![Spondyloarthritides
The spondyloarthritides comprise a group of related inflammatory diseases that show overlap in
their clinical features and have a shared immunogenetic association with HLA-B27 . The
spectrum of spondyloarthritis (SpA) includes:
1. axial spondyloarthritis (axSpA) comprising:
1. non-radiographic SpA (nr-axSpA)
2. radiographic axSpA (ankylosing spondylitis [AS])
2. Reactive SpA
3.Psoriatic arthritis
4.Arthritis with inflammatory bowel disease (enteropathic SpA).](https://image.slidesharecdn.com/presentationonankylosingspondylitis-250704100612-c4b9ce3c/75/Presentation-on-Ankylosing-Spondylitis-BY-DR-AVIJIT-AND-DR-WAHED-2-2048.jpg)
![ANKYLOSING SPONDYLITIS
• It is a chronic inflammatory seronegative arthritis
characterized by progressive stiffening and fusion of
axial skeleton. Common in young adult, 20–40 years,
Male:Female = 3:1. [M:F= 3:1]
• Etiology: Etiology is unknown, but probable,
etiologic factors are:
• Genetic predisposition–5-6% of people with AS share
the genetic marker HLA-B27
• Bacterias - Klebsiella pneumoniae and some other
Enterobacterias.](https://image.slidesharecdn.com/presentationonankylosingspondylitis-250704100612-c4b9ce3c/75/Presentation-on-Ankylosing-Spondylitis-BY-DR-AVIJIT-AND-DR-WAHED-8-2048.jpg)
Uploaded byDR AVIJIT DAS
Presentation on Ankylosing Spondylitis BY DR AVIJIT AND DR WAHED
Presentation on Ankylosing Spondylitis BY DR AVIJIT AND DR WAHED. Ankylosing spondylitis, also known as axial spondyloarthritis, is an inflammatory disease that, over time, can cause some of the bones in the spine, called vertebrae, to fuse. This fusing makes the spine less flexible and can result in a hunched posture. If ribs are affected, it can be difficult to breathe deeply. As ankylosing spondylitis worsens, new bone forms as part of the body's attempt to heal. The new bone gradually bridges the gaps between vertebrae and eventually fuses sections of vertebrae together. Fused vertebrae can flatten the natural curves of the spine, which causes an inflexible, hunched posture. Axial spondyloarthritis has two types. When the condition is found on X-ray, it is called ankylosing spondylitis, also known as axial spondyloarthritis. When the condition can't be seen on X-ray but is found based on symptoms, blood tests and other imaging tests, it is called nonradiographic axial spondyloarthritis. Symptoms typically begin in early adulthood. Inflammation also can occur in other parts of the body — most commonly, the eyes. There is no cure for ankylosing spondylitis, but treatments can lessen symptoms and possibly slow progression of the disease. Symptoms Early symptoms of ankylosing spondylitis might include back pain and stiffness in the lower back and hips, especially in the morning and after periods of inactivity. Neck pain and fatigue also are common. Over time, symptoms might worsen, improve or stop at irregular intervals. The areas most commonly affected are: The joint between the base of the spine and the pelvis. The vertebrae in the lower back. The places where tendons and ligaments attach to bones, mainly in the spine, but sometimes along the back of the heel. The cartilage between the breastbone and the ribs. The hip and shoulder joints. When to see a doctor Seek medical attention if you have low back or buttock pain that came on slowly, is worse in the morning or awakens you from your sleep in the second half of the night — particularly if this pain improves with exercise and worsens with rest. See an eye specialist immediately if you develop a painful red eye, severe light sensitivity or blurred vision. Causes Ankylosing spondylitis has no known specific cause, though genetic factors seem to be involved. In particular, people who have a gene called HLA-B27 are at a greatly increased risk of developing ankylosing spondylitis. However, only some people with the gene develop the condition. Risk factors Onset generally occurs in late adolescence or early adulthood. Most people who have ankylosing spondylitis have the HLA-B27 gene. But many people who have this gene never develop ankylosing spondylitis. Complications In severe ankylosing spondylitis, new bone forms as part of the body's attempt to heal. This new bone gradually bridges the gap between vertebrae and eventually fuses sections of vertebrae.
Presentation on Ankylosing Spondylitis BY DR AVIJIT AND DR WAHED
- 1. Presentation on Ankylosing Spondylitis DR. AVIJITDAS & DR. MD ABDUL WAHED Intern Doctor, Department of Medicine, Southern Medical College & Hospital.
