reuma umf

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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/bursiteleReumatologie clinic - generaliti

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Cele mai serioase probleme sunt poliartrita reumatoid, colagenozele, vasculitele, 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 , etcReumatologie clinic - generaliti

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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 materiiCursuri - 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 clinice1. Examenul clinic in bolile reumatologice: prezentare clinic 2h 2. Exporari paraclinice in reumatologie: prezentare clinic opional 3. Principii terapie medicamentoasa n reumatologie: antialgice, AINS, opional steroizi, imunomodulatoare, terapie biologica anticitokinica (antiTNF, antiIL-1, antiIL-6) prezentare clinica

Reumatologie clinic - generaliti

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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 ABA abatacept ACL anticorpi anticardiolipina ACR American College of Rheumatology ADA adalimumab AINS antiinflamatoare nesteroidiene ANCA anticorpi anticitoplasmaReumatologie clinic - generaliti

IFD interfalangiene distale IFP interfalangiene proximale IL - interleukina IFN infliximab LEF leflunomide LES lupus eritematos sistemic MCF metacarpofalangiene

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neutrofilului APL anticorpi antifosfolipidici AZA azatioprina BEL belimumab BMTC boala mixta de tesut conjunctiv CCP peptid ciclic citrulinat CTZ certolizumab CF ciclofosfamida CRP proteina C reactiva CS corticosteroizi DAS disease activity index DM dermatomiozita ETN etanercept EULAR European League against Rheumatism FR factor reumatoid GMB golimumab HAQ health assessment questionnaire HQ hidroxiclorochina MTF metatarsofalangiene MTX metotrexat PAN panarterita nodoasa PAR poliartrita reumatoida PM polimiozita PSH periartrita scapulohmerala RC radiocarpiana RTX rituximab SASN spondilartropatie seronegativa SpA spondilartropatie SSc - sclerodermie sistemica SSj sindrom Sjogren SSZ sulfasalazina TCZ tocilizumab TNF factor de necroza tumorala TT tibiotarsiana VSH viteza sedimentare hematii

Reumatologie clinic - generaliti

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CAPITOL 1 (CURS 1) INTRODUCERE: CE ESTE REUMATOLOGIA ? Durata 1 h curs

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

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

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

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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 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

o

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 interneSpecializarea este rezultatul necesar si natural al cresterii cunostiintelor intrun domeniu, inseparabil legate de multiplicarea si perfectionarea instrumentelor 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 radem la astfel de cereriFr. Shattuck, 1897, Prof of Medicine, Harvard Medical School

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).

? balneofizioterapia ; ? ortopedia

Ce face un reumatolog ?I. Anamneza Reumatologii au de a face cu doua simptome majore: Durerea Cel mai frecvent si mai constant simptom Durere cronica Le mort nest rien, la douleur oui n rien, oui Andre Malraux

Principalele simptome ale pacienilor reumatici (anamneza):

Durerea cronica & handicapul si dizabilitatea

Impotenta functionala, dizabilitate, handicapul

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 funcional HAQBoalaImpotena funcionalex. Imposibilitatea de a mica un deget

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)

Durerea

Disabilitateaex. Dificulti la cantatul la vioar

Handicapulex. Pierderea locului de munc, depresie

Ce face un reumatolog ? II. Examen obiectiv general Reumatologii sunt ultimii medici detectivi (ultimate physician detectives) Pacienti cu boli nelamurite, febrili, stari proaste, manifestari multisistemice colagenoza nediferentiata , VSH ?, AAN, FR + Varietate:

Reumatologii sunt ultimii medici detectivi (ultimate physician detectives) www.ac.orgDr 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]

Boli multisistemice (lupus, vasculite) ? doar musculoscheletale, o articulatie (artroza) Boli rare: LES, SSc ? boli comune (artroze, osteoporoza, etc) Specialitati nelimitate la un organ !

Varietate, confuzie

Diagnosticul n reumatologie este n esen un diagnostic clinic TratamentCe face un reumatolog ? III. Tratament Reumatologii sunt capabili sa trateze azi foarte eficient boli, care pana nu demult determinau handicap si dizabilitate 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

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 !!!

IMPACT !!!


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Ce face un reumatolog ? IV. Evaluare, monitorizare Evaluare, Reumatologii tratand boli cronice sunt capabili si obligati, 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 pentru examinare unitara a fi vazut de un acelasi medic .

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.

ACCESIBILITATE

Reumatologia - cuprins Concept general Baze stiintifice Evaluarea pacientului cu boli reumaticeClinica 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 boli inrudite Vasculite vase mari Polimialgia reumatica PMR si arterita gigantocelulara AGC Boala Takayashu

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 !

Vasculite vase medii Poliarterita nodoasa PAN Tromangeita obliteranta TAO

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


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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

Manifestari reumatice asociate cu boli metabolice, endocrine, renale si hematologice Guta Artrite microcristaline: calcium pirofosfat, hidroxiapatita, etc Endocrine Hematologice: hemofilia, siclemia Renale

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

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.

