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Supervisor : Dr dr Karya Triko Biakto Sp.OT (K) Spine

Advisor : dr William & dr Vicky

Team Members: Suderi, Kamal, Haikal, Balqis, Afua

Wednesday, March 14th 2018

syndrome of the neck

• Entrapment syndrome of the neck: compression of nerves in the

cervical part.
• Cervical spondylotic myelopathy : compresion of the spinal cord in the cervical
region of the spine
• Cervical radiculopathy :nerve root compression in the cervical region of the

Frontera WR (2015) Essentials of Physical Medicine and Rehabilitation : Musculoskeletal Disorders, Pain Rehabilitation. Elseviers Saunders Publication, Third
Passias PG (2016) Cervical Myelopathy. Jaypee Brothers Medical Publishers,
• The neck is made up by the
cervical part of the

• There are seven cervical

vertebrae and eight cervical
nerve roots.

• The curves within the

cervical of the spine is
reffered as cervical lordosis.

• The cervical spine affords

neck mobility.

Thompson J (2010) Netter’s Concise Orthopaedic Anatomy. Elsevier’s Saunders Publication, Second ​Edition ISBN: 978-1-4160-5987-5 Pp 60
• Spinal canal
diameter :
normal 17 mm,
considered as
spinal stenosis)

Frontera WR (2015) Essentials of Physical Medicine and Rehabilitation : Musculoskeletal Disorders, Pain Rehabilitation. Elseviers Saunders
Publication, Third Edition
• A complex system of ligaments serves to stabilise and
protect the cervical spine.

Thompson J (2010) Netter’s Concise Orthopaedic Anatomy. Elsevier’s Saunders Publication, Second ​Edition
• Intervertebral discs are located between the vertebral
bodies of C2-C7 which serve flexibility and absorption or
distribution of load throughout the spine.

Passias PG (2016) Cervical Myelopathy. Jaypee Brothers Medical Publishers, First Edition

Cervical myelopathy Cervical radiculopathy

• Degenerative cervical • disc herniation ("soft disc")
spondylosis • degenerative cervical spondylosis
• Congenital stenosis
• Tumor • neural compression
• Epidural abscess • nerve root irritation caused by direct
• Trauma
• Cervical kyphosis
• Neurologic compression
• direct cord compression
• ischemic injury secondary to
compression of anterior spinal artery

Passias PG (2016) Cervical Myelopathy. Jaypee Brothers Medical Publishers, First Edition

Frontera WR (2015) Essentials of Physical Medicine and Rehabilitation : Musculoskeletal Disorders, Pain Rehabilitation. Elseviers Saunders Publication, Third Edition

Cervical myelopathy

Ligamentum flavum
Cervical radiculopathy
Mechanical Chemical irritation
decompresion (nucleus pulposus)

Intraneural inflammation

Functional changes

Compromised nerve Hyperecitability and

function pain
(sensorimotor deficits) (ectopic impulses)
Somatotrophic organisation of spinal cord

Thompson J (2010) Netter’s Concise Orthopaedic Anatomy. Elsevier’s Saunders Publication, Second ​Edition
Cervical myelopathy Cervical radiculopathy
• Chief complaint : Clumsiness in • Chief complaint: sharp pain radiating
the hands / gait abnormality to the dermatom that are affected
• may present with insidious onset of
• Onset : subtle and slowly progress neck pain that is worse with vertebral
over a period of years motion
• Disturbance at the • unilateral arm pain radiating down
• upper extremities myelopathic • Suprascapular pain (C5-C6)
hands, difficulties in handwriting,
buttoning shirts and grasping or • Infrascapular pain (C7)
manipulating small objects • Scapular (C8)
• Lower extremities ( wide based, • unilateral dermatomal numbness &
jerky gaits and history of falls) tingling
• numbness/tingling in thumb (C6)
• Bowel and bladder dysfunction • numbness/tingling in middle finger
(advance stage) (C7)
• History of medical, surgical, social • unilateral weakness
and family background • difficulty with overhead activities (C7)
• difficulty with grip strength (C7)
Physical examination
• General examination :
• Inspection (myelopathic hand,
muscle atrophy); Palpation
(Tenderness, pain); Percussion;

