Professional Documents
Culture Documents
Alexandria University
The Naval and Underwater Medicine Institute
Military Medical Academy
2014
Supervisors
Prof. Dr. / Diaa F. Mohaseb /
Faculty of Medicine
Alexandria University
Acknowledgment
Index
N
o
1
2
3
4
5
6
7
8
9
1
0
1
1
1
2
1
3
1
4
Subject
Index of figures
Index of tables
Introduction
What is ozone?
Physical and chemical properties of ozone
Is ozone toxic?
Generation of ozone
How does ozone act?
Administration of ozone
Side effects of ozone
Pag
e
5
6
7
7
9
10
11
15
19
22
Osteoarthritis
29
Causes of osteoarthritis
30
Classification of osteoarthritis
32
Pathophysiology of osteoarthritis
33
1
5
1
6
1
7
1
8
1
9
2
0
2
1
2
2
2
3
2
4
2
5
2
6
2
7
2
8
2
9
3
0
3
1
3
2
3
3
3
34
35
38
40
Grading of osteoarthritis
43
45
Treatment of osteoarthritis
47
Rheumatoid arthritis
55
58
63
64
65
66
68
70
73
82
Clinical experience
87
Recommendation
91
References
92
4
3
5
103
13
13
14
14
4
5
15
18
19
20
21
21
22
22
31
31
8
9
10
11
12
13
14
15
41
42
42
43
16
17
18
19
45
46
20
21
50
22
57
57
62
62
23
24
25
26
69
27
70
28
72
29
72
30
knee
Ozone intra-articular injection
knee joint
Common joints affected by R.A
Common joints affected by R.A
Characters of rheumatoid arthritis
Effects of rheumatoid arthritis on
different organs
24
Table
numbe
r
1
25 ,26
,27
28
Table name
Different indications of
ozone use
Different methods of ozone
applications and their
indications
Contraindications of
systemic ozone applications
78
79
80
81
Comparison between OA ,
RA , OP risk factors
Comparison between OA ,
RA , OP physical effects
Comparison between OA ,
RA , OP treatment options
Comparison between OA ,
RA , OP pain management
Introduction
What is ozone?
Ozone (from the Greek means to give off a smell) is an
alternate version of oxygen. Oxygen in the air we breathe
is actually two molecules of oxygen attached together, or
O2. Ozone is an activated form of oxygen where there
are actually three atoms of oxygen attached together,
forming a molecule that is O3. Ozone (O3) behaves
completely
differently
than
O2.
Ozone
is
far more energetic and oxidative than Oxygen, which is
Historical Notes
Christian Friedrich Schonbein (17991868) discovered
ozone in 1840, when working with a voltaic pile in the
presence of oxygen, he noticed the emergence of a gas
with an electric and pungent smell that could be a sort
of super-active oxygen". We can smell it during a
thunderstorm because the electric discharge of lightning
between the clouds and the earth, catalyses the formation
of ozone from atmospheric oxygen. Although Schonbein
had probably guessed that ozone could be used as
disinfectant, his discovery did not save him when he
contacted a Bacillus anthrax infection while exploring a
chemical method for preserving meat. The concept that
ozone derives from oxygen when an electric discharge was
generated by a voltaic arc was practically applied by the
chemist Werner von Siemens, who invented the so called
super-induction tube (Siemenss tube), consisting of two
interposed electrode plates set at a high voltage which, in
the presence of oxygen, could generate some ozone. It
became possible to produce ozone at will and clarify that
ozone is indeed a very reactive, unstable and unstorable
gas that had to be produced instantly from oxygen and
used at once. Industrial ozone generators could then be
used for industrial application and disinfection of water,
after it was shown the potent and broad bactericidal
activity of ozone. Today nobody doubts about its strong
disinfectant properties and there are more than 3,000
municipal treatment facilities in the world. As the need of
water increases daily and it is indispensable to prevent the
spread of infectious diseases, the importance of ozone for
practical applications becomes immense. (3, 4)
10
11
12
Is Ozone toxic?
