As it Is - Back to Action at the Houses of Parliament

As It Is - Back to Action at the Houses of Parliament

In the last decade, great advance has been made in treatment of ankylosing spondylitis (AS). This has been focused on therapies such as the biologics eg. Anti-TNF. One of the cornerstones in treatment of AS remain exercise and physiotherapy. This spans the treatment pathway for AS as recommended by ASAS/EULAR.

Studies have shown that exercise in AS improves function (Passalent, 2011) (van Tubergen & Hidding, 2002). A Cochrane review suggest that an individual home-based or supervised exercise program is better than no intervention (Dagfinrud, Kvien, & Hagen, 2005). Supervised group physiotherapy is better than home exercises and that combined inpatient spa-exercise therapy followed by group physiotherapy is better than group physiotherapy alone. The benefit of group therapy may be due to both the motivation and opportunity for exercise that it provides. Both these factors are important in improving function is AS (Brophy et al., 2013). In a small study, high intensity exercise improved disease activity and reduced cardiovascular risk factors in patients with active axial SpA (Sveaas et al., 2014).

The evidence from the many studies have form the recommendations for the management of AS (Zochling, van der Heijde, Burgos-Vargas, et al., 2006). Exercise and physiotherapy forms the non-pharmacological treatments for AS  (Zochling, van der Heijde, Dougados, & Braun, 2006).

As it is, I was back at the Houses of Parliament on November 18^th November 2014, to highlight the need for better access to physiotherapy for patients with AS. The event organized by NASS was hosted by Huw Irranca-Davies MP.

With the team from Portsmouth, L-R: Roger, me and physiotherapists Emma, Claire and Ronnie

With the NASS Team, Hedley Hamilton, Laura G and Laura R

With Debbie Cook, Director of  NASS

With Gillian Eames, Sebastian, Paul Curry and wife. Paul shared his story of AS.

A survey in 2013 by NASS showed that 60% of people in UK with AS do not have regular access to  physiotherapy. The evidence supports the role of physiotherapy and exercise as key to managing the condition. Physiotherapy remains one of the cornerstones of treatment for AS and is provided by 90 physiotherapy branches. Improved access to the right care for patients with AS including physiotherapy will ensure that patient remain physically active and in work where possible.

#AS_It_Is

@synovialjoints

Views are my own. These are opinions, not specific medical advice and cannot replace the need to see your physician for review of your individual medical condition.

References

Brophy, S., Cooksey, R., Davies, H., Dennis, M. S., Zhou, S.-M., & Siebert, S. (2013). The effect of physical activity and motivation on function in ankylosing spondylitis: a cohort study. Seminars in Arthritis and Rheumatism, 42(6), 619–26. doi:10.1016/j.semarthrit.2012.09.007

Dagfinrud, H., Kvien, T. K., & Hagen, K. B. (2005). The cochrane review of physiotherapy interventions for ankylosing spondylitis. Journal of Rheumatology. doi:10.1002/14651858.CD002822.pub3

Passalent, L. A. (2011). Physiotherapy for ankylosing spondylitis: evidence and application. Current Opinion in Rheumatology, 23, 142–147. doi:10.1097/BOR.0b013e328342273a

Sveaas, S. H., Berg, I. J., Provan, S. A., Semb, A. G., Hagen, K. B., Vøllestad, N., … Dagfinrud, H. (2014). Efficacy of high intensity exercise on disease activity and cardiovascular risk in active axial spondyloarthritis: a randomized controlled pilot study. PloS One, 9(9), e108688. doi:10.1371/journal.pone.0108688

Van Tubergen, A., & Hidding, A. (2002). Spa and exercise treatment in ankylosing spondylitis: fact or fancy? Best Practice & Research. Clinical Rheumatology, 16, 653–666. doi:10.1016/S1521-6942(02)90240-8

Zochling, J., van der Heijde, D., Burgos-Vargas, R., Collantes, E., Davis, J. C., Dijkmans, B., … Braun, J. (2006). ASAS/EULAR recommendations for the management of ankylosing spondylitis. Annals of the Rheumatic Diseases, 65(4), 442–52. doi:10.1136/ard.2005.041137

Zochling, J., van der Heijde, D., Dougados, M., & Braun, J. (2006). Current evidence for the management of ankylosing spondylitis: a systematic literature review for the ASAS/EULAR management recommendations in ankylosing spondylitis. Annals of the Rheumatic Diseases, 65(4), 423–32. doi:10.1136/ard.2005.041129

Going Head over Heels for inflammatory back pain

Reading goes Head over Heels for inflammatory back pain

Increasing awareness of inflammatory low back pain in Reading

On Saturday 19th July 2014 I spent the day in Reading Town Center promoting awareness of inflammatory back pain to the public. Reading is the first site nationally for the Don't Turn Your Back on It campaign. This is a campaign backed by the National Ankylosing Spondylitis Society (NASS).

