Screening and referral for axial spondyloarthritis--need of the hour

Although axial spondyloarthritis (axSpA) is as prevalent as rheumatoid arthritis, it is commonly under recognized due to variety of reasons. AxSpA contributes to significant loss of function and disability among young adults. With the availability of newer assessment methods and effective therapeutic agents, early diagnosis and appropriate treatment are possible. As mechanical back pain is widely prevalent in general population, selection of patients with high likelihood of having axSpA and referral to rheumatologists is very important to allow prompt diagnosis and management of axSpA yet avoid improper utilization of resources. Various referral strategies have been developed for this purpose which have included patients with chronic back pain for >3 months with age of onset <45 years and one or more typical spondyloarthritis features with high sensitivity and specificity. Consistent application of both simple and complex strategies has demonstrated similar results in various clinical studies. About 35-45 % of patients referred to rheumatologists using these strategies were finally diagnosed to have axSpA. Potential referring providers include primary care physicians, physical therapists, orthopedic and spine surgeons, chiropractors, rehabilitation medicine physicians, ophthalmologists, gastroenterologists, and dermatologists. Increasing the awareness and education of the referring providers are two very important steps in the success of the referral strategy. With proper application of any strategy described below, a rheumatologist will need to see two to three patients with chronic back pain to identify one patient with axSpA.