Spondyloarthritis Flashcards
A disease affecting the joint of the spine, that does NOT have the rheumatoid factor in the blood
Seronegative Spondyloarthritis
Inflammation in the spine
- i.e. Sacroiliitis, spondyltitis
Synovitis
- Affecting peripheral joints of the legs>arms
- Typically on one side of the body
Enthesopathy
- Inflammation where ligaments, tendons, & joint capsule attach to bone
Inflammatory Eye Disease
- i.e. Iritis (Uveitis), Conjunctivitis
Blood Work
- Usually does NOT show Rheumatoid Factor (Seronegative)
Tendency to run in families
- Often associated w/ HLA-B27 genetic marker
Common Features
Psoriasis
- Common skin disease (2% US pop)
- Dry, red/grey, scaly patches of skin
- Finger/toenails: Discolouration, pitting, ridging
- 10% may develop inflammatory arthritis
Appears in families - Multigenic Inheritance
M=F: 30-50 y/o
Can begin in childhood
Dactylitis: sausage-like finger & toes due to swelling
Enthesitis: esp. in heels & back
Psoriatic Arthritis
1) Primarily joints of fingers & toes (DIP ARTHRITIS)
2) Joints of limbs - asymmetric (OLIGOARTHRITIS ≤ 2-4 joints involved)
3) Multiple joints - symmetric - resembles RA (Symmetrical POLYARTHRITIS)
4) Arthritis Mutilans - rare, deforming
5) Sacrioiliac Joints & Spine - “PSORIATIC SPONDYLITIS”
Can have conjunctivitis/iritis in the eyes
Spondylitis & iritis more common in people who are HLA-B27 (+)
5 Subgroups of Psoriatic Arthritis
Ulcerative colitis & Chron’s disease
- Inflammatory conditions of the bowel - result in diarrhea
Associated w/ arthritis
May affect the spine & sacroiliac joints
- may also affect the joints in the legs & arms
Enteropathic Spondylitis (Intestinal Arthropathy)
Aka: Reiter’s arthritis
Generally asymmetrical
Typically causes hot, swollen joints
Usually occurs in the lower limbs
May cause stiffening in the spine as well
Triggered by infection in the bowel or genitourinary tract
May become chronic
Reactive Arthritis
Stiffness/fusing of the spine by inflammation
Documented since ancient times
Essentially a disease of young adults
- Onset: adolescence/young adulthood
Average age: 26 y/o
Rare beyond 45 yrs
Delay in diagnosis average 8.9 yrs
Prevelance
- 0.1% African & Inuit
- 0.5-1% White
- 6% Haida Indigenous people
- M:F 1:1
Ankylosing Spondylitis
Many advancements have been made in recent years, yet exact cause still unclear
Familial clustering
Association w/ genetic marker HLA-B27
- 90-95% are HLA-B27 (+)
Possible multigenic
Infective mechanism being explored as trigger but no evidence in the joint
Causes of AS
MSK Involvement
- Sacroilitis
- Enthesitis
- Synovitis
Other systems & organs involved
- Eyes
- Bowels
- Lungs
- Heart
Features of AS
Hallmark sign of AS
90% or more cases start with ________
6025% w/ Chrohn’s/ulcerative colitis have _________
Slow onset of pain
- deep, dull, diffuse pain in buttock area
- d/t inflammation in SI joints
Bilateral disease
- initially comes & goes on one side, then other side
Fusion can occur over time
Sacroilitis
s can impinge on spinal nerves
Entheses: Place where tendons, ligaments & joint capsule attach to bone
Inflammation of the sites, leading to bony erosion, bony overgrowth (syndesmophytes), possible bony fusion & rigidity
Inflammation starts at SI joints, progresses in ascending fashion affecting all levels of spine
Common sites can include both spine & peripheral regions
Can take several years; diagnosis can take 5-6 years
Early stage: bony loss -> osteopenia
Later stage osteoporosis -> risk of #
- fusion/rigidity -> risk of #s
Stiffness
- lumbar/thoracic/cervical region -> Loss of ROM
- ribcage - ↓ lung capacity
Enthesitis
Inflammation -> Erosive Damage Repair -> New Bone Formation
Normal -> Inflamed -> Encroach -> Fusion -> Full fusion
Sequence of Structural Damage in AS
Inflammation of the synovium
Usually affects peripheral joints - commonly: shoulders, hips, knees
Involvement of joints may precede, accompany, or follow spinal involvement
Peripheral joint involvement occurs in 30% of cases
Synovitis
Clinical Criteria:
- LBP & stiffness for more than 3 months that improves w/ exercise but is not relieved by rest
- Limitation of motion of the lumbar spine in both sagittal & frontal planes
- Limitation of chest expansion relative to normal values correlated for age & sex
Radiological Criterion:
