JOINT DISEASES Joint disease, any of the diseases or injuries that affect human joints.

Arthritis is no doubt the best-known joint disease, but there are also many others. Diseases of the joints may be variously short-lived or exceedingly chronic, agonizingly painful or merely nagging and uncomfortable; they may be confined to one joint or may affect many parts of the skeleton. Synovitis The synovial membrane is the principal site of inflammation in persons with rheumatoid arthritis (RA) and many other inflammatory arthritides. Synovitis is characterized pathologically by neovascularization; infiltration of the synovium with lymphocytes, plasma cells, and macrophages; and synovial lining cell hyperplasia. These cause synovial proliferation, recognized clinically by warmth, tenderness, and a boggy consistency of the soft tissues overlying the involved joint. The inflamed synovium may overgrow and erode intra-articular bone and cartilage. Enthesitis The enthesis is the transitional zone where collagenous structures such as tendons and ligaments are interwoven into bone. Other examples of entheses include the interface between cortical bone and the periosteum and between vertebral bodies and the annulus fibrosus. It is the principal site of pathology in the seronegative spondyloarthropathies. As a result of inflammation at these interfaces, the radially oriented collagen fibers undergo metaplasia, forming fibrous bone. These metaplastic transformations result in new bone formation (periostitis), gradual ossification of syndesmoses (eg, the sacroiliac joints), and syndesmophyte formation along the outer fibers of the vertebral discs. When enthesitis occurs in a diarthrodial joint, a secondary synovitis may develop. Crystal deposition The deposition of crystals in articular structures may lead to symptomatic joint disease. The responsible crystals include monosodium urate, calcium pyrophosphate dihydrate, basic calcium phosphate (including hydroxyapatite), and calcium oxalate. Monosodium urate crystal deposition occurs on the surface of hyaline cartilage, within the synovium and in periarticular structures, including tendon sheaths and bursae. As a result, inflammation related to urate crystal deposits may be localized to a bursa or tendon sheath adjacent to the joint or may be widespread, involving multiple joint structures. Clinically, an acute

gouty joint is inflamed, with overlying erythema, warmth, or both. Prominent periarticular inflammation may resemble cellulitis. Calcium pyrophosphate crystal deposition is confined to hyaline cartilage, fibrocartilage, and areas of chondroid metaplasia (ie, degenerated areas of tendons, ligaments, and joint capsule) within the joint. Shedding of these crystals into the joint space may trigger an acute inflammatory arthritis, known as pseudogout. Infectious arthritis The synovium may become the seat of acute or chronic infections related to bacterial, fungal, or viral organisms. These infections almost always arise from blood-borne organisms and may be part of a systemic infection. The infection is based in the synovium. The cardinal pathologic findings include intense infiltration by neutrophils with resultant necrosis of the synovium and subsequent formation of granulation and scar tissue. A dense mass of fibrin, infiltrated by neutrophils, forms over the surface of the synovium. Bacterial products released within the joint are capable of producing rapid cartilage destruction. Structural or mechanical joint derangement Degeneration of the articular cartilage is the principal pathologic feature of osteoarthritis. It occurs in response to both local and host factors. Local factors include previous joint trauma (eg, meniscal tears), congenital or developmental joint alterations (eg, congenital hip dysplasia, slipped capital femoral epiphysis), alterations of the subchondral bone (eg, osteopetrosis, avascular necrosis, Paget disease), alterations of supporting structures (eg, hypermobility), and cartilage derangements (eg, ochronosis, crystal deposition). Host factors include genetic traits, obesity, and occupation. Damage to the articular cartilage is associated with subchondral bone sclerosis and marginal osteophyte formation. Patients with osteoarthritis may have an associated synovitis, with the formation of bland synovial effusions. Simple arthralgia: y Pain is main symptom y No stiffness y No swelling seen around the joint y May be history of viral illness NB: Arthralgia is a known side-effect of the following; ACE inhibitors, proton pump inhibitors, quinolones, gonadorelin analogues and tibolones. Seronegative arthropathy: y History of psoriasis

y y y y y y y y

Bowel disorders (Crohn's or ulcerative colitis) Bladder symptoms Anterior uveitis Streptococcal sore throat Bowel infection- yersinia, salmonella or shigella Chlamydial urethritis Presents with asymmetrical large joint pain Oligoarticular involvement and possibly sacroiliitis

