A middle-aged man with chronic low back pain for 3 years with heel pain and abdominal pain for 10 years.

1. Welcome
Dr. Md. Mamunul ABEDIN
Assistant Registrar
Dept. Of Physical Medicine & Rehabilitation
Shaheed Suhrawardy Medical College Hospital

2. “A Middle aged Man
with
Chronic Low Back Pain”

3. Particulars of the patient
▪ Name : Mr. Anisur Rahman
▪ Age : 53 years
▪ Sex : Male
▪ Marital status : Married
▪ Occupation : Service holder
▪ Religion : Islam
▪ Address : Mirpur, Dhaka
▪ Date of Admission : 03.10.2021
▪ Date of Examination : 03.10.2021

4. Presenting Complaints
1. Low back pain for 3 years
2. Pain in left upper thigh & heel for 3 years
3. Lower abdominal pain for 10 years

5. H/O Present Illness
Patient states that he has been suffering from
low back pain for the last 3 years which is
gradual in onset, moderate in intensity, dull
aching in nature, episodic initially but
continuous for the last 6 months, non-
radiating, worse in the morning after waking
from sleep that improves with physical activity

6. or exercises or taking painkillers, associated
with stiffness in the morning for about an hour.
Patient also complaints of pain in the left heel
and in the left upper thigh for the same
duration, which is gradual in onset, sharp
stabbing in character, moderate in severity,
non-radiating, exacerbated after prolonged
H/O Present Illness (contd.)

7. H/O Present Illness (contd.)
sitting & taking initial steps, and relieved after
walking for a while & taking painkillers. He
also complained of mild neck pain occasionally
which is non-radiating. For these pain, he
faces some difficulties in Dressing, Walking,
Stair climbing etc. He also complaints of pain
in the right lower abdomen for the last 10 yrs

8. H/O Present Illness (contd.)
which is dull & diffuse only in that region,
changing intensity from mild to moderate over
the time, coincides with lower back pain for
the last 3 years, not associated with anorexia,
nausea, vomiting, diarrhoea, blood mixed stool
or any alteration of bowel habit. He lost 4 Kg
weight over last 7 months.

9. H/O Present illness (contd.)
He gave no history of trauma, fever, burning
micturition, sexual exposure, painful red eye,
skin lesions, nail changes, oral ulcer, cough,
breathlessness or chest pain. He is non-diabetic
& non-asthmatic, known case of hypertension &
ischemic heart disease.

10. H/O Past Illness
• He has a history of cardiac intervention (PCI)
in October 2020
• He was diagnosed with peptic ulcer disease
in 2019
• H/o Appendicectomy 25 years back

11. Socio-Economic Condition
• Patient belongs to middle socio-economic status
• Monthly income is average 40,000 BDT
• Lives in apartment house & uses sanitary latrine
• Drinks boiled water & takes usual Bangladeshi
diet

12. Personal History
• Working at DOTS corner of a TB hospital in
Dhaka for 26 years
• Non - smoker, non alcoholic
• No habit of chewing betel leaf

13. Psychosocial history
• He is a practicing Muslim, satisfied with
his way of living and quality of life
• Not involved in any kind of litigation

14. Family History
• He is married for 25 yrs with 1 son & 2 daughters
• Has 5 brothers and 2 sisters
• His father died of ischemic stroke
• All other family members are apparently in good
health
• No h/o consanguinity of marriage among parents
• No h/o similar type of illness or tuberculosis
among the first degree relatives

15. Immunization History
Patient is immunized as per EPI schedule
including BCG vaccination.

16. Drug History
• He had taken several painkillers prescribed
by local doctors but those gave only temporary
relief of symptoms without any permanent
remission
• Taken triple therapy for peptic ulcer in 2019
• Currently taking medications for ischemic
cardiac disease & hypertension

17. Clinical Examination

18. General Examination
▪ Appearance : Ill looking, anxious
▪ Body build : Average
▪ Co-operation : Co-operative
▪ Decubitus : On choice
▪ Anaemia : Absent
▪ Jaundice : Absent
▪ Cyanosis : Absent
▪ Oedema : Absent
▪ Dehydration : Absent

19. ▪ Clubbing : Absent
▪ Koilonychias : Absent
▪ Leuconychia : Absent
▪ Lymph nodes : Not Palpable
▪ Neck vein : Not engorged
▪ Thyroid gland : Not enlarged
▪ Nail changes : Absent
▪ Skin : Normal
General Exam (contd.)

