Patient-Friendly Summary of the ACR Appropriateness Criteria: Inflammatory Back Pain: Known or Suspected Axial Spondyloarthritis

Background:Axial spondyloarthritis (axSpA) is associated with inflammatory bowel disease (IBD). In IBD patients, the clinical probability of axSpA increases in those with chronic back pain (CBP) whose symptoms started before the age of forty-five years old. In practice, this should trigger a rheumatology review especially if accompanied by other symptoms suspicious of inflammatory disease. However, in any health system, the goal of identifying all possible cases need to be balanced with the practical realisation of the finite resources available.Objectives:The study aimed to define the clinical characteristics of a subgroup of IBD patients who are routinely managed in secondary care who have an increased clinical probability for axSpA. Identification of these characteristics may help improve the quality and specificity of referrals to Rheumatology from Gastroenterology clinics.Methods:An analytical cross-sectional study was undertaken. Consecutive IBD patients attending routine Gastroenterology clinics were sent a modified validated back pain questionnaire. The questionnaire included the presence or absence of a previous diagnosis of axSpA; components of validated inflammatory back pain criteria; diagrams to indicate the location of back pain and other musculoskeletal pain; personal and family history of known axSpA manifestations; and details of their IBD course, activity and treatment.IBD patients, with back pain duration > 3 months with onset before 45 years were considered to have a medium diagnostic probability (MDP) for axSpA. MDP-positive IBD patients were compared with MDP-negative IBD patients and logistic regression was used to model the association with clinical features.Results:Four hundred and seventy consecutive IBD patients (mean age 54 years; 46% male) were surveyed. Two hundred and nine patients (59%) replied, of whom 191 patients (69%) consented to participate. One hundred and seventy-three (91%) of those who consented had a valid completed questionnaire and were included for data analysis. Of these, 74% had Ulcerative Colitis and 26% had Crohn’s disease. Their mean age was 58 years, 39% male. Mean age at IBD diagnosis was 39 years, mean IBD disease duration 19 yrs. CBP (back pain greater than three months) was reported by 76%. Inflammatory back pain fulfilling Calin, Berlin, ASAS criteria was seen in 23%, 29%, and 15% respectively. In addition, 80% reported peripheral musculoskeletal pain. Self-reported personal history of enthesitis, reactive arthritis (ReA), acute anterior uveitis (AAU), skin psoriasis (PSO) and dactylitis were 50%, 30%, 24%, 15% and 0% respectively. Self-reported family history of IBD, ReA, PSO, axSpA and AAU were 60%, 36%, 22%, 11%, and 1% respectively.Ninety-one (53%) patients were MDP-positive and 82 (47%) patients were MDP-negative. The clinical characteristics associated with MDP (adjusted for age at invitation) were: the presence of inflammatory back pain using ASAS criteria [OR 8.84 (1.61,48.67); p=0.01], longer interval between symptom onset and gastroenterologist diagnosis of IBD [OR 1.09 (1.03,1.16); p=0.005], and use of rectal topical 5-aminosalicylic acid [OR 3.27 (1.11,9.68); p=0.03].Conclusion:Chronic back pain and peripheral musculoskeletal pain are common in a secondary care IBD population. In IBD patients, with back pain duration > 3 months and onset before 45 years, the presence of inflammatory back pain, longer diagnostic delay of IBD and the use of rectal topical 5-aminosalicylic acid were associated with a higher clinical probability of axSpA. The identification of these clinical features may not only improve the quality and specificity of Rheumatology referrals from Gastroenterology in this subgroup of patients but also lends real world evidence to current ASAS-endorsed recommendations for early referral of patients with a suspicion of axial spondyloarthritis.Disclosure of Interests:Chong Seng Edwin Lim Grant/research support from: AbbVie - Research support/grant but NOT for this study., Mark Tremelling: None declared, Louise Hamilton: None declared, Alexander Macgregor: None declared, Karl Gaffney Grant/research support from: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Consultant of: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Speakers bureau: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma

Download Full-text

Comorbid pain in axial spondyloarthritis, including fibromyalgia

Therapeutic Advances in Musculoskeletal Disease ◽

10.1177/1759720x20966123 ◽

2020 ◽

Vol 12 ◽

pp. 1759720X2096612

Author(s):

Clementina López-Medina ◽

Anna Moltó

Keyword(s):

