Transcript Rheumatology & the Thoracolumbar spine

September 5th – 8th 2013
Nottingham Conference Centre, United Kingdom
www.nspine.co.uk
Rheumatology & the
Thoracolumbar spine
Topics to cover
Differential Diagnosis of Inflammatory Pathology
Blood Investigations
Implications for Physiotherapy Treatment
But also
Some anatomical/physiological considerations
The Big Problem
Does physiotherapy work?
Vertebrae
Pelvis
Ligaments
Ligaments
Other musings
The problem
Flags
Serious
pathology
Can’t emphasise their importance enough
A test is no substitute for history
Rheumatological TL spine problems
CANCER
SEPSIS
Inflammatory spinal
disease
–
–
–
–
–
Ankylosing spondylitis
Psoriatic
Enteropathic
Reactive
Seronegative
Fibromyalgia
“Normal” back pain
Fracture
Crystal
Rheumatoid
Neurological
Medical
Cancer and sepsis
Symptoms
Night pain
Weight loss
Unwell
Fever
Who gets
Anyone
Sepsis
– Extremes of age
– Diabetes
– IVDU
Cancer
– Old age
– Previous cancer
Seronegative
(spondylo)arthropathies
Common in same
family
Some shared genes
E.g. B27 and spinal
disease
Axial involvement
common
Spondylitis
Psoriatic
SAPHO
Reiter’s
AS
Acne related
Enteropathic
Undifferentiated
Nature of the beast
A disease of entheses
Shared genetic background
Body surface antigen exposure?
– Psoriasis
– Bowel inflammation
– Elevated IgA levels
Iritis/conjunctivitis
Ankylosing spondylitis
•Enthesis
– Specialised tissue
– Site where
ligaments/tendon
insert into bone
Some myths & corrections
M:F 15:1
M:F 3:1
X-rays diagnostic
Imaging a problem
B27 helpful
1%  6%
Diagnosis easy
4½ years
Ascending
Neck especially
women
Differential
All the seronegatives are variants on each other
Don’t worry about the subtypes
It’s the history stupid!
Diagnosing Ankylosing spondylitis
ASAS
Sacroiliitis on imaging
+
≥ 1 Clinical feature
HLA B27
+
≥ 2 Clinical features
Active (acute) inflammation on MRI, highly suggestive of SpA sacroiliitis
Definite radiographic sacroiliitis
Inflammatory back pain, arthiritis, enthesitis
Uveitis, dactylitis, psoriasis, Crohn's disease (ulcerative colitis)
Good response to NSAIDs
Family history of SpA,
Elevated CRP.
The Diagnosis
History
Examination
Non-specific tests
Specific tests
Diagnostic tests – very few
History
Inflammatory back pain > 30 mins
Worse on holiday
Better at work especially if manual
Worse in evenings
It’s the history stupid!
Examination
Eye & Skin disease
Anogenital
So to tests
Diagnostic
Specific tests
HLA B27
Present in 5% of population
Overall risk of AS ≈ 1%
B27 positive ≈ 6%
1st degree relative AS and B27 + 30%
Depends on racial group
Genotype different to phenotype
Generally not a good test – but note ASAS
Non-specific tests
Acute phase response
– ESR
– C-reactive protein
– Anaemia
– Thrombocytosis
– Low albumin
– Raised ferritin
Gravity
ESR
Fibrinogen
Gravity
ESR
Gravity
ESR
Factors affecting ESR
Increased
Female Gender
Age
Anaemia
Pregnancy
Inflammation
– Raised fibrinogen
Myeloma
– Weakly by immunoglobulins
Decreased
Male Gender
Congestive cardiac failure
Polycythaemia
Factors affecting Plasma Viscosity
Increased
Age
Pregnancy
Inflammation
– Raised fibrinogen
Myeloma
– Weakly by immunoglobulins
Decreased
Congestive cardiac failure
C-Reactive Protein
Factors affecting CRP
Increased
Pregnancy
Inflammation
Weakly by obesity
Predicts death
Decreased
Acute Phase Reactants
Go up
CRP
ESR
Platelets
Alkaline phosphatase
Ferritin
g-Glutamyl Transferase (gGT)
Go down
Haemoglobin
Albumin
Uric acid
Calcium
Available iron
Fibromyalgia
A positive diagnosis i.e. not just what you are
left with
Excess mortality Cancer!
Important messages
Important exclusions
Secondary or primary care?
Activity and arthritis
Exercise
Physiotherapy
Occupational therapy
In-patient rehabilitation
Precautions
An aside
Does physiotherapy work?
Cohen’s effect size
Compares lots of different treatment types
Signal versus noise
ES
ES
ES
ES
0.2-0.3
≈ 0.5
≥ 0.8
<0
Small
Moderate
Large
Harmful
x
ES 
sd
2.5
2
1.5
1
0.5
0
-0.5
-1
Celecoxib
GPR
Rehabilitation
Balneotherapy
Hospital exercise
BASFI
Hospital exercise
Exercise
Exercise
Group
Celecoxib
GPR
Rehabilitation
Balneotherapy
Conventional…
Hospital exercise
Home
Home
Group
Efficacy (Effect Size)
PAIN
3
2.5
2
1.5
1
0.5
0
-0.5
-1
Van der Berg et al. Rheumatology 2012:51:1388-1396
Effect on Metrology
BASMI
2
1.5
1
0.5
0
-0.5
-1
Group
Home
Exercise
Exercise +
stanger bath
Exercise
Celecoxib
Conclusions
Physical therapy works (reasonably)
Supervised group > Home > None
Precautions
Can’t make it worse
Susceptible to fracture
So go for it
Any questions?
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