The dogma that Ozone is toxic depends on the effect of
Ozone on the lungs ,eyes ,nose and ,to a lesser extent, the
skin because particularly the respiratory mucosa does not
contain enough neutralizing substances for this murderous
acid mixture .Indeed the respiratory tract lining uids
(RTLFs), that amounts to only 2040 ml dispersed as an
aqueous film layer over the alveolar space of about 70m2
is easily overwhelmed by this acidic mixture of strong
oxidants .Particularly children ,asthmatic and other
broncho-pulmonary patients are at risk and the ozone . (11)
The chaotic human activities such as industrial processes,
vehicular traffic have led to a dangerous environmental
pollution of the air present in the troposphere, which
extends 817 km from the earths surface. Exaggerated
anthropogenic emissions of nitrogen monoxide (NO) and
13
How
Ozone
Is
Generated
Concentrations Measured?
and
Its
14
is
determined
by
three
15
16
17
18
19
20
21
22
23
24
25
26
27
28
indications
Underlying effects
1. Arterial Circulatory
disorders
O2-release effect
Activation of
RBC metabolism
Disinfection
Wound cleansing
improved wound
healing
3. Pathological
intestinal conditions
colitis
Proctatitis
Disinfection
Immune activation
anti-inammatory
processes
fistulas
4. Infections
and virus caused
diseases
Immune modulation
5. Additive therapy in
carcinogenic conditions
Immune activation
6. Geriatric conditions
O2-release effect
Immune- and enzyme
29
activation
7. Rheumatic diseases
inammatory
conditions
degenerative
conditions
8. Dentistry
anti-inammatory
processes
Activation of
antioxidative capacity
Immune modulation
Disinfection
Wound cleansing
improved wound
healing
applications
Indication
Mechanism
of action
1. Systemic applications
Arterial
circulatory
disorders
Major
autohemotherapy
as an
extracorporeal
Activation of
red blood cell
metabolism
with increase
of 2,3-DPG
and ATP plus
resultant
30
blood treatment
and intravenous
reinfusion of the
patients own
blood.
improvement
in O2-release
Infections,
Immune
activation,
additive
therapy in
carcinoma
patients,
geriatric field
Activation of
immunocomp
etent cells
with release
of cytokines,
such as
Interferon and
Interleukins.
Modulation of
immune
system with
increase of
IFN-, TGF-
Rheumatic
arthritis
Rectal insufflation
Arterial
circulatory
disorders
(stage II)
general
Immune
activation,
Increase of
the
antioxidative
capacity by
activation of
SOD, GSHPx,
Catalase ...
see above
31
adjuvant
cancer
therapy.
Hepatitis
A,B,C
Minor
autohemotherapy
as extracorporeal
blood treatment
and intramuscular
injection.
Allergies,
acne,
furunculosis.
Adjuvant
cancer
therapy.
Non-specific
activation of
the immunesystem
general
stimulation.
2. Topical application
Transcutanous gas
bath in ozone
resistant plastic
bag
Low-pressure
application with
suction cup or in
Ulcus cruris;
dermatosis,
fungus
infections
Microbicidal
effect of
ozone:
bactericidal,
fungicidal,
virus
inactivating
effect
Decubitus,
diabetic
gangrene
badly healing
wounds,
fistulas,
wound
cleansing
improved
wound
healing
Immune
32
plastic boot
radiation
damage
activation
(TGF-)
Proctatitis;
colitis
Antiinammatory
effect,
better O2supply,
wound
healing effect
e.g. Candida
infection
fungicidal
effect
Rheumatoid
arthritis,
Knee
arthritis,
Gonarthrosis;
traumatic
knee
disorders
antiammator
y effect,
activation of
SOD as
radical
scavenger,
activation of
immunocomp
etent and
cartilage
cells,
release of
TGF-
Rectal Insufflation
Vaginal
Insufflation
Intra-articular
injection (mainly
knee and
shoulder)
"Blistering"
paravertebral
injection and
intramuscular
injections (in
combination with
tonanalgetic
Myotraumati
c syndrome,
myogelosis,
trigger points
Activation of
cell
metabolism,
ATP-increase
Activation of
33
treatment)
Ozonized water as
spray or
compresses
drop wise
application
Ozonized water as
spray,
or rinsing with O3water
Topical treatment
antioxidants
fresh lesions,
burns,
fungus
infections,
herpes
Wound
cleansing,
antiinammatory
effects,
activation of
cell
metabolism,
Immune
activation
(TGF-)
Otitis
Immune
activation
(TGF-)
Dental
medicine:
following
tooth
extractions,
buccal
infections
(e.g.
Candida)
parodontosis
Disinfection,
wound
healing effect,
see above.
Fungus
infections,
bacterial
infections,
burns, skin
Fungicidal
and
bactericidal
effect,
wound
34
lesions.
healing.