• Motoric of head
• ROM : Flexion, extension, side
bending and rotation Myelopathy Hand
“Wasting of the intrinsic muscle
• Limitations of extension and spastifity of the hand”
(painful) indicates stenosis or
root compression
Motoric examination for • Pathological Reflex
upper extremities
• Muscle strength
• Physiological reflex

• Tromner reflex

Hoffman reflex
Unilateral motoric disturbance
• Muscle strength • Tendon reflex
• C5 radiculopathy • C5 radiculopathy
• deltoid and biceps weakness • diminished biceps reflex
• C6 radiculopathy • C6 radiculopathy
• brachioradialis and wrist extension • diminished brachioradialis reflex
• C7 radiculopathy
• C7 radiculopathy • diminished triceps reflex
• triceps and wrist flexion weakness
• C8 radiculopathy
• weakness to distal phalanx flexion of
middle and index finger (difficulty
with fine motor function)
• Sensoric of the upper extremities
• Decreased touch, temperature and pain sensation
Myelopathy: bilateral (diffuse non dermatomal)
Radiculopathy : unilateral arm pain based on the dermatom

• vibratory and positional dysfunction

• Can be found in myelopathy (advance stage)
• Affect the dorsal column

Frontera WR (2015) Essentials of Physical Medicine and Rehabilitation : Musculoskeletal Disorders, Pain Rehabilitation. Elseviers Saunders Publication, Third
Motoric and sensoric of Cervical roots
Special Test
Cervical Myelopathy Cervical Radiculopathy
• Lhermitte Sign test: extreme • Spurling Test
cervical flexion leads to electric • extension, rotation to affected side,
shock-like sensations that radiate lateral bend, and vertical
down the spine and into the compression
extremities • Pain and paresthesias at the
ipsilateral arm

• finger escape sign

• patient holds fingers extended and
adducted, the small finger
spontaneously abducts due to
weakness of intrinsic muscle
(myelopathy hand)
Special Test (continuous)
Cervical Myelopathy Cervical Radiculopathy
• shoulder abduction test
• grip and release test • shoulder abduction (lifting arm
• normally a patient can make a fist above head) often relieves
and release 20 times in 10 seconds. symptoms
Myelopathic patients may struggle • valuable physical exam test to
to do this differentiate cervical pathology from
other causes of shoulder/arm pain
• Motoric of lower extremities
• Muscle strength
• Physiological reflex Pathological reflex
Sensoric of the lower extremities

• Decreased touch, temperature and pain sensation

• Myelopathy: bilateral (diffuse non dermatomal)

• vibratory and positional dysfunction

• Can be found in myelopathy (advance stage)
• Affect the dorsal column

Frontera WR (2015) Essentials of Physical Medicine and Rehabilitation : Musculoskeletal Disorders, Pain Rehabilitation. Elseviers Saunders Publication, Third
Motoric and sensoric of Lumbosacral roots
Gait and balance

• Toe walk, heel walk and toe-to-heel walk

• patient has difficulty performing

• Romberg test
• Balancing difficulty present if lesion affect the dorsal column
Diagnostic studies
• Imaging
• Plain radiographs :
disk space
narrowing, end plate
decreased disc
• Myelography : useful test in cervical radiculopathy before the advent of MRI. May
visualise compression but does not provide information about extradural process

• Computed Tomography (CT SCAN): in patients with implanted pacemakers or other

devices that do not allow in MRI. Spinal canal may be measured but increased
radiation exposure.

• Magnetic Resonance imaging (MRI) :

• gold standard.
• Severe and non surgical unrespon.
• Provides excellent visualization of the spinal cord and soft tissue, including degenerative
alteration and neural compression

Boos N, et all (2008) Spinal Disorder. Springer-Verlag Berlin Heidelberg New York,
• Bone Scan
• limited to spondylolysis, infection, and metastatic or
primary spinal tumors.

• Diagnostic Spinal Injections

• diagnostic procedure.
• If a patient has substantial decrease in pain with image-
guided contrast-enhanced injection of anesthetics at a
specific nerve root, the clinician can consider that specific
nerve root to be the main cause of arm pain.