20. • Pulse rate : 78 bpm
• Blood pressure : 130/80 mm Hg
• Temperature : 98.6° F
• Respiratory rate: 14/min
• Height : 1.75 m
• Weight : 58 Kg
• BMI : 18.9 Kg/m²
General Exam (contd.)

21. Systemic Examination

22. Locomotor System
Gait : Antalgic
Upper limbs (Arms)
All the joints of upper limbs are normal.
• No visible swelling, deformity and wasting
• No tenderness present over joint line
• Range of motion: Normal

23. Lower Limbs (Legs)
Hip Joints:
-No visible swelling or deformity
-Temperature : Normal
-No tenderness present over any hip joint or
greater trochanter but pain at the end range
of movement at right side
Locomotor System (contd.)

24. Range of Motion:
Right Left Normal
Flexion 115 121 ≥ 1200
Extension 5 17 50- 200
Abduction 30 25 ≥ 400
Adduction 22 25 ≥ 250
Int. rotation 42 41 ≥ 350
Ext. rotation 41 38 ≥ 450
Locomotor System (contd.)

25. Ankle joints:
No swelling, tenderness or deformity
Range of motion:
Other joints of Lower limb: Normal
Right Left Normal
Dorsiflexion 14 15 200
Plantar flexion 46 43 45 - 500
Locomotor System (contd.)

26. Examination of Spine :
Look: Cervical lordosis : Reduced
Lumber lordosis : Normal
No visible swelling, gibbus or deformity
Feel: Diffuse tenderness (Gr-I) over lower
dorsal and upper lumbar region
(midline & paraspinal)
Local temperature : Normal
Step sign : Negative
Locomotor System (contd.)

27. Examination of Spine :
Move:
• Cervical spine : Reduced in all direction
Movement Range of Motion Normal
Flexion 42° 80°
Extension 35° 50°
Lateral flexion
Right 35° 45°
Left 35° 45°
Rotation
Right 52° 80°
Left 62° 80°
Locomotor System (contd.)

28. Examination of Spine :
Move:
• Lumbar spine: Normal ROM
Movement Range of Motion Normal
Flexion 60° 60°
Extension 30° 30°
Lateral flexion
Right 32° 30°
Left 30° 30°
Rotation
Right 42° 40°
Left 40° 40°
Locomotor System (contd.)

29. Examination of Sacroiliac joints :
Right Left
Tenderness - + (Gr- I )
Compression test - -
Distraction test - -
Pump Handle test - -
Gaenslen test - -

30. Cervical Spine
ROM: Flexion
Cervical Spine ROM:
Lateral Rotation
Cervical Spine
ROM: Extension

31. Compression test Distraction Test Gaenslen
test
FABER test Pump Handle test

32. Special Tests
▪ Straight leg raising (SLR) : Right : 80°
Left : 80°
▪ FABER test : + on both side
▪ Spurling Test : Negative
▪ Modified Schober’s test : 6.5 cm
▪ Finger to Floor distance : 3 cm
▪ Tragus to wall distance : 10 cm
▪ Chest expansion : 2.5 cm
Locomotor System (contd.)

33. Examination of Enthesis
▪ Achilles Tendon : Non Tender
▪ Heel : Gr-II tenderness in medial
plantar aspect of left heel
▪ Tibial tubercle : Non Tender
▪ Iliac crest : Non Tender
▪ Ischial tuberosity : Non Tender
▪ Greater trochanter : Non Tender

34. Nervous system Examination :
Higher psychic function : Normal
Gait : Antalgic
Speech : Normal
Signs of Meningeal Irritation : Absent
Cranial nerves : Intact

35. Examination of Motor System :
Bulk of Muscle : Normal
Tone of Muscle : Normal

36. Power of muscles :
Upper Limbs :
Right Left
Shoulder
Abductors 5/5 5/5
Adductors 5/5 5/5
Flexors 5/5 5/5
Extensors 5/5 5/5
Elbow
Flexors 5/5 5/5
Extensors 5/5 5/5
Wrist
Flexors 5/5 5/5
Extensors 5/5 5/5
Examination of Motor System (contd.):

