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Low back pain. A bane of human existence.
Almost everyone – 90% of us in fact – will have at least one bout of it. Snow shoveling, too much weight on the barbell, a strange twist while carrying in the groceries. A quick visit to a primary care doc, a prescription NSAID, a few days or weeks of rest, and a gradual resolution of symptoms is the usual course.
But in Toronto, a small group of clinicians aims to change this clinical picture. They’ve developed a secondary screening program to identify back pain patients at risk of axSpA, potentially bypassing the diagnostic merry-go-round, years of pain, and disease progression. Success relies on the alertness of primary care and the expertise of advanced practice physical therapists to make sure the right patients arrive in the rheumatologist’s office.
“We know the delay is on average 8-10 years, and often by the time a patient does show up in a rheumatology office, much damage has occurred,” Laura Passalent, a clinician researcher at University Health Network, Toronto, said in an interview. “But spondyloarthritis gets lost in the background noise of mechanical and musculoskeletal back pain, so it’s hard for primary care to accurately diagnose, and patients often bounce around the health care system for years before someone finally suspects. We are trying to change that paradigm, reduce the time to diagnosis, and identify patients earlier. If we can, we can treat earlier, and the evidence suggests that, like early treatment in RA, we can prevent disease progression.”
As in rheumatoid arthritis, getting patients on biologics sooner rather than later improves radiologic outcomes, daily function, and quality of life. Studies bear that out, including one by Ms. Passalent’s rheumatologist colleagues, Robert Inman, MD, and Nigel Haroon, MD, PhD, also with UHN. Their study of 334 patients with ankylosing spondylitis found that early treatment with a tumor necrosis factor (TNF) inhibitor reduced the odds of disease progression by up to 50% and was especially effective in those who got early treatment (Arthritis Rheum. 2013 Oct;65[10]:2645-54). Those who started at least 10 years after symptom onset were twice as likely to progress. Those who were on biologics for more than 50% of their disease duration were three times less likely to progress.
“It’s known that biologics improve the signs and symptoms of SpA, and the great majority of patients feel better on them,” Dr. Inman said in an interview. “But the really important outcomes are preventing structural damage, a finding already well established in RA. This study changed our thoughts on altering the natural history of this disease.”
Diagnostic delays worsen long-term outcomes in axSpA, just as in RA, but unlike RA, axSpA has no stepwise diagnostic algorithm, Dr. Inman said. “We had a real problem identifying a simple, reliable pathway for referrals. One of the strategies we investigated was this screening clinic model to facilitate appropriate and early referrals that are no longer dependent on primary care physicians.”
Community back pain clinics
Raja Rampersaud, MD, a spine surgeon at UHN, developed the first model – a community clinic that triages and treats people with low back pain. Primary care providers refer into the clinics, and advanced practice clinicians work with patients to create care plans. These might include low-level medical therapy, exercise, and other self-management techniques.
Ms. Passalent and her team partnered with these clinics in a pilot project to identify axSpA patients. The team provided clinician education and referral criteria for patients. These include back pain of more than 3 months’ duration in patients younger than 50 years who have other signs of inflammatory back pain. Primary care providers can refer such patients to a secondary screening program, run by an advanced care clinician, that further refines the diagnosis.
The clinic work-up includes the following:
- History, involving a description of back pain, peripheral joint involvement, and extra-articular manifestations.
- Physical exam looking at spinal mobility and vital signs, as well as tender/swollen joints, enthesitis, and dactylitis.
- Investigations that include pelvis and lateral lumbar and cervical spine radiographs, HLA-B27 testing, and measurements of C-reactive protein and erythrocyte sedimentation rate.
For those who don’t tick the axSpA boxes, the practitioner provides education on self-management, basic nonpharmacologic interventions, exercise guidance, and referrals back into primary care for their therapy.
But those who screen positive receive a direct rheumatology referral. This is an especially important component of the program because, like the United States, Canada has a chronic shortage of rheumatologists. However, in Canada there can be even greater distances than in the United States between a patient’s town and the closest rheumatology office. The back pain screening clinic reduced waiting time from up to 2 years to around 3 weeks – a notable accomplishment in a country with only about 500 rheumatologists – less than 1 per 75,000 residents.
