Axial spondyloarthritis (SpA) within the advanced practitioner musculoskeletal physiotherapy scope.
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
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.
Past medical history
Chronic back pain
Irritable bowel syndrome
Gluten allergies
Reiter's syndrome
Diagnostics results:
Objective examination/ Physical examination and findings.
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Objective examination/ Physical examination and findings.
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:
Summary of discussions and management plan:
Management plan and follow up and outcomes for management plan :
With share decision making :
MRI with STIR useful for assessing soft tissues ? Inflammatory dishoarded .
Outcomes :
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 patientâs 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.
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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.
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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.
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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.
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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
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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 individualâs 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.