Spine Mobility: Assessment Description:Occiput-to-wall distance (left): The patient places his or her heels and back against a wall and attempts to touch the wall with the occiput, keeping the chin horizontal. The distance in cm from the wall to the tragus is measured. Fingertips-to-floor distance (center): With straight knees, the patient bends forward to touch the floor. When in fullest flexion, the distance b/w fingertips &floor is measured in cm. Chest expansion (right): Measurement is taken at max. expiration & then at max. inspiration at the 4th ICS (nipple line); however, other areas may be used as long as the measurement is consistent over time. The patient should stand with hands on head. The best of three efforts should be recorded in cm. The difference b/w max. exhalation & max. inhalation should be 7 - 12 cm. Less than 3 cm is abnormal.
Rheumatic disorders summary
Rasha Khamis Al-Dabbagh5th year IUG medical student
• 3% of the population• : ,3:1• 4th-5th decade• Smoking
• Unknown• Multifactorial: – HLA-DR4 – Some antigen -possibly a virus- sets off a chain of events culminating in a chronic inflammatory disorder with abnormal immunological reactions. – Autoantibodies “Rheumatoid Factor”
Stage 2 destruction : – Articular cartilage erode & tendons may rupture. – S&S: stiffness & LOM esp. in the morning, tendon ruptures. Subcutaneous nodules in 25% (olecranon process).
Stage 3 deformity : – Articular destruction, capsular stretching, tendon rupture. Progressive instability & deformity. – S&S: severe muscle wasting, painful callosities under metatarsal heads. – Deformities : o Ulnar deviation, MCP subluxation or dislocation, claw feet, atlantoaxial sublaxation o Swan neck deformity o Button hole deformity o Z deformity of the thumb o Carpal tunnel syndrome
• ESR & CRP in active phase.• RF in 80%, used in assessing prognosis.• ANA in 30-40%.
• Minimal criteria: – Bilateral symmetrical polyarthritis. – Involving proximal joints of hands or feet. – At least 6 weeks.• Subcutaneous nodules, periarticular erosins on x-ray confirm the diagnosis.
• 80 % Classical „periodic‟ course: relapsing & remitting.• 5% Rapidly progressive: with visceral involvement.• 10% -in men over 55yrs- explosive onset after which it tends to subside & follow a mild course.• In few patients only 1-2 attacks then disappears.
• NSAIDS• Low-dose corticosteroids• DMARD e.g gold & pencillinamine• Surgical: – Operative Tx e.g. synovectomy, tendon repair or joint stabilization – Reconstructive surgery – Arthrodesis, osteotomy, arthroplasty
• Chronic inflammatory disease• 0.2% in Western Europe• >• 15-25 years
• Multifactorial: – HLA-B27 – Trigger e.g. GU or GI infection
• Three characteristic lesions: 1. Synovitis of synovial joints. 2. Inflammation of fibro-osseous junctions of fibrous joints, tendons & ligaments (enthesopathy). 3. Ossification across the peripheries of intervertebral discs.
• Fairly constant sequence: Inflammation > granulation tissue > cartilage or bone erosion > replacement by fibrous tissue > fibrous tissue ossification > ankylosis
• Mainly in spine & sacroiliac joints, sometimes hips & shoulders, rarely peripheral joints.• Persistent backache & stiffness worse in morning or after inactivity.• LOM of spine, extension being earliest & most severe.• In > 10% onset in a peripheral joint.• Atypical onset is more common in .
Fingertips-to-floor Chest expansionWall test distance
• Fuzziness or frank erosion of sacroiliac joints, later sclerosis, eventually ankylosis.• Intervertebral discs ossification causes bony bridges „syndesmophytes‟, if several levels are involved bamboo spine .
• Other sero-ve spondylarthropathies• Ankylosing hyperostosis „Forestier‟s disease‟: – Mild or nonexistent S&S. – Incidental x-rays show widespread ossification of ligaments & tendon insertions.• Mechanical back pain: – in young adults – Muscle strains, facet joint dysfunction, discogenic disorders.
