1. DR Y.SASIKUMAR

2.  Used to refer to a family of diseases that
share certain clinical features which are
inflammation of axial joints , asymmetric
oligoarthritis, and enthesitis , eye and bowel
inflammation.
 a strong association with the human
leukocyte antigen (HLA) B27.

3. The SpA family consists of the following disorders:
 • Ankylosing spondylitis
 • SpA associated with psoriasis or psoriatic
arthritis
 • Undifferentiated spondyloarthritis (USpA)
 • Reactive arthritis.
 • SpA associated with Crohn's disease and
ulcerative colitis
 • Juvenile onset spondyloarthritis

4.  The prevalence of SpA in a Caucasian
population is approximately 0.5% - 2%.
 Ankylosing spondylitis and USpA are the most
frequent types of SpA.
 Much less frequent is reactive arthritis

5. CLINICAL MANIFESTATIONS
 Musculoskeletal features
Inflammatory back pain, peripheral arthritis,
enthesitis, and dactylitis.
1. Inflammatory back pain — Back pain is the
most common symptom, being present in
about 70% of patients.
Onset before the age of 40 years.
Insidious onset.
Improvement with exercise.
No improvement with rest.

6. Peripheral arthritis —
The peripheral arthritis in SpA usually has an
acute onset.
predominantly involves the lower extremities,
especially the knees and ankles.
Arthritis is typically asymmetrical

7. Enthesitis
The enthesis is the site of insertion of
ligaments, tendons, joint capsule, to bone.
 Enthesitis which refers to inflammation
around the enthesis.
 They are usually associated with
swelling,severe pain and tenderness.

8. Dactylitis (sausage digits)
 Also known sausage toe or sausage finger.
 Dactylitis is not specific for SpA.
 It is also seen in the digits which are involved
with tuberculosis, syphilis, sarcoidosis and
sickle cell disease

9. Inflammatory eye disease
 Conjunctivitis-The symptoms subside within
a few weeks.
 Anterior uveitis-The initial attack is usually
acute and unilateral.
Patients complain of redness, pain, and
photophobia.

10.  Is a chronic inflammatory disease of the axial
skeleton manifested by back pain and
progressive stiffness of the spine.
 It affects young adults with a peak age of
onset between 20 and 30 years.
 Male to female prevalance is 3:1

11. CLINICAL FEATURES
 back pain
 Buttock pain
 Limited spinal mobility and chest expansion
 Hip pain
 Shoulder pain
 Peripheral arthritis

12.  TMJ involvement
 Enthesitis
 Constitutional features — may have fatigue
and Fever
 Acute anterior uveitis
Atlantoaxial-axial subluxation —
It can lead to spinal cord compression.
 Cauda equina syndrome — Is a rare
complication

13. Pulmonary disease
 Patients have restriction in chest expansion due to
costovertebral rigidity.
 Apical pulmonary fibrosis.
Renal disease
 Analgesic abuse nephropathy.
 IgA nephropathy .
It is uncommon.
 Secondary amyloidosis is also can affect the kidneys

14. CLASSIFICATION CRITERIA —The criteria consists of a subset of
clinical parameters and a subset of radiological parameters:
Clinical parameters
 • Low back pain and stiffness for more than three months that
improves with exercise, but is not relieved by rest
 • Limitation of motion of the lumbar spine in both the sagittal
and frontal planes
 • Limitation of chest expansion relative to normal values
correlated for age and sex
Radiological parameters
 • Sacroiliitis grade >2 bilaterally
 • Sacroiliitis grade 3 to 4 unilaterally
 A patient is regarded as having definite AS if he or she fulfills at
lest one radiological parameter plus at least one clinical
parameter.

15.  History .
 Physical examination —
Reduced range of motion of the low back —
modified Schober test
• With the patient standing erect, the position of the 5th lumbar
spinous process is marked by a pen; additional marks are made
10 cm above and 5 cm below in the midline.
• The patient bends forward maximally and the distance between
the upper and lower marks is measured.
People with normal spinal mobility have an increase in the
measured distance of 5 cm.

17. Occiput to wall distance —
 Increasing occiput to wall distance is
associated with loss of lumbar and cervical
lordosis and increasing thoracic spinal
kyphosis.

19. Chest expansion
 Chest expansion is measured at the level of
the 4th intercostal space.
 The expansion is usually 5 cm or more.
 An expansion of less than 2.5 cm is
abnormal.
Sacroiliac joint tenderness
Patients with pain in the region of the
sacroiliac joints may have tenderness, elicited
by direct pressure over the sacroiliac joint

21. Laboratory testing
 Acute phase reactants —
CRP & ESR are elevated
 HLA-B27 testing —
Among Caucasians, HLA-B27 is present in 95%
those with AS.
HLA-B27 is present in about 8 percent of this
population.

