np outreach curriculum in rheumatology st. joseph’s health care, london, on dr. sherry rohekar...
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NP Outreach Curriculum in RheumatologySt. Joseph’s Health Care, London, ON
Dr. Sherry RohekarNovember 12, 2009
An Important IssueOne of the most common reasons for seeking
medical attention, second only to respiratory issues
84% of adults will have low back pain at some point
Wide variety of approaches for treatmentSuggests that optimal approach is unsure
Most episodes are self-limitedSome suffer from chronic or recurrent courses,
with substantial impact on quality of life
EpidemiologyAlmost any structure in the back can cause
pain, including ligaments, joints, periosteum, musculature, blood vessels, annulus fibrosus and nervesIntervertebral discs and facet joints most
commonly affected85% of those with isolated low back pain do
not have a clear localization Usually called “strain” or “sprain” no
histopathology, no anatomical locationMen and women equally affectedAge of onset 30-50 years
EpidemiologyLeading cause of work disability in those <
45 yearsMost expensive cause of work disability in
terms of worker’s compensationMultiple known risk factors:
Heavy lifting, twisting, vibration, obesity, poor conditioning
Deyo R and Weinstein J. N Engl J Med 2001;344:363-370
Common Pathoanatomical Conditions of the Lumbar Spine
Deyo R and Weinstein J. N Engl J Med 2001;344:363-370
Differential Diagnosis of Low Back Pain
HistoryAny evidence of systemic disease?
Age (especially >50), hx of cancer, unexplained weight loss, IVDU, chronic infection
DurationPresence of nocturnal painResponse to therapyMany patients with infection or malignancy will
not have relief when lying down Note for arthritis patients – young age, nocturnal
pain and worsening with rest are common in AS
HistoryAny evidence of neurologic compromise?
Cauda equina syndrome is a medical emergency Usually due to tumor or massive herniation
compressing the nerves of the cauda equina Urinary retention with overflow, saddle anesthesia,
bilateral sciatica, leg weakness, fecal incontinenceSciatica caused by nerve root irritation
Sharp/burning pain down posterior or lateral leg to foot or ankle; can be associated with numbness/tingling
If due to disc herniation often worsens with cough, sneeze or performing the Valsalva
HistoryAny evidence of neurologic compromise?
Spinal stenosis is caused by narrowing of the spinal canal, nerve root canals, or intervertebral foramina Most commonly due to bony hypertrophic changes in
facet joints and thickening of the ligamentum flavum Disc bulging or spondylolisthesis may also cause Back pain, transient leg tingling, pain in calf and
lower extremity that is triggered by ambulation and improved with rest
Can differentiate from vascular claudication through detection of normal arterial pulses on exam
Physical ExaminationInspection of back and posture (ie. Scoliosis,
kyphosis)Range of motionPalpation of the spine (vertebral tenderness
sensitive for infection)If high suspicion of malignancy, do a
breast/prostate/lymph node examPeripheral pulses to distinguish from
vascular claudication
Physical ExaminationStraight leg raise: for those with sciatica or
spinal stenosis symptomsPatient supine, examiner holds patient’s leg
straightElevation of less than 60 degrees abnormal and
suggests compression or irritation of nerve rootsReproduces sciatica symptoms (NOT just
hamstring)Ipsilateral straight leg raise sensitive but not
specific for herniated diskCrossed straight leg raise (symptoms of sciatica
reproduced when opposite leg is raised) insensitive byt highly specific
Physical examinationNeurologic examination
L5: ankle and great toe dorsiflexion
S1: plantar flexion, ankle reflex
Dermatomal sensory lossL5: numbness medial
foot and web space between 1st and 2nd toes
S1: lateral foot/ankle
ImagingAP and lateral L-spine if no clinical
improvement after 4-6 weeksGuidelines for American College of Physicians
and American Pain Society: “Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain”Do perform x-rays if: fever, unexplained weight
loss, hx of cancer, neurologic deficits, EtOH, IVDU, age <18 or >50, trauma, immunosuppression, prolonged steroid use, skin/urinary infection, indwelling catheter
ImagingCT and MRI
More sensitive for detection of infection and cancer than plain films
Also able to image herniated discs and spinal stenosis, which cannot be appreciated on plain films
Beware: herniated/bulging discs often found in asymptomatic volunteers may lead to overdiagnosis/overtreatment
MRI better than CT for detection of infection, metastases, rare neural tumours
Natural HistoryMost recover rapidly
90% of patients seen within 3 days of symptom onset recovered within 2 weeks
Recurrences are commonMost have chronic disease with intermittent
exacerbationsSpinal stenosis is the exception usually
gets progressively worse with time
TherapyNon-specific low back pain
Few RCTs; methodology of studies generally poor quality
NSAIDs and muscle relaxants good for symptomatic relief Try giving regular rather than prn
Spinal manipulation (ie. chiropractic) of limited utility in studies
Should recommend rapid return to normal activities with neither bed rest nor exercise in the acute period Bed rest found to not improve and may delay recovery
Exercises not useful in acute phase; use in chronic
TherapyNonspecific low back pain
Traction, facet joint injections, TENS ineffective or minimally effective
Systematic reviews of acupunture have shown little benefit
? Massage therapy some promising resultsSurgery only effective for sciatica, spinal
stenosis or spondylolisthesis
TherapyHerniated intervertebral discs
Nonsurgical treatment for at least a month Exceptions: cauda equina syndrome, progressive
neurologic deficitsEarly treatment same as for nonspecific low back
pain, but may need short courses of narcotics for pain control
Bed rest not usefulSome patients benefit from epidural corticosteroid
injectionsIf severe pain, neurologic defecits MRI and
consider surgery
TherapySpinal stenosis
Physiotherapy to reduce risk of fallsAnalgesics, NSAIDs, epidural corticosteroids
(no clinical trials)Decompressive laminecotomySpinal fusion + decompression if there is
additional spondylolisthesisSymptoms often recur, even after successful
surgery
TherapyChronic low back pain
Intensive exercise improves function and reduces pain, but is difficult to adhere to
Anti-depressants: many with chronic low back pain are also depressed ? Maybe for those without depression (tricyclics)
Opiates Small RCT showed better effect on pain and mood
than NSAIDs No improvement in actity Significant side effects: drowsiness, constipation,
nausea
TherapyChronic low back pain
Referral to multidisciplinary pain center Cognitive-behavioural therapy, education, exercise,
selective nerve blocksSurgical procedures rarely helpful
IntroductionSpondyloarthritis
Refers to inflammatory changes involving the spine and the spinal joints. Remember – can sometimes have peripheral arthritis
without spinal symptoms!
