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September 5 th – 8 th 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.

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September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom nspine.co.uk

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September 5 th 8 th 2013 nottingham conference centre united kingdom nspine co uk

September 5th – 8th 2013

Nottingham Conference Centre, United Kingdom

www.nspine.co.uk


Rheumatology the thoracolumbar spine

Rheumatology & the Thoracolumbar spine


Topics to cover

Topics to cover

Differential Diagnosis of Inflammatory Pathology

Blood Investigations

Implications for Physiotherapy Treatment


But also

But also

  • Some anatomical/physiological considerations

  • The Big Problem

  • Does physiotherapy work?


Vertebrae

Vertebrae


Pelvis

Pelvis


Ligaments

Ligaments


Ligaments1

Ligaments


Other musings

Other musings


The problem

The problem


Flags

Flags

Serious pathology

Psychosocial

Employment

Can’t emphasise their importance enough

A test is no substitute for history


Rheumatological tl spine problems

Rheumatological TL spine problems

CANCER

SEPSIS

Inflammatory spinal disease

  • Ankylosingspondylitis

  • Psoriatic

  • Enteropathic

  • Reactive

  • Seronegative

Fibromyalgia

“Normal” back pain

Fracture

Crystal

Rheumatoid

Neurological

Medical


Cancer and sepsis

Cancer and sepsis

Symptoms

Who gets

Anyone

Sepsis

Extremes of age

Diabetes

IVDU

Cancer

Old age

Previous cancer

Night pain

Weight loss

Unwell

Fever


Seronegative spondylo arthropathies

Seronegative (spondylo)arthropathies

Common in same family

Some shared genes

E.g. B27 and spinal disease

Axial involvement common

Spondylitis

AS


Nature of the beast

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

Ankylosing spondylitis

  • Enthesis

    • Specialised tissue

    • Site where ligaments/tendon insert into bone


Some myths corrections

Some myths & corrections


Differential

Differential

  • All the seronegatives are variants on each other

  • Don’t worry about the subtypes

  • It’s the history stupid!


Diagnosing ankylosing spondylitis asas

Diagnosing Ankylosingspondylitis ASAS

  • Active (acute) inflammation on MRI, highly suggestive of SpAsacroiliitis

  • 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.

Sacroiliitis on imaging

+

≥ 1 Clinical feature

HLA B27

+

≥ 2 Clinical features


The diagnosis

The Diagnosis

  • History

  • Examination

  • Non-specific tests

  • Specific tests

  • Diagnostic tests – very few


History

History

  • Inflammatory back pain > 30 mins

  • Worse on holiday

  • Better at work especially if manual

  • Worse in evenings

It’s the history stupid!


Examination

Examination


Eye skin disease

Eye & Skin disease


Anogenital

Anogenital


So to tests

So to tests


Diagnostic

Diagnostic


Specific tests

Specific tests


Hla b27

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

Non-specific tests

  • Acute phase response

    • ESR

    • C-reactive protein

    • Anaemia

    • Thrombocytosis

    • Low albumin

    • Raised ferritin


September 5 th 8 th 2013 nottingham conference centre united kingdom nspine co uk

ESR

Gravity


September 5 th 8 th 2013 nottingham conference centre united kingdom nspine co uk

ESR

Gravity

Fibrinogen


September 5 th 8 th 2013 nottingham conference centre united kingdom nspine co uk

ESR

Gravity


Factors affecting esr

Factors affecting ESR

Increased

Decreased

Male Gender

Congestive cardiac failure

Polycythaemia

Female Gender

Age

Anaemia

Pregnancy

Inflammation

  • Raised fibrinogen

    Myeloma

  • Weakly by immunoglobulins


Factors affecting plasma viscosity

Factors affecting Plasma Viscosity

Increased

Decreased

Congestive cardiac failure

Age

Pregnancy

Inflammation

  • Raised fibrinogen

    Myeloma

  • Weakly by immunoglobulins


C reactive protein

C-Reactive Protein


Factors affecting crp

Factors affecting CRP

Increased

Decreased

Pregnancy

Inflammation

Weakly by obesity

Predicts death


Acute phase reactants

Acute Phase Reactants

Go up

Go down

Haemoglobin

Albumin

Uric acid

Calcium

Available iron

CRP

ESR

Platelets

Alkaline phosphatase

Ferritin

g-GlutamylTransferase (gGT)


Fibromyalgia

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

Activity and arthritis

  • Exercise

  • Physiotherapy

  • Occupational therapy

  • In-patient rehabilitation

  • Precautions


An aside

An aside


Does physiotherapy work

Does physiotherapy work?


Cohen s effect size

Cohen’s effect size

  • Compares lots of different treatment types

  • Signal versus noise

  • ES 0.2-0.3Small

  • ES ≈ 0.5Moderate

  • ES≥ 0.8Large

  • ES< 0Harmful


Efficacy effect size

Efficacy (Effect Size)

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


Effect on metrology

Effect on Metrology


Conclusions

Conclusions

  • Physical therapy works (reasonably)

  • Supervised group > Home > None


Precautions

Precautions

Can’t make it worse

Susceptible to fracture

So go for it


Any questions

Anyquestions?

[email protected]


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