Degenerative and Inflammatory Joint Disease Pit 2013 Dr Ayu p

Ayu Paramaiswari Rheumatology sub division, Department of Internal Medicine Sardjito General Hospital

JOINT PAIN

Inflammatory

Characterized by inflammation affecting • Synovium • Synovial Cavity • Entheses

Athralgia: • Joint tenderness with no abnormality • Altered pain sensation • Early rheumatic syndrome (SLE).

Non – inflammatory/ degenerative • Alteration in the structure or mechanic of the joint • May occur as a result of: •Cartilage or meniscal damage • Alteration in joint anatomy (congenital, developmental,metabolic, post inflammatory

OSTEOARTHRITIS

Diagnosis knee OA 

Clinical & lab

Age > 50 ys  Stiffness < 30 mts  Crepitus  Bony pain  Bony swelling  Palp: No warm  ESR < 40 mm/hrs  Sinovial Fluid OA: 5 of the 9 above 



clinical

Age > 50 yrs  Stiffness < 30 mts  Crepitus  Bony pain  Bony swelling  Palp: no warm OA: 3 of the 6 above 

American College of Rheumatology (ACR 1986) Adopt: IRA 2004, panduan Diagnosis & Pengelolaan OA

Radiological grading of Kellgren Laurence  







Grade 0 = normal Grade I = doubtful narrowing of joint space and possible osteophyte lipping Grade II = definite osteophyte and possible narrowing of the joint space Grade III = moderate multiple osteophytosis, definite narrowing of joint space, some sclerosis and possible deformity of bone contour. Grade IV = large osteophytes, markednarrowing of joint space, severe sclerosis and definite deformity of joint contour

Drugs in OA  Symptom

modifying drugs

○ Analgesics, NSAIDs ○ Corticosteroids ○ Accupuncture?

 Structure

modifying drugs

○ Diacerein ○ Glucosamine –chondroitin ○ Hyaluronate ○ Doxycyclin, minocyclin

Type of inflammatory disorder Rheumatoid Arthritis • • The Spondiloarthropathies • •

Systemic Lupus Erithematosus (SLE)

Psoriatic arthritis Ankilosing Spondilitis Reiter ‘s disease Entherophatic arthritis

• + RA : Rhupus Sydr • + Scleroderma: MCTD

Spondyloarthropathies A group of Inflammatory diseases Inheritance of human leukocyte antigen (HLA)-B27 increases the relative risk of developing spondyloarthropathy These diseases are not associated with rheumatoid factor and thus are often referred to as the "seronegative" spondyloarthropathies

Insidious Disease

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Clinical Symptoms and Sign of Spondyloarthopathies Inflammatory Spinal Pain

OR

Synovitis (Asymmetrical or Predominantly lower limbs)

PLUS (One or more of the following:)  

   

Alternate buttock pain Sacroiliitis Positive family history Psoriasis Inflammatory bowel disease Urethritis or cervicitis or acute diarrhea occurring within 1 month before the onset of arthritis

* European Spondyloarthropathy Study Group Criteria for Spondyloarthropathy, 1991 Dougados M, et al. Arthritis Rheum. 1991 Oct;34(10):1218-1227.

Sensitivity 78-88%; Specificity 92-95%

Spondyloarhtropathies (SpA) Arthritis associated with acute anterior uveitis

Psoriatic Arthritis

Ankylosing Spondylitis (AS) uSpA

Spondyloarthropathies Reactive (SpA)

Arthritis (Reiter’s)

Arthritis of IBD

Juvenile Chronic Arthritis

SpA are a group of rheumatic disorders that share several common factors: 1. Synovitis and enthesitis 2. Similar association with HLA-B27 3. AS is the prototype

Granfors, Granfors, K. K. et et al. al. Arthritis Arthritis & & Rheum Rheum 2002, 2002, 46:606-13. 46:606-13. DougadosM. et al. Arthritis & Rheum 1991;34:1218-1227 DougadosM. et al. Arthritis & Rheum 1991;34:1218-1227 Munoz-Fernandez Best Pract Pract Res Res Clin Clin Rheumatol. Rheumatol. 2006 2006 Jun;20:487-505 Jun;20:487-505 Munoz-Fernandez and and Martin-Mola. Martin-Mola. Best

INFLAMMATORY BACK PAIN



Distribution of pain with sacroiliitis.

