Inflammatory Arthropathies Kyung Dong University Dept. of Occupational Therapy Kim Chan Mun Ankylosing Spondylitis(AS) Rheumatoid Arthritis(RA)

Ankylosing Spondylitis Definition “A seronegative( 음성혈청반응 ), progressive inflammatory disease presenting with pain and stiffness of the spine leading to bony ankylosis of the sacroiliac and spinal joint

Aetiology Age : commonest between 15 and 49 years Sex : men > women, 3:1 Incidence : 0.6% adult males heredity : 30 times more commonly in relatives of patients than in the general population Association condition : sacroiliitis ( 엉치엉덩관절염 ) occurs in with ulcerative colitis ( 궤양결장염 ), crohn’s disease ( 염증성 창자병 ) or Reiter’s syndrome

Pathology Start at the sacroiliac joints with synovitis Cellular infiltration of periosteum to ligament or muscle junctions Continues the chronic inflammation leads to fibrosis which gradually becomes calcified and ossified Can progress to bony anklyosis of the sacroiliac joint, symphysis pubis, joint of the lumbar, thoracic and cervical Sometimes the shoulder and knee

Clinical features Onset : often with mild pain and stiffness in the lower lumber spine, acute with severe pain over the sacroiliac joint and lumbar spine Morning stiffness : common in the early stage Fatigue : also common Spinal feature : pain and stiffness in the lumbar spine(sciatica, muscle spasm, flattening of the lumbar spine)

Deformity : without exercise the patients can become fixed in spinal flexion Iritis : painful inflammation around the iris( 홍채 ) Skin : associated psoriasis( 건선 ) Colon : ulcerative colitis

Treatment Relieve pain : heat and hot pack Mobilize joints affected Minimize deformity hydrotherapy

Rheumatiod Arthritis(RA) NSAIDs(Nonsteroidal Antiflammatory Drugs) : promote inflammation, pain, and feverfever Traditional DMARDs( disease-modifying antirheumatic drugs) Immunosuppressants, including MTX( Methotrexate) Tumor necrosis factor (TNF) inhibitors Newer biologics

Rheumatoid Arthritis non-suppurative ( 비화농성 ), progressive, systemic inflammatory disease of unknown cause characterized by – Symmetric synovitis – Joint erosions – Multisystem extra-articular

Aetiology 1,5 million in the UK women > men, 3:1(Golding 1988, Carson-Dick 1972) Age : 20~55 years Cause : unknow, disturbance of the auto immune system Pathology Disorder of the connective tissue affecting articular and extra-articular structures

Articular changes First joint structure affected is the synovial membrane, inflamed and congested ( 충혈 ) with blood, membrane proliferate ( 급격히 증가 ) and forms folds, sometimes focal areas of necrosis Synovitis, villous, gross Finger joint, bony ankylosis Synovial membrane

Pannus : 관절 내부 활막 세포의 염증성 산출물에 의한 증식에 의해 두꺼워지 것

Rheumatiod nodules

Erosions

Clinical feautres Nature of Pain(Shipley 1995) Localised or diffuse( 방산통 ) Unilateral or bilateral Aching or sharp Present only with use Present constantly Worse at night or at rest Associated with sensory symptoms

Clinical feautres Tenderness (Ritchie et al 1968) Swelling ; MCP, PIP, wrist and MTP Heat ; this is not always obvious Erythema( 홍반 ) Loss of function stiffness Decreased range of movement

Clinical feautres Commom deformity in RA Shoulder girdle : protracted Shoulder : flexion, adduction, medial rotation Elbow : flexion, increased carry angle Forearm : pronation Wrist : volar subluxation, flexion, radial deviation MCP : volar subluxation, flexion, ulnar deviation PIP,DIP : botonniere, swan neck

Swan neck deformity PIP hyperextension, DIP flexion boutonniere deformity PIP flexion, DIP extension

Volar subluxation of the carpus on the radius as a result erosive synovitis of the radiocarpal joint flexion contracture Relationship between wrist and metacarpophalangeal joint deformity, radial deviation

Influence of the long flexors in metacarpophalangeal drift deformity weakened ligaments cannot resist a pull toward volar subluxation, during power pinch or grasp

Clinical feautres Commom deformity in RA hips : flexion, adduction, lateral rotation Knee : flexion, valgus Ankles : valgus MTP : plantar subluxation, hyperextension PIP, DIP : flexion

Hammer toes volar subluxation of the MTP combines with PIP flexion, DIP hyperextension Cock-up or claw toes exhibit volar subluxation of the metartarsal head with flexion of the PIP and DIP

Diagnosis

Management To relieve pain and muscle spasm : drug, heat, spint, exercise and relaxation To prevent deformity To maintain range of movement : pool, little To promote rest : little walking To maintain muscle strength To prevent circulatory and respiratory complication : medication