As musculoskeletal experts managing patients with chronic back pain, physiotherapists are critical in helping to reduce the unacceptable 8.5-year average delay to diagnosis in axial spondyloarthritis (axial SpA).
Approximately 5% of patients presenting in physiotherapy clinical practice with chronic back pain will have inflammatory back pain and may require referral to rheumatology. However, not all patients eventually diagnosed with axial SpA will fit a textbook definition of axial SpA, and presentation of symptoms can be highly variable from patient to patient.
Claire Jeffries is a Physiotherapy Clinical Specialist in Hydrotherapy and Rheumatology for The Solent NHS Trust and Chair of AStretch: a national committee of physiotherapists with a special interest in axial spondyloarthritis. Below, Claire presents her top tips for recognising axial SpA early and referring to rheumatology.
Although axial SpA is associated with inflammatory back pain, some patients with axial SpA may present with mechanical sounding pain: including lower back pain, radiating buttock pain, or sometimes even thigh pain anterior or posterior to the knee. It is therefore important to enquire about prior episodes of back pain, as often axial SpA patients will experience multiple episodes of back pain which come and go or are eased with NSAIDs. This could be mistaken for a natural healing process associated with mechanical back pain, when in fact it could be intermittent episodes of flare or inflammation.
A good indication of inflammatory back pain is night pain or waking in the second half of the night due to pain, whereby patients are then unable to get back to sleep. Many patients with axial SpA describe being disturbed in the night due to pain, thereby needing to get up and walk around in the night or take painkillers in order to go back to sleep. Asking about sleep can therefore give a good indication of the nature of the back pain. Similarly, presentations of alternating buttock pain should always raise suspicion of an inflammatory condition.
Many patients with inflammatory back pain will respond well to NSAIDs. Prior NSAID response can therefore be indicative of inflammatory back pain. If appropriate, you may need to guide your patients to seek GP review to consider a course of NSAIDs if they have not previously tried them.
Axial SpA is associated with a range of extra-articular manifestations, or EAMs, including acute anterior uveitis, psoriasis, and inflammatory bowel disease (ulcerative colitis and Crohn’s disease) – conditions associated with the eyes, skin, and bowels, respectively. Dactylitis and enthesitis are also EAMs of axial SpA. Presence or prior bouts/ history of these conditions could indicate that a patient’s back pain is more likely to be inflammatory or axial SpA related. For example, history of a one off knee effusion, episode of uveitis or a previous gastrointestinal infection may all prove important information for you & raise your level of suspicion.
As there may be a family link in axial SpA, ascertaining if anyone in your patients’ immediate family circle has had axial SpA, inflammatory back pain or any of the EAMs mentioned above could prove to be important information. If yes, this could raise the probability of your patients’ symptoms being inflammatory in nature.
Historically, axial SpA was considered a predominantly male disease, likely due to the fact that radiographic axial SpA, or ankylosing spondylitis, is more common in males. However, with the advent of MRI to identify earlier inflammatory changes, we now know that non-radiographic axial SpA is just as common in females. It is therefore important to move away from just thinking of axial SpA solely as ankylosing spondylitis, identified by X-ray changes to the spine, and instead consider the wider net of people with non-radiographic axial spondyloarthritis also. These patients may present with a variety of symptoms – but the key feature is chronic back pain with onset aged <45 years.
The SPADE tool is a quick and easy resource that can help you determine whether referral to rheumatology is necessary, based on present symptoms. Visit our page on the SPADE tool. Being aware of NICE guidance is also critical.
It is really important that you understand the appropriate pathways to rheumatology services in your area, as this may vary depending on where you are in the UK. Contact, reach out and link with your local rheumatology services. It will always prove really helpful if you can gain advice and guidance from the rheumatology consultant or local rheumatology team on any suspicious cases. Also, find out what they do/do not like physiotherapists to do and their expectations for referral. For example, blood tests can help build up a clinical picture of potential axial SpA. However, some rheumatology services may prefer that you refer directly to rheumatology, without performing any further tests or investigations in primary care, e.g. blood tests for HLA-B27, CRP or ESR, which are not diagnostic for axial SpA, but may help with determining your index of suspicion of axial SpA*.
For information, advice and to join a community of people who live with the condition visit the NASS website. Or visit our helpline.
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