• Non Operative

• Cervical myelopathy : Indicates in mild disease with

no functional impairment function and poor
candidates for surgery
• Cervical radiculopathy :70-80% of patients with
radiculopathy improve via resorption of soft discs
and decreased inflammation around irritated nerve
• Observation : watch patients carefully for progression
• Immobilization : Hard collar (myelopathy), semihard collar
• Medicamentous : Gabapentin, NSAIDS / COX-2 inhibitors,oral
corticosteroids, GABA inhibitors (neurontin),narcotics, muscle
• Rehabilitation therapy :
• Myelopathy: neck strengthening, balance and gait training
• Radiculopathy : moist heat, cervical isometric exercises,
• Lifestyle modifications :
• Myelopathy: avoid cervical spinal hyperextension, drink water with a straw,
avoid prolonged overhead activities.
• Radiculopathy : appropriate body mechanics, proper lifting techniques,
suitable pillow and mattress use, appropriate exercise.
• Selective nerve root corticosteroid injections
• In cervical radiculopathy
• Provides long-term relief in 40-70% of cases
• increased risk compared to lumbar selective nerve root
injections may cause complications :
• dural puncture
• meningitis
• epidural abscess
• nerve root injury
Posterior approach
• Cervical myelopathy: moderate to severe progressive
(unsteady gait, limited function in the upper

• Cervical radiculopathy: potentially to become cervical

myelopathy Anterior approach

• treatment procedures include

• anterior cervical discectomy and fusion
• posterior laminectomy and fusion
• posterior laminoplasty
• combined anterior and posterior procedure

Thompson J (2010) Netter’s Concise Orthopaedic Anatomy. Elsevier’s Saunders Publication, Second ​Edition

• Cervical myelopathy :
• Post operation : pseudoarthrosis, restenosis, spinal instability, post-op
radiculopathy and axial pain.
• Severe disability
• Neurogenic bladder.
• Cervical radiculopathy
• Progressive neurological weakness, residual neck or radicular pain, chronic
pain syndrome, disability and myelopathy (rare)
Entrapment syndrome
of the shoulder
Anatomy Neurovascular of Shoulder

• The suprascapular nerve originates from

the upper trunk of the brachial plexus
• Innervates the supraspinatus and
infraspinatus muscles and provides
sensation to the glenohumeral and
acromioclavicular joints.
• The suprascapular notch, making a sharp
turn around the scapular spine.
There the nerve travels within

scapular notch or scapular

incisura a fibroosseous tunnel

bridged superiorly by the

scapular ligament.
What is the “Unhappy or Terrible Triad” in
regard to the shoulder?
A shoulder dislocation along with rotator cuff tear and peripheral nerve injury.
Dislocations should be considered as a clinical spectrum that includes

1) Isolated dislocations,

2) Injuries producing either detachment of the rotator cuff or neurologic deficit

alone, and ;

3) Combined injuries.
A) Suprascapular Nerve Compression

Chronic or repetitive compression of the

suprascapular nerve and its branches is much more

common than is generally recognised. The peculiar

anatomy of the nerve makes it unusually vulnerable

to both traction and entrapment (compression).

What are the common sites of entrapment of
the suprascapular nerve?

The suprascapular nerve courses from nerve roots C5 and C6 and runs

posterolaterally to the suprascapular notch beneath the transverse

scapular ligament. The nerve is commonly injured at the suprascapular

notch by ganglia or tumor. Injury at the suprascapular notch affects

both the supraspinatus and the infraspinatus muscles and mimics

rotator cuff pathology.

What are the Clinical features for this entrapment?
• unexplained pain in the suprascapular region or at the back of the

• Weakness of shoulder

• wasting of the supraspinatus muscle and diminished power of

abduction and external rotation.
Physical Exam

• atrophy along the posterior scapula

• pain with palpation of suprascapular notch

• weakness of supraspinatus

• weakness of infraspinatus

• weakness to external rotation with elbow at side

Physical Exam (Cont.)
• weakness seen with shoulder abduction to 90 degree, 30 degrees
forward flexion, and with internal rotation (Jobe test positive)
What diagnostic tests are available to help confirm
suprascapular nerve injury?

Electromyography and measurement of nerve conduction velocity may

help to establish the diagnosis. Ultrasonography and MRI are useful in

excluding a soft-tissue mass.


• Stop any type of activity which might stress the suprascapular nerve;

after a few weeks, graded muscle strengthening exercises can be


• Within 3 to 6 months. If there is no improvement, or if imaging

studies reveal a soft-tissue mass, operative decompression is justified.

