the presentation gives a detail information about the seronegative spondyloarthropathy. this ppt also provide recent evidences to frame the rehab protocol.

1. SERONEGATIVE
SPONDYLOARTHROPATH
Y
PRESENTED BY
SANA MASROOR
MPT (ORTHO.)- 3RD SEM.
JAMIA MILLIA ISLAMIA
2018

2. Introduction
• The spondyloarthropathies (SpA) are a heterogeneous group of chronic inflammatory rheumatic
disorders that share characteristic clinical features including inflammatory back pain, asymmetric
peripheral arthritis, enthesitis, dactylitis, and tenosynovitis; genetic predisposition (HLA-B27); and
extra-articular manifestations (A. S Duba et al., 2018).
• There are other gene also involved, including the interleukin-1 family gene cluster. (Timms AE et al.,
2004)
• "Seronegative" refers to the fact that these diseases are negative for rheumatoid factor, indicating a
different pathophysiological mechanism of disease than what is commonly seen in rheumatoid arthritis.
Duba, A. S., & Mathew, S. D. (2018). The Seronegative Spondyloarthropathies. Primary Care: Clinics in Office Practice, 45(2), 271-287.
2

3. • Spondyloarthropathy is a word that describes a group of conditions that all share
two common characteristics. First, there is the presence of arthritis that affects the
spine or extremities with evidence of family inheritance. Secondly, inflammation occurs
in the ligaments, tendons, and occasionally in organs such as the eye ( Langley R et al.,
2005).
3

4. Prevalence
• Axial SpA is a common disease entity and the prevalence has been documented by a number of epidemiological
studies using different methods.
• In the USA, the prevalence of all SpA is about 1% , and for AS about 0.5% (Helmick CG et al 2008 & Reveille
JD,et al, 2012 )
• Around the world, the prevalence of SpA is variable; 0.1-1% in South Asia and Southeast Asia, 0.5% in France
and Greece, 1% in Italy, Turkey, and China, and 1.9% in Germany (Akkoc N et al,2008 & Stolwijk C,et al 2012).
• The HLA prevalence in the general Indian population was found to be varying between 26% with relatively lower
positivity seen in the South Indian population.
• HLA-B27 positivity was found in 53%, 80% and 93% of Arab, Indian Subcontinent and Caucasian AS patients,
respectively, and 50%, 25% and 33% of the same respective ethnicties in ‘other SpA’ patients.
Quraishi, M. K., Badsha, H., Khan, B., Shahzeb, M., Hegde, S., Mofti, A., & Ooi, K. K. (2018). Interethnic Variations and Clinical Features of Spondyloarthropathies in a Middle
Eastern Country. The open rheumatology journal, 12, 10.
4

5. Classification
• In 1974, Moll and coworkers1 established the concept of seronegative SpA in patients with
inflammatory arthritis who were rheumatoid factor (RF) negative. Moll and coworkers
described five distinct subtypes of SpA:
(1) ankylosing spondylitis (AS),
(2) psoriatic arthritis (PsA),
(3) reactive arthritis (ReA),
(4) enteropathic arthritis (EnA), and
(5) undifferentiated SpA.
5

6. Diagnostic criteria
• The initial axial SpA manifestation is sacroiliitis, diagnosed on a radiological examination
on the basis of modified new york criteria of 1984.
• Sacroiliitis on the radiograph is the diagnostic criteria for SpA according to European
Spondyloarthropathy Study Group Criteria (ESSG) and Amor criteria.
• But not optimal
Sieper, J., Rudwaleit, M., Baraliakos, X., Brandt, J., Braun, J., Burgos-Vargas, R., ... & Van Der Heijde, D. (2009). The Assessment of
SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Annals of the rheumatic diseases, 68(Suppl 2), ii1-
ii44.
6

7. 7

8. 8

9. Rudwaleit, M. V., Van Der Heijde, D., Landewé, R., Akkoc, N., Brandt, J., Chou, C. T., ... & Van den Bosch, F. (2011). The Assessment of
SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Annals of the rheumatic
diseases, 70(1), 25-31. 9

10. 10

11. Inflammatory low back pain
• Inflammatory back pain is the leading symptom of the SpA and mirrors inflammation of SI joints, spine and
spinal entheses.
• Clinical history has been proposed as a screening test to identify patients with SpA among those who have
chronic back pain. (Rudwaleit M et al., 2006)
• Although IBP is considered as the foremost clinical symptom for axial SpA, its sensitivity and specificity with
respect to diagnosis of axial SpA does not exceed 80%. (Sieper J et al., 2009)
11

12. Sieper, J., Rudwaleit, M., Baraliakos, X., Brandt, J., Braun, J., Burgos-Vargas, R., ... & Van Der Heijde, D. (2009). The Assessment of SpondyloArthritis international Society
(ASAS) handbook: a guide to assess spondyloarthritis. Annals of the rheumatic diseases, 68(Suppl 2), ii1-ii44.
12

