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
Disclosures I have received honoraria for participation on advisory boards and speaking engagements from: AbbVie Amgen Janssen Novarits
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
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
60-90% 5-10% Mechanical Back Pain Inflammatory Back Pain Axial Spondyloarthritis 1-2%
Axial Spondyloarthritis
Axial Spondyloarthritis Nonradiographic axial spondyloarthritis Ankylosing Spondylitis
Epidemiology ~1.5 % prevalence (SpA) - ~0.5 % (AS) Ages 15-40 HLA-B27 Axial (SI joint > spinal) versus peripheral joint disease Enthesitis Extra articular involvement
ANKYLOSING SPONDYLITIS
SpA cellular and molecular pathology genetic susceptibility inflammation SpA: cellular and molecular pathology destruction remodeling
NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS
Assessment of Axial Spondyloarthritis
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
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
HISTORY
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
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
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
HISTORY
Peripheral joint arthritis
Extra articular manifestations
Family History First or second degree relative with: Ankylosing spondylitis Inflammatory bowel disease Uveitis Psoriasis/ psoriatic arthritis
NSAIDs Good response (present/past)
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
LABORATORY
Acute Phase Reactants Erythrocyte sedimentation rate C-reactive protein
HLA B27 ~ 8% prevalence in population ~ 90 % prevalence in AS
Case Study: Investigations ESR: 3mm/h CRP: < 3mg/L 48
Case Study: Investigations ESR: 3mm/h CRP: < 3mg/L HLA B27: present 49
IMAGING
Case Study: Imaging 51
Case Study: Imaging
Case Study: Imaging 53
Case Study: Diagnosis? Non-radiographic axial SpA 54
www.uhnspondylitis.ca
Laura Passalent PT, BScPT, MHSc, ACPAC Physiotherapist Practitioner Spondylitis Program Toronto Western Hospital laura.passalent@uhn.ca