Boli osoase si cartilaginoase Artroza Boala Paget Osteonecroza

Reumatologia cuprins 3 Boli ereditare, congenitale si erori inascute de metabolism Boli nonarticulare/ abarticulare si asociate cu manifestari regionale reumatice Boli ereditare de colagen: Marfan,Ehlers Danlos Displazii osoase si articulare Osteocondoplazii

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 !!!

Neoplasme si tumorlike Tumori maligne osoase primare / secundare Tumori osoase benigne Manifestari reumatice paraneoplazice

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)

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

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 !!!

Conditii speciale Copilul Sarcina


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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)

EVALUAREA CLINIC

Durerea Scal vizual analog (100mm)Fr durere Cea mai mare durere posibil

Scal numeric 1 - 100 1 2 3 4 5 6 7 8 9 10

Scal verbal1. Fr durere 2. Durere uoar 3. Durere moderat 4. Durere sever 5. Durere foarte sever, insuportabil

Scala VAS pentru intensitatea durerii Fara durere Scala VAS pentru eficacitatea tratamentului Fara ameliorarea durerii Ameliorarea completa a durerii Cea mai rea durere posibila

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 durere Exemplul arata un pacient cu o durere de intensitate 9. Cea mai rea durere posibila

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

EVALUAREA CLINIC

Evaluarea global a activitii bolii Pacient Apreciind activitatea bolii Dvs n ultimele zile ?0 1 Nici una 2 3 4 5 6 7 8 9 10 Foarte mare

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

Medic, evaluator ?


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European Journal of Pain Supplements 3 (2009) 105109

Contents lists available at ScienceDirect

European Journal of Pain Supplementsjournal homepage: www.EuropeanJournalPain.com

Pain and rheumatology: An overview of the problemCarlomaurizio Montecucco, Lorenzo Cavagna, Roberto Caporali *Division of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, Piazzale Golgi 2, CAP 27100 Pavia (PV), Italy

a r t i c l e

i n f o

a b s t r a c tActually pain is a very important health problem, affecting the majority of people, leading to a signicant worsening of patients quality of life and being responsible for a large amount of both medical resources expenses and indirect costs. Between the different causes of pain, rheumatic conditions are predominant; in fact diseases such as osteoarthritis (OA), rheumatoid arthritis (RA), bromyalgia (FM) and extra-articular rheumatisms (EARs) are not only frequently observed, but are also invariably associated with pain occurrence. According to the wide range of rheumatic diseases described, pain expression is complex and not univocal, being inuenced not only by the underlying disease, but also by other factors. Generally, 3 rhythms of pain presentation are described in rheumatic conditions: the inammatory rhythm, characteristic of chronic arthritis, the mechanic one, characteristic of degenerative joints diseases such as OA, and the bromyalgic one, described in patients affected by FM; however also a true neuropathic pain may be present in these patients. This classication may be useful in the initial screening of the diseases potentially underlying to a painful syndrome, and in the follow-up of patients once established the diagnosis. With this paper we describe the different aspect and the burden of pain in different rheumatic diseases. 2009 European Federation of International Association for the Study of Pain Chapters. Published by Elsevier Ltd. All rights reserved.

Article history: Received 9 June 2009 Accepted 21 July 2009

Keywords: Chronic pain Rheumatic diseases Inammation

1. Introduction According to The International association for the study of pain, pain is described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in term of such damage (International Association for the Study of Pain Task Force in Taxonomy, 1994); pain is surely the most common reason people seek medical attention (Katz and Rothenberg, 2005a) and this is particularly evident in the eld of Rheumatology. In fact pain is frequently the rst symptom in the majority of rheumatic disorders (Centers for Disease Control and Prevention, 2001; WHO, 2003), generally resulting in a signicant burden of suffering, deeply affecting patients quality of life (Fitzcharles and Shir, 2008) and inuencing also the lifestyle of families involved (Main and Williams, 2002). Pain expression in the clinical setting is not univocal, being acute or chronic, related to different causes (e.g. inammatory, mechanic or neuropathic) (Katz and Rottenberg, 2005b) and affected by a variety of factors (MacKichan et al., 2008); between the acute causes of pain, crystal induced arthritis (CIA) and osteoporotic fractures are the typical examples, whereas rheumatoid arthritis (RA) and other inammatory arthritides such as psoriatic arthritis (PsA) and ankilosing spondilitis (AS), osteoarthritis (OA) and bromyalgia (FM) are typically associated* Corresponding author. Tel.: +39 0382501878; fax +39 0382503171. E-mail address: [email protected] (R. Caporali).