Speaking to public on inflammatory back pain.
The children of parents were attracted to the 'dinosaur' spine.

The Don't Turn Your Back On It campaign came to Broad Street, Reading to help people suffering from chronic lower back pain to identify if the cause of their pain. Identifying inflammatory low back pain is the key to early diagnosis of ankylosing spondylitis (AS). Currently there is a still an average delay of 8.5 years from symptom onset to diagnosis of AS. With increase public awareness, this should help reduce delay in patients seeing their GPs for onward referral to a Rheumatologist for a diagnosis of AS.

A group of acrobats performed at the event to bring attention to the issue. This got the crowd thinking and talking about back pain seeing the acrobats bending and flexing their spines. We talked to hundreds of people and were interested to hear their individual stories.

Acrobats performing in the middle of Reading Town Center (Broad Street).

 It was a wonderful performance from the acrobats on a wonderful Saturday afternoon.
The rain stayed away despite the forecast of heavy showers!

Information leaflets on inflammatory back pain were handed out by the team on the day. This included Claire Harris, physiotherapy advisor at NASS and Chair of AStretch. Sally Dickinson from NASS was also on the stand along with NASS trustee Peter Wheatley-Price. I was also supported by Susan Hicks, specialist physiotherapist from the Royal Berkshire Hospital. 

The team on the day promoting awareness of inflammatory back pain in Reading.

The campaign hopes to help people suffering from chronic lower back pain  for more than 3 months and encouraged them to  visit the campaign website. Here they can complete a short symptom checker to assess if their back pain may be inflammatory. They are advised that the results can then be discussed with their GP. Further information about the campaign, types and causes of back pain and educational resources offering insights into the lives of people living with chronic back pain are also available on the website. 

@synovialjoints

Views are my own. These are opinions and not consultations. It cannot replace the need to see your physician for review of your individual medical condition.

I

Not all back pain is the same

Not all back pain is the same

In the last 10 years, much progress has been made in defining chronic low back pain (CLBP).  CLBP is defined as back pain > 3 months duration. There are 2 different types of CLBP, namely inflammatory and mechanical back pain. This takes into account the exclusion of CLBP with red flags or sinister features. Inflammatory back pain (IBP) is known to be a presenting feature of ankylosing spondylitis (AS). AS is a chronic inflammatory arthritis with predominant involvement of the spine resulting in inflammation of joints, in particular the sacroiliac (SI) joints.

I wanted to take some time to appreciate the papers from the beginning of the last decade (from 2004) which has highlighted the features and use of IBP identification. IBP is part of the new classification of the spondyloarthritides (SPA) by the Assessment of SpondyloArthritis International Society (ASAS)¹. SPA is a group of inflammatory conditions with AS being the characteristic clinical condition.

            On average it takes 8.5 years for the diagnosis of AS to be made. It is important that patients with IBP are detected early and referred for further investigation and treatment. IBP is the leading symptom for axial SPA and is present in 70% of patients with SPA². The features of IBP are ³,⁴.

Inflammatory back pain (if 4 out of 5 features are present)5

Age of onset < 45 years Insidious onset Improvement  with exercise No improvement with rest Pain at night (with improvement on getting up)

                       

SPA affecting the spine (axial SPA) is present in 5% of patients with CLBP⁶.  If IBP is present, the likelihood of axial SPA goes up from 5% to 14%. On the other hand, if IBP is absent, the likelihood of axial SPA falls to less than 2%⁷. This is an important point as IBP alone is not enough to make a diagnosis of axial SPA. To reach a high enough probability of axial SPA (that is > 90%), other clinical features are needed ⁸.

