Clinical, radiographic and HLA associations as markers for different patterns of psoriatic arthritis.
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OBJECTIVE: The aim of this study was to examine whether the five clinical forms of psoriatic arthritis (PsA) identified by Moll and Wright (Semin Arthritis Rheum 1973;3:55-78) could be clearly distinguished, especially as the disease evolved over time, to analyse whether radiographic features or HLA associations could define subsets with greater precision and to identify predictors of disease outcome. METHODS: Seventy-three patients (37 males and 36 females) were followed for a median time of 8 yr (range 1-16 yr). A standard clinical protocol was used to assess patients at each visit and two clinical scores. based on the joint areas involved, were defined to evaluate the mode of onset and the evolution of arthritis. X-ray films of the hands, feet and sacroiliac joints were taken and the patients were divided into two categories according to the presence or absence of erosions and an X-ray erosion score was also used. Three classification methods were used to define the different clinical subsets. HLA-A, B and DR antigens were tested by standard microlymphocytotoxicity assays. A multiple linear regression model was used in the statistical analysis. RESULTS: The five classical clinical subsets defined by Moll and Wright did not remain since distinct peripheral arthritis patterns tended to evolve over time. Only two discrete groups were identified, axial disease (AD) (sacroilitis with or without peripheral arthritis) in 29% of cases and peripheral disease (PD) without sacroilitis in 71%. AD was positively associated with the duration of arthritis (P < 0.04), presence of mutilation (P < 0.02) and the joint area score over disease evolution (JASE) (P < 0.02). There were erosions in 71% of the patients. Erosions correlated with the presence of mutilation (P < 0.007) and with the JASE (P < 0.0005). HLA-B27 was found in 43% of patients with AD, but only in 11% of PD patients (P < 0.01). No other clear HLA correlations were found. CONCLUSIONS: Despite the relatively small number of patients, this longitudinal study suggests that only two clinical subsets can be clearly defined in PsA, AD and PD; these are primarily determined on clinical grounds although HLA-B27 is strongly associated with AD. The evolution of PD pattern with time means that narrower peripheral arthritis subsets are of little clinical use. (+info)
Three pathways between the sacroiliac joint and neural structures.
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BACKGROUND AND PURPOSE: Despite ongoing clinical suspicion regarding the relationship between sacroiliac joint (SIJ) dysfunction and lower extremity symptoms, there is a paucity of scientific literature addressing this topic. The purpose of this study was to describe patterns of contrast extravasation during SIJ arthrography and postarthrography CT in patients with lower back pain and to determine whether there are pathways of communication between the SIJ and nearby neural structures. METHODS: Fluoroscopically guided SIJ arthrography was performed on 76 SIJs. After the injection of contrast medium, anteroposterior, lateral, and oblique radiographs as well as 5-mm contiguous axial and direct coronal CT images were obtained. Contrast extravasation patterns were recorded for each joint. These observations included a search for contrast extravasation from the SIJ that contacted nearby lumbosacral nerve roots or structures of the plexus. RESULTS: Sixty-one percent of all joints studied revealed one of five contrast extravasation patterns. Three of these observed patterns show a pathway of communication between the SIJ and nearby neural structures. These included posterior extravasation into the dorsal sacral foramina, superior recess extravasation at the sacral alar level to the fifth lumbar epiradicular sheath, and ventral extravasation to the lumbosacral plexus. CONCLUSION: Three pathways between the SIJ and neural structures exist. (+info)
Studying patients with inflammatory back pain and arthritis of the lower limbs clinically and by magnetic resonance imaging: many, but not all patients with sacroiliitis have spondyloarthropathy.
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OBJECTIVE: Clinical and magnetic resonance imaging (MRI) data of 170 consecutive patients with inflammatory back pain (IBP) and/or oligoarthritis of the lower limbs were evaluated in a retrospective study. The aim was to determine the frequency of sacroiliitis and spondyloarthropathy (SpA) in this population, and to assess the significance of HLA B27 measurements for diagnosis in early disease. METHODS: Pelvic X-rays were performed in all IBP patients and dynamic MRI of the sacroiliac joints in patients with IBP who had indefinite results on sacroiliac X-rays (n = 32). RESULTS: European Spondyloarthropathy Study Group criteria for SpA were fulfilled by 106/170 patients (62.4%); eight additional patients had symptoms suggestive of SpA (4.7%). The most frequent SpA subset was undifferentiated SpA (uSpA), diagnosed in 46/106 patients (43.4%). Sacroiliitis was detected by MRI in 21/32 patients with IBP and unclear X-rays (65.6%). Of those, 14 were diagnosed as SpA and seven females with moderate unilateral sacroiliitis, but no features of SpA, also not on follow-up (at least 1 yr), were classified as undifferentiated sacroiliitis (US). Ten of the 14 SpA (71.4%) and none of the seven US patients were HLA B27 positive. CONCLUSION: HLA B27 positivity in IBP patients with MRI-proven sacroiliitis positively predicts SpA. uSpA is a frequent SpA subset. There are HLA B27-negative non-SpA patients with moderate unilateral sacroiliitis whom we propose to be classified as US. (+info)
Four clinical tests of sacroiliac joint dysfunction: the association of test results with innominate torsion among patients with and without low back pain.