Peripheral Arthritis



Rheumatoid Arthritis Polyarthritis (≥ joint)

Spondyloarthropathy Arthritis ( Oligoarthritis) Arthritis ≤ 4

Manifestations in Ankylosing Spondylitis (AS) Axial disease Sacroiliitis, spondylitis

Eye Uveitis

Peripheral disease

Skin

Arthritis, enthesitis, dactylitis

Psoriasis

Gut Inflammatory bowel disease (IBD)

De Quervain Tendinitis

Carpal Tunnel Syndrome

Trigger finger

Entesitis

Achiles Tendinitis

Plantar fasciitis Tendinitis dorsum

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Hallmark of AS is fusion of the spine & sacroiliac joints because of development of first cartilage and then bone bridging the joints. Bamboo Spine

Special maneuvers:

Test of lumbar stifness

Modified New York Criteria for AS 

Clinical criteria  Low back pain and stiffness for >3 mo, which improves

with exercise, but is not relieved by rest  Limited lumbar spine motion: in sagittal and frontal planes  Limitations of chest expansion (age/sex standardized) 

Radiographic criteria: Requires EITHER Bilateral sacroiliitis  Grade 2 or Unilateral sacroiliitis  Gr 3

Definite AS = 1 clinical plus 1 radiographic criteria Probable AS = 3 clinical criteria and no radiologic criteria or 1 radiologic criterion and no clinical criteria van der Linden S, et al. Arthritis Rheum. 1984;27:361-368.

Contrasted to RA 

SpA



RA

 Mostly MALE

 Mostly FEMALE

 Negative RF

 Typically RF positive

 Primary involvement

 Primary involvement

of AXIAL JOINT  Less prominent involvement of peripheral joint

of PERIPHERAL JOINT  Rare involvement of axial joint.

Treatment 

Medication



Non pharmacologic

 NSAID

 Physical therapy

 DMARDS ( mtx,

 Exercise

suflasalazine, leflunomide, azathioprine)  Anti Tnf alfa  Glucocorticoid

 Surgical intervention ○ Corrective surgery ○ Decompression surgery  Peripheral joint

arthroplasty

Rheumatoid Arthritis 

Description       



Morning stiffness Arthritis of 3 or more joints Arthritis of hand joints Symmetric arthritis Rheumatoid nodules Serum rheumatoid factor Radiographic changes

A person shall be said to have rheumatoid arthritis if he or she has satisfied 4 of 7 criteria, with criteria 14 present for at least 6 weeks

Rheumatoid Arthritis: PIP Swelling Swelling is confined to the area of the joint capsule  Synovial thickening feels like a firm sponge 

Rheumatoid Arthritis: Ulnar Deviation and MCP Swelling An across-the-room diagnosis  Prominent ulnar deviation in the right hand  MCP and PIP swelling in both hands  Synovitis of left wrist 

Rheumatoid Arthritis Classification 1987 Criteria

Arnett, A&R, Vol 31, pp. 315-324

Rheumatoid Arthritis Classification 2010 Criteria

Aletaha, A&R, Vol 62, pp. 2569-2581

Rheumatoid Arthritis Deformities

Swan neck deformities Rheumatoid vasculitis

Boutenaire deformities

Rheumatoid Nodules Bayonete deformities

Rheumatoid Arthritis Extraarticular Involvement Pulmonary •Pleurasy

Cyclic Citrullinated Peptide Antibodies (anti CCP)

Schellekens, A&R, Vol 43, pp. 155-163

DMARDs (Disease-Modifying AntiRheumatic Drugs) Traditional     

Biologics

Hydroxychloroquine (Plaquenil) Sulfasalazine Methotrexate Leflunomide (Arava)

    

Less commonly used:

   

   

Minocycline Azathioprine Gold, PO or IM Cyclosporine

Etanercept (Enbrel) Infliximab (Remicade) Adalimumab (Humira) Golimumab (Simponi) Certolizumab Pegol (Cimzia) Anakinra (Kineret) Rituximab (Rituxan) Abatacept (Orencia) Tocilizumab (Actemra)

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