Features Of Inflammatory Back Pain Research Articles

Awareness and knowledge of the common features of inflammatory back pain among primary care physicians in the western region of Saudi Arabia.

Often, there is a delay in the diagnosis of inflammatory back pain (IBP) in the primary care setting. This may be attributed to the inability of healthcare providers to distinguish between inflammatory and mechanical back pain. This study aimed to evaluate primary care physicians' current practices for assessing patients with IBP using clinical, radiographic, and laboratory tests. A questionnaire-based survey was emailed to all primary care physicians in the western region of Saudi Arabia by the Saudi Commission of Health Specialists from February to May 2021. The questionnaire included data about axial spondyloarthropathy based on the Calin, Berlin, and European Spondyloarthropathy Study Group criteria. A total of 103 primary care physicians responded who represented around 24% of primary care physicians at primary healthcare. The most often perceived IBP symptoms include a response to NSAIDs, morning stiffness lasting >30 minutes, age of onset <45 years old, duration of back pain >3 months, and improvement with exercise. The most frequently questioned patient or family history conditions were peripheral arthritis (92.2%), family history of spondyloarthritis (83.5%), and inflammatory bowel disease (97.6%). The most-reported investigations were CRP/ESR (86.4%) and spinal radiography (66%). For treatment of IBP, NSAIDs were most prescribed (48.6%), followed by physiotherapy (45.6%) and disease-modifying anti-rheumatic drugs (41.7%). Primary care physicians were more confident in management of mechanical back pain than IBP (P < .001). Primary care physicians have good knowledge of IBP symptoms but not of disease-specific features and modest confidence in evaluating patients with IBP, indicating the need for educational programs and a more effective, feasible referral strategy.

O21 Unrecognised inflammatory back pain: a retrospective review of people presenting to musculoskeletal physiotherapy with undiagnosed axSpA

Abstract Background Axial spondyloarthritis (axSpA) is commonly mistaken as chronic mechanical back pain. Delayed diagnosis averages 5-8 years with impacts on effective and timely management, outcomes and quality of life. Research on diagnostic delay suggests that a lack of recognition of inflammatory back pain and possible axSpA has been a contributing factor. Published referral criteria including NICE guidance (2017) and quality standards (2018) on spondyloarthritis in over-16s highlight the importance of earlier diagnosis and were developed to support earlier recognition and referral of suspected axSpA in primary care settings. This aim of this study was to investigate the occurrence of referral for musculoskeletal physiotherapy care and treatment prior to diagnosis of axSpA and to evaluate levels of recognition. Methods A retrospective review was undertaken of all patients diagnosed with axSpA who had been referred to and received physiotherapy care within nine physiotherapy services prior to diagnosis (1990-2016). Unrecognised axSpA was taken as the individual referred for and receiving three or more episodes of physiotherapy prior to diagnosis. Data was obtained on assigned diagnostic codes, number of episodes of physiotherapy care and contacts per episode. Results Two hundred and sixty three (263) people diagnosed with axSpA (age range 17-69 years) had been referred by a GP and received physiotherapy care prior to their diagnosis. Within this axSpA population, 103 (44%) had received 3 or more musculoskeletal physiotherapy assessments and episodes of care. Number of treatment contacts within each care episode ranged from 3 (47 people) to 58 contacts (1 person) [median=11 contacts-10 people]. Average time from initial physiotherapy care episode to date of diagnosis was 6.4 years (range=0.3-12.8 years, median=8.8 years). The most common assigned diagnostic code was back pain (49.6%), followed by 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%). Analysis indicates that in nearly half of individuals who came to be diagnosed with axSpA, features of inflammatory back pain and possible axSpA were not recognised on at least six or more assessment occasions by either referrers or treating clinicians. Conclusion This study illustrates the extent of unrecognised axial spondyloarthritis referred to and missed in musculoskeletal clinical practice. This lack of recognition highlights the importance of professional education on signs, symptoms and risk factors for axSpA to support earlier diagnosis and treatment. Screening for and recognition of inflammatory back pain and other features for when to suspect and refer for possible axSpA in assessments of people with back pain need to be part of routine musculoskeletal clinical practice. Further research into contributors to diagnostic delay and the most effective education strategies to support earlier recognition of axSpA is needed. Disclosures C. McCrum: Honoraria; Novartis. K. Kenyon None. J. Cleaton None.

