118307083-reumatologie ghid

GHIDUL DE STUDIU

REUMATOLOGIE

Titlul cursului:

REUMATOLOGIE CLINIC

Autori:

Simona Rednic

Laura Damian,Ioana Felea, Ileana Filipescu

Laura Muntean, Siao-pin Simon, Maria Magdalena Tma

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Reumatologie clinic - generaliti

INTRODUCERE DESCRIEREA CURSULUI: OBLIGATORIU

Sensibilizarea studenilor n legtur cu epidemiologia, tipurile, importana i impactul social al bolilor reumatologice si musculoscheletale

Deprinderea principiilor examenului clinic musculoscheletal Invarea principalelor investigaii paraclinice utilizate n reumatologie i a

semnificatiei acestora Recunoaterea i ncadrarea unei boli musculoscheletale, ca i ndrumarea

corect a acestora Recapiturea principalelor clase de medicamente utilizate n tratamentul

reumatologic Recunoaterea importanei prezentrii, sumarizrii, particularitilor

anamnestice si de examen clinic n principalele boli reumatologice o Utilizarea sindroamelor pentru ghidarea intrebarilor si gndirii clinice o Diferenierea artritelor inflamatorii de artroz o Caracterizarea principalele tipuri i pattern-uri articulare

Obiective specifice fiecrui curs (vezi acolo)

+ Discutarea pe marginea unor cazuri clinice si a unor scenarii clinice integratoare cu evaluarea deprinderilor obtinute

Cui i este adresat cursul i cine poate participa?

Studentii anului V medicin general

Importana cursului, probleme care vor fi abordate

Aprox 30-40% din populatie are simptome de afectare articulara sau durere axial (vertebral) la un moment dat n via

Doar 2/3 (20%) dintre acetia au simptome suficient de exprimate pentru a solicita consult medical

1 din 4-5 consultaii de medicin general se datoreaz afeciunilor musculoscheletale

Prevalena afectrii musculoscheletale crete semnificativ cu vrsta i cu mbtrnirea populaiei, majoritatea celor peste 70 de ani avnd manifestri articulare

Cele mai frecvente probleme sunt artroza, durerea lombar, guta, fibromialgia i tendinitele/bursitele

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Cele mai serioase probleme sunt poliartrita reumatoid, colagenozele, vascu-litele, care trebuie diagnosticate precoce, tratate prompt i ndrumate rapid

Dizabilitatea datorat afeciunilor musculoscheletale este de 5-10% n populaia general i este pe primul loc ca i cauz de dizabilitate

Locul pe care l ocup cursul n programa analitic i corelaiile acestuia cu alte discipline i noiuni studiate anterior

In cadrul modulului corespunztor n anul V Avnd in vedere aspectul multisistemic al unora dintre imbolnaviri, notiunile

anterioare de medicin intern, cardiologie, pneumologie, gastroenetrologie, nefrologie sau hematologie sunt necesare;

Unele dintre imbolnviri necesit tratament chirurgical pentru care cunostiinte de ortopedie sunt necesare, iar altele necesit terapie recuperatorie in care notiuni de balneofiziokinetoterapie pot fi utile;

Cunotiinele i abilitile psihomotorii de la care se pleac i care se presupune ca sunt deja cunoscute

Anatomie muscular i osteoarticular Semiologie clinic general i musculoscheletal Farmacologie clinic: antialgice, AINS, steroizi, imunomodulatoare, biologice

antiTNF, anticitokine , etc

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Perioada de desfurare a cursului i programul (data, ora, loc) diferitelor activiti educative

Cursuri 14 ore o n cadrul modulului corespunztor: orar anunat la nceputul modulului

i afiat la afiierul catedrei 1 curs 2 ore /sptmn, 7 sptmni Stagii clinice 14 ore

o secia clinic reumatologie, spital de zi, ambulatorii de specialitate: orar anunat la nceputul modulului i afiat la afiierul catedrei

Prezentri de caz , demonstraii clinice, alte manifestri o n cadrul stagiului n funcie de disponibiliti urmrii afiierul

catedrei Tabla de materii Cursuri - 14 h (7 cursuri a 2 ore) 1. Introducere ce este reumatologia ? 2. Poliartrita reumatoid 3. Spondilatropatiile 4. Este aceasta o colagenoz ? Lupusul eritematos sistemic, sindromul

antifosfolipidic 5. Este aceasta o colagenoz ? Sclerodermia sistemica, miopatiile

inflamatorii, sindromul Sjogren, policondrita recidivanta, boala mixt de esut conjunctiv, etc

6. Vasculitele sistemice - o vedere din balon asupra vasculitelor 7. Artroza 8. Osteoporoza 9. Artritele microcristaline guta i alte artrite microcristaline 10. La grania reumatologiei - manifestri reumatismale n alte boli

(endocrine, hematologice, digestive, etc) sau recapitulare

curs 1 h curs 1.5 h curs 1.5 h curs 2 h curs 2 h curs 2 h curs 1 h curs 1 h curs 1 h curs 1 h

Prezentri clinice 1. Examenul clinic in bolile reumatologice: prezentare clinic 2. Exporari paraclinice in reumatologie: prezentare clinic 3. Principii terapie medicamentoasa n reumatologie: antialgice, AINS,

steroizi, imunomodulatoare, terapie biologica anticitokinica (antiTNF, antiIL-1, antiIL-6) prezentare clinica

2 h opional opional

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Evaluarea cunotiinelor i abilitilor practice Condiii pentru acceptarea la examen i promovare

Prezena la stagiu min 6 stagii clinice (se permite 1 singur absen) Prezena la curs min 5 cursuri ( se permit max 2 cursuri absen) Prob scris: evaluarea cu intrebri cu complement simplu i multiplu ( 30

ntrebri) Prob practic: o manevr obligatorie (list cu manevre ataate 21) + un

scenariu clinic (exemple la stagiu i cursuri)

Calendarul evalurilor pe parcurs, al examenului final i al examenelor ulterioare n caz de nepromovare

Se va discuta la fiecare modul i cu fiecare grup Cadrele didactice i programul de consultaii (afiier catedr)

Prof Dr Simona Rednic ef lucrri Dr Siao pin Simon Asist univ dr Ileana Filipescu Asist univ dr Maria Magdalena Tama Ali membri: doctoranzi, medici primari, specialiti, rezideni , etc

Programul bibliotecilor, cabinetelor, laboratoarelor sau slilor de studiu / alte faciliti de nvare i practic (cercuri tiintifice, granturi, conferine, ateliere de lucru, etc)

Centru de comunicare reumatologie permanent Conferine, alte manifestri afiierul catedrei

Glosarul de termeni, abrevieri i definiii; AAN anticorpi antinucleari IFD interfalangiene distale ABA abatacept IFP interfalangiene proximale ACL anticorpi anticardiolipina IL - interleukina ACR American College of Rheumatology

IFN infliximab

ADA adalimumab LEF leflunomide AINS antiinflamatoare nesteroidiene LES lupus eritematos sistemic ANCA anticorpi anticitoplasma MCF metacarpofalangiene

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neutrofilului APL anticorpi antifosfolipidici MTF metatarsofalangiene AZA azatioprina MTX metotrexat BEL belimumab PAN panarterita nodoasa BMTC boala mixta de tesut conjunctiv

PAR poliartrita reumatoida

CCP peptid ciclic citrulinat PM polimiozita CTZ certolizumab PSH periartrita scapulohmerala CF ciclofosfamida RC radiocarpiana CRP proteina C reactiva RTX rituximab CS corticosteroizi SASN spondilartropatie seronegativa DAS disease activity index SpA spondilartropatie DM dermatomiozita SSc - sclerodermie sistemica ETN etanercept SSj sindrom Sjogren EULAR European League against Rheumatism

SSZ sulfasalazina

FR factor reumatoid TCZ tocilizumab GMB golimumab TNF factor de necroza tumorala HAQ health assessment questionnaire

TT tibiotarsiana

HQ hidroxiclorochina VSH viteza sedimentare hematii

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Curs reumatologie clinica curs 1: Introducere: Ce este reumatologia?

CAPITOL 1 (CURS 1) INTRODUCERE: CE ESTE REUMATOLOGIA ?

