APPROACH TO POLY-ARTHRITIS

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 • 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 • Polymialgiarheumatica

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 • Rheumatoid arthritis • 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 • Commonly involved • 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, keratoconjunctivitissicca • Vasculitis Nailfold infarcts, skin ulcers, pyodermagangrenosum, 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 • 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. Seronegativespondilo-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