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

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

  2. Rheumatology & the Thoracolumbar spine

  3. Topics to cover Differential Diagnosis of Inflammatory Pathology Blood Investigations Implications for Physiotherapy Treatment

  4. But also • Some anatomical/physiological considerations • The Big Problem • Does physiotherapy work?

  5. Vertebrae

  6. Pelvis

  7. Ligaments

  8. Ligaments

  9. Other musings

  10. The problem

  11. Flags Serious pathology Psychosocial Employment Can’t emphasise their importance enough A test is no substitute for history

  12. Rheumatological TL spine problems CANCER SEPSIS Inflammatory spinal disease • Ankylosingspondylitis • Psoriatic • Enteropathic • Reactive • Seronegative Fibromyalgia “Normal” back pain Fracture Crystal Rheumatoid Neurological Medical

  13. Cancer and sepsis Symptoms Who gets Anyone Sepsis Extremes of age Diabetes IVDU Cancer Old age Previous cancer Night pain Weight loss Unwell Fever

  14. Seronegative (spondylo)arthropathies Common in same family Some shared genes E.g. B27 and spinal disease Axial involvement common Spondylitis AS

  15. Nature of the beast • A disease of entheses • Shared genetic background • Body surface antigen exposure? • Psoriasis • Bowel inflammation • Elevated IgA levels • Iritis/conjunctivitis

  16. Ankylosing spondylitis • Enthesis • Specialised tissue • Site where ligaments/tendon insert into bone

  17. Some myths & corrections

  18. Differential • All the seronegatives are variants on each other • Don’t worry about the subtypes • It’s the history stupid!

  19. 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

  20. The Diagnosis • History • Examination • Non-specific tests • Specific tests • Diagnostic tests – very few

  21. History • Inflammatory back pain > 30 mins • Worse on holiday • Better at work especially if manual • Worse in evenings It’s the history stupid!

  22. Examination

  23. Eye & Skin disease

  24. Anogenital

  25. So to tests

  26. Diagnostic

  27. Specific tests

  28. 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

  29. Non-specific tests • Acute phase response • ESR • C-reactive protein • Anaemia • Thrombocytosis • Low albumin • Raised ferritin

  30. ESR Gravity

  31. ESR Gravity Fibrinogen

  32. ESR Gravity

  33. Factors affecting ESR Increased Decreased Male Gender Congestive cardiac failure Polycythaemia Female Gender Age Anaemia Pregnancy Inflammation • Raised fibrinogen Myeloma • Weakly by immunoglobulins

  34. Factors affecting Plasma Viscosity Increased Decreased Congestive cardiac failure Age Pregnancy Inflammation • Raised fibrinogen Myeloma • Weakly by immunoglobulins

  35. C-Reactive Protein

  36. Factors affecting CRP Increased Decreased Pregnancy Inflammation Weakly by obesity Predicts death

  37. Acute Phase Reactants Go up Go down Haemoglobin Albumin Uric acid Calcium Available iron CRP ESR Platelets Alkaline phosphatase Ferritin g-GlutamylTransferase (gGT)

  38. Fibromyalgia • A positive diagnosis i.e. not just what you are left with • Excess mortality - Cancer! • Important messages • Important exclusions • Secondary or primary care?

  39. Activity and arthritis • Exercise • Physiotherapy • Occupational therapy • In-patient rehabilitation • Precautions

  40. An aside

  41. Does physiotherapy work?

  42. Cohen’s effect size • Compares lots of different treatment types • Signal versus noise • ES 0.2-0.3 Small • ES ≈ 0.5 Moderate • ES ≥ 0.8 Large • ES < 0 Harmful

  43. Efficacy (Effect Size) Van der Berg et al. Rheumatology 2012:51:1388-1396

  44. Effect on Metrology

  45. Conclusions • Physical therapy works (reasonably) • Supervised group > Home > None

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