Durata 1 h curs

Tabla de materii o Definitia reumatologiei o Principalele aspecte anamnestice, examen obiectiv, evaluare si

terapeutice care caracterizeaza reumatologia o Exemple si cazuri

Ce trebuie s tie ? o Esenial Identitatea reumatologiei ca specialitate separata si obiectul ei de

studiu ( ca specialitate noua are o criza de identitate) Cand, cum si ce cazuri trebuie indrumate la reumatolog Examenul clinic muscular, osteoarticular i al extermitilor

o Important principalele probleme ale reumatologiei Durerea cronica Handicapul Terapiile active

Terapia antialgica antialgice, AINS, opioide Imunomodularea neselectiva sau selectiva (anticitokinica)

o Util Criterii de diagnostic si clasificare manual de criterii Evaluarea si monitorizrea unor boli cronice indici, scoruri de

activitate, scoruri de cronicitate, scala de raspuns

Reumatism este o denumire comuna utilizata pentru multe dureri si probleme, din care unele nu

au inca un nume si care au sigur multe cauze

William Heberden (1710 1801 Commentaries on the History and Cure of

Diseases, ch 79

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o Facultativ Manevre specifice pentru unele articulatii Punctii intraarticulare periarticulare

Ce trebuie s fac ?

o S observe, descrie i explica Cazurile de pe sectia clinica Puncia articular Manevre articulare, radiografii, ecografie osteoarticulara,

capilaroscopie, etc Evolutia pacientilor cronici si schimbarea starii clinice a acestora Terapiile imumodulatoare si mai ales terapiile biologice si efectele

acestora

o Sa faca personal, individual sau in echipa Anamneza Examen clinic musculoscheletal succint GALS Injectiile: subcutanata, indradermica, im, iv pentru terapiile

antireumatice i perfuziile iv pentru tearpia biologic

Caz sau scenariu clinic

o Cazuri de bolnavi reumatici celebri Auguste Renoir poliartrita reumatoida Peter Paul Rubens poliartrita reumatoida Raoul Dufy poliartrita reumatoida, tratament cortizonic Mircea Eliade poliartrita reumatoida, efectul medicamentelor Christiaan Barnard - poliartrita reumatoida, efectul

medicamentelor Paul Klee sclerodermie sistemica Flannery OConnor lupus eritematos sistemic Frida Kahlo fracturi multiple vicios consolidate, fibromialgie Jerry Lewis durere lombara cronica JF Kennedy durere lombara cronica

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Algoritm sau schema succinta a capitolului

Ce este reumatologia ? Specialitate care se ocupa de bolile autoimune, artritele si

bolile musculoscheletale Varietate: LES, SSc ? boli comune (artroze, osteoporoza, etc)Reumatism este un termen comun pentru multe boli si dureri, din care multe

nu au inca nume si care sunt se datoreaza unui numar mare de cauzeWilliam Heberden (1710-1801), Commentaries on the History and Cure of

Diseases, chapter 79

Ramura a medicinii interne Specializarea este rezultatul necesar si natural al cresterii cunostiintelor intr-

un domeniu, inseparabil legate de multiplicarea si perfectionareainstrumentelor de lucru. Exista insa limite, absurditati chiar, In urma cu cativa ani, un absolvent si fost intern al scolii, mi-a cerut in aparenta serios, sa ii dau numele unui specialist in reumatism. Ne putem permite sa rademla astfel de cereri

Fr. Shattuck, 1897, Prof of Medicine, Harvard Medical School

? balneofizioterapia ; ? ortopedia

Ce este un reumatolog ? Un reumatolog este un internist sau un

pediatru calificat prin educatie suplimentara si experienta clinica

practic n diagnosticul i tratamentul artritelor, ca i al altor afeciuni a articulaiilor, muchilor, oaselor i

structurilor periarticulare (ligamente, tendoane, enteze).

CeCe face un face un reumatologreumatolog ??I. I. AnamnezaAnamneza

Reumatologii au de a face cu doua simptome majore: Durerea

Cel mai frecvent si mai constant simptom

Durere cronicaLe mort nLe mort nestest rienrien, la , la douleurdouleur ouioui

Andre Andre MalrauxMalraux

Impotenta functionala, dizabilitate, handicapul

Principalele simptome ale pacienilor reumatici (anamneza):

Durerea cronica &

handicapul si dizabilitatea

Durerea cronic: epidemiologie

Durerea cronic sever, > 3 luni 11-30% din populaie

F:B = 56:44

Vrsta: 54% ntre 31-60 ani; 28% >60 ani;

Cauze principale: patologie reumatismal (artroze, lombalgie) > cancer > cefalee etc

Patologii a cror frecven crete cu vrsta

Fa de perioada napoleonian

(speran de via de 40-45 ani) n care reumatismele i cancerele nu apucau s

apar, n secolul XXI avem mai multe motive de durere !!!

Un studiu recent publicat (2009) care

cuprinde mai mult de 46000 de pacieni din ntreaga Europa evideniaz o

prevalen a durerii cronice de pn la 19% din populaia generala.

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Impactul funcImpactul funcionalional HAQHAQBoalaBoala DurereaDurerea

Impotena funcionalImpotena funcionalex. Imposibilitatea de a mica un deget

Disabilitateaex. Dificulti la cantatul la vioar

Handicapulex. Pierderea locului de munc, depresie

Dizabilitatea i handicapul

Dac impotena funcional a unui segment anatomic intereseaz pe

oricine, dizabilitatea si handicapul se judec in

context social !!!

(un deget tumefiat si dureros determin un grad diferit de dizabilitate i handicap

la un violonist sau la un paznic)

CeCe face un face un reumatologreumatolog ??II. II. ExamenExamen obiectivobiectiv generalgeneral

Reumatologii sunt ultimii medici detectivi(ultimate physician detectives)

Pacienti cu boli nelamurite, febrili, stari proaste, manifestarimultisistemice colagenoza nediferentiata , VSH ?, AAN, FR +

Varietate:

Boli multisistemice (lupus, vasculite) ? doarmusculoscheletale, o articulatie (artroza)

Boli rare: LES, SSc ? boli comune (artroze, osteoporoza, etc)

Specialitati nelimitate la un organ !

Varietate, confuzie

Reumatologii sunt ultimii medici detectivi

(ultimate physician detectives) www.ac.org

Dr House = Sherlock HolmesShore explained that he was always a Sherlock Holmes fan, and found the character's trait

of indifference to his clients unique The resemblance is evident in several elements of the series' plot, such as House's

reliance on psychology to solve a case, his reluctance to accept cases he finds uninteresting,

House's home address, Apartment 221B, a reference to Holmes' home).Other similarities between House and Holmes include the playing of an instrument (Holmes

plays the violin, House the piano, the guitar, and the harmonica), use of drugs (House's addiction to Vicodin and Holmes' recreational use of cocaine) and House's relationship with Dr. James Wilson, whose name is similar to Dr. John Watson.[

Several characters have names similar to those in the Sherlock Holmes books. In the season two finale "No Reason", House is shot by a crazed gunman credited as "Moriarty",

which is the same name as Holmes's nemesis. The main patient in the pilot episode is named Rebecca Adler, after Irene Adler, a female character from the first Sherlock Holmes

short story.David Shore said that Dr. House's name is meant as "a subtle homage" to Sherlock Holmes.[10][17] In the season four episode "It's a Wonderful Lie", House receives a

"second edition Conan Doyle" as a Christmas gift.[18] In the Season 5 episode "Joy to the World", House receives a book by Joseph Bell, Conan Doyle's inspiration for Sherlock

Holmes,[19] as a Christmas present from Wilson, along with a message that says "Greg, It made me think of you". Wilson names an Irene Adler as the alleged sender before taking

dit f it [20]

Diagnosticul n reumatologie este n esen un diagnostic clinic

Reumatologii sunt capabili sa trateze azi foarte eficientboli, care pana nu demult determinau handicap sidizabilitate importanta (si chiar deces !!!)

Durerea ! Terapii imune

Corticoterapia Imunodepresia medicamentoasa MTX, AZA, CF, CyA, MMF Terapia biologica anti-TNF, IL-1, IL6, antiCD20, anti LT

IMPACT !!! IMPACT !!!

CeCe face un face un reumatologreumatolog ? ?

III. III. TratamentTratament

Tratament

Resursele terapeutice ale reumatologiei s-au lrgit foarte mult n ultimii ani,

existnd o palet larg de terapii pentru durere, pentru imunomodulare

nespecific sau specific prin terapiile biologice.

Butada lui Sir William Osler, 1st Baronet

(1849-1919) Cnd un pacient cu artrit intr pe ua din fa, simt ca a vrea s ies pe usa

din spate este practic contrazis de noile terapii !!!

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CeCe face un face un reumatologreumatolog ??IV. IV. EvaluareEvaluare, , monitorizaremonitorizare

Reumatologii tratand boli cronice sunt capabili siobligati, sa stabileasca relatii pe termen lung de o viata (long life relations) cu pacientii lor Monitorizarea !

Evaluarea cantinantiva criterii diagnostic; numere NAT,NAD; scoruri(DAS, cutanat, HAD, SF 36, 6min walking); indici de activitate (DAS, SLEDAI, etc)

Egalizarea evaluarii

Baze de date, antrenamente pentru evaluare egala, conditii pentruexaminare unitara

a fi vazut de un acelasi medic .

ACCESIBILITATE ACCESIBILITATE

Evaluare i monitorizare

Monitorizarea pacienilor cu boli reumatologice cronice necesit o

evaluare cantitativ ct mai obiectiv

Vezi exemple o Evaluarea durerii o Evaluarea activitii bolii, etc.

