The need to define musculoskeletal inflammation: a report from the GRAPPA 2010 annual meeting.

Psoriatic arthritis (PsA) is a form of spondyloarthritis, a group of conditions that share a spectrum of components including arthritis, enthesitis, dactylitis, and spine inflammation. In PsA, however, the unpredictable, heterogeneous, and often insidious involvement of joints or juxtaarticular tendons and ligaments can sometimes make clinical recognition of the disease a challenge. Underrecognition of PsA may be due to the absence of a single sensitive and specific diagnostic measure. Although the ClASsification of Psoriatic ARthritis (CASPAR) criteria introduced in 2006 have improved disease classification, they are designed to be applied to cases already diagnosed with inflammatory arthritis. Therefore, in order for these criteria to be applied, the clinician is required to recognize the presence of inflammatory arthritis, enthesitis, or spondylitis. At the 2010 annual meeting of GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis), the need to define inflammatory arthritis, enthesitis, dactylitis, and spondylitis, especially for nonrheumatologists, was discussed. Conclusions from breakout group discussions are summarized.

A historical perspective of the spondyloarthritis.

PURPOSE OF REVIEW: The history of ankylosing spondylitis, the main representative of the spondyloarthritides, is dating back to several thousand years BC and recently proven for medieval skeleton by HLA-B27 typing with modern molecular techniques. In modern time, the history of spondyloarthritis (SpA) is characterized by fluctuation between lumping and splitting. Actually, the recent advent of new classification criteria demands to discuss the consequences and clinical implications in the historical context of the development of the concept of SpA including the controversy of lumping and splitting. RECENT FINDINGS: The new Assessment of SpondyloArthritis International Society classification criteria for axial and peripheral SpA are primarily developed to provide support for clinical trials with biologicals and other treatment modalities, which intend to cover the whole spectrum, especially early clinical manifestations of spondyloarthritides. New insights into genetics and the evolving etiological role of Chlamydia in SpA including the most recent finding of the effective combination antibiotic therapy are major advances in the evolving history of SpA. SUMMARY: The concept of SpA is well accepted for the classification, diagnosis, and therapeutic management of a high proportion of individuals with inflammatory rheumatic conditions. For further advances research technologies are now available to enlarge the current body of clinical, immunologic, and genetic studies using pivotal microbiologic research and new antimicrobial therapeutic strategies.

Escalas de avaliação aplicadas à espondilite anquilosante pertinentes à fisioterapia / Ankylosing spondylitis evaluation scale related to physical therapy

A espondilite anquilosante (EA) é uma doença inflamatória crônica que acomete preferencialmente o esqueleto axial. A patologia evolui de forma insidiosa e é potencialmente debilitante, levando a redução da qualidade de vida dos indivíduos acometidos. Este estudo teve como objetivo realizar uma revisão literária das escalas de avaliação em EA (BASFI - Bath Ankylosing Spondylitis Functional Index, DFI - Dougado´s Functional Index, EVA – Escala Visual Analógica e BASDAI - Bath Ankylosing Spondylitis Disease Activity Index) pertinentes à fisioterapia, especificamente dos domínios: função, dor, mobilidade da coluna, rigidez e avaliação global do paciente, presentes na área SM-ARD/Fisioterapia. Foi abordada também uma escala de avaliação radiológica, SASSS (Stoke Ankylosing Spondylitis Spine Score). A revisão estendeu-se de outubro a dezembro de 2006, mediante pesquisas em livros de acervos particulares e públicos e em base de dados. Constatou-se neste estudo a necessidade da realização de pesquisas, metodologias ou complementos visando à validação de instrumentos no Brasil que sirvam de esclarecimento sobre o dinamismo e comportamento da EA diante da intervenção fisioterapêutica.

The Ankylosing Spondylitis (AS) is a chronic inflammatory disease that affects the axial skeleton. The pathology develops in an insidious way and it is potentially debilitated, taking reduction of the life quality. The objective of this study was to make a literature review of the evaluation scales in AS (BASFI - Bath Ankylosing Spondylitis Functional Index, DFI - Dougado´s Functional Index, VAS – Visual Analog Scale e BASDAI - Bath Ankylosing Spondylitis Disease Activity Index) related with physical therapy, specifically of the domains: function, pain, mobility of the column, rigidity and the patient's global evaluation, present in SM-ARD/ physical therapy area. This review showed also a scale of radiologic evaluation, SASSS (Stoke Ankylosing Spondylitis Spine Score). The literature revision was performed from October to December 2006, using books of private and public collections and data basis. It was verified, in this study, the need of researches, methodologies or complements aiming at the validation of instruments in Brazil in order to explain the dynamism and behavior of AS with physical therapy intervention.

