Arthritis and Joint Pain - PowerPoint Presentation

Slide1

Arthritis and Joint Pain

Mario de los Santos, PGY-2

Outpatient Report

Slide2

Introduction

I. Osteoarthritis

II. Rheumatoid Arthritis

III.

Spondyloarthritis

Slide3

Osteoarthritis

Slide4

History

- Osteoarthritis often cited as the oldest known diseaseEvident in Egyptian mummies and 70 million year-old dinosaur skeletons- Clinically characterized in the late 1700English physican William Heberden Bony outgrowths at DIP joints distinct from gout“Digitorum nodi”  Heberden nodes- Treatment  Willow bark and leavesSalicylic acidBayer modified to acetylsalicylic acid or aspirin in 1897

Slide5

Pathophysiology

- Affects

80% of patients > 55 years or older

and

95% of patients 65 years or older

- Biomechanical process

Joints respond pathologically to mechanical stress

- Acute injury

ACL tear

Repetitive injury (overuse or obesity)

Cartilage injury

Joint laxity

Abnormal joint mechanics

Slide6

Risk Factors

- Advancing age

- Obesity

Mechanical, metabolic, or cytokine-driven

Knee OA

- Female gender

- Joint injury

Caused by occupation, repetitive use, or trauma

- Genetic factors

Account for 60-70% of the risk of OA

Slide7

Clinical Presentation

- Hallmark features

Pain

Loss of function

- Symptoms worsen with activity and relieved by rest

- Morning stiffness lasting less than 30 minutes

- May recur after periods of inactivity

- Spine

Loss of mobility

Bone spurs

 canal stenosis  disk bulges  nerve root impingement

Slide8

Hand Osteoarthritis

- Bony enlargement of the proximal and distal interphalangeal joints Bone spurs- Squaring of the 1st carpometacarpal joint- Clinical manifestationsDecreased range of motionPain that worsens with activity and improves with restSwelling (inflammatory)

Slide9

Hand Osteoarthritis

Classic criteria

- Hand

pain (including hand aching or stiffness) plus 

at least three

 of the following four features:

●Hard tissue enlargement of 2 or more of 10 selected joints. The 10 selected joints are the second and third distal interphalangeal (DIP) joints, the second and third proximal interphalangeal (PIP) joints, and the first carpometacarpal (CMC) of both hands

●Hard enlargement of two or more DIP joints

●Fewer than three swollen metacarpophalangeal (MCP) joints

●Deformity of at least 1 of the 10 selected joints

Slide10

2012 American College of Rheumatology (ACR) Recommendations

Slide11

Role of Physical Therapy

- ACR – Technical Expert Panel- Recommend patient’s with osteoarthritis be evaluated by PT- Assessment of ability to perform ADLs- To evaluate for assistive devices- Instruction in joint protection techniques- Provide thermal agents for relief of pain and stiffness

Slide12

Slide13

Knee Osteoarthritis

SignsOsteophytesEffusionsCrepitusROM limitationDeformities: Valgus - lateral joint space narrowing (“knock-kneed”)Varus – medial joint space narrowing (“bow-legged”)Cartilage loss  medial narrowing more commonBakers cyst – fluctuant swelling along posterior aspect of the knee

Slide14

Knee Osteoarthritis

Classic clinical criteria

 — 

presence of knee

pain plus 

at least three

 of the following six clinical

characteristics:

●

Greater than 50 years of age

●Morning stiffness for less than 30 minutes

●Crepitus on active motion of the knee

●Bony tenderness

●Bony enlargement

●No palpable warmth

- SN = 95%, SP = 69%

Slide15

Slide16

Slide17

Slide18

Hip Osteoarthritis

- Pain around the hipOA of the hipPain referred to the hip from other structures Lumbosacral spine- Groin or buttock painExacerbated by weight-bearing

Slide19

Hip Osteoarthritis

Classic Criteria

- Presence

of hip pain plus 

at least two

 of the following three features:

●Erythrocyte sedimentation rate (ESR) of less than 20 mm/h

●Radiographic osteophytes (femoral or acetabular)

●Joint space narrowing on radiography (superior, axial or medial)

Slide20

Slide21

Joint Injections

- Use

for joints that cause disproportionate pain or limit function

-

Corticosteroids

Successful injection = 3 months pain relief

Long term risks

= cartilage atrophy

No more than 3 injections per year

-

Hyaluronic Acid

Relief for OA of the knee

Series of 3 weekly injections

Most effective when joint is “dry”

