Psoriatic Arthritis | BJC Health Connected Care

When is your back pain INFLAMMATORY? 0

Lumbar Spine Xray showing syndesmophytes

Dr Roberto Russo, Rheumatologist

The characteristic presenting symptom in the majority of patients with Spondyloarthritis (a group of diseases with the prototype being Ankylosing Spondylitis) is inflammatory back pain.

The definition of inflammatory back pain has been debated for many years. No single clinical feature of back pain is sufficiently specific nor sensitive and as such composite criteria have been developed.

The Calin criteria, published in 1977, suggested inflammatory back pain is present when back pain has 4 of the following 5 features:

Age at onset <40 years
Duration of pain > 3 months
Insidious onset
Improvement in pain with exercise
Presence of morning stiffness

The Berlin criteria followed in 2006, which defined inflammatory back pain as present when 2 of the following are present:

Morning stiffness >30 minutes
Improvement in back pain with exercise but not with rest
Alternating buttock pain
Waking during the second half of the night

Most recently, in 2009, the Assessment in SpondyloArthritis international Society (ASAS) gathered a panel of experts who put forward the following criteria:

Age at onset <40 years
Insidious onset
Improvement with exercise
No improvement with rest
Pain at night (with improvement upon getting up)

The ASAS group found that when 4 of the 5 features are present, the back pain was very likely to be inflammatory in nature (sensitivity of 77% and specificity of 91%).

In subsequent studies, the ASAS criteria was found to have the best overall performance, where as the Calin criteria was most sensitive and the Berlin criteria most specific.

In essence if patients present with back pain and have a number of the features presented above, then a spondyloarthritis should be considered and referral to a Rheumatologist is most appropriate.

Dr Roberto Russo is both a rheumatologist and a nuclear medicine physician, as well as a director of BJC Health. BJC Health provides coordinated, comprehensive, and colocated multidisciplinary care to achieve effective solutions for patients. We call this model of care, Connected Care. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.

This blog focuses on musculoskeletal disease, healthcare in general, and our Connected Care philosophy. Read More.

Posted on: 10-16-2011
Posted in: Ankylosing Spondylitis, Arthritis: inflammatory, Back & Neck, Psoriatic Arthritis

Linking Dermatologists to Rheumatologists 0

By Dr Irwin Lim, Rheumatologist

As a gross generalisation, my Sydney dermatology colleagues are very busy, and have short consultation times. In these minutes, they’ll undress the patient, have a look at the skin, & work out the management options. Since I’m being a little inflammatory (apologies in advance – my dermatology friends will forgive me), dermatologists only need to decide on 3 main options for the rash/skin lesion: let the passage of time pass & watch it, cut it out, or stick some steroid on it.

With regards Psoriasis, and in another gross generalisation (and this is unfortunately, probably accurate), many dermatologists will likely not have time to fully consider rheumatic manifestations. Up to 30% of patients with the autoimmune skin condition, psoriasis, will also have psoriatic arthritis.

While psoriatic arthritis can cause terrible joint deformity, in many, the symptoms and signs are much more subtle. Think tennis elbow or “heel spurs” or achilles pain (enthesopathy). Often, the problem is spinal pain that is instead attributed to “age” or some lifting injury. Or, the patient may have pain in the hands, feet or knees, often without obvious swelling.

The chance of psoriatic arthritis is higher when the patient with psoriasis has psoriatic nail disease. Typically, a very recognisable manifestation for the dermatologist.

How do we get dermatologists to pick up these manifestations and therefore direct their psoriasis patients to appropriate therapy for their joint, tendon, spine disease?

Improved awareness is one way. I’ve just returned from a combined dermatology & rheumatology weekend meeting. The meeting agenda was very good, with content relevant to both specialties. Importantly, there were combined sessions to highlight why our specialities need to work better together. Connected Care. Wouldn’t that be good?

A practical measure is the use of questionnaires. These could be handed out to psoriasis patients waiting in dermatology clinics. Once filled, they can be presented to the dermatologist. If the questionnaire suggests psoriatic arthritis, the referral can then be made to a rheumatology service. Fast, easy, efficient.

Dr Irwin Lim is a rheumatologist and a director of BJC Health.

BJC Health provides a connected care multidisciplinary team philosophy to deliver positive lifestyle outcomes through a holistic approach to those with degenerative & inflammatory arthritis, tendon injury and lifestyle diseases. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.

This blog focuses on arthritis-related diseases, healthcare in general, and our Connected Care philosophy.