Back Pain ◽

Vertebral Fractures ◽

Structural Damage ◽

Axial Spondyloarthritis ◽

Inflammatory Diseases ◽

Correct Diagnosis ◽

Degenerative Changes ◽

Inflammatory Back Pain ◽

Management Options ◽

Biomechanical Stress

The main symptom in patients with axial spondyloarthritis (axSpA) is inflammatory back pain, caused principally by inflammation of the sacroiliac joints and the spine. However, not all back pain in patients with axSpA is related to active inflammation: other types of pain can occur in these patients, and may be related to structural damage (e.g. ankylosis), degenerative changes, vertebral fractures or comorbid fibromyalgia, which are not uncommon in these patients. Structural damage and ankylosis may lead to a biomechanical stress, which can lead to chronic mechanical pain; and degenerative changes of the spine may also exist in patients with axSpA also leading to mechanical pain. Osteoporosis is more prevalent in axSpA patients than in the general population, and vertebral fractures may result in acute bone pain, which can persist for several months. Fibromyalgia, which is also more prevalent in patients with chronic inflammatory diseases (including axSpA), presents with widespread pain which can mimic entheseal pain. A correct diagnosis of the origin of the pain is crucial, since treatments and management may differ considerably. Recognizing these causes of pain may be a challenge in clinical practice, especially for fibromyalgia, which can coexist with axSpA and may have a significant impact on biologic drug response. In this review, we provide an update of the most common causes of pain other than inflammatory back pain in axSpA patients, and we discuss the latest management options for such causes.

Download Full-text

OP0002 EARLY INFLAMMATORY BACK PAIN SERVICE – REDUCING TIME TO DIAGNOSIS IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS – THE FIRST 8 YEARS

10.1136/annrheumdis-2019-eular.4909 ◽

2019 ◽

Author(s):

Rebecca Adshead ◽

Hasan Tahir ◽

Philippa Knight ◽

Simon Donnelly

Keyword(s):

Back Pain ◽

Axial Spondyloarthritis ◽

Inflammatory Back Pain ◽

Time To Diagnosis

Download Full-text

Identifying patients with axial spondyloarthritis in primary care: how useful are items indicative of inflammatory back pain?

Annals of the Rheumatic Diseases ◽

10.1136/ard.2011.151167 ◽

2011 ◽

Vol 70 (10) ◽

pp. 1782-1787 ◽

Cited By ~ 72

Author(s):

A Braun ◽

E Saracbasi ◽

J Grifka ◽

J Schnitker ◽

J Braun

Keyword(s):

Primary Care ◽

Back Pain ◽

Chronic Back Pain ◽

Axial Spondyloarthritis ◽

Age At Onset ◽

Inflammatory Back Pain ◽

Single Item ◽

Inflammatory Drugs ◽

Waking Up ◽

Key Questions

BackgroundThe value of clinical items defining inflammatory back pain to identify patients with axial spondyloarthritis (SpA) in primary care is unclear.ObjectiveTo identify predictive clinical parameters for a diagnosis of axial SpA in patients with chronic back pain presenting in primary care.MethodsConsecutive patients aged <45 years (n=950) with back pain for >2 months who presented to orthopaedic surgeons (n=143) were randomised based on four key questions for referral to rheumatologists (n=36) for diagnosis.ResultsThe rheumatologists saw 322 representative patients (mean age 36 years, 50% female, median duration of back pain 30 months). 113 patients (35%) were diagnosed as axial SpA (62% HLA B27+), 47 (15%) as ankylosing spondylitis (AS) and 66 (21%) as axial non-radiographic SpA (nrSpA). Age at onset ≤35 years, improvement by exercise, improvement with non-steroidal anti-inflammatory drugs, waking up in the second half of the night and alternating buttock pain were identified as most relevant for diagnosing axial SpA by multiple regression analysis. Differences between AS and nrSpA were detected. No single item was predictive, but ≥3 items proved useful for good sensitivity and specificity by receiver operating characteristic modelling.ConclusionThis study shows that a preselection in primary care of patients with back pain based on a combination of clinical items is useful to facilitate the diagnosis of axial SpA.

Download Full-text

ACR Appropriateness Criteria® on Low Back Pain

Journal of the American College of Radiology ◽

10.1016/j.jacr.2009.02.008 ◽

2009 ◽

Vol 6 (6) ◽

pp. 401-407 ◽

Cited By ~ 57

Author(s):

Patricia C. Davis ◽

Franz J. Wippold ◽

James A. Brunberg ◽

Rebecca S. Cornelius ◽

Robert L. De La Paz ◽

...

