1. APPROACH TO POLY-ARTHRITIS
DR CB NEL

2. Joints cartilage/synovium
Arthritis
Inflammatory
Rheumatoid arthritis
Seronegative
spondiloarthropaties
Gout
Septic
Degenerative
Osteoartritis
Lower back pain

3. Diagnostic approach Inflammatory vs. Noninflamatory Acute vs. Chronic
Temporal pattern of joint involvement
Distribution of joint involvement
Age of patient
Sex of patient
Systemic involvement

4. Inflammatory vs Mechanical
Morning stiffness
>1 hr
Fatigue
Profound
Activity
Improves symptoms
Rest
Worsens symptoms
Systemic involvement
Yes
Swelling, warmth, erythema, tenderness, loss of function
Morning stiffness
<30 min
Fatigue
Minimal
Activity
Worsens symptoms
Rest
Improves symptoms
Systemic involvement No

5. Acute vs. Chronic

6. Acute Polyarthritis Infection Other inflammatory Gonococcal
Meningococcal
Acute rheumatic fever
Bacterial endocarditis
Viral(esp.. rubella, hepatitis B, parvovirus, Epstein-Barr, HIV)
Other inflammatory
Rheumatoid arthritis
Juvenile chronic arthritis
SLE
Reactive arthritis
Psoriatic arthritis
Polyarticular gout
Sarcoid arthritis
Serum sickness

7. Chronic Polyarthritis (>6 weeks)
Inflammatory
Rheumatoid arthritis
Polyarticular Juvenile chronic arthritis
SLE
Progressive systemic sclerosis
Polymyositis
Reiter’s syndrome
Psoriatic arthritis
Enteropathic arthritis
Polyarticular gout
Pseudogout (CPPD)
Sarcoid arthritis
Vasculitis
Polymialgia rheumatica

8. Chronic Polyarthritis (>6 weeks)
Noninflammatory
Osteoarthritis
Pseudogout (CPPD)
Polyarticular gout
Paget’s disease
Fibromyalgia
Benign hypermobility syndrome
Hemochromatosis

9. Temporal patterns of joint involvement
Intermittent
Rheumatoid arthritis
Psoriatic arthritis
Reactive Arthritis
Palandromic
Gout
Migratory
Rheumatic fever
Gonococcal arthritis
Additive
Nonspecific
Rheumatoid arthritis
SLE

10. Distribution of joint involvement
Rheumatoid arthritis
Commonly involved
Wrist, MCP, PIP, elbow, glenohumeral, cervical spine, hip, knee, ankle, tarsal, MTP
Commonly spared
DIP, thoracolumbar spine

11. Distribution of joint involvement
Osteoarthritis
Commonly involved
First CMC, DIP, PIP, cervical spine, thoracolumbar spine, hip, knee, first MTP, toe IP
Commonly spared
MCP, wrist, elbow, glenohumeral, ankle, tarsal

12. Distribution of joint involvement
Reactive arthrits
Commonly involved
Knee, ankle, tarsal, MTP, toe IP, elbow, axial
Gonococcal arthritis
Knee, wrist, ankle, hand IP
Commonly spared
Axial

14. Hand Involvement

15. RHEUMATOID ARTHRITIS

16. CLINICAL FEATURES Prolonged morning stiffness
Synovitis of small joints of hands, wrists and feet
Other synovial structures (tenosynovitis, bursae) also common
Typical hand features:
Symmetrical swelling of the MCP and PIP joints
Tenderness of involved joints
Swan neck deformities
Boutonniére deformities
Z-deformity of the thumb
Dorsal subluxation of the ulna styloid
Triggering of the fingers

17. EXTRA-ARTICULAR MANIFESTATIONS
Systemic
Fever, fatigue, weight loss, increased infection risk
MSK
Muscle-wasting, tenosynovitis, bursitis, osteoporosis
Haematological
Reactive thrombocytosis, microcytic anaemia, anaemia of chronic disease(normochromic, normocytic)
Lymphatic
Splenomegaly, Felty’s syndrome(RA, splenomegaly, neutropenia)