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BACKGROUND AND PURPOSE: The purpose of this study was to assess the association between innominate torsion (asymmetric anteroposterior positioning of the pelvic innominates) and Gillet, standing forward flexion, sitting forward flexion, and supine-to-sit tests. SUBJECTS: A sample of 21- to 50-year-old patients with low back pain (n=150) and a comparison group of patients with upper-extremity impairments (n=138) were recruited from outpatient physical therapy facilities. METHODS: The association of single and combined test results with innominate torsion (calculated from pelvic landmark data) and with presence or absence of low back pain were estimated via odds ratios, sensitivities, specificities, and predictive values. RESULTS: Individual test sensitivities were low (8%-44%), as were negative predictive values (28%-38%), for identifying the presence of innominate torsion. Combining tests and controlling for sex, age group, leg-length difference, or iliac crest level did not improve performance characteristics. The associations of test results with low back pain were weak, with the exception of the Gillet test (odds ratio=4.57). CONCLUSION AND DISCUSSION: The data do not support the value of these tests in identifying innominate torsion, although the use of these tests for identifying other phenomena (eg, sacroiliac joint hypomobility) cannot be ruled out. Further exploration of the association of Gillet test results with low back pain is warranted. (+info)
Measurement of sacroiliac joint dysfunction: a multicenter intertester reliability study.
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BACKGROUND AND PURPOSE: Previous research suggests that visual estimates of sacroiliac joint (SIJ) alignment are unreliable. The purpose of this study was to determine whether handheld calipers and an inclinometer could be used to obtain reliable measurements of SIJ alignment in subjects suspected of having SIJ dysfunction. SUBJECTS: Seventy-three subjects, evaluated at 1 of 5 outpatient clinics, participated in the study. METHODS: A total of 23 therapists, randomly paired for each subject, served as examiners. The angle of inclination of each innominate was measured while the subject was standing. The position of the innominates relative to each other was then derived. An intraclass correlation coefficient (ICC), the standard error of measurement (SEM), and a kappa coefficient were calculated to examine the reliability of the derived measurements. RESULTS: The ICC was .27, the SEM was 5.4 degrees, and the kappa value was .18. CONCLUSION AND DISCUSSION: Measurements of SIJ alignment were unreliable. Therapists should consider procedures other than those that assess SIJ alignment when evaluating the SIJ. (+info)
Evolution of chronic recurrent multifocal osteitis toward spondylarthropathy over the long term.
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OBJECTIVE: To retrospectively assess, with a sufficiently long followup (mean 11.6 years; median 9 years), the long-term outcome of chronic recurrent multifocal osteitis (CRMO), a multifocal, inflammatory bone disease. METHODS: Patients included were 8 children/adolescents and 7 adults with no family history of rheumatic disease who had been diagnosed as having CRMO between 1979 and 1995. Ten patients had undergone at least 1 bone biopsy of the lesions, with histologic examination and multiple cultures. In 1996, in addition to an in-depth interview, 12 patients underwent an extensive physical examination, laboratory evaluation, HLA-A, B, C, and DR typing, bone radiography and scintigraphy, and computed tomography scan of the sternoclavicular and sacroiliac joints. RESULTS: Remission was observed in 3 patients. The other 12 patients developed various associations of vertebral (n = 10), sacroiliac (n = 6), anterior thoracic (n = 7), peripheral articular (n = 2), enthesopathic (n = 4), or dermatologic (palmoplantar pustulosis in 3 cases and psoriasis in 2) involvements. Spine involvement was the most common and occurred the earliest (median time to appearance after the onset of osteitis 5.63 years). Clinical sacroiliitis was always unilateral. No patients carried the HLA-B27 haplotype. CRMO responded well to nonsteroidal antiinflammatory drugs. Twelve patients met the European Spondylarthropathy Study Group criteria for spondylarthopathy. CONCLUSION: After 10 years, CRMO had usually evolved to spondylarthropathy, but with certain features not usually seen in the latter: predominantly, unilateral sacroiliitis, no familial form, and no link with HLA-B27. (+info)
The active straight leg raising test and mobility of the pelvic joints.
