APPROACH TO POLY-ARTHRITIS DR CB NEL

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

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

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

Acute vs. Chronic

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

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

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

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

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

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

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

Hand Involvement

RHEUMATOID ARTHRITIS

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

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)

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

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

Early RA

RA HANDS

Extensor tenosinovitis

Olecranon bursitis and subcutaneous nodules

Baker’s popliteal sist

RA FEET

RA feet

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)

CLASSIFICATION CRITERIA OF RA NEW CRITERIA HAS BEEN PUBLISHED IN 2010

TREATMENT A multidisciplinary team approach is followed

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

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

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

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

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

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

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

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

OSTEOARTHRITIS

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)

PATHOLOGICAL CHANGES IN OA

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

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

OA HANDS

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

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

Seronegative spondilo-arthropathies

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

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

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

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

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

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

PLANTAR FASCIITIS

ACHILLES TENDON ENTHESITIS

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

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

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)

Symmetric psoriatic polyarthritis resembling RA

Distal interphalangeal joint involvement

Nail pitting Skin Enthesophathy Dactilitis Psoriatic Arthritis Nail pitting Skin Enthesophathy Dactilitis

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

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