Arthritis - An Overview PMR Refresher Course

1. GOVERNMENT OF INDIA
MINISTRY OF HEALTH & FAMILY WELFARE

2. Arthritis & Its Management
Dr. Rajendra Sharma

3. Outline
1. History and Clinical examination
2. Lab investigations
3. Imaging
4. Treatment
5. Rehabilitation

4. Chronology Of Complaints
1.Onset
Acute < 6 wks
e.g.infectious arthritis, crystal
arthropathy, reactive
arthritis.
Chronic >6 wks
e.g. Non inflamatory (OA)
Inflammatory(RA)
Fibromyalgia.
2.Evolution
Chronic eg.OA
Intermittent
e.g. Crystal arthropathy
Migratory arthritis
e.g. Rheumatic fever, Viral arthritis
3. Extent of articular involvement
Monoarticular (1 joint)
Oligoarticular (2/3 joint)
Polyarticular (> 3 joints)
4.Distribution of joint
involvement
Symmetrical- eg. RA, SL
Asymmetrical- eg. psoriatic
arthritis, spondyloarthropathy,
gout
Involvement of axial skeletal- eg
AS, OA

6. RHEUMATOID ARTHRITIS
(Klippel, 1997; Kelly et al, 1997)
DEFINITION
• Systemic autoimmune inflammatory disorder
of unknown etiology that primarily affects the
synovial lining of the diarthrodial joints.
• This chronic, symmetric erosive synovitis
develops in the joints and leads to
destruction.
• These erosions are pathognomonic of RA.

7. CLINICAL FEATURES
ARTICULAR
• Appendicular dominant
polyarthritis.
• Symmetrical involving small
joints of hand (except DIP).
• Axial involvement extremely
rare (MC- Atlantoaxial
subluxation).
EXTRARTICULAR
• Ocular: Episcleritis
• Lung: NSIP
• Heart: Pericarditis
Endocarditis
FELTYS SYNDROMRE
• RA + Spleenomegaly
• Anaemia+ Neutropenia
• Increase risk of Lymphoma
• Advanced stages
• < 1% cases due to early t/t with
DMARDs

8. LAB TESTS
1. CBC: thrombocytosis, hypochromic microcytic
anemia, eosinophilia
2. Rheumatoid factor
3. Anti-CCP
4. Acute phase reactants: ESR and C-reactive protein
5. Synovial fluid analysis

9. Anti–Cyclic Citrullinated Rheumatoid Factor (RF)
Peptide Antibody
1. Useful in diagnosis and prognosis
of rheumatoid arthritis (RA)
2. Newest anti-CCP assay yields
a specificity of 98%, sensitivity of
80% for RA
3. Present in 70% of patients with
established RA
4. Can be seen years prior to RA onset
and rarely develop after onset,
suggesting that they are not just a
consequence of inflammation.
5. Anti-CCP antibodies are directed
against citrullinated proteins.
Citrullination results from the post-
translational modification (ie not
encoded in the original protein) of the
amino acid arginine to citrulline by the
enzyme peptidyl arginine deiminase
6. Associated with a more severe disease
course and lower chance of drug-free
remission.
1. RF has a sensitivity of 70% and specificity of
70% for rheumatoid arthritis (RA)
2. RF is present in 50% with early RA, and 80% with
established disease
3. RF refers to a family of antibodies directed against
the Fc portion of IgG
4. High-affinity IgM-RF, as well as IgG and IgA subtypes,
are commonly found in RA (note that approximately
30% of RA patients are negative for RF)
5. High-titer IgM- and IgA-RF are associated with
increased bone erosion, more rapid disease
progression, worse outcome, and extra-articular
manifestations
6. A transient increase of IgM-RF is part of the normal
immunoregulatory process during a bacterial or viral
infection, and therefore low-titer IgM-RF can be
found in 10-15% of healthy individuals.
7. IgM-RF is also present in high titer in most patients
with primary Sjögren’s syndrome or mixed
cryoglobulinemia, and can be found in all other
rheumatic autoimmune diseases, as well as chronic
infections.

11. RADIOGRAPHIC FINDINGS

12. X-ray Demonstrating
• Juxta articular osteopenia
• Progression of erosions of the proximal interphalangeal joint.

13. Clinical Disease Activity Index (CDAI)
The CDAI is a useful clinical composite score for following patients with rheumatoid arthritis
CDAI = SJC(28) + TJC(28) + PGA + EGA
A CDAI reduction of 6.5 represents moderate improvement
Interpretation CDAI
Remission ≤ 2.8
Low Disease
Activity
> 2.8 and ≤ 10
Moderate Disease
Activity
> 10 and ≤ 22
High Disease
Activity
> 22
Deficiencies Does not include the
ankles / feet. Does not
include inflammatory
markers (although this
is what makes it a
quick and
useful clinical tool)
SJC(28): Swollen 28-
Joint Count
shoulders, elbows, wrists,
MCPs, PIPs including thumb
IP, knees
TJC(28): Tender 28-
Joint Count
(shoulders, elbows, wrists,
MCPs, PIPs including thumb
IP, knees)
PGA: Patient Global
disease
Activity (patient’s self
assessment of overall RA
disease activity on a scale 1-
10 where 10 is maximal
activity)
EGA: Evaluator’s Glob
al disease Activity
Evaluator’s assessment of
overall RA disease activity on
a scale 1-10 where 10 is
maximal activity)