Contraindications
"Contra applications"
Thyrotoxicosis or
hyperthyroidism
Glucose-6-PhosphateDehydrogenasedeficiency (Favism)
35
Osteoarthritis
Definition:
Osteoarthritis (OA) also known as degenerative arthritis
or degenerative
joint disease or osteoarthrosis, is a
group of mechanical abnormalities involving degradation
of joints, including articular
cartilage and subchondral
bone.
Osteoarthritis is the most common form of arthritis,
affecting millions of people around the world. Often called
wear-and-tear arthritis, osteoarthritis occurs when the
protective cartilage on the ends of bones wears down over
.time
While osteoarthritis can damage any joint in the body, the
disorder most commonly affects joints in hands, neck,
.lower back, knees and hips
Osteoarthritis gradually worsens with time, and no cure
exists. But osteoarthritis treatments can slow the
progression of the disease, relieve pain and improve joint
function. (26)
Etymology
OA is derived from the Greek word part osteo-, meaning
"of the bone", combined with arthritis: arthr-, meaning
"joint", and -itis, the meaning of which has come to be
associated with inammation. The -itis of OA could be
36
Epidemiology
Globally approximately 250 million people have
osteoarthritis of the knee (3.6% of the population). OA
affects nearly 27 million people in the United States,
accounting for 25% of visits to primary care physicians,
and half of all NSAID prescriptions. It is estimated that
80% of the population have radiographic evidence of OA
by
age65,
although
only
60%
of
those
will
have symptoms. In the United States, hospitalizations for
.OA increased from 322,000 in 1993 to 735,000 in 2006
As of 2004, OA globally causes moderate to severe
.disability in 43.4 million people
In the United States, there were approximately 964,000
hospitalizations for osteoarthritis in 2011, a rate of 31
stays per 10,000 populations. It was the second-most
expensive condition seen in U.S. hospital stays in 2011. By
payer, it was the second-most costly condition billed to
Medicare and private insurance. (27)
37
38
39
especially identical
twins,
indicating
a
hereditary
basis. Although a single factor is not generally sufficient to
cause the disease, about half of the variation in
.susceptibility has been assigned to genetic factors
As early human ancestors evolved into bipeds, changes
occurred in the pelvis, hip joint and spine which increased
the risk of osteoarthritis. Additionally genetic variations
that increase the risk were likely not selected against
because usually problems only occur after reproductive
.success
The development of OA is correlated with a history of
previous joint injury and with obesity, especially with
respect to knees. Since the correlation with obesity has
been observed not only for knees but also for non-weight
bearing joints and the loss of body fat is more closely
related to symptom relief than the loss of body weight, it
has been suggested that there may be a metabolic link to
.body fat as opposed to just mechanical loading
Changes in sex hormone levels may play a role in the
development of OA as it is more prevalent among postmenopausal women than among men of the same age. A
study of mice found natural female hormones to be
protective
while
injections
of
the
male
.hormone dihydrotestosterone reduced protection
:Secondary (2
As a result of certain disorders which lead to same
:pathology as OA. These include
Alkaptonuria.
Diabetes Mellitus.
Ehlers-Danlos Syndrome
40
Marfan syndrome
Obesity
41
Pathophysiology of osteoarthritis
While OA is a degenerative joint disease that may cause
gross cartilage loss and morphological damage to other
joint tissues, more subtle biochemical changes occur in
the earliest stages of OA progression. The water content
of healthy cartilage is finely balanced by compressive
force driving water out & swelling pressure drawing water
in. Collagen fibers exert the compressive force, whereas
the GibbsDonnan effect & cartilage proteoglycans create
osmotic pressure which tends to draw water in. However
during onset of OA, the collagen matrix becomes more
disorganized and there is a decrease in proteoglycan
content within cartilage. The breakdown of collagen fibers
results in a net increase in water content. This increase
occurs because whilst there is an overall loss of
proteoglycans (and thus a decreased osmotic pull), it is
outweighed by a loss of collagen. Without the protective
effects of the proteoglycans, the collagen fibers of the
cartilage can become susceptible to degradation and thus
exacerbate
the
degeneration. Inammation of
the
surrounding joint capsule can also occur, though often
mild (compared to what occurs in rheumatoid arthritis).