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Objective signs to assess impairment in patients who are disabled by peripartum pelvic girdle pain hardly exist. The purpose of this study was to develop a clinical test to quantify and qualify disability in these patients. The study examined the relationship between impaired active straight leg raising (ASLR) and mobility of pelvic joints in patients with peripartum pelvic girdle pain, focusing on (1) the reduction of impairment of ASLR when the patient was wearing a pelvic belt, and (2) motions between the pubic bones measured by X-ray examination when the patient was standing on one leg, alternating left and right. Twenty-one non-pregnant patients with peripartum pelvic girdle pain in whom pain and impairment of ASLR were mainly located on one side were selected. ASLR was performed in the supine position, first without a pelvic belt and then with a belt. The influence of the belt on the ability to actively raise the leg was assessed by the patient. Mobility of the pelvic joints was radiographically visualized by means of the Chamberlain method. Assessment was blinded. Ability to perform ASLR was improved by a pelvic belt in 20 of the 21 patients (binomial two-tailed P = 0.0000). When the patient was standing on one leg, alternating the symptomatic side and the reference side, a significant difference between the two sides was observed with respect to the size of the radiographically visualized steps between the pubic bones (binomial two-tailed P = 0.01). The step at the symptomatic side was on average larger when the leg at that side was hanging down than when the patient was standing on the leg at that side. Impairment of ASLR correlates strongly with mobility of the pelvic joints in patients with peripartum pelvic girdle pain. The ASLR test could be a suitable instrument to quantify and qualify disability in diseases related to mobility of the pelvic joints. Further studies are needed to assess the relationship with clinical parameters, sensitivity, specificity and responsiveness in various categories of patients. In contrast with the opinion of Chamberlain, that a radiographically visualized step between the pubic bones is caused by cranial shift of the pubic bone at the side of the standing leg, it is concluded that the step is caused by caudal shift of the pubic bone at the side of the leg hanging down. The caudal shift is caused by an anterior rotation of the hip bone about a horizontal axis near the sacroiliac joint. (+info)
Quantitative analyses of sacroiliac biopsies in spondyloarthropathies: T cells and macrophages predominate in early and active sacroiliitis- cellularity correlates with the degree of enhancement detected by magnetic resonance imaging.
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OBJECTIVE: Sacroiliitis is a hallmark of the spondyloarthropathies (SpA). The degree of inflammation can be quantified by magnetic resonance imaging (MRI). The aim of this study was to further elucidate the pathogenesis of SpA by quantitative cellular analysis of immunostained sacroiliac biopsy specimens and to compare these findings with the degree of enhancement in the sacroiliac joints (SJ) as detected by dynamic MRI. METHODS: The degree of acute sacroiliitis detected by MRI after intravenous administration of gadolinium-DTPA was quantitatively assessed by calculating the enhancement observed in the SJ and chronic changes were graded as described in 32 patients with ankylosing spondylitis (n=18), undifferentiated SpA (n=12) and psoriatic arthritis (n=2). Back pain was graded on a visual analogue scale (VAS, 0-10) and disease duration (DD) was assessed. Shortly after MRI, SJ of patients with VAS > 5 were biopsied guided by computed tomography. Immunohistological examination was performed using the APAAP technique; only whole sections > 3 mm were counted. RESULTS: By MRI, chronic changes II in 13 patients (group II, DD 7.3 (SD 4.8) years), while enhancement < 70% was found in eight (group A, DD 5.6 (SD 3.3) years) and > 70% in 12 patients (group B, DD 4.7 (SD 5.8) years). The relative percentage of cartilage (78-93%), bone (7-18%) and proliferating connective tissue (1-4%) was comparable between the groups (range). There were more inflammatory cells in group I compared with group II (mean (SD) 26.7(20.1) versus 5.3 (5. 2), p=0.04) and group A compared with B (21.8 (17.3) versus 6.0 (5. 6), p=0.05) cells/10 mm(2)), T cells (10.9 (8.5)) being slightly more frequent than macrophages (9.6 (16.8/10 mm(2))). Clusters of proliferating fibroblasts were seen in three and new vessel formation in seven cases. CONCLUSION: This study shows that T cells and macrophages are the most frequent cells in early and active sacroiliitis in SpA. The correlation of cellularity and MRI enhancement provides further evidence for the role of dynamic MRI to detect early sacroiliitis. (+info)