13. Ankylosing Spondylitis
13

14. Introduction
• Ankylosing spondylitis (AS), a chronic inflammatory disease, mainly affects the axial skeleton, peripheral
joints, and tendons. History of uveitis, positive family history for AS, impaired spinal mobility or chest
expansion supports the diagnosis (Ozgur Akgul et al., 2011); Khan MA et al., 2002).
• The main AS symptoms are pain, muscle stiffness, decreased function activity, and decreased spinal mobility.
These symptoms are often accompanied by sleep disturbances and psychological problems, such as depression
(WD Chang et al., 2016).
• The disease first manifests before the age of 40, and has a male predominance of 3:1(Taurog J et al., 2016)
• HLA-B27 and its association with AS was discovered in 1973, and is found in greater than 90% of patients
with AS (Bowness P et al., 2015).
14

15. Etiology
• AS is genetically determined immunopathological disorder.
• Common among HLA-B 27 positive
• There are various triggering factor that initiates abnormal immune response, which target the HLA-B27
positive cell.
• In autoimmune model, HLA-B27 predicted to generate auto reactive CD-8 Tcells through its normal role
of antigen presentation.
• In an animal model study, it was concluded that the spondyloarthritis HLA-B27 over expressing rat model
develop disease in the absence of CD-8 T cells, simply over expressing TNF-α in mice model is sufficient
to generate enthesiopathy, polyarthritis and IBD (Judith A Smith et al., 2015).
15

16. Clinically relevant anatomy
• Pain in AS can be caused by sacroiliitis, enthesitis and spondylitis.
• Initially the sacroiliac joints, situated in the lumbar part of the back, which connect the spine and the pelvis,
are damaged. Subsequently the inflammation moves to entheses, where ligaments and tendons integrate into
bone → spine is affected by this inflammation.
• Patients diagnosed with AS form calcium deposits in the ligaments between and around the intervertebral
discs.
• An accumulation of the deposits leads to ossification, starting from the vertebral rim towards the annulus
fibrosis and characterised by syndesmophytes.
• In highly advanced cases, the spine can fuse together as a result of the bone formation. 16

17. Tam, L. S., Gu, J., & Yu, D. (2010). Pathogenesis of ankylosing spondylitis. Nature Reviews Rheumatology, 6(7), 399.
17

18. Pathology
Inflammatory reaction with cell
infiltration, granulation tissue
formation and erosion of adjacent
bone
Replacement of the granulation
tissue by fibrous tissue
Ossification of the fibrous tissue
leading to ankylosis of the joint
18

19. 19

20. Clinical features
 Main clinical feature - Inflammatory back pain (Sacroiliitis)
 Inflammation at other locations in the axial skeleton.
 Peripheral arthritis.
 Enthesitis. (McGonagle Det al., 1998)
 Anterior uveitis. (Martin TM et al., 2002)
 Manifestations in other organ (Lautermann D et al., 2002)
Characteristic symptoms and physical findings:
• Spinal stiffness
• Loss of spinal mobility: With restrictions of flexion, extension of the LS
• Structural damage
• Limited expansion of the chest
• Lumbar lordosis is destroyed, the buttocks atrophy, and the neck may stoop forward.
20

21. Gyurcsik, Z. N., András, A., Bodnár, N., Szekanecz, Z., & Szántó, S. (2012). Improvement in pain intensity, spine stiffness, and mobility during a
controlled individualized physiotherapy program in ankylosing spondylitis. Rheumatology international, 32(12), 3931-3936.
21

22. Diagnostic procedure
• Laboratory data include blood tests to determine the presence of the substances that indicate an inflammatory
process:
• Erythrocyte sedimentation rate (ESR)
• C-reactive proteins (CRP): This is also a marker of inflammation and is found in 50-70% of people with AS.
• HLA-B27 antigen: HLA B27 is positive in 80-90% of AS patients.
• X-ray shows up areas where the bone has been worn away by the condition.
• MRI scanning may also be useful in identifying early sacroiliitis.
• Radiographic findings are graded on a scale of 0 to 4 where 0 represents normal findings and 4 represents
complete ankylosis. 22

23. Radiological grading of sacroiliitis
23

24. Radiologic scoring
methods for ankylosing
spondylitis
BASRI – Bath AS Radiology Index:
The BASRI-spine method suffers from a substantial
ceiling effect when compared with mSASSS and it
is insensitive for minor radiological changes, but can
also be used for quantification of disease
progression in AS. For evaluation of the sacro-iliac
joints, the New York criteria for sacroiliitis can be
integrated in BASRI by establishing the mean score
of both SI joints (0-4).
Jang JH, et al. Ankylosing spondylitis: patterns of radiographic involvement - a re-examination of accepted principles in a cohort of 769 patients.
Radiology (2011) Vol 258 (1): 192-198
24