14. Indian Consensus Guidelines for RA
• Early RA: < 24 months
• Established disease: > 24 months
• Late disease: > 5 years
The diagnosis of RA in early disease may be difficult. The following, if
present would favour RA
• Persistent inflammatory arthritis of more than 4 joints.
• Many active joints.
• High ESR and/or CRP
• Positive IgM RF or anti-CCP2 (Antibody to CCP is more
specific than RF)
• Radiographic changes of juxtaarticular osteopenia, erosions
and joint space narrowing.

15. Poor Prognosis in RA
1. Rheumatoid Nodules
2. RF (+)
3. Xray consistent with Erosive Disease
4. Persistent Synovitis
5. Insidious Onset

16. INDIAN RECOMMENDATIONS
• Based on DAS28 score and presence/absence of poor prognostic
factors, the patients are to be categorized for the purpose of
deciding the line of treatment.
• Disease Activity:
Low (DAS< 3.2 or CDAI ≤ 10)
Moderate (DAS 3.2–5.1, CDAI 10–22)
High (DAS> 5.1 or CDAI > 22)
R Misra et al article “Indian Rheumatology Association consensus statement on the management of adults with
rheumatoid arthritis” Indian Journal of Rheumatology 2008 November; Vol. 3, No. 3 (Suppl)

17. Without bad prognostic factors
Disease activity Duration of disease < 2 years Duration of disease > 2 years
Low MTX MTX/LEF/SSZ/MTX+HCQS
Moderate MTX/LEF/SSZ/MTX+HCQS
High MTX + HCQS/
MTX + LEF/
MTX + SSZ/MTX + SSZ +HCQS
With bad prognostic factors
Disease activity Duration of disease < 2 years Duration of disease > 2 years
Low MTX + HCQS/
LEF + HCQS/
SSZ +HCQS
MTX/LEF/
MTX + SSZ +HCQS
Moderate MTX + SSZ/LEF +HCQS
High MTX + HCQS/
MTX + LEF/
MTX + SSZ/MTX + SSZ +HCQS
R Misra et al article “Indian Rheumatology Association consensus statement on the management
of adults with rheumatoid arthritis”Indian Journal of Rheumatology 2008 November; Vol. 3, No. 3 (Suppl)

18. Indian Recommendations for
TNF inhibitors
Patient should
1. Fulfill the 1987 ACR classification criteria for RA.
2. Have active RA (DAS28 score > 5.1 at two time points, 1 month apart.
3. Have failed standard therapy as defined by failure to respond or tolerate
adequate therapeutic trials of at least two standard DMARDs.
One of the failed or not tolerated therapies must be methotrexate
Adequate therapeutic trial is defined as:
a. Treatment for ≥ 6 months, with at least 2 months at a standard target
dose unless significant toxicity limited the dose tolerated.
b. Treatment for < 6 months where treatment was withdrawn because of
drug intolerance or toxicity, but normally after ≥ 2 months at therapeutic
doses.
R Misra et al article “Indian Rheumatology Association consensus statement on the management of adults with
rheumatoid arthritis” Indian Journal of Rheumatology 2008 November; Vol. 3, No. 3 (Suppl)

19. DMARDs
Tofacitinib

20. Antagonist to Inflammation mediators - BiologicalsProinflammatory Cytokines
Most Potent Mediator of Inflammation
TNF Anti TNF
IL-1
Tocilizumab
Mechanism of Action of Biological RA
• Etanercept
• Infliximab
• Adalimumab
• Golimumabs
• Pegylated certolizumabs
Anakinra
Recombinant IL-1 inhibitor
IL-6
Anti–interleukin-6 receptor monoclonal antibody
T-Cell
Stimulation
B-Cell
Stimulation
Abatacept
Intracellular
Signaling
Pathways Rituximab
Inflammation
Janus
Associated
Kinases (JAK)
TOFACINITIB
Tyrosine kinase inhibitor
1st Oral
Biological
Approved
against JAK