Association between inflammatory back pain features, acute and structural sacroiliitis on MRI, and the diagnosis of spondyloarthritis.

To evaluate the association between inflammatory back pain (IBP) features, acute and structural MRI findings suggestive of sacroiliitis, and diagnosis of spondyloarthritis (SpA). Data from 224 patients who underwent MRI for suspected sacroiliitis (2005-2015) was retrospectively reviewed by an expert rheumatologist for the presence of IBP features and for clinical standard of reference diagnosis. A telephone questionnaire was performed in cases of missing data. Acute and structural MRI parameters were scored by an experienced radiologist for the presence of sacroiliitis using the Assessment of Spondyloarthritis International Society (ASAS) criteria, Berlin score, and observer's global impression (GI) scores. Association between IBP features and MRI scores, and odds ratio for SpA diagnosis, were calculated. One hundred ninety-three subjects were included (119 F:74 M, mean age 39.7 ± 15.6, mean follow-up 49 ± 18months). Fifty-two (26.9%) subjects were diagnosed with SpA. IBP scores were significantly higher in SpA patients (p < 0.001). IBP, ASAS, and GI MRI scores were significantly associated with the SpA diagnosis (p < 0.001 for all). The presence of night pain and morning stiffness was significantly associated with sacroiliac-joints' bone marrow edema (BME, p < 0.05). Sensitivity for diagnosis of SpA was high for IBP (96%) and low for the MRI parameters (26.9-57.4%), and specificity was low for IBP (32%) and high for the MRI parameters (88.3-94.3%). The presence of IBP features is highly associated with diagnosis of SpA and correlates with MRI BME, all probably reflect inflammation. The combination of IBP and MRI should be the cornerstone in the clinician's final diagnosis of SpA.

Knowledge of features of inflammatory back pain in primary care in the West Midlands: a cross-sectional survey in the United Kingdom.

There is a relative lack of confidence among GPs in the assessment and management of IBP vs. mechanical back pain. A simple screening tool for SpA, applicable in primary care urgently needs to be developed. It is reasonable for patients with symptoms suggestive of inflammatory back pain to be referred to secondary care without further investigations. The objective of this study was to assess current practice of our local general practitioners (GPs) in using clinical features, as well as radiological and laboratory investigations to assess patients with IBP. An online, observational questionnaire-based survey was done in 10 West Midlands CCGs including disparate geographical and socioeconomic areas. The survey consisted of 23 questions based on Calin, Berlin and ESSG Criteria for spondyloarthropathies. GPs were asked to rate the importance of a range of symptoms as indications of IBP IBP (10 point scale, range 1-10), and what their views were on which were the most important treatments for patients with suspected inflammatory back pain(4 point scale, range 1-4). The 4 most important symptoms for predicting inflammatory back pain according to our local cohort of GPs were 'morning stiffness' 'sleep disturbances caused by back pain' 'insidious onset' and 'age of onset' < 45. Among the treatment options, NSAIDs were ranked as the most important treatment option for IBP. DMARDS were rated as the next most important treatment option, ahead of physiotherapy and anti-TNF therapy. This study has highlighted relative lack of confidence among GPs in the assessment of IBP. Whether this reflects a need for education or poor performance of these questions in primary care populations requires further study.

041 Knowledge of Features of Inflammatory Back Pain in Primary Care in West Midlands: A Cross-Sectional Survey

041 Knowledge of Features of Inflammatory Back Pain in Primary Care in West Midlands: A Cross-Sectional Survey

Advances in managing ankylosing spondylitis.

