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Seronegativespondyloarthropathies&inflammatorylow
backpainPart2
Whenitcomestothediagnosisoflowbackpain,inupto85%ofcases,nocleardiagnosiscanbemadeand
pathologicalchangesarenotcloselyrelatedtosymptoms(Javik&Deyo,2002).Whiletheexactprevalence
rangesbetweenstudiesitisestimatedthatbetween8595%oflowbackpaincasescanbediagnosedas
mechanicallowbackoflegpain(LBP).SomeexamplesofthisofmechanicalLBPinclude:lumbar
strain/sprain,degenerativediscdisease,spondylolisthesis,spinalstenosis,discherniation,traumatic
fracture,congenitaldisease(scoliosis)andinternaldiscdisruption(thatisnotanexhaustivelisteither).
Sometimestheseconditionsarefurtherseparatedintospecificandnonspecificcauses.Theremaining3
5%canbeattributedtovisceraldisease(e.g.prostitis,endometriosis,nephrolithiasis,pyelonephritis,aortic
aneurysm,cholecystitis,andpancreatitis)andnonmechanicalspinalconditions(cancer,infection,Paget
disease,Scheuermanndisesaseandinflammatorydiseases)(Jarvik&Deyo,2002,p.587).
Aswelearntinthepreviousblog,withintheclassofinflammatorydisordersthereisasubgroupcalled
seronegativespondyloarthropathieswhichincludeHLAB27positiveconditionssuchaspsoriatic
arthritis,ankylosingspondylitis,reactivearthritis,inflammatoryboweldiseaseandundifferentiated
arthritis(Zochling&Smith.,2010).
Foralloftheseconditionsinflammatorylowbackpainisaclinicalfeature,whichhas5keyfeatures
(Sieperetal.,2008):
Painonsetyoungerthat40yearsofage.
Insidiousonset.
Painimprovementwithexercise.
Painworseningwithrest.
Painatnight(withoutimprovementongettingup).
ThediagnosisofinflammatoryLBPis77%sensitiveand91.7%specificifatleast4orthe5featuresare
present(Sieperetal.,2008,p.786).AccordingtotheEuropeanSpondyloarthropathyStudyGroup
(ESSG)Classification,thediagnosisofspondyloarthropathycanbemadeifsomeonepresentswith
inflammatoryspinalpainandanyofthefollowing:
Positivefamilyhistory
Psoriasis
Inflammatoryboweldisease
Acutediarrhoea,urethritisorcervicitisprecedingtheonsetofarthritis
Alternatingbuttockpain
Enthesopathy
Radiologicalsacroiliitis(Zochling&Smith,2010).
ThereareseveralclinicalassessmenttoolsI'dalsoliketoremention(whichareexplainedinfurtherdetailin
part1ofthisblog):CASPAR(psoriaticarthritis),NewYorkClassificationCriteria(sacroiliitis),theESSG
(diagnosingspondyloarthropathies)andtheInternationalClassificationCriteriabytheASAS(splitting
symptomsintoaxialandperipheral).
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Sonowthatwehaverecappedonthekeyideaspresentedinpart1ofthistopic,let'sfocusonthefiner
detailsofassessment,discusstheroleofmedicalimaginganddrugs,andtalkabouttheevidence
surroundingmanagementfortheseconditions.

QUESTIONINGFORINFLAMMATORYLOWBACKPAIN
Cliniciansmayquestionforinflammatoryconditionswhenpatientspresentwith:multiplejointpains,
atraumaticswollenandpainfuljoints,moreprominentmorningstiffness,andnightpain.Ifyou're
tryingtogathermoreinformationaboutthispotentialinflammatorypain,belowaresomequestionsthatgo
intofurtherdetail(Goodman&Fuller,2014Maitland,Hengeveld,Banks,&English,2005):
1.Howdidthepaindevelop?Isthereamomentintimeorhistoryoftrauma?Diditbegingradually?
Werethereanyotherchangesinyourlifeorphysicalhealthduringthattime?
2.Doyousufferfromstiffnessinthemorning?Ifso,howlongdoesittaketosettleandwhatdoyoudo
toeasethestiffness?
3.Doyoubecomestiffaftersittingforprolongedperiods?Ifso,howlongdoesittaketosettleafter
standingup?
