An aching back is something we have likely all experienced at some point or another, and most times is not a cause for concern. If it’s persistent and doesn’t improve with time, some may start to worry and seek medical advice. What appears to start out as a common ailment can turn out to be axial spondyloarthritis, an autoimmune inflammatory disorder that mainly involves the sacroiliac joints and the spine.
In axial spondyloarthritis, back pain has a peculiar pattern, called inflammatory back pain, where patients report improvement of the pain with movement and exercise, but not with rest. Patients also report that the pain awakens them from sleep, but responds well to non-steroidal anti-inflammatory drugs (NSAIDs). In addition, patients may also have inflammation in joints of extremities, eye (called uveitis), skin (psoriasis) and intestines (Crohn’s disease).
The average delay from the symptom onset to diagnosis can be as long as eight to 11 years. If enough time goes by, inflammation can cause irreversible damage to the joints and spine. The impact on quality of life is also quite severe due to chronic back pain and stiffness, which can lead to impaired mobility.
The diagnosis can be challenging for medical professionals and patients and is one of the reasons it goes undetected for years. It’s symptoms could be mistaken for a common ailment, like back pain, and physicians may not be thinking about the possibility of a complex disease, such as axial spondyloarthritis.
Abhijeet Danve, MD, FACP, assistant professor of medicine (rheumatology) and Yuliya Afinogenova, MD, fellow (rheumatology, allergy, and immunology) are conducting a study to understand what primary care providers (PCPs) know about spondyloarthritis and how they manage chronic back pain with patients, especially younger ones.
“It is not an easy task in the busy primary care office to properly assess all patients with chronic back pain and select those who would warrant a rheumatology referral, especially because axial spondyloarthritis is a very clinical diagnosis and a patient story is extremely important. On the one hand, we do not want to miss patients who may potentially have a rheumatic disease. On the other hand, we do not want to overwhelm rheumatologists with unnecessary referrals,” said Afinogenova.
The survey is a collaboration between Yale School of Medicine, University of Connecticut, and Oregon Health & Science University. The research is being funded by a fellowship seed grant from the Society for Ankylosing Spondylitis and Axial Spondyloarthritis (SPARTAN).
It is not an easy task in the busy primary care office to properly assess all patients with chronic back pain and select those who would warrant a rheumatology referral, especially because axial spondyloarthritis is a very clinical diagnosis and a patient story is extremely important. On the one hand, we do not want to miss patients who may potentially have a rheumatic disease. On the other hand, we do not want to overwhelm rheumatologists with unnecessary referrals
Yuliya Afinogenova, MD
Under the leadership of Danve, Yale Spondyloarthritis Program is planning to broaden the study to include other providers caring for back pain patients, including spine surgeons, physical therapists, physiatrists, and chiropractors. “One of the main reasons for delayed diagnosis is lack of referral of patients with suspected disease to rheumatologists,” said Danve. “Another reason is that a rheumatologist’s expertise is usually required for diagnosis, since there is no specific biomarker yet.”
“The most helpful laboratory tests are c-reactive protein, which measures inflammation, and HLA-B27 genetic test, which informs about the risk of disease. HLA-B27 can support the diagnosis, but is not a confirmatory test because only 6% of the U.S. population has positive HLA B27 and only 5 to 8% will develop axial spondyloarthritis. An X-ray of the pelvis to look for sacroiliac joint inflammation is the initial imaging test; an MRI is performed if the x-ray is inconclusive and suspicion is high,” said Danve.
Danve has developed an online screening tool (A-tool) that can help identify patients with suspected axial spondyloarthritis. His team is studying the effectiveness of A-tool in an ongoing research study. They are also collecting blood samples with the aim of finding specific diagnostic biomarkers. In 2019, Danve was awarded the Jane Bruckel Early Career Investigator award by the Spondylitis Association of America for his work in the spondyloarthritis field.
“Early diagnosis is the most important unmet need at present especially because we have effective newer targeted therapies available that can prevent long term damage and suffering,” said Danve. “If suspected back pain patients are referred early to rheumatologists, prompt diagnosis is possible.”
The Section of Rheumatology, Allergy, and Immunology is dedicated to providing care for patients with rheumatic, allergic and immunologic disorders; educating future generations of thought leaders in the field; and conducting research into fundamental questions of autoimmunity and immunology. To learn more about their work, visit Rheumatology, Allergy & Immunology.