Axial Spondyloarthritis (SpA) within the Advanced Practitioner Musculoskeletal Physiotherapy Scope

Case Study: A 39-Year-Old Female Patient with Chronic Lower Back Pain

Axial spondyloarthritis (SpA) within the advanced practitioner musculoskeletal physiotherapy scope.

• Axial spondyloarthritis (SpA) description , definition , with references
• This case study demonstrates the safe and effective, successful examination and care management plan of a patient with suspected axial spondyloarthritis (SpA) in an advanced practitioner physiotherapy clinic (APP).
• The study demonstrate the effective relationship between GPs and advanced practitioners in musculoskeletal physiotherapy within NHS
• what is the Deferential diagnosis of the Axial spondyloarthritis (SpA) description
• patient demonstrated an appropriate axial spondyloarthitis SpA threshold based on the total of the patient's subjective history. She had an gradually  onset, age of onset 39 years old, it improved with exercise, NSAIDs, worsened with rest/inactivity, and had Early morning stiffness  30 mint to 1 hour, according to the Assessment of Spondyloarthritis International Society (ASAS) diagnostic criteria for inflammatory back pain . With percent of past medical history of extra-articular (Irritable bowel syndrome, Gluten allergies , Reiter's syndrome, Psoriasis disorder) despite abcens of  peripheral signs (arthritis, dactylitis, enthesitis), a sustained history of > 3 months and beginning in her third decade suggest axial SpA.

As well as confirmed by the MRI scan and bloods which it has helped with appropriate treatment plan and good outcomes.

The referral sent from GP:

The patient is 39 year-old femal. She has 10 years of history of of Chronic lower back pain, because she is overweight, and she works full time office job. Also she looks after her elderly parents and her own two kids and she is a single mother. All these pressures and reasons led to her injury of Chronic lower back pain.

The patient has Injured gluteal area, had a fall on to her Right side buttock 18 months ago. Progressed to mechanical intermittent sciatica on Right leg, mainly front thigh, since 6 months ago, gluteal burning sensation, localized pain end of spine, minor swelling toes mainly big toe Right side?

She described the progression in her pain that make her wake up at midnight every day. Also she is not able to twist her lower limbs overnight. Early morning stiffness 30 to 60 mint, Although during the day the pain decreased and gradually get worst at night.

In the past, the patient tried to contain her pain symptoms through prescription medication. Neuropathic medication foe her sciatica pain which is slightly improved her paraesthesia pain, recetly GP prescribed Steroid anti-inflammatory disorder NSAIDs which it has improved her stiffness pain dramatically. Also she reports that she is feeling better after walking her dog as gentle exercise but due to her overweight her knees gets painful from the walking which she has to stop.

She had private physiotherapy and manipulation sessions with acupunture where it has improved her sciatica pain but always the pain returns if she stoppes the physiotherapy ttt.

Subjective findings:

1. Aggravating/ eases factors

• Aggregated by shopping or housework as physcial  activities,  Prolonged sitting
• Eases by NSAIDs
• hands on physiotherapy and gentle walking

2. A Visual analogue scale (VAS) 7/10 vas at night and earl morning , 2-3/10 vas during day time.

3. Start back tool which she scored mild risk and the Oswestry Disability Index (ODI) scoring 31%5

4. Roland-Morris Disability Questionnaire not been used in this case due to tight time

5. No red flags records, According to the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT), CES, Spinal Fracture, Malignancy, and Infection are the four priority areas that must be ruled out based on the prevalence and incidence of low back pain.

Subjective Findings

Past medical history

Chronic back pain

Irritable bowel syndrome

Gluten allergies

Reiter's syndrome

Diagnostics results:

• X-RAY showed clear , no IVD disorder
• Blood test: Inflammatory markers were negative.
• Low Vit D.

Objective examination/ Physical examination and findings.

 

• Pt consented to be examined today
• Lumbar flexion in standing limited by stiffness pain
• Lumbar extension in standing moderately limited >> stiffness pain
• Left and right rotation/ side bending both limited due to localized pain on the lower end of spine and burning
• pain on Right Gluteus referred to groin .
• Straight leg raise on right = 40 refers pain to gluteal + groin , left = 90
• Able to stand up on tiptoes and heels
• Not able squat single leg= bilateral , due to gluteal burning pain and Rt groin ?
• Mild Swelling big toe and tender toes.
• Tender on palpation : mid buttock ++ , no groin tenderness., tender SIJ > lumbar spine Rt side.

Objective examination/ Physical examination and findings.

• Pt consented to be examined today
• Lumbar flexion in standing limited by stiffness pain
• Lumbar extension in standing moderately limited >> stiffness pain
• Left and right rotation/ side bending both limited due to localized pain on the lower end of spine and burning
• pain on Right Gluteus referred to groin .
• Straight leg raise on right = 40 refers pain to gluteal + groin , left = 90
• Able to stand up on tiptoes and heels
• Not able squat single leg= bilateral , due to gluteal burning pain and Rt groin ?
• Mild Swelling big toe and tender toes.
• Tender on palpation : mid buttock ++ , no groin tenderness., tender SIJ > lumbar spine Rt side.

