3AS Prevalence 0.1-0.2% M>F Late teens to age 40 More common in whites than in nonwhitesHLA-B27 positivityChronic progressive disease and develop disability due to spinal inflammation leading to fusion, often with thoracic kyphosis or erosive diseaseWorse during first 10 yearsBegins at sacroiliac joints
4Symptoms Morning stiffness and fatigue Fever and weight loss Radiation of pain into both buttocksCriteria for diagnosis:Morning stiffness that lasts more than 30 minutesImprovement of back pain with exercise but not restNocturnal back pain during second half of the night onlyAlternating buttock painAchilles tendonitis, Plantar fascitis
5Signs: Stooped posture and a stiff back Loss of lumbar lordosis – straight backSchober test confirms-marking a 10-cm length of the lumbar spine (with patient in the erect position), starting at the fifth lumbar spinous process. Instruct the patient to maximally flex his or her spine. Remeasure the distance between the marks. Normal flexion increases the distance by at least 5 cm.Loss of chest expansion (<3-cm difference between minimum and maximum chest diameter) late stage of diseaseEyes can be involvedAortic valvular leak can happen
7TherapyNSAIDsTNF alphaSteroidsMethotrexateMonitor with ESR, CRP
8Physical therapy Exercise program and postural training Spinal extension and deep-breathing exercisesMaintaining an erect posture during daily activitiesSleeping on a firm mattress with a thin pillow also tend to reduce the tendency toward thoracic kyphosis.Water therapy and swimming
10?Myofascial trigger points (MTrPs). 200 paired musclesAny one of these muscles can develop myofascial trigger points (MTrPs). MTrPs are hyperirritable tender spots in palpable tense bands of skeletal muscle that refer pain and motor dysfunction, often to another location.
11Major clinical components: The TrPThe taut bandThe local twitch response
12Latent TrPs Cause motor dysfunction: Stiffness, Restricted range of motion without pain
13Active TrPs Most common: postural muscles- of the neck, shoulder, and pelvic girdles andthe masticatory musclesOthers: upper trapezius, scalene, sternocleidomastoid, levator scapulae, and quadratus lumborum muscles
14Features of myofascial pain: Results in palpable nodules and the taut bands associated with TrPs.TrP triggers:Acute overload, overwork fatigue, direct impact trauma, and radiculopathyPatients with active MTrPs usually complain of poorly localized, regional, aching pain in subcutaneous tissues, including muscles and joints.They rarely complain of sharp, clearly localized cutaneous-type pain.
15Disturbances of autonomic functions - abnormal sweating, persistent lacrimation, persistent runny nose, excessive salivation, and pilomotor activitiesProprioceptive disturbances- imbalance, dizziness, tinnitus, and distorted perception of the weight of lifted objects
16Loss of motor functions: Spasm of other muscles, weakness of the involved muscle function, loss of coordination by the involved muscle, and decreased work tolerance of the involved muscle.
17Taut bandBy gently rubbing across the direction of the muscle fibers in a superficial muscle, the examiner can feel a nodule at the MTrP and a ropelike induration that extends from this nodule to the attachment of the taut muscle fibers at each end of the muscleThe taut band can be snapped or rolled under the finger in accessible muscles. With effective inactivation of the TrP, this palpable sign becomes less tense and often (but not always) disappears, sometimes immediately
18Tender nodulePalpation along the taut band reveals a nodule exhibiting a highly localized and exquisitely tender spot that is characteristic of a MTrP.
19Local twitch response: Snapping palpation of the TrP frequently evokes a transient twitch response of the taut band fibers. Twitch responses can be elicited both from active and latent TrPs.
20Diferential Diagnosis FeatureMyofascial Pain (TrPs)FibromyalgiaFemale-to-male ratio1:14-9:1PainLocal or regionalWidespread, generalTendernessFocalWidespreadMuscleFeels tense (taut bands)Feels soft and doughyMotionRestricted range of motionHypermobilityExaminationExamine for TrPsExamine for tender pointsFeatureMyofascial Pain (TrPs)FibromyalgiaFemale-to-male ratio1:14-9:1PainLocal or regionalWidespread, generalTendernessFocalWidespreadMuscleFeels tense (taut bands)Feels soft and doughyMotionRestricted range of motionHypermobilityExaminationExamine for TrPsExamine for tender points
22Associated with: Gastrointestinal infections- Shigella Salmonella and Campylobacter species andGenitourinary infections (especially with Chlamydia trachomatis).Usually develops 2-6 weeks after infection
23Prognosis:A self-limited course, with resolution of symptoms by 3-12 monthsHas a high tendency to recurHLA-B27 positivityM:F 9:1 Age: years
24Symptoms/Signs: Malaise, fever, prostatitis, epidydimitis Low-back pain, heel painAchilles or plantar fascia inflammationSmall joints of the hands and feet – sausage shaped digitsPalm and soles skin exfloiation and pustulesPenile foreskin inflammationSymptomatic treatment
26TMJ function:Movements- side to side, up and down, as well as protrusion and retrusion.This allows movements needed for speaking, chewing, and making facial expressions.
27Causes for TMJ disease: Rheumatoid arthritis, osteoarthritisOther causes- hypermobile TMJs, nocturnal jaw clenching, nocturnal bruxism, jaw clenching due to psychosocial stresses, and local traumaTrigeminal neuralgia of mandibular divisionIncidence: 10 million people have TMJF:M ratio is roughly 4:1Common in adults aged years
28Symptoms Muscles of mastication: dull ache, unilateral Pain radiates to the ear and jaw and is worsened with chewingWhen opening the mouth locking of the jawEar clicking or poppingHeadache and/or neck acheA bite that feels uncomfortableNeck, shoulder, and back painBruxism, teeth clenching
29SignsLimitation of jaw opening (normal range is at least 40 mm as measured from lower to upper anterior teeth)Palpable spasm of facial muscles (masseter and internal pterygoid muscles)Unilateral facial swellingClicking or popping in the TMJTenderness to palpation of the TMJ via the external auditory meatus (the tips of the fingers placed behind the tragi at each external acoustic meatus and pulled forward while the patient opens the jaw)Crepitus over joint (in advanced disease)Lateral deviation of mandible
30Tests Non specific Treatment: Analgesics - Nonsteroidal anti-inflammatory drugs (NSAIDs)Muscle relaxants - BenzodiazepinesMoist heat and massage of masticatory muscles