First data
Ms. Passalent and the team presented their initial data from this model at recent annual meetings of the Canadian Rheumatology Association and the American College of Rheumatology (Arthritis Rheumatol. 2018;70[suppl 10]:Abstract 661).
During the first 3 years of the project, 410 patients were seen. Time from primary care referral to the secondary clinic appointment was roughly 22 days. These patients were young, with a mean age of about 37 years, and had experienced back pain for an average of 7 years. About 14% were positive for HLA-B27, but that characteristic signal actually performed poorly as an independent axSpA screen. It was highly specific (94%) but not very sensitive (28%), with a 71% positive and negative predictive value.
Assessment by the advanced care provider, on the other hand, had 90% specificity and 68% sensitivity. The negative and positive predictive values were 80% and 84%, respectively.
Among those who had a rheumatology consult, 18% received an axSpA diagnosis.
“We were very pleased to be able to decrease the time to diagnosis, from 9 years to 6 or 7,” Ms. Passalent said. “It’s still a long time, but you have to keep in mind this program is just getting started.”
Other benefits
It’s proven that early treatment prevents bone damage and improves spine-related function and quality of life for these patients. But if biologics help bone inflammation, could they also benefit the extra-articular manifestations that often accompany axSpA?
“The main comorbidities are anterior uveitis, inflammatory bowel diseases, and psoriasis,” Dr. Inman said. “In our cohort, 35% have uveitis, 12% have IBD, and 10% have psoriasis. Those are significant numbers, and the damage accrues over time. They are all inflammatory and maybe autoimmune.”
These extra-articular manifestations influence individual treatment plans, he said. “The presence of skin, eye, or joint inflammation does inform our selection. Generally, though, blocking TNF-alpha with a monoclonal antibody should also effectively treat these other issues in addition to SpA.”
A 2018 review touched on the uveitis/SpA treatment connection (Perm J. 2018;22:17-041. doi: 10.7812/TPP/17-041). Biologics – especially TNF blockers – are excellent choices for refractory uveitis and may confer a double benefit in patients with both diseases. Biologic choices for IBD and psoriasis also typically overlap those used in axSpA.
The literature is still evolving on this concept of cotreatment, Dr. Inman said, but it could represent an exciting option to prevent damage in multiple systems with one approach.
The future
Ms. Passalent, Dr. Inman, and Dr. Haroon see good things ahead for everyone involved in axSpA if the secondary screening clinic protocol expands throughout Canada.
“The thing that impresses me as a frontline worker, you can be an agent of change. If you’re surrounded by the right people and a supportive organization, you really can help to influence transformative change. It doesn’t happen overnight, but if you stick to it and work with the right champions, it’s amazing what influence on patient care you can have,” Ms. Passalent said.
Dr. Inman, Dr. Haroon, and Ms. Passalent have been consultants and received research funds from several pharmaceutical companies.
Low back pain. A bane of human existence.
Almost everyone – 90% of us in fact – will have at least one bout of it. Snow shoveling, too much weight on the barbell, a strange twist while carrying in the groceries. A quick visit to a primary care doc, a prescription NSAID, a few days or weeks of rest, and a gradual resolution of symptoms is the usual course.
But in Toronto, a small group of clinicians aims to change this clinical picture. They’ve developed a secondary screening program to identify back pain patients at risk of axSpA, potentially bypassing the diagnostic merry-go-round, years of pain, and disease progression. Success relies on the alertness of primary care and the expertise of advanced practice physical therapists to make sure the right patients arrive in the rheumatologist’s office.
“We know the delay is on average 8-10 years, and often by the time a patient does show up in a rheumatology office, much damage has occurred,” Laura Passalent, a clinician researcher at University Health Network, Toronto, said in an interview. “But spondyloarthritis gets lost in the background noise of mechanical and musculoskeletal back pain, so it’s hard for primary care to accurately diagnose, and patients often bounce around the health care system for years before someone finally suspects. We are trying to change that paradigm, reduce the time to diagnosis, and identify patients earlier. If we can, we can treat earlier, and the evidence suggests that, like early treatment in RA, we can prevent disease progression.”