Posted on: 08-21-2011
Posted in: Arthritis: inflammatory, Psoriatic Arthritis

Enthesopathy: If it’s not overuse, then what could it be? 0

Google images: Oxford Medicine Online

By Dr Roberto Russo, Rheumatologist

In my last post I introduced the enthesis, explaining that it is the site where the tendon (or other soft tissues) joins onto bone (hard tissue) to transmit force, which is either wanted or unwanted. In addition, I highlighted the close relationship between the enthesis and surrounding structures, such as the bursa and fat, forming what is known as the enthesis organ.

I wish now to bring that discussion forward and draw your attention to when things go wrong.

It is a simple concept to consider that when the forces put through an enthesis are larger than what that structure can withstand, then injury must follow. This is in fact true, and this form of enthesopathy is termed mechanical.

This is often encountered in the sporting population or in those who perform a repetitive task under load. However, I should point out that in this situation the enthesis is less likely to fail than the adjacent tendon or ligament, such that this population is more common to experience a tendon injury, termed a tendinopathy, or a ligament strain or rupture.

So if it is not mechanical, then what could it be?

As a Rheumatologist I wish this question were more frequently considered. That is because there are a number of medical conditions that can affect the enthesis, including most commonly a number of rheumatic diseases and a range of metabolic illnesses such as diabetes, high cholesterol, and other endocrine disorders.

Of the rheumatic diseases, a group of related conditions termed sero-negative arthropathies are characterized by inflammation/injury of the enthesis, termed enthesitis. They are termed sero-negative because those affected do not have an antibody in their blood called Rheumatoid Factor, which is seen in about 70% of those afflicted by Rheumatoid arthritis (which is also a condition associated with enthesitis). Other rheumatic diseases where enthesitis occurs include the arthritis caused by crystals, such as gout, and even osteoarthritis.

The sero-negative arthropathies are comprised of Ankylosing Spondylitis, Psoriatic arthritis, Reactive arthritis, and Enteropathic arthritis. Although as mentioned, they are related by the fact that Rheumatoid Factor is absent they also often share a genetic marker termed HLA-B27. This genetic marker is present in about 90% of those with Ankylosing Spondylitis and about 50% of those with Psoriatic arthritis. However, HLA-B27 is present in up to 10% of the ‘normal’ population and so there are other factors at play that will determine who will develop one of these diseases and who does not. What these factors are exactly is not as yet known, although an environmental agent is probably involved, which is most likely to be an infection (despite the fact that a specific causative infection has not been found). Therefore, the current idea is that these conditions develop in a genetically predisposed host who encounters a particular environmental factor at a time that is just right to trigger the disease.

So why does this sequence of events lead to an immune attack against the enthesis?

Well there are a number of theories but none that are certain. The most popular is that there is a similarity between the factor that triggered the disease and the structure of the enthesis attracting the attention of the immune system.

Whatever it is, what is certain is that the inflammation and injury that occurs at the enthesis results in pain and swelling, such that when the question is asked ‘if it is not mechanical, then what could it be?’; the answer ‘a rheumatic disease, such as a sero-negative athropathy’ should soon follow.

This blog focuses on musculoskeletal disease, healthcare in general, and our Connected Care philosophy. Read More.

Posted on: 07-22-2011
Posted in: Ankylosing Spondylitis, Arthritis: inflammatory, Autoimmune disease, Psoriatic Arthritis, Tendon & Ligament

Phil Mickelson & Psoriatic Arthritis 0

By Irwin Lim, Rheumatologist

It’s a good day for disease awareness when a celebrity actually “comes out” and tells the world that they have that disease.

In Australia, Kylie Minogue and Jane McGrath come to mind as their battles with breast cancer brought lots of media attention. The McGrath Foundation continues to make a big difference, both in its charitable activities and in maintaining a high public profile.

Arthritis gets much less press. Much less attention.

Golfer Phil Mickelson has recently been diagnosed with psoriatic arthritis. This high profile sportsman then teamed up with two pharmaceutical companies, Amgen and Pfizer, as well as with the Joint Smart Coalition (a shared project of both the National Psoriasis Foundation and the Arthritis Foundation) to help increase awareness of this disease.

A website called On Course with Phil has been set up as an education resource for those with psoriasis.

Psoriatic arthritis is not a pleasant disease to have as Phil discovered. It’s another arthritis that is often undiagnosed and poorly managed, due to general lack of awareness about it.

While we can feel sorry for Phil, it’s a win for disease awareness.

Dr Irwin Lim is a rheumatologist and a director of BJC Health.

This blog focuses on arthritis-related diseases, healthcare in general, and our Connected Care philosophy.

Stop Press: Stopping recurrent fractures after suffering a fracture from weak bones (osteoporosis) is a priority. We are going to run a Refracture Prevention Program at our Parramatta rooms to try & stop bones breaking.

Posted on: 03-20-2011
Posted in: Arthritis: inflammatory, Psoriatic Arthritis