As most people with axial spondyloarthritis (axSpA) know, substantial diagnostic delay is the norm rather than the exception. Back pain affects approximately one in five people, and most individuals first seek treatment from primary care doctors, chiropractors, physical therapists, and other healthcare providers who may not be familiar with inflammatory disease, particularly axSpA, or who do not specialize in its diagnosis. At the same time, limited consultation time can make it difficult to fully evaluate symptoms that could point to inflammatory arthritis. Together, these factors contribute to missed opportunities for earlier recognition and referral.
To address this gap, rheumatologist Abhijeet Danve, MD, MHS developed the Axial Spondyloarthritis Screening Tool (A-Tool©), a symptom-based questionnaire designed to help identify people with chronic back pain who may need further evaluation for axSpA or another form of spondyloarthritis with axial involvement.
Unlike typical referral pathways that depend on blood tests or imaging in addition to clinical features, the A-Tool© focuses entirely on clinical features reported by patients. It asks straightforward yes/no questions based on key characteristics of axSpA, such as symptom onset before age 45, gradual onset back pain lasting longer than three months, improvement with movement and exercise, nocturnal pain, and associated conditions such as psoriasis, uveitis, or inflammatory bowel disease.
“The patient is the best advocate for their own symptoms,” Dr. Danve says. “What if we directly go to the patients and ask them simple questions which will help us understand who are the right patients, the ones who need referrals to rheumatology?”
An earlier version of the A-Tool© used a two-step structure with prescreening questions followed by a screening questionnaire, but the current version (Modified A-Tool©) uses a single streamlined assessment with a weighted scoring system that reflects the relative importance of different clinical features. The Modified A-Tool© also includes a diagnostic component that may be useful in primary care settings, particularly when relevant clinical data are available.
The A-tool© was evaluated in the Finding axSpA (FaxSpA) study, which recruited people with chronic back pain through online patient portals and social media. Of the 100 enrolled participants, 86 completed the clinical evaluation, including history and examination, laboratory testing, and imaging including MRI of SI joints. In total, 29 were diagnosed with axSpA, suggesting that a structured self-referral approach can help identify previously unrecognized cases in a population where chronic back pain is common.
The study also highlighted limitations of screening approaches, including variability in how patients interpret symptom-based questions. However, the Modified A-Tool© attempts to make the questions clear and easily interpretable. In addition, Dr. Danve frames these limitations within a broader diagnostic reality in which axSpA is frequently missed.
“Currently, there is no baseline,” he says. “There are very few non-rheumatologists who are actually thinking about axial spondyloarthritis as part of the differential diagnosis, which makes it difficult to arrive at the diagnosis.”
Dr. Danve adds that while some patients identified through the A-Tool©-based screening approach may ultimately not have axSpA, the greater risk lies in ongoing under-recognition and delayed diagnosis. He emphasizes that the A-tool© is not intended for diagnosis but to facilitate referral of appropriate at-risk people to follow up with rheumatology.
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