Expensive

Similar pain relief to steroids, last 3-6 months

Slide22

Indications for consultation

- If diagnosis

uncertain



rheumatology

- For

assistance with needle aspiration or

injection



rheumatology

or orthopedic surgery

-

S

evere

OA unrelieved by oral, topical, and

intra-articular medications

O

rthopedic consultation for surgical evaluation

Hip and knee replacement surgery

Goal - pain

reduction and function similar to patients without arthritis

Effective

– 90% patient satisfaction

Short term outcomes similar in obese and non-obese patients

Physical rehabilitation

Slide23

Slide24

Rheumatoid Arthritis

Slide25

History

- Pre-Columbian North AmericanSymmetrical polyarticular erosive arthritis reportedin Native American remains – 4500 BC- First modern account in 1800 by French medical student Landré-Beauvais- "emollient pastes were applied, blood was let at the arm and foot, and subsequently baths were given for nearly six months, although they made the condition worse." 

Slide26

Rheumatoid Arthritis – Presentation

- Typical Classic RAInsidiousMorning stiffness > 60 minutesPain/Swelling MCP and PIP joints of the fingersInterphalangeal joints of the thumbs and the wristsMTP joints of the toesElbows, shoulders, ankles and kneesSparing of the lumbar spine and DIP joints- Annual incidence = 30 per 100,000 worldwide- Age of onset = 30 to 55 years

Slide27

Pathophysiology

- Proinflammatory cytokines – TNF alphaInduce the production of degradative enzymes and promote osteoclast activation cartilage damage and bone erosion

Slide28

Presentation

- Initial clinical

p

resentation

Polyarticular

disease with gradual onset

Systemic symptoms: myalgia, fatigue, low-grade fever, weight loss and depression.

- Palindromic rheumatism

Episodic pattern

One to several joints are affected sequentially for hours to days

Alternating symptom-free periods lasting days to months

-

Monoarthritis

Large joints – wrist, knee, shoulder, hip or ankle

Slide29

Laboratory Analysis

- Labs

ESR

CRP

Anemia of chronic disease

Thrombocytosis

Hypoalbuminemia

- Synovial fluid analysis

Elevated leukocyte counts with neutrophil predominance

Slide30

Serology

-

Rhematoid

Factor - present

in up to 70%

(

sp

= 80%)

Mixed

cryoglobulinemia

(100%)

Sjogren

syndrome (70%)

Systemic lupus erythematosus (20-30%)

Healthy population (up to 10%)

- Anti-

citrullinated

peptide

Specificity = 95%

- ANA

Present in up to 40%

- Absence of anti-CCP and RF does not rule out RA

Slide31

Slide32

Imaging Studies

- Plain radiographsHands and feet images should be obtained at baseline and at repeated intervalsPeriarticular osteopeniaErosionsSymmetric joint-space narrowing- MRI Can detect bone erosions earlier - UltrasoundDetects synovitisNo established role in diagnosis or prognostication

Slide33

Extraarticular Involvement

- Cardiovascular

Premature coronary artery disease

- Musculoskeletal

Low bone mass and fracture

WHO – incorporated RA in the web-based fracture risk calculator (FRAX)

-

Pulmonary

Interstitial

lung disease

- Dermatologic

Felty

syndrome – pancytopenia, splenomegaly and leg ulcers

- Skin

Rheumatoid vasculitis

Rheumatoid nodules

- Ophthalmologic

Scleritis

and scleral ulcers

- Renal

Secondary amyloidosis

Slide34

Management

- Aims of treatment:

Eliminate

inflammation

quickly

Preserving function

Maintain remission

Avoiding

joint

injury

- Regular visits

Fatigue, weight loss, morning stiffness, joint pain, functional limitations and acute phase reactants

Radiographic monitoring

Progressive joint damage = insufficient therapeutic regimen

Slide35

Management

- NSAIDs

Do not alter disease course

Symptomatic relief

- Corticosteroids

Used to reduce inflammation initially while other agents become effective

High-doses used for extra-articular manifestations

- Disease-Modifying

Antirheumatic

Drugs (DMARDs)