37. Power of muscles :
Lower Limbs :
Right Left
Hip
Abductors 5/5 5/5
Adductors 5/5 5/5
Flexors 5/5 5/5
Extensors 5/5 5/5
Knee
Flexors 5/5 5/5
Extensors 5/5 5/5
Ankle
Dorsiflexors 5/5 5/5
Planterflexors 5/5 5/5
Examination of Motor System (contd.):

38. Deep Tendon Reflexes :
Biceps Triceps Supinator Knee Ankle
Right Normal Normal Normal Normal Normal
Left Normal Normal Normal Normal Normal
Examination of Motor System (contd.):

39. Plantar Reflex : Flexor bilaterally
Hoffmann’s reflex : Negative bilaterally
Clonus : Absent
Coordination :
Romberg’s sign : (-)
Finger-nose test : normal
Heel-shin test : normal
Rapid alternating movements : normal
Examination of Motor System (contd.):

40. • Pain : normal
• Touch : normal
• Temperature : normal
• Vibration : normal
• Joint position sense : normal
• Two point discrimination : normal
• Point localization : normal
Examination of Sensory System:

41. Inspection : Shape: normal
Chest movement: bilaterally
symmetrical
Palpation : Tracheal position: normal
Chest expansion: 2.5 cm
Vocal fremitus: normal
Percussion : Resonant
Auscultation : Breath sound: vesicular
Vocal resonance: normal
Examination of Respiratory System:

42. Lips, gums, teeth: normal
Tongue: normal
Inspection:
-An oblique scar mark at right iliac fossa
-No other abnormalities detected
Examination of Alimentary System:

43. Palpation:
-Tenderness (Gr-II) present in right iliac fossa
on deep palpation
-Liver: not enlarged
-Spleen: not palpable
-Kidneys: not ballotable
Examination of Alimentary System:

44. Percussion: no abnormality detected
Auscultation: no abnormality detected
Per-rectal examination:
Inspection: Normal
Digital Rectal Examination: no abnormality
detected
Examination of Alimentary System:

45. • Cardiovascular system
• Genitourinary system
Examination of these systems revealed no
apparent abnormality
Examination of Other Systems:

46. Functional Examination:
Ambulation He faces difficulty in walking, stair
climbing etc.
Transfer Can transfer to toilet chair & shower
without assistance
Dressing Skill Can put on and take off clothes of
his upper body but difficulty putting
on socks & shoes
Eating Skill No difficulties
Personal
Hygiene
No difficulties
Communication No difficulties
Pain Score (Visual Analogue Scale): 6/10

47. Mr. Anisur Rahman, 53 yrs, male, muslim,
service holder, hypertensive, non-diabetic, non-
asthmatic hailing from Mirpur, Dhaka presented
with moderate pain in the lower back region for
the last 3 years, gradual in onset, localized dull
aching, episodic initially but continuous for the
last 6 months, worse in the morning after
Salient Features

48. waking from sleep that improves with physical
activities or taking painkillers, and associated
with stiffness in the morning for about an hour.
He has inflammatory pain in the left heel & upper
thigh, and mild, non-radiating occasional neck
pain for the same duration. He has pain in his
right lower abdomen for the last 10 years which is
Salient Features (contd.)

49. dull & diffuse, changing intensity from mild to
moderate over the time, coincides with low back
pain for the last 3 years, not associated with
anorexia, nausea, vomiting, diarrhea, blood mixed
stool or any alteration of bowel habit. He lost 4 kg
weight over the last 7 months. He gave no history
of trauma, fever, burning micturition, sexual
Salient Features (contd.)

50. exposure, painful red eye, skin lesions, nail
changes, oral ulcer, cough, breathlessness or
chest pain. He had cardiac intervention last year,
peptic ulcer disease in 2019 and had appendicec-
tomy 25 years back. Though patient works in
DOTS corner of a TB hospital, no such history of
Tuberculosis of his own or in his family members.
Salient Features (contd.)