with chronic pain. Pain in rheumatic diseases may be very important because its correct interpretation may help the clinician in the diagnostic process. However, patients with rheumatic diseases may experience similar levels of pain independently from the underlying pathological condition, and pain control is not always easily achievable, thus representing a very important problem for both patient and clinician (Sheane et al., 2008). 2. Pain in rheumatology Pain is a multifactorial sensation involving peripheral nociception, central sensitization, and cortical interpretation (Katz and Rottenberg, 2005b). Generally pain is categorized as nociceptive when arising in areas of tissue damage, neurogenic when associated with specic nerve damage and mixed, when both nociceptive and neuropathic components are present (Fitzcharles and Shir, 2008); its way of presentation is not univocal and several kinds of pain are described, in particular in rheumatic diseases; in these conditions multi-site chronic pain is more common than singlesite chronic pain (Carnes et al., 2007). 2.1. Acute pain Acute pain is related to the occurrence of local tissue damage with subsequent nociceptors activation (Loeser and Melzack, 1999). CIA in general and gout in particular may be seen as the

1754-3207/$36.00 2009 European Federation of International Association for the Study of Pain Chapters. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.eujps.2009.07.006

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classical example of rheumatic disease leading to acute pain; in fact podagra (deposition of urate crystals in the rst toe) and other possible localizations of gout (e.g. ankle, knee, etc.) are between the most painful pathologic conditions described, with the patient that cannot bear for their joints to be touched and with a pain typically burning, piercing or crushing in character (Bingham et al., 2009). In similar cases the early identication of the disease, based on the clinical presentation and on the observation of urate crystals in synovial uid at light/polarized microscope, is essential, because the right treatment may lead to complete control, without further acute attacks and avoiding the risk of chronicization. Also, osteoporotic fractures are associated with an acute pain: in this case too, a correct diagnosis may prompt the clinician not only to control pain but also to study the patient in order to avoid further fractures. This point is crucial in view of the strong impact of this complication on the quality of life of the patients (Cooper et al., 1993; Johnell and Kanis, 2006).

2.3. Neuropathic pain According to the latest denition, neuropathic pain (NP) is a direct consequence of a lesion or disease affecting the somatosensory system (Treede et al., 2008); the damage might be referred to an injury either in the peripheral or in the central nervous system or both and it could be associated with various sensory and/or motor phenomena (Backonja, 2003). Clinically NP is characterized by spontaneous or evoked pain, described in term of a burning or tingling sensation or as a hypersensitivity to touch or cold (Katz and Rottenberg, 2005b) and ranging from dysesthesias to allodynia (Chong and Bajwa, 2003). In rheumatic diseases, NP is frequently due to a nerve involvement in term of mononeuropathy, moneuritis multiplex, poly-neuropathy, cranial neuropathy and entrapment neuropathy. Small and medium vessel vasculitis are frequently associated with a neurological involvement, so that mono- or poly-neuropathy are between the classication criteria of ChurgStrauss syndrome (Masi et al., 1990) and polyarteritis nodosa (Lightfoot et al., 1990); on the other hand, NP may be clinically evident also in other systemic vasculitis such as Behet disease (Akbulut et al., 2007), mixed cryoglobulinemia (Gemignani et al., 2005), microscopic polyangiitis and Wegener Granulomatosis (Cattaneo et al., 2007). Moreover, neuropathic involvement is between the items of both the original and reassessed Birmingham Vasculitis Activity Score (BVAS) (Luqmani et al., 1994; Mukhtyar et al., 2008) and of the Vasculitis Damage Index (VDI) (Exley et al., 1997), tools commonly used in the assessment of vasculitis activity and damage. In RA patients NP may be due to either to the occurrence of nerve entrapment (Rosenbaum, 2001) or to peripheral neuropathy (PN) (Rosenbaum, 2001; Albani et al., 2006); between the entrapment neuropathies, carpal tunnel syndrome (CTS) is not a rare nding and is said to occur in a quarter of RA patients, being frequently the rst symptom of the disease (Fleming et al., 1976; Rosenbaum, 2001). Regarding PN recently we observed that for RA patients is not easily to discern between neuropathic and arthritic pain, so indicating the need of a careful neurological examination in order to identify this complication of the disease (Albani et al., 2006).

2.2. Chronic pain Chronic pain is commonly triggered by an injury or disease, but it may be perpetuated by factors other than the cause of pain, such as the activation of neurogenic mechanisms (Loeser and Melzack, 1999). In rheumatic diseases several types of chronic pain are described, mainly related to the type of the underlying disease.

2.3. Inammatory pain Inammatory pain is characteristic of the different forms of chronic arthritis, in which patients generally experienced a worsening of the symptom at night or at rest, with reduction after physical activity (Salaf et al., 2005a; Coady et al., 2007). In fact there are several evidences that patients with arthritis identify different pain sensation at rest and on activity (Harkness et al., 1982; Komatireddy et al., 1997; Cutolo and Straub, 2008). Moreover pain is frequently associated with a prolonged morning stiffness (e.g. >30 min), another feature typically described in inammatory diseases (Cutolo and Straub, 2008). So a presentation rhythm of joint pain with similar characteristic is highly suspect for the occurrence of an inammatory arthritides, with the subsequent diagnosis being conrmed by a complete clinical, laboratory and radiological evaluation.

