Additional papers of interest

Additional papers of interest

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Axial spondyloarthritis 10 years on: still looking for the lost tribe. Rheumatology.

Barnett R, Ingram T, Sengupta R. Axial spondyloarthritis 10 years on: still looking for the lost tribe. Rheumatology. 2020;59(Supplement_4):iv25-iv37. https://doi.org/10.1093/rheumatology/keaa472

Despite the publication of various recommendations, quality standards and referral strategies to promote early diagnosis in axial SpA over the last decade, there remains a significant delay to diagnosis, leading to a lost tribe of undiagnosed, untreated patients with persistent back pain and axial SpA symptoms. This review discusses the various factors contributing to diagnostic delay in axial SpA, while providing recommendations to improve the diagnostic pathway, for example use of the online Spondyloarthritis Diagnosis Evaluation (SPADE) tool (http://www.spadetool.co.uk/). Significant shortcomings exist at both the primary and secondary care level, with healthcare professionals often lacking knowledge and awareness of axial SpA. Myths regarding the classical signs and symptoms still prevail, including the perception of axial SpA as a male disease, only occurring in individuals who are HLA-B27 positive with raised inflammatory markers. Individuals within this lost tribe of undiagnosed patients are likely lacking adequate treatment and are thereby at risk of worse clinical outcomes. It is therefore vital that public health initiatives are implemented to improve education of healthcare professionals and to ensure early specialist referral, to ultimately improve the lives of patients with axial SpA.

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The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection.

Rudwaleit M, van der Heijde D, Landewe R, Listing J, Akkoc N, Brandt J, et al. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis. 2009;68(6):777-83. https://ard.bmj.com/content/68/6/777

It is important to note that, as discussed above, such classification criteria are not intended for use in diagnosis – the primary objective of classification criteria is to identify a homogenous population for clinical trials and research, whereby patients are similar in terms of clinical characteristics. However, the 2009 Assessment of Spondyloarthritis International Society (ASAS) classification criteria were seminal in that they formally recognised the concept of nr-axial SpA – placing emphasis on early disease and use of MRI to identify early inflammatory changes, to allow for earlier detection of patients with the condition and inclusion of patients with nr-axial SpA in clinical trials.

Symptoms starting slowly

Pain in the lower back

Improves with movement

Night time waking

Early onset (under 40)