September 5th – 8th 2013Nottingham 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

Psychosocial

Serious pathology Employment

Can’t emphasise their importance enoughA test is no substitute for history

Rheumatological TL spine problems

CANCERSEPSISInflammatory spinal

disease– Ankylosing spondylitis– Psoriatic– Enteropathic– Reactive– Seronegative

Fibromyalgia“Normal” back painFractureCrystalRheumatoidNeurologicalMedical

Cancer and sepsis

SymptomsNight painWeight lossUnwellFever

Who getsAnyoneSepsis

– Extremes of age– Diabetes– IVDU

Cancer– Old age– Previous cancer

Seronegative (spondylo)arthropathies

Common in same familySome shared genes

E.g. B27 and spinal disease

Axial involvement common

Spondylitis

Psoriatic

SAPHO

Enteropathic

Undifferentiated

Acne related

Reiter’s

AS

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 otherDon’t worry about the subtypesIt’s the history stupid!

Diagnosing Ankylosing spondylitis ASAS

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 NSAIDsFamily history of SpA, Elevated CRP.

Sacroiliitis on imaging+

≥ 1 Clinical feature

HLA B27+

≥ 2 Clinical features

The Diagnosis

HistoryExaminationNon-specific testsSpecific testsDiagnostic tests – very few

History

Inflammatory back pain > 30 minsWorse on holidayBetter at work especially if manualWorse 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

ESR

Grav

ity

ESR

Grav

ity

Fibrinogen

ESR

Grav

ity

Factors affecting ESR

IncreasedFemale GenderAgeAnaemiaPregnancyInflammation

– Raised fibrinogen

Myeloma– Weakly by immunoglobulins

DecreasedMale GenderCongestive cardiac failurePolycythaemia

Factors affecting Plasma Viscosity

IncreasedAgePregnancyInflammation

– Raised fibrinogen

Myeloma– Weakly by immunoglobulins

DecreasedCongestive cardiac failure

C-Reactive Protein

Factors affecting CRP

IncreasedPregnancyInflammationWeakly by obesity

Predicts death

Decreased

Acute Phase Reactants

Go upCRPESRPlateletsAlkaline phosphataseFerriting-Glutamyl Transferase (gGT)

Go downHaemoglobinAlbuminUric acidCalciumAvailable iron

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=iOXwG7mzKoPqzM&tbnid=ey8rlQaHHxBILM:&ved=0CAUQjRw&url=http://www.rheumtutor.com/asas-criteria-for-peripheral-spa/&ei=MTAmUpCTB-2S0QXK6YCABg&bvm=bv.51495398,d.d2k&psig=AFQjCNE7OmAFdtVfYjr2fBtGA6pVPXBeww&ust=1378320808040169

Fibromyalgia

A positive diagnosis i.e. not just what you are left with

Excess mortality - Cancer!Important messagesImportant exclusionsSecondary or primary care?

Activity and arthritis

ExercisePhysiotherapyOccupational therapyIn-patient rehabilitationPrecautions

An aside

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=akzT11ctD17g6M&tbnid=Ur59dIYWqCkA9M:&ved=0CAUQjRw&url=http://antiworldnews.wordpress.com/2012/02/12/internet-study-facebook-fatigue-is-spreading/&ei=KDomUom6NYf80QX_9IG4BQ&bvm=bv.51495398,d.d2k&psig=AFQjCNECgJY0IfpbFyIF0P23ezBtT9GkKw&ust=1378323346353389

Does physiotherapy work?

Cohen’s effect size

Compares lots of different treatment typesSignal versus noise

ES 0.2-0.3 SmallES ≈ 0.5 ModerateES ≥ 0.8 LargeES < 0 Harmful

sdxES

Efficacy (Effect Size)

GroupHome

Home

Hospita

l exe

rcise

Conventional

exerci

se

Balneotherap

y

Rehabilit

ation

GPR

Celecoxib

-1-0.5

00.5

11.5

22.5

BASFI

Group

Exerci

se

Exerci

se

Hospita

l exe

rcise

Hospita

l exe

rcise

Balneotherap

y

Rehabilit

ation

GPR

Celecoxib

-1-0.5

00.5

11.5

22.5

3

PAIN

Van der Berg et al. Rheumatology 2012:51:1388-1396

Effect on Metrology

Group Home Exercise Exercise + stanger bath

Exercise Celecoxib-1

-0.5

0

0.5

1

1.5

2

2.5

BASMI

Conclusions

Physical therapy works (reasonably)Supervised group > Home > None

Precautions

Can’t make it worseSusceptible to fractureSo go for it

Any questions?

Adrian.jones@nuh.nhs.uk