4.Doyoutakeantiinflammatorymedication?Ifso,whattype,dosageandeffectdoesthishave?
5.Doyousufferfrompaininyourjoints?Ifso,whichones?
6.Haveyounoticedanyswellingorotherskinchangesintheseregions?
7.Doesanyoneinyourfamilyhaveahistoryofrheumatoidarthritisorothertypesofinflammatory
disorderssuchasinflammatoryboweldiseaseorCrohnsdisease.
8.Doyouhaveanyothersymptomsthathaveoccurredaroundthesametimeasthepainbegansuchas
urinaryretention,paininotherpartsofyourbody,orincontinence?
9.Whatdoyounormallydotohelpeasethepain?Thisisparticularlyimportanttodiscusswiththe
patientasitgivesvitalinformationaboutthebehaviourofthepain.Forexample,ifthereisaparticular
positionofcomfortormovementthatisprovocative,thepainmaydisplayamechanicalnature,whereas
ifnomovementsaremoreprovocativeorsettlingthatothers,thepainmaydisplayamoreinflammatory
nature.
Apointtonoteisthatthesequestionshelpustodelvemoredeeplyintotheproblempresentedtous.They
don'tactasaclinicalpredictionruleordiagnosticcriteria.Insteadthesequestionshelpyoudevelopa
hypothesislistofwhatthepotentialcausesare,sothatyoucandirectyourtreatmenttowardsidentifyingthe
maincontributingfactor.Justremember,thatintheinitialconsultation,you'retryingtoworkoutifthe
personinfrontofyouissuitableforphysiotherapyandtryingtodecideiftheycametothebest
practitionerfortheirproblem?

CONSIDERATIONSFORASSESSMENT
Yourevaluationofthispatientmayneedtobemoredetailed.Rememberingthatthecommonsymptoms
accompanyinglowbackpainareenthesopathy,dactylitis,sacroiliitis,uveitisandinflammatorybowel
disease,belowaresomechangesyoumightconsidermakinginyourassessment:
Assessmentofspinalrangeofmovementinthecervical,thoracicandlumbarspinelookingatthe
globalmovementofthespine,notjustoneregion.
Gripstrength,observationofthehandandfingerjointsandnailcondition.
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FingerrangeofmovementattheMCP,PIPandDIPjoints.
Wristactiveandpassiverangeofmovement.
Takingnoteofotherchangesintheaffectedareassuchasswelling,warmthtotouch,tendernesson
palpation,hyperalgesiaandvisibledeformity.Oftenrednessandswellingcanbehardtodetectwhen
theunderlyingjointisthemainsourceofpain,butwarmththatdoesnotsettlefollowingmobilisationisan
inflammatorysign(Maitlandetal.,2005).
Ensuringthatyoucomparetheiractiveandpassiverangeofmovementtodetermineifthereisa
strengthlimitation,painlimitationortruejointrestrictiontorangeofmotion.
Functionalassessmentofsinglelegstance,squatdepth,singlelegsquatcontrol,abilitytobalanceon
handsandkneesandextendonearmandtheoppositeleg,kneelingpushupcontrol,andbridgecontrol.
Allthewhilethinking"whatcantheydoandifIgivethemexerciseswherewillIbegin?"
Ifyouaregoingtorecommendexercisetherapy,havingthetreatingmedicalpractitionerdoageneral
healthcheckisagoodideaasthesepatientsareoftenathigherriskofdevelopingcardiovascular
disease.
Askingthepatienttocompletepain,functionalandqualityoflifeoutcomemeasurestogatherarangeof
measuresforreevaluationatalatertime.
Overallyouaretryingtogainameasureofpain,physicalfunction,spinalstiffness,ameasureforother
effectedjointsandaglobalmeasureofqualityoflife.Fromthereyoucanfurtherdesignthemosttailored
andsuitableexerciseprogram.Youarealsotryingtodecideifthepatientissuitableforphysicaltherapy,
whattreatmentsmightbesuitable,andwhatthemainproblemsare?