3. Epidemiology of rheumatic pain Actually rheumatic diseases are the prominent cause of chronic pain in developed world (Fitzcharles and Shir, 2008); in fact pain is consistently present in any rheumatic condition such as OA, FM, extra-articular rheumatisms (EARs), RA and other chronic forms of arthritis (Sokka, 2005). Moreover literature data indicate that the overall prevalence of rheumatic pain is steadily increasing in the general population, according to its senescence (Harkness et al., 2005), and that this problem is emerging also in non developed countries, where its prevalence varies from 12% (Vietnam) to 47% (Per) in urban areas and from 12% (Shantou, China) to 55% (Australian Aborigines) in rural areas (Chopra, 2008). Recent estimates on the prevalence of rheumatic diseases indicate that in the United States, RA affects 1.3 million adults, spondylarthritides affect from 0.6 million to 2.4 million adults, nearly 27 million have clinical OA, up to 3.0 million have had self-reported gout and 5.0 million have FM (Helmick et al., 2008; Lawrence et al., 2008). Although these data suggest the strong impact of rheumatic conditions on the general population, it is important to remember that the epidemiology of different rheumatic diseases is worldwide inhomogeneous. Recently, in a survey (Salaf et al., 2005b) conducted in an Italian population sample, up to 27% of subjects reported the occurrence of chronic musculoskeletal pain, females being most commonly affected than men and disease prevalence increasing signicantly with patients age. In this study, the most

2.4. Mechanic pain Mechanic pain is characteristic of degenerative diseases such as OA, a common and slowly progressive chronic condition, mainly evident in older people, frequently leading to physical disability (Harris et al., 1989). Pain in OA is greater during the day, when patient is on activity, and improves with the rest (Bellamy et al., 2004; Salaf et al., 2005a); similarly to RA, also in OA there is a relationship between pain and morning stiffness, but generally the latter is not longer than 10 minutes (Salaf et al., 2005b). Differential diagnosis of pain may be further complicated by inammatory ares that may frequently occur in OA patients. Pain sensation not clearly classiable as inammatory or mechanic is typical of FM, a syndrome of unclear pathogenesis, characterized by long-lasting, widespread musculoskeletal pain, in the presence of 11 or more tender points located at specic anatomical sites (Coster et al., 2008). FM patients generally present a reduced threshold for pain in the muscles, together with many other nonmusculoskeletal symptoms including fatigue, sleep disturbance, headache, migraine, variable bowel habits, diffuse abdominal pain, and urinary frequency (Bliddal, 2007).


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Soft tissue disorders (8,81%)

4. The burden of pain in rheumatic diseasesperipheral OA (8,95%)

RA (0,46%) Crystal induced arthritis (0,88%) AS (0,37%) PsA (0,42%)

Other connective tissue diseases (1,12%)

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

frequently observed rheumatic conditions leading to chronic pain were symptomatic peripheral OA, with a prevalence of 8.95% and EARs (8.81%), whereas inammatory arthritis occurred in 3.06% of population study and FM in 2.22% (Fig. 1). In another study performed in a small rural town of Tuscany on a large sample of people aged more than 65 years, about one third of the cohort was affected by symptomatic OA in one or more peripheral joints, with prevalence values for knee, hip and hand OA, respectively of 29.8%, 7.7%, and 14.9% (Mannoni et al., 2003). Different results have been described in another survey performed on patients older than 85 years in an Urban town of Netherlands (van Schaardenburg et al., 1994); in the study the prevalence of symptomatic OA was respectively of 18%, 7% and 5% in hand, hip and knee, suggesting that both demographic (e.g. the age of patients enrolled) and working factors (e.g. rural vs dweller workers) may inuence long-term appearance and expression of OA. However a signicant disparity between the degree of joint radiographic damage and the perception of pain is frequently observed in OA; in fact 3060% of individuals with moderate to severe OA at X-rays are completely asymptomatic, and 10% of individuals with moderate to severe pain have normal X-rays (Creamer et al., 1997; Hannan et al., 1998). Taken together, these observations indicate the complexity of pain in OA, in which factors other than the damage of the cartilage and sub-chondral bone are involved (Claw and Witter, 2009). Regarding RA the prevalence range from 0.33% to 1% (Cimmino et al., 1998; Alamanos et al., 2006), although in peculiar population such as the Pima Indians, the prevalence may rise up to 5.3% (Del Puente et al., 1989), suggesting that genetic, behavioral and climatic factors as well as environmental exposures may inuence the disease appearance. Regarding other potentially painful diseases, in France, in women aged more than 45 years, the overall prevalence of diagnosed osteoporosis was 9.7%, the 45.3% of which reporting at least one previous fracture (Lespessailles et al., 2009); similar gures have been described also in USA (Robitaille et al., 2008) and in Chinese women (Wang et al., 2009), thus underlying the worldwide epidemiologic relevance of the problem. FM is described in all age groups, with a prevalence ranging from 1% to 10% of population; in general it is said a female syndrome, but also men may develop the syndrome. Frequently FM in men is under-diagnosed for a number of reasons, such as gender differences in seeking medical help, sex-related differences in pain perception and psychosocial inuences (Bliddal, 2007). On this basis is evident that musculoskeletal conditions although inhomogenous in the occurrence are a worldwide problem of individuals, health systems, and social care systems (WHO, 2003).

