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Early differential diagnosis of ankylosing spondylitis among patients with low back pain in primary care

Early differential diagnosis of ankylosing spondylitis among patients with low back pain in... Diagnosing and treating low back pain (LBP) is a worldwide major primary care challenge in which a differential diagnosis between non-specific LBP and conditions with a known pathology is essential for choosing the optimal treatment strategy. The time required for the diagnosis of a condition such as ankylosing spondylitis (AS) was previously found too long. However, a recently published paper by Bashir et al. found that distinct episodes of axial pain separated by more than 6 months seem more predictive than currently applied characteristics in reaching an early diagnosis of AS. Keywords: Early diagnosis, Spondylitis Ankylosing, Low Back pain, Primary health care Background specific LBP is identified by the exclusion of the first With a global one-month point prevalence of 23.2%, two first categories [5]. Most cases are, therefore, low back pain (LBP) is a major health challenge considered unrelated to specific known spinal abnor- across cultures [1]. LBP is the leading cause of work malities [6]. Patients with LBP constitute a group disability and years lived with disability (YLDs) world- with alarge variationinthe manifestations,possible wide [2, 3]. bio-psycho-social causes, precipitating and maintain- Clinical diagnosis of LBP based on the patients’ ing factors, course, and prognosis [7]. Most patients history and clinical examinations is the key initial as- with LBP appear to follow a particular pain trajec- sessment by the first-line assessor of LBP—often the tory over long periods and do not have frequently general practitioner (GP). This triage determines the recurring or widely fluctuating patterns [8]. However, subsequent diagnostic workup and informs the fu- a subgroup constituting 13% of patients can be clas- ture treatment plan for the patient, including in- sified as having a fluctuating pain trajectory [9]. Pa- volvements of allied health care providers and tients belonging to the fluctuating pain trajectory medical specialist referrals [4]. The purpose of diag- show small improvements in functional capability nostic triage of LBP is to allocate patients to one of [9]. Furthermore, their psychological status is with- three broad categories: specific spinal pathology (< out improvement after 12 months, with the propor- 1% of cases), radicular syndrome (∼ 5–10% of cases), tion of patients classified as depressed remaining or non-specific LBP (90–95% of cases), where non- constant (27–30%). Almost half had experienced pain for more than 3 years, and a third was still consult- ing their general practitioner about back pain at the * Correspondence: ariis@dcm.aau.dk 12-month follow-up [9]. A newly published paper by Center for General Practice at Aalborg University, Fyrkildevej 7, 1. Sal, 9220 Bashir et al. provides findings that might explain Aalborg Ø, Denmark Department of Physiotherapy, University College of Northern Denmark why patients with non-specific fluctuating pain have (UCN), Selma Lagerløfs Vej 2, 9220 Aalborg Ø, Denmark © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Riis et al. BMC Family Practice (2020) 21:90 Page 2 of 3 worse prognoses compared to patients with non- Conclusion specific constant pain [10]. A newly published paper found that two distinct periods of axial pain is predictive of receiving an AS diagnosis. Main text This can support clinicians in reaching earlier diagnoses Ankylosing Spondylitis (AS) is considered a relatively of AS among patients with non-specific pain, and this rare diagnosis in general practice [11]. However, in finding is important to inform future research into the populations such as in the UK, with a high propor- differential diagnosis of patients with fluctuating non- tion of HLA-B27 positive in the population, the specific LBP. prevalence of AS among patients with LBP is up to Abbreviations 5% [11]. AS is acondition with alongtimebetween AS: Ankylosing spondylitis; LBP: Low back pain an initial consultation for LBP before receiving an AS diagnosis [12]. The diagnostic delay in AS has previ- Acknowledgements Not applicable. ously been found unacceptably long, with females, younger patients, HLA-B27 negative, or patients with Authors’ contributions psoriasis having the longest diagnostic delay [13]. AR, JLO, and JLT contributed to the original idea. AR wrote the first draft of the manuscript. AR, JLO, and JLT made critical comments during the process Early