18. EXTRA-ARTICULAR MANIFESTATIONS
Ocular
Episcleritis, scleritis, scleromalacia, keratoconjunctivitis sicca
Vasculitis
Nailfold infarcts, skin ulcers, pyoderma gangrenosum, mononeuritis multiplex, visceral arteritis
Cardiac
Pericarditis, myocarditis

19. EXTRA-ARTICULAR MANIFESTATIONS
Neurological
Atlantoaxial subluxation, carpal tunnel syndrome, peripheral
neuropathies, mononeuritis multiplex
Pulmonary
Nodules, pleural effusions, pulmonary fibrosis, bronchiolitis, Caplan’s
syndrome(RA plus pneumoconiosis), bronchiectasis
Nodules
Subcutaneous, lungs, pericardium
Amyloidosis

21. Early RA

22. RA HANDS

23. Extensor tenosinovitis

24. Olecranon bursitis and subcutaneous nodules

25. Baker’s popliteal sist

26. RA FEET

27. RA feet

28. SPECIAL INVESTIGATIONS
CRP and ESR usually elevated
Rheumatoid factor positive in 70%
Anti-CCP positive in a sub-population
X-rays: periarticular osteopenia and marginal erosion
(x-ray changes takes months to develop)

29. CLASSIFICATION CRITERIA OF RA
NEW CRITERIA HAS BEEN PUBLISHED IN 2010

30. TREATMENT
A multidisciplinary team approach is followed

31. PATIENT EDUCATION
The nature of the disease as well as its chronic course
Disease is characterised by fluctuations
It takes a considerable time before the therapy starts to show results
Ignorance and especially the fear of becoming an invalid must be adressed

32. PHYSIOTHERAPY Exercise programme Maintain muscle strength
Maintain joint mobility as well as prevent contractures

33. OCCUPATIONAL THERAPY
Patient guidance with regard to work activities and joint-saving techniques, as well as the positions of joints during sleep
Rest and night splints are also important
Other aids for daily activies are also provided

34. PHARMACOLOGICAL THERAPY
Analgesics
DMARD (changes the course of the disease)
Corticosteroids
Immunotherapy
Other

35. ANALGESICS Oral analgesics (Paracetamol, tramadol) NSAID’s Coxibs
gastro-intestinal and renal side-effects
high-risk cases
Misoprostol (Cytotec)
Proton pump inhibiters
H2 antagonists
Coxibs

36. CORTICOSTEROIDS Low dose oral (chronic as a “DMARD”)
Intra-articular steroids
Pulse high dose treatment
Flares
Treatment of complications

37. DMARD’S Chloroquine Sulphasalazine Methotrexate
Other immunosuppressants
Combination therapy
Biologic agents when patients fail DMARD therapy
- TNF alpha inhibiters
- B cell inhibiters
- Interleukin 6 inhibiters

38. OTHER Orthopaedic aids Orthopaedic surgical treatment
Rx extra-articular complications
Supportive therapy
education
anxiety
depression

39. OSTEOARTHRITIS

40. OSTEOARTHRITIS Most common arthritis Strongly associated with aging
Characterised by focal loss of articular cartilage with new bone proliferation and remodelling of the joint contour
Inflammation is NOT a prominent feature
Risk factors
Family history
Caucasians
Women
Trauma
Adverse loading(obesity,sport,profession)

41. PATHOLOGICAL CHANGES IN OA

42. SYMPTOMS Artralgia and functional restriction
Insidious onset of symptoms
Pain worsened by movement and relieved by rest
Brief (<15min.) morning stiffness and brief “gelling” after rest

43. PHYSICAL SIGNS Bony swelling and deformity around joint margins
Joint-line tenderness
Decreased range of movement
Palpable coarse crepitations
Muscle wasting
Antalgic gait common with involvement of lower limbs