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Low Back ◽

Appropriateness Criteria ◽

Acr Appropriateness Criteria

Download Full-text

General Practitioners’ Perceptions of Their Ability to Identify and Refer Patients with Suspected Axial Spondyloarthritis: A Qualitative Study

The Journal of Rheumatology ◽

10.3899/jrheum.131293 ◽

2014 ◽

Vol 41 (5) ◽

pp. 897-901 ◽

Cited By ~ 10

Author(s):

Marloes van Onna ◽

Simone Gorter ◽

Aniek van Meerendonk ◽

Astrid van Tubergen

Keyword(s):

Back Pain ◽

Qualitative Study ◽

General Practitioners ◽

Chronic Back Pain ◽

Axial Spondyloarthritis ◽

Inflammatory Back Pain ◽

Coding System ◽

Disease Spectrum ◽

Insidious Onset ◽

Mechanical Back Pain

Objective.To explore the knowledge, beliefs, and experiences of general practitioners (GP) about inflammatory back pain (IBP) and axial spondyloarthritis (axSpA) and potential barriers for referral of patients suspected of having axSpA.Methods.A qualitative study involving semistructured interviews with GP was conducted. Transcripts of the interviews were independently read and annotated by 2 readers. Illustrative themes were identified and a coding system to categorize the data was developed.Results.Ten GP (all men; mean age 49 yrs) were interviewed. All could adequately describe “classic” ankylosing spondylitis (AS) and mentioned chronic back pain and/or stiffness as key features. All GP thought that AS is almost exclusively diagnosed in men. Six GP knew that there is a difference between mechanical back pain and IBP, but could recall only a limited number of variables indicative of IBP, such as awakening night pain (4 GP), insidious onset of back pain (1 GP), improvement with movement (1 GP), and (morning) stiffness (2 GP). Two GP mentioned peripheral arthritis as other SpA features, none mentioned dactylitis or enthesitis. GP awareness of associated extraarticular manifestations was low. Most GP expressed that (practical) referral measures would be useful.Conclusion.GP are aware of “classic”, but longterm features of axSpA. Knowledge about the disease spectrum and early detection is, however, limited. Addressing these issues in training programs may improve recognition of axSpA in primary care. This may ultimately contribute to earlier referral, diagnosis, and initiation of effective treatment in patients with axSpA.

Download Full-text

Inflammatory back pain

10.1093/med/9780198755296.003.0006 ◽

2016 ◽

Author(s):

Stefan Siebert ◽

Sengupta Raj ◽

Alexander Tsoukas

Keyword(s):

Back Pain ◽

Axial Spondyloarthritis ◽

Morning Stiffness ◽

Early Morning ◽

Inflammatory Back Pain ◽

Spinal Disease ◽

Buttock Pain ◽

Common Features ◽

Gradual Onset ◽

Pain Improvement

Inflammatory back pain (IBP) refers to a collection of symptoms that may help identify patients with possible inflammatory spinal disease. A number of criteria sets have been proposed for IBP, which share common features such as: onset of symptoms aged <40 years, alternating buttock pain, improvement with exercise, worsening with rest, gradual onset, early morning stiffness, and improvement with NSAIDs. The IBP criteria were initially developed and validated in patients with ankylosing spondylitis, but have subsequently been shown to perform similarly in patients with axial spondyloarthritis (axSpA). The Berlin criteria demonstrated the highest specificity (84%) and the Calin criteria the highest sensitivity (92%). IBP criteria have been used in primary and secondary care referral strategies to facilitate the identification of patients with potential axSpA. It is important to note that IBP does not equate to a diagnosis of axSpA and many patients with IBP will not have axSpA.

Download Full-text

The epidemiology of ankylosing spondylitis, axial spondyloarthritis, and back pain

10.1093/med/9780198755296.003.0003 ◽

2016 ◽

Author(s):

Stefan Siebert ◽

Sengupta Raj ◽

Alexander Tsoukas

Keyword(s):

Back Pain ◽

Ankylosing Spondylitis ◽

Axial Spondyloarthritis ◽

Epidemiological Studies ◽

Population Based ◽

Inflammatory Back Pain ◽

True Incidence ◽

Primary Care Population ◽

Prevalence Estimates ◽

History Of

Low back pain is a leading cause of disability worldwide. The prevalence of inflammatory back pain (IBP) has been calculated to be in the range 8–15% in a UK primary care population and 5–7% in a US population-based cohort. IBP rates are significantly higher in patients with psoriasis, uveitis, or inflammatory bowel disease than the general population. There is a paucity of good epidemiological studies to define the true incidence and prevalence of ankylosing spondylitis (AS), axial spondyloarthritis (axSpA), and spondyloarthritis (SpA), with wide variation as a result of geographic, demographic and methodological factors. The global prevalence estimates range from 0.01–0.2% for AS, to 0.32–0.7% for axSpA and around 1% for SpA overall. The global incidence estimates range from 0.44–7.3 cases per 100,000 person-years for AS to 0.48–62.5 cases per 100,000 person-years in SpA. The demographics and natural history of disease progression are also discussed.

