seronegative spondyloarthropathy Flashcards
features of spondyloarthropathy
Involvement of spine and Sacro-Iliac Joint (SIJ)
Peripheral arthritis – asymmetrical and large lower limb joints
Negative Rheumatoid factor
Genetic factor HLA-B27
Extra-articular features: skin, iritis of eye
Enthesitis - inflammation at ligament and tendon insertion
Familial incidence
More common in males
Overlapping of clinical features
ankylosing spondylitis
Chronic progressive inflammatory disease
Spine and SIJ predominantly affected
Peripheral joint involvement in 60%
epidemiology
Prevalence of 0.1-0.2% Typical presentation in ‘young males’ Male: Female = 3:1 or 5:1 Age of onset 15 - 30 Less disabling in women: older age >40 95% have HLA-B27 factor
Pathology
Affects synovial and cartilaginous joints
Involvement of synovium, articular capsule and ligaments where attached to bone
Enthesitis - inflammation site of attachment ligament or tendon to bone*
Adjacent bony erosions
Reactive bone formation ‘bridging’ between vertebral body margins – syndesmophytes
Inflammation followed by fusion partial / complete of joints
Calcification of ALL and PLL - spinal fusion - ‘Bamboo spine’
Inflammation SIJ (Sacroilitis)
Erosion symphysis pubis
Ankylosis costovertebral joints
Enthesitis
Common sites TA insertion Iliac crest PSIS/ASIS Costochondral junction
radiological changes
Sclerosis / erosion SIJ Fusion of SIJ Syndesmophytes ‘Squaring’ of vertebrae Calcification Anterior Longitudinal Ligament (ALL) + Posterior Longitudinal Ligament (PLL) Tufting iliac crest
lab investigations
Raised Erythrocyte Sedimentation Rate (ESR)
Marker of inflammation
Positive HLA-B27 Factor
Negative Rh Factor (seronegative)
articular features
Low back pain +/- buttock pain- Insidious onset Peripheral Joints- hips and shoulders most common Spinal stiffness Deep / dull aching Early morning stiffness Difficulty getting out of bed ‘log roll’ manoeuvre Duration: 1 - 2 hours Worse after period of immobility Better with exercise
Pain
Worse at rest & eased by mild exercise
Night pain especially in second half of night
Postural changes
Loss of normal lumbar lordosis and increased thoracic kyphosis
Increasingly flexed posture
Pain at tendon insertion sites
TA & plantar fascia
Bony tenderness
clinical features - systemic involvement
Fatigue Weight loss Malaise Low grade pyrexia Anaemia Iritis (20%) Lung disease (<1%) Cardiac disease (<1%) Crohn’s disease + Ulcerative colitis
clinical features other
Neurological
Atlantoaxial involvement +/- subluxation
Risk of spinal cord compression
Costovertebral joints
Ankylosis joints - Restricted chest expansion
c/o Shortness of breath (SOB), chest pain/discomfort
Cardiovascular
Aortic valve incompetence
progression of AS
Initial changes in SIJs and lumbosacral region
Progresses through the spine
Inflammatory changes initially
Progressive stiffness
Ossification costovertebral joints
X-Ray ankylosis SIJ & formation of syndesmophytes‘
Bamboo’ spine
medical mgmt of AS
Patient education*
Pharmacological Rx (Medications)
Surgery
Correction of spinal deformity
THR, TKR
pharmacological treatment
NSAIDs are recommended as first-line Rx for pain and stiffness.
Cardiovascular, GI and renal risks
Analgesics, such as paracetamol and opioid (like) drugs, might be considered for residual pain after previously recommended treatments have failed, are contraindicated, and/or poorly tolerated
Corticosteroid injections for local musculoskeletal inflammation may be considered.
The use of systemic glucocorticoids for axial disease is not supported by evidence.
There is no evidence for the efficacy of Disease Modifying Anti-Rheumatic Drugs (DMARDs) (e.g MTX) for axial (spinal) disease.
DMARDS may be considered in peripheral arthritis.
Anti-TNF therapy should be given to patients with persistently high disease activity despite conventional treatments
physio assessment subjective AS
Subjective Assessment
Problems arising …multiple symptoms?
Symptoms body chart
One joint or multiple joints ?
Pain behaviour (24 hour, aggs/eases, quality of pain)
Stiffness, Swelling? Crepitus, weakness etc
Functional difficulty
History of onset ?insiduous
General health –extra-articular symptoms
Investigations
Management to date
Drug history
Outcome measures: AS therapy screening tools; Stoke AS Spinal Score (SASSS), Bath indices
PA - AS
Postural changes ‘Stooped posture’ Poking chin thoracic kyphosis Loss of lumbar lordosis Flexion hips + knees Shortened pectorals
assessment for AS
cervical spine - flexion/extension
rotation
side flexion
tragus to wall test
Lumbar spine
- forward flexion
- modified schober’s test
- lateral flexion
- trunk rotation
- height
ROM peripheral joints
E.g. Goniometry
Chest expansion
Difference between Inspiration / expiration
4th ICS and at Xiphoid process (Normal 5cm)
Pulmonary Function tests (PFT’s) – test lung volumes
Compression SIJ’s: assessing for pain Presence of tenderness Ischial tuberosities, greater trochanters Costochondral junctions ASIS Iliac crest Calcaneii Pubic symphysis
BASMI AS
Cervical rotation Tragus to wall distance Lateral flexion spine Modified Schober’s test Intermalleolar distance
assessment of function AS
Self-reported
E.g Bath Ankylosing Spondylitis Functional Index
http://www.basdai.com/BASFI.php
Functional tests
Mobility tests.. Timed walks
Timed functional tasks
Battery of tests of function/mobility
non-pharmacological treatment AS
The cornerstone of non-pharmacological treatment of patients with AS is patient education and regular exercise.