25. Braun, J., & Baraliakos, X. (2011). Imaging of axial spondyloarthritis including ankylosing spondylitis. Annals of the Rheumatic
Diseases, 70(Suppl 1), i97–i103.
25

26. • The prefered method for scoring chronic changes of the spine in clinical studies is currently the Modified
Stoke Ankylosing Spondylitis Spine Score (mSASSS), which investigates only lateral views of the
cervical and lumbar spine and scores for corner erosions, sclerosis, syndesmophytes and bone bridging. It
showed better reproducibility both intra and inter-observer and better sensitivity to change.
Ramiro S, et al. Scoring radiographic progression in ankylosing spondylitis: should we use the modified Stoke Ankylosing Spondylitis Spine score
(mSASSS) or the Radiographic Ankylosing Spondylitis Spinal Score (RASSS)? Arthritis Research and Therapy (2013) 15:R14
26

27. Standard questionnaires can also be used as part of the assessment to build a picture of the
evolution of the disease.Available questionnaires include:
• AMOR criteria for Spondyloarthritis
• BASDAI index ( Bath Ankylosing Spondylitis Disease Activity Index)
• BASMI (Bath Ankylosing spondylitis Metrology Index)
• BASFI index ( Bath Ankylosing Spondylitis Functional Index)
• BAS-G index ( Bath Ankylosing Spondylitis Global Index)
Chelsea L. Jordan et al., Differential Diagnosis and Management of Ankylosing Spondylitis Masked as Adhesive Capsulitis: A
Resident's Case Problem, Journal of Orthopaedic & Sports Physical Therapy, 2012: 842–852. 27

28. • BASFI (Bath Ankylosing Spondylitis Functional Index); is 10item index that evaluate the functional capacity in per-
forming daily activities of patients with AS. The average of the results of the ten scales is the BASFI score (0–10), with
higher values indicating greater impairment in functional capacity.
• BASDAI (Bath Ankylosing Spondylitis Disease ActivityIndex) is the gold standard for measuring and evaluating
disease activity in AS. Patients answered 6 questions pertaining to the 5 major symptoms of AS: fatigue, spinal pain and
joint pain/swelling, areas of localized tenderness, morning stiffness duration, and morning stiffness severity. The final
score ranges from 0 to 10 with higher score suggesting suboptimal control of disease.
• BASMI (Bath Ankylosing Spondylitis Metrology Index) which consists of five steps: cervical rotation, tragus to wall
distance, lumbar side flexion, modified Schober’s and inter-malleolar distance. Patients repeated each measurement three
times and the best of them was used. Each is allocated on a numerical scale from zero to ten and the finals core of BASMI
is the arithmetic mean of the five values, the end result may vary from 0 to 10.
de Souza, M. C., Jennings, F., Morimoto, H., & Natour, J. (2017). Swiss ball exercises improve muscle strength and walking performance in ankylosing
spondylitis: a randomized controlled trial. Revista Brasileira de Reumatologia (English Edition), 57(1), 45-55.
28

29. 29

30. SASDAS was calculated by simple linear
addition of five components:
• patient global assessment (VAS 0–10 cm),
• back pain (BASDAI question no. 2, 0–10
cm),
• peripheral pain and swelling (BASDAI
question no. 3, 0–10 cm),
• duration of morning stiffness (BASDAI
question no. 6, 0–10 cm), and
• ESR in millimetres per hour, divided by 10.
Bansal, N., Duggal, L., & Jain, N. (2017). Validity of Simplified Ankylosing Spondylitis Disease Activity Scores (SASDAS) in Indian Ankylosing Spondylitis
Patients. Journal of clinical and diagnostic research: JCDR, 11(9), OC06.
30

31. Examination
• Lumbar Flexion (modified Schober’s)
• Lumbar Side Flexion
• Tragus to Wall
• Cervical Rotation
• Intermalleolar Distance
• Chest Expansion
31

32. Health-related QOL in patients with Ankylosing spondylitis
Specific instruments for the assessment of QoL in AS are:
• Ankylosing Spondylitis Quality of Life (ASQoL) (Doward LC et al., 2003)
• The Evaluation of Ankylosing Spondylitis Quality of Life (EASI-QoL) (Haywood KL et al., 2010).
• The AS Arthritis Impact Measurement Scales 2 (AS-AIMS 2) (Guillemin F, et al., 1999)
• The Patient Generated Index – Ankylosing Spondylitis. (PGI-AS) (Haywood KL et al., 2003)
32