- Sacroiliitis grade ≥ 2 bilaterally or grade 3-4 unilaterally
- Definite AS:
- If radiological criterion is associated w/ at least 1 clinical criterion
New York Criteria for AS
In patients with ≥3months back pain & age at onset <45yrs:
Sacroiliitis on imaging + ≥1 SpA feature
OR
HLA-B27 + ≥ other SpA features
ASAS Classification Criteria for SpA
- Inflammatory back pain
- Arthritis
- Enthesitis (heel)
- Uveitis
- Dactylitis
- Psoriasis
- Chron’s/collitis
- Good response to NSAIDs
- Familial history for SpA
- HLA-B27
- Elevated CRP
SpA Features
Eyes:
- Iritis & Uveitis (30%)
- If left untreated, can lead to scarring & visual impairment
- Prompt visit to ophthalmologist
Bowels:
- Inflammatory bowel disease
- 60% sub-clinical changes in bowel
Lungs:
- Apical fibrosis (1%)
- ↓ chest expansion d/t rigidity d/t thoracic involvement
- Avoid smoking
Heart:
- 2-5% after many years
- Inflammation & scarring of conduction system
- 1% inflammation of aorta
- Incompetent valves
- ↑ CV risk 2-3 fold
Other Systems & Organs Involved
Pain:
- Worse after rest, intermittent or persistent
- Sources include enthesitis, sacroiliitis, synovitis, & muscle spasm
Stiffness:
- AM Stiffness in spine
- After periods of inactivity; relieved w/ movement
↓ ROM:
- In ALL directions in the spine d/t pain soft tissue contractures, muscle guarding, bony changes, & ankylosing
Deformity/Instability:
- D/t bony fusion, flexion deformity of hips, C1-C2 instability & 2° osteoporosis
↓ Strength:
- D/t disuse, joint effusion, & pain
Altered Posture/Muscle Imbalances:
- Flexion posture (progressively gets more flexed w/ advanced stages)
Altered Breathing Mechanics:
- Flexion posture
- Costovertebral & costochondral involvement of the chest wall limiting lateral costal breathing
- Diaphragmatic breathing pattern
Fatigue:
- D/t disease process, cardiac involvement, ↓ vital capacity
Deconditioning:
- D/t ↓ activity level, altered biomechanics
Clinical Features of Spondyloarthritis
- Forward posture of head
- Flattening of anterior chest wall
- Thoracic kyphosis
- Protrusion of abdomen
- Flattening of lumbar lordosis
- Slight flexion of hips on pelvis
AS Posture
Back pain > 3 months
- Improvement w/ exercise
- Pain at night
- Insidious onset
- Age of onset < 40 years
- No improvement w/ rest
If 4/5 criteria are fulfilled, sensitivity 77%, specificity 91.7%
New Criteria for Inflammatory Back Pain
AM Stiffness: Usually prolonged > 60mins
Max pain/stiffness: Early AM
Exercise/activity: Improves symptoms
Duration: Chronic
Age of Onset: 12-40 yrs
Radiographs: Sacroiliitis, Syndesmophytes, Spinal Ankylosis
Inflammatory Back Pain
AM Stiffness: Minor < 40 mins
Max pain/stiffness: Late in the day
Exercise/activity: Worsens symptoms
Duration: Acute/chronic
Age of onset: 20-65 yrs
Radiographs: Osteophytes, disc space narrowing, malalignment
Mechanical Back Pain
Posture: Tragus to wall
Trunk lateral flexion
Trunk flexion/extension: modified Schobers & Smythe test
Trunk Rotation
Chest Expansion
Cervical Mobility (Rotation & Side Flexion)
Peripheral Joint Scan
Enthesitis Sites
Major Muscle Groups
- Short neck flexors
- Mid traps
- Lower traps
- Lower abdominals
- Glute max
Physical Ax
Mases for AS - 13 Sites:
- 1st costochondral jt
- 7th costochondral jt
- PSIS
- ASIS
- Iliac Crests
- 5th Lumbar Spinous Process
- Proximal insertion of achilles tendon
Braun for AS - 12 Sites:
- Iliac Crests
- Greater Trochanter of Femur
- Med/Lat condyles of femur
- Proximal insertion of achilles tendon
- Insertion of plantar fascia to the calcaneus
SPARCC Index - 16 Sites
Enthesitis Sites
More common sites in Psoriaric Arthritis:
- Achilles tendon
- Patella 10/2, 6
- Plantar fascia
- Anseranus bursa
- Greater trochanter of femur
- Iliac crests
- Rotator cuff
- Costochondral
Enthesitis Sites
- Function: BASFI
- Pain: NRS for last week & night time (BASDI)
- Spinal mobility
- Patient global ax.: NRS (BAS-G)
- Stiffness: Using last 2 questions in BASDI
- Fatigue: (BASDI)
- Swollen Joint Count/Enthesitis
Domains
Bath Ankylosing Spondylitis Disease Activity Index
Accounts for FATIGUE, PAIN & STIFFNESS
BASDI
- Medication
- Physical interventions
- Lifestyle/Self-management
- Surgery
Management of Spondyloarthritis
NSAIDs:
- GI upsets, ulcers, bruising, headache, drowsiness
- Improve BASDI, BASFI & disease activity
- Cornerstone of medical tx.