Seronegative SpondyloarthritisAbsence of Rheumatoid Factor
Psoriatic Arthritis Ankylosing Spondylitis Reactive Arthritis Enteropathic Arthritis Undifferentiated Spondyloarthropathy
How do you differentiate inflammatory from mechanical back pain?
Inflammatory vs. Mechanical Back PainInflammatoryAge of onset < 40Insidious onset> 3 months duration> 60 min am stiffnessNocturnal painImproves with activityTenderness over SI
jointsLoss of mobility in all
planesDecreased chest
expansionUnlikely to have
neurologic deficits
Mechanical
Any ageAcute onset< 4 weeks duration< 30 min am stiffnessNo nocturnal painWorse with activityNo SI joint tendernessAbnormal flexionNormal chest
expansionPossible neurologic
deficits
Clinical Features
SacroiliitisUsually bilateral and symmetricInitially involves the synovial-lined lower 2/3
of the SI jointEarliest change: erosion on the iliac side of
SI joint (cartilage is thinner)Could cause “pseudowidening” of SI joint
Bony sclerosis, then complete bony ankylosis or fusion
Spinal Involvement
Spinal InvolvementGradual ossification of the outer layers of the
annulus fibrosis (Sharpey’s fibers) form interverterbral bony bridgesCalled syndesmophytes
Fusion of the apophyseal joints and calcification of the spinal ligaments along with bilateral syndesmophyte formation can result in “bamboo spine”
EnthesitisEnthesis: site of insertion of ligament,
tendon or articular capsule into boneEnthesitis: inflammation of enthesis
resulting in new bone formation or fibrosisCommon sites: SI joints, intervertebral
discs, manubriosternal joints, symphysis pubis, iliac crests, trochanters, patellae, clavicles, calcanei (Achille’s or plantar fasciitis)
More Than Just Back Pain . . .“ANK SPOND”A Aortic insufficiency, ascending aortitis,
conduction abnormalities, pericarditisN Neurologic: atlantoaxial subluxation
and cauda equina syndromeK Kidney: amyloidosis, chronic prostatitisS Spine: Cervical fracture, spinal
stenosis, spinal osteoporosis
More Than Just Back Pain . . .P Pulmonary: upper lobe fibrosis,
restrictive changesO Ocular: anterior uveitis (25-30% of
patients)N Nephropathy (IgA)D Discitis or spondylodiscitis
Also: microscopic colitis in terminal ileum and colon (30-60%)
More Than Just Back Pain . . .Remember that patients with AS can also
have a peripheral arthritisUsually an oligoarthritis of the lower
extremitiesOccasionally, patients will present with
peripheral arthritis before they have back complaints
Physical ExamSchober test
Detects limitation in forward flexion of the lumbar spine
Place mark at dimples of Venus (or level of the posterio superior iliac spine) and another 10 cm above, at the midline
Ask patient to maximally forward flex with locked knees
Measure should increase from 10 cm to at least 15 cm
Modified Schober Test
Making The Diagnosis
TreatmentPhysiotherapy for all
Maintains good postureMaintains chest expansionMinimizes deformities
TreatmentNSAIDs
Good for mild symptomsPotentially disease modifyingIndomethacin seems to work the bestBeware of side effects, especially
gastrointestinal disease
TreatmentDMARDs
Sulfasalazine 1000-2000 mg bid Seems to be the most effective for spinal symptoms
Methotrexate 15-25 mg weekly For patients with prominent peripheral arthritis Doesn’t work very well for spinal symptoms
TreatmentSteroids
Not very effective at all in ASLocal injections for enthesitis or peripheral
arthritisAnti-TNFα agents
Remicade (infliximab), Enbrel (etanercept) and Humira (adalimumab) Very useful for treating symptoms, improving ROM,
improving fatigue Hopefully disease-modifying . . .