ROLEOFDRUGTHERAPIES
Therearetwoaimsforthetreatmentofspondyloarthropathies.Thefirstistoimprovefunctional
outcomesandthesecondistoreduceclinicaldeterioration(Dougados&Baeton,2011).Thereasonyou
willreferpatientstoaRheumatologististoensuretheyaremanagedwiththebestdrugtherapies.Often
patientswitheitherRheumatoidArthritisorseronegativespondyloarthropathieswillreceiveeithera
pharmaceuticaldrugorbiologictotackletheirautoimmuneresponse.Thesedrugshavean
immunosupressanteffect.Interestinglyhowever,eventhoughthereisadifferenceindefinitionandcause
betweenrheumatoidarthritisandseronegativespondyloarthropathies,theirmedicationmanagementis
oftensimilar(Papagoras&Drosos,2012).
NSAIDSarethe"cornerstoneofpharmacologicalinterventionforankylosingspondylitis,rapidlyreducing
painandstiffnessafter4872hours"(Dougados&Baeton.,2011,p2132).TheaimofNSAIDSistoreduce
painanddysfunctionintheacutephasesbut,NSAIDSmayalsobeprescribedonalongtermbasistotry
preventspinaldeterioration.
OneadvanceinmanagementhasbeentheintroductionofbiologicssuchasTNFblockade
drugs.MedicaltreatmentofRheumatoidArthritismayincludebothpharmaceuticaldrugsandbiologics,
suchasantiTNF(antitumournecrosisfactoralpha).AntiTNFadrugmanufacturedthroughbiological
processratherthanchemicalones(pharmaceuticaldrugs),andactstointerferewithcytokinefunction,
blockcostimulationofTcellsanddepleteBcells.Overall,thisresultsinanimmunosuppressanteffect.It
hasbeenshowntohavegoodimpactsonRAandotherspondyloarthropathies,butthereremainconcerns
thatthereisaincreasedriskofinfectionintheearlystagesofdruguse,andincreasedriskofdeveloping
lymphomalongerterm(Davies,Symmons,&Hyrich.,2014).Eventhoughsuchrisksexist,oftenthereisno
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otherchoice,especiallyifNSAIDShavefailedtoreducethepainandfunctionallossassociatedwithaxialor
peripheralarthritis(Papagoras&Drosos,2012).
Therearemoreconventionaldrugssuchasmethotrexate.Methotrexateisaclassofdrugcalleddisease
modifyingantirheumaticdrug(DMARDs)andiscommonlyusedtotreatotherinflammatoryconditionssuch
asrheumatoidarthritis.IthasbeenproveneffectiveinthetreatmentofRheumatoidArthritisbutalsohas
positiveimpactsontheextraspinalmanifestationsofinflammatorydiseasessuchaspsoriasis,uveitisand
inflammatoryboweldisease.Theeffectivenessofmethotrexateonreducinginflammatorylowbackpain
remainsundetermined(Dougados&Baeton,2011).Whydowecareaboutthedrugtherapysideof
managinginflammatorylowbackpain?Becausetheimmunosuppressantmedicationchangeshowthebody
willrespondtomanualtherapyandexercisetherapy.
Forexample,psoriaticarthritisleadstojointdeformityinthewristsandhands,buttheremayalsobescaling
andchangesintheskin(frompsoriasis).Careneedstobetakentoprotectjointswhenexercisingaswellas
caringforskinintegrityandalsoknowingtheymayhavingadifferenthealing/recoveryresponsetoexercise.
PerhapsapatientwithseverePsAisn'tsuitableforhydrotherapyduetotheriskofinfectionfromapublic
pool?Or,perhapsyouneedtocarefullyselectwhatweightbearingoccursthroughtheupperlimbsand
whenopenorclosedchainexercisesaremostappropriate?Understandinghowthesetreatmentsmay
effecttheimmunefunctionofyourpatientmayalsoimpactthetreatmenttheycompleteinphysicaltherapy.

RoleofMedicalImaging
Theearliestaxialchangeswithspondyloarthropathiesisthoughttobesacroiliitis,withcervicalinvolvement
occurringmuchlaterinlife(Paparo,etal.,2014).Sacroiliitisisthehallmarksymptomfortheseconditions
andgenerallyinvolvestheanteriorinferiorsynovialaspectsofthejointandposterosuperiorligaments,
generallyaffectingbothSIJssymmetrically(Amrami,2012Paparo,etal.,2014).Thingsthatmaypresent
onimagingare"juxtaarticularosteoporosis,superficialerosionsandprogressivesubchondral
osteosclerosis"(Paparo,etal.,2014,p.157).Moreseverecasesleadtoboneresorptionandanincreasein
jointspace.