- Thought to retard progression of bone formation i.e. syndesmophytes
- Moderate evidence that continuous standard dose vs. intermittent use may influence bone formation
- Meta-analysis found ↑ CV morbidity & mortality
DMARDs
- Nausea, vomiting, rashes, mouth ulcers, hair loss, cough, bruising
- Not effective in axial disease
- Sulfazalazine use in early & peripheral disease, ↓ ESR
- Methotrexate in PsA for peripheral disease
Corticosteroids
- Oral for peripheral joints; rare secondary to risk of skin flares, osteoporosis
- Local steroid injection: Enthesitis, dactylitis, peripheral joints, SI joint
- Topical steroid use for uveitis
Biologics
- Responsive to all domains
- Slows radiographic progression (syndesmophytes)
- Infusion reaction site/injection site reaction
- Nausea, abdominal pain
- Headache
- Infections (bacterial)
- Risk of TB reactivation
- 20% of AS pt’s non-responders therefore there is an unmet need for alternative therapies
Medications PT Considerations
- Control & ↓ inflammation
- Pain management
- Reduce spinal stiffness/↑ ROM
- ↑ spinal/peripheral soft tissue flexibility
- Posture correction
- ↑ muscle strength & endurance
- ↑ CV & fitness level
Physical Interventions
1) AS Specific: Dynamic mobility, posture, & stretch therapy
2) Strength, cardiorespiratory, functional therapy (balance, motor skills)
3) Physical Activity Levels -> Prevention
Include:
- Safety!!
- Assessment (objective & outcome measures)
- Monitoring & feedback
- Anti-TNF therapy
- Setting
- Adherence
- Dosage
Exercise & AS Guidelines
Activity/rest
Ice
Compression
- tape
- splints
- compression sleeves (peripheral joints)
Exercise!! (affects inflammatory mediators in the blood)
Control Inflammation
- PNE
- Exercise
- Thermal modalities
- Pool
- Ice
- Electrical modalities
- Manual therapy (neurophysiological effect)
Pain Management
Exercise
- ROM: Cspine, Tspine, Lspine, hips, shoulders
- Stretching: Suboccipital extensors, pecs, psoas, adductors, glutes, quads, hams, calves
- Strengthening
- Breathing
- Neurodynamics
Pool/Hydrotherapy
Manual Therapy
- Facilitation, mobilizations, manipulation (if indicated)
Reduce Stiffness/Increase Mobility
Neck posture: Stretch suboccipitals, strengthen short neck flexors
Pectorals = Stretch
Rib cage = Breathing exercises & cardio
Tspine, Lspine, Pelvis = Strengthen mid & low traps, back extensors, glutes & core
Spine = ↑ ROM
Pelvis = Stretch hip flexors, adductors, quads, hams & calves
Target Areas for Exercise
- Swivel chair
- Tilted work surface/drafting table
- Additional rear view mirrors
- Long handled appliances/reachers
- Back support (Obus For Me)
Adapted Equipment/Ergonomics
3Rs:
REALIGN - Osteotomy
REST - Arthrodesis
REPLACE - Arthroplasty
Surgical Management