This can happen as breakdown products from the cartilage
are released into the synovial space, and the cells lining
the joint attempt to remove them. New bone outgrowths,
called "spurs" or osteophytes, can form on the margins of
the joints, possibly in an attempt to improve the
congruence of the articular cartilage surfaces. These bone
changes, together with the inammation, can be both
painful and debilitating. (31)
a unique
properties
tissue
which
42
Constituents of cartilage
% Cellular : chondrocytes 1-2
-1
% Liquid phase : 70 - 80
-2
% Solid phase : 20 30
-3
43
Molecules
which
are
responsible
for
degrading cartilage matrix
Stromelysins
Gelatinases
TIMP 2
2 - macroglobulin
44
Prostanoid synthesis
Chondrocyte apoptosis
-2
-1
45
-3
(36)
46
1. Age
In demographic studies, age is the most consistently
identified risk factor for OA, regardless of the joint
being studied. Prevalence rates for both radiographic
OA and, to a lesser extent, symptomatic OA rise
steeply after age 50 in men and age 40 in women.
OA is rarely present in individuals less than 35 years
of age, and secondary causes of OA or other types of
arthritis should strongly be considered in this
population.
2. SEX:
Female gender is also a well-recognized risk factor for
OA. Hand OA is particularly prevalent among women.
47
3. OBESITY:
Cohort studies have demonstrated a clear
association of obesity with the development of
radiographic knee OA in women and a weaker
association with hip OA. Whether obesity is a risk
factor for the development of hand OA remains
controversial. Regardless, this remains one of the
most important modifiable risk factors for OA and
patients should be counseled appropriately.
4. JOINT STRESS:
Occupation-related repetitive injury and physical
trauma contribute to the development of secondary
(non-idiopathic) OA, sometimes occurring in joints
that are not affected by primary (idiopathic) OA,
such as the metacarpophalangeal joints, wrists and
ankles. Although the prevalence of knee OA is
greater in adults who have engaged in occupations
that require repetitive bending and strenuous
activities, an association with regular, intense
exercise remains controversial. While early studies in
joggers failed to find a higher prevalence of OA of
the knee in joggers compared to non-joggers, a
recent study of the Framingham data base in elderly
48
5. GENETICS:
Twin studies have demonstrated an important role
for genetics in the development of OA. In some
cases, this is associated with a particular genetic
syndrome, such as Stickler syndrome or familial
chondrocalcinosis. Genome-wide studies continue to
evaluate for particular chromosomes, particularly
those involved in bone or articular cartilage structure
and metabolism, and associations of familial OA. (40,
41)
49
50
51
52
53
Grading of Osteoarthritis
54
55
56
57
58
(48)
Pharmacological Therapy
:Acetaminophen
Several studies have shown acetaminophen to
be superior to placebo and equivalent to non
steroidal anti-inammatory agents (NSAIDs) for
the short-term management of OA pain. At
present, acetaminophen (up to 4,000 mg/daily)
is the recommended initial analgesic of choice
for symptomatic OA. (ACR Guidelines-Guidelines
for Medical Management of OA of the knee)
However, many patients eventually require
NSAIDs or more potent analgesics to control
.pain
(1
59
Non-steroidal Anti-inflammatory (2
:Agents (NSAIDs)
NSAIDs have been an important treatment for
the symptoms
of OA for a very long time. The
mechanism by which NSAIDs exert their antiinammatory and analgesic effects is via inhibition of
the
prostaglandin-generating
enzyme,
cyclooxygenase (COX). In addition to their
inammatory
potential,
prostaglandins
also
contribute to important homeostatic functions, such
as maintenance of the gastric lining, renal blood ow,
and platelet aggregation. Reduction of prostaglandin
levels in these organs can result in the wellrecognized
side
effects
of
traditional nonselective NSAIDs
(ibuprofen,
naprosyn,
and
indomethacin) that is, gastric ulceration, renal
insufficiency, and prolonged bleeding time. The
elderly are at higher risk for these side effects. Other
risk factors for NSAID-induced GI bleed include prior
peptic ulcer disease and concomitant steroid use.
Potential renal toxicities of NSAIDs include azotemia,
proteinura, and renal failure requiring hospitalization.
Hematologic and cognitive abnormalities have also
been reported with several NSAIDs. Therefore, in
elderly patients, and those with a documented
history of NSAID-induced ulcers, traditional nonselective NSAIDs should be used with caution, usually
in lower dose and in conjunction with a proton pump
inhibitor. Renal function should be monitored in the
elderly. In addition, prophylactic treatment to reduce
risk of gastrointestinal ulceration, perforation and
bleeding is recommended in patients > 60 years of
age with: prior history of peptic ulcer disease;
anticipated duration of therapy of > 3 months;
moderate to high dose of NSAIDs; and, concurrent
60
corticosteroids. The
development
of
selective
cyclooxygenase-2 (COX-2) inhibitors offers a strategy
for the management of pain and inammation that is
.likely to be less toxic to the GI tract
:COX-2 Inhibitors (3
Cyclooxygenase-2 (COX-2) inhibitors are a class of
NSAIDs) that recently received Food and Drug
Administration (FDA) approval. These specific COX-2
inhibitors are effective for the pain and inammation
of OA. Their theoretical advantage, however, is that
they will cause significantly less toxicity than
conventional NSAIDs, particularly in the GI tract.
