Spondylitis awareness and diagnosis

We've had a lot of interest in this topic from our website visitors so we thought we'd offer an update, below.

Ankylosing spondylitis (AS) and axial spondyloarthritis (axSpA) can be easy to miss in primary care. Symptoms may initially look like common mechanical back pain, and research shows that patients can experience significant delays before receiving the right diagnosis.

For nurse practitioners and other advanced practice providers, the goal isn’t to make a specialist diagnosis. It’s to recognize when persistent back pain may have an inflammatory cause, begin an appropriate initial evaluation, and know when to refer.

Recognizing the pattern
Consider inflammatory back pain in patients whose symptoms:

• Began before age 45
• Have lasted for three months or longer
• Improve with movement or exercise rather than rest
• Include prolonged morning stiffness or pain that wakes them at night

Other clues can include heel pain, swollen joints or digits, and a personal or family history of psoriasis, inflammatory bowel disease or uveitis.

When several of these features occur together, spondyloarthritis should be considered.

Remember: symptoms can look different in women
Women can experience longer delays in receiving an axSpA diagnosis. Symptoms may not always follow the pattern clinicians expect and may extend beyond the lower back.

The practical takeaway: persistent symptoms that suggest inflammatory pain deserve a closer look, even when initial findings are inconclusive.

What can primary care clinicians do?
Depending on the patient’s presentation, initial evaluation may include inflammatory markers and imaging. Normal test results do not necessarily rule out axSpA, so continued clinical suspicion may warrant rheumatology referral.

A rheumatologist can determine whether additional imaging, testing or specialist treatment is appropriate.

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Supporting patients while they’re being evaluated
Exercise and physical therapy play important roles in managing spondyloarthritis and maintaining mobility. NSAIDs are also commonly used to help manage pain and stiffness.

Patients whose symptoms persist despite initial treatment may need specialist assessment for additional treatment options.

For primary care clinicians, the important point is not to let persistent inflammatory-type back pain linger without further evaluation.

A quick reminder for your next patient
When you see a younger patient with persistent back pain, ask:

"When did it begin? How long has it lasted? Does movement make it better or worse?"

Those few questions can help distinguish everyday mechanical back pain from symptoms that deserve a closer look, and potentially help a patient reach the right diagnosis sooner.

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Sources

• Clinical Rheumatology
• ACR Open Rheumatology
• Arthritis & Rheumatology