Once established that rheumatic pain is not a rare nding, the subsequent step is the assessment of its burden on both patients and society. General data indicate that rheumatic diseases are the prevalent cause of functional limitation and years lived with disability 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 patients quality of life (Reginster, 2002; Fitzcharles and Shir, 2008), with a correlation that is particularly evident in RA; in fact Health Assessment Questionnaire (HAQ), a tool used worldwide for the evaluation of RA quality of life, is deeply inuenced by the levels of pain (Hkkinen et al., 2005). Moreover a strict relationship between pain intensity, inammation and patients function is described in the early phases of arthritis conditions, conrming the strong impact of the symptom on these patients (Fitzcharles and Shir, 2008). Regarding OA several questionnaires such as the Western Ontario McMaster (WOMAC) osteoarthritis index (Bellamy et al., 1988) and the Lequesne Index (Lequesne et al., 1987) have conrmed the effects of pain on patients daily activities; furthermore, according to literature data, OA is the sixth leading cause of disability at the global level, accounting for the 2.8% of total years of living with disability (Woolf and Peger, 2003). But the impact of OA is strengthened also by other factors; the AMICA study (Approccio Multidisciplinare Italiano alla Cura e diagnosi dellArtrosi) found that the occurrence of comorbidities intensies pain 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 is thus associated with a poorer quality of life and with a long-term physical disability of OA patients. However this relationship is not clear; one may suppose that the concomitant occurrence of two chronic conditions can inuence physical activity, leading to reduced joint mobility and overweight. Another possibility is the occurrence of an additive effect between the conditions; for example OA symptoms may be worsened in case of PN occurrence and PN may facilitate the progression of OA (Cimmino et al., 2005). Osteoporotic fractures are generally associated with an increased patient morbidity and impairment of quality of life (Salaf et al. 2007); however, fractures of the hip and vertebrae are also linked with an increased mortality up to 5 years following the event. Furthermore the burden of osteoporotic fracture is seemingly rising in the future, mainly due to the progressive increase in life expectancy (Holreyd et al., 2008). Pain is surely the main problem of FM. In these patients pain control is not easily achievable, affecting patients quality of live at the same level of RA (Silverman et al., 2009); in general, a multimodal approach involving not only the rheumatologist but also other medical gures such as psychiatric, psychologist, physiotherapist, is needed (Abeles et al., 2008). But pain meaning in FM is discussed too; generally the patients are reassured that, despite the severity of their pain, FM does not lead to bodily damage or death (Bliddal, 2007). On the contrary several papers described an association between widespread pain occurrence, characteristic of FM, and an increased risk of cancer death (Macfarlane et al., 2001, 2007). On this basis it is evident the importance of a complete evaluation of FM patients before the diagnosis and during follow-up. Moreover we must take into account that FM is a diagnosis of exclusion, frequently co-occurring with other rheumatologic diseases, 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 diseases is high, leading frequently to disability and impaired quality of life of patients; but rheumatic pain has also an economic burden,

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that comprehend direct (e.g. drugs, medical care, hospitals, disability pensions) and indirect costs (premature mortality, short- and long-term disability, loss of productivity, etc.). In fact the economic impact has been estimated as up to 12.5% of the gross national product of countries such as the USA, UK, France and Australia (Reginster, 2002). In particular OA impacts on USA economy more than $60 billion per year (Buckwalter et al., 2004); furthermore although RA is less frequent with respect to OA, the outpatients pro-capite expense is superior with respect to OA (estimated annual cost $9300 vs $5700) (Maetzel et al., 2004). Regarding osteoporosis, direct inpatient hospital costs of vertebral fractures exceeded 41 millions euros in Spain (Bouza et al., 2007), whereas in German hip fractures economic burden was 2736 millions of euro for direct cost and 262 millions of euro for indirect costs (Konnopka et al., 2008); taking into account all fractures, the annual cost following every event is about 5000 euro/patient, (Rousculp et al., 2007). Finally in FM the economic burden is similar to those of RA; in fact the mean annual expenditures were similar between FM ($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).