51. On examination, Patient is ill looking and
anxious with stable vital signs. His gait is
antalgic; Grade-I tenderness over lower dorsal,
upper lumbar in midline & paraspinal area, and
left SI joint; Grade-II tenderness over medial
plantar aspect of the left heel. He has limited
movement of cervical spine in all direction but
Salient Features (contd.)

52. normal ROM in lumbar region. Painful restriction
of flexion, extension, abduction & adduction in
right hip joint, and abduction & external rotation
in left hip joint. FABER test is positive on both
sides. Chest expansion is reduced (2.5cm). There
is an oblique scar mark over the right ileac fossa
and grade-II tenderness over that area on deep
Salient Features (contd.)

53. palpation. All other systemic examination reveals
no abnormality. His Pain Score in Visual
Analogue Scale is 6/10. Due to these conditions,
he faces difficulties in walking, stair climbing,
putting on socks & shoes etc.
Salient Features (contd.)

54. ?
PROVISIONAL DIAGNOSIS

55. Provisional diagnosis
Enteropathic Spondyloarthropathy
with IHD with HTN

56. Differential diagnosis
• Ankylosing Spondylitis with Intestinal Tuberculosis
• Disseminated Tuberculosis
• Abdominal Malignancy with Skeletal Metastasis
• Degenerative Joint Disease with Plantar Fasciitis
- with IHD with HTN

57. Investigations:
Investigation Result
CBC As on 09.09.2021
Hb% 12.9 gm/dl
ESR 90 mm
TC 5,800/cmm
Platelet 1,95,000/cmm
PCV 34.7%
S. Creatinine 0.87 mg/dL
Urine R/M/E Normal
Blood sugar (Random) 6.1 mmol/L
CRP Negative, 3.2 mg/L

58. Investigation Result
SGPT 20.8 u/L
Alkaline Phosphatase 88 u/L
S. Bilirubin 0.54 mg/dL
HBsAg Negative
Anti-HCV Negative
Anti-HIV Negative
VDRL Non reactive
HLA B27 Positive
MT 22 mm at the end of 72 hours
Investigations (contd.) :

59. Investigation Result Normal
QuantiFERON-TB Gold Plus (QFT-Plus) 30.09.2021
TB1 Ag 2.25 IU/mL 0.35 IU/mL
TB2 Ag 2.12 IU/mL 0.35 IU/mL
Investigations (contd.) :

60. CXR P/A view

61. USG of Whole Abdomen
As on 10.10.2021
Impression: Normal Study

62. Plain X-RAY L/S SPINE (B/View)

63. Plain X-ray Both SI joint (oblique view)
Left SI Joint
Right SI Joint
Left sided
sacroiliitis
Grade II

64. Plain X-ray Cervical Spine (Both view)

65. Investigation Result (as on 13.04.2019)
Upper G.I. Tract
Endoscopy
Pre-pyloric complete erosion
compatible with pre-pyloric
G.U.
Colonoscopy Terminal Ileal Ulcers
Investigations (contd.) :

66. Investigation HISTOPATHOLOGY
Microscopic
features
Ileal mucosa presenting ulceration
covered by inflammatory exudate.
Predominant inflammatory cells are
polymorphs, lymphocytes & plasma
cells. The deeper zone shows dense
lymphocytic infiltrates with few
germinal follicles and moderate
fibrosis.
No granuloma or dysplasia is seen.
Diagnosis Infectious Ileitis
Investigations (contd.) :

67. Investigations (contd.) :
Colonoscopy
(18.10.2021)
Second Degree
Hemorrhoids,
otherwise
Normal Findings

68. MRI of Both SI joint

69. MRI of Both SI joint

70. MRI of Both SI joint

71. USG of Both SI joint
Signs of Synovitis in both SI joint

72. USG of Both Hip joint
Rt Hip Lt Hip
Mild effusion in right hip joint

73. USG of Both Heel
Rt Heel Lt Heel
Left plantar fascia is mildly swollen.

74. USG of Both Heel
Lt Heel
Lt Tendo Achilles
Rt Tendo Achilles
Left tendo Achilles is mildly swollen.

75. MRI of L/S
spine

76. MRI of L/S
spine

77. MRI of L/S
spine

78. Future Plan of Investigation
– S.PSA, CEA
– Fecal Calprotectin
– MRI of Abdomen

79. Confirmatory Diagnosis
Enteropathic Spondyloarthritis
with Latent TB
with IHD with HTN

80. Functional Assessment
Tools Score
BASFI 0.4
BASDAI 4.6
BAS-G 3.5

81. Management
Objectives:
• To relieve pain
• To mobilize the affected joints
• To minimize deformity
• To improve quality of life

82. • Non-Pharmacological
• Pharmacological
Management (contd.)