21. 2016 EULAR Recommendations on RA
Management

22. Contd....

23. Contd...

24. APLAR TREATMENT RECOMMENDATIONS FOR
THE MANAGEMENT OF RA IN AP REGION
• SECTION 1- General RA treatment strategy
• SECTION 2-Role of NSAIDs
• SECTION 3-Role of corticosteroids
• SECTION 4-Role of conventional DMARDS
• SECTION 5-Role of biological DMARDs
• SECTION 6- Role of Tofacitinib

25. Diagnosis of RA
CBC, LFT, RFT, Chest X-Ray, Viral hepatitis serology, Comorbidities, Extraarticular disease manifestation
,Infections- TB , Viral Hepatitis ,Vaccination Status, Pregnancy & Lactation
Pretreatment Investigation s & Screening
+/- Symptomatic
NSAIDs
Taper and stop NSAIDS
Start DMARD
Monotherapy +/-
corticosteroids
MTX
Or if MTX is contraindicated
•Leflunomide
•Sulphasalazine
•Hydroxychloroquine
•Cyclosporine
•IM gold
•Tacrolimus
•Igrtimod
•Bucillamine
Sustained
remission/LDA
Go to fig 2B
Start combination
DMARDs therapy +/-
corticosteroids
Start triple
therapy
Start bDMARDs
plus MTX
Sustained
remission/LDA
Switch
Biologicals
Poor prognostic
factors present
Poor prognostic
factors absent
Oral corticosteroid
monotherapy not
recommended
Go to fig
2B
Sustained
remission/LDA
Sustained
remission/LDA
Inadequate response after 6
months
Screen for TB , HCV, infections
Failure
Inadequate response
after 3 months
International Journal of Rheumatic Disease 2015;18:685-713

26. Patient on
DMARD
Monotherapy
Patient on combination or
triple therapy +/-
corticosteroids
Patients on Biologics
plus MTX +/-
corticosteroids
Patient in sustained remission/LDA for 6-12 months
Shared decision between Patient and Physician
Continue treatment at
lowest possible dose
Taper and stop steroid
Discontinue Biologics
Titrate biologics to the lowest possible dose
Continue monitoring at regular intervals
Scenario 1 Scenario 2 Scenario 3
Fig 2B
International Journal of Rheumatic Disease 2015;18:685-713

27. Rehabilitation Intervention for Rheumatoid Arthritis
Acute Stage
 Patients may be accompanied by fever, weight loss, anemia, and fatigue. In this stage, complete
bed rest for a few days may help relieve joints and systemic symptoms.
 If one to two joints are more severe, resting splints are recommended. Application of a cold pack
or TENS over the inflammatory joints may help reduce joint swelling and relieve joint pain.
 If there is severe spasm and pain in the nearby muscles, local hot packs or gentle massage would
be beneficial.
 Bed rest should be as short as possible, because prolonged bed rest may lead to deconditioning.
 For prevention of joint and soft tissue contracture, actively inflamed joints should be moved
gently through the possible range by the patient (active ROM) or with assistance from another
person (active-assisted ROM).
 Three repetitions for each joint, once or twice daily, are suggested. As joint inflammation
subsides, the range may be increased gradually to the full range, possibly with assistance. A PNF
technique could be applied early on for selected muscle groups.
 Passive stretching is usually not performed in an inflammatory joint, and if performed it should be
done with extreme caution, because it may worsen or prolong the inflammatory process, or lead
to subluxation or rupture of a joint.
 For minimizing muscle atrophy, isometric exercise at submaximal effort is recommended in the
inflammatory condition. At first, a few non resistive repetitions should be performed with a
gradual increase in repetition and resistance.
 Isotonic exercise is not recommended in the acute inflammatory stage. Patient education
(including joint protection and energy conservation techniques) should commence.

28. Rehabilitation Intervention for Rheumatoid Arthritis
Subacute and Chronic Stages
 After the acute stage subsides, joint pain, morning stiffness, and joint
swelling diminishes.
 Isotonic exercise can be added to the exercise program gradually, with
increases in repetition and resistance.
 Local cold therapy can be changed to hot therapy if swelling of the joint
subsides.
 Splints, foot orthosis, or assistive devices can be prescribed if indicated.
 A forearm support crutch or cane is more preferable than a traditional
wrist support device.
 If patient condition improves, endurance training, aerobic exercise, and
recreational exercise can be added to the exercise program.

29. Principles of Joint Protection for
Rheumatic Diseases
1. Respect pain as a signal to stop the activity.
2. Maintain muscle strength and joint range of
motion.
3. Use each joint in its most stable anatomic and
functional plane.
4. Avoid positions of deformity and forces in their
direction.
5. Use the largest, strongest joints available for the
job.

30. Principles of Joint Protection for
Rheumatic Diseases
6. Ensure correct patterns of movement.
7. Avoid staying in one position for long periods.
8. Avoid starting an activity that cannot be stopped
immediately if it proves to be beyond capability.
9. Balance rest and activity.
10. Reduce the force.