The features of axial SpA that should be identified include clinical features, laboratory tests (eg. HLA-B27) and radiological imaging (eg. MRI). The clinical features that may point towards axial SPA include a good response to NSAIDs within 48 hours, uveitis, family history and peripheral arthritis⁹,¹⁰. When patients have IBP, the presence of 3 or more features of SPA increases the likelihood of definite axial SPA (80-95%). If 1 or 2 additional features of SPA are present, then the likelihood of axial SPA is lower between 35-70%⁷, ¹¹. When IBP, clinical, laboratory and radiological factors are brought together, the sum of the presence of each factor can be calculated to give the probability of definite axial SPA¹². This will mean a better and quicker way to make a diagnosis of axial SPA and better outcome for patients.

The identification of IBP in patients presenting to their general practitioners (GPs) in primary care with CLBP is the first step towards further assessment and investigations of axial SPA. Education of GPs and physiotherapists who see patients in primary care is important. On the 29^th May 2014, I ran a Back Pain Seminar in Reading which was attended by over 70 GPs and physiotherapist. The focus was on the importance of identifying IBP in patients with CLBP. Patients with IBP can then be assessed for any clinical features associated with SPA and referred for any relevant investigations. This will help reduce the delay in diagnosing axial SpA and ankylosing spondylitis.

The Faculty (L-R): Berit Sund (organiser), Sally Dickinson, Claire Harris, Dr. Antoni Chan, Susan Hicks, Claire Jeffries

Sally Dickinson from the National Ankylosing Spondylitis Society (NASS) giving an update on the role of NASS

References

1.        Sieper J, Rudwaleit M, Baraliakos X, et al. The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis. 2009;68 Suppl 2:ii1-44. doi:10.1136/ard.2008.104018.

2.        Dougados M, van der Linden S, Juhlin R, et al. The European Spondylarthropathy Study Group Preliminary Criteria for the Classification of Spondylarthropathy.; 1991:1218-1227. doi:10.1002/art.1780341003.

3.        Rudwaleit M, van der Heijde D, Landewé R, et al. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis. 2009;68(6):777-83. doi:10.1136/ard.2009.108233.

4.        Rudwaleit M, Metter A, Listing J, Sieper J, Braun J. Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria. Arthritis Rheum. 2006;54(2):569-78. doi:10.1002/art.21619.

5.        Sieper J, van der Heijde D, Landewé R, et al. New criteria for inflammatory back pain in patients with chronic back pain: a real patient exercise by experts from the Assessment of SpondyloArthritis international Society (ASAS). Ann Rheum Dis. 2009;68(6):784-8. doi:10.1136/ard.2008.101501.

6.        Underwood MR, Dawes P. Inflammatory back pain in primary care. Br J Rheumatol. 1995;34(11):1074-7. Available at: http://www.ncbi.nlm.nih.gov/pubmed/8542211.

7.        Rudwaleit M, van der Heijde D, Khan M a, Braun J, Sieper J. How to diagnose axial spondyloarthritis early. Ann Rheum Dis. 2004;63(5):535-43. doi:10.1136/ard.2003.011247.

8.        Rudwaleit M, Khan M a, Sieper J. The challenge of diagnosis and classification in early ankylosing spondylitis: do we need new criteria? Arthritis Rheum. 2005;52(4):1000-8. doi:10.1002/art.20990.

9.        Sieper J, Rudwaleit M. Early referral recommendations for ankylosing spondylitis (including pre-radiographic and radiographic forms) in primary care. Ann Rheum Dis. 2005;64(5):659-63. doi:10.1136/ard.2004.028753.

10.     Rudwaleit M, Sieper J. Referral strategies for early diagnosis of axial spondyloarthritis. Nat Rev Rheumatol. 2012;8(5):262-8. doi:10.1038/nrrheum.2012.39.

11.     Brandt HC, Spiller I, Song I-H, Vahldiek JL, Rudwaleit M, Sieper J. Performance of referral recommendations in patients with chronic back pain and suspected axial spondyloarthritis. Ann Rheum Dis. 2007;66(11):1479-84. doi:10.1136/ard.2006.068734.

12.     Feldtkeller E, Rudwaleit M, Zeidler H. Easy probability estimation of the diagnosis of early axial spondyloarthritis by summing up scores. Rheumatology (Oxford). 2013;52(9):1648-50. doi:10.1093/rheumatology/ket176.

@synovialjoints

Views are my own. These are opinions and cannot replace the need to see your physician for review of your individual medical condition.