Home exercises are effective.
Physical therapy with supervised exercises, land or water based, individually or in a group, should be preferred as these are more effective than home exercises.
Patient associations and self-help groups may be useful (e.g ASAI, AI)
physiotherapy for AS
Education
Self-Management
Exercise should be individually tailored
Exercise
Land based or Hydrotherapy (van Tubergen and Hidding, 2002)
Supervised exercise more beneficial than home exercise (Dagfinrud et al, 2008
Postural alignment
General Cardiovascular exercise.. How?
Maintain/improve joint range and flexibility incl Cervical /Thoracic spine and rib mobility
Strengthening
Which muscle groups most likely to be weaker? (think of posture)
Pain modalities … Examples?
What Exercise precautions should be considered?
exercise precautions AS
Heart Abnormalities
Severely restricted breathing
Atlanto-occipital/Atlanto-axial subluxation
Osteoporosis +/- vertebral crush fractures
psoriatic arthritis
pathology
An inflammatory arthritis (spondyloarthropathy) associated with psoriasis Seronegative –ve Rh factor 2% population have Psoriasis PsA: 1% of population Age of onset 20- 40 Males = Females HLA B27 +/- spinal involvement HLA DR4 +/- polyarthritis 75% psoriasis precedes arthritis 10% arthritis precedes psoriasis 15% synonymous
unknown
abnormal responses to bacterial antigens
associated genes HLA-C
Psoriatic arthritis clinical features (PsA)
Any form of psoriasis
Peripheral symmetrical polyarthritis +/- axial involvement
Asymmetrical spondylitis and sacroiliitis
Typical inflammatory involvement DIPJ’s
Dactylitis (‘sausage digits’)
Telescoping of fingers (‘opera glass hands’)
Nail lesions (pitting)
Enthesitis
patterns of PsA
30%-50% oligoarticular (asymmetrical) or monoarthritis
5%-24% spondyloarthropathy +/- hip, and shoulder
18%-50% polyarticular (symmetrical, polyarthropathy)
Indistinguishable from RA
8% DIP arthritis - classic presentation
Frequently accompanied by nail dystrophy
2% arthritis mutilans - rare destructive progressive form
“telescoping digits” ( hands and feet)
widespread ankylosis
PsA joint changes
normal joint
marginal erosions
erosions progessing centrally, new bone formation whiskering
apparent joint widening
pencil in cup central erosion of the distal phalanx and further marginal bony proliferation whittling of proximal phalanx
clinical features of PsA
DIPJ involvement
Inflammatory changes & psoriatic changes
(onycholysis - pitting - ridging - erosion of nail)
Spinal involvement
Sacroiliitis
Spondylitis
Cervical spine - subluxation
Systemic
Early morning stiffness
Fatigue
Malaise /Low grade fever
Enthesitis
Achilles tendon/ plantar fascia /pelvis /spine
Ocular
Conjunctivitis 20%
investigations
PsA
Blood Tests
Increased ESR
50% have HLA-B27
-ve Rh F
X-Ray Spinal changes similar to AS Syndesmophytes/ enthesitis Peripheral changes: ‘whiskering’ Ankylosis Osteolysis Cup-and-pencil deformity Erosion of one end of bone with expansion of the base of the metacarpal
Diagnosis: CASPAR criteria
PsA
Current psoriasis, hx or family hx of psoriasis (2 points)
Psoriatic nail dystrophy e.g. onycholysis, pitting, and hyperkeratosis observed on P/E (1 point)
A negative test result for the presence of RhF rheumatoid factor (1 point)
Either current or hx of dactylitis (swelling of an entire digit) (1 point)
Radiographic evidence of juxta-articular new bone formation appearing as ill-defined ossification near joint margins (excluding osteophyte formation) on plain radiographs of the hand or foot (1 point)
PsA treatment
Similar guidelines to RA or AS ( if spinal involvement).
Pharmacological
NSAID’s
DMARDS: Methotrexate/ Sulfazalazine/Leflunomide
Anti –TNFs
Treatment for Psoriasis e.g. Meds/UV therapy
non-pharmacological treatment RsA
Education Exercise Hydrotherapy Aerobic etc... Modalities (Caution with skin lesions) Heat/Cold TENS Posture correction Orthoses/ Footwear Ergonomics Hand Therapy + OT
