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Rheumatology in Sports Medicine

Rheumatology in Sports Medicine. Rich Derby, LtCol, USAF Dewitt Sports Fellowship Oct, 2009. Objectives. Case review / presentation of specific rheumatologic conditions Making the diagnosis Management considerations for specific conditions Role of exercise. Rheumatology.

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Rheumatology in Sports Medicine

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  1. Rheumatologyin Sports Medicine Rich Derby, LtCol, USAF Dewitt Sports Fellowship Oct, 2009

  2. Objectives • Case review / presentation of specific rheumatologic conditions • Making the diagnosis • Management considerations for specific conditions • Role of exercise

  3. Rheumatology “A subspecialty concerned with the study of inflammatory or degenerative processes and metabolic derangement of connective tissue structures which pertain to a variety of musculoskeletal disorders.” Pathophysiology of many rheumatic conditions are immunologic in nature – thus immunology and genetics plays highly in rheumatology subspecialty

  4. Impact of Rheumatologic disease ‘An estimated 15% (40 million) of Americans had some form of arthritis in 1995. By the year 2020, an estimated 18.2% (59.4million) will be affected.’ (national arthritis data workgroup) Lawrence RC, et al. Estimate of the prevalence of arthritis and selected musculoskeletal disorders in the united states. Arthritis & Rheumatism. Vol. 41, No. 5, May 1998, pp 778-799

  5. Narrowing focus of Rheum conditions to sports med • Patient cases • Age • Location of condition • Severity / associations • Differential dx considerations • Condition management • Role of exercise • A few pony/zebras to ponder

  6. Case 1 • 10 y/o notes to mom lower back pain for at least 3 months • No fevers, no rash • No acute trauma, surgery, inciting event • Active with soccer …chronic heel pain treated as Severs

  7. Consider the ddx • Muscular strain/overuse • Spondylolysis/lithesis • Juvenile Idiopathic Arthritis • Diskitis • Neoplastic process • Fracture • Others….

  8. Juvenile Idiopathic Arthritis • Approximately 300K annualized incidence in US kids** • Lumps a fairly large variety of arthritis conditions • Durbin criteria categorizes majority of conditions (80%) into 7 subsets • Hallmark – chronic arthritis in those < 16 lasting for > 6 weeks.

  9. JIA Classification • Systemic • Pauci/Oligo articular • Polyarticular RF(-) • Polyarticular RF(+) • Enthesitis-related • Psoriatic • Undifferentiated Subsets of previously defined JRA 80%

  10. Systemic (10-15%): M=F ; < 17 y/o Any joint Fever, lymphadenopathy, hepatosplenomegaly, rash Leukocystosis, anemia, elevated ESR, ANA/RF(-) >50% destructive joint Pauciarticular(50%): F>M ; <10 y/o Large joints; < 4 Uveitis Elevated ESR, low ANA Rare destruction of joints Polyarticular(35-40%) RF(-): F>M ; <10 y/o Any joint; > 5 Uveitis Elevated ESR, mild anemia, low ANA RF(+): F>M; 10-14 y/o Destruction of joints >50% ? Early onset of adult RA JRA Characteristics (65%)

  11. Enthesitis-related arthritisdiagnostic criteria • Arthritis and enthesitis (or) • Arthritis / enthesitis and two of the following: • S-I joint tenderness and/or inflammatory lumbosacral pain • HLA-B27 positive • Arthritis in a male > 6 years of age (M>>F incidence) • Acute anterior uveitis • Family History of ankylosing spondylitis, enthesitis-related arthritis, sacroiliitis with inflammatory bowel disease, Reiter’s syndrome or acute anterior uveitis

  12. Enthesitis-related arthritis • 8-13% of JIA • Highly correlative with spondyloarthopathy • Consider ankylosing spondylitis, reactive arthropathy, psoriatic, and enteritis/IBD related • Assess for enthesitis (Achilles, plantar facia), morning stiffness, decreased forward flexion (Schober test), FABER, psoriatic rash, and GI sx.

