ORS 2

Click here for the audio guide.

Please click see the video for an overview of the clinical manisfestation of a severe Ankylosing Spondylitis. It tells of a journey of the “Folded Man” and on his road to recovery.

ANKYLOSING SPONDYLITIS (AS)

• Also known as BECHTEREW’S DSE, MARIE STRUMPELL’S DSE, RHEUMATIOD SPONDYLOLITIS
• Prototype of seronegative spondyloarthropathies
  

Incidence:

• More common in males (3:1 ratio); more symptomatic and severely affected
• Female patients: have more peripheral joint involvement
• Age group: 20-40 yrs old

Clinical features:

1. Sacroiliitis– hallmark of the disease
2. Onset is insidious
3. Presents a sharp, jolting pain in the buttock or hips
4. Involves ligamentous insertion (enthesopathy), fibrocartilage and IV disc

Difference between mechanical causes of spinal disease and AS:

• Insidious onset
• Onset <40 yrs old
• More or less persistent discomfort for weeks to months
• Associated with morning stiffness
• Improvement with exercise (worse at rest)
• Diffuse radiation of pain to thoracic region and buttocks
• Asymmetrical decrease in ROM
• (+) Hip joint involvement
• (-) Neurologic deficit and (-) low back maneuver
• Involvement of other systems

• Peripheral joint involvement
• Typical extraspinal sites include:
  • Manubriosternal joint
  • Symphysis pubis
  • Shoulder
  • Hip joints

• Cardiovascular involvement
• Aortitis
• Fibrosis extending to mitral valve, septum or AV node
• Pericarditis
• Aortic insufficiency
• Left ventricular hypertrophy

• Anterior Uveitis
  • Lung involvement
  • Neurologic Problems
  • Immune Neuropathy or Renal Amyloidosis (rare)

Diagnosis:

1. Radiologic Examination

NEW YORK CLASSIFICATION of PELVIC X-RAYS

• 1 – blurring of joint margin
• 2 – narrowing of joint space
• 3 – erosions
• 4 – fusion
• Bamboo spine Deformity  – syndesmophyte formation
• Patients may have inflammation of disk with destruction of adjacent vertebral bodies that radiographically resembles infection or tuberculosis (Romulus Lesions)

• Laboratory Findings
• No characteristic auto antibodies or immune abnormalities
• Nonspecific increase in ESR, anemia, increase in alpha 2 globulin
• Minority of patients are HLA-B27 positive especially if axial distribution is present

Treatment:

1. NSAID (Indomethacin)
2. Exercises
3. Hydrotherapy
4. Total hip replacement

Wedge osteotomy

PSORIATIC ARTHRITIS

• Psoriasis is a benign inflammatory skin disease with genetic predisposition.  Skin erosions are described as silvery scales most commonly located over the knee, elbows and scalp.  Nail findings include stippling (pitting) and onycholysis.

onycholysis

Incidence:

• Male and female patients equally affected
• Onset is between 30-50 yrs old

Clinical Features:

• Gradual onset with skin disease often preceding a joint disease by months or years
• Auspitz sign

• Koebner response

• Sausage digits

• Enthesopathy

• Arthritis mutilans
• Opera glass hands

• Asymmetrical involvement; involves the UE earlier than the LE with joint stiffness of at least 30 mins
• Axial involvement of the SI joint is common
• Symmetrical involvement includes eye inflammation as conjunctivitis iritis, episcleritis and keratoconjunctivitis

General symptoms of PsA include:

• swollen, tender joints on one or both sides of your body
• morning stiffness
• swollen fingers and toes
• painful muscles and tendons
• scaly skin patches, which may get worse when joint pain flares up
• flaky scalp
• fatigue
• nail pitting
• separation of your nail from the nail bed
• eye redness
• eye pain

Laboratory Features:

1. Radiographic Findings:
   1. Pencil point in cup deformity – whittling due to destruction of phalanges adjacent to the inflamed joints; seen in the end stage of the dse.

