1. September 5 th – 8 th 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

9. Other musings

10. The problem

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

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

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

14. 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

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 M:F 15:1M:F 3:1 X-rays diagnosticImaging a problem B27 helpful1%  6% Diagnosis easy4½ years AscendingNeck especially women

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

19. 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

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% 1 st 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 Female Gender Age Anaemia Pregnancy Inflammation – Raised fibrinogen Myeloma – Weakly by immunoglobulins Decreased Male Gender Congestive cardiac failure Polycythaemia

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

35. C-Reactive Protein

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

37. Acute Phase Reactants Go up CRP ESR Platelets Alkaline phosphatase Ferritin  -Glutamyl Transferase (  GT) Go down Haemoglobin Albumin Uric acid Calcium Available iron

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

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

43. An aside

45. Does physiotherapy work?

46. 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

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

48. Effect on Metrology

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

51. Precautions Can’t make it worse Susceptible to fracture So go for it

52. Any questions ? Adrian.jones@nuh.nhs.uk