Using Tree Branches to understand Inflammatory Back Pain

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By Dr Irwin Lim, Rheumatologist

If you present with back pain to your GP, your physiotherapist, your chiropractor, your osteopath, your kinesiologist, your acupuncturist, your massage therapist, etc…….chances are that they’ll try to ask questions and examine you to rule out worrying causes of back pain.

Causes such as compression of the nerve roots. Or even fracture or an occult tumour. Thankfully, these occur infrequently.

Most back pain is then treated as being non-specific.

This means that the health practitioner cannot be absolutely certain of the cause. It’s assumed to be due to a mechanical or degenerative problem, usually due to some strained ligament/tendon/muscle. And in many cases, this is the correct assumption.

The cause which is often missed or overlooked is Inflammatory Back Pain (read here about the distinction between inflammatory vs mechanical pain).

Part of the reason is that this is a difficult type of pain to understand and the terms used to classify inflammatory-type back pain are confusing.

The natural history of this type of back pain is also not clearly worked out.

How many people with inflammatory-type back pain progress to developed Axial Spondyloarthritis?

How many with non-radiographic Axial Spondyloarthritis (what does this term even mean! Read about it here) eventually progress to get damage on their X-rays and get diagnosed with Ankylosing Spondylitis?

I think these graphics help:

from: Unanswered questions in the management of axial spondyloarthritis: by Xenofon Baraliakos & Atul Deodhar.
from: Unanswered questions in the management of axial spondyloarthritis: by Xenofon Baraliakos & Atul Deodhar.
from Unanswered questions in the management of axial spondyloarthritis: by Xenofon Baraliakos & Atul Deodhar

from Unanswered questions in the management of axial spondyloarthritis: by Xenofon Baraliakos & Atul Deodhar

You can access the original article at:  http://link.springer.com/article/10.1007%2Fs10067-014-2740-x

Thanks to my friends, Drs Phil Robinson & Sam Whittle for pointing me towards this tree. I’ll be using it in a talk or two to help others understand Inflammatory Back Pain.

Does this tree make it clearer for you?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
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WHAT-ology?

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By Dr Irwin Lim, Rheumatologist

Thanks to my friend and colleague, Sam Whittle (@samwhittle), for taking this picture.

What-ology

I find myself increasingly trying to advocate for a higher profile for Rheumatologists.

While this may sound self-serving, and it probably is, there’s other good reasons.

Rheumatology is not a sexy speciality.

Regular folk don’t understand what we actually treat. When they hear that we deal with arthritis, various aches and pains, and autoimmune disease, some are interested but others politely change the topic.

Some go on to tell us about their painful bunion or that dicky knee.

Arthritis is not a high profile topic. It does not tug at the heartstrings in the same way cancer or diseases affecting children do.

You may be surprised to know that many doctors also don’t understand the breadth of conditions rheumatologists treat or the depth of our diagnostic and therapeutic skill.

Rheumatology as a specialty is not as lucrative as procedural specialties such as cardiology or surgery so many younger training doctors are also not looking at it as a career option.

With health systems tightening their budgets everywhere, an outpatient based speciality like rheumatology seems to be slowly being squeezed out of public hospitals in Australia. Given most training of doctors still occurs in hospital, this lack of visibility and lack of mentors for young doctors at a time they are making career choices is troubling.

We need more visibility. More exposure. The limelight.

We need to inspire the next generation of physicians. We need to educate and advocate, directed at both the public and our colleagues.

I believe that a higher profile for rheumatologists is a crucial step in improving the situation for our patients. It will help with quicker diagnosis, better access, more funding.

I’m not sure you agree but I’ll be interested in your thoughts.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
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Spondyloarthritis Word Soup

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By Dr Irwin Lim, Rheumatologist

I’m welcoming delegates to a meeting tonight. We’re going to be talking about Spondyloarthritis.

Spondyloarthritis has always been confusing. Is it a group describing related diseases or a single disease entity leading to a variety of different manifestations? (click here to read about a particular patient history highlighting this)

Messy. Complicated. Lots of labels used to describe kind-of-the-same thing.

I wanted to convey this in a graphic way so I chose some word art.

Wordle SpA

I then wanted to convey that the last decade has seen attempts to improve our scientific understanding, our ability to treat, and our ways to classify this/these disease/s. Here’s the 2nd graphic:

Wordle SpA Ordered

It’s an exciting time for us in rheumatology. With improved knowledge and the strong will being shown, we will tidy up this area, meaning better outcomes for patients.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
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How to treat a ganglion cyst

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By Dr Irwin Lim, Rheumatologist

You may have one of these. A firm lump near a bony area, usually the wrists or around the foot or ankle.

The lump’s really quite firm and over time, it becomes less easy to compress. It can grow in size and occasionally, particularly after some trauma, it may become smaller and resolve.

Ganglion Cysts are not dangerous.

They can be removed surgically but most patients want to avoid surgery so these often come to our attention. Usually, when they become uncomfortable or annoying.

These pictures show one way to treat them.

Ganglion1

The cyst is punctured with a larger-bore needle (I usually make 2 punctures, using a 19G needle).

The fluid which is usually thick like jelly or toothpaste, can then be squeezed out.

Ganglion2

If it’s too thick to squeeze out, doctors may inject some cortisone (steroid).

It’s generally a satisfying procedure for both patient and doctor.

Have you had a ganglion cysts? How was it treated?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
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Don’t Turn Your Back On It: 2 months into the campaign

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By Dr Irwin Lim, Rheumatologist

Trying to improve disease awareness is hard work, potentially unrewarding and frustrating. So, any attempt at a public awareness campaign is approached with a degree of hope and trepidation.

I’ve written about the Don’t Turn Your Back On It campaign (read Who’s Got Your Back? & The Back Cave).

It’ a campaign designed to get young males (and yes, I know females are affected to) with chronic back pain to visit a website where they’ll answer a few key questions to determine if they have Inflammatory Back Pain.

Inflammatory Back Pain Symptom Screener

Inflammatory Back Pain Symptom Screener

 

Having Inflammatory back pain may mean that the diagnosis is spondyloarthritis / ankylosing spondylitis so determining this is a key stepping stone to a correct diagnosis.

This campaign, supported by Abbvie (a pharmaceutical company), Arthritis & Osteoporosis NSW, a number of allied health professionals, rheumatologists and patient advocates has just entered its 3rd month.

I thought it worth sharing some milestones achieved:

  •  ~14,000 visits to the campaign website
  •  >3,300 positive screener results (approx. 38% of total screener submissions)
  • ~300 positive screener recipients electing to receive further information

An important part of the campaign involved attempting to engage GPs:

  • GP postcard mailer distributed to ~4,000 GPs in our state, New South Wales
  • The Back Pain Maze poster placed in ~900 GP waiting rooms
  • ~700 AS GP Fact sheets downloaded through an online portal

Traditional media & social media highlights include:

  • Media articles in >19 publications (mainly local community papers)
  • 113 Media clippings generated – including radio snippets, and national TV coverage (A Current Affair, estimated audience of 1 million viewers – watch “Michael Slater Reveals Secret Illness“)
  • >700 website visits from Facebook & Twitter

It’s encouraging. A good start. We hope there’ll be more interest and that we can keep the ball rolling.

Please help if you can. Share the links so we can get more people with chronic back pain screened, and hopefully, reduce the delay for some in getting the correct diagnosis.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
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