Reumatologia - cuprins Concept general Baze stiintifice Evaluarea pacientului cu boli

reumatice Clinica Laborator Artrocenteza Imagistica Rx, echo, CT, RMN,

scinti, osteo Biopsii, histo Componenta psihosociala Dizabilitate, handicap

Tratament Medicamentoase

antialgice AINS Steroizi MMF de fond Imunodepresoare,

citotoxice Terapie biologica Hipouricemiante,

colchicina Antiosteoporotice

Terapii recuperare Terapii chirurgicale

Care sunt bolile pe care le diagnostichez i trateaz reumatologii? Mai mult de 150 de boli i condiii sunt

clasificate ca boli reumatice (patogenez, tablou clinic, prognostic i

tratament diferite) Reumatologii diagnosticheaz i

trateaz artrite, unele boli autoimune sistemice (colagenoze, vasculite

sistemice, afeciuni musculoscheletale regionale sau diseminate, osteoporoza,

etc. vezi cuprins tratat reumatologie)

Reumatologia - cuprins

Boli reumatice sistemice colagenoze

Poliartrita reumatoida PAR Lupus eritematos sistemic LES si

lupus medicamentos Sclerodermia sistemica ScS Boli inflamatorii musculare

dermato/polimiozita DM/PM Boala mixta de tesut conjunctiv

BMTC Sindromul Sjogren SSj Sindromul antifosfolipidic SAPL Boala Still a adultului AOSD

Vasculite sistemice si boliinrudite Vasculite vase mari

Polimialgia reumatica PMR siarterita gigantocelulara AGC

Boala Takayashu Vasculite vase medii

Poliarterita nodoasa PAN Tromangeita obliteranta TAO

Granulomatoza Wegener GW Sindromul Churg Strauss Vasculite de vase mici Crioglobulinemia Boala Behcet Policondrita recidivanta

Care sunt bolile pe care le diagnostichez i trateaz reumatologii?

Este important s eliminm termenul reumatism din vocabularul nostru

medical, dar i din cel curent !

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Reumatologia cuprins 2 Spondilatropatii

seronegative Spondilita anchilozanta SA Sindromul Reiter si artitele reactive Manifestari reumatice in nolile

enterale inflamatorii (artrite enterale) Manifestari reumatice in psoriaziz si

alte boli cutanate

Artrite asociate cu infectii Artrite septice Boala Lyme Infectii micobacteriene si fungice oa Artrite virale Manifestari reumatice in SIDA Boala Whipple RAA

Manifestari reumaticeasociate cu bolimetabolice, endocrine, renale si hematologice Guta Artrite microcristaline: calcium

pirofosfat, hidroxiapatita, etc Endocrine Hematologice: hemofilia,

siclemia Renale

Boli osoase si cartilaginoase Artroza Boala Paget Osteonecroza

Reumatologia cuprins 3 Boli ereditare,

congenitale si eroriinascute de metabolism asociate cu manifestarireumatice Boli ereditare de colagen:

Marfan,Ehlers Danlos Displazii osoase si articulare Osteocondoplazii

Neoplasme si tumor-like Tumori maligne osoase primare

/ secundare Tumori osoase benigne Manifestari reumatice

paraneoplazice

Boli nonarticulare/ abarticulare siregionale Lombalgia Cervicalgia Reumatism abarticular:

tendinite, bursite, entezite, epicondilite

Neuropatii de compresie Fibromialgia Sindroame dureroase

regionale sau sdr miofasciale Distrofia simpatica reflexa

(sindrom dureros regional complex)

Cnd trebuie cutat un reumatolog ? Multe dintre bolile reumatice nu sunt uor de recunoscut i identificat mai

ales n etapele iniiale. Reumatologii sunt antrenai s

desfoare o munc de detectiv care presupune screening-ul mai multor

organe pentru a determina apartenea simptomelor.

Este important ca bolile, mai ales cele imun-inflamatorii, s fie recunoscute

devreme n aa fel nct tratamentul s fie instituit precoce, atunci cnd

modificrile sunt reversibile. Acestea sunt bolile care cu precdere

trebuie ndrumate la reumatolog !!!

Reumatologia cuprins 4

Boli reumatice in context sportiv

Boli reumatice in context profesional

Alte boli cu manifestari reumatice Sarcoidoza

Amiloidoza

Fenomenul Raynaud

Miopatii genetice si metabolice

Conditii speciale Copilul

Sarcina

Deoarece unele boli reumatologice sunt complexe i manifestrile se dezvolt n

timp, uneori o singur vizit la un reumatolog nu este de ajuns, pentru a

pune diagnosticul i a stabili tratamentul corespunztor

Aceste boli adesea se schimb sau

evolueaz n timp. Reumatologii identific mpreun cu pacienii lor

aceste evoluii.

Urmrirerea i monitorizarea este cheia diagnosticului i tratamentului corect n

reumatologie !!!

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Activitati (teme) obligatorii si facultative Informatii curs 1 Ce este reumatologia ?

Invatati sa evaluati durerea pe o scala analoga vizuala (VAS)

Scal vizual analog (100mm)

Scal numeric 1 - 10

Scal verbal1. Fr durere2. Durere uoar3. Durere moderat4. Durere sever5. Durere foarte sever, insuportabil

EVALUAREA CLINIC

Durerea

Fr durere Cea mai mare durere posibil

0 1 2 3 4 5 6 7 8 9 10

Scala VAS pentru intensitatea durerii Fara Cea mai rea durere durere posibila Scala VAS pentru eficacitatea tratamentului Fara Ameliorarea ameliorarea durerii completa a durerii Scorul VAS este masurat prin distanta in cm de la 0 la marca tratasata de pacient sau de nota pe care acesta o da durerii Fara Cea mai rea durere durere posibila Exemplul arata un pacient cu o durere de intensitate 9. Nota Scala VAS permite o masuratoare cantitativa a unui simptom subiectiv (durerea) o experienta in intregime personala. Nu ajuta pentru compararea pacientilor intre ei, ci pentru monitorizarea in timp a unei dureri la un acelasi pacient sau a evolutiei acesteia la un grup de pacienti. !!!

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Chestionarul de durere McGill Este utilizat pentru cuantificarea experientei dureroase a pacientului . Cuprinde o serie de 102 feluri de descrie durerea grupate in clase si subclase

descriind diverse clase si subclase care descriu diverse aspecte ale experientei dureroase

Chestionarul McGill necesita in general 5 10 minute pentru completare.

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Invatati sa evaluati activitatea globala a bolii pe o scala analoga vizuala (VAS)

Evaluarea activitatii bolii global se face in acelasi fel ca si a durerii

Pacient Apreciind activitatea bolii Dvs n

ultimele zile ?

Lund n considerare felul n care v afecteaz artrita reumatoid, marcai cu o linie vertical...

EVALUAREA CLINIC

Evaluarea global a activitii bolii

Foarte bine Foarte ru

0 1 2 3 4 5 6 7 8 9 10Nici una Foarte mare

Medic, evaluator ?

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21


th

tole G

ortaitys. Beeoare nthe

characteristic of chronic arthritis, the mechanic one, characteristic of degenerative joints diseases such

associeasantr pote(Internonomy

causes (e.g. inammatory, mechanic or neuropathic) (Katz and Rot-tenberg, 2005b) and affected by a variety of factors (MacKichanet al., 2008); between the acute causes of pain, crystal inducedarthritis (CIA) and osteoporotic fractures are the typical examples,whereas rheumatoid arthritis (RA) and other inammatory arthrit-ides such as psoriatic arthritis (PsA) and ankilosing spondilitis (AS),osteoarthritis (OA) and bromyalgia (FM) are typically associated

and neuropathic components are present (Fitzcharles and Shir,2008); its way of presentation is not univocal and several kindsof pain are described, in particular in rheumatic diseases; in theseconditions multi-site chronic pain is more common than single-site chronic pain (Carnes et al., 2007).

2.1. Acute pain

Acute pain is related to the occurrence of local tissue damagewith subsequent nociceptors activation (Loeser and Melzack,1999). CIA in general and gout in particular may be seen as the

* Corresponding author. Tel.: +39 0382501878; fax +39 0382503171.

