Assessment of Inflammatory Back Pain: New Concepts in Diagnosis
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1 Assessment of Inflammatory Back Pain: New Concepts in Diagnosis March 2 nd, 2018 Spine Therapy Network Interprofessional Synposium Sheraton Toronto Airport Hotel, Toronto, CANADA Laura Passalent PT, BScPT, MHSc, ACPAC Physiotherapist Practitioner, Arthritis Program, Toronto Western Hospital Clinician Investigator, Krembil Research Institute Lecturer, Department of Physical Therapy, University of Toronto
2 Disclosures I have received honoraria for participation on advisory boards and speaking engagements from: AbbVie Amgen Janssen Novarits
3 Case Study: History 32 yr old male 1.5 year Hx of alternating buttock pain (insidious onset); 60 min a.m. stiffness; pain/stiffness improve with activity; difficulty sleeping, both getting and staying asleep 3
4 Case Study: History Prior Rx: MT (temp relief); Ibuprofen 400mg BID (mod relief); Tylenol ES PRN (mod relief) PMHx: unremarkable FamHx: Sister with Crohn s disease 4
5 60-90% 5-10% Mechanical Back Pain Inflammatory Back Pain Axial Spondyloarthritis 1-2%
6 Axial Spondyloarthritis
7 Axial Spondyloarthritis Nonradiographic axial spondyloarthritis Ankylosing Spondylitis
8 Epidemiology ~1.5 % prevalence (SpA) - ~0.5 % (AS) Ages HLA-B27 Axial (SI joint > spinal) versus peripheral joint disease Enthesitis Extra articular involvement
9 ANKYLOSING SPONDYLITIS
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15 SpA cellular and molecular pathology genetic susceptibility inflammation SpA: cellular and molecular pathology destruction remodeling
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19 NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS
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21 Assessment of Axial Spondyloarthritis
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23 Axial SpA Evaluation History Description of back pain (including Red Flags) Peripheral joint involvement EAMs, PMHx, FamHx, Meds, Social Hx Physical Exam Spinal mobility Peripheral Exam (tender/swollen joints, enthesitis, dactylitis, skin, nails) Investigations Radiographs (SIJ, L/S, C/S) Labs (HLA B27, CRP, ESR) +/- MRI
24 Axial SpA Evaluation History Description of back pain (including Red Flags) Peripheral joint involvement EAMs, PMHx, FamHx, Meds, Social Hx Physical Exam Spinal mobility Peripheral Exam (tender/swollen joints, enthesitis, dactylitis, skin, nails) Investigations Radiographs (SIJ, L/S, C/S) Labs (HLA B27, CRP, ESR) +/- MRI
25 HISTORY
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33 IBP: independent contributors (Sieper J et al, 2009) Independent contributors Insidious onset (p=0.001) Pain at night (p=0.001) Age at onset <40yrs (p=0.004) Improvement with exercise/activity (p=0.001) No improvement with rest (p=0.006) I.-P.A.I.N
34 Key comparisons Clinical Feature Inflammatory back pain Mechanical back pain Age of onset* < 40 years Any age Type of onset Insidious Variable Chronicity > 3 months < 3 months Aggravating/relieving factors Better with exercise/activity Worse with rest Worse with movement/activity Better with rest Usually flexion or extension pattern of pain Morning stiffness >30 minutes < 30 minutes Night pain Often awakening in the second half of the night Variable
35 Case Study: History 32 yr old male 1.5 year Hx of alternating buttock pain (insidious onset); 60 min a.m. stiffness; pain/stiffness improve with activity; difficulty sleeping, both getting and staying asleep 35
36 HISTORY
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39 Peripheral joint arthritis
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41 Extra articular manifestations
42 Family History First or second degree relative with: Ankylosing spondylitis Inflammatory bowel disease Uveitis Psoriasis/ psoriatic arthritis
43 NSAIDs Good response (present/past)
44 Case Study: History Prior Rx: MT (temp relief); Ibuprofen 400mg BID (mod relief); Tylenol ES PRN (mod relief) PMHx: unremarkable FamHx: Sister with Crohn s disease 44
45 LABORATORY
46 Acute Phase Reactants Erythrocyte sedimentation rate C-reactive protein
47 HLA B27 ~ 8% prevalence in population ~ 90 % prevalence in AS
48 Case Study: Investigations ESR: 3mm/h CRP: < 3mg/L 48
49 Case Study: Investigations ESR: 3mm/h CRP: < 3mg/L HLA B27: present 49
50 IMAGING
51 Case Study: Imaging 51
52 Case Study: Imaging
53 Case Study: Imaging 53
54 Case Study: Diagnosis? Non-radiographic axial SpA 54
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58 Laura Passalent PT, BScPT, MHSc, ACPAC Physiotherapist Practitioner Spondylitis Program Toronto Western Hospital
Axial Spondyloarthritis. Doug White, Rheumatologist Waikato Hospital
Axial Spondyloarthritis Doug White, Rheumatologist Waikato Hospital Disclosures Presentations / Consulting Abbott Laboratories AbbVie MSD Novartis Roche Clinical Trials Abbott Laboratories AbbVie Actelion
37 year old male with several year history of back pain
37 year old male with several year history of back pain Inflammatory Low Back Pain Clues onset before the age of 40 years insidious onset, chronic (>3 months) pain morning stiffness for longer than 30
www.fisiokinesiterapia.biz Peak onset between 20 and 30 years Form of spondyloarthritis (cause inflammation around site of ligament insertion into bone) and association with HLA-B27 Prevalence as high
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Hello, I m Christopher Ritchlin, from the University of Rochester Medical Center, and I have the pleasure today of discussing with you abstracts
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