As in rheumatoid arthritis, getting patients on biologics sooner rather than later improves radiologic outcomes, daily function, and quality of life. Studies bear that out, including one by Ms. Passalent’s rheumatologist colleagues, Robert Inman, MD, and Nigel Haroon, MD, PhD, also with UHN. Their study of 334 patients with ankylosing spondylitis found that early treatment with a tumor necrosis factor (TNF) inhibitor reduced the odds of disease progression by up to 50% and was especially effective in those who got early treatment (Arthritis Rheum. 2013 Oct;65[10]:2645-54). Those who started at least 10 years after symptom onset were twice as likely to progress. Those who were on biologics for more than 50% of their disease duration were three times less likely to progress.
“It’s known that biologics improve the signs and symptoms of SpA, and the great majority of patients feel better on them,” Dr. Inman said in an interview. “But the really important outcomes are preventing structural damage, a finding already well established in RA. This study changed our thoughts on altering the natural history of this disease.”
Diagnostic delays worsen long-term outcomes in axSpA, just as in RA, but unlike RA, axSpA has no stepwise diagnostic algorithm, Dr. Inman said. “We had a real problem identifying a simple, reliable pathway for referrals. One of the strategies we investigated was this screening clinic model to facilitate appropriate and early referrals that are no longer dependent on primary care physicians.”
Community back pain clinics
Raja Rampersaud, MD, a spine surgeon at UHN, developed the first model – a community clinic that triages and treats people with low back pain. Primary care providers refer into the clinics, and advanced practice clinicians work with patients to create care plans. These might include low-level medical therapy, exercise, and other self-management techniques.
Ms. Passalent and her team partnered with these clinics in a pilot project to identify axSpA patients. The team provided clinician education and referral criteria for patients. These include back pain of more than 3 months’ duration in patients younger than 50 years who have other signs of inflammatory back pain. Primary care providers can refer such patients to a secondary screening program, run by an advanced care clinician, that further refines the diagnosis.
The clinic work-up includes the following:
- History, involving a description of back pain, peripheral joint involvement, and extra-articular manifestations.
- Physical exam looking at spinal mobility and vital signs, as well as tender/swollen joints, enthesitis, and dactylitis.
- Investigations that include pelvis and lateral lumbar and cervical spine radiographs, HLA-B27 testing, and measurements of C-reactive protein and erythrocyte sedimentation rate.
For those who don’t tick the axSpA boxes, the practitioner provides education on self-management, basic nonpharmacologic interventions, exercise guidance, and referrals back into primary care for their therapy.
But those who screen positive receive a direct rheumatology referral. This is an especially important component of the program because, like the United States, Canada has a chronic shortage of rheumatologists. However, in Canada there can be even greater distances than in the United States between a patient’s town and the closest rheumatology office. The back pain screening clinic reduced waiting time from up to 2 years to around 3 weeks – a notable accomplishment in a country with only about 500 rheumatologists – less than 1 per 75,000 residents.
First data
Ms. Passalent and the team presented their initial data from this model at recent annual meetings of the Canadian Rheumatology Association and the American College of Rheumatology (Arthritis Rheumatol. 2018;70[suppl 10]:Abstract 661).
During the first 3 years of the project, 410 patients were seen. Time from primary care referral to the secondary clinic appointment was roughly 22 days. These patients were young, with a mean age of about 37 years, and had experienced back pain for an average of 7 years. About 14% were positive for HLA-B27, but that characteristic signal actually performed poorly as an independent axSpA screen. It was highly specific (94%) but not very sensitive (28%), with a 71% positive and negative predictive value.
Assessment by the advanced care provider, on the other hand, had 90% specificity and 68% sensitivity. The negative and positive predictive values were 80% and 84%, respectively.
Among those who had a rheumatology consult, 18% received an axSpA diagnosis.
“We were very pleased to be able to decrease the time to diagnosis, from 9 years to 6 or 7,” Ms. Passalent said. “It’s still a long time, but you have to keep in mind this program is just getting started.”
Other benefits
It’s proven that early treatment prevents bone damage and improves spine-related function and quality of life for these patients. But if biologics help bone inflammation, could they also benefit the extra-articular manifestations that often accompany axSpA?
“The main comorbidities are anterior uveitis, inflammatory bowel diseases, and psoriasis,” Dr. Inman said. “In our cohort, 35% have uveitis, 12% have IBD, and 10% have psoriasis. Those are significant numbers, and the damage accrues over time. They are all inflammatory and maybe autoimmune.”