• Medical: – Exercise – Postural training to prevent deformity – Analgesics & NSAIDs• Surgical: – Joint replacement for hip stiffness – Vertebral osteotomy for severe flexion deformity
• Common features: 1. Characteristic spondylitis & sacroiliitis. 2. HLA-B27 association. 3. Familial aggregation. 4. Familial overlap with members having one disorder & relatives having another.• Includes: – Ankylosing spondylitis – Psoriatic arthritis – Reiter‟s disease – IBD associated arthritis
• Psoriatic arthritis ≠ RA + Psoriasis• : equal• HLA-B27 in 60%• S&S: – Mainly in IP joints of fingers & toes. – Not as symmetrical as in RA. – Arthritis mutilans in severe cases. – ¼ develop AS-like sacroiliac & vertebral changes.
• Treatment: – Judicious splintage to prevent deformity. – Topical skin preparations. – NSAIDs. – Surgery for unstable joints.
• Triad: polyarthritis, conjunctivitis & non-specific urethritis.•Synoivitis is due to abnormalimmune response to infectionor its products elsewhere urogenital or bowelinfection Lymphogranuloma venereum & Chlamydia trachomatis in GUT. Shigella, Salmonella & Yersinia enterocolitica in GIT.
• Hx of GU infection or diarrhea.• Mainly large joints, knee & ankle.• Tenosynovitis & plantar fasciitis are common• Sacroiliitis & spondylitis causing backache & stiffness occur at some stage.• „Self-limiting‟ but 80% have symptoms for many years.• Ocular lesions: conjunctivitis, episcleritis & uveitis.
• Normal at first• Erosive arthritis after many months.• AS-like sacroiliac & vertebral changes.
• HLA-B27 in 75% .• ESR in active phase.• Urethral fluids, faeces or Ab test may indicate the organism.
• Directed at the GU or GI infection “Antibiotics”.• Chlamydia: daily tetracycline for 6 months.• Local: – Rest & splintage in severe arthritis. – Anti-inflammatory agents.
• Noninfective inflammatory joint disease > 3 months in children < 16 years.• : equal.• 1 per 1000 children.• Multifactorial: Genetic predisposition + abnormal immune response to some antigen.• RF is -ve
1. Systemic JCA: – Age < 3 years. – Onset: intermittent fever, rashes & malaise. – May be lymphadenopathy, hepatosplenomegaly. – Joint swelling after weeks-months.
2. Pauciarticular JCA: – Commonest form. – Age < 6 years, girls. – Few joints, no systemic illness. – Pain & swelling in medium-sized joints. – Chronic iridocyclitis in 50%.
3. Polyarticular sero+ve JCA: – Older girls. – Resembles RA juvenile RA . – RF is +ve.4. Sero-ve spondarthritis: – Older boys. – Sacroiliitis & spondyliitis. – May be hips & knees. – HLA-B27 often +ve juvenile AS .
• Stiffness , sometimes permanent.• Growth defects & retardation.• Iridocyclitis , may lead to blindness.• Amyloidosis, can be fatal.
• General: similar to RA• Local: prevent stiffness & deformity – Night splints. – Prone lying for some period daily to prevent flexion contracture of hips. – Active exercises.• Surgical: for painful eroded joints – Custom-designed arthroplasty of hip & knee. – Arthrodesis of wrist & ankle.
• Most recover with moderate LOM.• 5-10% severely crippled esp. JRA.• 3% mortality : – Overwhelming infection, – Renal failure due to amyloidosis.
• Auto-immune disorders.• Like RA triggered by viral infection in genetically predisposed individuals.• SLE: – Progressive joint deformity is unusual. – A curious complication is avascular necrosis usually in femoral head.
• A descriptive term for a condition in which patients complain of pain & tenderness in muscles & other soft tissues around the back of the neck & shoulders, lower back & upper buttocks.• No pathology in affected tissues.• Depression & anxiety.
• Criteria: – Widespread pain in all four body quadrants. – At least 9 pairs of tender points in physical examination.
• Cause: – unknown – Suggested theories: • Abnormality of ”sensory processing” i.e. ”low pain threshold”. • Activation of stress responses by sudden accidents or traumatic life events.• Tx: – Physiotherapy & daily exercise. – Injections into painful areas. – Psychotherapy.