Abstract
Background
Axial spondyloarthritis (axSpA) is an inflammatory disease underlying around 5% of back pain presentations. It is essential that physiotherapists screen for possible axSpA and know when to refer to rheumatology. In the UK, diagnostic delays of 5-8.5 years are common. Challenges with differentiating axSpA from non-specific low back pain and poor awareness of features of axSpA that should prompt rheumatology referral may be contributing factors. Early intervention is important and NICE guidance on back pain and sciatica (2016), spondyloarthritis (2017) and the National Back and Radicular Pain Pathway (2017) aim to support better screening and earlier diagnosis. This study aimed to explore physiotherapistś awareness, knowledge and confidence in screening for and recognising signs, symptoms and risk factors of suspected axSpA and criteria for rheumatology referral.
Methods
An online survey of UK musculoskeletal physiotherapists was undertaken combining a multi-vignette design (axSpA, non-specific low back pain and radiculopathy) and questioning on awareness, knowledge and confidence in screening for axSpA. Distribution included online professional networks, special interest groups, social media and snowballing. Data analysis used descriptive statistics and conceptual content analysis for free text responses.
Results
One hundred and thirty-two surveys were analysed. Vignette analysis found only 67% of respondents (n=88/132) indicated inflammatory pathologies as a possible cause of persistent back pain. Only 60% (79/132) of respondents identified the vignette with features suspicious of axSpA compared to the vignettes of non-specific low back pain (94%) and radiculopathy (80%). Most respondents (92%, n=73/79) who correctly identified the axSpA vignette appropriately indicated referral to rheumatology. Demonstrating a ‘full awareness’ or ‘good awareness’ of NICE guidance (2017) referral criteria for axSpA was only evident within 50% of ‘clinical reasoning’ responses, and only within 20% of responses describing their approach to ‘further subjective screening’. Importance of features raising suspicion of axSpA was rated highest for family history of inflammatory arthritis (median=9/10) and least for male gender (median=5/10). Considerable importance was given to CRP, ESR and HLAB27 positivity (median=8/10). Despite expressing confidence (≥7/10) in recognising features of possible axSpA, a significant number failed to identify the axSpA vignette. Better awareness and knowledge of axSpA was associated with greater familiarity with the NICE guidance on spondyloarthritis and previous education on SpA.
Conclusion
The study suggests that physiotherapists may not be giving adequate consideration to possible axSpA in the differential diagnosis of persistent low back pain. Although certain features of SpA were better recognised, a significant lack of awareness and knowledge of signs, symptoms and risk factors for suspected axSpA was found. Awareness of criteria for referral to rheumatology was also limited. The consequences for diagnostic delay are significant and indicate the need for professional education and applying guidance to improve screening and earlier recognition.
Axial spondyloarthritis (axSpA) is an inflammatory disease underlying around 5% of back pain presentations. It is essential that physiotherapists screen for possible axSpA and know when to refer to rheumatology. In the UK, diagnostic delays of 5-8.5 years are common. Challenges with differentiating axSpA from non-specific low back pain and poor awareness of features of axSpA that should prompt rheumatology referral may be contributing factors. Early intervention is important and NICE guidance on back pain and sciatica (2016), spondyloarthritis (2017) and the National Back and Radicular Pain Pathway (2017) aim to support better screening and earlier diagnosis. This study aimed to explore physiotherapistś awareness, knowledge and confidence in screening for and recognising signs, symptoms and risk factors of suspected axSpA and criteria for rheumatology referral.
Methods
An online survey of UK musculoskeletal physiotherapists was undertaken combining a multi-vignette design (axSpA, non-specific low back pain and radiculopathy) and questioning on awareness, knowledge and confidence in screening for axSpA. Distribution included online professional networks, special interest groups, social media and snowballing. Data analysis used descriptive statistics and conceptual content analysis for free text responses.
Results
One hundred and thirty-two surveys were analysed. Vignette analysis found only 67% of respondents (n=88/132) indicated inflammatory pathologies as a possible cause of persistent back pain. Only 60% (79/132) of respondents identified the vignette with features suspicious of axSpA compared to the vignettes of non-specific low back pain (94%) and radiculopathy (80%). Most respondents (92%, n=73/79) who correctly identified the axSpA vignette appropriately indicated referral to rheumatology. Demonstrating a ‘full awareness’ or ‘good awareness’ of NICE guidance (2017) referral criteria for axSpA was only evident within 50% of ‘clinical reasoning’ responses, and only within 20% of responses describing their approach to ‘further subjective screening’. Importance of features raising suspicion of axSpA was rated highest for family history of inflammatory arthritis (median=9/10) and least for male gender (median=5/10). Considerable importance was given to CRP, ESR and HLAB27 positivity (median=8/10). Despite expressing confidence (≥7/10) in recognising features of possible axSpA, a significant number failed to identify the axSpA vignette. Better awareness and knowledge of axSpA was associated with greater familiarity with the NICE guidance on spondyloarthritis and previous education on SpA.
Conclusion
The study suggests that physiotherapists may not be giving adequate consideration to possible axSpA in the differential diagnosis of persistent low back pain. Although certain features of SpA were better recognised, a significant lack of awareness and knowledge of signs, symptoms and risk factors for suspected axSpA was found. Awareness of criteria for referral to rheumatology was also limited. The consequences for diagnostic delay are significant and indicate the need for professional education and applying guidance to improve screening and earlier recognition.
| Original language | English |
|---|---|
| Number of pages | 2 |
| Journal | Rheumatology |
| Volume | 59 |
| DOIs | |
| Publication status | Published - 20 Apr 2020 |