• Laboratory findings
  • No characteristic auto antibodies or immune abnormalities
  • Nonspecific; increase in ESR, anemia, increase in alpha 2 globulin
  • Minority of patients are HLA-B27 positive esp. if axial distribution is present

Treatment:

• Skin measures
• NSAIDs / aspirin
• Sulfasalazine is effective for joint manifestation but no effect on cutaneous psoriasis

REITER’S SYNDROME

• A clinical triad of non-gonoccocal arthritis, conjunctivitis and urethritis
• Believed to be triggered by infection of the genitourinary tract caused by Clamydia, Campylobacter, Salmonella, Shigella and Yersinia

Incidence:

• Occurs mainly in young adult males
• If it occurs in females, HLA-B27 positivity is 100%

Clinical Features:

1. Urethritis
   1. Discharge is mucopurulent,
   1. Prostatitis is common and in rare cases, hemorrhagic cystitis may be present
   1. Generally urine culture is negative but 20-40% have anticlamydial antibodies

• Conjunctivitis and iritis
  • Usually bilateral (in contrast to anterior uveitis of AS)

• Arthritis
  • Typically begins with weight bearing joints but is not symmetric
  • Most commonly affected: knees, feet and wrist; arthritis of hands and fingers may give a sausage digit appearance
  • Asymmetric small joint involvement esp. of the feet is more common in Reiter’s syndrome than AS

• Skin involvement
  • Keratoderma blenorrhagica
  • Balanitis Circinata

Laboratory Features

1. Laboratory findings
2. Elevated ESR and C-reactive protein
3. Sterile pyuria
4. Synovial fluid is purulent
5. HLA-B27 is present in patients with axial dse
6. Radiographic feature
7. Erosions (after 2 mos resembling RA),
8. Periosteal proliferation (in calcaneous, knees, and metatarsal bones)

Treatment

• NSAIDs such as indomethacin
• Acute stages: 
  • Bed rest and splinting
  • ROM exercises
  • Isometric strengthening exercises (started once swelling has subsided)
• Methotrexate or Azathioprine – given to patients with unremitting Reiter’s syndrome
• Antibiotics (Tetracycline) – given for treatment of urethritis & other extra –articular symptoms
• Intra-articular steroid – not recommended for long term therapy 

TABLE 1 – COMMON SPONDYLOARTHROPATHIES

Characteristics	Ankylosing Spondylitis	Reiter’s Syndrome	Psoriatic Arthritis	Enteropathic Arthropathy
Age of Onset	<40 yrs old	Middle aged adult	Young to middle age	Young to middle age
Onset	Gradual	Acute	Variable	Gradual
Sex	Male	Male	Equal	Equal
Sacroilitis or Spondylitis	100%	<50%	20%	<20%
Symmetry of Sacroiliitis	Symmetric	Asymmetric	Symmetric	Symmetric
Peripheral joint involvement	25%	90%	95%	Frequent
Eye involvement	25%-30%	Common	Occasional	Occasional
Cardiac involvement	1-4%	5-10%	Rare	Rare
Skin or nail involvement	–	Common	100%	Uncommon
Triggered by infection	Unknown	Yes	Unknown	Unknown

PRINCIPLES OF REHABILITATION INTERVENTION:

1. Rest

1. Local Rest
   1. Systemic Rest
   1. Short Rest Periods

2. Exercise

• Passive Exercise       
  • Active Exercise       
  • Stretching Ex.
  • Strengthening Ex.
  • Endurance Ex.
  • Aquatic Therapy
  • Others

3. Treatment with Heat & Cold Modalities

4. Orthotic Devices

5. Assistive Devices & Adaptive Aids

6. Self-care

7. Patient Education

ENERGY CONSERVATION MEASURES

1. Maximize biomechanical function of joints thru use of proper orthotics & assistive devices to effect energy-efficient ambulation & hand function
2. Use appropriate adaptive devices & clothing
3. Provide proper environmental design
4. Have rest periods throughout the day
5. Maintain ROM & strength
6. Maintain proper posture

PRINCIPLES OF JOINT PROTECTION:

1. Preservation of muscle strength and joint ROM and good joint alignment
2. Prevention of positions of deformity especially in the hands.
3. Utilization of the strongest joints (bigger joints) for the heavier jobs.
4. Use each joint in its most stable anatomic and functional plane.
5. Maintain muscle balance and correct patterns of motion.
6. Adaptation of tasks requiring static positioning. It is best to alternate rest with activities.
7. Elimination of activities that cannot be halted immediately.
8. Application of scientific management principles to each task. Scientific management embodies work simplification and time and motion economy. Plan ahead and do not overdo nor underdo too much.
9. Respect pain and stop activities that cause it.
10. Provide support for inflamed joints.
11. Use appropriate adaptive equipments & splints when necessary.