31. Orthoses and Splints
• It decreases inflammation and pain, function improvement,
and minimizing deformity for patients at different stages.
• To prevent undesirable position or motion.

32. Assistive devices with built-up
handles to avoid tight grasp.
A, Broad key holder, buttoning
and zipping aids. B, Easy-to-
hold utensils.

33. Extended handle devices to
decrease the demands of
range of motion at the
shoulder and hip joints. A,
Long-handled comb. B,
Reacher. C, Sock aid.

34. OSTEOARTHRITIS
Definition
• Osteoarthritis (OA) is a chronic degenerative
disorder of multifactorial etiology characterized
by loss of articular cartilage, hypertrophy of
bone at the margins, subchondral sclerosis and
range of biochemical and morphological
alterations of the synovial membrane and joint
capsule.

35. KELLGREN-LAWRENCE GRADING SCALE FOR
OA

36. PRINCIPLES OF MANAGEMENT
• Treatment of the OA is directed towards
- decreasing joint pain and stiffness,
- stabilizing and increasing joint mobility,
- reducing physical limitations and disability,
- improving health-related quality of life,
- limiting the progression of joint damage.
• The optimal management of OA combines both
non-pharmacologic and pharmacologic treatment
modalities.

37. PMR programme of care includes
• Patient education,
• Weight reduction interventions,
• Exercise therapy,
• Physical agent modalities,
• Assistive devices,
• Orthoses,
• Work-place interventions and
• Pharmacological treatment.

38. OARSI Guidelines for non surgical management of OA
Core Treatment
1. Land based exercise, weight management , strength training.
2. Water based exercise & self management and education.
Recommended treatment
1. OA knee only without co morbidities- Biomechanical interventions,
intraartical corticosteroid injection, walking cane, oral COX-2 Inhibitor
(selective NSAIDS), Oral non-selective NSAIDS, Capsaicin, Duloxetine ,
Acetaminophin
2. OA knee only with co morbidities- Biomechanical interventions,cane walking ,
intraartical corticosteroid injection, Topical NSAIDS.
3. Multiple joints without co morbidities- Oral COX-2 Inhibitor (selective
NSAIDS), intraartical corticosteroid injection, Oral non-selective NSAIDS,
Duloxetine , Biomechanical interventions, Acetaminophin.
4. Multiple joints with co morbidities – Balneotheraphy, - Biomechanical
interventions, intraartical corticosteroid injection, Oral COX-2 Inhibitor
(selective NSAIDS), Duloxetine

39. EDUCATION AND SELF MANAGEMENT
• Interventions specifically targeted at patient education and
behaviour modification.
• The focus is on
- information about the disease
- its treatment,
- alleviating fear of damage,
- advice regarding other self-management strategies,
- the importance of exercise, joint protection and energy
conservation techniques, and
- the appropriate use of analgesics.
• Research has found 1a level of evidence for the effect of patient
education on pain in knee OA*.
*Hansson EE et al. Effect of an education programme for patients with osteoarthritis in primary care–a randomized controlled
trial. BMC Musculoskelet Disord 2010;11:244.

40. Self Management Education Programmes
• OARSI 2014 Recommendation : Moderate benefits of self
management programmes on measures of pain and disability.
Recommendation: Appropriate
Level of evidence: SR and meta-analysis of RCTs.
Quality of evidence: Good.
• Cochrane 2014 Review* : Low to Moderate quality evidence that it
results in no or small benefits but are unlikely to cause harm.
• As of now Indian Evidence is lacking.
*Kroon FPB et al : Self-management education programmes for osteoarthritis. Cochrane Database of
Systematic Reviews 2014, Issue 1. Art. No.: CD008963

41. WEIGHT REDUCTION
• OARSI 2014 : Reductions in pain and physical disability for overweight
participants with knee OA after a moderate weight reduction regime
A 2007 SR and meta-analysis* found reductions in pain and physical
disability in overweight participants after a moderate weight reduction
regime.
• Weight loss is strongly recommended with high (1a) **level of evidence
regarding pain relief and disability in knee OA.
Recommendation: Appropriate Quality of overall evidence: Good
• AAOS 2013 : Recommends weight loss for patients with symptomatic OA
of knee and BMI >25,
Strength of recommendation Moderate
• As of now Indian Evidence is lacking.
*Christensen R et al : Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: a systematic review
and meta-analysis. Ann Rheum Dis 2007;66(4):433e9. Epub 2007/01/06. http://dx.doi.org/10. 1136/ard.2006.065904.
PubMed PMID: 17204567; PubMed Central PMCID: PMCPMC1856062.
**Christensen R et al. Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: a systematic review
and meta-analysis. Ann Rheum Dis 2007;66:433–9.

