Physiotherapists' awareness, knowledge and confidence in screening and referral of suspected axial spondyloarthritis: A survey of UK clinical practice
Background: Axial Spondyloarthritis (axSpA) is an inflammatory disease associated with significant diagnostic delays. It is essential that physiotherapists screen for possible axSpA and know when to refer to rheumatology. This study aimed to explore physiotherapists´ 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 radicular syndrome) 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. Sixty-seven percent 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 containing clinical features of axSpA compared to the vignettes of non-specific low back pain (94%) and radicular syndrome (80%). Of those respondents who correctly identified the axSpA vignette, most (92%) made the appropriate management choice of referral for specialist opinion. Demonstrating ‘full’ or ‘good’ awareness of national referral guidance for axSpA was only evident within 50% of ‘clinical reasoning’ responses, and 20% of responses describing respondent approach to ‘further subjective screening’. There was evidence of misplaced confidence in the recognition of clinical features of axSpA (≥7/10) with considerable clinical importance given to inflammatory markers and human leukocyte antigen B27 (median = 8/10). Conclusion: Physiotherapists may not be giving adequate consideration to possible axSpA in the differential diagnosis of persistent low back pain. There was a significant lack of awareness and knowledge of signs, symptoms and risk factors for suspected axSpA. 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.