B) Thoracic Outlet Syndrome

• Thoracic outlet syndrome (TOS) refers to the compression of the

neurovascular structures between the neck and axilla.

• May be produced by compression of the lower trunk of the brachial

plexus (C8 and T1) and subclavian vessels between the clavicle and

the first rib.

Thoracic outlet syndrome (TOS) is a broad term that sometimes also

refers as Scalenus syndrome where there is a compression of the

neurovascular structures in the area just above the first rib and behind

the clavicle that results in upper extremity symptoms.

B) Thoracic Outlet Syndrome (cont.)
TOS can be subdivided into vascular or neural compression symptoms,

or both, depending on which specific structures within the

cervicoaxillary canal are compromised.

How to evaluate a patient suspected of having TOS

Typically a woman in her thirties, complains of pain and paraesthesia

extending from the shoulder, down the ulnar aspect of the arm and

into the medial two fingers. Symptoms tend to be worse at night and

are aggravated by bracing the shoulders

What are the Clinical features for this entrapment?

In most cases, the physical examination findings of thoracic outlet

syndrome (TOS) are completely normal. Other times, the examination
is difficult because the patient may guard the extremity and exhibit
giveaway-type weakness. The sensory examination is often unreliable.
Physical examination

a) inspection

note specific postures, can increase loading on the brachial plexus, rounded shoulders, increased
thoracic kyphosis, downward rotation or depression of the scapula

At skin we may see cyanosis, congestion, pallor, distal ulcerations, signs of microembolic events
(rare), muscle atrophy.

b) palpation

over the supraclavicular area , may reveal tenderness and/or masses and skin temperature.
TOS Special test.

In Adson’s test the patient’s neck is extended and turned towards the

affected side while he or she breathes in deeply; this compresses the

inter scalene space and may cause paraesthesia and obliteration of the

radial pulse.
TOS Special test (cont)

In Wright’s test the arms are abducted and externally rotated; again the

symptoms recur and the pulse disappears on the abnormal side.

TOS Special test (cont)
In Roos test by asking the patient to hold his or her arms high above

their head and then open and close the fingers rapidly; this may cause

cramping pain on the affected side.

Unfortunately, these tests are neither sensitive nor specific enough to clinch the diagnosis.
What diagnostic tests are helpful in diagnosing TOS?

Klaassen describes one of the issues with TOS as a lack of a

gold standard for definitive diagnosis. Radiographs, CT scans,
and MRIs provide for detection of cervical ribs and fibrous
bands for identification of potential factors causing TOS.
What diagnostic tests are helpful in diagnosing
TOS? (Cont.)
Confirmation of a vascular abnormality is aided by the use of
duplex ultrasound, which has been found to be 92% sensitive and 95%
specific. In addition, electrophysiologic testing is valuable for
differential diagnosis and determining the presence of additional
abnormalities such as cervical nerve root or distal peripheral nerve
Treatment for TOS

By conservative treatment for TOS treatment, exercises can be done to strengthen

the shoulder girdle muscles, postural training and instruction in work practices and

ways of preventing shoulder droop and muscle fatigue. Analgesics may be needed

for pain.

Operative treatment is indicated if pain is severe, if muscle wasting is obvious or if

there are vascular disturbances.

Entrapment Syndrome of
the Elbow
Types of Entrapment of Elbow

1.Pronator syndrome(Median Nerve)

1.Cubital TunnelSydrome(Ulnar nerve)

PosteriorInterosseusNerve Syndrome(Radial Nerve)