22.  Imaging
An abnormal appearance of sacroiliac (SI) joint
on plain radiographs is a hallmark of
longstanding AS.
The changes are
widening, erosions, sclerosis, or ankylosis of
the SI joints
MRI of the pelvis is the most sensitive and
specific evaluation for sacroiliitis .

25. Imaging of the spine
 Squaring of the vertebral bodies due to
anterior and posterior spondylitis is an early
sign of spinal involvement due to AS

27.  Late stages of AS are associated with
bridging syndesmophytes, ankylosis of the
facet joints, calcification of the anterior
longitudinal ligament and anterior
atlantoaxial (C1-C2) subluxation.

29. GOALS OF THERAPY :
 • Symptomatic relief — To reduce the symptoms such
as pain and stiffness.
 Restore function — To return the patient to the best
possible functional capacity.
 Prevent joint damage
 Prevent spinal fusion & complications
 Minimize extraspinal and extraarticular manifestations
.

30.  PHYSICAL THERAPY AND EXERCISE
 Home-based or supervised group and
individual exercise programs can help to
maintain the function and relief of symptoms.
 An initial evaluation and training by a physio-
therapist should be part of the therapeutic
regimen.

31. PHARMACOLOGIC THERAPY
 Nonsteroidal antiinflammatory drugs
Unless contraindicated, NSAIDs should be the
first line of treatment for all symptomatic AS
patients.
 Sulfasalazine
Prior to the discovery of anti-TNF therapies in
AS, the only disease-modifying agent that
had been demonstrated to be useful in AS.

32. Tumor necrosis factor alpha antagonists
Eg - etanercept, infliximab, adalimumab.
 Approximately 80 percent of patients with AS
respond to treatment with one of these
agents.
 Improvement noted in-
• Patient assessment of pain
• A functional assessment,
• Degree of inflammation as assessed by
morning stiffness

33. Predictors of response
 The following parameters are predictors of a
good response to TNF antagonists.
• Younger age
• Shorter disease duration
• Good functional ability
• Elevated ESR and CRP
• Presence of HLA-B27

34. Methotrexate
 Some studies have suggested that
methotrexate may be effective in some
patients with AS.
 Currently a lack of evidence to support the
use of methotrexate in the treatment of AS.

35. Glucocorticoids
 systemic glucocorticoids on a long-term
basis for patients with AS is not
recommended.
 Injection of a long-acting corticosteroid into
the sacroiliac joints may be beneficial in
patients with marked pain at the sacroiliac
joints

36.  Psoriatic arthritis is an inflammatory arthritis
associated with psoriasis.
 Psoriatic arthritis (PsA) affects women and
men equally.

37. CLASSIFICATION CRITERIA — following criteria be used to
classify a patient has having psoriatic arthritis:
 • Presence of musculoskeletal inflammation (an
inflammatory arthritis, enthesitis, or back pain);
 PLUS three points from the following:
• Skin psoriasis (present) - 2 points
previously present by history- 1 point
A family history of psoriasis- 1 point
• Nail lesions (onycholysis, pitting) - 1 point
• Dactylitis (present or past, documented by a
rheumatologist) – 1point
• Negative rheumatoid factor - 1point
• Juxtaarticular bone formation on radiographs - 1 point

38.  Patterns of arthritis
• Distal arthritis, characterized by involvement of the
distal interphalangeal (DIP) joints.
• Asymmetric oligoarthritis in which less than five
small or large joints
• Symmetric polyarthritis, similar to rheumatoid
arthritis.
• Arthritis mutilans, characterized by deforming and
destructive arthritis.
• Spondyloarthritis

42.  Dactilitis
 Enthesitis
 Nail lesions — include nail pits, onycholysis,
nailbed hyperkeratosis, and splinter
hemorrhages.
 Ocular involvement — Uveitis.

44. Radiologic changes
 Typical radiological changes include lysis of
the terminal phalanges, fluffy periostitis and
new bone formation at the site of enthesitis,
gross destruction of isolated joints.

46.  The approach to the treatment of PsA
includes therapy for both skin and joint
disease.
 Non steroidal anti inflamatory drugs.
 Methotrexate — only limited observational
data showing efficacy in PsA

47. Leflunomide
 Promising results with leflunomide were
noted in an uncontrolled trial.
 Leflunomide is also effective in controlling
skin disease.
TNF inhibitors
 Clinical trials have proven the efficacy of TNF
inhibition in psoriatic arthritis

48.  Refers to patients who do not meet
established criteria for ankylosing
spondylitis, reactive arthritis, psoriatic
arthritis, or SpA related to inflammatory
bowel disorders.
 major clinical feature is back pain
 Most patients with USpA are young men.
 positive for HLA-B27 .

49.  A substantial proportion of patients will
evolve into a more specifically classifiable
subset such as AS or Psa.
 With a longer period of observation, a greater
proportion may progress to definite
ankylosing spondylitis

50. THANK YOU