European Journal of Pain Supplements 3 (2009) 105109

Contents lists availab

f

.EuE-mail address: [email protected] (R. Caporali).the most common reason people seek medical attention (Katzand Rothenberg, 2005a) and this is particularly evident in the eldof Rheumatology. In fact pain is frequently the rst symptom in themajority of rheumatic disorders (Centers for Disease Control andPrevention, 2001; WHO, 2003), generally resulting in a signicantburden of suffering, deeply affecting patients quality of life (Fitz-charles and Shir, 2008) and inuencing also the lifestyle of familiesinvolved (Main and Williams, 2002). Pain expression in the clinicalsetting is not univocal, being acute or chronic, related to different

2. Pain in rheumatology

Pain is a multifactorial sensation involving peripheral nocicep-tion, central sensitization, and cortical interpretation (Katz andRottenberg, 2005b). Generally pain is categorized as nociceptivewhen arising in areas of tissue damage, neurogenic when associ-ated with specic nerve damage and mixed, when both nociceptive1. Introduction

According to The Internationalpain, pain is described as an unplexperience associated with actual odescribed in term of such damagethe Study of Pain Task Force in Tax1754-3207/$36.00 2009 European Federation of Intdoi:10.1016/j.eujps.2009.07.006as OA, and the bromyalgic one, described in patients affected by FM; however also a true neuro-pathic pain may be present in these patients. This classication may be useful in the initial screeningof the diseases potentially underlying to a painful syndrome, and in the follow-up of patients once estab-lished the diagnosis. With this paper we describe the different aspect and the burden of pain in differentrheumatic diseases. 2009 European Federation of International Association for the Study of Pain Chapters. Published by

Elsevier Ltd. All rights reserved.

ation for the study ofsensory and emotionalntial tissue damage, orational Association for, 1994); pain is surely

with chronic pain. Pain in rheumatic diseases may be very impor-tant because its correct interpretation may help the clinician in thediagnostic process. However, patients with rheumatic diseasesmay experience similar levels of pain independently from theunderlying pathological condition, and pain control is not alwayseasily achievable, thus representing a very important problem forboth patient and clinician (Sheane et al., 2008).Rheumatic diseasesInammation

and not univocal, being inuenced not only by the underlying disease, but also by other factors. Gener-ally, 3 rhythms of pain presentation are described in rheumatic conditions: the inammatory rhythm,Pain and rheumatology: An overview of

Carlomaurizio Montecucco, Lorenzo Cavagna, RoberDivision of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, Piazza

a r t i c l e i n f o

Article history:Received 9 June 2009Accepted 21 July 2009

Keywords:Chronic pain

a b s t r a c t

Actually pain is a very impworsening of patients qualexpenses and indirect costin fact diseases such as ostular rheumatisms (EARs) aoccurrence. According to

European Journal o

journal homepage: wwwernational Association for the Stude problem

Caporali *

olgi 2, CAP 27100 Pavia (PV), Italy

nt health problem, affecting the majority of people, leading to a signicantof life and being responsible for a large amount of both medical resourcestween the different causes of pain, rheumatic conditions are predominant;rthritis (OA), rheumatoid arthritis (RA), bromyalgia (FM) and extra-artic-ot only frequently observed, but are also invariably associated with painwide range of rheumatic diseases described, pain expression is complex

le at ScienceDirect

Pain Supplements

ropeanJournalPain.comy of Pain Chapters. Published by Elsevier Ltd. All rights reserved.

2.2. Chronic pain

quently associated with a prolonged morning stiffness (e.g.

2.4. Mechanic pain

between the items of both the original and reassessed BirminghamVasculitis Activity Score (BVAS) (Luqmani et al., 1994; Mukhtyar

l ofMechanic pain is characteristic of degenerative diseases such asOA, a common and slowly progressive chronic condition, mainlyevident in older people, frequently leading to physical disability(Harris et al., 1989). Pain in OA is greater during the day, when pa-tient is on activity, and improves with the rest (Bellamy et al.,2004; Salaf et al., 2005a); similarly to RA, also in OA there is arelationship between pain and morning stiffness, but generallythe latter is not longer than 10 minutes (Salaf et al., 2005b). Dif-ferential diagnosis of pain may be further complicated by inam-matory ares that may frequently occur in OA patients.

Pain sensation not clearly classiable as inammatory or me-chanic is typical of FM, a syndrome of unclear pathogenesis, char-acterized by long-lasting, widespread musculoskeletal pain, in thepresence of 11 or more tender points located at specic anatomicalsites (Coster et al., 2008). FM patients generally present a reducedthreshold for pain in the muscles, together with many other non->30 min), another feature typically described in inammatory dis-eases (Cutolo and Straub, 2008). So a presentation rhythm of jointpain with similar characteristic is highly suspect for the occurrenceof an inammatory arthritides, with the subsequent diagnosisbeing conrmed by a complete clinical, laboratory and radiologicalevaluation.Chronic pain is commonly triggered by an injury or disease, butit may be perpetuated by factors other than the cause of pain, suchas the activation of neurogenic mechanisms (Loeser and Melzack,1999). In rheumatic diseases several types of chronic pain are de-scribed, mainly related to the type of the underlying disease.

2.3. Inammatory pain

Inammatory pain is characteristic of the different forms ofchronic arthritis, in which patients generally experienced a wors-ening of the symptom at night or at rest, with reduction after phys-ical activity (Salaf et al., 2005a; Coady et al., 2007). In fact thereare several evidences that patients with arthritis identify differentpain sensation at rest and on activity (Harkness et al., 1982; Koma-tireddy et al., 1997; Cutolo and Straub, 2008). Moreover pain is fre-classical example of rheumatic disease leading to acute pain; infact podagra (deposition of urate crystals in the rst toe) and otherpossible localizations of gout (e.g. ankle, knee, etc.) are betweenthe most painful pathologic conditions described, with the patientthat cannot bear for their joints to be touched and with a pain typ-ically burning, piercing or crushing in character (Bingham et al.,2009). In similar cases the early identication of the disease, basedon the clinical presentation and on the observation of urate crystalsin synovial uid at light/polarized microscope, is essential, becausethe right treatment may lead to complete control, without furtheracute attacks and avoiding the risk of chronicization. Also, osteopo-rotic fractures are associated with an acute pain: in this case too, acorrect diagnosis may prompt the clinician not only to control painbut also to study the patient in order to avoid further fractures.This point is crucial in view of the strong impact of this complica-tion on the quality of life of the patients (Cooper et al., 1993; Joh-nell and Kanis, 2006).

106 C. Montecucco et al. / European Journamusculoskeletal symptoms including fatigue, sleep disturbance,headache, migraine, variable bowel habits, diffuse abdominal pain,and urinary frequency (Bliddal, 2007).et al., 2008) and of the Vasculitis Damage Index (VDI) (Exleyet al., 1997), tools commonly used in the assessment of vasculitisactivity and damage. In RA patients NP may be due to either tothe occurrence of nerve entrapment (Rosenbaum, 2001) or toperipheral neuropathy (PN) (Rosenbaum, 2001; Albani et al.,2006); between the entrapment neuropathies, carpal tunnel syn-drome (CTS) is not a rare nding and is said to occur in a quarterof RA patients, being frequently the rst symptom of the disease(Fleming et al., 1976; Rosenbaum, 2001). Regarding PN recentlywe observed that for RA patients is not easily to discern betweenneuropathic and arthritic pain, so indicating the need of a carefulneurological examination in order to identify this complication ofthe disease (Albani et al., 2006).

3. Epidemiology of rheumatic pain

Actually rheumatic diseases are the prominent cause of chronicpain in developed world (Fitzcharles and Shir, 2008); in fact pain isconsistently present in any rheumatic condition such as OA, FM,extra-articular rheumatisms (EARs), RA and other chronic formsof arthritis (Sokka, 2005). Moreover literature data indicate thatthe overall prevalence of rheumatic pain is steadily increasing inthe general population, according to its senescence (Harknesset al., 2005), and that this problem is emerging also in non devel-oped countries, where its prevalence varies from 12% (Vietnam)to 47% (Per) in urban areas and from 12% (Shantou, China) to55% (Australian Aborigines) in rural areas (Chopra, 2008). Recentestimates on the prevalence of rheumatic diseases indicate thatin the United States, RA affects 1.3 million adults, spondylarthri-tides affect from 0.6 million to 2.4 million adults, nearly 27 millionhave clinical OA, up to 3.0 million have had self-reported gout and5.0 million have FM (Helmick et al., 2008; Lawrence et al., 2008).Although these data suggest the strong impact of rheumatic condi-tions on the general population, it is important to remember thatthe epidemiology of different rheumatic diseases is worldwideinhomogeneous. Recently, in a survey (Salaf et al., 2005b) con-ducted in an Italian population sample, up to 27% of subjects re-2.3. Neuropathic pain

According to the latest denition, neuropathic pain (NP) is a di-rect consequence of a lesion or disease affecting the somatosensorysystem (Treede et al., 2008); the damage might be referred to aninjury either in the peripheral or in the central nervous systemor both and it could be associated with various sensory and/or mo-tor phenomena (Backonja, 2003). Clinically NP is characterized byspontaneous or evoked pain, described in term of a burning or tin-gling sensation or as a hypersensitivity to touch or cold (Katz andRottenberg, 2005b) and ranging from dysesthesias to allodynia(Chong and Bajwa, 2003). In rheumatic diseases, NP is frequentlydue to a nerve involvement in term of mononeuropathy, moneuri-tis multiplex, poly-neuropathy, cranial neuropathy and entrap-ment neuropathy. Small and medium vessel vasculitis arefrequently associated with a neurological involvement, so thatmono- or poly-neuropathy are between the classication criteriaof ChurgStrauss syndrome (Masi et al., 1990) and polyarteritis no-dosa (Lightfoot et al., 1990); on the other hand, NP may be clini-cally evident also in other systemic vasculitis such as Behetdisease (Akbulut et al., 2007), mixed cryoglobulinemia (Gemignaniet al., 2005), microscopic polyangiitis and Wegener Granulomato-sis (Cattaneo et al., 2007). Moreover, neuropathic involvement is