33. Tool/Instrument No of items Contents Response Duration Evidence Reference
ASQoL 18 HRQoL (sleep, mood,
motivation, coping,
relationships, social life)
Yes/ no 4 min Cronbach’s
a = 0.89–0.92
Test–retest
r = 0.91–0.92
Doward LC et al.,
2003
Easi- QoL 20 Physical function, disease
activity, emotional well-being,
social participation
5 point categorical 5 min Cronbach’s
a = 0.88–0.92
Test–retest
r = 0.88–0.93
Haywood KL et al.,
2010
AS-AIMS 2 63
(61 items if
patient does
not drive a
car)
Physical, affect,
symptoms, role, social
interaction
5 point categorical No data
available
(original AIMS
2 = 23 min
Cronbach’s
a = 0.78–0.91
Test–retest
r = 0.69–0.9
Guillemin F et al.,
1999
PGI-AS 7 items –
single index
5 domains identified
by patients, 1 domain
related to comorbidities and 1
domain related to nonhealth-
related problems
10 point
descriptive plus
weighting.
Patients list the
most important
areas of their lives
are affected by AS
No data
available
Cronbach’s a = no
data available
Closed format
(r = 0.88 [0.81–
0.92])
Blind format (r =
0.82 [0.72–0.88])
Haywood K et al.,
2003
Kotsis, K., Voulgari, P. V., Drosos, A. A., Carvalho, A. F., & Hyphantis, T. (2014). Health-related quality of life in patients with ankylosing spondylitis: a
comprehensive review. Expert review of pharmacoeconomics & outcomes research, 14(6), 857-872.
33

34. MANAGEMENT
• Medical management
• Biological management
• Physiotherapy management
2016 Update of the ASAS-EULAR recommendations for the management of axSpA (van
der Heijde, D et al., 2016).
34

35. 35

36. Exercise for Ankylosing Spondylitis (AS): A Consensus Statement
• Recommendation 1: Assessment
• Recommendation 2: Monitoring
• Recommendation 3 : Safety
• Recommendation 4: Disease Management
• Recommendation 5: AS-Specific Exercise – Mobility
• Recommendation 6: AS-Specific Exercise –Other
• Recommendation 7: Physical Activity
• Recommendation 8: Dosage
• Recommendation 9: Adherence
• Recommendation 10: Exercise Setting
Millner, J. R., Barron, J. S., Beinke, K. M., Butterworth, R. H., Chasle, B. E., Dutton, L. J., ... & Pickering, K. A. (2016, February). Exercise for ankylosing
spondylitis: An evidence-based consensus statement. In Seminars in arthritis and rheumatism (Vol. 45, No. 4, pp. 411-427). WB Saunders.36

37. Physiotherapy management
• It aims to alleviate pain, increase spinal mobility and functional capacity,
reduce morning stiffness, correct postural deformities, increase mobility
and improve the psychosocial status of the patients.
• Treatment is essentially to minimize or prevent deformity
37

38. • A exercise routine with postural correction can be applied to delay, and possibly stop, the progression of the disease.
Spinal extension exercises are the key component and should be done twice daily.
• Proper sleeping posture on a solid, flat bed without pillow. Frequent sleeping or lying in prone position.
• Posture exercises with upper back hyperextension (performed with avoidance of lumbar hyperextension).
• Breathing exercises to increase or maintain rib cage excursion, as well as instruction in abdominothoracic breathing.
• Range of motion exercises for hips and knees to prevent flexion limitation and contractures.
• Periodic rest periods with avoidance of fatigue.
• Bracing or corseting (combined with exercises)
• Manual mobilisation improves chest expansion, posture and spinal mobility.
• Aerobic exercises
• Hydrotherapy/Aquatic Physiotherapy
• Group therapy
38

39. Exercise Type Methods Recommended
Dosage
Effects on Pulmonary Function
Incentive Spirometry
(Min Wook So, et al.
2012)
46 subjects with AS randomly allocated into conventional
exercise group and combination exercise group. CE
received flexibility and motion ex. And ISE instructed
how to use the incentive spirometer
30 Minute Sessions,
Once Per Day, For
16 Weeks
The patients given a combination
treatment also improved
significantly in pulmonary
functions (FVC, TLC, and VC)
Inspiratory Muscle
Training
(Drăgoi RG, et al
2015):
54 subjects of AS randomly allocated into group 1 who
received IM T with CE and group 2, received CE only.
Once a week group session for 40 minutes and home
exercise program five a day per week.
IMT three times a
week- 24sessions-
8weeks.
CE-8weeks
Increased Aerobic Capacity,
Improved Resting Pulmonary
Function and Ventilatory
Efficiency.
Manual Mobilisation
(Widberg K, et al.
2009)
32 subjects randomly allocated into treatment group and
control group. Treatment group received
physiotherapeutic intervention with a guidance of home
ex program and control group encourage to performed
their usual physical exercise.
1 Hour Sessions, 2
Times Per Week,
for 8 Weeks
Improved Chest Expansion,
Posture and Spinal Mobility
Aerobic Exercise
(Ozgocmen S, et al.
2012)
Research shows that in the short term aerobic exercise has
a major effect of all symptoms relating to ankylosing
spondylitis. Although there is no bad form of aerobic
exercise, studies show that swimming is the best for
pulmonary rehabilitation. Studies also show that high
impact contact sports should be avoided as this can have a
negative impact on symptoms relating to AS
1 hour per day, 5
days per week
andintensity should
not achieve more
than 17 on the
BORG Scale
Improved Chest Expansion,
Improved Functional Capacity
and Decreases the Chance of
Respiratory Failure.
39