42. EXERCISE
• The exercise programme in OA usually includes:
1) ROM exercises and stretching;
2) strengthening exercises;
3) balance and proprioceptive training;
4) aerobic exercise; and
5) water-based exercise.
• Cochrane 2015* : A meta-analysis of 32 RCTs, high quality evidence
indicates that exercises provide short term benefit that is sustained for at
least two to six months.
• Moderate quality evidence shows improvement in physical function in
patients with OA Knee. (Ia) level of evidence for land-based therapeutic
exercise.
• Aerobic and strengthening exercises are supported by (Ia) level of evidence
in knee OA
*Fransen M et al L: Exercise for osteoarthritis of the knee. Cochrane Database of Systematic Reviews 2015, Issue 1.
Art. No.: CD004376.

43. EXERCISES : Land Based
• OARSI 2014 : included a combination of strength training, active
range of motion exercise, and aerobic activity.
• Results were generally positive among land-based exercise type,
and did not significantly favor any specific exercise regimens
Recommendation: Appropriate
Level of evidence: SR and meta-analysis of RCTs.
Quality of evidence: Good
• Indian Evidence : Himmat et al (2014)** there is stronger
evidence to suggest that a combination of various forms of
therapeutic exercises is most beneficial, although it is still unclear
which exercise combinations work best.
** Dhillon HS et al : Effectiveness of Exercise Therapy and its Variations in Lower Limb Osteoarthritis: A
Literature Review. J Postgrad Med Edu Res 2014;48(4):190-196

44. Aquatic Exercises
• Physical Exercises taking place while the participants are immersed
in water at 320 to 340 c.
• OARSI 2014 : Short-term benefits for function and quality of life, but
only minor benefits for pain
Recommendation: Appropriate, Level of evidence: SR and meta-
analysis of RCTs and quasirandomized trials.
Quality of evidence: Good.
• Cochrane 2016*: Moderate quality evidence that patients may have
small short term and clinically relevant effects on pain, disability &
QOL in patients with knee OA.
• Indian Evidence : Himmat et al (2014)**: alternate methods of
training such as Tai Chi, aquatic exercises and agility training have
the potential to develop into beneficial additions or even
alternatives to standard exercises
* Bartels EM, Juhl CB, Christensen R, Hagen KB, Danneskiold-Samsøe B, Dagfinrud H, Lund H.Aquatic exercise for the treatment
of knee and hip osteoarthritis.Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD005523
**Dhillon HS, Sharma M, Sharma S. Effectiveness of Exercise Therapy and its Variations in Lower Limb Osteoarthritis: A
Literature Review. J Postgrad Med Edu Res 2014;48(4):190-196

45. PHYSICAL MODALITIES
• Short wave diathermy*: A systematic review and meta-
analysis points to significant effects of SWD on pain and
muscle performance in patients with knee OA with no
reported adverse effects.
• Heat/Cold**: The Cochrane review of 2003 could not show
any significant effects of either heat or cold in terms of pain
reduction in OA.
• Low level laser therapy (LLLT)***: Meta-analysis in 2015
with nine studies with 518 patients showed no therapeutic
benefit of LLLT compared with placebo for Knee OA patients
with respect to pain relief or functional improvement,
including right after therapy or at week 12 after therapy.
*LauferY et al: Effectiveness of thermal short-wave diathermy for the management of knee osteoarthritis: a
systematic review and meta-analysis.OsteoarthritisCartilage2012;20:957-66.
**Brosseau L et al: Thermotherapy for treatment of osteoarthritis. Cochrane Database Syst Rev 2003;4:CD004522
***JangH,LeeH: Meta-analysis of pain relief effects by laser ir-radiation on joint areas.
PhotomedLaserSurg2012;30:405-17.

46. Ultrasound
• OARSI 2014
Recommendation: Uncertain: knee-only
Rationale: Two 2010 SRs suggested a possible beneficial effect of
ultrasound for knee OA; however, the quality of the analyzed evidence was
low. No safety risks were reported .
A 2012 RCT found no significant differences between the groups for pain or
function.
Level of evidence: SR and meta-analysis of RCTs.
Quality of evidence: Good.
• Cochrane Review 2010* : May be beneficial for patients with OA knee. Low
quality evidence.
*Rutjes AWS, Nüesch E, Sterchi R, Jüni P.Therapeutic ultrasound for osteoarthritis of the knee or hip.Cochrane
Database of Systematic Reviews 2010, Issue 1. Art. No.: CD003132.

