Spondyloarthritis

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Original Editors - Els Bernaers

Top Contributors - Julie Schuermans, Kim Jackson, Els Bernaers, Admin, Rachael Lowe, Candace Goh, Lucinda hampton, 127.0.0.1, WikiSysop and Sehriban Ozmen  

Search Strategy[edit | edit source]

We used following databases:
• Pubmed
• Web of Knowledge
• Web of Science
• PEDro
The most frequently search terms:
• Spondyloarthritis
• Relevant structures
• Medical management
• Physical therapy
• Treatment
• Etiology
• Relevant anatomy
• …

Definition/Description[edit | edit source]

Spondyloarthritis is a name of a group of diseases that is included in a larger term 'arthritis'.[1][2][3][4] Inflammation can occur in spine, sacroiliac and peripheral joints as well near the attachments of tendons and ligaments.[3][4][5] This disease provokes to pain, stiffness and fatigue in back, legs and arms as in joints, ligaments and tendons.[3][6][7] Eruption, eye and intestinal problems may also occur.[1][3][4]
Spondyloarthritis in adults can be subdivided more specifically:[1][2][3][8][9][10][11]
- ankylosing spondylitis or Bechterew disease
- psoriatic arthritis[12]
- reactive arthritis[13]
- enteric arthritis
- undifferentiated arthritis

Clinically Relevant Anatomy[edit | edit source]

Spondyloarthritis is the overall name for a family of inflammatory rheumatic diseases. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Due to this fact, there is a large complexity. This is because there are several anatomic structures involved. We can assume that the inflammation can occur on all the joints of the spine. The facet joints, endplates, bone marrow, … every part of the spine can be affected by an inflammation. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Sacroiliitis in SpA is characterized by involvement of different joint structures. Whereas the iliac and the sacral side of the sacroiliac joints are almost equally affected, the dorsocaudal synovial part of the joint is involved significantly more often than the ventral part, especially in early disease. Sacroiliac enthesitis is not a special feature of early sacroiliac inflammation. There is a difference between axial and peripheral spondyloarthitis, with axial spondyloarthitis back pain and inflammation of the sacroiliac joints are the main complaints. In peripheral spondyloarthritis, the inflammation of peripheral joint and tendons are the main complaints. Further, spondyloarthritis can show an inflammation of peripheral joints (for example, knees and ankles), and tendons (for example, the Achilles tendon).Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Epidemiology /Etiology[edit | edit source]

 Spondyloarthritis is a pathology that specifically strikes young people.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The symptoms most frequently start before the age of 45. [14] It affects more males than females. [15][16]
Predisposition to spondyloarthritis, especially SpA, is determined largely by genetic factors.
The incidence rate is higher in populations with a higher prevalence of HLA-B27.[17]
Psoriatic skin lesions and colitis due to inflammatory bowel disease (IBD) have been considered as both basic, subtype-defining entities with their own genetic background (distinct from HLA-B27 genotype), and as manifestations of spondyloarthritis.[18]
There is a strong need to diagnose patients with SpA in an earlier stage; currently there is a delay of 5–10 years between onset of the first symptoms and diagnosis.[19][20]

Characteristics/Clinical Presentation[edit | edit source]

Symptoms that may occur with spondyloarthritis are pain, stiffness and fatigue in the back, legs and arms. There are no typical characteristics, because spondyloarthritis characterizes with more than one symptom.
Here are the most common characteristics.[2][6][7][9][12][21][22]
- back pain
- osteoporosis
- spinal fractures
- peripheral arthritis, usually asymmetric, relatively more in the lower limbs.([2][13][12])
- enteritis
- dactylitis
- inflammation of the heart valve – pneumonia
- extra articular disorders such as uveitis, skin porosiasis or inflammatory bowel disease
- strong familial aggregation of spondyloarthritis, psoriasis, IBD, uveitis
- association with HLA-B27
- no increased CRP and rheumatoid factor.
We see that significantly more women have knee pain as presenting symptom.[3][6][7][9][10][12]

We can assume that severity of symptoms can vary between individuals.[10]

All criteria developed so far (including the ESSG and Amor criteria) were developed as classification criteria, although they are often used as diagnostic criteria [23][24]

Differential Diagnosis[edit | edit source]

The disease starts with hip or low back pain. The most common symptom is intermittent pain that progressively gets worse thoughout the day, in the morning, and following intensive activity. [25]
Most patients experience back pain in the sacroiliac joints. However, pain can involve all the parts of the spine.
Pain relief is sometimes achieved by bending over. It is possible that a patient is not able to fully expand the chest due to the involvement of the joints between the ribs.