  13. SCHOBER TEST Mark spinous process of L5. With pt erect measure 10cm superior from L5 and mark. Pt forward flexes to maximally without bending knees. Measure distance between marks Normal > 15 cm.

  14. Psoriatic Arthritis diagnostic criteria • Arthritis and psoriasis (or) • Arthritis and two of the following: • Dactylitis • Nail pitting or onycholysis • Psoriasis in a first-degree relative

  15. Psoriatic Arthritis • < 5% of JIA • Pauciarticular, asymmetric distribution • Associated with spondyloarthropathy, enthesitis, dactylitis, nail abnormalities, uveitis • Assess for rash, swollen digits, abnl nails, FABER, enthesopathies • Erosive ‘pencil in cup’ changes on xray

  16. Sausage digit Pitting, onycholysis Pencil in cup

  17. JIA management • Treatment varies on pattern/category • Rheumatology consultation • Meds • NSAIDS (usually first line / maintenance) • Corticosteroids (oral / articular) • Immunomodulators

  18. JIA and Exercise • No proven benefit of exercise for improving functional ability, quality of life, aerobic capacity or pain in JIA patients • No short term adverse effect of exercise were noted in studies • No exacerbation of arthritis symptoms • Low amount of adequate research Takken T, et al. Exercise therapy in juvenile idiopathis arthritis: a Cochrane Review. Eur J Phys Rehabil Med. 2008 Sep;44(3)287-97.

  19. that said… • Kids with JIA have higher risk for sedentary lifestyle, poor aerobic fitness, and poor muscular strength • Expert recommendation advocates exercise in JIA for other (disease independent) benefits • Balance exercise with symptoms, disease specific risks Klepper SE. Exercise in pediatric rheumatic diseases. Curr Opin Rheumatol. 2008 Sep:20(5);619-24.

  20. Case 2 • 25 y/o AD male with swollen painful knee for 3-4 weeks • No trauma • ROS questions? • Recent infection • Rash • GI sx • Eye / GU sx

  21. Consider the ddx • Septic Joint • GC, Staph/strep, salmonella… • Reactive Arthritis • Subacute infection related arthritis (lyme, viral, etc..) • Bursitis • Crystal-induced arthritis • Others….

  22. Reactive Arthritis (aka) Reiter’s Syndrome • 30-200 cases per 100 K (varies greatly by geography) • 20-40 year old range of pt; M>F • Lack of consensus criteria / definition • Arthritis following bacterial GI / GU infection • Hallmark is asymmetric, oligoarthritis of LE associated with conjunctivitis, urethritis, and other articular / non-articular findings

  23. Modified ACR criteria Arthritis > 1 month with uveitis / cervicitis Arthritis > 1 month and other urethritis or cervicitis or bil conjunctivitis Episode of arthritis and conjunctivitis Episode of arthritis > 1 month, urethritis, conjunctivitis 3rd International Workshop criteria-1996 Peripheral arthritis Predominately lower limb, asymmetric/oligo Plus Evidence of preceding infection Diarrhea/urethritis in prior 4 wks Exclusion of other causes

  24. Physical Asymmetric / oligoarthritis LE (15-30%) Sausage digit (16%) Enthesopatic pain: achilles, ischial tuberosity (30%) Sacroillitis (14-49%) Spondylitis (12-26%) Conjuctivitis (35%) GI (diarrhea/enteroscopic lesions) (25-70%) Circinate balanitis (4-20%) Kerratoderma blennorhagia (5-30%) Psoriasisform lesions palms/soles (10%) Oral ulcers (5-10%) Labs HLA B27 positive (50-85%) ANA/RF negative ESR/CRP elevated UA aseptic pyuria, +/- proteinuria Synovial fluid: neg cultures, 5-50K WBC, no crystals Rads Acutely: normal Chronic case: erosive changes, unilateral SI changes Features of reactive arthritis

  25. Reactive arthritis manifestations

  26. Arthritis NSAIDs Steroid injection Immunomodulators Mucocutaneous Topical steroids Eyes Optho c/s, steroids Mydriatics Antibiotics Rx if active infection established Growing evidence for prolonged rx (3-9 mo) Cipro bid Azithro 1g daily **for yersinia / chlamydia Management Kwiatkowska B, Filipowicz-Sosnowska A. Reactive arthritis. Pol Arch Med We. 2009;119(1-2):60-65.

