Physiotherapists' awareness, knowledge and confidence in the recognition and referral of possible axial spondyloarthritis: are we contributing to diagnostic delays?

Abstract

Steen MER1,2, Cairns MC1,3, McCrum C4,5 1University of Hertfordshire, Hatfield, United Kingdom, 2Whittington Health NHS Trust, Physiotherapy Department, London, United Kingdom, 3Physiocare, Twyford, United Kingdom, 4University of Brighton, Brighton, United Kingdom, 5East Sussex Healthcare NHS Trust, Physiotherapy Department, Eastbourne, United Kingdom Background: Axial Spondyloarthritis (axSpA) is an inflammatory disease that occurs in around 5% of back pain presentations. As such, physiotherapists need to know when and how to screen for possible axSpA and when to refer to rheumatology. In the UK, there is considerable diagnostic delay of 5-8.5 years. This delay is suggested to relate to challenges with differentiating axSpA from non-specific low back pain and poor awareness of features that should prompt rheumatology referral. Early intervention is important and recent UK guidance on back pain and sciatica (NICE 2016) and spondyloarthritis (NICE 2017) have been published to support better screening and earlier diagnosis. Purpose: To explore physiotherapists' awareness, knowledge and confidence in screening and recognising signs, symptoms and risk factors which should raise suspicion of possible axSpA and prompt onward referral. Methods: An anonymous online survey with an embedded multi-vignette design (axSpA, non-specific low back pain and radiculopathy) was undertaken with UK physiotherapists using a sample of convenience and snowballing strategies. The survey was distributed via online professional networks, special interest groups and social media. Data analysis used descriptive statistics and conceptual content analysis for free text responses. Results: One hundred and thirty-two surveys were analysed. Only 67% of respondents (n=88/132) reported considering inflammatory pathologies as a possible cause of persistent back pain. Only 60% of respondents identified the vignette with features suspicious of axSpA (inflammatory back pain), compared to the non-specific low back pain (94%) and radiculopathy (80%) vignettes. Most respondents (92%, n=73/79) who identified axSpA as the primary diagnosis made an appropriate onward referral. Demonstrating a 'full awareness' or 'good awareness' of the NICE (2017) guidance referral criteria was only evident within 50% of responses describing clinical reasoning and only within 20% of responses on further questioning required. 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 results (median 8/10). Despite expressing confidence (≥7/10) in their knowledge to recognise features of possible axSpA, a significant number failed to identify the axSpA vignette. Better awareness and knowledge of axSpA was associated with increased familiarity with NICE (2017) guidance on spondyloarthritis and continuing professional development. Conclusion(s): The study suggests that physiotherapists may not be giving adequate consideration to inflammatory pathologies in the differential diagnosis of persistent low back pain. Although certain pertinent features are better recognised, a significant lack of awareness of signs, symptoms and features associated with suspicion of axial spondyloarthritis was reported. Myths about the role of inflammatory marker levels and HLA B27 positivity in suspecting spondyloarthritis may need challenging. Implications: A lack of awareness and knowledge of axial spondyloarthritis and when to refer to rheumatology appears evident, even amongst experienced clinicians. The consequences for diagnostic delay are significant and indicate the need for professional education and use of guidance to improve screening and earlier recognition. The survey provides a valuable evaluation and educational tool that can be used to measure and raise awareness of axSpA. Key-Words: Spondyloarthritis, back pain, professional education Funding acknowledgements: This study was supported by an National Ankylosing Spondylitis Society Educational Bursary. Ethics approval: Did this work require ethics approval?:Yes Institution: University of Hertfordshire Ethics Committee: Health, Science, Engineering and Technology Ethics Committee Ethics number: HSK/PGT/UH/03202