45. OA HANDS

46. SPECIAL INVESTIGATIONS
NO impact on inflammatory markers(CRP, ESR)
X-ray changes
Joint space narrowing
Subchondral sclerosis
Osteophytes
Bone cysts
Correlation between x-ray changes and the level of pain and disability is variable

47. TREATMENT OF OA Exercise Lose weight Heat or cold Analgesia
Paracetamol
Topical NSAID
Oral NSAID
Opioids
Intra-articular steroids can give temporary relief
Surgery
For uncontrolled pain
Progressive functional impairment

48. Seronegative spondilo-arthropathies

50. CLINICAL FEATURES OF THE SERONEGATIVE SPONDARTHRITIS
Asymmetrical inflammatory oligoarthritis (lower>upper limb)
Sacroiliitis and inflammatory spondylitis
Inflammatory enthesitis
Tendency for familial aggregation
NO association with positve Rheumatoid factor
Absence of nodules and other extra-articular features of RA
Strong association with HLA-B27

51. ENTHESITIS: Inflammation of the attachment of tendons or ligaments to bone (hallmark feature of the seronegative spondarthritis)

52. LOWER BACKPAIN Inflammatory Mechanical Age < 40 years Any age
Progression
Slowly/Chronic
Acute
Duration of symptoms
> 3 months
< 4 weeks
Morning stiffness
> 60 min.
< 3o min.
Night pain(vertebral)
Common
Absent
Exercise
Improve
Worsens
SI-joint tenderness
Vertebral mobility
↓ all directions
↓ flection
Chest expansion
Decreased
Normal

54. ANKYLOSING SPONDYLITIS
Predilection for the sacroiliac joints and spine
Male : female ratio of 3:1
Progressive stiffening and fusion of axial skeleton

55. SPINAL FEATURES Insidious onset over months to years
Restriction of lumbar movements
Possible involvement of the entire spine as disease progress
Progressive spinal fusion
Loss of lumbar lordosis
Marked thoracic kyphosis
Reduced chest expansion

58. EXTRASPINAL FEATURES Plantar fasciitis and Achilles tendinitis
Asymmetrical peripheral arthritis: shoulders, hips, knees and ankles
Anterior uveitis
Aortic incompetence
Cardiac conduction defects
UPPER lobe pulmonary fibrosis
Osteoporosis

59. PLANTAR FASCIITIS

60. ACHILLES TENDON ENTHESITIS

62. TREATMENT Physiotherapy Regular NSAID’s
Sulfasalazine for peripheral arthritis
Tumour necrosis factor(TNF)-Alpha inhibiters

63. REACTIVE ARTHRITIS Classically young men
Acute onset inflammatory oligoarthritis 1-3 weeks afer an infection affecting the small and large joints of the lower limbs
Infective “trigger”
Bacterial dysentery (due to Salmonella, Campylobacter, Shigella, Yersinia)
Non-spes. urethritis (due to Clamydia)
First attack usually self-limiting with spontaneous remission within 4-6 months
Treatment:
Mostly symptomatic with NSAID’S
DMARD’s in worse cases

64. PSORIATIC ARTHROPATHY
Five major articular presentations:
Asymmetrical inflammatory oligoarthritis
Symmetrical polyarthritis (Strongly resemble RA)
Predominantly distal interphalangeal joint arthritis
Psoriatic spondylitis (strongly resemle Ankylosing spondylitis)
Arthritis mutilans
Skin lesions
Nail changes: pitting, onycholysis, subungual hyperkeratosis
Treatment similar to Ankylosing spondulitis
(methotrexate will also help for peripheral arthritis)

65. Symmetric psoriatic polyarthritis resembling RA

66. Distal interphalangeal joint involvement

67. Nail pitting Skin Enthesophathy Dactilitis
Psoriatic Arthritis
Nail pitting Skin Enthesophathy Dactilitis

68. ARTHRITIS ASSOCIATED WITH INFLAMMATORY BOWEL DISEASE
Two patterns of articular involvement:
Acute oligoarthritis with a predilection for the lower limb joints.
Sacroiliitis and ankylosing spondylitis

69. QUESTIONS?