Pain Supplements 3 (2009) 105109ported the occurrence of chronic musculoskeletal pain, femalesbeing most commonly affected than men and disease prevalenceincreasing signicantly with patients age. In this study, the most

l offrequently observed rheumatic conditions leading to chronic painwere symptomatic peripheral OA, with a prevalence of 8.95% andEARs (8.81%), whereas inammatory arthritis occurred in 3.06%of population study and FM in 2.22% (Fig. 1). In another study per-formed in a small rural town of Tuscany on a large sample of peo-ple aged more than 65 years, about one third of the cohort wasaffected by symptomatic OA in one or more peripheral joints, withprevalence values for knee, hip and hand OA, respectively of 29.8%,7.7%, and 14.9% (Mannoni et al., 2003). Different results have beendescribed in another survey performed on patients older than85 years in an Urban town of Netherlands (van Schaardenburget al., 1994); in the study the prevalence of symptomatic OA wasrespectively of 18%, 7% and 5% in hand, hip and knee, suggestingthat both demographic (e.g. the age of patients enrolled) and work-ing factors (e.g. rural vs dweller workers) may inuence long-termappearance and expression of OA. However a signicant disparitybetween the degree of joint radiographic damage and the percep-tion of pain is frequently observed in OA; in fact 3060% of individ-uals with moderate to severe OA at X-rays are completelyasymptomatic, and 10% of individuals with moderate to severepain have normal X-rays (Creamer et al., 1997; Hannan et al.,1998). Taken together, these observations indicate the complexityof pain in OA, in which factors other than the damage of the carti-lage and sub-chondral bone are involved (Claw and Witter, 2009).Regarding RA the prevalence range from 0.33% to 1% (Cimmino

peripheral OA (8,95%)

Soft tissue disorders (8,81%)

Crystal induced arthritis (0,88%) PsA

(0,42%) Other connective tissue diseases

(1,12%)

RA (0,46%)

AS (0,37%)

Fig. 1. Prevalence of different rheumatic diseases in the general adult population ofMarche according to MAPPING study results (adapted from: Salaf et al., 2005b).Legend: AS = ankylosing spondylitis; PsA = psoriatic arthritis; peripheralOA = peripheral osteoarthritis.

C. Montecucco et al. / European Journaet al., 1998; Alamanos et al., 2006), although in peculiar populationsuch as the Pima Indians, the prevalence may rise up to 5.3% (DelPuente et al., 1989), suggesting that genetic, behavioral and cli-matic factors as well as environmental exposures may inuencethe disease appearance.

Regarding other potentially painful diseases, in France, in wo-men aged more than 45 years, the overall prevalence of diagnosedosteoporosis was 9.7%, the 45.3% of which reporting at least oneprevious fracture (Lespessailles et al., 2009); similar gures havebeen described also in USA (Robitaille et al., 2008) and in Chinesewomen (Wang et al., 2009), thus underlying the worldwide epide-miologic relevance of the problem. FM is described in all agegroups, with a prevalence ranging from 1% to 10% of population;in general it is said a female syndrome, but also men may developthe syndrome. Frequently FM in men is under-diagnosed for anumber of reasons, such as gender differences in seeking medicalhelp, sex-related differences in pain perception and psychosocialinuences (Bliddal, 2007). On this basis is evident that musculo-skeletal conditions although inhomogenous in the occurrence area worldwide problem of individuals, health systems, and socialcare systems (WHO, 2003).4. The burden of pain in rheumatic diseases

Once established that rheumatic pain is not a rare nding, thesubsequent step is the assessment of its burden on both patientsand society. General data indicate that rheumatic diseases arethe prevalent cause of functional limitation and years lived withdisability in developed countries (Reginster and Khaltaev, 2002),affecting also the psychosocial status of patients and their families(Woolf and Peger, 2003). Rheumatic pain impacts also patientsquality of life (Reginster, 2002; Fitzcharles and Shir, 2008), witha correlation that is particularly evident in RA; in fact HealthAssessment Questionnaire (HAQ), a tool used worldwide for theevaluation of RA quality of life, is deeply inuenced by the levelsof pain (Hkkinen et al., 2005). Moreover a strict relationship be-tween pain intensity, inammation and patients function is de-scribed in the early phases of arthritis conditions, conrming thestrong impact of the symptom on these patients (Fitzcharles andShir, 2008). Regarding OA several questionnaires such as the Wes-tern Ontario McMaster (WOMAC) osteoarthritis index (Bellamyet al., 1988) and the Lequesne Index (Lequesne et al., 1987) haveconrmed the effects of pain on patients daily activities; further-more, according to literature data, OA is the sixth leading causeof disability at the global level, accounting for the 2.8% of totalyears of living with disability (Woolf and Peger, 2003). But theimpact of OA is strengthened also by other factors; the AMICAstudy (Approccio Multidisciplinare Italiano alla Cura e diagnosidellArtrosi) found that the occurrence of comorbidities intensiespain expression and worsens joint function in OA (Cimmino et al.,2005). The presence of comorbid conditions such as osteoporosis,diabetes, cardiovascular and lung chronic diseases, peptic ulcer isthus associated with a poorer quality of life and with a long-termphysical disability of OA patients. However this relationship isnot clear; one may suppose that the concomitant occurrence oftwo chronic conditions can inuence physical activity, leading toreduced joint mobility and overweight. Another possibility is theoccurrence of an additive effect between the conditions; for exam-ple OA symptoms may be worsened in case of PN occurrence andPN may facilitate the progression of OA (Cimmino et al., 2005).Osteoporotic fractures are generally associated with an increasedpatient morbidity and impairment of quality of life (Salaf et al.2007); however, fractures of the hip and vertebrae are also linkedwith an increased mortality up to 5 years following the event. Fur-thermore the burden of osteoporotic fracture is seemingly rising inthe future, mainly due to the progressive increase in life expec-tancy (Holreyd et al., 2008).

Pain is surely the main problem of FM. In these patients paincontrol is not easily achievable, affecting patients quality of liveat the same level of RA (Silverman et al., 2009); in general, a mul-timodal approach involving not only the rheumatologist but alsoother medical gures such as psychiatric, psychologist, physiother-apist, is needed (Abeles et al., 2008). But pain meaning in FM is dis-cussed too; generally the patients are reassured that, despite theseverity of their pain, FM does not lead to bodily damage or death(Bliddal, 2007). On the contrary several papers described an asso-ciation between widespread pain occurrence, characteristic ofFM, and an increased risk of cancer death (Macfarlane et al.,2001, 2007). On this basis it is evident the importance of a com-plete evaluation of FM patients before the diagnosis and during fol-low-up. Moreover we must take into account that FM is a diagnosisof exclusion, frequently co-occurring with other rheumatologicdiseases, such as RA and Systemic Lupus Erythematosus (SLE)(Bliddal, 2007; Silverman et al., 2009).

All these data indicate that the burden of pain in rheumatic dis-

Pain Supplements 3 (2009) 105109 107eases is high, leading frequently to disability and impaired qualityof life of patients; but rheumatic pain has also an economic burden,

pro-capite expense is superior with respect to OA (estimated an-nual cost $9300 vs $5700) (Maetzel et al., 2004). Regarding osteo-

and Depression Score (Zigmond and Snaith, 1983) are available.Furthermore, also patient barriers such as lack of motivation, fear

Del Puente A, Knowler WC, Pettitt DJ, Bennett PH. High incidence and prevalence ofrheumatoid arthritis in Pima Indians. Am J Epidemiol 1989;129:11708.

l ofand distrust to medication, poor adherence to treatment may con-tribute to sub-optimal pain control in rheumatologic conditions(Fitzcharles and Shir, 2008). On the other hand it is important tounderline that also external factors may indirectly inuence pain;the classical example is the withdrawal from the commerce ofrofecoxib because of evidence of an increased risk of myocardialinfarction (Bresalier et al., 2005). This event led to a reduction ofcoxib use in patients with OA, without any increase of prescriptionof other NSAIDs or analgesic, thus suggesting an undertreatment ofpain in the clinical setting, because of cardiovascular side effectsfear (Alacqua et al., 2008).

6. Conclusion

Pain is very common in rheumatic diseases, with a prevalencesteadily increasing according to the senescence of population; thissymptom deeply affect patients quality of life, resulting in a burdenof suffering together with sleep and mood problems. Moreover theburden of rheumatic pain is also economic, with a large amount ofdirect and indirect costs. But pain is useful for patients classica-porosis, direct inpatient hospital costs of vertebral fracturesexceeded 41 millions euros in Spain (Bouza et al., 2007), whereasin German hip fractures economic burden was 2736 millions ofeuro for direct cost and 262 millions of euro for indirect costs (Kon-nopka et al., 2008); taking into account all fractures, the annualcost following every event is about 5000 euro/patient, (Rousculpet al., 2007). Finally in FM the economic burden is similar to thoseof RA; in fact the mean annual expenditures were similar betweenFM ($10911) and RA ($10716); the co-occurrence of both diseases,however not a rare nding, almost doubles annual expenses(FM + RA = $19,395) (Silverman et al., 2009).

