Inflammatory Low Back Pain
Case 5: Jonathon
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Objectives
When working with CPP, you will be able to:
1. Identify inflammatory versus non-inflammatory
signs and symptoms
2. List 3 assessment tools that may be useful
3. Identity appropriate investigations
4. Appropriate access of RACE line
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Mechanical Low Back Pain
Jonathon, 31 year old male, comes to your
office with the complaint of low back pain and
stiffness that has been escalating over the last 6
weeks.
Initially, he notices some stiffness in the morning
after playing hockey the night before. This would
last for 45 minutes. Now, he is unable to play
hockey and has stiffness upon waking that lasts
for > 2 hours.
There are no particular movements that
aggravate or ease his pain but in fact all
movements are associated with stiffness and
tightness.
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What are your Key Questions?
 How do you determine if
this is mechanical back
pain or inflammatory
back pain?
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All Approaches will help you identify
inflammatory from mechanical symptoms.
 Brief Pain Inventory
 General MSK Screening questions
 Q. 9-13 Inflammatory Screen
 Mechanical Patterns Screen
 Mechanical Movement Questions
 Are you experiencing morning stiffness in your Back that
lasts longer than 30 minutes ?
 Classification Criteria for Rheumatoid Arthritis
 Morning stiffness, Joint Count, Joint Location, Activity
Reaction
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Brief Pain Inventory Screen
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Rheumatological Screening
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On history,…
 Jon describes his pain as diffuse and constant
without any leg symptoms. His stiffness starts to
ease about mid-morning and his pain lessens but
he is never without any symptoms.
 He denies any trauma to his back.
 He is feeling more fatigued than usual and has
also noted some stiffness in his neck the last few
weeks.
 He has tried some naproxen over the counter but
does not get much relief.
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Relevant History…
 His father has a long standing low back problem
and walks in a stiff bent posture. He has also
noticed an uncle with the same posture.
 He works as an account representative for a home
alarm system company.
 He has been under some stress with a new
manager who is demanding more sales calls and
higher revenue quotas
 He is a smoker, alcohol consumption is 10 drinks
a week and he has gained 15 pounds in the last 6
months.
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Physical Exam
 What physical examination techniques would you use?
We found:
Flexion and Extension aggravated low back pain
Flexion reduced to ½ range with stiffness
Extension reduced to ¼ range
Neck movements are reduced in all planes
Difficult to find any comfortable position
 Negative SLR
Normal Neurological examination
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Physical Exam
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Pain and Function
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Management Tools
 How would you determine if investigations were
appropriate ?
We used:
a) Is there poor or no response to appropriate treatment?
b) Are pain levels unmanaged with best medications?
c) Are there prolonged rheumatological symptoms greater
than 6 weeks ?
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Investigations
 Jon would like some tests done as he feels that
his pain and stiffness is more than he has felt
before and he has not been responding to
treatment.
 He has asked for an MRI of his back and is willing
to pay privately for the service
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Rheumatologic Investigations
 Should you investigate for all inflammatory
conditions?
 What would you order if you were concerned
about rheumatoid arthritis ?
 Will imaging help you with diagnosis? Prognosis?
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Rheumatology Laboratory
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Rheumatology Radiology
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Not Sure ?
 What is the diagnosis?
 Should I investigate?
 What is the most effective
treatment?
 Should follow-up be with a
rheumatologist ?
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Key Resources for your patients
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Clinical Impression
 Inflammatory Low Back Pain
 Ankylosing Spondylitis
 Symptoms don’t fit a Mechanical pattern
 Morning Stiffness is prolonged
 Rheumatological Symptoms are greater than 6
weeks
 Laboratory investigations may be targeted at
diagnosis
 Xrays will help with prognosis
 Management
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Key Clinical Information
 What are the key criteria for Inflammatory Low Back
Pain?
 Morning Stiffness
 Lack of mechanical pattern
 Recurrent and Persistent disability
 What Medication may be best for him ?

Indomethacin

Acetominophen
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Summary
When working with Inflammatory Low Back Pain, it is
important to:
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Identify the differences between inflammatory and
non-inflammatory joint disease
Provide Appropriate investigations
Prescribe effective management
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References
 Arthritis Resource Guide, Arthritis .ca
 Guidelines and Protocols Advisory Committee
 Bcguidelines.ca
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