WHAT DOES SERonegative mean
does not have a rheumatoid factor in the blood
What are the common features of ankylosing spndylitis
- Inflammation in the spine
- Synovitis
- Enthesopathy (inflammation at bony attachment sites)
- Inflammatory eye disease
- blood work
- Tendency to run in families
What does synovitis affect? does it occur bilaterally or unilaterally
peripheral joints of the legs>arms
Typically unilateral
who develops Psoriatic arthritis
15-30% of people with psoriasis
Is there a genetic component to psoriatic arthritis?
Yes, appears in families
When does psoriatic arthritis typically present
30-50 years old
What may occur with psoriatic arthritis
- Dactylitis
- Enthesitis
What is dactylitis
Sausage like fingers & toes due to swelling
In psoriatic arthritis where does enthesitis commonly occur
Heels & back
What are the 5 subgroups of psoriatic arthritis
- DIP Arthritis: Primarily joints of fingers &toes
- Asymmetric oligoarthritis: Joints of limbs -2-4 joints involved
- Symmetrical polyarthritis: Multiple joints - symmetric - resembles rheumatoid arthritis
- Arthritis mutilans: rare, deforming
- Psoriatic spondylitis: Sacroiliac joints & spine
What are the two main categories of spondyloarthritis
- Axial spondyloarthritis (spine + pelvis)
2. Peripheral spondyloarthritis
What is enteropathic spondylitis
intestinal arthropathy
What may be seen with enteropathic sondylitis
- Ulcerative colitis and crohn’s disease
Is reactive arthritis typically symmetrical or asymmetrical
asymmetrical
What does reactive arthritis cause? where does it typically occur?
Hot, swollen joints. Maybe stiffening of spine
In lower limbs
what triggers reactive arthritis
Infection in the bowel or genitourinary tract
What does ankylosing mean
stiffening or fusing
What is ankylosing spondylitis
stiffness/fusing of the spine by inflammation
When is the onset of ankylosing spondylitis
adolescence/young adulthood
Average age: 26
Is ankylosing spondylitis easy to detect
How is it normally diagnosed
no- typically a delayed diagnosis
MRI is hallmark tool for diagnosis
how does Ankylosing spondylitis pain present
worst when youre resting better when youre moving
which ethnic group has a high prevalence of ankylosis spondylitis
Haida Indigenous
Ankylosing spondylitis M:F ratio?
1:1
Causes of ankylosing spondylitis?
Unclear!
- Familial clustering
- associated with genetic marker
Features of ankylosing spondylitis?
MSK Involvement - Sacroiliitis - Enthesitis - Synovitis Other systems & organs involved? - Eyes - Bowels - Lungs - Heart
What is the hallmark sign of ankylosing spondylitis?
Sacroiliitis
___% of cases of ankylosing spondylitis start with sacroiliitis
> 90%
How does sacroiliitis present
Deep, dull, diffuse pain in their buttock - worse when sitting better when moving
What is sacroiliitis
inflammation in SI jointst
is sacroiliitis uni or bilateral
Normally bilateral at some point - will come and go on one side then the other
Is sacroiliitis ____ can occur over time
fusion
What is an entheses
places where tendons, ligaments, and joint capsule attach to bone
What is enthesitis
Inflammation of the sites, leading to bony erosion bony overgrowth, possibility bony fusion and rigidity
Where does enthesitis begin
at SI joints, progresses in ascending fashion affecting all levels of the spine
Is diagnosis quick or long for enthesitis
long - 5-6 years
What is a big difference between RA and ankylosing spondylitis?
RA - reduction of bone
Ankylosing spondylitis - laying down more bone
What is seen in early stage enthesitis
bony loss - osteopenia
what is seen in later stage enthesitis
Osteoporosis and Fusion/rigidity - risk of fractures
What is an area of concern for fractures
impinge on spinal nerves
What is the proposed sequence of structural damage in ankylosing spondylitis?
