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

JOINT PAIN

Athralgia: Joint tenderness with

no abnormality Altered pain sensation Early rheumatic syndrome (SLE).

Inflammatory

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

Characterized by inflammation affecting Synovium Synovial Cavity Entheses

OSTEOARTHRITIS

Diagnosis knee OA

Clinical & lab

clinical

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

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 Psoriatic arthritis Ankilosing Spondilitis Reiter s disease Entherophatic arthritis

Systemic Lupus Erithematosus (SLE)

+ 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

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

Ankylosing Spondylitis (AS) uSpA

Psoriatic Arthritis

Spondyloarthropathies Reactive (SpA)

Arthritis (Reiters)

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

Arthritis of IBD

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

Juvenile Chronic Arthritis

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
Psoriasis

Arthritis, enthesitis, dactylitis

Gut
Inflammatory bowel disease (IBD)

De Quervain Tendinitis

Carpal Tunnel Syndrome

Trigger finger

Entesitis

Achiles Tendinitis
Tendinitis dorsum

Plantar fasciitis

15

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
Mostly MALE Negative RF Primary involvement

RA
Mostly FEMALE Typically RF positive Primary involvement

of AXIAL JOINT Less prominent involvement of peripheral joint

of PERIPHERAL JOINT Rare involvement of axial joint.

Treatment

Medication
NSAID DMARDS ( mtx,

Non pharmacologic
Physical therapy Exercise Surgical intervention Corrective surgery Decompression surgery Peripheral joint

suflasalazine, leflunomide, azathioprine) Anti Tnf alfa Glucocorticoid

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
Rheumatoid Nodules Bayonete deformities

Boutenaire 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)

THANK YOU