Symptomatic cervicogenic headache.

Cervicogenic headache is a little-known clinical condition whose true importance has only recently been recognized. A number of causes may lie at the basis of the onset of headache (symptomatic cervicogenic headache). However, despite exhaustive attempts, sometimes it is not possible to identify a clear cause responsible for the onset of the syndrome (primitive cervicogenic headache). The genesis of symptomatic cervicogenic headaches sometimes may be easy to identify as a result of a close, pre-existing, cause-effect relationship (i.e. trauma). On other occasions it may be much more laborious to pinpoint the pathology responsible for headache (some cranio-cervical anomalies, etc.). Clinically, it is necessary to perform a thorough preliminary clinical and anamnestic evaluation which can orient subsequent investigations to achieve a diagnosis in the least time possible with the minimum discomfort to the patient and his relatives, not to mention lower costs for society.

Validation of the proposed ILAR classification criteria for juvenile idiopathic arthritis. International League of Associations for Rheumatology.

OBJECTIVE: The new International League of Associations for Rheumatology (ILAR) classification criteria were proposed to facilitate communication among pediatric rheumatologists. Before they are applied in daily practice they should be clinically validated. METHODS: We retrospectively applied the proposed criteria on our pediatric rheumatology patient population seen between June 1 and August 31, 1998. RESULTS: We saw 67 patients with oligoarticular (oJRA), 6 with polyarticular/RF negative (pJRA), and 8 with systemic juvenile rheumatoid arthritis (sJRA), all classified according to American College of Rheumatology criteria, 5 with juvenile psoriatic arthritis (PsA) according to the Vancouver criteria, and 11 with juvenile spondyloarthritis (SP) according to the European Spondylarthropathy Study Group preliminary criteria. Of the 97 patients, 85 could be clearly classified according to the ILAR criteria. Twelve patients (12%) were classified as "other." Six patients could not be classified as "oligo" because of a family history of psoriasis, and did not fulfill the criteria for PsA either. All 6 "other" patients fulfilled criteria for 2 different categories. CONCLUSION: With this ILAR proposed classification criteria 88% of patients could be classified. In patients classified as "other," the psoriatic trait caused the most difficulty in classification.

[Determination of the best diagnostic criteria of sacroiliitis with MRI]. / Détermination des meilleurs critères diagnostiques des sacro-iliites en IRM.

AIM: To determine which signs are the most accurate in the diagnosis of sacroiliitis with MRI. MATERIAL AND METHODS: 40 consecutive patients with inflammatory low back pain underwent MRI at 1.5 T with FSE T2 and SE T1 weighted-images before and after Gadolinium-DOTA injection. 22 patients were suffering from spondylarthropathy while the other 18 patients constituted the control group. Each examination was interpreted by two independent observers who analysed 11 different signs. RESULTS: Intra and inter observer reproducibility were high (respectively 76% and 70%). Inter observer reproducibility was excellent for bone marrow edema (89%) but low for bone productions (38%). Three lesions displayed a high positive predictive value: ligamentous contrast enhancement (86%), bone marrow edema (80%) and bone erosions (70%). Intra articular enhancement of the sacro-iliac joint was a less sensitive sign than bone marrow edema. CONCLUSION: This study confirms the excellent positive predictive value of MRI for an early diagnosis of active sacroiliitis. Bone marrow edema seems to be a more pertinent sign than intra articular enhancement.

Evaluation of the Amor and ESSG classification criteria for spondylarthropathies in a Turkish population.

