The crucial role of early recognition in axial spondyloarthritis

The term axial SpA encompasses both ankylosing spondylitis (AS) or radiographic axial SpA (r-axial SpA), where clear structural changes to the spine can be observed via x-ray, and non-radiographic axial spondyloarthritis (nr-axial SpA) which is diagnosed from other clinical features and using magnetic resonance imaging.  85 – 90% of people with axial SpA carry the HLA-B27 gene. 

Other extra musculoskeletal manifestations (EMMs) can include;

•              Acute anterior uveitis (inflammation of eyes)
•              Psoriasis
•              Inflammatory bowel disease (IBD) – Crohn’s/ulcerative colitis.
•              Enthesitis
•              Dactylitis

Axial SpA is estimated to affect 1 in 200 adults in the UK, symptoms usually start in teenage years, and early 20’s (average onset of 26 years).  Affecting both men and women equally, it is no longer seen as a male disease.  Men with axial SpA show a higher rate of radiological progression whereas nr-axial SpA is more prevalent in women. Women generally have higher disease activity scores and more peripheral manifestations (enthesitis, IBD, psoriasis and peripheral arthritis).

The current UK time to diagnosis averages 8.5 years from symptom onset.  A delayed diagnosis can be extremely debilitating. People with delayed diagnosis may suffer from a less favourable response to treatment and worse outcomes in disease activity, fatigue, function, spinal mobility and radiographic damage to the spine. These individuals also experience difficulty sleeping and have a higher prevalence of mental health disorders. One study demonstrated impaired spinal mobility to be twice as high in individuals with a diagnostic delay of over six years.

A study of 900 people with axial SpA found that 52% of people did not feel that they were listened to or believed when seeking a diagnosis.

The barriers in private physio practice are;

•          awareness of axial Spa presentation and symptoms
•          awareness of relevant national guidance such as NICE guidelines (NG65) and GIRFT
           axial spondyloarthritis pathway
•          a lack of access to diagnostics and reports (whole spine MRI)
•          no direct referral pathway into rheumatology

The National Axial Spondyloarithtis Society (NASS) is dedicated to transforming the diagnosis, treatment, and care of individuals with axial SpA, empowering them to live well with the condition.  NASS has developed a symptom checker which is a clinically validated tool that combines three internationally recognised clinical criteria - ASAS, Berlin and Calin. You can complete the symptom checker with your patients online and they can take the results to their Primary Care appointment for onward referral to rheumatology

https://www.actonaxialspa.com/symptoms-checker/

The symptom checker asks;

1.            Did your back pain start before the age of forty?

2.            Did your back pain start gradually?

3.            Has your back lasted > 3 months?

4.            Do you experience stiffness in your back in the morning for at least 30 minutes?

5.            Does your back pain improve when you move around?

6.            Does your back pain improve when you rest?

7.            Do you have pain in your buttocks, which moves from one buttock to the other?

8.            Do you wake in the second half of the night because of your back pain?

NASS has a toolkit of resources for healthcare professionals. For more information visit; https://www.actonaxialspa.com/hcp-toolkit/

For information and resources for people living with axial SpA visit https://nass.co.uk/

NASS:

• Runs a patient helpline (0208 741 1515) and asknass@nass.co.uk which is open on weekdays. 
• Provides guidebooks available to order or download via https://tinyurl.com/ybkp5s9s

Your SpAce a free online supported self management programme which helps people with axial SpA engage with others, learn more about axial SpA, and build skills to manage the impact it has on their life.