Download Full-text

P271 An analysis of short-term repeat MRI scans of vertebral corner lesions in suspected early axSpA: defining the prevalence and evolution of clinically significant spinal lesions without concurrent SIJ changes on imaging

Rheumatology ◽

10.1093/rheumatology/keaa111.264 ◽

2020 ◽

Vol 59 (Supplement_2) ◽

Author(s):

Saion Chatterjee ◽

Helena Marzo-Ortega ◽

Dennis McGonagle ◽

Alexander N Bennett ◽

Raj Sengupta

Keyword(s):

Back Pain ◽

Axial Spondyloarthritis ◽

De Novo ◽

Current Evidence ◽

Inflammatory Back Pain ◽

Short Term ◽

Spinal Imaging ◽

Asas Criteria ◽

Mri Scans

Abstract Background MRI offers an enhanced opportunity to detect early spinal changes of axial spondyloarthritis (axSpA), by identifying characteristic inflammatory and structural lesions, so called Romanus lesions. These include bone marrow oedema lesions on the vertebral corners and fatty replacement of these lesions, both highly suggestive features of axSpA. Current evidence suggests that treatment of these lesions requires early biologic therapy, hence early identification is imperative. We evaluate the prevalence and variation of vertebral corner lesions on short-term repeat MRI scans in patients with suspected early axSpA. Methods 109 MRI scans were performed at baseline and at 4, 8 and 12-weeks on 30 patients with suspected axial spondyloarthritis, who fulfilled the ASAS inflammatory back pain criteria, and had normal sacroiliac joints (SIJs) on antero-posterior pelvis radiographs. The protocol included sagittal T1 and short-tau inversion recovery of the cervico-thoracic spine and thoracolumbar spine. Results 29 patients completed the study (66% were male, 72% HLA-B2-positive). All patients had ≥1 clinical spondyloarthritis (SpA) feature and 86% had ≥2. 13 patients used NSAIDs regularly over the 12-week study period. Overall, 40 corner lesions were present in participants at baseline scanning. 67 new vertebral corner lesion changes occurred at different time points over the follow-up period compared to baseline. 43 changes were new or worsening lesions, while 24 changes were an improvement or resolution of a lesion. 48.6% (14/29) of patients had a minimum of 1 corner lesion present at baseline. 78.5% (11/14) of patients with baseline corner lesions experienced either a decrease/improvement or increase/progression of spinal corner lesions. 20.7% (6/29) of patients demonstrated transient corner lesions at baseline or follow-up with resolution by the 12-week scan (likely artefact). 5/29 patients met spinal imaging criteria suggestive of AS (3 at baseline, 1 only transiently at 1 month, and 1 which persisted from interval scanning). At 12-weeks, 13.8% of patients had at least 3 concomitant baseline or de-novo vertebral corner lesions present (minimum number needed for diagnostic significance). 75% of these patients did not have evidence of concomitant SIJ changes (10.3% of all patients). HLA-B27 status, gender, NSAID use, and number of SpA features were not associated with corner lesion development or improvement. Conclusion Approximately half of all patients who meet ASAS criteria for inflammatory back pain, but do not meet ASAS criteria for axSpA, demonstrated at least 1 vertebral corner lesion on MRI scan at baseline, which may represent artefact or a prelude to future disease progression. 13.8% of patients had at least 3 concomitant baseline or de-novo vertebral corner lesions present on MRI at the conclusion of 12-weeks of follow-up. In cases of suspected axSpA with negative SIJ MRI imaging, 10.3% of patients had significant spinal evidence of axSpA on MRI, highlighting the importance of spinal imaging and monitoring as part of the diagnostic work-up for axSpA. Disclosures S. Chatterjee None. H. Marzo-Ortega None. D. McGonagle None. A. Bennett None. R. Sengupta None.

Download Full-text