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Published byAlysha Cornforth Modified over 9 years ago
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September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk
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Rheumatology & the Thoracolumbar spine
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Topics to cover Differential Diagnosis of Inflammatory Pathology Blood Investigations Implications for Physiotherapy Treatment
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But also Some anatomical/physiological considerations The Big Problem Does physiotherapy work?
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Vertebrae
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Pelvis
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Ligaments
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Other musings
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The problem
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Flags Psychosocial Serious pathology Employment Can’t emphasise their importance enough A test is no substitute for history
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Rheumatological TL spine problems CANCER SEPSIS Inflammatory spinal disease – Ankylosing spondylitis – Psoriatic – Enteropathic – Reactive – Seronegative Fibromyalgia “Normal” back pain Fracture Crystal Rheumatoid Neurological Medical
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Cancer and sepsis Symptoms Night pain Weight loss Unwell Fever Who gets Anyone Sepsis – Extremes of age – Diabetes – IVDU Cancer – Old age – Previous cancer
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Seronegative (spondylo)arthropathies Common in same family Some shared genes E.g. B27 and spinal disease Axial involvement common Spondylitis Psoriatic SAPHO Enteropathic Undifferentiated Acne related Reiter’sASAS
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Nature of the beast A disease of entheses Shared genetic background Body surface antigen exposure? – Psoriasis – Bowel inflammation – Elevated IgA levels Iritis/conjunctivitis
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Ankylosing spondylitis Enthesis – Specialised tissue – Site where ligaments/tendon insert into bone
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Some myths & corrections M:F 15:1M:F 3:1 X-rays diagnosticImaging a problem B27 helpful1% 6% Diagnosis easy4½ years AscendingNeck especially women
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Differential All the seronegatives are variants on each other Don’t worry about the subtypes It’s the history stupid!
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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 NSAIDs Family history of SpA, Elevated CRP. Sacroiliitis on imaging + ≥ 1 Clinical feature HLA B27 + ≥ 2 Clinical features
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The Diagnosis History Examination Non-specific tests Specific tests Diagnostic tests – very few
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History Inflammatory back pain > 30 mins Worse on holiday Better at work especially if manual Worse in evenings It’s the history stupid!
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Examination
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Eye & Skin disease
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Anogenital
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So to tests
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Diagnostic
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Specific tests
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HLA B27 Present in 5% of population Overall risk of AS ≈ 1% B27 positive ≈ 6% 1 st degree relative AS and B27 + 30% Depends on racial group Genotype different to phenotype Generally not a good test – but note ASAS
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Non-specific tests Acute phase response – ESR – C-reactive protein – Anaemia – Thrombocytosis – Low albumin – Raised ferritin
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ESR Gravity
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ESR Gravity Fibrinogen
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ESR Gravity
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Factors affecting ESR Increased Female Gender Age Anaemia Pregnancy Inflammation – Raised fibrinogen Myeloma – Weakly by immunoglobulins Decreased Male Gender Congestive cardiac failure Polycythaemia
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Factors affecting Plasma Viscosity Increased Age Pregnancy Inflammation – Raised fibrinogen Myeloma – Weakly by immunoglobulins Decreased Congestive cardiac failure
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C-Reactive Protein
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Factors affecting CRP Increased Pregnancy Inflammation Weakly by obesity Predicts death Decreased
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Acute Phase Reactants Go up CRP ESR Platelets Alkaline phosphatase Ferritin -Glutamyl Transferase ( GT) Go down Haemoglobin Albumin Uric acid Calcium Available iron
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Fibromyalgia A positive diagnosis i.e. not just what you are left with Excess mortality-Cancer! Important messages Important exclusions Secondary or primary care?
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Activity and arthritis Exercise Physiotherapy Occupational therapy In-patient rehabilitation Precautions
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An aside
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Does physiotherapy work?
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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
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Efficacy (Effect Size) Van der Berg et al. Rheumatology 2012:51:1388-1396
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Effect on Metrology
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Conclusions Physical therapy works (reasonably) Supervised group > Home > None
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Precautions Can’t make it worse Susceptible to fracture So go for it
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Any questions ? Adrian.jones@nuh.nhs.uk
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