Whenitcomestomedicalimaging,XRAYremainsthemostcosteffectivetreatmentoption(Mattar,Salonen,
&Inman.,2013).ItisMRI,however,thatisconsideredtobethecurrentgoldstandardformedical
imaging.ManystudiesarenowhighlightingthebenefitofusingMRIforearlydetectionofjointchanges
basedontheabilitytohaveaT1andT2weightedimage(Amrami,2012Papagoras&Drosos,2012
Paparo,etal.,2014).MRIhastheabilitytoshowboneoedemawithhypointensityonT1andhyper
intensityonT2weightedimages(Paparo,etal.,2014).
Asyoumayhavenoticed,manyofthediagnosticcriteriausetheNewYorkClassificationCriteriafor
sacroiliitis,despiteMRIbeingthecurrentgoldstandard.ThiscriteriausesXRAYtoratethedegreeof
sacroiliitis(Mattar,Salonen,&Inman.,2013,p.652).

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Unfortunatelywiththeseconditions,itcanbeaverylongtimebeforebonedamageisevidenceonXRAY,
hencethepushfortheuseofMRIinearlierdiagnosis.Someauthorsevenusethetermpreradiological
axialspondyloarthropathytoemphasisetheearlydetectionofchanges((Papagoras&Drosos,2012).CT
scansalsoshowgreatdetailinbonelesions.IlovethisimagetodemonstratethedifferencebetweenXRAY
andCTforsomeonewithGr3sacroiliitisaccordingtotheNewYorkClassificationCriteria(Paparo,etal.,p.
158).

IMPLICATIONSFORPHYSICALTHERAPY
Eventhoughtherehavebeendevelopmentsinearlierdiagnosisandbetterdifferentiationbetween
conditions,understandingtheprognosisandlongtermmanifestationsoftheseconditionsremainstobefully
understood.Therehavebeensomegreatadvancesinknowledgeoftheseconditionsoverthepast1020
yearsbutfurtherresearchintotheroleofphysiotherapyisstillrequired.In2004asystematicreview
waspublishedinCochrane(Dagfinrud,Hagen&Kvien)whichconcludedthattherewasmoderateevidence
tosupportthepositiveimpactsofasupervisedexerciseprogram.
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FromthisCochranereviewthefollowingpointscanbemade:
Physiotherapyinterventionisbetterthannointervention.
Supervisedexercisegroupsarebetterthanhomebasedexerciseprograms.
Duetothepoordescriptionsofexerciseprogramsinthestudiesreviewed,cleardirectionsonwhattype
ofprogramisbestcan'tbegiven.
Accordingtothisreview"westilldon'tknowwhichparticulartreatmentprotocolshouldbe
recommended"(Dagfinrud,Hagen,&Kvien.,2004).
NoRCTcomparingphysiotherapyinterventionstootherformsofexercisewerefound.
Evidencetosupporthandsontreatmentsarestilllacking.
Furtherresearchisrequiredtounderstandthebestexercisemethodorinterventionwithspecificdosage
andfrequency.
Ohdear!Thatdoesn'tseemtoohelpful?Butreallywhatitissayingisthatwhilewestilldon'tknowexactly
whatthebestprotocolis,westillknowthatPhysiotherapyinterventionhasapositiveimpact.Fromthe
readingI'vedone,exerciseisdefinitelymoreresearchedthathandsontreatments.Perhapsthisreflectsthe
abilityforexercisetherapytobetteraddressthegoalsofreducedpain,reducedspinalstiffnessand
improvedfunctionaloutcomes?