- 2. Spondyloarthritides The spondyloarthritides comprisea group of related inflammatory diseases that show overlap in their clinical features and have a shared immunogenetic association with HLA-B27 . The spectrum of spondyloarthritis (SpA) includes: 1. axial spondyloarthritis (axSpA) comprising: 1. non-radiographic SpA (nr-axSpA) 2. radiographic axSpA (ankylosing spondylitis [AS]) 2. Reactive SpA 3.Psoriatic arthritis 4.Arthritis with inflammatory bowel disease (enteropathic SpA).
- 6. ASAS- EULAR recommendations forthe management of axSpA • Patients should be educated about axSpA and encouraged to exercise on a regular basis and stop smoking; physiotherapy should be considered. • Patients suffering from pain and stiffness should use an NSAID as first- line drug treatment up to the maximum dose, taking risks and benefits into account. For patients who respond well to NSAIDs, continuous use is preferred if needed to control symptoms. • Analgesics, such as paracetamol and opioid- (like) drugs, might be considered for residual pain after previously recommended treatments have failed, are contraindicated, and/or poorly tolerated. • Glucocorticoid injections directed to the local site of musculoskeletal inflammation may be considered. Patients with axial disease should not receive long- term treatment with systemic glucocorticoids.
- 7. ASAS- EULAR recommendationsfor the management of axSpA • Patients with purely axial disease should normally not be treated with csDMARDs; sulfasalazine may be considered in patients with peripheral arthritis. • TNFi, IL- 17i† should be considered in patients with persistently high disease activity despite conventional treatments • If there is a history of recurrent uveitis or active IBD§, preference should be given to a monoclonal antibody against TNF¶ In patients with significant psoriasis, an IL- 17i† may be preferred. • Following a first b/tsDMARD failure, switching to another DMARD (TNFi or IL- 17i†) should be considered. • Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage, independent of age; spinal corrective osteotomy in specialised centres may be considered in patients with severe disabling deformity.
- 8. ANKYLOSING SPONDYLITIS • Itis a chronic inflammatory seronegative arthritis characterized by progressive stiffening and fusion of axial skeleton. Common in young adult, 20–40 years, Male:Female = 3:1. [M:F= 3:1] • Etiology: Etiology is unknown, but probable, etiologic factors are: • Genetic predisposition–5-6% of people with AS share the genetic marker HLA-B27 • Bacterias - Klebsiella pneumoniae and some other Enterobacterias.
- 9.
- 10. Pathological changes inankylosing spondylitis o An inflammatory arthritis affecting the synovium, capsule and ligaments around the joints, as well as the insertions of tendons into bone. o Inflammation is known as an enthesopathy (around the spine and pelvis). o Involves an imbalance in bone production and reabsorption.(Increased levels of cytokines: effect on bone mineral absorption leading to osteoporosis early on in the disease process) . o Bony ridge form at periphery of IV joints leading to ossification of annulus fibrosis & surrounding tissue (seen in radiography & term as Syndesmophytes) o Ligamentous calcification (posterior and anterior longitudinal ligaments and the inferior and superior interspinous ligaments) o (appearance on XRay : bamboo spine). o AS occurs in (symphysis pubis, costovertebral and manubriosternal joints)
- 11. Symptoms Symptoms (early AS) 1.Pain in sacroiliac and lower back regions: ➡permanent; dull ➡worsens in rest; in the morning;nocturnal ➡reliefs in motion; in the afternoon 2. Buttock pain: irradiates into posterior surface of hip migrates from left to right gluteus 3. Lower back stiffness: in the morning,for 30 minutes ≥ ➡reliefs after activity, warm shower 4. Chest pain: mimicries intercostal neuralgia and intercostal muscles myositis worsens in coughing, sneezing, deep breathing.
- 12. Symptoms 5. Stiffness andtenderness of back muscles. 6. Flattening of lumbar lordosis 7. Bilateral sacroilitis. 8. Enthesopathies - pain in the site of ligament attachment to bone: ➡Iliac crests ➡Trochanters ➡spinous processes of vertebrae ➡costovertebral joints 9. Extra-articular manifestations - usually eyes affection (anterior uveitis); bilateral, acute onset, lasts for 2-3 months, registered in 30% of patients.
- 13. Symptoms (advanced AS) 1.Pain in different segments of spine. 2. Question mark posture 3. Atrophy of back muscles. 4. Decreased thorax excursion. 5. Decreased articulations in spine. 6. Ankylosis of sacroiliac and intervertebral joints. 7. Cutaneous lesions - that are identical topustular psoriasis 8. Cardiovascular system involvement: ➡ Aortitis ➡ aortic insufficiency ➡ pericarditis, myocarditis 9. Bronchopulmonary system involvement - fibrosis of apical lung segments. 10. Urinary system involvement ➡ Amyloidosis ➡ IgA-nephropathy 11. Gastrointestinal system involvement ➡ Vulcerative colitis ➡ Crohn's disease
- 14. Signs • There isloss of lumbar lordosis, thoracic kyphosis and compensatory hyperextension of neck (in advanced stage, question mark sign “?” or stoped posture). • The patient is unable to look up and unable to turn to any side without movement of whole body. • Restricted movement of spine in all directions. • Standing against the wall, the patient is unable to make contact between the occiput of head and the wall. • Sacroiliitis, Achilles tendinitis and plantar fasciitis are present.