47. TENS
• OARSI 2014 :
Recommendation: Uncertain: knee-only OA
A 2009 SR: inconclusive results regarding the effect of TENS for pain
relief in knee OA. No evidence to suggest that TENS was unsafe.
A recent RCT *revealed no statistically significant difference for pain
between TENS and a sham TENS procedure.
Level of evidence: SR of randomized or quasi-randomized clinical trials.
Quality of evidence: Good.
• Cochrane Review 2009* *: Couldn't confirm that TENS is effective for
pain relief . Current systematic review is inconclusive.
*Atamaz FC et al. Comparison of the efficacy of transcutaneous electrical nerve stimulation,
interferential currents, and shortwave diathermy in knee osteoarthritis: a double-blind, randomized,
controlled, multicenter study. Arch Phys Med Rehabil 2012;93(5):748e56. Epub 2012/03/31.
http://dx.doi. org/10.1016/j.apmr.2011.11.037. PubMed PMID: 22459699.
* *Rutjes AWS, Nüesch E, Sterchi R, Kalichman L, Hendriks E, Osiri M, Brosseau L, Reichenbach S, Jüni
P. Transcutaneous electrostimulation for osteoarthritis of the knee.Cochrane Database of Systematic
Reviews 2009, Issue 4. Art. No.: CD002823.

48. PHYSICAL MODALITIES
• AAOS 2013 Recommendation : Unable to recommend for or
against the use of physical agents in patients with
Symptomatic OA Knee.
SOR : Inconclusive
• Indian Experience (2013)***: All the therapies administered
(pulsed electromagnetic energy, therapeutic ultrasound,
exercises) help to reduce pain in knee osteoarthritis but
none of the modality proved more effective than others.
.
*** Adhya B, Gupta A , Dhillon MS , Goswami U, Kumar V. A Study on efficacy of different Therapeutic Modalities to Alleviate
Pain due to Knee Osteoarthritis.Vol 7, No 3 (2013) Pages: 279-284

49. ASSISTIVE DEVICES AND FOOT ORTHOSES
• The use of a stick is recommended for OA of knee, because it helps in
off-loading of the arthritic joint.
• A single-blind RCT* concluded that canes, in comparison with usual
disease management, could be used to diminish pain and improve
function and some aspects of quality of life in participants with knee
OA.
• The use of appropriate comfortable shoes**. There is (Ib) level of
evidence for the same.
• The literature on the effectiveness of the use of lateral wedged
insoles in patients with medial knee OA found no significant effect on
pain or function***.
*Jones A et al. Impact of cane use on pain, function, general health and energy expenditure during gait in patients with knee
osteoarthritis: a randomised controlled trial. Ann Rheum Dis 2012;71(2):172e9. Epub 2011/12/01. http://dx.doi.org/10.
1136/ard.2010.140178. PubMed PMID: 22128081.
**Turpin KM et al. Biomechanical and clinical outcomes with shock-absorbing insoles in patients with knee osteoarthritis:
immediate effects and changes after 1 month of wear. Arch Phys Med Rehabil 2012;93:503–8.
***Reilly KA et al : A systematic review of lateral wedge orthotics-how useful are they in the management of medial
compartment osteoarthritis? Knee 2006;13:177–83.

50. ORTHOSES
• OARSI 2014* : Recommend use of biomechanical interventions. Knee braces and
foot orthoses were effective in decreasing pain, joint stiffness, and drug dosage and
also improved physical function, with insignificant adverse events.
Recommendation: Appropriate
Level of evidence: SR of RCTs and non-randomized clinical trials.
Quality of evidence: Fair.
• Cochrane Review (2015)* *: Evidence was inconclusive for the benefits of bracing
for pain, stiffness, function and quality of life in the treatment of patients with
medial compartment knee OA. The optimal choice for an orthosis remains unclear,
and long-term implications are lacking.
• Indian Experience : No RCT or systematic reviews availale.
*Raja K, Dewan N. Efficacy of knee braces and foot orthoses in conservative management of knee
osteoarthritis: a systematic review. Am J Phys Med Rehabil/Assoc Acad Physiatry 2011;90(3):247e62. Epub
2011/01/29. http://dx.doi.org/10. 1097/PHM.0b013e318206386b. PubMed PMID: 21273902.
**Duivenvoorden T, Brouwer RW, van Raaij TM, Verhagen AP, Verhaar JAN, Bierma-Zeinstra SMA.Braces and
orthoses for treating osteoarthritis of the knee.Cochrane Database of Systematic Reviews 2015, Issue 3. Art.
No.: CD004020

51. WORK/WORK PLACE INTERVENTIONS
• There is evidence that work activities such as kneeling, squatting,
lifting and climbing can cause or aggravate knee OA.
• People with hip or knee OA who want to start/return to work should
have
- rapid access to vocational rehabilitation,
- counseling about modifiable work-related factors such as altering
work behavior,
- changing work tasks or altering work hours,
- use of assistive technology,
- workplace modification,
- commuting to/from work and support from management, colleagues
and family towards employment
• There is a (IIl) level of evidence about the effectiveness for work place
interventions*.
*Abasolo L et al. Musculoskeletal work disability for clinicians: time course and effectiveness of a specialized intervention program by
diagnosis. Arthritis Rheum 2007;57:335–42.