- inflammation
- Erosive damage repair
- New bone formation
- The beginning of syndesmophytes
- Grows side to side
- Results in fusion
What is synovitis
inflammation of the synovium
Where is commonly affected by synovitis
peripheral joints: shoulders, hips, knees
Peripheral joint involvement occurs in about ___% of ankylosing spondylitis cases?
30%
What is the clinical criteria for diagnosing ankylosing spondylitis? (New York Criteria)
- LBP and stiffness for >3months that improves withe exercise but is not relieved by rest
- Limitation of motion of the lumbar spinne in both the sagittal and frontal places
- Limitation of chest expansion relative to nromal values correlated for age and sex
What is the radiological criterion for ankylosing spondylitis? (New York Criteria)
- Sacroiliitis grade >2 bilaterally or grade 3-4 unilaterally
What is the needed for definite diagnosis of ankylosing spondylitis? (New York Criteria)
The radiological criterion is associated with at least 1 clinical criterion
What is the ASAS Classification criteria for Axial Spondyloarthritis
- In Pt with >3mths back pain ang age at onset <45 years
- Sacroiliitis on imaging plus 1 of more SpA feature OR HLA-B27 plus 2 or more SpA features
What are SpA features according to ASAS Classification Criteria
- Inflammatory back pain
- arthritis
- enthesitis (heel)
- Uveitis
- Dactylitis
- Psoriasis
- Crohn’s/colitis
- Good response to NSAIDs
- Familial history for SpA
- HLA-B27
- Elevated CRP
is the New York Criteria or ASAS Classification Criteria more commonly used now
ASAS Classification Criteria
Is there a seperate ASAS Classification Criteria for Peripheral spondyloarthritis ?
yes
Other systems involved in spondyloarthritis?
- Eyes
- bowels
- Lungs (decreased chest expansion due to rigidity)
- Heart (inflammation + scarring of conduction system, incompetent valves)
Clinical features of spondyloarthritis?
- Pain - worse after rest
- stiffness (AM in the spine, after inactivity)
- Decreased spine ROM
- Deformity/instability
- Decreased strength (due to disuse, joint effusion, and pain)
- Altered posture/muscle imbalances
- Altered breathing mechanics
- Fatigue
- Deconditioning
What causes the deformity/instability seen in spondyloarthritis
Bony fusion
Flexion deformity of the hips
C1-C2 instability
2nd degree OP
What causes the fatigue seen in spondyloarthritis
- Disease process
- Cardiac involvement
- Decreased vital capacity
What is the posture seen in Ankylosing spondylitis
- Forward posture of the head
- Flattening of the anterior chest wall
- Thoracic kyphosis
- protrusion of abdomen
- Flattening of the lumbar lordosis
- Slight flexion of the hips on pelvis
What is the criteria for inflammatory back pain
- Back pain > 3months
- Improvement with exercise
- Pain at night
- Insidious onset
- Age of onset <40 years
- No improvement with rest
If 4/5 criteria are fulfilled,
AM Stiffness for:
- Inflammatory back pain
- Mechanical back pain
- Usually prolonged >60mins
- Minor <40mins
Max. pain/stiffness for:
- Inflammatory back pain
- Mechanical back pain
- Early AM
- Later in the day
Exercise/activity effect on symptoms for:
- Inflammatory back pain
- Mechanical back pain
- Improves symptoms
- Worsens symptoms
Duration for:
- Inflammatory back pain
- Mechanical back pain
- Chronic
- Acute/chronic
Age of onset for:
- Inflammatory back pain
- Mechanical back pain
- 12-40 years
- 20-65 years
Radiographs for:
- Inflammatory back pain
- Mechanical back pain
- Sacroiliitis, syndesmophytes, spinal ankylosis
- Osteophytes, disc psace narrowing, malalignment
What are some outcome measures for ankylosing spondylitis
- Function - BASFI
- Pain - NRS for last week and night time (BASDI)
- Spinal mobility
- Patient global assessment - NRS (BAS-G)
- Stiffness - using last 2 questions in BASDI
- Fatigue - BASDI
- Swollen joint count/entesitis
what are the components of a physical assessment for ankylosing spondylitis
- Posture - tragus to wall
- Trunk lateral flexion
- Trunk flexion/extension: Modified schobers + smythe test
- Trunk rotation
- Chest expansion
- Cervical mobility
- Peripheral joint scan
- Enthesitis sites
- Major muscle groups
What are the common enthesitis sites in Psoriatic arthritis
- achilles tendon
- Patella (on corners)
- Plantar fascia
- Anseranus bursa
- Greater trochanter of femur
- iliac crests
- rotator cuff
- costochondral
What are major muscle group affected by ankylosing spondylitis
- Short neck flexors
- Mid trapezius
- lower trapezius
- lower abdominals
- Gluteus maximus
4 major management areas for spondyloarthritis
- Medication
- Physical interventions
- Lifestyle/Self-management
- Surgery
What is the difference between ankylosing spondylitis and spondyloarthritis
- ankylosing spondylitis is when the spinal fusion (progression from spondyloarthritis)
What are 4 classes of MEdications used for treating spondyloarthritis
- NSAIDS
- DMARDS
- Corticosteroids
- Biologics
benefits and downsides of NSAIDs in treatment of spondyloarthritis ?