Conict of interest statement No conicts of interest are present for the authors. ReferencesAbeles M, Solitar BM, Pillinger MH, Abeles AM. Update on bromyalgia therapy. Am J Med 2008;121:55561. Akbulut L, Gur G, Bodur H, Alli N, Borman P. Peripheral neuropathy in Behet disease: an electroneurophysiological study. Clin Rheumatol 2007;26:12404. Alacqua M, Trir G, Cavagna L, Caporali R, Montecucco CM, Moretti S, et al. Prescribing pattern of drugs in the treatment of osteoarthritis in Italian general practice: the effect of rofecoxib withdrawal. Arthritis Rheum 2008;59:56874. Alamanos Y, Voulgari PV, Drosos AA. Incidence and prevalence of rheumatoid arthritis, based on the 1987 American college of rheumatology criteria: a systematic review. Semin Arthritis Rheum 2006;36:1828. Albani G, Ravaglia S, Cavagna L, Caporali R, Montecucco C, Mauro A. Clinical and electrophysiological evaluation of peripheral neuropathy in rheumatoid arthritis. J Peripher Nerv Syst 2006;11:1745. Backman CL. 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5. Factors affecting pain expression Pain expression is not univocal overtime and may be inuenced by psychosocial, demographic and clinical factors. In particular the relationship between psychosocial problems and pain is complicated and bidirectional, with both factors inuencing each other (MacKichan et al., 2008). Psychological aspect is particularly evident in RA, an inammatory arthritides having a strong impact on mental distress soon after the onset (Smedstad et al., 1996; Backman, 2006); in this disease there are evidences that psychosocial interventions improve coping and self efcacy, reduce psychological distress, and reduce pain, at least in short term (Backman, 2006). Psychological distress plays a role in pain perception also in SLE (Karlson et al., 2004) and FM (Wineld, 1999; Abeles et al., 2008). On this basis we understand the need to assess whether psychological problems are important components of pain; for this purpose several tools such as the Hospital Anxiety and Depression Score (Zigmond and Snaith, 1983) are available. Furthermore, also patient barriers such as lack of motivation, fear and distrust to medication, poor adherence to treatment may contribute to sub-optimal pain control in rheumatologic conditions (Fitzcharles and Shir, 2008). On the other hand it is important to underline that also external factors may indirectly inuence pain; the classical example is the withdrawal from the commerce of rofecoxib because of evidence of an increased risk of myocardial infarction (Bresalier et al., 2005). This event led to a reduction of coxib use in patients with OA, without any increase of prescription of other NSAIDs or analgesic, thus suggesting an undertreatment of pain in the clinical setting, because of cardiovascular side effects fear (Alacqua et al., 2008).

6. Conclusion Pain is very common in rheumatic diseases, with a prevalence steadily increasing according to the senescence of population; this symptom deeply affect patients quality of life, resulting in a burden of suffering together with sleep and mood problems. Moreover the burden of rheumatic pain is also economic, with a large amount of direct and indirect costs. But pain is useful for patients classication and follow-up; in fact pain expression is variable according to the underlying rheumatic disease and its right interpretation may be essential for the rst diagnostic classication of the patients.

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Web referencesKonnopka A, Jerusel N, Knig HH. The health and economic consequences of osteopenia- and osteoporosis-attributable hip fractures in Germany: estimation for 2002 and projection until 2050. Osteoporos Int 2008 Dec 2. [Epub ahead of print]. Lespessailles E, Cott FE, Roux C, Fardellone P, Mercier F, Gaudin AF. Prevalence and features of osteoporosis in the French general population: the instant study. Joint Bone Spine. 2009 Mar 16. [Epub ahead of print]. Mukhtyar C, Lee R, Brown D, Carruthers D, Dasgupta B, Dubey S, Flossmann O, Hall C, Hollywood J, Jayne D, Jones R, Lanyon P, Muir A, Scott D, Young L, Luqmani R. Modication and validation of the birmingham vasculitis activity score (Version 3). Ann Rheum Dis. 2008 Dec 3. [Epub ahead of print]. Salaf F, Cimmino MA, Malavolta N, Carotti M, Di Matteo L, Scendoni P, et al. Italian Multicentre Osteoporotic Fracture Study Group. The burden of prevalent fractures on health-related quality of life in postmenopausal women with osteoporosis: the IMOF study. J Rheumatol 2007;34:15516. [Epub 2007 May 15]. Wang Y, Tao Y, Hyman ME, Li J, Chen Y. Osteoporosis in China. Osteoporos Int 2009 May 5. [Epub ahead of print].

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Intrebari si teme recapitulative1) 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


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b) c) d) e) f) g) h)

Cauza declansatoare este prezenta Cauza declansatoare nu mai este prezenta Durerea persista si dupa disparitia cauzei declansatoare Are caracter protectiv Nu mai are caracter protectiv (devine boala insasi) Se insoteste de anxietate 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, 2008Curs reumatologie clinica curs 1: Introducere: Ce este reumatologia?