5. Factors affecting pain expression

Pain expression is not univocal overtime and may be inuencedby psychosocial, demographic and clinical factors. In particular therelationship between psychosocial problems and pain is compli-cated and bidirectional, with both factors inuencing each other(MacKichan et al., 2008). Psychological aspect is particularly evi-dent in RA, an inammatory arthritides having a strong impacton mental distress soon after the onset (Smedstad et al., 1996;Backman, 2006); in this disease there are evidences that psychoso-cial interventions improve coping and self efcacy, reduce psycho-logical distress, and reduce pain, at least in short term (Backman,2006). Psychological distress plays a role in pain perception alsoin SLE (Karlson et al., 2004) and FM (Wineld, 1999; Abeleset al., 2008). On this basis we understand the need to assesswhether psychological problems are important components ofpain; for this purpose several tools such as the Hospital Anxietythat comprehend direct (e.g. drugs, medical care, hospitals, disabil-ity pensions) and indirect costs (premature mortality, short- andlong-term disability, loss of productivity, etc.). In fact the economicimpact has been estimated as up to 12.5% of the gross nationalproduct of countries such as the USA, UK, France and Australia(Reginster, 2002). In particular OA impacts on USA economy morethan $60 billion per year (Buckwalter et al., 2004); furthermorealthough RA is less frequent with respect to OA, the outpatients

108 C. Montecucco et al. / European Journation and follow-up; in fact pain expression is variable according tothe underlying rheumatic disease and its right interpretation maybe essential for the rst diagnostic classication of the patients.Exley AR, Bacon PA, Luqmani RA, Kitas GD, Gordon C, Savage CO, et al. Developmentand initial validation of the vasculitis damage index (VDI) for the standardisedclinical assessment of damage in the systemic vasculitides. Arthritis Rheum1997;40:37180.

Fitzcharles M, Shir Y. New concepts in rheumatic pain. Rheum Dis Clin North AmConict of interest statement

No conicts of interest are present for the authors.

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Maetzel A, Li LC, Pencharz J, Tomlinson G, Bombardier CCommunity Hypertensionand Arthritis Project Study Team. The economic burden associated withosteoarthritis, rheumatoid arthritis, and hypertension: a comparative study.Ann Rheum Dis 2004;63:395401.

Main CJ, Williams AC. Musculoskeletal pain. BMJ 2002;325:5347.Mannoni A, Briganti MP, Di Bari M, Ferrucci L, Costanzo S, Serni U, et al.

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27


Intrebari si teme recapitulative 1) Care dintre urmatoarele caracteristi ale durerii articulare sugereaza o patologie

inflamatorie ? a) Aparitia sau accentuarea la efort b) Aparitia sau accentuarea in repaus c) Nocturna d) Insotita de redoare matinala e) Insotita de manifestari sistemice

2) Insirati cele 5 semne cardinale ale inflamatiei. 3) Ce intelegeti printr-o articulatie activa ? O articulatie cu

a) Colectie (hidartroza) b) Angulatie c) Sinovita d) Noduli periarticulari e) Eritem

4) Care sunt elemetele dupa care considerati ca o durere regionala are mai degraba cauza periarticulara (burse, tendoane) decat articulara ? a) Se accentueaza la orice miscare articulara b) Apare la unele miscari articulare (selectiva) c) Se accentueaza la anumite pozitii care determina compresie d) Este mai accentuata la miscari active e) Este mai mare la miscari pasive

5) Cat este schimbarea minima pe SVA de durere de 10 cm considerata ca semnificativa a) 5 mm b) 10 mm c) 13 mm d) 20 mm e) 30 mm

6) Cum se clasifica durerea dpdv al mecanismului fiziopatologic ? 7) Cum se clasifica durerea dpdv al duratei ? 8) Dupa ce perioada de evolutie consideram o durere ca fiind cronica ?

a) 1 saptamana b) 1 luna c) 3 luni d) 6 luni e) Care vine si trece

9) Notati cu * elemetele care caracterizeaza durerea acuta, iar cu # durerea cronica a) Dureaza peste 3- 6 luni

28


b) Cauza declansatoare este prezenta c) Cauza declansatoare nu mai este prezenta d) Durerea persista si dupa disparitia cauzei declansatoare e) Are caracter protectiv f) Nu mai are caracter protectiv (devine boala insasi) g) Se insoteste de anxietate h) Se insoteste de depresie

10) Care sunt cuvintele cu care pacientii descriu mai degraba durerea neuropata ? a) Inteapa b) Strange c) Arde d) Apasa e) Amorteala

Rspunsuri corecte

1) Raspuns corect: b, c, d, e 2) Raspuns corect: tumor, calor, rubor, dolor, functio lesa 3) Raspuns corect: a, c, e 4) Raspuns corect: b, c, d 5) Raspuns corect: c 6) Raspuns corect: nociceptiva si neuropata 7) Raspuns corect: acuta si cronica 8) Raspuns corect: c 9) Raspuns corect * b,e,g; # b,c,f,h, 10) Raspuns corect: a,c, e

Bibliografie selectiv (Manuale, tratate, articole de revista, materiale audiovizuale - atlase, visdeocasete, informatie multimedia in format digital, programe educative pe intranet sau internet, adrese web ale unor baze de date) 1. Ciurea P. et al Reumatologie, editura Medicala Universitara, Craiova, 2007 2. Da Silva JAP, Woolf AD. Rheumatology in Practice, Springer Verlag, London,

2010 3. Harrisons ed. Manual de Medicina (editia 15), A. S. Fauci E. Braunwald K. J.

Isselbacher ed. editura Teora, Bucuresti, 2003 (retiparire editia 2001) 4. Hunder GG ed. Atlas of Rheumatology, Lippincott Williams & Wilkins,

Philadelphia, 2002 5. Ionescu R. Esentialul in Reumatologie, editia a 2-a revizuita, editura Amaltea,

Bucuresti, 2006 6. Klippel JH ed Primer on the Rheumatic Diseases , Springer, New York, 2008

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7. Stone JH ed. A Clinicians Pearls and Myths in Rheumatology, Springer, Dordrecht, Heidelberg, 2009

8. West S. Rheumatology Secrets , 2nd edition, Hanley & Belfus Inc, Philadelphia, 2002

31

Demonstraie practic: principiile examinrii pacientului cu boal reumatologic

CAPITOL 2 - DEMONSTRAIE CLINIC: PRINCIPIILE EXAMINRII PACIENTULUI CU BOAL

REUMATOLOGIC (4 H) Tabla de materii

I. Cnd facem screeningul afeciunilor reumatologice ? II. Anamneza Principalele simptome reumatologice Elementele de difereniere ntre afeciunile reumatologice

inflamatoare i degenerative Elementele cheie ce trebuie incluse n istoricul bolilor

reumatologice III. Examenul obiectiv musculoscheletal Principalele modificri la examenul obiectiv Examenul de screening pentru afeciunile reumatologice Elementele cheie ce trebuie evaluate prin examenul obiectiv al

sistemului musculoscheletal

Obiectivele educaionale: la sfritul discuiilor vei fi capabili s: o tii care sunt simptomele ce sugereaz o afeciune reumatologic o Recunoatei principalele modificri patologice la examenul

obiectiv al sistemului musculoscheletal o Identificai artritele i s le difereniai de afeciunile reumatologice

degenerative o Recunoatei existena diversitii topografice a artritelor i a

caracterului sistemic al unor boli reumatologice inflamatoare o tii cnd s ndrumai un pacient cu acuze musculoscheletale

pentru consult i terapie la medicul specialist reumatolog o nelegei impactul profund pe care bolile reumatologice l au

asupra activitilor zilnice, vieii profesionale, sociale i familiale

Ce trebuie s tii ! o Esenial Principalele simptome reumatologice Principalele modificri la examenul obiectiv Examenul de screening pentru afeciunile reumatologice Diagnosticul diferenial al afeciunilor inflamatorii i

degenerative recunoatere artrit o Important Analiza detaliat a durerii musculoscheletale Evaluarea manifestrilor generale ce pot acompania afeciunile

reumatologice inflamatoare Identificarea semnelor care sugereaz existena unei

componente inflamatorii ntr-o artropatie

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Recunoaterea manifestrilor extraarticulare particulare ce acompaniaz anumite forme de reumatism inflamator

o Util Caracteristicile i topografia durerii referate n bolile

reumatologice Caracteristicile durerii indicatoare de posibil malignitate Modificrile examenului obiectiv care difereniaz ntre

leziunile intraarticulare i cele periarticulare o Facultativ Evaluarea capacitii funcionale, disabilitii i handicapului n