- 15. Question mark posture Questionmark posture, or suppliant posture -loss of lumbar lordosis, fixed kyphosis,compensated extension cervical spine, protruberant abdomen
- 17. Question mark posture Questionmark posture, or suppliant posture -loss of lumbar lordosis, fixed kyphosis,compensated extension cervical spine, protruberant abdomen
- 18. Question mark posture Questionmark posture, or suppliant posture -loss of lumbar lordosis, fixed kyphosis,compensated extension cervical spine, protruberant abdomen
- 19. Question mark posture Questionmark posture, or suppliant posture -loss of lumbar lordosis, fixed kyphosis,compensated extension cervical spine, protruberant abdomen
- 20. Question mark posture Questionmark posture, or suppliant posture -loss of lumbar lordosis, fixed kyphosis,compensated extension cervical spine, protruberant abdomen
- 21. Question mark posture Questionmark posture, or suppliant posture -loss of lumbar lordosis, fixed kyphosis,compensated extension cervical spine, protruberant abdomen
- 22. Question mark posture Questionmark posture, or suppliant posture -loss of lumbar lordosis, fixed kyphosis,compensated extension cervical spine, protruberant abdomen
- 23. Question mark posture Questionmark posture, or suppliant posture -loss of lumbar lordosis, fixed kyphosis,compensated extension cervical spine, protruberant abdomen
- 24. Question mark posture Questionmark posture, or suppliant posture -loss of lumbar lordosis, fixed kyphosis,compensated extension cervical spine, protruberant abdomen
- 25. Question mark posture Questionmark posture, or suppliant posture -loss of lumbar lordosis, fixed kyphosis,compensated extension cervical spine, protruberant abdomen
- 26. Question mark posture Questionmark posture, or suppliant posture -loss of lumbar lordosis, fixed kyphosis,compensated extension cervical spine, protruberant abdomen
- 27. Question mark posture Questionmark posture, or suppliant posture -loss of lumbar lordosis, fixed kyphosis,compensated extension cervical spine, protruberant abdomen
- 28. Question mark posture Questionmark posture, or suppliant posture -loss of lumbar lordosis, fixed kyphosis,compensated extension cervical spine, protruberant abdomen
- 29. Question mark posture Questionmark posture, or suppliant posture -loss of lumbar lordosis, fixed kyphosis,compensated extension cervical spine, protruberant abdomen
- 30. TREATMENT 1. Regular physicaltherapy 2. NSAIDS : Indomethacin (up to maximum of 50 mg PO tid) COX-2 inhibitors 3. Sulfasalazine, in doses of 2 to 3 g/d- Effective for axial and peripheral arthritis 4. Methotrexate, in doses of 10 to 25 mg/wk- primarily for peripheral arthritis 5. Local Corticosteroids injection- for persistent synovitis and enthesopathy 6. Medications to avoid- Long term Systemic Corticosteroids, gold and Penicillamine 7. Anti-TNF-a therapy - heralded a revolution in the management of AS. Infliximab (chimeric human/mouse anti-TNF-a monoclonal antibody) Etanercept (soluble p75 TNF-a receptor-IgG fusion protein) have shown rapid, profound, and sustained reductions in all clinical and laboratory measures of disease activity 8. Pamidronate, thalidomide, a-emitting isotope 224Ra 9. Most common indication for surgery - severe hip joint arthritis, total hip arthroplasty.
- 31. PHYSIOTHERAPY TREATMENT: Regular physiotherapyis very essential in the management of a patient of AS and only physiotherapist is the person who can help the patient to fight with the disease. relevant physiotherapy modalities in the management of AS include : Supervised & unsupervised exercises Training Manual therapy Massage Hydrotherapy Electrotherapy Acupuncture Patient information & educational programs
- 32. PHYSIOTHERAPY TREATMENT: General instructionto patients:- Make the exercise part of your daily routine. Try to do a complete set of exercises at least twice daily at a time convenient to you. Heat and cold application amy precede exercises to enhance relaxation and decrease pain. Perform only those exercises given to you by your physiotherapist. Perform exercises on a firm surface. Exercise slowly with a smooth motion, do not rush. Avoid holding your breath while exercising. Modify the exercise regime during an acute attack and contact your physical therapist if you have any complaints or problems with the exercises.
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