Recognising axial spondyloarthritis: Advice for chiropractors

Recognising axial spondyloarthritis: Advice for chiropractors

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As musculoskeletal specialists in primary care, chiropractors can play a key role in reducing the unacceptable 8.5-year delay to diagnosis in axial spondyloarthritis (axial SpA).

Jonathan Field is Chair of the Pain Faculty at the Royal College of Chiropractors and Clinical Lead for the Back Active NHS Community Physical Therapy Service in North Hampshire. Below, Jonathan describes how to recognise and refer patients with suspected axial SpA.

For every 100 patients attending their service, Jonathan and his team identify approximately 5 patients who meet the criteria for suspected inflammatory spinal disease. Those individuals at risk are identified using the axial spondyloarthritis referral tool, developed jointly by the Royal College of Chiropractors and the Institute of Osteopathy, in collaboration with NASS. This tool has been validated by the Royal College of GPs and the Chartered Society for Physiotherapy.

The referral tool is available below and is comprised of the following:

 

We recommend reading through the referral template and guidance and utilising this next time a patient presents to you in clinic with chronic back pain.

For more details on how Jonathan and his team identify patients with axial spondyloarthritis in their service, please watch the video above, or read the associated blog below.

 

 

(Referral template developed jointly by the Royal College of Chiropractors and the Institute of Osteopathy, in collaboration with NASS. Endorsed by the Royal College of GPs and the Chartered Society for Physiotherapy)

How we screen for patients with axial spondyloarthritis in clinic

All new patients are asked 5 simple screening questions:

  1. Did the back pain come on gradually, over a period >3 months?
  2. Did the back pain start before the age of 40?
  3. Is the pain not eased with rest, but gets better with activity?
  4. Does the pain wake patients at night?
  5. Are there >30 minutes of significant stiffness on rising first thing in the morning?

 

For those who answer any of these questions positively, we ask an additional 7 questions:

  1. Does the pain come in the buttocks, and alternate from side to side?
  2. Does the patient have enthesitis?
  3. Does the patient have dactylitis?
  4. Is there any family history of spondyloarthritis?
  5. Do they personally have any history of psoriasis?…
  6. Uveitis?…
  7. Or inflammatory bowel disease?

 

If any 3 answers to these questions are positive, we request that the GP perform an HLA-B27 and CRP test*. If 4 or more are positive, we suggest a rheumatology referral is made. We use the template referral letter produced by the Royal College of Chiropractors when writing to the GP, that lays out the guidance and evidence behind the request for the referral: Referral template.

We recommend reading through the referral template and guidance and utilising this next time a patient presents to you in clinic with chronic back pain.

 

*Notes:

  • HLA-B27 is not diagnostic of axial SpA, but a large proportion of people with axial SpA will be positive for this blood test. Approximately 8% of white western Europeans carry this gene, in comparison to 75-90% of individuals with axial SpA. However, only about 1 in 15 people who are HLA-B27 positive go on to develop the condition. Over 100 genes are now thought to be involved in axial SpA, with HLA-B27 believed to be responsible for no more than 25-30% of the genetic risk.
  • Similarly, CRP is not diagnostic of axial SpA. But elevated CRP can be an indicator of inflammation.

 

 

 

Know your axial spondyloarthritis features, ask the appropriate questions, and refer early to rheumatology. This way, we can really help reduce delay to diagnosis in these conditions, to ultimately improve outcomes for our patients.

 

Chronic back pain, age of onset <45 years? Think possible axial spondyloarthritis

Symptoms starting slowly

Pain in the lower back

Improves with movement

Night time waking

Early onset (under 40)