symptoms of AS besides LBP are stiffness and of debate and writing. AR, JLO, and JLT read and approved the final version fatigue. These are considered non-specific symptoms of the manuscript. and are similar to symptoms reported among patients Funding with non-specific LBP [14]. Other diagnostic charac- None of the authors received external funding for writing this paper. teristics of AS, such as pain in the second half of the night and relief of pain and stiffness by exercise, are Availability of data and materials also often reported by patients with non-specific LBP Not applicable. [4, 15]. Nonsteroidal anti-inflammatory drugs can Ethics approval and consent to participate provide pain relief of AS, but no established diagnos- Not applicable. tic serum biomarkers allow the identification of AS in patients with early LBP [16]. Consent for publication Not applicable. Among the large group of patients with non- specific LBP, recent studies have found fear avoidance Competing interests and other psychosocial factors predictive of worse AR is an associate editor for BMC Family Practice. The other authors declare that they have no competing interests. outcomes when experiencing LBP [17, 18]. While in- cluding these factors in diagnostic screening tools Received: 20 April 2020 Accepted: 8 May 2020 provides some diagnostic information, it is important to stress the potential for misclassification of patient References risk when using the available screening tools [19], 1. Burton AK, Müller G, Balagué F, Cardon G, Eriksen HR, Hänninen O, et al. On thus making the clinical difference between non- behalf of the cost b13 working group on guidelines for prevention in low specific LBP and AS hard to detect, which can in- back pain. chapter 2 european guidelines for prevention in low back pain. Eur Spine J. 2006;15(Suppl 2):S136–68. crease delay for correct diagnosis. 2. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years Good early predictors for AS have previously been lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries difficult to identify [20]. However, a newly published 1990–2010: a systematic analysis for the global burden of disease study 2010. Lancet. 2012;380(9859):2163–96. paper, including 74 patients with AS, concluded that 3. Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. The global burden distinct episodes of axial pain separated by more than of low back pain: estimates from the global burden of disease 2010 study. 6 months are frequently observed before an AS diag- Ann Rheum Dis. 2014;73:968–74. 4. Low back pain and sciatica in over 16s: assessment and management. NICE nosis [10]. These episodes of pain among patients guideline [NG59]. 2016. Available at https://www.nice.org.uk/guidance/ng59. with LBP are highly associated with later receiving an 5. Bardin LD, King P, Maher CG. Diagnostic triage for low back pain: a practical AS diagnosis (OR 12.7, 95% CI 4.7 to 34.6) [10]. approach for primary care. Med J Aust. 2017;206(6):268–73. 6. Buchbinder R, van Tulder M, Öberg B, Costa LM, Woolf A, Schoene M, Croft Among patients later diagnosed with AS, recurrent P, Lancet Low Back Pain Series Working Group. Low back pain: a call for episodes of LBP were an even more frequent finding action. Lancet. 2018;391(10137):2384–8. than either large joint symptoms or tendon symptoms 7. Vlaeyen JWS, Maher CG, Wiech K, Van Zundert J, Meloto CB, Diatchenko L, et al. Low back pain. Nat Rev Dis Prim. 2018;4:52. [10]. In this new study, distinct episodes of axial pain 8. Dunn KM, Campbell P, Jordan KP. Long-term trajectories of back pain: separated by more than 6 months seem more predict- cohort study with 7-year follow-up. BMJ Open. 2013;3(12):e003838. ive than currently applied characteristics in reaching 9. Dunn KM, Jordan K, Croft PR. Characterizing the course of low back pain: a latent class analysis. Am J Epidemiol. 2006;163(8):754–61. an early diagnosis of AS [10]. However, these findings 10. Bashir MT, Iversen L, Burton C. Clinical features in primary care electronic need to be duplicated in future research including lar- records before diagnosis of Ankylosing spondylitis: a nested case-control ger study populations. study. BMC Fam Practice. In Press. Riis et al. BMC Family Practice (2020) 21:90 Page 3 of 3 11. Hamilton L, Macgregor A, Toms A, Warmington V, Pinch E, Gaffney K. The prevalence of axial spondyloarthritis in the UK: a cross-sectional cohort study. BMC Musculoskelet Disord. 2015;16:392. 12. Sykes MP, Doll H, Sengupta R, Gaffney K. Delay to diagnosis in axial spondyloarthritis: are we improving in the UK? Rheumatology (Oxford). 2015;54(12):2283–4. 