Pronator Syndrome
(Median Nerve)
• Median nerve contains both motor and
sensory fibers from the C5, C6, C7, C8
and T1 nerve roots.
• in anterior forearm under the bicipital
aponeurosis (lacertus fibrosus). And
between the two heads of proanor teres
• The median nerve supplies all
superficial ventral muscles of the
forearm, except for the flexor carpi
ulnaris muscle, including the pronator
teres, flexor carpi radialis, palmaris
longus, and flexor digitorum
5 potential sites of entrapment include
•supracondylar process
•residual osseous structure on distal humerus present in 1% of population
•ligament of Struthers
•travels from tip of supracondylar process to medial epicondyle
•bicipital aponeurosis (a.k.a. lacertus fibrosus)
•between ulnar and humeral heads of pronator teres
•FDS aponeurotic arch
Clinical features
•paresthesias in thumb, index, middle finger and radial
half of ring finger as seen in carpal tunnel syndrome
•in pronator syndrome paresthesias often made
worse with repetitive pronosupination
. The patient is unable to make the ‘OK sign’
Physical examination
• forearm pain elicited by resistance to pronation or resistance to
isolated flexion of the third and fourth proximal interphalangeal
joints can be observed
• provocative tests are specific for different sites of entrapment
• positive Tinel sign in the proximal anterior forearm but no Tinel sign at wrist
nor provocative symptoms with wrist flexion as would be seen in CTS
• resisted elbow flexion with forearm supination (compression at bicipital
• resisted forearm pronation with elbow extended (compression at two heads
of pronator teres)
• resisted contraction of FDS to middle finger (compression at FDS fibrous
•rest, splinting, and NSAIDS for 3-6 months
•mild to moderate symptoms
•splint should avoid forearm rotation
•surgical decompression of median nerve
• only when nonoperative management fails for 3-6 months
•decompression of the median nerve at all 5 possible sites of compression
Cubital Tunnel Syndrome ( ulnar nerve)
• The ulnar nerve contains motor and
sensory fibers arising from the C8 and T1
• The ulnar nerve is quite superficial at the
elbow, where it descends posterior to the
medial epicondyle within the cubital
• In the elbow and forearm, the ulnar
nerve supplies the elbow joint, the flexor
carpi ulnaris muscle, and the ulnar half of
the flexor digitorum profundus to the
fourth and fifth fingers.
Sites of entrapment
•most common
•between the two heads of FCU/aponeurosis (most common site)
•within arcade of Struthers (hiatus in medial intermuscular septum)
•between Osborne's ligament and MCL

• The condition may occur :

when a person frequently bends the elbows (such as when pulling, reaching, or lifting),

constantly leans on the elbow, or sustains a direct injury to the area.

Clinical features
•paresthesias of small finger, ulnar half of ring finger, and ulnar dorsal
•exacerbating activities include
•cell phone use (excessive flexion)
•occupational or athletic activities requiring repetitive elbow
flexion and valgus stress
•night symptoms
•caused by sleeping with arm in flexion
Physical Examination
•inspection and palpation
•interosseous and first web space atrophy
•ring and small finger clawing
•observe ulnar nerve subluxation over the medial epicondyle as the elbow
moves through a flexion-extension arc
•decreased sensation in ulnar 1-1/2 digits
• Motor
motorloss of the ulnar nerve results in paralysis of intrinsic muscles (adductor
pollicis, deep head FPB, interossei, and lumbricals 4 and 5) which leads to
Spesial Test Provocation test
• Tinel’s percussion test,
Motorik test • elbow flexion test,
• Weakened grasp • Pressure Provocation test of
• Weak pinch elbow,
• Froment sign
• Jeanne sign
•NSAIDs, activity modification, and nighttime
elbow extension splinting
•first line of treatment with mild symptoms
•night bracing in 45° extension with forearm
in neutral rotation
•management is effective in ~50% of cases
• medial epicondylectomy
• indications
• visible and symptomatic subluxating ulnar nerve
•in situ ulnar nerve decompression without
•when nonoperative management fails
•before motor denervation occurs
•ulnar nerve decompression and anterior transposition
•failed in situ release
•throwing athlete
•patient with poor ulnar nerve bed from tumor,
osteophyte, or heterotopic bone
PIN Compression Syndrome
The radial nerve carries motor and
sensory fibers from the C5, C6, C7, C8,
and T1 nerve roots