Oneimportantthingtoconsideristhattheseconditionschangethestructuralintegrityofthebonesand
joints.Onastructuralleveltherearechangesoccurringinthejointsthatneedtobeconsidered,suchas
calciumdepositionsinthejoints,destructionofcollagenandreducedsofttissuetensilestrength.One
criticismofmanualtherapythatIoftenreadaboutintheliterature,isthedifficultytoaccuratelymeasurehow
muchloadwetransfertoapatientwithmanualtherapytechniques.Normally,myresponsetothisqueryis
thatIusethepatient,mytactilesensationandclinicalreasoningtodeterminewhatisasuitablegradeof
treatmenteventhoughIcan'tquantifytheloadintermsofkilogramsorpounds.But,whatifthestructural
integrityofyoupatientisn'tthesameasanormaljoint?Itdefinitelyisapointtoponderoverand
probablythebiggestreasonwhymanipulationisoftencontraindicatedinpatientswithacuteinfectionor
acuteinflammation?Itdoesn'tmeanthatmanualtherapyisoffthetableasatreatment,butjustkeepitin
thebackofyourmindthatitishardtodeterminehowmuchloadthetissuescantolerateandhowmuchload
youareprovidingwithyourtreatment.Whilethereissomeevidenceonthetopicofmanualtherapyfor
osteoarthritis,thestudiessurroundingmanualtherapyforthisspectrumofpatientsisscarce.

TAKEHOMEMESSAGES
ThereasonIwantedtowritethisblogistosharewithyouhowlearningmoreaboutthesemedicalconditions
canchangehowweconceptualiseourphysiotherapyapproach.Admittedly,thisisadifficulttopictowrite
aboutanddiagnosingpatientswithaseronegativespondyloarthropathyisbynomeanseasy.Firstly,these
patientsrepresentaverysmallpercentageofthepopulationthatsuffersfrombackpain.Secondly,these
conditionscanbethoughtofasaspectrumofdisorderseventhoughdifferentdiagnosticcriteriaexist,it
canbechallengingtodistinctlyseparatethemfromeachother.Andfinally,thesymptomsmightbedifficultto
differentiateinordertoidentifytheprimaryproblem.ThereasonIwrotethisbloghowever,istoremindusall
thattheoutliersdoexistandeverynowandthenourclinicalreasoningwillbeputtothetest.Sothetake
homemessageis:
Makethepiecesfit.
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Bethoroughwithyourquestioningaboutpainbehaviourandnature.
Bethoroughaboutyourquestioningoffamilyhistory,medicalhistoryandotherphysicalsymptoms.
Whenindoubtaskforhelp.
Theseconditionsdon'texcludephysiotherapyinterventions,infact,manyofthemaretreatedwithatailored
exerciseprogram.Knowinghoweachconditioninteractswiththemusculoskeletalsystemandcontributesto
painpresentationswillhelpyoumakeyourtreatmentmorepatientcentred.Ifyouaresuspiciousofan
inflammatorydisorderthenreferraltoaRheumatologistwouldberecommendedandyoucansupportthis
referralbylistingtheinformationyou'vegatheredfromyourassessment.
Sian
References:
Akgul,O.,&Ozgocmen,S.(2011).Classificationcriteriaforspondyloarthropathies.WorldJOrthop,2(12),
10715.
Amrami,K.K.(2012).Imagingoftheseronegativespondyloarthopathies.RadiologicClinicsofNorth
America,50(4),841854.
Brosseau,L.,Wells,G.A.,Tugwell,P.,Egan,M.,Dubouloz,C.J.,Casimiro,L.,...Bell,M.(2004).Ottawa
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rheumatoidarthritisinadults.PhysicalTherapy,84(10),934972.
Davies,R.,Symmons,D.P.,&Hyrich,K.L.(2014).Biologicsregistersinrheumatoid
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Dagfinrud,H.,&Hagen,K.(2004).Physiotherapyinterventionsforankylosingspondylitis.TheCochrane
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Dougados,M.,&Baeten,D.(2011).Spondyloarthritis.TheLancet,377(9783),21272137.
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Goodman,C.C.,&Fuller,K.S.(2014).Pathology:implicationsforthephysicaltherapist:ElsevierHealth
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Jadon,D.R.,&McHugh,N.J.(2014).Otherseronegativespondyloarthropathies.Medicine,42(5),257261.
Khan,M.A.(2002).Updateonspondyloarthropathies.AnnalsofInternalMedicine,136(12),896907.
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Linden,S.V.D.,Valkenburg,H.A.,&Cats,A.(1984).Evaluationofdiagnosticcriteriaforankylosing
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