Benefits:
- Improve BASDI, BASFI, and disease activity
- Slow progression of bone formation
Downsides:
- GI upsets, ulcers, bruising, headache, drowsiness
- Increase CV morbidity (in already at risk group)
Are DMARDS used in Peripheral or axial spondyloarthritis?
Peripheral
What are the downsides of DMARDS
Nausea Vomiting Rashes Mouth ulcers Hair loss cough Bruising
what are risks of longterm corticosteroid use
Skin Flares
Osteoporosis
What are local corticosteroid injections used for
Enthesitis
Dactylitis
Peripheral joints
SI Joint
What are topical corticosteroids used for
Uveitis
benefits and downsides of Biologics in treatment of spondyloarthritis ?
Benefits: - Responsive to all domains (pain, am stiffness, peripheral arthritis, dactylitis, enthesitis, uveitis, IBD - Slows radiographic progression - syndesmophytes Downsides: - Nausea, abdominal pain - headache - infections - Risk of TB reactivation - 20% are non-responders
what are the benefits of physical interventions
- Control and decrease inflammation
- pain management
- Reduce spinal stiffness/increase ROM
- Increase spinal/peripheral soft tissue flexibility
- Posture correction
- Increase muscle strength and endurance
- Increase cardiovascular and fitness level
How do the physical fitness levels of those with AS compare to controls
- Lower cardiorespiratory levels and reduced flexibility
- lower amounts of vigorous activity
- Higher disease activity = lower PA levels
What are the results of manual therapy on ankylosing spondylitis
Significant improvements in chest expansion, posture, spinal mobility, and BASMI
When can you not perform manual therapy on an ankylosing spondylitis patient
when a joint has acute inflammation
how do you best control inflammation in AS
- Activity/rest
- Ice
- Compression
- Exercises
how do you best control pain in AS
- Pain neurophysiology education
- exercise
- Thermal modalities
- pool
- ice
- electrical modalities
- manual therapy
What are the target areas for exercises in AS
- Pectorals
- Rib cage
- C- T- and L- spine
- Neck posture
- T- spine, L-spine, pelvis
- pelvic/LE
What is the goal of exercises for the pectorals
Stretch
What is the goal of exercises for the rib cage
Breathing exercises & cardio
What is the goal of exercises for the C- T- and L- spine
Improve ROM
What is the goal of exercises for neck posture
Stretch suboccipitals
Strengthen short neck flexors
What is the goal of exercises for the T-spine, L-spine, and Pelvis
Strengthen mid & lower traps, back extensors, gluts & core
What is the goal of exercises for the pelvis and lower limb
Stretch hip flexors, adductors, quads, hams & calves
What adapted equipment/ergonomics may be useful for someone with AS
- Swivel chair
- Tilted work surface/drafting table
- additional rear view mirrors
- long handled appliances/reacher
- Back support
What are 3 options for surgical management of AS
- Realign - osteotomy
- Rest - arthrodesis
- Replace - arthroplasty