52. INTRA ARTICULAR STEROID
• OARSI 2014: clinically significant short-term decreases in pain. Short-term effects
were found to be significantly greater than those of intra-articular hyaluronic acid
Recommendation: Appropriate
Level of evidence: SR and meta-analysis of RCTs.
Quality of evidence: Good.
• AAOS 2013 : Unable to recommend for or against the use of intra-articular (IA)
corticosteroids for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Inconclusive
• Cochrane 2015* : Intra-articular corticosteroids may cause a moderate improvement
in pain and a small improvement in physical function, but the quality of the
evidence is low and results are inconclusive
• Indian Experience : No RCT or systematic reviews availale.
*Jüni P, Hari R, Rutjes AWS, Fischer R, Silletta MG, Reichenbach S, da Costa BR.Intra-articular corticosteroid for knee
osteoarthritis.Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD005328

53. Intraarticular Viscosupplementation
• OARSI 2014 : Inconsistent conclusions among the meta-analyses and conflicting
results regarding IAHA’s safety influenced panel votes
Recommendation: Uncertain: knee-only OA
Level of evidence: SR and meta-analysis of RCTs.
Quality of evidence: Good.
• AAOS 2013: Unable to recommend using hyaluronic acid for patients
with symptomatic osteoarthritis of the knee.
• Cochrane 2006* : Viscosupplementation is an effective treatment for OA knee with
beneficial effects. There is heterogeneity in effects across product class.
• Indian Experience ( Sarvajeet Pal 2014)**: In open-label, multicentre, phase 4 clinical
trial enrolled patients (N=394) and found significant long term improvement of
outcome measures like WOMAC, SF-12, PTGA (Patient Global Assessment),COGA (
Clinical Observer Global assessment) with single 6 ml of Hylan GF 20 injection.
*Bellamy N, Campbell J, Welch V, Gee TL, Bourne R, Wells GA.Viscosupplementation for the treatment of
osteoarthritis of the knee.Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD005321.
** Pal S, Thuppal S,Reddy KJ, Avasthi S, Aggarwal A et al. Long-Term (1-Year) Safety and Efficacy of a Single 6-
mL Injection ofHylan G-F 20 in Indian Patients with Symptomatic Knee Osteoarthritis.The Open Rheumatology
Journal, 2014, 8, 54-68

54. Osteoarthritis: Summary of treatment
NICE guidelines for Osteoarthritis 2013

55. SPONDYLOARTHROPATHY
• It comprises the whole spectrum of patients with radiographic
sacroilitis (AS) and without radiographic sacroilitis.
• Group of diseases with overlapping clinical features and pathological
mechanisms
• Seronegative arthropathy (RA factor -ve).
• HLA B27 positive.
• 1st site – Enthesitis.
• Extra articular manifestations predominate axial involvement.
• Excellent response to NSAIDs – 1st line of treatment.

56. Assessment of Spondyloarthritis International
Society Classification
• Patients with Back Pain 3 Months or More
and Age at Onset Younger Than 45 Years

57. ANKYLOSING SPONDYLITIS
Definition
• Chronic inflammatory disorder of the axial skeleton affecting the
sacroiliac joint and the spine
• The hallmark is bilateral sacroiliitis
Epidemiology
• Onset → late adolescent and early adulthood
• Males >> Females
• More common in whites
• Genetic marker → (+) HLA-B27~ 90%
Mechanism
• Exact mechanism is unknown
• Synovitis and inflammation with intimal cell hyperplasia—
lymphocyte and plasma cell infiltrate

58. Modified New York Criteria for
Ankylosing Spondylitis
Clinical Variables
• Inflammatory back pain >3 months
• Limitation of motion of the lumbar spine in both the sagital and
frontal planes
• Limitation of chest expansion relative to normal values
Radiologic Variables (Plain Radiographs)
• Sacroiliaitis grade ≥2 bilaterally
• Sacroiliaitis grade 3 to 4 unilaterally
Definite Diagnosis
• At least one clinical variable plus at least one radiologic variable

59. Lab Findings
• (+) HLA-B27, 90%—(clinically: test to find HLA-
B27 factor is expensive)
• ↑ ESR and C-Reactive Protein
• Anemia—normochromic/normocytic
• RF (–) and ANA (–)

60. Radiograph Grading of Sacroiliitis
Grade 0 - Normal (A) Grade I – Suspicious (B)
Grade II – Mild irregularity & sclerosis of articular surfaces with preserved joint space (B)
Grade III – Joint space narrowing besides intense irregularity and subchondral sclerosis(C)
Grade IV – Bilateral ankylosis (D)

