Psoriatic Arthritis

Aetiology
1. Exact cause unknown, research suggests something (infection?) acts as a trigger in people who are susceptible to this arthritis
Pathology
1. PsA is an inflammatory arthritis associated with psoriasis. symptoms range from mild to severe - the typical rheumatic symptoms being joint stiffness, pain and swelling, and tenderness of ligament and tendon insertions. Although traditionally perceived as a mild disorder, about 2/3rds of people with PsA have progressive, damaging arthritis.
Diagnostic criteria (> 6 for PsA)
1. Back pain at night or stiffness in the morning (1)
  1. Asymmetric oligoarthritis (2)
    1. Gluteal pain without other details (1) or Alternating gluteal pain (2)
      1. Sausage digit or toe (2)
        Heel pain or other enthesopathy (2)
        Iritis (2)
        Diarrhoea within 1 month onset of arthritis (1)
        Sacroiliitis (3)
        Presence of HLA-B27 antigen and/or positive family Hx of AS, ReA, psoriasis, uveitis or chronic bowel disease (2)
Treatment
1. Medical management Control Inflammation
  1. Pain management
    1. Analgesics
  2. NSAIDS
  3. DMARDS (Sulfasalazine & Methotrexate) if not responding to 2 either in combination or alone use cheapest biologic
    1. Biologic therapy
      1. Review in 12 weeks for improvement of: Atleast 2/4 PsARC criteria(1 of which has to be joint tenderness and swelling score) & no worsening in any of 4 criteria.
        If Pt has no response to PASI (Psoriasis Area and Severity Index) Discontinue Anti-TNF inhibitor used
2. Surgery
3. Podiatric management
  1. Foot orthoses
    1. Active enthesitis (Offload areas)
    2. Tenosynovitis particularly Tib post (Medial heel wedge)
    3. Poor rear foot alignment, low MLA, residual foot impairments even when disease activity has been suppressed (offload/realign accordingly)
  2. Skin/Nail/ Lesion care/ Self management, Hygiene advice
  3. Footwear advice
  4. Excercises
    1. Strengthening muscles eg Tib post
    2. Stretches
  5. IA Steroids
    1. Tx for Dactlyitis/ Enthesitis
  6. Long term Mx
    1. Decrease foot pain, increase physical function, increase Health related QoL
Differential diagnosis
1. MSK conditions
  1. PF
  2. AT
  3. Tib Post
2. Nails
  1. Fungal
  2. O/X
3. Other seronegative spondylarthropathy (AS)
Referralls
1. Orthotist
  1. Assessment of biomechanical deficits (Functional problems)
  2. Design, manufacture, delivery & review of orthotses (orthopaedia aids) and footwear
2. General practitioner
  1. First contact
  2. Diagnosis/referral
  3. Initiate treatment
  4. Long-term condition/co-morbidities management
3. Occupational therapist
  1. Maintaining activities of daily living
  2. Education, with provision of aids and coping skills
4. Physiotherapist
  1. maintaining functional ability
  2. musculoskeletal assessment
  3. pain management and patient education
Assessment
1. Peripheral joint assessment
  1. 66/68 tender/swollen joint count
  2. DAS
  3. PSARC
  4. ACR response criteria
2. Enthesitis assessment
  1. Leeds enthesitis Index (LEI)
    1. 6 sites: Bilateral AT insertions, Bilateral medial femoral condyles, Bilateral lateral epicondyles of the humerus
3. Dactylitis assessment
  1. Leeds dactylitis index (LDI)
    1. 0-3Scale. 0=no tenderness. 1= tender. 2= tender + wince. 3= tender + withdraw

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Psoriatic Arthritis

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