Management: y Assess joints for pain motion and appearance y Provide rest and immobilization as ordered y Maintain proper body alignment y Continue medical regimen as ordered y Provide adequate resting periods y Use of heat and cold compresses y Medical follow-up y Availability of community agencies RHEUMATOID ARTHRITIS Rheumatoid arthritis is a highly inflammatory polyarthritis often leading to joint destruction, deformity and loss of function. Assessment: Look y Gait. y Swelling. y Redness in joints or tendons. y Skin changes Examine for psoriasis, raynauds phenomenon, ulceration of skin and rashes. y Wasting of regional muscles y Deformity or contracture. Feel Palpate the margins of each joint. Synovial thickening is felt as a "soft spongy" texture with the additional presence of fluid identified by fluctuant swelling. Each joint is palpated in turn and presence or absence of synovial thickening is recorded. Move This technique is the most useful in localizing the pathology. There are three techniques of movement in the joint examination. y Active movement. The patient utilizes his own muscles and contractile structures to move a particular joint through its range of movement. This tests the joint as well as the contractile structures. y Passive movement: Here the patient is encouraged to relax and the examiner moves the joint through its accepted range of movement. By ensuring that the joint muscles are relaxed, this checks the actual joint capsule

itself. The joint range of movement may be found to be reduced. y Resisted movement: This isolates the cause to a particular tendon or bursa. The joint is made to relax then force is applied by the patient against resistance of the examiner. Reproduction of the pain confirms the source to be the contractile soft tissue structure. Presence of:  Morning stiffness in and around joints, lasting more than 1 hour.  Arthritis of three or more joint areas involved simultaneously.  Arthritis of at least one area in a wrist, metacarpal or proximal interphalangeal joint.  Symetrical arthritis involving the same joint areas- Fusiform swelling of the PIP joints of the hands is a common early finding upon palpation. MCP, wrists, elbows, knees, ankles and MTP are other joints commonly affected where swelling is easily detected.  Signs of inflammation- Pain on passive motion is the most sensitive test for joint inflammation. Occasionally inflamed joints will feel warm to the touch. Permanent deformity is an unwanted result of the inflammatory process.  Midday fatigue is a frequent complaint in inflammatory arthritis sometimes with anorexia, malaise and weight loss is also common.  Cracking and clicking of joints  Presence of Rheumatoid nodules. Management: y REST AND EXERCISE: People with rheumatoid arthritis need a good balance between rest and exercise, with more rest when the disease is active and more exercise when it is not. -Rest helps to reduce active joint inflammation and pain and to fight fatigue. Alternate periods of rest and activity through the day. This is called pacing. -General rest is an important part of rheumatoid arthritis treatment, but avoid keeping your joints in the same position for too long a time. Get up and move; use your hands. -Exercise is important for maintaining healthy and strong muscles, preserving joint mobility, and maintaining flexibility.