NSAIDs exert their anti-inammatory effect primarily
by inhibiting an enzyme called cyclooxygenase
(COX), also known as prostaglandin (PG) synthase.
COX catalyzes the conversion of the substrate
.molecule, arachidonic acid, to prostanoids
: Pathway of prostanoid synthesis
PGD2
Prostacyclin
PG2
thromboxane
61
62
63
Surgical Management
Patients in who function and mobility remain
compromised despite maximal medical therapy, and
those in whom the joint is structurally unstable,
should be considered for surgical intervention.
Patients in whom pain has progressed to
unacceptable levels-that is, pain at rest and/or
nighttime pain-should also be considered as surgical
candidates. Surgical options include arthroscopy,
osteotomy and arthroplasty. Arthroscopic removal of
intra-articular
loose
bodies
and
repair
of
degenerative menisci may be indicated in some
patients with knee OA. Tibial osteotomy is an option
for some patients who have a relatively small varus
angulation (less than 10 degrees) and stable
Ligamentous support. Total knee arthroplasty is
recommended for patients with more severe varus,
or any valgus, deformity and Ligamentous instability.
Arthroplasty is also indicated for patients who have
had ineffective pain relief following a tibial
osteotomy, and for those with advanced hip OA.
Patients who have not yet developed appreciable
muscle weakness, generalized or cardiovascular
64
65
-1
-2
-a
Dexterity
-b
-c
66
Future Directions
Osteoarthritis is the most prevalent articular disease
in the elderly. Disease markers that will detect early
disease and agents that will slow down or halt
disease progression are critically needed. Current
management should include safe and adequate pain
relief using systemic and local therapies, and should
include medical and rehabilitative interventions that
limit functional deterioration. Research is continuing
to focus on the pathophysiology of OA as we are in
need of strategies to slow the progression of OA or
reverse the process.(51)
67
Rheumatoid
arthritis (RA)
is
an autoimmune
disease that results in a chronic, systemic inammatory
disorder that may affect many tissues and organs, but
principally attacks exible (synovial) joints. It can be a
disabling and painful condition, which can lead to
substantial loss of functioning and mobility if not
adequately treated. (52)
The process involves an inammatory response of the
capsule around the joints (synovium) secondary to
swelling (turgescence) of synovial cells, excess synovial
uid, and the development of fibrous tissue (pannus) in
the synovium. The pathology of the disease process often
leads
to
the
destruction
of
articular
cartilage
and ankylosis (fusion) of the joints. RA can also produce
diffuse inammation in the lungs, the membrane around
the heart (pericardium), the membranes of the lung
(pleura), and white of the eye (sclera), and also nodular
lesions, most common in subcutaneous tissue. Although
the cause of RA is unknown, autoimmunity plays a big
part, and RA is a systemic autoimmune disease. It is
a clinical diagnosis made on the basis of symptoms,
.physical exam, radiographs (X-rays) and labs
68
Epidemiology
RA affects between 0.5 and 1% of adults in the developed
world with between 5 and 50 per 100,000 people newly
developing the condition each year. In 2010 it resulted in
.about 49,000 deaths globally
Onset is uncommon under the age of 15 and from then on
the incidence rises with age until the age of 80. Women
.are affected three to five times as often as men
69
70
71
72
Lungs
Fibrosis of the lungs is a recognized response to
rheumatoid disease. It is also a rare but well recognized
consequence
of
therapy
(for
example
with methotrexate and
leunomide). Caplan's
syndrome describes lung nodules in individuals with RA
and additional exposure to coal dust. Pleural effusions are
also associated with RA. Another complication of RA
is Rheumatoid Lung Disease. It is estimated that about
one quarter of Americans with RA develop Rheumatoid
Lung Disease. (57)
Kidneys
Renal amyloidosis can occur as a consequence of chronic
inammation. RA
may
affect
the
kidney glomerulus directly
through
a vasculopathy or
a mesangial infiltrate but this is less well documented
(though this is not surprising, considering immune
complex-mediated
hypersensitivities
are
known
for pathogenic deposition of immune complexes in organs
where blood is filtered at high pressure to form other
uids, such as urine and synovial uid). Treatment
with Penicillamine and gold salts are recognized causes
of membranous nephropathy. (58)
73
74
Other,
rather
rare,
skin
associated
symptoms
include pyoderma gangrenosum, Sweet's syndrome, drug
reactions, erythema nodosum, lobe panniculitis, atrophy of
finger skin, palmar, diffuse thinning (rice paper skin), and
skin fragility (often worsened by corticosteroid use). (61,62,63)
Ocular
The eye is directly affected in the form of episcleritis which
when
severe
can
very
rarely
progress
to
perforating scleromalacia. Rather more common is the
indirect effect of keratoconjunctivitis sicca, which is a
dryness
of
eyes
and
mouth
caused
by lymphocyte infiltration of lacrimal and salivary glands.