  27. Course • Varied and unpredictable • 15-30% with chronic / recurrent arthritis, sacroillitis or progress to ankylosing spondylitis • Severe disability in fewer than 15% • Improved course/response with antibx treatment is area of growing interest.

  28. Case 3 • 35 y/o with muscle aches and overall fatigue • 6 months or more • Notes non-restorative sleep • No constitutional sx (fevers, wt changes…) • ‘Something is wrong with me’

  29. Consider the ddx FIBROMYALGIA • Myopathies • Autoimmune, med induced • Endocrine dysfunction • Thyroid, Glucose, Adrenal • Nutritional dysfunction • Vit D, B12 • Chronic fatigue syndrome • Myofascial pain syndrome • Psychiatric • Somatic d/o, anxiety, depression • ….OR

  30. Fibromyalgia • Affect 2-5% of adult US population • Women 10 x more common • 35-50 y/o • Average 10 health care visits yearly • Multiple associations • Headache, sleep disturbance, IBS, anxiety, depression, fatigue, cognitive difficulties, restless leg, PMS, parethesia, ………..

  31. 1990 ACR Diagnostic Criteria • Widespread pain involving both sides of the body, above and below the waist as well as the axial skeletal system, for at least 3 months • Presence of 11 tender points among the nine pairs of specified sites (18 points)

  32. The American College of Rheumatology 1990 Criteria recommended anatomic tender point locations for diagnosis of fibromyalgia.

  33. Considerations • Clinical diagnosis • Limited w/u (no consensus on labs) • Expand on hx (associated conditions) • Consider socio/economic influences • Family Hx • Assess function (http://www.myalgia.com/FIQ/fiq.pdf) • Etiology unclear / unproven • Disordered central pain processing • Wide variety of treatments • High non-response rate to any treatment chosen

  34. Management MULTIMODALITY Support group Aerobic exercise Medications Biofeedback Acupuncture Resistance training Self-help / study

  35. Medications • Amitriptyline (several trials) • Cyclobenzaprine (one trial) • Fluoxetine (2 RCTs) • Duloxetine (2 RCTs) • Milnacipran (1 RCT) • Tramadol ( 1 of 2 RCTs) • Pregalbin (1 RCT) Short term pain relief, some with secondary outcome improvements (sleep, fatigue) Abeles M, Solitar BM, Pillinger MH, Abelesa AM. Update on Fibromyalgia Therapy. The American Journal of Medicine (2008) 121, 555-561

  36. Aerobic Exercise The Ottawa Panel recommends aerobic fitness exercises for the management of fibromyalgia as a result of the emerging evidence shown in the literature.(grades A, B, and C+ although most trials were rated low quality) Brosseau L, Wells GA, et al. Ottawa Panel Evidence-Based Clinical Practice Guidelines for Aerobic Fitness Exercises in the Management of Fibromyalgia: Part 1. Physical Therapy. July 2008;88(7):857-71

  37. Resistance Exercise The Ottawa Panel recommends strengthening exercises for the management of fibromyalgia as a result of the emerging evidence shown in the literature.(grades A B, and C+ although most trials were rated low quality) Brosseau L, Wells GA, et al. Ottawa Panel Evidence-Based Clinical Practice Guidelines for Strengthening Exercises in the Management of Fibromyalgia: Part 2. Physical Therapy. July 2008;88(7):873-86

  38. Case 4 • 45 y/o with back pain & stiffness • Long subacute history, worse over last 3-4 mos • Worse in morning, gets better with exercise • No systemic symptoms • Gets fair result in pain relief from prn NSAIDs

  39. Consider the ddx • Low back pain (unspecified) • Red Flag dz • Neurologic, tumor, fx • Osteoarthritis / disk dz • Spondyloarthritis • Ankylosing Spondy, Reiter’s, enteropathic, psoriatic, undiff • others….