Three types of exercise are helpful: range of motion exercise, strengtheningexercise, and endurance (cardio or aerobic) exercise. Water aerobics are an excellent choice because they increase range of motion and endurance while keeping weight off the joints of your lower body. y PROTECTION OF JOINTS -At least once a day, move each joint through its full range of motion. Do not overdo or move the joint in any way that causes pain. This helps keep freedom of motion in your joints -Avoid situations that are likely to strain your joints -Learn proper body mechanics. This means learning to use and move your body in ways that reduce the stress on your joints. hands, since you want to protect their flexibility. Ask your health care provider or physical therapist for suggestions on how to avoid joint strain. -Use the strongest joint available for the job. Avoid using your fingers, for example, use your wrist or shoulder for the job. -Using a splint for a short time around a painful joint reduces pain and swelling by supporting the joint and letting it rest. Splints are used mostly on wrists and hands, but also on ankles and feet. -Other ways to reduce stress on joints include self-help devices like zipper pullers, long-handled shoe horns help with getting on and off chairs, toilet seats, and beds; and changes in the ways that a person carries out daily activities. y HOT AND COLD APPLICATION -Apply heat. Heat can help ease your pain and relax tense, painful muscles. One of the easiest and most effective ways to apply heat is to take a hot shower or bath for 15 minutes. Other options include using a hot pack or an electric heat pad set on its lowest setting. If your skin has poor sensation or if you have poor circulation, don't use heat treatments. -Apply cold. Cold may dull the sensation of pain. Cold also has a numbing effect and decreases muscle spasms. Don't use cold treatments if you have poor circulation or numbness. Techniques may include using cold packs, soaking the affected joints in cold water and ice massage.

-Alternating the application of hot and cold helps in reducing joint stiffness and pain. Well-Balanced Diet Medication: -Analgesics: Aspirin -NSAIDs -Gold Compounds: Sodium thiomalate for IM injection or aurothioglucose for oral. -Corticosteroids -DMARDs: Methotrexate JUVENILE RHEUMATOID ARTHRITIS Juvenile rheumatoid arthritis (JRA) is arthritis that causes joint inflammation and stiffness for more than 6 weeks in a child of 16 years of age or less. Inflammation causes redness, swelling, warmth, and soreness in the joints, although many children with JRA do not complain of joint pain. Any joint can be affected and inflammation may limit the mobility of affected joints. Classification (by the number of joints involved, symptoms, and the presence or absence of certain antibodies in the blood):  Pauciarticular/oligoarticular: o most common form of JRA; about half of all children with JRA have this type o four or fewer joints are affected o disease typically affects large joints, such as the knees o girls under age 8 are most likely to develop this type of JRA o some children have special proteins in the blood called antinuclear antibodies (ANAs) o eye disease affects about 20 to 30 percent of children with pauciarticular JRA (Up to 80 percent of those with eye disease also test positive for ANA and the disease tends to develop at a particularly early age in these children)  Polyarticular: o about 30 percent of all children with JRA have polyarticular disease o five or more joints are affected o small joints, such as those in the hands and feet, are most commonly involved, but the disease may also affect large joints o often is symmetrical, that is, it affects the same joint on both sides of the body o some children with polyarticular disease have a special kind of antibody in their blood called IgM rheumatoid factor (RF)

a more severe form of the disease, which doctors consider to be the same as adult rheumatoid arthritis Systemic: o systemic form affects 20 percent of all children with JRA (small percentage of these children develop arthritis in many joints and can have severe arthritis that continues into adulthood) o besides joint swelling, the systemic form of JRA is characterized by fever and a light pink rash, and may also affect internal organs such as the heart, liver, spleen, and lymph nodes o sometimes called Still's disease o almost all children with this type of JRA test negative for both RF and ANA o

Assessment: -Note key symptoms; assess walking with a limp, morning stiffness, favored use of one arm or leg and general inactivity (child with juvenile rheumatoid arthritis often experiences short bouts of fever in the evening and Joints appear swollen) -Take a medical history. Ask about the duration of the symptoms. The pain and swelling must last six weeks to support a diagnosis of juvenile rheumatoid arthritis. Ask about any family history of other autoimmune diseases. -Conduct a physical exam. Examine the joints for swelling and tenderness. Tests will look for decreased strength in the muscles around these joints. Lymph nodes in the neck will be checked for enlargement. Look for signs of the extent and severity of the arthritis including rash, sensitivity of the eye to bright light, lumps and signs that the internal organs have been affected. -Eliminate other explanations. Other illnesses can mimic juvenile rheumatoid arthritis. Blood tests would be ordered to rule out any competing diagnosis such as injury, infections, bone diseases, Lyme disease and lupus. A bone scan will further explain reasons for bone and joint pain. -Other tests: y erythrocyte sedimentation rate (ESR) test - rate is faster in those with arthritis y antinuclear antibody (ANA) test - blood test for autoimmunity; also a strong predictor of eye complications in juvenile rheumatoid arthritis y rheumatoid Factor (RF) test - looks for an antibody sometimes found in children with juvenile rheumatoid arthritis; does not give a definitive diagnosis (the antibody is found more often in adults with arthritis)

