Case 1
Nadine is a 51 year-old mother of 3. She is also expecting her 1st granddaughter.
She first met her rheumatologist after a 20-year history of spinal pain. Nadine described pain from her neck to her tailbone. The pain was present all the time and would even wake her up from sleep. She often found it then difficult to go back to sleep.
She also described marked early morning stiffness. While this used to improve once she started to walk around, this now persisted most of the day.
Her father did have similar spinal restriction and she seemed to remember that he was quite stooped. Her son is starting to develop back pain.
Over the years, she had been treated with chiropracty and had been prescribed anti-inflammatory medication by a number of doctors. She no longer drives and avoids lifting due to the pain. Sitting in a plane or a longer car trip can cause her to be crippled with pain.
In addition to the spinal pain, she has had intermittent pain at the elbows, wrist, ankles and most recently, the knees. At times, there has been swelling of the joints with reduced movement.
On examination, she had very restricted movements of the neck, the thoracic spine and her lumbar spine. Her ability to expand her chest was reduced. She was tender at the sacroiliac joints.
The X-ray of her sacroiliac joints did show grade 2 sacroiliitis on both sides. The genetic test, HLA-B27 was found to be positive and the blood tests also showed raised inflammatory markers.
The work up and testing showed that she was a good candidate for TNF-inhibitor therapy. She was commenced on TNF-inhibitor therapy a few months ago and has noticed much reduced pain and stiffness at the spine. Her other joint pains have resolved.
Now, Nadine only takes anti-inflammatory medication occasionally. Her spinal movements, while better, remain quite restricted. It is now crucial for her to exercise, and with the help of her physiotherapist, she is enrolled in a program to improve her lumbar spine flexibility and to improve her general fitness.
Case 2
Greg is 42 years-old. He works as a helicopter pilot and has always kept himself in good shape with exercise. He continues to use the gym 3 times a week.
He first developed back pain after a football injury at school, when he was 17 years-old. Over the years, he has had intermittent low back pain. Usually, these have been precipitated by some sporting injury.
One particular episode, at age 31, was prolonged. He developed more pain at night with right-sided buttock pain with some pain radiating down his right leg. He was diagnosed as having sciatica but an MRI of the lower back did not show any nerve root impingement.
He was then sent to see a rheumatologist. X-rays of the lower back and sacroiliac joints appeared normal. An MRI of the sacroiliac joints showed changes of inflammation suggestive of early sacroiliitis.
Greg’s symptoms were controlled rapidly with anti-inflammatory medication. Greg has tried to cease the anti-inflammatory medication but this always leads to his symptoms flaring. As such, he has had to accept regular use of medication. He continues to exercise regularly.
Case 3
Noah is 32 years-old. At the age of 21, he developed right then left heel pain. This became a chronic problem, unresponsive to physiotherapy, orthotics and cortisone injections.
At age 27, he developed a painful, restricted right shoulder. This was blamed on his work as a builder’s labourer.
At age 28, he developed severe pain at the lower back and at either buttock on different occasions. This pain would often wake him up in the early hours of the morning. He would also suffer with marked stiffness.
Over time, he developed ankle, forefeet and right sternoclavicular joint pain and swelling.
Noah reported symptoms of depression. His relationship with his partner was strained and he avoided social situations.
In the 7 years, he had consulted 4 physiotherapists, 2 family physicians, 2 chiropractors and a naturopath.
When he finally presented to a rheumatologist in 2007, he was very unwell. He had lost 20kg in weight over 18 months, and was overdosing on anti-inflammatory medications just to help him get through his daily activities. He developed abdominal pain with anaemia, probably due to some gastrointestinal bleeding from the high doses of anti-inflammatory medications. His blood tests did show high inflammatory markers with a positive genetic marker, HLA-B27. X-rays of the sacroiliac joints showed grade 3 sacroiliitis.
The diagnosis of ankylosing spondylitis was made. He was started on Methotrexate then Salazopyrin EN with corticosteroids. These did not help.
TNF-inhibitor therapy was commenced in 2008. The response was rapid and dramatic. After 1 week, he noticed much less pain and stiffness, and was soon able to sleep through the night.
After 3 years of disease remission on TNF-inhibitor therapy, he has put on 15kg, and is now working as a fitness trainer. He does not need to take any other medication. He is a much happier person and is enjoying the time with his 5 month-old baby.
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