When severe, dryness of the cornea can lead
to keratitis and loss of vision. Preventive treatment of
severe dryness with measures such as nasolacrimal
duct blockage is important. (64, 65, 66)
Hepatic
Cytokine production in joints and/or hepatic (liver) Kupffer
cells leads to increased activity of hepatocytes with
increased production of acute-phase proteins, such as Creactive protein, and increased release of enzymes such
as alkaline phosphatase into
the
blood.
In Felty's
syndrome, Kupffer cell activation is so marked that the
resulting increase in hepatocyte activity is associated with
nodular hyperplasia of the liver, which may be palpably
enlarged. Although Kupffer cells are within the
hepatic parenchyma, they are separate from hepatocytes.
As a result there is little or no microscopic evidence
of hepatitis (immune-mediated
destruction
of
hepatocytes). Hepatic involvement in RA is essentially
asymptomatic.
Hematological
Anemia is by far the most common abnormality of the
blood cells which can be caused by a variety of
mechanisms. The chronic inammation caused by RA
leads to raised hepcidin levels, leading to anemia of
chronic disease where iron is poorly absorbed and also
sequestered into macrophages. RA may also cause a warm
autoimmune hemolytic anemia.[18] The red cells are of
normal size and color (normocytic and normochromic). A
75
76
Causes (etiology)
RA is a form of autoimmunity, the causes of which are still
not completely known. It is a systemic (whole body)
77
78
Pathophysiology
The key pieces of evidence relating to pathogenesis are
:the following
1.
2.
3.
4.
5.
6.
7.
8.
79
80
Phases
81
Diagnosis
Blood tests
When RA is clinically suspected, immunological studies are
required, such as testing for the presence of rheumatoid
factor (RF, a non-specific antibody). A negative RF does
not rule out RA; rather, the arthritis is called seronegative.
This is the case in about 15% of patients. During the first
year of illness, rheumatoid factor is more likely to be
negative with some individuals converting to seropositive
status over time. RF is also seen in other illnesses, for
82
Imaging
Signs
of
destruction
and
inammation
on ultrasonography and magnetic resonance imaging in
the second metacarpophalangeal joint in established RA.
X-rays of the hands and feet are generally performed in
people with a polyarthritis. In RA, there may be no
changes in the early stages of the disease, or the x-ray
83
Criteria
84
joint
involvement,
designating
the metacarpophalangeal joints, proximal interphalangeal
joints, the interphalangeal joint of the thumb, second
through fifth metatarsophalangeal joint and wrist as small
joints,
and shoulders, elbows, hip
joints, knees,
and ankles as large joints:
Involvement of 1 large joint gives 0 points
Involvement of 210 large joints gives 1 point
Involvement of 13 small joints (with or without
involvement of large joints) gives 2 points
Involvement of 410 small joints (with or without
involvement of large joints) gives 3 points
Involvement of more than 10 joints (with
involvement of at least 1 small joint) gives 5 points
serological parameters including the rheumatoid
factor as well as ACPA "ACPA" stands for "anticitrullinated protein antibody":
Negative RF and negative ACPA gives 0 points
Low-positive RF or low-positive ACPA gives 2
points
High-positive RF or high-positive ACPA gives 3
points
acute phase reactants: 1 point for elevated
erythrocyte
sedimentation
rate, ESR,
or
elevated CRP value (c-reactive protein)
duration of arthritis: 1 point for symptoms lasting six
weeks or longer(86)
The new criteria accommodate to the growing
understanding of RA and the improvements in diagnosing
RA and disease treatment. In the "new" criteria serology
and autoimmune diagnostics carries major weight, as
ACPA detection is appropriate to diagnose the disease in
an early state, before joints destructions occur.