40. Strengthening ex on
Swiss ball (Marcelo
Cardoso de Souzaa et
al., 2017)
60 subjects with AS randomly allocated into
intervention group and control exercise group.
IG received resistive ex performe on a swiss
ball and CG remaines with medical treatment
only
8 ex twice a week- a
50min session for 16
weeks
Load determined by
1RM
The patients in IG show improvement in
muscle strength, walking performance and
patient satisfaction.
High intensity ex
(Silji Halvorsen et al.,
2014)
28 subjects of AS randomly allocated into ex
group who received strength and endurance
training and control group, received no
treatment.
Ex performed 60
minutes- 3 times a
week. Twice a week
under supervision
for 12 weeks
Patients in IG group improve the functional
status and reduces the CV morbidity risk
factor (↓ arterial stiffness, IL-17 and IL-
23), improve RH
Pilates, mckenzie,
hechscher training
and kinetotherapy
(Mihaela Oana Rosu
et al., 2014
96 subjects randomly allocated into group 1
and group 2. Group 1 received pilates,
mckenzie and hechscler training and group 2
encourage to performed their usual physical
receives multimodal therapy.
50min.- 3 times a
week for 48 weeks
After 48 weeks, there is significant
improvement in chest expansion, clinical
and functional AS-related parameters in
patients performing the original kinetic
program for a 48-week period. But training
combining Pilates, McKenzie and
Heckscher exercises should be regularly
used for the improvement of pain, spine
mobility and physical functioning, as well
as pulmonary function in patients with AS.
40

41. 41

42. • Hui Liang et al., 2015; suggest that home based exercise intervention may be beneficial at reducing
BASFI, BASDAI, depression and pain in AS.
• V. Dundar et al., 2014; concluded that 15min. Aquatic exercise at 32-33°C followed by after that
conventional exercise is effective in improving pain, general health and social component.
• Ana Zao et al., 2017; support the evidence that multimodal exercise in management of AS is beneficial
approach.
• Previously Gona Ince et al., 2006; also shown that multi modal approach for 3 month is effective in AS.
• Mateusz W Romanowski et al., 2017; compare deep tissue massage and therapeutic massage, daily for 2
week, result shown that both are effective in reducing pain so it could be incorporated as a adjunt therapy in
the management of AS.
• Agata Stanek et al., 2015; conclude that WBC for 3 minutes followed by kinesiotherapy have significance
effect in improving the BASDAI, BASFI and spinal mobility compare to kinesiotherapy alone.
• Duygun Silte et al., 2016; evaluate the effectiveness of therapeautic US with exercise therapy is safe and
effective treatment approach in AS.
42

43. Reiter’s Syndrome
• Reiter’s Syndrome is a reactive arthritis that develops in response to an infection and characterized by a
triad of arthritis, conjunctivits, and abacterial urethritis.
• It is considered an autoimmune disease marked by inflammatory synovitis and erosion at the insertion sites
of ligaments and tendons. It commonly occurs after the presence enteric infection. (CO Alebiosu, et al.
2004).
• Reiter's Syndrome is more commonly seen in males, but recently studies suggest that the incidence in
women is potentially underestimated. Women's symptoms tend to be less severe than men and women are
prone to genitourinary diseases often causing a misdiagnosis (Goodman CC et al., 2009).
• Individuals with the HLA-B27 genetic marker have an increased risk for developing Reiter's Syndrome
following sexual contact or exposure to a bacterial infection.
• There is a strong prevalence of Reiter's Syndrome in individuals with HIV.
43

44. Causes
• Reiter’s Syndrome usually follows an episode of bacillary dysentery, which is a bacterial infection
characterized by blood in the stool. Up to 85% of people with Reiter's possess the HLA-B27
association. Individuals with the appropriate genetic background can develop Reiter's Syndrome through
an enteric infection.
• Bacteria that most often cause infections and Reiter's syndrome are Chlamydia, Salmonella, Shigella,
Yersinia, and Campylobacter. These can be manifested from sexually transmitted diseases or
contaminated food.
• Reiter's Syndrome can not be transmitted from person to person. However, the bacteria that triggered the
disease can be passed on from one person to another.
44