61. EULAR 2016 Recommendations For Axial
Spondyloarthritis Management
©2017 by BMJ Publishing Group Ltd and European League Against Rheumatism
Désirée van der Heijde et al. Ann Rheum Dis doi:10.1136/annrheumdis-2016-210770

62. Contd....
©2017 by BMJ Publishing Group Ltd and European League Against Rheumatism
Désirée van der Heijde et al. Ann Rheum Dis doi:10.1136/annrheumdis-2016-210770

63. Contd....

64. Rehabilitation Intervention
Ankylosing Spondylitis
• Pain relief may be achieved with the use of anti-inflammatory drugs
and physical modalities including hot or cold packs, hot baths,
hydrotherapy, spa therapy, diathermy, electric therapy, and mobility
exercise.
• Before mobility exercise, a hot pack, or hot bath (shower), followed
by 5 to 10 minutes of warm-up exercise is suggested.
• The target areas for stretching are the sub occipital muscles,
pectoral muscles, hamstrings, hip flexors, and spinal rotators.
• The ROM exercise should include extension of all segments of the
spine, as well as full ROM of the neck, shoulders, and hips.
• Strengthening exercises for the major muscle groups including back
extensors, shoulder retractors, hip extensors, and other postural
muscles.
• Aerobic training with brisk walking, cycling (with upright handle-
bars), swimming, or other aquatic therapy can help increase muscle
endurance.

65. Rehabilitation Intervention
Ankylosing Spondylitis
• Inflammation of the costochondral joints or costovertebral joints or
entheses may cause chest pain and inhibit deep breathing.
• Treatment with anti-inflammatory drugs and heat therapy may help
relieve pain and improve breathing patterns.
• Daily deep-breathing exercises with an emphasis on full rib cage expansion
are encouraged.
• Education about the postural alignment (e.g., measure body height, touch
the occipital protuberance to the wall while standing), and avoid a
stooped posture.
• A firm mattress and a small pillow or neck support are desirable for sleep.
• Lying on the side in a curved position should be avoided. Daily prone lying
for 10 to 15 minutes or more is recommended.
• Contact sports, cervical traction, or spinal manipulation should be
avoided.
• For enhancing activities of daily living, prism glasses, long-handled
devices, or a cane may be needed.

66. GOUT
Represent a heterogeneous group of diseases
found exclusively in humans that include the
following characteristics:
• Elevated serum urate concentration
(hyperuricemia)
• Recurrent attacks of acute arthritis in
which monosodium urate monohydrate
crystals are demonstrable in synovial fluid
leukocytes.
Gout often runs in families, probably because of inherited
factors affecting serum urate levels through renal urate clearance.
Certain foods promote hyperuricemia and gout, including
alcohol, seafood, and red meat.
The consumption of some foods, especially milk and yogurt,
might be protective.

67. Classification Criteria of Acute Gouty Arthritis
(Modified from Wallace)
The presence of characteristic urate crystals in the joint fluid, or a tophus proven to
contain urate crystals by chemical means or polarized light microscopy, or the
presence of 6 of the following clinical, laboratory, and radiographic phenomena:
• More than one attack of acute arthritis
• Maximal inflammation developed within 1 day
• Attack of monoarticular arthritis
• Joint redness observed
• First metatarsophalangeal joint painful or swollen
• Unilateral attack involving the first metatarsophalangeal joint
• Unilateral attack involving the tarsal joint
• Suspected tophus
• Hyperuricemia
• Asymmetric swelling within a joint (radiograph)
• Subcortical cysts without erosions (radiograph)
• Negative culture of joint fluid for microorganisms during attack
of joint inflammation

68. Treatment Options For Gout

69. Treat as early as possible
Therapeutic Options depending upon
severity, number of affected joints
and duration of attack
Education about the disease
Individual lifestyle Advice
Screening for comorbidities and current medication
Avoid
colchicine
Avoid colchicine
and NSAIDs
NSAIDs classics
or coxibs+ PPI
if appropriate
Colchicine
1mg
followed by
1 hour later
by 0.5mg Prednisolone
30-35 mg/day
for 5 days
Resolution
of flare
IA inj. of
corticosteroid
Combination therapy
colchicine + NSAIDs or
corticosteroid
Consider IL-
1 blocker
Educate for self medication
Consider initiation ULT
Together with flair
prophylaxis
Severe
renal
failure
Presence of strong
CYPA34 or P
glycoprotein
inhibitors
Contraindication to
colchicine + NSAIDs
or corticosteroid
P Richette et al. Ann Rheum Dis doi:10.1136/ annrheum dis- 2016-209707
2016 Eular recommendation for acute flare in gout
2016 EULAR recommendation for the management of flares in Patients with Gout

70. 2016 EULAR Recommendations for Management of
hyperuricaemia & gout

71. Contd...