Impression of the clinical diagnosis: Chronic lower back pain with degenerative lumbar arthritis , traumatic disc bulge and nerve root irritation at L3 level.

Deferential diagnosis:

• Hip arthritis
• Traumatic Gluteal tendinopathy
• Spondyloarthropathy sacroiliac joint

Summary of discussions and management plan:

• Which of the signs and symptoms will I place on my priority list?
• What kind of common and less common problems need to be excluded?
• How will I address these in my management plan?

Management  plan and follow up and outcomes for management plan  :

With share decision making :

• Will send patient to Further diagnostics plan which is MRI with STIR for degenerative disc arthritis  +/-nerve impingement L3-4 Vs Spondyloarthropathy sacroiliac joint.

MRI with STIR useful for assessing soft tissues ? Inflammatory dishoarded .

• Will Request further bloods : Include Anti-CCP  HLA-B27 .
• If the outcomes are not correlated to the clinical presentation will request hip and pelvic X-ray + Big toe X-ray.

Outcomes :

• MRI scan showed multiple levels of Lx degenerative arthritis of L3-4-5 with narrowing foramina L3-4> L5, SIJ Spondyloarthropathy.

Treatment plan discussion with shared decision making :

Discussed the MRI scan report and nature of the inflammatory disorder and correlation with clinical presentation , explained the potentials treatment conservative approaches as exercises NSAIDs , safe cold/ warm application , healthy diet Vs invasive procedure as cortisone injection and  Discussed risk and benefit

With shared decision making :

Pt is happy to continue with her private physiotherapy and NSAIDs and booked Follow up in 8 weeks  till received the Bloods results .

With follow up appointment:   Pt reported no improvement with her early stiffness and mid night pain and bloods shows positive  HLA-B27  and anti-CCP.

I have referd her to Rheumatology referral to be seen by the Rheumatology consultant for advanced plan treatn and injection discussion.

I have liaised with rheumatology team and they reported  that she  had 2 sessions of  HumiraSIJ injection and the localized burning pain, stiffness pain,  swelling big toe almost have resolved.  Sciatica pain has controlled but not disappeared.

Outcomes learning to be covered in the assignment

Domain 1

Demonstrate advanced use of interpersonal and communication skills during the history taking, physical examination, reassessment, and management of individuals, including all documentation e.g. consideration of verbal and non-verbal communication, adapting to individual preferences, cognitive and sensory impairment, and language needs. Avoids jargon and negative assumptions.

Demonstrate an advanced level of effective, direct, person-centred approach to practice, responding and rapidly adapting the assessment and intervention to the emerging information and the patient’s perspective e.g. enabling individuals to make and prioritise decisions about their care, exploring risks, benefits, and consequences of options on their MSK condition and life, such as paid/unpaid work, including doing nothing.

 

Demonstrate comprehensive knowledge of indications, contraindications, effects, and side-effects of therapeutic drugs, understanding local and national formularies, resources, NICE guidelines, and policies related to their use in the examination and management of MSK conditions e.g. analgesics, non-steroidal and anti-inflammatory drugs, corticosteroid, and drugs used in treating individuals with metabolic bone disease, gout, inflammatory arthritis, and in the management of persistent pain.

 

Domain 2

Demonstrate advanced application of comprehensive knowledge of the examination and management of individuals with MSK conditions e.g. able to assess and manage commonly seen patterns and syndromes and the causes to which they relate: joint, bone pain, muscle pain and weakness, systemic extra-skeletal problems related to trauma, degenerative, neoplastic, developmental/congenital, and psychological causes etc.

 

Demonstrate an advanced level of critical and evaluative collection of clinical information to ensure reliability and validity, ensuring concise and accurate documentation for clinical management, and in accordance with local protocols, legal and professional requirements.

Domain 3

Demonstrate sensitivity and specificity of handling in the implementation and instruction of individuals in appropriate therapeutic rehabilitation exercise programmes e.g. graded return to normal activity, modifying activity advice and programmes.

 

Demonstrate adaptability of knowledge of MSK management and rehabilitation in the context of person centred practice.

Demonstrate criticality of evidence-informed practice in the application of knowledge of MSK management and rehabilitation, in the context of person-centred care.

Domains 4

Demonstrate a critical and evaluative approach to all aspects of advanced practice

 

Demonstrate adaptability of comprehensive knowledge of biomedical sciences in the context of person-centred practice.

Demonstrate an advanced level of sensitivity to changes in an individual’s behaviour.

"Demonstrate critical awareness of the central role of communication skills in the development of advanced

Demonstrate a critical understanding of the key role of person-centred complex clinical reasoning skills in all aspects of advanced clinical practice.

 Demonstrate critical awareness of public health strategies and guidelines on the promotion of wellness

 Demonstrate an advanced level of learning through critical reflection during and after the clinical encounter.