45. Clinical characteristics
• Urethritis, conjunctivitis, and arthritis are the three symptoms classically associated with Reiter’s
Syndrome.
• Urethritis discharge is intermittent and may be asymptomatic.
• Conjuctivits is usually minimal. The arthritis is usually asymmetrical and
• Polyarticular arthritis, occuring in the large joints of the lower extremities, including the knees, ankles, and
1st metatarsophalangeal. In some cases, hand joints may be involved (Kasper DL et al., 2005).
• Individuals can also present with fungal infections (uveitis, keratitis) of the cornea.
• Individuals can present with three musculoskeletal manifestations including acute inflammatory arthritis,
inflammatory back pain, and enthesitis (Achilles tendon and ischial tuberosity, tibial tuberosity, illiac crest
and ribs)
45

46. 46

47. 47

48. Systemic Involvement
• Musculoskeletal manifestation are acute inflammatory arthritis, inflammatory back pain (in severe
cases), and enthesitis. Enthesitis is inflammation at the insertion of tendons and ligaments into bones.
Dactylitis or "sausage digit", plantar fasciitis, and Achilles tendinitis are the most common sites.
• Skin lesions are very similar to those of psoriasis.
• Constitutional symptoms include fatigue, malaise, fever, and weight loss.
• Cardiovascular involvement with aortitis, aortic insufficiency, and conduction defects occur rarely.
• Associated co-morbidites: Reiter's Syndrome is associated with and may be the presenting symptom
of HIV.
48

49. Diagnostic test
• The combination of peripheral arthritis with urethritis lasting longer than 1 month is necessary before the
diagnosis can be confirmed.
• Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein are detected.
• The presence of certain bacteria in urine samples, genital swabs, and stool cultures can be used to
identify the infection through laboratory tests.
• Radiographic abnormalities may include the classic features of ill-defined erosions, enthesopathy, bone
proliferation, early juxta-articular osteoporosis, uniform joint space loss and fusiform soft tissue
swelling (Jacobson JA et al., 2008).
• An MRI is the diagnostic imaging of choice to help diagnose Reiter's Syndrome. The affected bone will
present with a moth-eaten appearance, bony expansion, and loss of cortical definition
49

50. 50

51. 51

52. Medical Management
• Tetracyclin or erythromycin 500 mg taken orally 4 times per day for 10 days is recommended in treatment of
patients with Reiter's Syndrome due to sexual exposure.
• No treatment is necessary for conjunctivitis or mucocutaneous lesions, although topical opthalmic
glucocorticosteroids may be required to treat iritis .
• Arthritis is treated with NSAIDs . Enthesopathy may need to be treated with local injection of corticosteroids,
to decrease inflammation at the site of the injection.
• Surgery is rarely indicated but may include synovectomy, fusion, or tendon repair.
52

53. Physical Therapy Management
• Physical Therapy is helpful during the recovery phase of the disease (after exacerbation of symptoms has
ceased).
• Patient education is necessary to promote joint protection and proper body mechanics when performing daily
activities to maintain joint integrity.
• An exercise regimen that includes regular aerobic activity as well as exercises that promote joint range of
motion and muscles strengthening should be utilized.
• Aerobic exercise should include low impact activities, such as swimming, walking, or recumbent bike,
depending on the patient's cardiovascular level.
• Immobilization and inactivity are discouraged as they can lead to decreased range of motion, contractures,
joint stiffness, decreased muscle strength and decreased flexibility, as well as overall decreased cardiovascular
fitness, which can cause a cascade effect on other body systems. Goals of treatment should include pain
relief, improved activities of daily living, reduce joint swelling, prevention of joint damage and disability.
53

54. Psoriatic arthritis
• Psoriatic arthritis is a chronic progressive inflammatory joint disease that can be associated with psoriasis
(Goodman CC et al., 2009).
• The condition may affect both peripheral joints and the axial skeleton causing pain, stiffness, swelling, and
possible joint destruction.
• This joint pathology progresses slowly and can be more of a nuisance than disabling.
54

55. Prevalence
• Occurs in 6%-42% of persons that have psoriasis
• Approximately 2% of general population has psoriasis
• Psoriatic arthritis is estimated to have a prevalence of 0.1%-0.25% in the
US
• Equal prevalence in both males and females.
• Can occur at any age but typically occurs between ages of 30-50 years old
• 80-90% chance of having psoriatic arthritis if one of your first degree
relatives has the disorder (Fuller KS et al., 2009).
55

