Inflammatory Low Back Pain Case 5: Jonathon

Faculty/Presenter Disclosure with Faculty’s Name: Faculty’s Name: Faculty’s Name: Personal relationships with commercial interests (one slide per faculty member/presenter).

Disclosure of Commercial Support . . Mitigating potential bias N/A N/A N/A Specific outline of connections/support for development/presentation of the program from commercial entities or organizations including educational grants, in-kind services (eg, logistics) AND specific aspects of the faculty/presenter connections that a reasonable program participant might consider relevant to the presentation, (eg, products made by companies named in Slide 1 that could be germane to the presentation).

Objectives When working with CPP, you will be able to: Identify inflammatory versus non-inflammatory signs and symptoms List 3 assessment tools that may be useful Identity appropriate investigations Appropriate access of RACE line

Mechanical Low Back Pain Jonathon, 31 year old male, comes to your office with the complaint of low back pain and stiffness that has been escalating over the last 6 weeks. Initially, he notices some stiffness in the morning after playing hockey the night before. This would last for 45 minutes. Now, he is unable to play hockey and has stiffness upon waking that lasts for > 2 hours. There are no particular movements that aggravate or ease his pain but in fact all movements are associated with stiffness and tightness.

What are your Key Questions? How do you determine if this is mechanical back pain or inflammatory back pain?

All Approaches will help you identify inflammatory from mechanical symptoms. Brief Pain Inventory General MSK Screening questions Q. 9-13 Inflammatory Screen Mechanical Patterns Screen Mechanical Movement Questions Are you experiencing morning stiffness in your Back that lasts longer than 30 minutes ? Classification Criteria for Rheumatoid Arthritis Morning stiffness, Joint Count, Joint Location, Activity Reaction

Brief Pain Inventory Screen

Rheumatological Screening

On history,… Jon describes his pain as diffuse and constant without any leg symptoms. His stiffness starts to ease about mid-morning and his pain lessens but he is never without any symptoms. He denies any trauma to his back. He is feeling more fatigued than usual and has also noted some stiffness in his neck the last few weeks. He has tried some naproxen over the counter but does not get much relief.

Relevant History… His father has a long standing low back problem and walks in a stiff bent posture. He has also noticed an uncle with the same posture. He works as an account representative for a home alarm system company. He has been under some stress with a new manager who is demanding more sales calls and higher revenue quotas He is a smoker, alcohol consumption is 10 drinks a week and he has gained 15 pounds in the last 6 months.

Physical Exam What physical examination techniques would you use? We found: Flexion and Extension aggravated low back pain Flexion reduced to ½ range with stiffness Extension reduced to ¼ range Neck movements are reduced in all planes Difficult to find any comfortable position Negative SLR Normal Neurological examination Pattern 1 Prone Extension Positive SLR negative Hip tightness is a fitness indicator but not diagnostic 16

Physical Exam

Pain and Function

Management Tools How would you determine if investigations were appropriate ? We used: Is there poor or no response to appropriate treatment? Are pain levels unmanaged with best medications? Are there prolonged rheumatological symptoms greater than 6 weeks ? Could also use: Patient Brief Pain Assessment DN4 for neuropathic pain Pain Disability Index

Investigations Jon would like some tests done as he feels that his pain and stiffness is more than he has felt before and he has not been responding to treatment. He has asked for an MRI of his back and is willing to pay privately for the service

Rheumatologic Investigations Should you investigate for all inflammatory conditions? What would you order if you were concerned about rheumatoid arthritis ? Will imaging help you with diagnosis? Prognosis?

Rheumatology Laboratory

Rheumatology Radiology

Not Sure ? What is the diagnosis? Should I investigate? What is the most effective treatment? Should follow-up be with a rheumatologist ?

Key Resources for your patients

Clinical Impression Inflammatory Low Back Pain Ankylosing Spondylitis Symptoms don’t fit a Mechanical pattern Morning Stiffness is prolonged Rheumatological Symptoms are greater than 6 weeks Laboratory investigations may be targeted at diagnosis Xrays will help with prognosis Management

Key Clinical Information What are the key criteria for Inflammatory Low Back Pain? Morning Stiffness Lack of mechanical pattern Recurrent and Persistent disability What Medication may be best for him ? Indomethacin Acetominophen

Summary When working with Inflammatory Low Back Pain, it is important to: Identify the differences between inflammatory and non-inflammatory joint disease Provide Appropriate investigations Prescribe effective management

References Arthritis Resource Guide, Arthritis .ca Guidelines and Protocols Advisory Committee Bcguidelines.ca