These extra-articular manifestations influence individual treatment plans, he said. “The presence of skin, eye, or joint inflammation does inform our selection. Generally, though, blocking TNF-alpha with a monoclonal antibody should also effectively treat these other issues in addition to SpA.”
A 2018 review touched on the uveitis/SpA treatment connection (Perm J. 2018;22:17-041. doi: 10.7812/TPP/17-041). Biologics – especially TNF blockers – are excellent choices for refractory uveitis and may confer a double benefit in patients with both diseases. Biologic choices for IBD and psoriasis also typically overlap those used in axSpA.
The literature is still evolving on this concept of cotreatment, Dr. Inman said, but it could represent an exciting option to prevent damage in multiple systems with one approach.
The future
Ms. Passalent, Dr. Inman, and Dr. Haroon see good things ahead for everyone involved in axSpA if the secondary screening clinic protocol expands throughout Canada.
“The thing that impresses me as a frontline worker, you can be an agent of change. If you’re surrounded by the right people and a supportive organization, you really can help to influence transformative change. It doesn’t happen overnight, but if you stick to it and work with the right champions, it’s amazing what influence on patient care you can have,” Ms. Passalent said.
Dr. Inman, Dr. Haroon, and Ms. Passalent have been consultants and received research funds from several pharmaceutical companies.
Low back pain. A bane of human existence.
Almost everyone – 90% of us in fact – will have at least one bout of it. Snow shoveling, too much weight on the barbell, a strange twist while carrying in the groceries. A quick visit to a primary care doc, a prescription NSAID, a few days or weeks of rest, and a gradual resolution of symptoms is the usual course.
But in Toronto, a small group of clinicians aims to change this clinical picture. They’ve developed a secondary screening program to identify back pain patients at risk of axSpA, potentially bypassing the diagnostic merry-go-round, years of pain, and disease progression. Success relies on the alertness of primary care and the expertise of advanced practice physical therapists to make sure the right patients arrive in the rheumatologist’s office.
“We know the delay is on average 8-10 years, and often by the time a patient does show up in a rheumatology office, much damage has occurred,” Laura Passalent, a clinician researcher at University Health Network, Toronto, said in an interview. “But spondyloarthritis gets lost in the background noise of mechanical and musculoskeletal back pain, so it’s hard for primary care to accurately diagnose, and patients often bounce around the health care system for years before someone finally suspects. We are trying to change that paradigm, reduce the time to diagnosis, and identify patients earlier. If we can, we can treat earlier, and the evidence suggests that, like early treatment in RA, we can prevent disease progression.”
As in rheumatoid arthritis, getting patients on biologics sooner rather than later improves radiologic outcomes, daily function, and quality of life. Studies bear that out, including one by Ms. Passalent’s rheumatologist colleagues, Robert Inman, MD, and Nigel Haroon, MD, PhD, also with UHN. Their study of 334 patients with ankylosing spondylitis found that early treatment with a tumor necrosis factor (TNF) inhibitor reduced the odds of disease progression by up to 50% and was especially effective in those who got early treatment (Arthritis Rheum. 2013 Oct;65[10]:2645-54). Those who started at least 10 years after symptom onset were twice as likely to progress. Those who were on biologics for more than 50% of their disease duration were three times less likely to progress.
“It’s known that biologics improve the signs and symptoms of SpA, and the great majority of patients feel better on them,” Dr. Inman said in an interview. “But the really important outcomes are preventing structural damage, a finding already well established in RA. This study changed our thoughts on altering the natural history of this disease.”
Diagnostic delays worsen long-term outcomes in axSpA, just as in RA, but unlike RA, axSpA has no stepwise diagnostic algorithm, Dr. Inman said. “We had a real problem identifying a simple, reliable pathway for referrals. One of the strategies we investigated was this screening clinic model to facilitate appropriate and early referrals that are no longer dependent on primary care physicians.”
Community back pain clinics
Raja Rampersaud, MD, a spine surgeon at UHN, developed the first model – a community clinic that triages and treats people with low back pain. Primary care providers refer into the clinics, and advanced practice clinicians work with patients to create care plans. These might include low-level medical therapy, exercise, and other self-management techniques.