Destruction of the joints viewed in radiological images was
a significant point of the ACR criteria from 1987. This
criterion no longer is regarded to be relevant, as this is
85
The criteria are not intended for the diagnosis for routine
clinical care; they were primarily intended to categorize
research (classification criteria). In clinical practice, the
:following criteria apply
The
detection
of rheumatoid
factors or autoantibodies against ACPA such
as
auto-antibodies
to mutated
citrullinated
Vimentin can
confirm
the
suspicion of RA. A negative autoantibody result does not
exclude a diagnosis of RA.(88)
86
Differential diagnoses
Several other medical conditions can resemble RA, and
usually need to be distinguished from it at the time of
:diagnosis
87
88
Monitoring progression
89
90
Management
There is no cure for RA, but treatments can improve
symptoms and slow the progress of the disease. Diseasemodifying treatment has the best results when it is started
.early and aggressively
The goals of treatment are to minimize symptoms such as
pain and swelling, to prevent bone deformity (for example,
bone erosions visible in X-rays), and to maintain day-today functioning. This can often be achieved using two
main classes of medications: analgesics such as NSAIDs,
and disease-modifying antirheumatic drugs (DMARDs). RA
should generally be treated with at least one specific antirheumatic medication. The use of benzodiazepines (such
as diazepam) to treat the pain is not recommended as it
does not appear to help and is associated with risks.
Analgesics, other than NSAIDs, offer lesser, but some
benefit with respect to pain, whilst not causing the same
level of gastrointestinal irritation. (93)
Lifestyle
Regular exercise is recommended as both safe and useful
to maintain muscles strength and overall physical
function. It is uncertain if specific dietary measures have
.an effect
91
92
Anti-inammatory agents
NSAIDs reduce both pain and stiffness in those with RA.
Generally they appear to have no effect on people's long
term disease course and thus are no longer first line
agents. NSAIDs should be used with caution in those
.with gastrointestinal, cardiovascular, or kidney problems
COX-2 inhibitors, such as celecoxib, and NSAIDs are
equally effective. They have a similar gastrointestinal risk
as a NSAIDs plus a proton pump inhibitor. In the elderly
there is less gastrointestinal intolerance to celecoxib than
to NSAIDs alone. There however is an increased risk
of myocardial infarction with COX-2 inhibitors. Anti-ulcer
medications are not recommended routinely but only in
.those high risk of gastrointestinal problems
Glucocorticoids can be used in the short term for are-ups,
while waiting for slow-onset drugs to take effect. Injection
of glucocorticoids into individual joints is also effective.
While long-term use reduces joint damage it also results in
osteoporosis and susceptibility to infections, and thus is
not recommended. (96)
Surgery
In early phases of the disease, an arthroscopic or
open synovectomy may be performed. It consists of the
removal of the inamed synovia and prevents a quick
destruction of the affected joints. Severely affected joints
may require joint replacement surgery, such as knee
replacement. Postoperatively, physiotherapy is always
necessary. (97)
Alternative medicine
93
Dietary supplements
The American College of Rheumatology states that no
herbal medicines have health claims supported by high
quality evidence and thus they do not recommend their
use. There is no scientific basis to suggest that herbal
supplements advertised as "natural" are safer for use than
conventional medications as both are chemicals. Herbal
medications, although labeled "natural", may be toxic or
fatal if consumed. Some evidence supports omega-3 fatty
94
Manual therapies
The evidence for acupuncture is inconclusive with it
.appearing to be equivalent to sham acupuncture
Prevention
There is no known prevention for the condition. Reduction
of risk factors and aggressive treatment after diagnosis
.are recommended actions
Prognosis
The course of the disease varies greatly. Some people
have mild short-term symptoms, but in most the disease is
progressive for life. Around 20%30% will have
subcutaneous nodules (known as rheumatoid nodules);
.this is associated with a poor prognosis
Prognostic factors
95
Persistent synovitis
Extra-articular findings
rheumatoid nodules)
(including
subcutaneous
Family history of RA
Socioeconomic factors
Elevated
acute
phase
response
(erythrocyte
sedimentation rate [ESR], C-reactive protein [CRP])
Increased clinical severity.