Ankylosing spondylitis (AS) is a chronic inflammatory disease with prominent involvement of the spine and sacroiliac joints which frequently leads to significant spine deformity and disability. The development of effective therapies for AS, particularly with anti-tumor necrosis factor agents, has resulted in improved symptoms and functions for many patients, and clinical research increasingly suggests that effective therapy can also prevent destruction in the spine and other structures. Recent focus of disease classification in AS has emphasized that many individuals with features of inflammatory back pain but no visible changes on plain x-rays have active inflammatory disease when imaged with magnetic resonance imaging (MRI). Recent studies indicate that individuals with “non-radiographic” spondylitis can also respond to anti-inflammatory therapies. Several new agents are also showing promise for treatment of AS. These developments represent a significant advance in the management of this debilitating condition.

FRI0122 Evaluation of the Two-Step Referral Strategy for Axial Spondyloarthritis in the Spondyloarthritis Caught Early Cohort

BackgroundCurrently, in primary care no satisfactory referral model exists for referral to the rheumatologist of patients with chronic back pain (CBP) with possible axial spondyloarthritis (axSpA). Recently, a non-invasive, inexpensive...

Large vessel vasculitis and spondyloarthritis: coincidence or associated diseases?

Introduction: Although cardiac complications have been reported in established spondyloarthritis (SpA), little is known about peripheral axial SpA in large vessel vasculitis (LVV). The aim of this study was to assess the prevalence of SpA in patients with newly diagnosed LVV.Method: Retrospective single-centre analysis of all newly diagnosed LVV patients was performed between January 2011 and December 2012. Vasculitides were confirmed on thoracic magnetic resonance imaging (MRI) or 18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT). Patients completed a standardized questionnaire incorporating the Berlin criteria to assess inflammatory back pain. Existing scans were reassessed for sacroiliitis and ferritin antibodies measured in all patients.Results: Fifteen patients exhibiting new LVV were identified. Diagnosis was confirmed using MRI in nine patients and FDG-PET/CT in six. Six patients (40%) fulfilled American College of Rheumatology (ACR) criteria for giant cell arteritis (GCA) and polymyalgia rheumatica (PMR), and nine PMR only. Four patients fulfilled the Berlin criteria for inflammatory back pain, with three demonstrating sacroiliitis on imaging. All remaining patients demonstrated no sacroiliitis. One further patient with LVV lacking features of inflammatory back pain had known psoriatic arthritis (PsA). Patients with coexisting SpA were younger (mean age 57 years vs. 66 years) and had higher C-reactive protein (CRP) levels (200 mg/L vs. 85 mg/L) at presentation. Four SpA patients and seven out of nine patients with isolated LVV had ferritin antibodies.Conclusions: We have demonstrated a higher than anticipated prevalence of SpA in LVV, given the reported 0.5–1% prevalence in the general population. Coexisting SpA should be considered in LVV patients exhibiting inflammatory back pain despite steroid initiation. Ferritin antibodies demonstrated a similarly high prevalence in aortitis and SpA as reported previously in untreated GCA and PMR.

FRI0350 Large vessel vasculitis and sacroiliitis: coincidence or associated diseases?

BackgroundCoexisting large vessel vasculitis has previously been reported in cases of established spondyloarthritis (SpA) (1-3). The prevalence of sacroiliitis or peripheral SpA among patients with large vessel vasculitis is however...

A case of axial undifferentiated spondyloarthritis diagnosis and management

A 32-year-old white man presented with features of inflammatory back pain, including awakening at night and morning stiffness. He had acute back pain 4 years earlier as a result of a herniated lumbar disc. The orthopedic consultation included tests for neurologic deficits; a Lasègue test; a finger-to-floor distance test; X-rays of the lumbar spine; and MRI of the lumbar spine. The rheumatologic consultation included recordal of clinical history and family history; physical examination, including a Schober's test, lateral spine flexion, chest expansion, cervical rotation, and tragus-to-wall distance; blood tests, including genotyping for human leukocyte antigen B27 positivity, and measurements of C-reactive protein level and erythrocyte sedimentation rate; MRI of the sacroiliac joints with use of short tau inversion recovery sequences; and measurement of the Bath Ankylosing Spondylitis Disease Activity Index and the Bath Ankylosing Spondylitis Functional Index. Axial undifferentiated spondyloarthritis. NSAIDs and physiotherapy.