As it enters the supinator muscle, the

posterior interosseous nerve dives
under the arcade of Frohse, a fibrous
arch formed by the proximal thickened
edge of the superficial head of the
supinator muscle.
five potential sites of compression
•fibrous tissue anterior to the radiocapitellar joint
•between the brachialis and brachioradialis
•“leash of Henry”
•are recurrent radial vessels that fan out across the
PIN at the level of the radial neck
•extensor carpi radialis brevis edge
•medio-proximal edge of the extensor carpi radialis
•"arcade of Fröhse"
•which is the proximal edge of the superficial
portion of the supinator
•supinator muscle edge
•distal edge of the supinator muscle
Clinical feature
• defining symptoms pain in the forearm
• location depends on site of PIN compression, (e.g., pain just distal to
the lateral epicondyle of the elbow may be caused by compression at
the arcade of Frohse)
• weakness with finger, wrist and thumb movements
Physical examination
• inspection
• chronic compression may cause forearm extensor compartment muscle atrophy
• motion
• weakness
• finger metacarpal extension weakness
• wrist extension weakness
• inability to extend wrist in neutral or ulnar deviation
• the wrist will extend with radial deviation due to intact ECRL (radial n.) and absent ECU (PIN).
• provocative tests
• resisted supination
• will increase pain symptoms
• normal tenodesis test
• tenodesis test is used to differentiate from extensor tendon rupture from RA
• Cervical spine nerve compression
• Brachial plexus compression
• Peripheral neuropathy
• rest, activity modification, stretching, splinting, NSAIDS
• indications
• recommended as first-line treatment for all cases
• lidocaine/corticosteroid injection
• indications
• a compressive mass, such as lipoma or ganglion, has been ruled out
• isolated tenderness distal to lateral epicondyle
• trial of rest, activity modification, anti-inflammatories were not effective
• technique
• single injection 3-4 cm distal to lateral epicondyle at site of compression
Surgical decompression
• indications
• symptoms persist for greater than three months of nonoperative treatment
• compressive mass detected on imaging
• outcomes
• results are variable
• spontaneous recovery of motor function was seen in 75 - 97% of non-
traumatic case series
• may continue to improve for up to 18 months
Kerala Journal of Ortopedi • • Volume 28 • nomor 1-2 • Januari-Juni / Juli-Desember 2015

Journal Reading
Update on Diagnosis and
Management of
Rheumatoid Arthritis
Supervisor : Dr dr Karya Triko Biakto Sp.OT (K) Spine

Advisor : dr William & dr Vicky

Team Members: Suderi, Kamal, Haikal, Balqis, Afua

Wednesday, March 14th 2018


• The diagnosis and management of Rheumatoid arthritis (RA) has gone

through changes, which include the advances in diagnostic and
therapeutic modalities.
• The appreciation of the need for inclusion of inflammatory markers
and antibodies along with the duration and joint involvement formed
the base of the updated 2010 classification criteria of RA. Likewise,
the crux of management has shifted, to assessing the disease activity
which is mandatory to use the potent agents in the correct
combinations and dosage.
Diagnosis of Rheumatoid Arthritis

• The 2010 ACR/ EULAR classification criteria for Rheumatoid arthritis

redefine the current paradigm of approach to RA by focusing on
features at earlier stages of disease.
• This involves a scoring system based on joint involvement, serology
(RF/Anti CCP), acute phase reactants (ESR/CRP) and duration of
• Rheumatoid arthritis can be diagnosed as early as 6 weeks which
means early start of DMARDs is quite possible by applying this
Disease Assessment in Rheumatoid Arthritis

• There are instruments to measure rheumatoid arthritis disease

activity and to define remission using complex mathematical
equations. They are DAS 28 (disease activity score), SDAI (simplified
disease activity index), CDAI (clinical disease activityindex), PAS
(patient activity scale) II and RAPID 3 (Routine assessment of patient
index data 3).
Visual Analog Scale
DAS 28
Management of Rheumatoid Arthritis

• The management used for Rheumatoid Arthritis are DMARDs.

• The nomenclature of agents hence, has been changed as cs DMARDS
(conventional synthetic), bo DMARDS (biologic originator), bs
DMARDS (biosimilar) and ts DMARDS (targeted) which is the jak
kinase inhibitor tofacitinib.
Patients Eligible for DMARD Tapering

Disease-modifying antirheumatic drug (DMARD) tapering should be

considered if patients:
• fulfil standardised clinical criteria for remission state (disease activity score
(DAS)28 <2.6; DAS44 <1.6; simplified disease activity index (SDAI) <3.3;
Clinical Disease Activity Index <2.8; American Colleague of Rheumatology
(ACR)/European League Against Rheumatism (EULAR) remission),
• show sustained remission for at least 6 months documented by
appropriate disease activity instruments at three sequential visits,
• use stable DMARD treatment with respect to type and dose of DMARDs
over the last 6 months and
• do not use glucocorticoids to maintain their remission state
How to Tapering and stopping of DMARDs ?

