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For Primary Care Physicians

Has Your Patient Had Inflammatory Back Pain for 3+ Months?

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According to the CDC’s 2012 NHANES study, axial spondyloarthritis (axSpA) – an inflammatory rheumatic disease – affects roughly 3.2 million adults in the U.S. alone, making it more common than rheumatoid arthritis. Despite this reality, axSpA is not always well understood by the general public or even medical professionals.

AxSpA is often difficult to diagnose partly because its most common symptom, back pain, is a pervasive patient complaint. This partially explains why it can take up to 10 years to obtain the correct diagnosis. One helpful clue, however is the presence of inflammatory back pain.

Below we present axSpA resources specifically geared to Primary Care Physicians and other health care professionals working in the primary care setting.

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Could your patient’s chronic back pain be inflammatory and indicate SpA?

Here are three different criteria that can help determine if your patient may have IBP:

Calin A et al.

JAMA 1977

  • Age at onset < 40 years
  • Duration of back pain > 3 months
  • Insidious onset
  • Morning stiffness
  • Improvement with exercise

IBP if 4 / 5 are present.

Rudwaleit et al.

Arthritis Rheum 2006

  • Morning stiffness > 30 minutes
  • Improvement with exercise, not with rest
  • Awakening at second half of the night because of pain
  • Alternating buttock pain

IBP if 2 / 4 are present.

ASAS

Sieper J et al.

Ann Rheum Dis 2009
  • Age at onset < 40 years
  • Insidious onset
  • Improvement with exercise
  • No improvement with rest
  • Pain at night (with improvement upon getting up)

IBP if 4 / 5 are present.

Other signs of spondyloarthritis:

Most cases of spondyloarthritis can be diagnosed or, at least, initially suspected, based on medical history and clinical examination.

Enthesitis

Inflammation of the entheses, where joint capsules, ligaments, or tendons attach to bone. This can be felt in multiple areas of the body from shoulders down to the feet.

Dactylitis (Sausage Digits)

Inflammation of an entire digit (a finger or toe.)

Uveitis/Iritis

Inflammation of the eye. Symptoms often occur in one eye at a time, and they may include redness, pain, sensitivity to light, and skewed vision.

Psoriasis

Crohn’s Disease/Ulcerative Colitis

Bloodwork in Spondyloarthritis

Bloodwork may not always be helpful in screening for SpA, as many of the usual inflammatory markers are missing. SpA is seronegative (a negative blood test result), and has no association with rheumatoid factor or antinuclear antibodies. The presence of the HLA-B27 gene marker, however, can be a very helpful clue, though not everyone with SpA will test positive for this marker.

Also, common indicators of systemic inflammation, such as an elevated erythrocyte sedimentation rate (ESR/SED rate) and elevated C-reactive protein (CRP) are not always present in SpA patients.

Imaging in Spondyloarthritis

One of the hallmarks of spondyloarthritis, particularly of ankylosing spondylitis, is involvement of the sacroiliac (SI) joints. Inflammation of the SI joints, called sacroiliitis, can be seen on MRI. Using conventional X-rays to detect this involvement can be problematic because it can take from seven to 10 years of disease progression for changes in the SI joints to be serious enough to show up on X-ray. Note that spondyloarthritis can present differently at onset in some people. This tends to be the case in women more than men. Quoting rheumatologist Dr. Elaine Adams, “Women often present in a little more atypical fashion so it’s even harder to make the diagnosis in women.” For example, many women have anecdotally reported that their symptoms started in the neck rather than in the lower back. If you suspect your patient may have spondyloarthritis, please refer them to a rheumatologist as soon as possible.  Early diagnosis and commencement of appropriate treatment can mean much better outcomes.