Mortality
RA is known to reduce the lifespan of patients by
anywhere from three to 12 years. Positive responses to
treatment may indicate a better prognosis. A 2005 study
by the Mayo Clinic noted that RA sufferers suffer a doubled
risk of heart disease, independent of other risk factors
such as diabetes, alcohol abuse, and elevated cholesterol,
blood pressure and body mass index. The mechanism by
which RA causes this increased risk remains unknown; the
presence of chronic inammation has been proposed as a
contributing factor. It is possible that the use of new
biologic drug therapies extends the lifespan of people with
RA and reduces the risk and progression of
96
97
Risk Factors
osteoporosi osteoarthriti
s
s
Age-related
Menopause
Family history
Use of certain
medications (e.g.,
glucocorticoids,
seizure medications)
Calcium deficiency
or inadequate
vitamin D
Inactivity
Overuse of joints
X
Excessive alcohol
Anorexia nervosa
Excessive weight
Smoking
Rheumatoid arthritis
98
Physical
Effects
Affects
entire
skeleton
Affects
joints
Is an
autoimmu
ne disease
Bony
spurs
Enlarged
or
malformed
joints
Height
loss
99
Treatment
Options
Raloxifene
Bisphosphonates
Calcitonin
Parathyroid
hormone
Estrogen/hormon
e therapy
RANK ligand
(RANKL) inhibitor
Calcium and
vitamin D
Weight
management
100
Glucocorticoids
NSAIDs
X
X
Methotrexate
Diseasemodifying
antirheumatic
drugs, biologic
response
modifiers, tumor
necrosis factor
inhibitors.
Pain Management
Osteoporosi
s
Osteoarthritis
Rheumatoid
Arthritis
Pain medication
(e.g., NSAIDS,
narcotics, muscle
relaxants)
Rehabilitation
Support groups
Exercises: postural
Exercises:
isometric, isotonic,
isokinetic
101
Joint splinting
Physical therapy
Passive exercises
Hip fracture
surgical repair (may
include hip
replacement
depending on type
of fracture)
Joint replacement
surgery (usually for
pain, malformation,
or impaired
mobility)
Massage therapy
Acupuncture
102
103
104
105
106
course
should
through
107
Clinical experience
In the Naval Hyperbaric Medical Institute, we manage the
patients of knee osteoarthritis with intra-articular ozone
injections. Over the last 18 months, 100 patients were
given the intra-articular ozone injections.
108
Description of patients
The treated group was formed of:
1) 95 females and 5 males
2) 70 patients were degenerative osteoarthritis and 30
patients were rheumatoid arthritis
3) 90 patients were complaining from bilateral knee
osteoarthritis.
68
patients
of
the
degenerative
osteoarthritis group were bilateral while 22 patients from
the rheumatoid arthritis group were bilateral.
4) All patients complaining from bilateral osteoarthritis
received intra-articular and peri-articular ozone injections
in both knees in the same cession.
5) The sum of joints treated with ozone injections was 190
joints.
Methods of diagnosis and follow up:
Patients were diagnosed as osteoarthritis by the following
measures:
1) Clinical examination:
Patients were examined for presence of:
a) Pain
b) Swelling
c) Crepitus
d) Range of movement
e) Stiffness
2) Radiological examination:
Plain x-ray knee was done to reveal the criteria of
osteoarthritis:
109
110
Results
1) 75 patients showed improvement in their clinical
examination and laboratory investigations after the first
course with a percentage of 75 % success
2) 20 patients showed mild improvement and they
received a second course after 3 weeks that revealed
improvement in 14 patients raising the results to 89 %
3) 5 patients showed no improvement what so ever after
the first course with a percentage of 5%
4) 6 patients showed no more improvement after second
course
5) Out of the 75 improved patients, 60 patients were
degenerative osteoarthritis while 15 patients were
rheumatoid arthritis.
6) Out of the non improved patients, 4 were rheumatoid
arthritis and one patient was degenerative osteoarthritis.
7) Out of the 20 patients who received a second course, 9
patients were degenerative osteoarthritis while 11
patients were rheumatoid arthritis.
8) Out of the 14patients who improved after the second
course, 8 patients were degenerative osteoarthritis and 6
patients were rheumatoid arthritis.
9) Out of the 25 patients who did not improve after the
first course, 22 patients were obese
10) Out of the 11 patients who did not respond to
treatment, 7 patients were obese.
11) 40 patients returned after one year complaining of
appearance of manifestations of osteoarthritis. Those
patients received another course of intra-articular ozone
therapy and all of them improved.
111
112
Recommendations
113
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130
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