Reduce or block joint damage

Initial choice depends on disease duration, activity and prognosis

Slide36

Non-biologic DMARDs

- Methotrexate

Gold standard therapy

Better tolerated, good efficacy, low cost

-

Hydroxychloroquine

, sulfasalazine and minocycline

Relatively short disease duration

L

ow disease activity

N

o evidence of erosive disease

- Combination therapy: sulfasalazine, MTX, and

hydroxychloroquine

Poor prognostic features

Moderate – high level of disease activity

Slide37

Biologic DMARDs

- Used when non-biologic DMARDs do not achieve remission

- TNF-alpha inhibitors

Etanercept

(Enbrel)

Infliximab (

Remicade

)

Adalimumab

(

Humira

)

Certolizumab

pegol

(

Cimzia

)

- No clear difference in efficacy

- Combination biologics should be avoided.

- MTX + TNF-alpha inhibitor = further reductions in disease activity

- Rituximab (anti-CD20+)

FDA approved in combination with MTX for TNF-alpha inhibitor non-responders

Slide38

Spondyloarthritis

Slide39

Ankylosing Spondylitis

- Affects 0.1% of the U.S. population- Male predominance - Peak age of onset is 20-30 years- Association with HLA-B27- Initial pain:Low backButtocksPosterior thighs- Progressive inflammatory back pain and stiffnessBony changes ascend the spine  stooped postureLimited mobility of the spine and the chest

Slide40

Slide41

Psoriatic Arhtritis

- Affects up to 30% of patients with psoriasis- FeaturesEnthesitisDactylitis (sausage digit)Tenosynovitis- Patterns of diseaseArthritis of the distal interphalangeal joints Asymmetric oligoarthritis (<5 joints)Symmetric polyarthritisArthritis mutilansSpondylitis

Slide42

Reactive Arthritis

- Post-infectious, aseptic, usually

oligoarticular

and self-limited (6 months)

- Develops days to weeks after infection

- Annual incidence: 30 per 100,000 persons

- 1/3 manifest triad: arthritis, urethritis and conjunctivitis

- Classic pathogens

Campylobacter

Chlamydia trachomatis

Salmonella

Shigella

Yersinia

Slide43

Inflammatory Bowel Disease-Associated Arthritis

-

Arthritis is the most common

extraintestinal

manifestation of IBD

Peripheral

Axial

- 50% of patients with IBD develop musculoskeletal symptoms

- Arthritis can develop prior to GI manifestations

- Colonic involvement = higher risk

- Peripheral

arthropathy

 Parallels disease activity

-

Spondyloarthropathy

(ankylosing spondylitis,

sacroilitis

) 

Does not

parallel disease activity

Slide44

References

-

Marc C. Hochberg, Roy D. Altman, et al. American College of Rheumatology 2012 Recommendations for the Use of

Nonpharmacologic

and Pharmacologic Therapies in osteoarthritis of the Hand, Hip, and Knee.

Arthritis Care and Resea

rch 2012; 465-474

- Kenneth C

Kalunian

.

Diagnosis and classification of osteoarthritis

.

In:

UpToDate

, Post TW (Ed),

UpToDate

, Waltham, MA. (Accessed on

January 18 2015.)

-

Altman R, Asch E, Bloch D, et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association.

Arthritis Rheum

1986; 29:1039

.

-

Peat G, Thomas E, Duncan R, et al. Estimating the probability of radiographic osteoarthritis in the older patient with knee pain.

Arthritis Rheum

2007; 57:794

.

-

PJW

Venables

, et al.

Clinical manifestations of rheumatoid arthritis

.

In:

UpToDate

, Post TW (Ed),

UpToDate

, Waltham, MA. (Accessed on

January 22, 2015.)

-

Jacoby RK, Jayson MI,

Cosh

JA. Onset, early stages, and prognosis of rheumatoid arthritis: a clinical study of 100 patients with 11-year follow-up.

Br Med J

1973; 2:96

.

-

Zeidler

H, Amor B. The Assessment in

Spondyloarthritis

International Society (ASAS) classification criteria for peripheral

spondyloarthritis

and for

spondyloarthritis

in general: the

spondyloarthritis

concept in progress.

Ann Rheum Dis

2011; 70:1

.

-

Rothfuss

KS,

Stange

EF,

Herrlinger

KR.

Extraintestinal

manifestations and complications in inflammatory bowel diseases.

World J Gastroenterology

2006:12:2819-4831