Management: o The major emphasis of treatment for JIA is to help the child regain normal level of physical and social activities. This is accomplished with the use of physical therapy, pain management strategies and social support o Therapists can recommend the best exercise and also make protective equipment. Moreover, the child may require the use of special supports, ambulatory devices or splints to help them ambulate and function normally. o Home remedies include getting regular exercises to increase muscle strength and joint flexibility. Swimming is perhaps the best activity for all children with JIA. Other activities include walking, bicycling (esp. indoor stationary bikes). Always be certain the child warms up the muscles through stretching before exercising. o Stiffness and swelling can also be reduced with application of cold packs but a nice warm bath or shower can also improve joint mobility. o Regular examinations by an ophthalmologist (a doctor who specializes in eye diseases) are necessary to prevent serious eye problems such as iritis (inflammation of the iris) or uveitis (inflammation of the inner eye, or uvea). Many children with pauciarticular disease outgrow arthritis by adulthood, although eye problems can continue and joint symptoms may recur in some people. o Make sure the child eats a balanced diet that includes plenty of calcium to promote bone health. o Discourage impact sports that can be hazardous to weakened joints and bones.

Roche gets EU approval for RoActemra for children with rare form of arthritis The European Commission has approved the use of Swiss drug major Roche s (ROG: SIX) RoActemra (tocilizumab) for the treatment of active systemic juvenile idiopathic arthritis (sJIA) in patients two years of age and older who have responded inadequately to previous therapy with NSAIDs and systemic corticosteroids (medicines used to treat inflammation). The drug, known as Actemra outside of Europe, is already used to treat adult rheumatoid arthritis in patients who were either intolerant to or failed to respond to other medicines to treat inflammation. In the first half of this year, sales of RoActemra/Actemra rocketed 99% to 277 million Swiss francs ($351.4 million). The drug is already approved for sJIA in the USA, Mexico, India and Switzerland, and Vontobel analyst Andrew Weiss is forecasting peak sales of around $2.6 billion a year. This approval in Europe is an important advance in the treatment of sJIA, a debilitating condition affecting children, said Hal Barron, chief medical officer and head, global product development, adding: RoActemra is the first and only biological treatment to demonstrate significant efficacy in this patient population and offers physicians a new option for this extremely difficult to treat disease. Disease affects 10%-12% of children with JIA Roche explains that sJIA is the rarest form of juvenile idiopathic arthritis (JIA), also known as juvenile rheumatoid arthritis (JRA). The disease affects about 10% to 20% of children with JIA, with the peak age of onset between 18 months and two years, although the disease can persist into adulthood. sJIA has a 2% to 4% overall estimated mortality rate, and accounts for almost two-thirds of all deaths among children with arthritis. The severity of sJIA varies from person to person and can include symptoms ranging from joint inflammation accompanied by intermittent fever, skin rash, anaemia, enlargement of the liver or spleen and inflammation of the lining of the heart and/or lungs. In the most severe cases of sJIA, up to two-thirds of children experience chronic arthritis, and approximately half of children will develop significant joint disabilities. RoActemra is currently used for the treatment of adult rheumatoid arthritis in people who have either responded to, or who were intolerant to, previous

therapy with one or more DMARDs or tumor necrosis factor (TNF) inhibitors. It is the only licensed biologic treatment to target the interleukin-6 (IL-6) pathway, which plays a pivotal role in sJIA pathogenesis, the company says. Source: Retrieved from: http://www.thepharmaletter.com/file/106345/rochegets-eu-approval-for-roactemra-for-children-with-rareform-of-arthritis.html