![IBD-related arthritis
Type 1 (arthritis parallels IBD activity) - 4% to 6% of IBD patients, acute in
onset, asymmetric; + extraarticular manifestations (erythema nodosum,
uveitis).
Most arthritic episodes are self-limited with 80% resolving within 3
months. This type of arthritis does not result in radiographic changes or
deformities.
Type 2 (arthritis is independent of IBD activity) - 3% to 4% patients;
symmetric (80%), polyarticular (metacarpophalangeal [MCP] joints >
knees and ankles > other joints), runs a course independent of the activity
of the inflammatory bowel disease](https://image.slidesharecdn.com/assessingbackpaininrheumatology-201106012924/85/Assessing-back-pain-in-rheumatology-27-320.jpg)
Uploaded byDiana Girnita
Assessing back pain in rheumatology
The document discusses back pain assessment from a rheumatology perspective, detailing healthcare spending related to back pain and common diagnostic approaches. It emphasizes that most low back pain is mechanical, outlines when imaging should be utilized, and highlights red flags and symptoms to consider. Management tips suggest prioritizing exercise and physical therapy, avoiding certain tests in the early stages, and providing guidelines for inflammatory arthritis treatment.
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Assessing back pain in rheumatology
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- 2. Date of download:9/30/2020 Copyright 2020 American Medical Association. All Rights Reserved. US Health Care Spending 1996-2016 JAMA. 2020;323(9):863-884. doi:10.1001/jama.2020.0734 : Each of the 3 columns sums to the estimated $2.7 trillion of 2016 spending.
- 3. Back pain 1996to 2016 total health care spending increased from an estimated $1.4 trillion to an estimated $3.1 trillion. Private insurance 48%; Medicare 42%, CASH 10% Out of 154 conditions 1. Low back and neck pain - $134.5 billion 2. Musculoskeletal disorders (joint and limb pain, myalgia, and osteoporosis) at $129.8 billion 3. Diabetes at $111.2 billion 4. Ischemic heart disease at $89.3 billion
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- 6. Questions to ask? P-Q-R-S-T P—Provocative and palliative factors Q—Quality of pain R—Radiation of pain S—Severity of pain or systemic symptoms T—Timing
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- 8. FEVER Bowel/bladder dysfunction Night pain unrelieved by rest History of cancer History of trauma in patients with osteoporosis.
- 9. Most low backpain is mechanical in nature and should slowly improve over 2 to 6 weeks. Pain > 4-6 weeks obtain plain films
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- 11. Rheumatology Secrets, 3rdedition
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- 13. Rheumatology Secrets, 3rdedition
- 14. Should obtain X-raysin all cases? If your approach is altered Red flags (infection? Cancer? MM vs Lymphoma) Suspect sacroiliac involvement
- 15. When to orderMRI? To diagnose inflammatory arthritis Patients with previous history of lumbar spine surgery (to exclude infection or nerve root compression resulting from scar tissue) Vertebral fracture
- 16. When to orderEMG? Signs and symptoms of a radiculopathy If this information will change your approach MRI imaging has replaced the need for an EMG The EMG is usually carried out at least 3 weeks after the onset of symptoms
- 18. Features of Spondyloarthopaties Dactilytis Enthesitis ( elbow, Achilles tendon, plantar fascia) Eye involvement GI involvement (diarrhea, abdominal pain, ) Skin changes
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- 20. Symptoms – mostimportant!! Age of onset <40 years of age Symptom duration >3 months Morning stiffness >60 min Nocturnal pain -frequent Improvement with exercise Sacroiliac joint tenderness No neurological deficit
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- 22. HLA-B27 is notdiagnostic! HLA-B27 is present 90% of whites and 50%- 80% of non-white patients with AS HLA-B27-+ individual has a 50 to 100X increased relative risk of developing AS Only 2% (1 out of 50) of HLA-B27+ develop AS during their lifetime.
- 23. CRP Prognostic sign,if high Many patients with AS have normal CRP
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- 26. Inflammatory Bowel Disease– related arthritis Idiopathic, inflammatory bowel disease (ulcerative colitis, Crohn’s disease) Microscopic colitis (lymphocytic colitis and collagenous colitis). Infectious gastroenteritis and pseudomembranous colitis. Whipple’s disease. Gluten-sensitive enteropathy (celiac disease)
- 27. IBD-related arthritis Type1 (arthritis parallels IBD activity) - 4% to 6% of IBD patients, acute in onset, asymmetric; + extraarticular manifestations (erythema nodosum, uveitis). Most arthritic episodes are self-limited with 80% resolving within 3 months. This type of arthritis does not result in radiographic changes or deformities. Type 2 (arthritis is independent of IBD activity) - 3% to 4% patients; symmetric (80%), polyarticular (metacarpophalangeal [MCP] joints > knees and ankles > other joints), runs a course independent of the activity of the inflammatory bowel disease
- 28. IBD features P—pyodermagangrenosum A—aphthous stomatitis; more common in UC I—inflammatory eye disease (acute anterior uveitis): more common in Crohn’s disease. N—nodosum (erythema)
- 29. Psoriatic Arthritis –easily missed,diagnosed late!!! 26% of patients with psoriasis Aggressive! 45% to 50% of patients will develop erosions within the first 2 years of their disease and eventually 67% will develop radiographic changes Psoriasis precedes arthritis by an average of 8 to 10 years in 67% of patients.; Arthritis precedes psoriasis or occurs simultaneously in 33% of patients If psoriasis is not obvious, check Umbilicus, scalp, anus, and behind ears.