83. Non-Pharmacological
• Patient education
• Exercises
• Physical Therapy

84. Patient Education
• Nature of the disease
• Prognosis
• Treatment options
• Importance of exercises

85. Exercises
• Spine mobilizing exercises
– NASS guideline
• Aerobic exercises
– Swimming, Cycling, Walking
• Deep Breathing exercises

89. Pharmacological Management
• Tab. Sulfasalazine (2000 mg daily) on divided dose
• Cap. Omeprazole 20mg 1 cap bid

90. Future Plan
• To Start Anti-TB regimen
• Vaccination
• Consider Biologics

93. Modified New York Criteria,1984

94. BASFI (Bath AS Functional Index)
• To determine the degree of functional limitation
in a patient with AS.
• It comprises 10 questions which are answered
with a visual analogue scale with 0 being easy
and 10 being impossible.
• The mean of the ten scales gives the BASFI score
a value between 0 to 10.

95. BASFI (Contd.)
1.Putting on your socks or tights without help or aids.
(eg. sock aid)?
2. Bending forward from the waist to pick up a pen
from the floor without an aid?
3. Reaching up to a thigh shelf without help or aids
(eg. Helping hand)?
4.Getting out of an arm-less during chair without
using your hands or any help?
5. Getting up of the floor without help from lying on
your back?

96. 6. Standing unsupported for ten minutes without
discomfort?
7. Climbing 12-15 steps without using a handrail
or walking aid?
8. Looking over your shoulder without turning
your body?
9. Doing physically demanding activities?
10. Doing a full day’s activities at home or at work?
BASFI (Contd.)

97. BASDAI
(Bath AS Disease Activity Index)
• To determine the effectiveness of current drug
therapy or the need to institute a new drug therapy
for the treatment of AS.
• It comprises 6 questions related to the five major
symptoms of AS.
• 0 to 10 measuring scale where 0 being no problem
and 10 being worst

98. BASDAI (Contd.)
• Mean of the two scores of morning stiffness is
taken. In case of duration of morning stiffness 0
hour is score 0, 1 hour is score 5 and 2 or more is
score 10.
• Score 4 or more indicates suboptimal disease
control.

99. BASDAI
(Bath AS Disease Activity Index)
1. How would you describe the overall level of fatigue/
tiredness?
2. How would you describe the overall level of AS
neck, back or hip pain you have had?
3. How would you describe the overall level of pain/
swelling in joints other than neck,back or hips you
have had?

100. BASDAI (Contd.)
4. How would you describe the overall level of
discomfort you have had from any areas tender to
touch or pressure.
5. How would you describe the overall level of
discomfort you have had from the time you wake up?
6.How long does your morning stiffness last from the
time you wake up?

101. BAS-G
(Bath AS Patient Global Score)
• To monitor the well being of patient with AS.
• On a 0 to 10 measuring scale where 0 is no effect
on well being and 10 is very severe.
• Differences in scores = previous score – current
score (minimum difference is –10 and maximum
difference is + 10)
• A negative difference indicates deterioration and a
positive difference indicates improvement.

102. BAS-G
(Bath As Patient Global Score)
1. How have you been over the last week?
2. How have you been over the last six
month?

103. ACR Recommendations 2015
Strongly recommend
- Treatment with NSAIDs
- Use of TNFi with active AS despite Rx with NSAIDs
- Against Rx with systemic glucocorticoids
- Use of Physical Therapy
Conditionally recommend
- Against Rx with DMARDs
- Rx with DMARDs in adults with active AS despite Rx
with NSAIDs & who have contraindications to TNFi