DMARDs (sulfalazine, methotrexate -> for peripheral disease, don’t improve spinal inflammation)
- local steroid injections
- biologics (anti-TNF are first line biologics, anti-IL17 are second line, can also use anti-IL12/23)
Surgery may be indicated in some patients to improve QoL.
ix in ankylosing spondylitis
- Lab: no diagnostic ix! FBC and inflammatory markers in primary care before referral; In secondary care HLA testing is carried out.
- Imaging: plain X-rays useful in established disease but can be normal early on (pelvic, lumbar);
MRI is the most sensitive, can also be useful in evaluating response to treatment.
oligoarthritis and polyarthritis definition
Oligo: 2-4
Poly: 5+
Nociplastic pain
a type of chronic pain that is not due to tissue damage or nerve damage
a third group of pain
Scoring system for hyper mobility
Beighton
(keep in mind that the score gets worse with age, so ask about childhood)
screening questions for fibromyalgia
- sleep
- fatigue
- irritable bowel
Symptoms of fibromyalgia
- Fatigue
- exhaustion
- chronic pain (back, chest, pelvic…)
- headache
- poor sleep (unrefreshing sleep)
- palpitations
- difficulty concentrating
- brain fog
- urine frequency
- urge incontinence
- IBS / change in bowel habit
- reflux
- depression anxiety
- dry mouth
Definition and Aetiology of fibromyalgia
Definition: acquired disorder of pain/sensory processing (‘nociplastic pain’). It is a syndrome, not a disease.
Aetiology: Acquired, genetic predisposition; CNS is overreacting to sensations in the body.
More common in females (5:1), peak incidence at 30-40yo
Signs on clinical examination in fibromyalgia
- tenderness
- no joint swelling/redness/warmth, heat
- GALS: many show generalised pain
- hyperalgesia (things that should not be painful are painful)
- alodynia (things that should be slightly painful are very painful)
Ix in fibromyalgia
Fibromyalgia is NOT a diagnosis of exclusion!!
- you can do a ‘fibromyalgia syndrome diagnostic’ worksheet - ‘symptoms severity index’
- explain to the patient that there is no test you can do to confirm the diagnosis
- normal bloods
Tests to do just in case / ‘to make sure I am not missing anything’
- ESR
- FBC
- U&E (?renal failure)
- Ca, phosphate
- TFT
- HbA1c
- urine dip
DO NOT DO: RF, ANA, ANCA, CK, Igs, Vit D (unless you have a goof reason; e.g. a % of people have RF+ but no RA, everyone is Vit D deficienct so that won’t help you
Management of fibromyalgia
Conservative
- MDT: relationship, careful communication
- Education/Information
- Exercises - slow and steady
- CBT/ACT
Medical
- antidepressant (amitriptyline) - NO gabapentin/opioids/benzos/NSAIDs
Other
- acupuncture
Prognosis of fibromyalgia
- can expect to have the condition for a longer time, perhaps even life long.
- some treatments and measures can help with symptoms
- may experience flares