Diagnostic Procedures[edit | edit source]

Antecedents and physical examination are the major factors leading to diagnosis, although radiologic evidence of sacroiliitis is very helpful [26][27] In the early-1990s, two classification criteria, Amor and the European Spondyloarthropathy Study Group (ESSG), were proposed for diagnosing SpA [28][29]


Amor criteria for spondyloarthritis [30]:

Paramters
 Scoring
Clinical symptoms or past history of

Lumbar or dorsal pain at night or morning stiffness of lumbar or dorsal region

1
Asymmetric oligoarthritis
 2

Buttock pain
Or if alternate buttock pain

1

2

Sausage-like toe or digit
 2
Heel pain or other well- defined enthesitis
 2
Iritis
 2
Non- gonococcal urethritis or cervicitis within 1 month before the onset of arthritis

1

Acute diarrhoea within 1 month befor the onset of arthritis
1
Psoriasis, balanitis or inflammatory bowel disease ( ulcerative colitis or chrohn’s disease)
 2
Radiological findings
Sacroiliitis (bilateral grade 2 or unilaterale grade 3) 3
Genetic background
Presence of HLA-B27 or family history of ankylosing spondylitis, reactieve arthritis, uveitis, psoriasis or inflammatory bowel disease
 2
Response to treatment
Clear- cut improvement within 48 hours after non steroidal anti- inflammatory drug intake or rapid relapse of the pain after their discontinuation
 2

A patient is considered to be suffering from spondyloarthritis if the sum is ≥ 6


The need for a standardized, evidence-based approach to spondyloarthritis classification led to the development of the European Spondyloarthropathy Study Group (ESSG) [31] preliminary classification criteria for spondyloarthritis in 1991 [32]:
Inflammatory spinal pain or synovitis (asymmetric, predominantly in lower limbs) and any one of the following: [33]

  • Positive family history
  • Psoriasis
  • Inflammatory bowel disease
  • Acute diarrhea or urethritis or cervicitis preceding the arthritis
  • Alternate buttock pain
  • Enthesopathy
  • Radiological sacroilits

Another is the concept of IBP (Low Back Pain), which is defined as the presence of at least four of the following five parameters [34], [35]:

  1. Age at onset less than 40 years
  2. Insidious onset
  3. Improvement with exercise
  4. No improvement with rest
  5. Pain at night (with improvement upon getting up).

Studies are under way to define ASAS criteria for nonaxial (peripheral) SpA.
In the ASAS classification criteria, several SpA features are described. These features are called SpA features because they are frequently present in patients with SpA ,[36][37]

File:ASAS classification.png

The main features of an early diagnosis of any rheumatic disease, including spondyloarthritis, are clinical history, clinical symptoms, clinical examination, laboratory parameters and imaging. [38]
Clinical symptoms:

  • Inflammatory back pain
  • Arthritis ( swelling, joint effusion, or detected by imaging)
  • Accompanying features, including psoriasis, crohn-like colitis and anterior uveitis

Clinical history:

  • Family
  • Rheumatic symptoms
  • Accompanying features

Clinical examination:

  • Lateral flexion of the lumbar spine (<10cm)
  • Chest expansion (<4cm)
  • Cervical rotation (<70°)

Laboratory parameters:

  • HLA-B27
  • C- reactive protein
  • Erythrocyte sedimentation rate

Imaging:

  • Radiography
  • MRI
  • Ultrasonography

Outcome Measures[edit | edit source]

  • BASFI Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • BASDAI Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • BASMI Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title  The_Bath_Indices
  • Pain Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • ASQoL Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Questionnaire Rasch model: Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

- assessment of functional disability
- quality of life
- VAS for spinal pain
- joint pain
- global status
- fatigue
- duration of morning stiffness
- review of the systems
- falls and cardiovascular risks,
- self-helplessness as well as self-reported joint
- soft tissue pain.


Examination[edit | edit source]

Patients with spondyloarthritis will complain about back pain, fatigue and stiffness. The pain will decrease when the patients exercise, but will persist at they rest. It is common for the patient to have pain at night, this pain can improve when the patients gets out of bed and moves around. (this should improve when they get up).Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The motion of the lumbar spine of the patients will be limited in both the sagittal and the frontal planes. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Psoriasis, finger swelling, Crohn's disease or ulcerative colitis can be indicative for Spondyloarthritis.
NSAIDS have shown to help relieve symptoms

Sacroiliitis grade ≥ 2 bilaterally or grade 3 to 4 unilaterally is suggestive for SpA.
(grade 0: normal; grade I: some blurring of the joint margins - suspicious; grade II: minimal sclerosis with some erosion; grade III: definite sclerosis on both sides of joint 5 & severe erosions with widening of joint space with or without ankylosis; grade IV: complete ankylosis)  Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

There are also active inflammatory and chronic lesions that can be found on a MRI-scan (see images). Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
MRI1.png

Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleSieper et al. The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis


Laboratory testing
• Common presence of human leukocyte antigen-B27
• Elevated C-reactive protein
• Absence of rheumatoid factor Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Medical Management
[edit | edit source]

There is a wide range of pharmacological remedies to reduce the symptoms of spondyloarthritis. For example, NSAIDs, DMARD'S, corticosteroids, antibiotics and TNF-alpha blockers, each with their own specific improvement.[3][7][11][12][13][39] Whit some patients, a surgical treatment is recommended but this the widespread complications of the disease severity must be considered.[3]

Physical Therapy Management
[edit | edit source]

Physiotherapy
Apart from a drug treatment, physiotherapy is recommended.[5][11][40]
Education, for the patient and the further course of the disease, is helpful.[6]
It is important to start the treatment early to avoid chronic symptoms and loss of function as much as possible.[5][41][40]
It is important for these patients to do daily special stretching and strengthening exercises to maintain the strength and mobility in the joints and reduce pain and stiffness.[3][40][42]
Special attention should be given to a good posture of the patient.[40]

Key Research[edit | edit source]

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Resources
[edit | edit source]

add appropriate resources here

Clinical Bottom Line[edit | edit source]

add text here

Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

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  1. ↑ 1.0 1.1 1.2 Braun J. et al, Spondyloarthritides, Internist., 2011 May 19
  2. ↑ 2.0 2.1 2.2 Braun J., Sieper J., Spondyloarthritides., Z Rheumatol. 2010 Jul; 69(5):425-32
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Reveille J.D., Americain college of Rheumatology, 2005 Jun http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/spondyloarthritis.asp
  4. ↑ 4.0 4.1 4.2 Van Der Heijde D.M.F.M., Spondyloarthritis onderzoek – SPACE, Leids universitair Medisch Centrum, http://www.lumc.nl/con/2096/82547/81117042303221/
  5. ↑ 5.0 5.1 5.2 Van Reesema S., Zwart N., Spondylo-artritis, Ziekenhuis Deventer, http://www.dz.nl/reuma/folders/toonfolder-1056.html
  6. ↑ 6.0 6.1 6.2 6.3 Sieper J. et al, The assessment of spondyloarthritis International society handbook: a guide to assess spondyloarthritis., Ann Rheum Dis., 2009;68;1-44
  7. ↑ 7.0 7.1 7.2 7.3 Mease P.J., Psoriatic arthritis – update on pathophysiology, assessment, and management., Bull NYU Hosp Jt Dis.,2010;68(3):191-8
  8. ↑ Buschiazzo E. et al, Epidemiology of spondyloarthritis in Argentina, Am J Med Sci. 2011 Apr; 341(4):289-92
  9. ↑ 9.0 9.1 9.2 Van Den Berg R., How should we diagnose spondyloarthritis according to the ASAS classification criteria: a guide for practicing physicians, Pol Arch Med Wewn., 2010(11):452-7
  10. ↑ 10.0 10.1 10.2 Roussou E., Sultana S., Early spondyloarthritis in multiracial society: differences between gender, race, and disease subgroups with regard to first symptom at presentation, main problem that disease is causing to patients, and empolyment status., Rheumatol Int. 2011 Feb 17
  11. ↑ 11.0 11.1 11.2 Braun J., Therapy of spondyloarthritides. Adv Exp Med Biol., 2009;649:133-47
  12. ↑ 12.0 12.1 12.2 12.3 Slobodin G. et al, Psoriatic arthropathy: where now?, Isr Med Assoc J., 2009 Jul;11(7):430-4
  13. ↑ 13.0 13.1 Carter J.D. et al, Combination antibiotics as a treatment for chronic Chlamydia-induced reactive arthritis: a double blind, placebo controlled, prospective trial., Arthritis Rheum., 2010 May;62(5): 1298-307
  14. ↑ Braun J., Sieper J., Spondyloarthritides., Z Rheumatol. 2010 Jul; 69(5):425-32 :4: 2C
  15. ↑ Burgos-Vargas R.The assessment of the spondyloarthritis international society concept and criteria for the classification of axialspondyloarthritis and peripheral spondyloarthritis: A critical appraisal for the pediatric rheumatologist. Pediatric Rheumatology 2012, 10:14  : 2C
  16. ↑ Rudwaleit M .Et al. The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis. 2011;70(1):25.: 4
  17. ↑ Braun J, Sieper J. Early diagnosis of spondyloarthritis. Nature clinical practice rheumatology. october 2006 vol 2 no 10  : 2C