13. Redeker I, Callhoff J, Hoffmann F, Haibel H, Sieper J, Zink A, Poddubnyy D. Determinants of diagnostic delay in axial spondyloarthritis: an analysis based on linked claims and patient-reported survey data. Rheumatology (Oxford). 2019;58(9):1634–8. 14. Nice guidelines. National Institute for Health and Care Excellence: Clinical Guidelines. Spondyloarthritis in over 16s: diagnosis and management. London: National Institute for Health and Care Excellence (UK). Available at: https://www.nice.org.uk/guidance/ng65. 15. van Hoeven L, Luime J, Han H, Vergouwe Y, Weel A. Identifying axial spondyloarthritis in Dutch primary care patients, ages 20-45 years, with chronic low back pain. Arthritis Care Res (Hoboken). 2014;66(3):446–53. 16. Turina MC, Yeremenko N, van Gaalen F, van Oosterhout M, Berg IJ, Ramonda R, et al. Serum inflammatory biomarkers fail to identify early axial spondyloarthritis: results from the SpondyloArthritis caught early (SPACE) cohort. RMD open. 2017;3(1):e000319. 17. Riis A, Karran EL, Thomsen JL, Jørgensen A, Holst S, Rolving N. The association between believing staying active is beneficial and achieving a clinically relevant functional improvement after 52 weeks: a prospective cohort study of patients with chronic low back pain in secondary care. BMC Musculoskelet Disord. 2020;21(1):47. 18. Fujii T, Oka H, Takano K, Asada F, Nomura T, Kawamata K, Okazaki H, Tanaka S, Matsudaira K. Association between high fear-avoidance beliefs about physical activity and chronic disabling low back pain in nurses in Japan. BMC Musculoskelet Disord. 2019;20(1):572. 19. Karran EL, McAuley JH, Traeger AC, Hillier SL, Grabherr L, Russek LN, Moseley GL. Can screening instruments accurately determine poor outcome risk in adults with recent onset low back pain? A systematic review and meta- analysis. BMC Med. 2017;15(1):13. 20. Walsh JA, Pei S, Penmetsa GK, Leng J, Cannon GW, Clegg DO, et al. Cohort identification of axial spondyloarthritis in a large healthcare dataset: current and future methods. BMC Musculoskelet Disord. 2018;19(1):317. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Family Practice Springer Journals

Early differential diagnosis of ankylosing spondylitis among patients with low back pain in primary care

BMC Family Practice , Volume 21 (1) – May 16, 2020

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Springer Journals
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Copyright © The Author(s) 2020
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1471-2296
DOI
10.1186/s12875-020-01161-6
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Abstract

Diagnosing and treating low back pain (LBP) is a worldwide major primary care challenge in which a differential diagnosis between non-specific LBP and conditions with a known pathology is essential for choosing the optimal treatment strategy. The time required for the diagnosis of a condition such as ankylosing spondylitis (AS) was previously found too long. However, a recently published paper by Bashir et al. found that distinct episodes of axial pain separated by more than 6 months seem more predictive than currently applied characteristics in reaching an early diagnosis of AS. Keywords: Early diagnosis, Spondylitis Ankylosing, Low Back pain, Primary health care Background specific LBP is identified by the exclusion of the first With a global one-month point prevalence of 23.2%, two first categories [5]. Most cases are, therefore, low back pain (LBP) is a major health challenge considered unrelated to specific known spinal abnor- across cultures [1]. LBP is the leading cause of work malities [6]. Patients with LBP constitute a group disability and years lived with disability (YLDs) world- with alarge variationinthe manifestations,possible wide [2, 3]. bio-psycho-social causes, precipitating and maintain- Clinical diagnosis of LBP based on the patients’ ing factors, course, and prognosis [7]. Most patients history and clinical examinations is the key initial as- with LBP appear to follow a particular pain trajec- sessment by the first-line assessor of LBP—often the tory over long periods and do not have frequently general practitioner (GP). This triage determines the recurring or widely fluctuating patterns [8]. However, subsequent diagnostic workup and informs the fu- a subgroup constituting 13% of patients can be clas- ture treatment plan for the patient, including in- sified as having a fluctuating pain trajectory [9]. Pa- volvements of allied health care providers and tients belonging to the fluctuating pain trajectory medical specialist referrals [4]. The purpose of diag- show small improvements