van Onna M, Gorter S, Maiburg B, Waagenaar G, van Tubergen A. Education improves referral of patients suspected of having spondyloarthritis by general practitioners: a study with unannounced standardised patients in daily practice. RMD open. 2015;1(1):e000152-e. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4623373/
68 participants (30 GPs and 38 GP residents) were included, of which 19 received education on SpA. A significantly higher proportion of GPs from the intervention group referred patients to the rheumatologist compared with the control group after education. Furthermore, for the intervention group, following education on SpA symptoms there was an >40% improvement in referral for axial and peripheral SpA from GPs. This work suggests that educational initiatives to improve referral and recognition of patients suspected for SpA should be developed and supported.
Adizie T, Elamanchi S, Prabu A, Pace AV, Laxminarayan R, Barkham N. Knowledge of features of inflammatory back pain in primary care in the West Midlands: a cross-sectional survey in the United Kingdom. Rheumatology International. 2018;38(10):1859-63. https://link.springer.com/article/10.1007%2Fs00296-018-4058-5
Large scale observational study of 141 GPs. Demonstrated a lack of confidence of GPs in differentiating inflammatory back pain, with most (87%) reporting seeing patients 3 times before attempting to make a diagnosis of inflammatory back pain. Just 5% rated themselves as “very confident” at discriminating inflammatory back pain. 64% were not aware of their existing local specialist axial SpA service. Most agreed that inflammatory back pain patients should be referred to a rheumatologist (95%) with a minority suggesting orthopaedics (5%). GPs felt their diagnostic skills could be improved by practical sessions (57%), referral pathways (69%) and electronic updates (24%), with teaching meetings (77%) preferred to digital forms of education (30%).
Al-Attar M, Gregory WJ, Mcbeth J, Dixon W. POS0980 ANALYSIS OF PRIMARY CARE CONSULTATION PATTERNS TO AID DIAGNOSIS OF AXIAL SPONDYLOARTHRITIS – AN EXPLORATORY CASE SERIES. Annals of the Rheumatic Diseases. 2021;80(Suppl 1):757 https://ard.bmj.com/content/80/Suppl_1/757 (EULAR 2021 ABSTRACT)
Preliminary exploratory analysis of unique EHR dataset of Salford axial SpA patients. Followed the journey of 10 patients with time to diagnosis of axial SpA ≥ 5 years. On average, patients had 15 primary care consultations (range 5-24) between first coded Axial SpA-related symptom and rheumatology referral. The abstract includes an illustration of the consultation pattern for a male patient who first presented to primary care with back pain at the age of 35. Despite a relatively typical presentation, his diagnosis was made incidentally 10 years later after an ESR was checked for unrelated reasons. He was significantly disabled in function at the point of being referred to rheumatology.
McCrum C, Kenyon K, Cleaton J, Dudley T. An unrecognised masquerader: a retrospective review of people presenting to musculoskeletal physiotherapy with undiagnosed spondyloarthritis. Physiotherapy. 2019;105:e102-e3. https://www.physiotherapyjournal.com/article/S0031-9406(18)30423-1/abstract
Demonstrated the importance of physiotherapists in early recognition and referral of axial SpA. Exploration of 263 people (age 17- 69 years) diagnosed with spondyloarthritis during the period 1990 – 2016, who had received outpatient physiotherapy care prior to their diagnosis. Average time from initial physiotherapy visit to diagnosis with SpA was 6.4 years. The most common clinical diagnostic codes assigned to these episodes of care included back pain (49.6%), shoulder (11.1%), knee (8.5%), neck (7.7%), ankle/foot (4.3%), tendonitis (4.2%), joint pain (3.4%), osteoarthritis (3.4%) and sacroiliac joint (2%). 44% received 3 or more physiotherapy episodes prior to diagnosis – number of contacts within each episode ranging from 3 (47 people) to 58 (1 person), a median of 11 contacts per episode (10 people).
Steen E, McCrum C, Cairns M. Physiotherapists’ awareness, knowledge and confidence in screening and referral of suspected axial spondyloarthritis: A survey of UK clinical practice. Musculoskeletal Care. 2021 https://doi.org/10.1002/msc.1537
Suggested that musculoskeletal physiotherapists may not be giving adequate consideration to axial SpA in back pain assessments. Awareness of national referral guidance was also limited. 132 survey responses were analysed. Only 67% (88/132) of respondents identified inflammatory pathologies as a possible cause of persistent back pain. Only 60% (79/132) recognised the axial SpA vignette compared to non-specific low back pain (94%) and radicular syndrome (80%). Most suspecting axial SpA would refer for specialist assessment (77/79; 92%). Awareness of national referral guidance was evident in only 50% of ‘clinical reasoning’ and 20% of ‘further subjective screening’ responses. There was misplaced confidence in recognising clinical features of axial SpA compared to knowledge levels shown, including high importance given to inflammatory markers and HLA-B27. Good awareness of the NICE 2017 guidance on SpA and continued professional development was associated with better awareness and knowledge of axial SpA features. Professional education on screening and referral for suspected axial SpA is needed to make axial SpA screening and referral criteria core knowledge in musculoskeletal clinical practice, to support earlier diagnosis and better outcomes for patients.
Osteopath & chiropractor services
Yong CY, Hamilton J, Benepal J, Griffiths K, Clark ZE, Rush A, et al. Awareness of axial spondyloarthritis among chiropractors and osteopaths: findings from a UK Web-based survey. Rheumatology advances in practice. 2019;3(2):rkz034-rkz. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6785804/
Large web-based survey of 237 chiropractors and 145 osteopaths demonstrated that although overall knowledge of ankylosing spondylitis is good among chiropractors and osteopaths, the term axial SpA is poorly understood. Specific learning needs include gender preponderance, awareness of acute anterior uveitis and the availability of biological therapies. There is lack of confidence in the onward referral process to rheumatology via the GP. Only 63% and 25% were familiar with the terms axial SpA and non-radiographic axial SpA, respectively. Only 29% recognized that axial SpA was common in women. Seventy-seven per cent were confident with inflammatory back pain. Respondents routinely asked about IBD (91%), psoriasis (81%), acute anterior uveitis (49%), peripheral arthritis (71%), genitourinary/gut infection (56%), enthesitis (30%) and dactylitis (20%). Forty-three per cent were confident with the process of onward referral to rheumatology via the GP. The principal perceived barrier to onward referral was reluctance by the GP to accept their professional opinion.