• Tapering and stopping of DMARDs is now also included in the

treatment guidelines of RA by major organisations. EULAR guidelines,
for instance, recommend stopping glucocorticoids first, even those
administered at low doses, before DMARD tapering is envisioned.
Then, bDMARDs should be tapered and stopped before synthetic
DMARDs are de-escalated.
• The ACR guidelines, similar to the EULAR recommendations, note that
sustained remission should be present before starting DMARD
tapering; low disease activity status is not considered as being of
sufficient quality to justify the withdrawal of DMARDs.

• Percentage method:
This method lowers dosage by a relatively stable decrement of 10 to 20 percent, while
accommodating convenience and individual patient response.
- 5 to 10 mg every one to two weeks from an initial dose above 40 mg of prednisone per
- For example, a patient taking 55 mg’s of prednisone per day would lower dosage to 45
mg or 50 mg depending on the individual patients’ profile. The patient would then stay
on that dose for one to two weeks based on their response to the lower amount.
- 5 mg every one to two weeks at prednisone doses between 40 and 20 mg per day.
- 2.5 mg every two to three weeks at prednisone doses between 20 and 10 mg per day.
- 1 mg every two to four weeks at prednisone doses between 10 and 5 mg per day.
- 0.5 mg every two to four weeks at prednisone doses from 5 mg per day and lower. This
can be achieved by alternating daily dose, eg, 5 mg day one, 4 mg day two.

• Alternate day method:

- Week 1. Alternate total daily dosage by 2.5 mg hydrocortisone. For example; Day 1- 65
mg, Day2-62.5, Day 3-65, Day 4-62.5 Day 5-65, Day 6-62.5 Day 7-65.
- Week 2. Stay on the lower dose. Using the hydrocortisone example above, the patient
would stay on 62.5 mg’s for one week to give the body time to adjust.
- Week 3. Return to alternating daily by 2.5 mg as in week one. Using the example above,
the patient would start week three by taking 62.5 mg, and alternate with a 60 mg dose.
- Week 4. Stay on the lower dose to give patients’ body time to adjust. In the example
above patient would stay on 60 mg’s for the entire week.
- A patient taking prednisone would use decrements of 1 or 2 mg on the alternate day
method. For example, a patient taking 25 mg prednisone per day would lower dosage to
24 or 23 mg on alternate days during week one. The patient would remain on the lower
amount during week two.
• In the RRR study and the HONOR study, cut-off points for a successful discontinuation of TNF
inhibitors were a baseline DAS28 value of 2.22 and 1.98, respectively, suggesting that ‘deep’
remission may be required to keep the biological-free remission and that residual
inflammation in patients in DAS28 remission could be associated with a higher likelihood to
• In the HONOR study, another baseline factor affecting adalimumab-free remission was
disease duration, indicating that patients with early RA have better chance to stop TNF
• Preliminary analyses in the POET study and earlier data from van der Woude et al also
suggest that longer disease duration is associated with higher relapse riskwhile other studies
did not find such association.
• In accordance, observations from the CORRONA registry suggest that rapid response to
DMARDs is associated with better maintenance of remission when the agents are tapered
later on.
Relapse (cont…)

• The concept that residual, mostly subclinical inflammation can be

associated with enhanced relapse risk has prompted investigators
to test whether imaging can help predict flare risk.
• This concept is also stimulated by observations that a substantial
proportion of patients with RA in remission can show signs of
synovitis by ultrasound or MRI. In fact, three studies found that
synovitis detected by ultrasound, mainly Doppler-detected
synovitis, is a strong predictor of failure of successful tapering of
biologic DMARD. (Naredo et al, Iwamoto et al)
• A recent study by Alivernini et al showed that synovial hypertrophy
is associated with higher risk of flares after tapering and
withdrawing TNF inhibitors.
Relapse (cont…)

• In the RETRO study, ACPA status clearly indicated higher relapse risk
with lower chances to maintain remission when ACPAs are present.
• Data from other studies, like BeSt and HIT-HARD (High induction
therapy with anti-rheumatic drugs), as well as preliminary data from
the POET study support this concept.