INFLAMMATORY BOWEL DISEASE

nflammatory bowel disease (IBD) is an umbrella term used to describe disorders that involve chronic inflammation of your digestive tract. Types of IBD include:

• Ulcerative colitis. This condition involves inflammation and sores (ulcers) along the superficial lining of your large intestine (colon) and rectum.
• Crohn’s disease. This type of IBD is characterized by inflammation of the lining of your digestive tract, which often can involve the deeper layers of the digestive tract.
  
  

Symptoms

Inflammatory bowel disease symptoms vary, depending on the severity of inflammation and where it occurs. Symptoms may range from mild to severe. You are likely to have periods of active illness followed by periods of remission.

Signs and symptoms that are common to both Crohn’s disease and ulcerative colitis include:

• Diarrhea
• Fatigue
• Abdominal pain and cramping
• Blood in your stool
• Reduced appetite
• Unintended weight loss
  
  

Causes

The exact cause of inflammatory bowel disease remains unknown. Previously, diet and stress were suspected, but now doctors know that these factors may aggravate but aren’t the cause of IBD.

One possible cause is an immune system malfunction. When your immune system tries to fight off an invading virus or bacterium, an abnormal immune response causes the immune system to attack the cells in the digestive tract, too. Heredity alsoseems to play a role in that IBD is more common in people who have family members with the disease. However, most people with IBD don’t have this family history.

Risk factors

• Age. Most people who develop IBD are diagnosed before they’re 30 years old. But some people don’t develop the disease until their 50s or 60s.
• Race or ethnicity. Although whites have the highest risk of the disease, it can occur in any race.
• Family history. You’re at higher risk if you have a close relative — such as a parent, sibling or child — with the disease.
• Cigarette smoking. Cigarette smoking is the most important controllable risk factor for developing Crohn’s disease.Smoking may help prevent ulcerative colitis. However, its harm to overall health outweighs any benefit, and quitting smoking can improve the general health of your digestive tract, as well as provide many other health benefits.
• Nonsteroidal anti-inflammatory medications. These include ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve), diclofenac sodium and others. These medications may increase the risk of developing IBD or worsen the disease in people who have IBD.

Complications

Ulcerative colitis and Crohn’s disease have some complications in common and others that are specific to each condition. Complications found in both conditions may include:

• Colon cancer. Having ulcerative colitis or Crohn’s disease that affects most of your colon can increase your risk of colon cancer. Screening for cancer begins usually about eight to 10 years after the diagnosis is made. Ask your doctor when and how frequently you need to have this test done.
• Skin, eye and joint inflammation. Certain disorders, including arthritis, skin lesions and eye inflammation (uveitis), may occur during IBD flare-ups.
• Medication side effects. Certain medications for IBD are associated with a small risk of developing certain cancers. Corticosteroids can be associated with a risk of osteoporosis, high blood pressure and other conditions.
• Primary sclerosing cholangitis. In this condition, inflammation causes scarring within the bile ducts, eventually making them narrow and gradually causing liver damage.
• Blood clots. IBD increases the risk of blood clots in veins and arteries.

Complications of Crohn’s disease may include:

• Bowel obstruction. Crohn’s disease affects the full thickness of the intestinal wall. Over time, parts of the bowel can thicken and narrow, which may block the flow of digestive contents. You may require surgery to remove the diseased portion of your bowel.
• Malnutrition. Diarrhea, abdominal pain and cramping may make it difficult for you to eat or for your intestine to absorb enough nutrients to keep you nourished. It’s also common to develop anemia due to low iron or vitamin B-12 caused by the disease.
• Fistulas. Sometimes inflammation can extend completely through the intestinal wall, creating a fistula — an abnormal connection between different body parts. Fistulas near or around the anal area (perianal) are the most common kind. In some cases, a fistula may become infected and form an abscess.
• Anal fissure. This is a small tear in the tissue that lines the anus or in the skin around the anus where infections can occur. It’s often associated with painful bowel movements and may lead to a perianal fistula.

Complications of ulcerative colitis may include:

• Toxic megacolon. Ulcerative colitis may cause the colon to rapidly widen and swell, a serious condition known as toxic megacolon.
• A hole in the colon (perforated colon). A perforated colon most commonly is caused by toxic megacolon, but it may also occur on its own.
• Severe dehydration. Excessive diarrhea can result in dehydration.

IBD-associated arthritis is used to describe types of inflammatory arthritis associated with IBD and include psoriatic arthritis, ankylosing spondylitis and reactive arthritis.