- 30. Features of Psoriaticarthritis Dactylitis Enthesitis
- 31. Rx changes inPsoriatic arthritis Pencil in a cup Enthesopathy
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- 34. North American SpineSociety recommended the following tests/treatments NOT be done in patients with back pain:
- 35. Do notorder MRI of the spine within the first 6 weeks in patients with nonspecific low back pain in the absence of red flags (trauma, use of corticosteroids, unexplained weight loss, progressive neurologic signs, age >50 years or <age 17 years, fever, IV drug abuse, pain unrelieved by bed rest, history of cancer). Do not order EMG/NCVs to determine the cause of neck and back pain without radicular symptoms.
- 36. Do notorder an MRI before ordering plain films in a patient presenting with joint or back pain Do not order HLA-B27 unless you suspect an undifferentiated spondyloarthropathy based on history and examination but have non- diagnostic radiographs.
- 37. Tips for Management Exerciseand weight loss are important in any rehabilitation program for mechanical low back pain. Within 1 week of an acute episode: 50% of patients improve; 75% will improve after 1 month; and 87% improve at 3 months. By 6 months, 93% are better. Prognosis is less favorable among patients receiving narcotics, disability benefits, and/or workmen’s
- 38. Tips for management Itis preferable to limit bed rest to 2 days or less and refer the patient to physical therapy for instructions in the use of ice, heat, proper lifting techniques, and correct spine stabilization exercises. Limited data does NOT support the routine use of facet injections, acupuncture, or transcutaneous nerve stimulators. Spinal manipulation may provide some relief in the early phases of acute nonserious injuries.
- 39. Inflammatory arthritis management Physicaltherapy NSAIDs Biologics: TNF alpha inhibitors and IL-17 inhibitors No role for Methotrexate Limited response to sulfasalazine
- 40. DISCLAIMER Please notethat these rheumatology discussions are for informational and educational purposes only. The discussions are based on limited information and exclude patient observation and hands-on clinical evaluation. As such, comments relating to patient care, evaluation, planning and treatment should be regarded as a professional dialogue only. Physicians attending the discussions shall remain in complete control of medical services they provide to their patients and shall be solely responsible for all acts and decisions in connection therewith. Licensed in CA, OH, IN and KY Soon in AZ and TX
- 41. Thank you! Rheumatologist Oncall Officephone: 1-650-252-1690 drg@rheumatologistoncall.com https://dianagirnitamd.com
Editor's Notes
- #6 Mechanical: degenerative disk disease, nonspecific low back pain/strain (with or without psychogenic co ponent), pregnancy, discogenic, spondylolisthesis, facet arthritis, fractures, etc. Radicular: foraminal nerve root compression, spinal stenosis Inflammatory: ankylosing spondylitis Infiltrative: cancer, infectious (osteomyelitis, abscess, and diskitis) Referred: intra-abdominal pathology (i.e., abdominal aneurysm, nephrolithiasis)
- #7 Psitting (worse with diskogenic), walking (worse with spinal stenosis, relieved with forward flexion), supine (pain unrelieved if cancer or infection), Valsalva maneuver (worse with intrathecal or radicular process), lumbar extension (worse with spinal stenosis and facet arthritis) versus flex- ion (worse with lumbar strain or fibromyalgia)
- #15 Why not obtain x-rays on all patients with low back pain? Always ask yourself if you would treat the patient differently based on this information. Age-related degen- erative changes in the lumbar spine are often unrelated to the cause of the patient’s myofascial pain. These images are often an unnecessary expense, and one lumbar series exposes the patient to the equivalent ionizing radiation dose of 40 chest x-rays.
- #16 MRI studies -25% to 50% of individuals without low back pain will have a disk bulge or protrusion at one or more lumbar disk levels. Consequently, disk bulges/protrusions on MRI in patients with low back pain are usually coincidental, whereas disk extrusion, especially with compression of the lumbar nerve, is usually a significant cause of
- #24 RF and ANA should be negative (i.e., seronegative spondyloarthropathy). IgA levels are frequently elevated in AS patients who develop an IgA nephropathy.
- #38 People who are more fit have fewer episodes of low back pain and recover from an episode of back pain more quickly. Exercise is important in maintaining the strength of the spinal segments.