56. Causes
• Genetic: Having a first-degree relative with psoriatic arthritis increases the likelihood of
contracting the disease by 80-90%.There are currently genome studies being done to determine the
biomarkers associated with psoriatic arthritis (Fuller KS et al., 2009).
• Environmental: Trauma and infection may trigger the development of psoriatic arthritis.
• Immunologic: Cytokines have been found to be in high abundance in the joints of people with
psoriatic arthritis. Cytokines are inflammatory messengers that are released when T cells are
activated. Tumour necrosis factor is a specific cytokine that is abundant in the skin, blood, and
joints of patients with psoriatic arthritis and psoriasis (Dafna D. Gladman et al. 2016)
56

57. Five Clinical Presentations
1. Distal Interphalangeal Dominant - Only DIPs of fingers or toes are affected with nail changes often
present.
2. Symmetric Arthritis - This type resembles rheumatoid arthritis. Five or more joints will be affected
in a symmetrical pattern throughout the body.
3. Asymmetric Swelling - Four or less joints are affected in an asymmetrical pattern due to the
combination of IP arthritis and tenosynovitis.
4. Spondylitis - Inflammation in the spine. The neck, low back, and SI joints are often affected.
5. Arthritis Mutilans - This type is the most severe and destructive. Mutilation of the small joints of
fingers and toes often occurs. The fingers may appear sausage like due to swelling. This is the most
rare form, occurring in less than 1% of all cases.
57

58. 58

59. Diagnostic test
• There is no definitive test. Diagnosis is made by ruling out other conditions.
• X-rays are the current gold standard. However, signs of psoriatic arthritis often do not appear on
radiographs until later stages of the disease when bone erosion has occurred.
• Contrast enhanced ultra sound is starting to play a leading role since it can detect changes in bone and soft
tissue much sooner than X-rays.
• Ultrasound and MRI are both highly sensitive to early inflammatory joint changes that occur in psoriatic
arthritis.
• DIP erosive changes on X-rays may support the diagnosis.
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60. 60

61. • Blood work should be done to detect for the HLA-B27 since it is a common
histocompatibility complex marker in people with psoriatic arthritis.
• A blood test for rheumatoid factor should be done to rule out rheumatoid arthritis.
• A blood test for antinuclear antibody (ANA) should be done to rule out Lupus.
• CBC should be done to check for a reduction in red blood cells that sometimes occurs in
psoriatic arthritis.
• A joint aspiration may be done in which a syringe removes fluid from a joint. The fluid
is then examined for the presence of infection, crystals, and white blood cells.
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62. Diagnostic criteria
• The CASPAR (Classification of Psoriatic Arthritis) criteria should also help to identify PsA
early. While the criteria were established in patients who had long-standing disease, they work
just as well in patients with early disease. (Coates LC, et al 2012).
• Group for Research and Assessment of Psoriasis and PsA (GRAPPA) is developing criteria
to identify inflammatory arthritis. Since it is not feasible for all patients with psoriasis to be
reviewed by a rheumatologist, several groups have developed screening tools that can be
administered to patients (Int J Clin Rheum, 2009).
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63. 63

64. Group for Research and Assessment of Psoriasis and
PsA (GRAPPA)
64
Coates, L. C., Kavanaugh, A., Mease, P. J., Soriano, E. R., Laura Acosta‐Felquer, M., Armstrong, A. W., ... & Espinoza, L. R. (2016). Group for research
and assessment of psoriasis and psoriatic arthritis 2015 treatment recommendations for psoriatic arthritis. Arthritis & rheumatology, 68(5), 1060-1071.

65. Differential diagnosis
65
Armstrong AW, Mease PJ. Managing Patients with Psoriatic Disease: The Diagnosis and Pharmacologic Treatment of Psoriatic Arthritis in Patients with
Psoriasis. Drugs 2014;74:423-441

66. Medical Management
• Goals of treatment: Reduce pain, stiffness and swelling, inhibit disease progression, optimize function,
decrease effects of the disease, and improve the patients quality of life.
• Mild disease Non-steroidal Anti-Inflammatory Drugs (NSAIDS), Local Corticosteroid Injections (must be
careful because can cause flare up of psoriasis in some patients, Neither NSAIDS or intra articular
corticosteroids will stop structural joint damage
• Moderate to Severe Disease: Disease-Modifying antirheumatic drugs (DMARD) also called Slow-Acting
Anti-rheumatic Drugs-these drugs will suppress the disease activity (SAARD).; Anti- tumor necrosis factor:
should be used if patient do not respond well to NSAIDS or DMARDS. These can include adalimumab,
etanercept, golimumab and infliximab
• New Drugs: Otezla is a new drug that has been approved in 2014 for psoriatic arthritis. This drug is an oral
phosphodieasterase-4 (PDE-4) inhibitor that will decreases pro-inflammatory mediators and increases anti-
inflammatory mediators.
66Waldron N. Care and support of patients with psoriatic arthritis. Nursing Standard 2012;26:35-39.