bolile reumatologice

Ce trebuie s facei ! o S observai Cazurile de pe secia clinic Felul n care se face anamneza i examenul clinic al

pacienilor cu afeciuni reumatologice o S facei sau interpretai personal, individual sau n echip Anamneza Examenul obiectiv de screening al afeciunilor reumatologice

o S v nsuii urmtoarele abiliti practice: 1. identificarea i descrierea nodulilor subcutanai 2. identificarea i descrierea faciesurilor caracteristice bolilor

reumatologice 3. evaluarea temperaturii tegumentare la nivelul articulaiilor 4. diferenierea ntre tumefierile de esuturi moi i deformrile

osoase 5. detectarea sinovitei 6. detectarea hidartrozei ocul rotulian 7. evidenierea sensibilitii intra- i periarticulare 8. manevra Lasegue efectuare i interpretare 9. manevra Tinel - efectuare i interpretare 10. detectarea arcului dureros mijlociu - efectuare i interpretare 11. semnul Gaensslen efectuare i interpretare 12. recunoaterea subluxaiilor articulare 13. identificarea i descrierea deformrilor caracteristice ale minii

n poliartrita reumatoid avansat 14. nodulii Heberden i Bouchard - detectare i interpretare 15. recunoaterea deformrilor n varus i valgus la nivelul

genunchilor i identificare hallux valgus 16. efectuarea micrilor active i pasive la nivelul articulaiilor

mari umeri, coate, olduri, genunchi 17. testul Schober - efectuare i interpretare 18. detectarea crepitaiilor la nivelul genunchilor 19. testarea instabilitii laterale a genunchilor 20. testarea capacitii funcionale a minilor capacitatea de

prehensiune i micrile de precizie

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I. Cnd facem screeningul afeciunilor reumatologice?

Screeningul sistemului musculoscheletal trebuie inclus n examenul medical general al tuturor pacienilor ntruct:

o multe boli reumatologice afecteaz i alte sisteme o numeroase boli medicale generale (endocrine, metabolice,

neoplazii) afecteaz aparatul locomotor o bolile reumatologice se ntlnesc frecvent n practica clinic

25% din consultaiile medicului de familie sunt pentru probleme reumatice

afeciunile reumatologice reprezint o cauz major de handicap

I. Anamneza Principalele simptome reumatologice

Durerea Redoarea Tumefierea/Deformarea Disabilitatea/Handicapul Simptome generale

Durerea

o Localizare Examinatorul trebuie s stabileasc cu precizie locul durerii. Terminologia pacientului poate s duc la erori

- s arate sediul maximei intensiti - aria pe care iradiaz

o Iradiere Durerea articular i periarticular poate iradia i poate fi

prezent la distan de structura de origine durere referat Caracteristicile durerii referate:

- este profund - limite indistincte - iradiaz segmental, nu trece linia median - este perceput mai ales distal - aria durerii referate poate fi diferit la diveri pacieni cu

aceeai afeciune

Examenul clinic osteoarticular poate fi mai relevant dect RMN ntruct evalueaz

semnificaia funcional a anomaliei observate.

! Durerea este de obicei cel mai important simptom pentru pacient.

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- cu ct structura afectat este mai superficial, cu att localizarea durerii este mai precis

- masajul ariei durerii referate amelioreaz durerea (presiunea pe structura de origine reproduce durerea)

Topografia iradierii durerii musculoscheletale

Structura de origine Durerea referat Coloana cervical Occiput, umeri, brae Coloana toracic Perete toracic anterior Coloana lombar Membre inferioare Umr Regiunea lateral a braului Cot Antebrae old Regiunea anterioar a coapsei, genunchi Genunchi Copase, old

o Caracter Adesea pacientul are dificulti la descrierea caracterului

durerii. Calitatea durerii se poate dovedi revelatoare pentru diagnostic

- durerea ascuit, lancinant n teritoriul de distribuie al unui nerv neuropatii compresive

- durerea atroce (cea mai rea) artrita microcristalin (ex: guta)

o Intensitate Este influenat de statusul emoional durera cronic este

adesea asociat cu anxietate i depresie care intensific percepia durerii.

o Factori de ameliorare/agravare Durerea

de utilizarea articular caracter mecanic

de repaus

Durerea de repaus caracter inflamator

de micare

Durerea nocturn reflect hipertensiunea intraosoas i acompaniaz afeciuni mai severe.

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Redoarea

o Senzaie subiectiv neplcut de rezisten la micri (probabil reflect distensia fluidului n limitele esutului inflamat, pierderea elasticitii tendoanelor i capsulei).

o Este maxim dimineaa la trezire i dup repaus prelungit.

Disabilitatea/Handicapul

o Disabilitate impactul pe care suferina articular l are asupra activitilor zilnice - ex. mbrcatul, autongrijirea, etc.).

o Handicap impactul bolii reumatologice asupra vieii sociale, capacitii de munc i calitii vieii.

Impactul funcional

Boala Durerea

Impotena funcionalex. imposibilitatea de a mica un deget

Disabilitateaex. dificulti la cntatul la un instrument muzical

Handicapulex. violonist pierderea locului de munc, depresie

!!! Caracteristicile durerii indicatoare de eventual malignitate (red flags signs)

persistent profund (osoas) progresiv sever

! Durata i severitatea redorii reflect gradul inflamaiei locale permite aprecierea gradului

de activitate a bolii.

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o Stabilirea capacitii funcionale se poate face cu diverse metode, care difer n funcie de afeciunea reumatologic ex. chestionare autoadministrate validate.

Simptome generale

o Bolile inflamatoare osteoarticulare (+/-afectare multisistemic) pot declana un rspuns de faz acut simptome generale nespecifice. Febr Inapeten Scdere n greutate Fatigabilitate Astenie Letargie Alterarea somnului Anxietate i depresie

Elementele de difereniere ntre afeciunile reumatologice inflamatoare i degenerative

Manifestri Afeciune inflamatoare Afeciune degenerativ Redoarea matinal > 1 or 30 minute Activitatea Amelioreaz simptomele Agraveaz simptomele Repausul Agraveaz simptomele Amelioreaz simptomele Manifestrile sistemice Da Nu Rspunsul la corticosteroizi

Da Nu

Elementele cheie ce trebuie incluse n istoricul bolii

o Care sunt principalele manifestri musculoscheletale

!!! Pacienii cu manifestri articulare care asociaz simptome generale i manifestri

extra-articulare sugestive pentru anumite forme de reumatism inflamator trebuie

ndrumai pentru consult i terapie la specialistul reumatolog.

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ntrebri utile pentru screeningul afeciunilor reumatologice 1. Avei dureri/redoare la nivelul membrelor superioare, inferioare sau spatelui ? 2. V putei mbrca complet, inclusiv s v legai ireturile fr nici o dificultate ? 3. Avei dificulti la mers, urcatul sau cobortul scrilor ?

! Un rspuns pozitiv la oricare din aceste ntrebri trebuie s fie urmat de un istoric detaliat al manifestrilor musculoscheletale i de examenul obiectiv de screening a aparatului locomotor.

o Distribuia afectrii articulare Monoarticular/Oligoarticular/Poliarticular Simetric/Asimetric Articulaii mici/Articulaii mari

Distribuia afectrii Exemple boli Monoarticular = 1 articulaie afectat

Infecioase (tuberculoas, gonococic), post-traumatice, degenerative (gonartroza, artropatia Charcot), microcristaline (guta, condrocalcinoza)

Oligoarticular = 2-4 articulaii afectate

Degenerative (artroza), spondilartrite (artrita reactiv, spondilita anchilozant, artrita psoriazic, artrite enterale), sarcoidoza

Poliarticular 5 articulaii afectate

Inflamatorii (poliartrita reumatoid, artrite din colagenoze), degenerative (artroza primitiv generalizat), infecioase (boala Lyme, hepatita B i C, HIV)

Axial = predominant la nivelul coloanei vertebrale

Spondilartrite, artroza

o Debutul cronologic Episodic - ex. guta Aditiv - poliartrita reumatoid

o Factorii declanatori Ex: activitatea, dieta, infecii sau traumatisme recente

o Factorii care agraveaz sau amelioreaz simptomele Ex: repausul/micarea

o Rspunsul simptomelor la interveniile terapeutice o Afectarea altor organe i sisteme o Impactul bolii la nivel individual, familial, profesional

II. Examenul obiectiv musculoscheletal Metodele utilizate la examenul obiectiv articular:

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1. Inspecia n repaus 2. Inspecia n timpul micrilor 3. Palparea (asociat cu mobilizarea articulaiilor)

! Articulaiile afectate trebuie comparate cu articulaiile simetrice sntoase.