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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


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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

Demonstraie practic: principiile examinrii pacientului cu boal reumatologic

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o

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 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 precizieDemonstraie practic: principiile examinrii pacientului cu boal reumatologic

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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 handicapExamenul clinic osteoarticular poate fi mai relevant dect RMN ntruct evalueaz semnificaia funcional a anomaliei observate.

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

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 afeciuneDemonstraie practic: principiile examinrii pacientului cu boal reumatologic

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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 Coloana cervical Coloana toracic Coloana lombar Umr Cot old Genunchi o Durerea referat Occiput, umeri, brae Perete toracic anterior Membre inferioare Regiunea lateral a braului Antebrae Regiunea anterioar a coapsei, genunchi Copase, old 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) Intensitate Este influenat de statusul emoional durera cronic este adesea asociat cu anxietate i depresie care intensific percepia durerii. 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.

o

o


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!!! Caracteristicile durerii indicatoare de eventual malignitate (red flags signs) persistent profund (osoas) progresiv sever

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.! Durata i severitatea redorii reflect gradul inflamaiei locale permite aprecierea gradului de activitate a bolii.

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 funcional ex. imposibilitatea de a mica un deget

Disabilitatea ex. dificulti la cntatul la un instrument muzical

Handicapul ex. violonist pierderea locului de munc, depresie


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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

!!! 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.

Elementele de difereniere inflamatoare i degenerative Manifestri Redoarea matinal Activitatea Repausul Manifestrile sistemice Rspunsul corticosteroizi

ntre

afeciunile

reumatologice

Afeciune inflamatoare > 1 or Amelioreaz simptomele Agraveaz simptomele Da la Da

Afeciune degenerativ 30 minute Agraveaz simptomele Amelioreaz simptomele Nu Nu

Elementele cheie ce trebuie incluse n istoricul bolii o Care sunt principalele manifestri musculoscheletale


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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 Infecioase (tuberculoas, gonococic), postafectat traumatice, degenerative (gonartroza, artropatia Charcot), microcristaline (guta, condrocalcinoza) Oligoarticular = 2-4 articulaii Degenerative (artroza), spondilartrite afectate reactiv, spondilita anchilozant, psoriazic, artrite enterale), sarcoidoza Poliarticular afectate 5 (artrita artrita

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

Axial = predominant la nivelul Spondilartrite, artroza coloanei vertebrale

o

o o o o o

Debutul cronologic Episodic - ex. guta Aditiv - poliartrita reumatoid Factorii declanatori Ex: activitatea, dieta, infecii sau traumatisme recente Factorii care agraveaz sau amelioreaz simptomele Ex: repausul/micarea Rspunsul simptomelor la interveniile terapeutice Afectarea altor organe i sisteme Impactul bolii la nivel individual, familial, profesional

II. Examenul obiectiv musculoscheletal Metodele utilizate la examenul obiectiv articular:Demonstraie practic: principiile examinrii pacientului cu boal reumatologic

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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


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Poliartrita reumatoid Guta

insensibili, duri, adereni la periost insensibili sau uor sensibili; uneori, se ulcereaz lsnd s se scurg un material albicios (cristalele de urat monosodic) i se pot suprainfecta mici, insensibili, mobili fa de piele, dar adereni la planul aponevrotic sau periost, cu distribuie simetric i evoluie fugace (nodulii lui Meynet)

Reumatismul articular acut

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! Tumefierea este un element important n diagnosticul artritelor.

Palparea difereniaz ntre cele 3 componente posibile ale tumefierii: colecia intraarticular (hidartroza), hipertrofia sinovialeiDemonstraie practic: principiile examinrii pacientului cu boal reumatologic

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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 Se aplic o presiune cu dou degete n regiunea suprapatelar i se comprim rotula cu ajutorul indexului plasat pe mijlocul acesteia. Prezena unei colecii este confirmat de impactul rotulei cu condilii femurali, concomitent cu senzaia de balonizare determinat de deplasarea lateral a lichidului.

o

o

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.Demonstraie practic: principiile examinrii pacientului cu boal reumatologic

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! Tumefierea capsular i sinovial este cel mai specific semn de artrit cronic.

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.


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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


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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.


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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 hiperextensia articulaiei interfalangiene proximale combinat + flexia fixat a articulaiei interfalangiene distale = degete n gt de lebd flexia fixat a articulaiei interfalangiene proximale + hiperextensia articulaiei interfalangiene distale = deformare n butonier http://en.wikipedia.org/wiki/File:Rheumatoid_Arthritis.JPG

o

o


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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 EhlersDanlos, 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/toate planurile de micare. leziunile periarticulare - afecteaz mobilitatea ntr-un singur plan, micrile pasive fiind reduse ntr-o mai mare msur dect cele active. Examenul mobilitii articulare poate fi completat cu unele msurtori instrumentale simple.