Ms. Passalent and her team partnered with these clinics in a pilot project to identify axSpA patients. The team provided clinician education and referral criteria for patients. These include back pain of more than 3 months’ duration in patients younger than 50 years who have other signs of inflammatory back pain. Primary care providers can refer such patients to a secondary screening program, run by an advanced care clinician, that further refines the diagnosis.
The clinic work-up includes the following:
- History, involving a description of back pain, peripheral joint involvement, and extra-articular manifestations.
- Physical exam looking at spinal mobility and vital signs, as well as tender/swollen joints, enthesitis, and dactylitis.
- Investigations that include pelvis and lateral lumbar and cervical spine radiographs, HLA-B27 testing, and measurements of C-reactive protein and erythrocyte sedimentation rate.
For those who don’t tick the axSpA boxes, the practitioner provides education on self-management, basic nonpharmacologic interventions, exercise guidance, and referrals back into primary care for their therapy.
But those who screen positive receive a direct rheumatology referral. This is an especially important component of the program because, like the United States, Canada has a chronic shortage of rheumatologists. However, in Canada there can be even greater distances than in the United States between a patient’s town and the closest rheumatology office. The back pain screening clinic reduced waiting time from up to 2 years to around 3 weeks – a notable accomplishment in a country with only about 500 rheumatologists – less than 1 per 75,000 residents.
First data
Ms. Passalent and the team presented their initial data from this model at recent annual meetings of the Canadian Rheumatology Association and the American College of Rheumatology (Arthritis Rheumatol. 2018;70[suppl 10]:Abstract 661).
During the first 3 years of the project, 410 patients were seen. Time from primary care referral to the secondary clinic appointment was roughly 22 days. These patients were young, with a mean age of about 37 years, and had experienced back pain for an average of 7 years. About 14% were positive for HLA-B27, but that characteristic signal actually performed poorly as an independent axSpA screen. It was highly specific (94%) but not very sensitive (28%), with a 71% positive and negative predictive value.
Assessment by the advanced care provider, on the other hand, had 90% specificity and 68% sensitivity. The negative and positive predictive values were 80% and 84%, respectively.
Among those who had a rheumatology consult, 18% received an axSpA diagnosis.
“We were very pleased to be able to decrease the time to diagnosis, from 9 years to 6 or 7,” Ms. Passalent said. “It’s still a long time, but you have to keep in mind this program is just getting started.”
Other benefits
It’s proven that early treatment prevents bone damage and improves spine-related function and quality of life for these patients. But if biologics help bone inflammation, could they also benefit the extra-articular manifestations that often accompany axSpA?
“The main comorbidities are anterior uveitis, inflammatory bowel diseases, and psoriasis,” Dr. Inman said. “In our cohort, 35% have uveitis, 12% have IBD, and 10% have psoriasis. Those are significant numbers, and the damage accrues over time. They are all inflammatory and maybe autoimmune.”
These extra-articular manifestations influence individual treatment plans, he said. “The presence of skin, eye, or joint inflammation does inform our selection. Generally, though, blocking TNF-alpha with a monoclonal antibody should also effectively treat these other issues in addition to SpA.”
A 2018 review touched on the uveitis/SpA treatment connection (Perm J. 2018;22:17-041. doi: 10.7812/TPP/17-041). Biologics – especially TNF blockers – are excellent choices for refractory uveitis and may confer a double benefit in patients with both diseases. Biologic choices for IBD and psoriasis also typically overlap those used in axSpA.
The literature is still evolving on this concept of cotreatment, Dr. Inman said, but it could represent an exciting option to prevent damage in multiple systems with one approach.
The future
Ms. Passalent, Dr. Inman, and Dr. Haroon see good things ahead for everyone involved in axSpA if the secondary screening clinic protocol expands throughout Canada.
“The thing that impresses me as a frontline worker, you can be an agent of change. If you’re surrounded by the right people and a supportive organization, you really can help to influence transformative change. It doesn’t happen overnight, but if you stick to it and work with the right champions, it’s amazing what influence on patient care you can have,” Ms. Passalent said.
Dr. Inman, Dr. Haroon, and Ms. Passalent have been consultants and received research funds from several pharmaceutical companies.