Principalele modificri la examenul obiectiv

Modificrile tegumentare/subcutanate Modificrile de culoare Cldura local Nodulii subcutanai

Tumefierea articular/periarticular Hidartroza Tumefierea capsular i sinovial Tumefierea esuturilor periarticulare

Sensibilitatea la palpare i mobilizare Deformrile articulare

Remodelarea capetelor osoase Subluxaia Dislocarea

Modificrile musculare Mobilitatea articular

Limitarea mobilitii active i pasive Hipermobilitatea articular

Crepitaiile articulare i tendinoase Stabilitatea articular Capacitatea funcional

Modificrile tegumentare i ale esutului subcutanat

o Roeaa local, urmat uneori de descuamare sau hiperpigmentare tegumentar, este un semn al inflamaiei periarticulare i face parte din tabloul artritei septice, gutei sau reumatismului articular acut.

o Creterea temperaturii tegumentare reflect prezena inflamaiei la nivelul articulaiei afectate.

o Nodulii subcutanai sunt prezeni n unele boli articulare i constituie adesea un argument important pentru diagnostic.

Cauzele i caracteristicile nodulilor asociai artropatiilor

Boala articular Caracteristici

39


Poliartrita reumatoid insensibili, duri, adereni la periost Guta insensibili sau uor sensibili; uneori, se ulcereaz

lsnd s se scurg un material albicios (cristalele de urat monosodic) i se pot suprainfecta

Reumatismul articular acut mici, insensibili, mobili fa de piele, dar adereni la planul aponevrotic sau periost, cu distribuie simetric i evoluie fugace (nodulii lui Meynet)

Majoritatea nodulilor apar pe suprafeele extensoare (olecran, tuberozitatea ischiatic, regiunea sacrat, tendonul lui Ahile) sau n zonele de presiune

(ex. pavilionul urechii n gut)

Tofi gutoi

http://en.wikipedia.org/wiki/File:GoutTophiElbow.JPG

Tumefierea articular i periarticular

o Inspecia articulaiile afectate sunt mai voluminoase dect cele simetrice sntoase i au contururile osoase estompate. Tumefierile articulare realizeaz aspecte caracteristice la

anumite sedii. - tumefierea articulaiilor interfalangiene proximale cu aspect

fusiform poliartrita reumatoid incipient. - tumefiere n potcoav n regiunea suprapatelar i n jurul

rotulei colecie intraarticular la nivelul genunchiului

Palparea difereniaz ntre cele 3 componente posibile ale tumefierii: colecia intraarticular (hidartroza), hipertrofia sinovialei

! Tumefierea este un element important n diagnosticul artritelor.

40


i a capsulei articulare i tumefierea structurilor juxtaarticulare (tendoane i burse).

Hidartroza Metoda clinic utilizat pentru detectarea hidartrozei depinde de

cantitatea de lichid acumulat. colecie mic la nivelul genunchiului ocul rotulian colecie mare semnul valului se execut cu genunchiul

n extensie, prin percuia n zona lateral a liniei articulare, iar undele de presiune determinate de acumularea lichidului vor fi resimite de pulpa degetului plasat de partea opus.

Cauze de hidartroz: artrite acute artrite cronice n puseu de activitate suprasolicitri mecanice repetate hidartroz reactiv (ex.

artroza reacionat) hemoragie intraarticular posttraumatic hemartroza

ocul rotulian

o Manevra se execut cu genunchiul n poziie extins

o Se aplic o presiune cu dou degete n regiunea suprapatelar i se comprim rotula cu ajutorul indexului plasat pe mijlocul acesteia.

o Prezena unei colecii este confirmat de impactul rotulei cu condilii femurali, concomitent cu senzaia de balonizare determinat de deplasarea lateral a lichidului.

Tumefierea capsular i sinovial

Se evideniaz prin palpare n timpul micrilor pasive tumefiere renitent, delimitat de marginile capsulare i care devine mai ferm spre sfritul micrii.

41


Tumefierea esuturilor periarticulare

o Poate fi consecina unei bursite sau tenosinovite.

Bursita tumefiere de consisten moale i sensibil la palpare n regiunile unde exist burse sinoviale.

Tenosinovita (inflamaia tendonului i a tecii tendinoase) determin o tumefiere foarte sensibil la palpare i mobilizare, localizat de-a lungul tendonului.

Cauze de tenosinovit: o infeciile (ex. gonococic, stafilococic, streptococic sau

mycobacterian) o suprasolicitrile repetitive (ex. tenosinovita De Quervain

inflamaia tecii sinoviale a lungului abductor i scurtului extensor al policelui)

o artropatii care pot avea tenosinovite n tabloul clinic: poliartrita reumatoid, spondilartritele, guta, sclerodermia sistemic, etc.

Sensibilitatea

o Localizarea precis a sensibilitii (durerea provocat) este cel mai util semn clinic pentru evaluarea localizrii intraarticulare sau periarticulare a modificrilor patologice. sensibilitate la palparea direct a liniei articulare artropatii sensibilitate localizat la nivelul structurilor afectate (ligamente,

tendoane sau burse) afeciuni reumatismale periarticulare multiple puncte dureroase n zone caracteristice

fibromialgia o n unele afeciuni musculoscheletale sunt utile manevrele de

provocare a durerii, care urmresc s creeze un conflict mecanic n zona de interes.

! Tumefierea capsular

i sinovial este cel mai specific semn de artrit cronic.

42


http://en.wikipedia.org/wiki/File:Tender_points_fibromyalgia.gif

Semnul Lasgue Reproducerea sciatalgiei la ridicarea membrului inferior extins hernia de disc lombar

http://en.wikipedia.org/wiki/File:Straight-leg-test.gif

43


Semnul Tinel Percutarea nervului median la locul compresiunii produce durere i parestezii n teritoriul de distribuie al acestuia sindromul de canal carpian

Arcul dureros mijlociu (painful arc) - durerea la abducia braului ntre 60-120 este caracteristic pentru leziunile calotei rotatorilor

o Semnul Gaensslen - Durerea provocat de comprimarea lateral

a ntregului ir de articulaii metacarpofalangiene sinovita din poliartrita reumatoid

Semnul Gaensslen Durerea provocat de comprimarea lateral a ntregului ir de articulaii metacarpofalangiene sinovita din poliartrita reumatoid

! Stress pain n cele mai multe/toate direciile cel mai sensibil semn de inflamaie articular.

44


Tiparul durerii provocate de mobilizarea articulaiei are semnificaie diagnostic. - durerea minim sau absent la flexia uoar, dar care

crete progresiv spre limitele extreme ale micrii (stress pain) leziuni inflamatorii

Deformrile articulare

o Subluxaia i dislocarea definesc pierderea parial i respectiv complet a contactului ntre suprafeele articulare.

o Numeroase boli articulare se asociaz cu deformri caracteristice, acestea nefiind ns patognomonice pentru o anumit boal.

Artroza digital noduli duri, de regul nedureroi, la nivelul articulaiilor interfalangiene distale (nodulii lui Heberden) i/sau proximale (nodulii lui Bouchard)

http://en.wikipedia.org/wiki/Heberden's_node

Poliartrita reumatoid n fazele avansate deformri complexe cu apariia aspectului de mn reumatoid

o devierea cubital a minilor i degetelor - mna n lab de crti

o hiperextensia articulaiei interfalangiene proximale combinat + flexia fixat a articulaiei interfalangiene distale = degete n gt de lebd

o flexia fixat a articulaiei interfalangiene proximale + hiperextensia articulaiei interfalangiene distale = deformare n butonier

http://en.wikipedia.org/wiki/File:Rheumatoid_Arthritis.JPG

45


Deviaii axiale n plan frontal, spre linia median deformare n varus Deviaii axiale prin ndeprtare de linia median deformare n valgus

http://www.answers.com/topic/genu-valgum

Hallux valgus

http://en.wikipedia.org/wiki/Bunion

Dezaxri n plan sagital deformare n flexum

Modificrile musculare o Prin inspecia i palparea maselor musculare se pot evidenia

modificri de volum, tonus i contractilitate. hipotrofie/atrofie muscular leziunile motoneuronilor

periferici, miozite, miopatii contracturi musculare hernii discale lombare, torticolis afectarea forei musculare polimiozita (scderea forei

musculare la centurile musculare proximale) sensibilitate la palparea maselor musculare miozite

Mobilitatea articular

o Examenul mobilitii articulare se face deopotriv prin micri active (efectuate de pacient) i pasive (efectuate de examinator), comparativ pentru articulaiile simetrice.

o Cauzele limitrii mobilitii articulare: articulare hidartroza, sinovita proliferativ, leziunile

structurale articulare extraarticulare retracii capsuloligamentare i tendinoase,

indurarea pielii n sclerodermia sistemic o Cauzele hipermobilitii articulare (creterea amplitudinii micrilor

pasive articulare care depesc limitele maxime fiziologice).

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Boli ereditare ale esutului conjunctiv - ex. sindromul Ehlers-Danlos, sindromul Marfan

Sindromul de hipermobilitate generalizat benign

http://en.wikipedia.org/wiki/File:Ehlers-Danlos_thumb.jpg

o Tiparul limitrii mobilitii articulare furnizeaz informaii valoroase pentru localizarea modificrilor patologice. boli articulare - sunt reduse micrile active i pasive n

majoritatea/t

118307083-reumatologie ghid

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