in functional capability nostic triage of LBP is to allocate patients to one of [9]. Furthermore, their psychological status is with- three broad categories: specific spinal pathology (< out improvement after 12 months, with the propor- 1% of cases), radicular syndrome (∼ 5–10% of cases), tion of patients classified as depressed remaining or non-specific LBP (90–95% of cases), where non- constant (27–30%). Almost half had experienced pain for more than 3 years, and a third was still consult- ing their general practitioner about back pain at the * Correspondence: ariis@dcm.aau.dk 12-month follow-up [9]. A newly published paper by Center for General Practice at Aalborg University, Fyrkildevej 7, 1. Sal, 9220 Bashir et al. provides findings that might explain Aalborg Ø, Denmark Department of Physiotherapy, University College of Northern Denmark why patients with non-specific fluctuating pain have (UCN), Selma Lagerløfs Vej 2, 9220 Aalborg Ø, Denmark © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Riis et al. BMC Family Practice (2020) 21:90 Page 2 of 3 worse prognoses compared to patients with non- Conclusion specific constant pain [10]. A newly published paper found that two distinct periods of axial pain is predictive of receiving an AS diagnosis. Main text This can support clinicians in reaching earlier diagnoses Ankylosing Spondylitis (AS) is considered a relatively of AS among patients with non-specific pain, and this rare diagnosis in general practice [11]. However, in finding is important to inform future research into the populations such as in the UK, with a high propor- differential diagnosis of patients with fluctuating non- tion of HLA-B27 positive in the population, the specific LBP. prevalence of AS among patients with LBP is up to Abbreviations 5% [11]. AS is acondition with alongtimebetween AS: Ankylosing spondylitis; LBP: Low back pain an initial consultation for LBP before receiving an AS diagnosis [12]. The diagnostic delay in AS has previ- Acknowledgements Not applicable. ously been found unacceptably long, with females, younger patients, HLA-B27 negative, or patients with Authors’ contributions psoriasis having the longest diagnostic delay [13]. AR, JLO, and JLT contributed to the original idea. AR wrote the first draft of the manuscript. AR, JLO, and JLT made critical comments during the process Early symptoms of AS besides LBP are stiffness and of debate and writing. AR, JLO, and JLT read and approved the final version fatigue. These are considered non-specific symptoms of the manuscript. and are similar to symptoms reported among patients Funding with non-specific LBP [14]. Other diagnostic charac- None of the authors received external funding for writing this paper. teristics of AS, such as pain in the second half of the night and relief of pain and stiffness by exercise, are Availability of data and materials also often reported by patients with non-specific LBP Not applicable. [4, 15]. Nonsteroidal anti-inflammatory drugs can Ethics approval and consent to participate provide pain relief of AS, but no established diagnos- Not applicable. tic serum biomarkers allow the identification of AS in patients with early LBP [16]. Consent for publication Not applicable. Among the large group of patients with non- specific LBP, recent studies have found fear avoidance Competing interests and other psychosocial factors predictive of worse AR is an associate editor for BMC Family Practice. The other authors declare that they have no competing interests. outcomes when experiencing LBP [17, 18]. While in- cluding these factors in diagnostic screening tools Received: 20 April 2020 Accepted: 8 May 2020 provides some diagnostic information, it is important to stress the potential for misclassification of patient References risk when using the available screening tools [19], 1. Burton AK, Müller G, Balagué F, Cardon G, Eriksen HR, Hänninen O, et al. On thus making the clinical difference between non- behalf of the cost b13 working group on guidelines for prevention in low specific LBP and AS hard to detect, which can in- back pain. chapter 2 european guidelines for prevention in low back pain. Eur Spine J. 2006;15(Suppl 2):S136–68. crease delay for correct diagnosis. 2. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years Good early predictors for AS have previously been lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries difficult to identify [20]. However, a newly published 1990–2010: a systematic analysis for the global burden of disease study 2010. Lancet. 2012;380(9859):2163–96. paper, including 74 patients with AS, concluded that 3. Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. The global burden distinct episodes of axial pain separated by more than of low back pain: estimates from the global burden of disease 2010 study. 6 months are frequently observed before an AS diag- Ann Rheum Dis. 2014;73:968–74. 4. Low back pain and sciatica in over 16s: assessment and management. NICE nosis [10]. These episodes of pain among patients guideline [NG59]. 2016. Available at https://www.nice.org.uk/guidance/ng59. with LBP are highly associated with later receiving an 5. Bardin LD, King P, Maher CG. Diagnostic triage for low back pain: a practical AS diagnosis (OR 12.7, 95% CI 4.7 to 34.6) [10]. approach for primary care. Med J Aust. 2017;206(6):268–73. 6. Buchbinder R, van Tulder M, Öberg B, Costa LM, Woolf A, Schoene M, Croft Among patients later diagnosed with AS, recurrent P, Lancet Low Back Pain Series Working Group. Low back pain: a call for episodes of LBP were an even more frequent finding action. Lancet. 2018;391(10137):2384–8. than either large joint symptoms or tendon symptoms 7. Vlaeyen JWS, Maher CG, Wiech K, Van Zundert J, Meloto CB, Diatchenko L, et al. Low back pain. Nat Rev Dis Prim. 2018;4:52. [10]. In this new study, distinct episodes of axial pain 8. Dunn KM, Campbell P, Jordan KP. Long-term trajectories of back pain: separated by more than 6 months seem more predict- cohort study with 7-year follow-up. BMJ Open. 2013;3(12):e003838. ive than currently applied characteristics in reaching 9. Dunn KM, Jordan K, Croft PR. Characterizing the course of low back pain: a latent class analysis. Am J Epidemiol. 2006;163(8):754–61. an early diagnosis of AS [10]. However, these findings 10. Bashir MT, Iversen L, Burton C. Clinical features in primary care electronic need to be duplicated in future research including lar- records before diagnosis of Ankylosing spondylitis: a nested case-control ger study populations. study. BMC Fam Practice. In Press. Riis et al. BMC Family Practice (2020) 21:90 Page 3 of 3 11. Hamilton L, Macgregor A, Toms A, Warmington V, Pinch E, Gaffney K. The prevalence of axial spondyloarthritis in the UK: a cross-sectional cohort study. BMC Musculoskelet Disord. 2015;16:392. 12. Sykes MP, Doll H, Sengupta R, Gaffney K. Delay to diagnosis in axial spondyloarthritis: are we improving in the UK? Rheumatology (Oxford). 2015;54(12):2283–4. 13. Redeker I, Callhoff J, Hoffmann F, Haibel H, Sieper J, Zink A, Poddubnyy D. Determinants of diagnostic delay in axial spondyloarthritis: an analysis based on linked claims and patient-reported survey data. Rheumatology (Oxford). 2019;58(9):1634–8. 14. Nice guidelines. National Institute for Health and Care Excellence: Clinical Guidelines. Spondyloarthritis in over 16s: diagnosis and management. London: National Institute for Health and Care Excellence (UK). Available at: https://www.nice.org.uk/guidance/ng65. 15. van Hoeven L, Luime J, Han H, Vergouwe Y, Weel A. Identifying axial spondyloarthritis in Dutch primary care patients, ages 20-45 years, with chronic low back pain. Arthritis Care Res (Hoboken). 2014;66(3):446–53. 16. Turina MC, Yeremenko N, van Gaalen F, van Oosterhout M, Berg IJ, Ramonda R, et al. Serum inflammatory biomarkers fail to identify early axial spondyloarthritis: results from the SpondyloArthritis caught early (SPACE) cohort. RMD open. 2017;3(1):e000319. 17. Riis A, Karran EL, Thomsen JL, Jørgensen A, Holst S, Rolving N. The association between believing staying active is beneficial and achieving a clinically relevant functional improvement after 52 weeks: a prospective cohort study of patients with chronic low back pain in secondary care. BMC Musculoskelet Disord. 2020;21(1):47. 18. Fujii T, Oka H, Takano K, Asada F, Nomura T, Kawamata K, Okazaki H, Tanaka S, Matsudaira K. Association between high fear-avoidance beliefs about physical activity and chronic disabling low back pain in nurses in Japan. BMC Musculoskelet Disord. 2019;20(1):572. 19. Karran EL, McAuley JH, Traeger AC, Hillier SL, Grabherr L, Russek LN, Moseley GL. Can screening instruments accurately determine poor outcome risk in adults with recent onset low back pain? A systematic review and meta- analysis. BMC Med. 2017;15(1):13. 20. Walsh JA, Pei S, Penmetsa GK, Leng J, Cannon GW, Clegg DO, et al. Cohort identification of axial spondyloarthritis in a large healthcare dataset: current and future methods. BMC Musculoskelet Disord. 2018;19(1):317. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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BMC Family PracticeSpringer Journals

Published: May 16, 2020

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