67. Physiotherapy management
• Physical therapy can play an important role in improving the life of a person with psoriatic arthritis.
• The 2013 NICE Quality Standard for RA recommends that patients should be offered educational and
self-management activities within one month of diagnosis.
• Physical therapy management should focus on education, improvement of range of motion,
strengthening, and general cardiovascular conditioning. Physical therapists may also provide UV
therapy and modalities to decrease pain.
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68. • The rehabilitation treatment program for patients with psoriatic arthritis should be individualized and
should be started early in the disease process.
• Rest: Local and systemic
• Exercise: Passive, active, stretching, strengthening, and endurance
• Modalities: Heat and cold treatments can temporarily relieve pain and reduce joint swelling
• Orthotics: Upper and lower extremities, spinal
• Assistive devices for gait and adaptive devices for self-care tasks: Including possible modifications to
homes and automobiles
• Education about the disease, energy conservation techniques, and joint protection
• Possible vocational readjustments
• Prolonged rest should be avoided to prevent the deleterious effects of immobility.
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69. • Recently studies have shown that hydrotherapy is also an effective treatment for patients with psoriatic
arthritis. Hydrotherapy has been shown to improve physical function, energy, sleep and relaxation,
cognitive function, work, and participation in patients with psoriatic arthritis ( Lindqvist MH et al., 2013).
• Resistance training is effective in improving physical capacity, disease activity and quality of life of
patients with psoriatic arthritis. The clinical improvements were not coupled to significant changes in
muscular strength (Silva DR et al, 2017).
• Combination of aerobic exercises (20 minutes, three times per week for two successive months) and NB-
UVB (Narrow band UVB- 311nm) offers important benefits and should be considered in rehabilitation of
patients with juvenile psoriatic arthritis (R K Elnaggar, 2015).
• Ultraviolet light A (UVA) is present in sunlight. Unlike UVB, UVA is relatively ineffective unless used
with a light-sensitizing medication psoralen, which is administered topically or orally (National Psoriasis
Foundation).
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70. References
Coates, L. C., Kavanaugh, A., Mease, P. J., Soriano, E. R., Laura Acosta‐Felquer, M., Armstrong, A. W., ... & Espinoza, L. R. (2016). Group for research and assessment of
psoriasis and psoriatic arthritis 2015 treatment recommendations for psoriatic arthritis. Arthritis & rheumatology, 68(5), 1060-1071.
Waldron N. Care and support of patients with psoriatic arthritis. Nursing Standard 2012;26:35-39.
Millner, J. R., Barron, J. S., Beinke, K. M., Butterworth, R. H., Chasle, B. E., Dutton, L. J., ... & Pickering, K. A. (2016, February). Exercise for ankylosing spondylitis: An evidence-
based consensus statement. In Seminars in arthritis and rheumatism (Vol. 45, No. 4, pp. 411-427). WB Saunders.
Kotsis, K., Voulgari, P. V., Drosos, A. A., Carvalho, A. F., & Hyphantis, T. (2014). Health-related quality of life in patients with ankylosing spondylitis: a comprehensive
review. Expert review of pharmacoeconomics & outcomes research, 14(6), 857-872.
Duba, A. S., & Mathew, S. D. (2018). The Seronegative Spondyloarthropathies. Primary Care: Clinics in Office Practice, 45(2), 271-287.
Gyurcsik, Z. N., András, A., Bodnár, N., Szekanecz, Z., & Szántó, S. (2012). Improvement in pain intensity, spine stiffness, and mobility during a controlled individualized
physiotherapy program in ankylosing spondylitis. Rheumatology international, 32(12), 3931-3936.
Jang JH, et al. Ankylosing spondylitis: patterns of radiographic involvement - a re-examination of accepted principles in a cohort of 769 patients. Radiology (2011) Vol 258 (1):
192-198
Braun, J., & Baraliakos, X. (2011). Imaging of axial spondyloarthritis including ankylosing spondylitis. Annals of the Rheumatic Diseases, 70(Suppl 1), i97–i103.
Sieper, J., Rudwaleit, M., Baraliakos, X., Brandt, J., Braun, J., Burgos-Vargas, R., ... & Van Der Heijde, D. (2009). The Assessment of SpondyloArthritis international Society
(ASAS) handbook: a guide to assess spondyloarthritis. Annals of the rheumatic diseases, 68(Suppl 2), ii1-ii44.
Roger-Silva, D., Natour, J., Moreira, E., & Jennings, F. (2018). A resistance exercise program improves functional capacity of patients with psoriatic arthritis: a randomized
controlled trial. Clinical rheumatology, 37(2), 389-395.
de Souza, M. C., Jennings, F., Morimoto, H., & Natour, J. (2017). Swiss ball exercises improve muscle strength and walking performance in ankylosing spondylitis: a randomized
controlled trial. Revista Brasileira de Reumatologia (English Edition), 57(1), 45-55.
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