  40. Ankylosing spondylitis • Inflammatory back pain • Sx before 45 y/o; night pain; morning stiffness, improves with exercise • 68 to 197 per 100,000 depending on population • Associated with HLA-B27 • 1-2% of HLA-B27 positive adults • 10-30% with HLA-B27 & FHx in first degree relative • Labs generally unhelpful for diagnosis • 40-75% with positive inflammatory markers • 15% with mild normocytic anemia • X-ray findings may lag years behind symptoms

  41. Extra–spinous manifestations • Uveitis • Chest pain • Enthesitis • Psoriasis • Inflammatory bowel dz • Fatigue/wt loss • Pulmonary fibrosis Consider other categories of Spondyloarthropathies

  42. Multinational 3E Initiative consensus panel recommendations(467 of 2699 reviewed papers 1966-2006) • Diagnostic (3 recs) • Monitoring (3 recs) • Treatment (6 recs) Sidiropoulos PI, Hatemi G, et al. Evidence-based recommendation for the management of ankylosing spondylitis: systematic literature search of the 3E Initiative in Rheumatology involving a broad panel of experts and practising rheumatologists. Rheum. 2008;47:355-361.

  43. Diagnostic • AK likely if in setting of back pain > 3 months there is presence of several of following: • Inflammatory back pain, alternating buttock pain, response to NSAIDs, onset of sx before age 45, peripheral disease manifestations (arthritis, enthesitis, dactylitis), acute anterior uveitis, positive family history, HLA-B27 +, sacroiliitis/spondylitis by imaging • For early diagnosis no additional imaging required if definite changes of sacroiliitis on xray. If equivical MRI is best imaging modality • Pt with > 3 mo chronic LBP and features of inflammatory back pain should be referred to rheum

  44. Monitoring • Useful measures to assess disease activity • BASDAI, CRP/ESR, extraarticular manifestation • Useful measures to assess disease severity • BASMI, XRAY, hip & extraarticular manifestations • Predictors of poor prognosis • Radiographic structural changes of spine at initial assessment, young age onset, persistently elevated acute phase reactants and dz activity

  45. Management • Bisphosphonates: useful for osteoporosis but insufficient data for rx of active AS • NSAIDs / steroid injection useful for enthesitis in AS • NSAID first line for pain and daily function (no significant difference long/short acting or COX-2) • May require continuous NSAID – consider COX-2 for GI protection • Axial symptoms are most responsive to NSAIDs • NSAID may precipitate first presentation of IBD – requires monitoring and possible GI consult

  46. Exercise Recommendations • Physiotherapy and ‘spa’ exercises are important components of management • Group treatment/program better than home exercise program Dagfinrud H, Hagen KB, Kvien TK. Physiotherapy interventions for ankylosing spondylitis. Cochrane Database, Issue 3, 2009

  47. Course • Variable • mild/self-limited to severe/disabling • Spontaneous remissions and exacerbations • Consider prognostic indicators • Most maintain good functional capacity • ? Effect on life expectancy • Surgery in severe cases helpful • Hip arthroplasty, wedge osteotomy • Swimming is an ideal exercise activity

  48. 55 y/o with hand pain Worsen pain over last few months Knuckles swollen No constitutional sx “Mom had arthritis so I’m sure I got it too” Prn NSAID / tylenol helps some Case 5

  49. Consider the ddx • Arthritis • Arthritis • Arthritis • Arthritis What brand though? - RA or OA - other collagen vasc dz

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