  18. ↑ Braun J, Sieper J. Early diagnosis of spondyloarthritis. Nature clinical practice rheumatology. october 2006 vol 2 no 10  : 2C
  19. ↑ Braun J, Sieper J. Early diagnosis of spondyloarthritis. Nature clinical practice rheumatology. october 2006 vol 2 no 10  : 2C
  20. ↑ Joachim Sieper, Martin Rudwaleit, Concepts and epidemiology of Spondyloarthritis Best Practice & Research Clinical Rheumatology Vol. 20, No. 3, pp. 401–417, 200 : 4
  21. ↑ Slobodin G., Recently diagnosed axial spondyloarthritis: gender differences and factors related to delay in diagnosis., Clin Rheumatol., 2011 Mar 1
  22. ↑ Colbert R.A., Early axial spondyloarthritis., Curr Opin Rheumatol., 2010 Sep;22(5):603-7
  23. ↑ Jürgen Braun* and Joachim Sieper†, Early diagnosis of spondyloarthritis , 2006 : 2C
  24. ↑ ozgur akgul, Classification criteria for spondyloarthropathies, , World J Orthop. 2011 December 18; 2(12): 107-115 : 2A
  25. ↑ Vanesa Cruzat & Raquel Cuchacovich & Luis R. Espinoza Undifferentiated Spondyloarthritis: Recent Clinical and Therapeutic Advances, , Curr Rheumatol Rep, 2010: 2A
  26. ↑ Amor B, Dougados M, Mijiyawa M: Criteria of the classification of spondyloarthropathies. Rev Rhum Mal Osteoartic 1990, 57:85–89. : 2A
  27. ↑ Rostom S, Dougados M, Gossec L. New tools for diagnosing spondyloarthropathy., Joint Bone Spine 2010; 77: 108-114 : 2A
  28. ↑ Amor B, Dougados M, Mijiyawa M: Criteria of the classification of spondyloarthropathies. Rev Rhum Mal Osteoartic 1990, 57:85–89. : 2A
  29. ↑ Dougados M, van der Linden S, Juhlin R, et al.: The European Spondyloarthropathy Study Group preliminary criteria for the classification of spondyloarthropathy. Arthritis Rheum 1991, 34:1218–1227. :2A
  30. ↑ Amor B, Dougados M, Listrat Vet al. Are classification criteria for spondylarthropathy useful as diagnostic criteria? Revue du Rhumatisme England Edition 1995; 62: 10–15. : 3C
  31. ↑ Joachim Sieper, Martin Rudwaleit, Concepts and epidemiology of Spondyloarthritis Best Practice &amp; Research Clinical Rheumatology Vol. 20, No. 3, pp. 401–417, 200 : 4
  32. ↑ Jürgen Braun* and Joachim Sieper†, Early diagnosis of spondyloarthritis , 2006: 2C
  33. ↑ Joachim Sieper, Martin Rudwaleit, Concepts and epidemiology of Spondyloarthritis Best Practice &amp; Research Clinical Rheumatology Vol. 20, No. 3, pp. 401–417, 200 : 4
  34. ↑ Vanesa Cruzat &amp; Raquel Cuchacovich &amp; Luis R. Espinoza Undifferentiated Spondyloarthritis: Recent Clinical and Therapeutic Advances, , Curr Rheumatol Rep, 2010: 2A
  35. ↑ Rosaline van den Berg, Désirée M.F.M. van der Heijde, How should we diagnose spondyloarthritis according to the ASAS classification criteria A guide for practicing physicians University Medical Centre, Leiden, The Netherlands, 2010 : 3B
  36. ↑ Rudaleit M, Landewe R, van der Heijde D, et al. The development of Assessment of SpondyloArthritis International Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis 2009, 68:777–783. : 2A
  37. ↑ Rosaline van den Berg, Désirée M.F.M. van der Heijde, How should we diagnose spondyloarthritis according to the ASAS classification criteria A guide for practicing physicians University Medical Centre, Leiden, The Netherlands, 2010 : 3B
  38. ↑ Jürgen Braun* and Joachim Sieper†, Early diagnosis of spondyloarthritis , 2006: 2C
  39. ↑ Rudwaleit M. et al, Effectiveness and safety of adalimumab in patients with ankylosing spondylitis or psoriatic arthritis and history of anti-tumor necrosis factor therapy., Arthritis Res Ther., 2010;12(3):R117
  40. ↑ 40.0 40.1 40.2 40.3 Maddali Bongi S., Del Rosso A., How to prescribe physical exercise in rheumatlogy., Reumatismo., 2010 Jan- mar;62(1):4-11
  41. ↑ Karapolat H. et al, Are swimming or aerobic excercise better than conventional excercise in ankylosing spondylitis patients? A randomized controlled study, Eur J Phys Rehabil Med., 2009 Dec;45(4):449-57
  42. ↑ Coronado R.A. et al, Spondyloarthritis in a patient with unilateral buttock pain and history of Chrohn disease., Phys Ther., 2010 May;90(5):784-92
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