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.
Courtesy Krembil Research Institute
Study authors Laura Passalent, Dr. Robert Inman, and Dr. Nigil Haroon
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.”