o

Testul Schober Se msoar (cu o band centimetric) distana ntre apofiza spinoas a vertebrei lombare L5 i un punct situat la 10 cm deasupra, dup ce pacientul execut o flexie lombar anterioar maxim. Test Schober < 15 cm limitarea mobilitii coloanei lombare

CrepitaiileDemonstraie practic: principiile examinrii pacientului cu boal reumatologic

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o

Crepitaiile articulare i tendinoase sunt sunete palpabile care apar n cursul mobilizrii structurilor afectate. crepitaii fine artrite i tenosinovite crepitaiile grosiere n leziuni structurale osoase i/sau cartilaginoase din artroze sau artrite distructive

Stabilitatea o Testarea stabilitii unei articulaii se face prin demonstrarea unor micri excesive n diferite planuri. Ex: testarea instabilitii laterale a genunchiului cu o mn se imobilizeaz coapsa, iar cu cealalt se imprim gambei extinse micri de lateralitate (n varus sau valgus) a genunchiului. Capacitatea funcional o Impotena funcional a unui grup restrns de articulaii poate fi apreciat n timpul activitii normale pe baza unor teste simple ex. timpul de ambulaie, capacitatea de prehensiune, etc. Examenul de screening pentru afeciunile reumatologice o Pentru identificarea rapid a principalelor anomalii musculoscheletale n practica curent se efectueaz un examen clinic pentru screeningul afeciunilor reumatologice (dureaz 1-2 minute). o n cadrul acestui screening sunt evaluate toate prile componente ale aparatului locomotor - este cunoscut sub acronimul GALS (Gait = mers; Arms = membre superioare; Legs = membre inferioare; Spine = coloana vertebral).

La sfritul examenului obiectiv se noteaz principalele modificri la nivelul tuturor componentelor sistemului musculoscheletal vezi exemplu de mai jos

A (aspect) M (mobilitate) Mers (Gait) Membre superioare (Arms) X X Membre superioare (Legs) Coloan (Spine) Tumefierea articulaiilor interfalangiene proximale II i III bilateral poliartrit reumatoid precoce ? Prezena unor anomalii la examenul de screening impune o examinare regional detaliat a sistemului musculoscheletal, care va fi efectuat de specialistul reumatolog. Examenul de screening a afeciunilor reumatologice (dup Doherty M et al, 1992) oDemonstraie practic: principiile examinrii pacientului cu boal reumatologic

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Inspecia n timpul mersului Pacientul se deplaseaz n fa, se ntoarce i vine napoi. Se apreciaz simetria mersului, durata diferitelor faze ale mersului, poziia corpului, balansarea braelor n contratimp cu pasul, demarajul, lungimea i limea pasului, viteza de deplasare i ntoarcerea. Inspecia n ortostatism Inspecia pacientului se face din fa, spate i lateral. Se evalueaz postura i simetria (statica coloanei vertebrale, deviaiile n ax ale genunchilor, chistele popliteale etc.) Se aplic o presiune n mijlocul muchiului supraspinos i se face o micare de rulare a tegumentelor suprajacente punct dureros n fibromialgie Examinarea coloanei vertebrale Pacientul execut flexia lateral a coloanei cervicale. Examinatorul i plaseaz 3 degete la nivelul proceselor spinoase lombare i solicit pacientul s execute o flexie lombar complet. Se observ dac flexia se execut normal i se apreciaz desfurarea regiunii lombare n timpul micrii (senzaia de ndeprtare a celor trei degete). Examinarea membrelor superioare Pacientul execut urmtoarele micri active: - duce minile dup cap, cu coatele flectate la 90 n lateral - abducia i rotaia extern a umerilor - duce braele pe lng corp cu coatele complet extinse extensia coatelor - execut flexia coatelor la 90 cu minile ntinse i palm ele n jos inspecia feei dorsale a minilor (articulaiile mici ale mainilor, tenosinovita de extensori) - ntoarce palmele n sus - evaluarea supinaiei la nivelul articulaiei radioulnare proximale i distale; inspecia feei palmare a minilor (articulaiile mici ale mainilor, tenosinovita de flexori) - face pumn - testarea capacitii de prehensiune - face pens digital testarea micrilor de precizie Examinatorul execut micarea de comprimare lateral a ntregului ir de articulaii metacarpofalangiene, ca i cum ar strnge mna pacientului (semnul Gaensslen) - evaluarea sinovitei articulaiilor metacarpofalangiene Examinarea membrelor inferioare Pacientul este plasat n decubit dorsal, se evalueaz urmtoarele aspecte: - flexia pasiv a oldurilor i genunchilor - evaluarea mobilitii, crepitaiilor la nivelul genunchilor - adducia i rotaia intern pasiv a oldurilor - evaluarea mobilitii oldurilor - ocul rotulian evaluarea hidartrozei - compresiunea lateral a ntregului ir de articulaii metatarsofalangiene evaluarea sinovitei articulaiilor metatarsofalangiene -

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