This study evaluated the Amor and European Spondylarthropathy Study Group (ESSG) classification criteria for spondyloarthropathies in Turkish patients seen from October 1990 to August 1993 at the Physical Medicine and Rehabilitation Department of the GATA Haydarpasa Training Hospital. The Amor and ESSG criteria were evaluated in 157 patients with spondylarthropathies and in 124 controls with a variety of other rheumatic diseases. The sensitivity, specificity, positive predictive value, and negative predictive value of each criteria set were calculated, as well as the sensitivity and specificity of each of the 24 criteria used in these sets. For Amor's criteria, sensitivity was 88.5%, specificity was 91.9%, positive predictive value was 93.3% and negative predictive value was 86.4%. For the ESSG criteria, sensitivity was 86.6%, specificity was 91.1%, positive predictive value was 92.5% and negative predictive value was 84.3%. No significant differences were found between the two criteria sets. Our data show that the Amor and ESSG criteria are of similar value for the classification of spondylarthropathies and are comparable in terms of sensitivity and specificity. They also demonstrate the need for monitoring patients with equivocal clinical patterns using both sets of criteria as tools that complement each other.

[Inflammatory foot disease]. / Pied inflammatoire.

The pathology of the foot is frequent in the inflammatory rheumatisms. It can finally contribute to the diagnosis. In rheumatoid arthritis, the metatarso-phalangeal joint involvement appears earlier and more obvious. The lesion of the midrearfoot is later and the beginning is more indisious, they often evolve in pes plano valgus deformity. In spondylarthropathies the involvement of the heel and of the toes predominates, but there are more specific symptoms for each disease particularly for the psoriasic rheumatism. Local cares, plantar orthoses, casts, corticosteroid injections, synoviortheses as well as a good hygiene of life are very useful. Surgery helps to keep the functional ability of the patient and its indications must be known.

The classification of psoriatic arthritis: what will happen in the future?

Some patients with psoriasis have articular involvement that falls within the spectrum of seronegative spondyloarthropathies. This form of arthritis has been classified by Moll and Wright into five clinical subsets. Recently this classification has been contested. We review the historical evolution of the concept of psoriatic arthritis and discuss its clinical spectrum.

Inter-observer reliability of the Spondylitis Functional Index Instrument for assessing spondylarthropathies.

OBJECTIVE: To study the Spondylitis Functional Index (SFI) by having two physical therapists observe patients with spondylitis perform various tasks listed on the instrument. The physical therapists' observations were compared with each other and with the self-reported abilities of the patients. METHODS: Subjects (n = 30) were recruited from a cross-section of patients participating in a prospective randomized, multicenter, double-blind, parallel clinical trial of the efficacy of sulfasalazine on ankylosing spondylitis (n = 13), psoriatic arthritis (n = 13), and Reiter's syndrome (n = 4) conducted at the Veterans Affairs Medical Center in Salt Lake City. Percents of agreement and Cohen's kappa analysis were used to assess the reliability of the observations of the therapists and patients. RESULTS: The overall percent of agreement between the observers on the SFI was 93%. The overall percent of agreement between observer 1 and patients on the SFI was 66% and between observer 2 and patients was 67%. The overall inter-observer reliability measured by the Pearson coefficient was 0.91 and by Cohen's kappa was 0.86. Between observer 1 and the patients the Pearson was r = 0.53 and kappa = 0.39. For observer 2 the Pearson was r = 0.52 and kappa 0.39. CONCLUSIONS: We consider the agreement and reliability between observers to be high. The agreement and inter-observer reliability was poor between observers and patients. The SFI, as enhanced for use in this study to assess change in functional ability of patients with spondylitis, demonstrated high reliability when used by trained observers.

Overview and classification of spinal infections.

Hematogenous spread is the most common cause for vertebral osteomyelitis. S. aureus is the most common organism in pyogenic vertebral osteomyelitis. Hematogenous osteomyelitis is common among diabetics and intravenous drug abusers. Tuberculous spondylitis remains common worldwide. In general, vertebral body infections not responding to antibiotic treatment and those creating unacceptable deformity or neurologic compromise require debridement via an anterior approach with strut grafting. Posterior infections are almost always postsurgical and require posterior irrigation and debridement in addition to antibiotics. Abscesses within the canal require antibiotics and surgical debridement especially when neurologic symptoms are present. Infections within the canal are approached posteriorly unless the pathology involves the anterior spine. Use of metal fixation within the site of an adequately debrided spinal infection is controversial but necessary on rare occasions. Posterior fixation for anterior infections is preferred. Much has been written about spinal infections and their treatment. Landmark articles and additional comprehensive sources on spinal infections have been included in the references.