Can rheumatologists unequivocally diagnose axial spondyloarthritis in patients with chronic back pain of less than 2 years duration? Primary outcome of the 2-year SPondyloArthritis Caught Early (SPACE) cohort.

OBJECTIVES: To investigate the prevalence of axial spondyloarthritis (axSpA) in patients with chronic back pain (CBP) of less than 2 years (2y) duration referred to the rheumatologist, the development of diagnosis over time, and patient characteristics of those developing definite (d-)axSpA over 2y. METHODS: We analysed the 2y data from SPondyloArthritis Caught Early, a European cohort of patients (<45 years) with CBP (≥3 months, ≤2y) of unknown origin. The diagnostic workup comprised evaluation of clinical SpA features, acute phase reactants, HLA-B27, radiographs and MRI (sacroiliac joints and spine), with repeated assessments. At each visit (baseline, 3 months, 1y and 2y), rheumatologists reported a diagnosis of axSpA or non-axSpA with level of confidence (LoC; 0-not confident at all to 10-very confident). MAIN OUTCOME: axSpA diagnosis with LoC≥7 (d-axSpA) at 2y. RESULTS: In 552 patients with CBP, d-axSpA was diagnosed in 175 (32%) at baseline and 165 (30%) at 2y. Baseline diagnosis remained rather stable: at 2y, baseline d-axSpA was revised in 5% of patients, while 8% 'gained' d-axSpA. Diagnostic uncertainty persisted in 30%. HLA-B27+ and baseline sacroiliitis imaging discriminated best 2y-d-axSpA versus 2y-d-non-axSpA patients. Good response to non-steroidal anti-inflammatory drugs and MRI-sacroiliitis most frequently developed over follow-up in patients with a new d-axSpA diagnosis. Of the patients who developed MRI-sacroiliitis, 7/8 were HLA-B27+ and 5/8 male. CONCLUSION: A diagnosis of d-axSpA can be reliably made in nearly one-third of patients with CBP referred to the rheumatologist, but diagnostic uncertainty may persist in 5%-30% after 2y. Repeated assessments yield is modest, but repeating MRI may be worthwhile in male HLA-B27+ patients.

A Good Response to Nonsteroidal Antiinflammatory Drugs Does Not Discriminate Patients With Longstanding Axial Spondyloarthritis From Controls With Chronic Back Pain.

OBJECTIVE: To compare the response to nonsteroidal antiinflammatory drugs (NSAIDs) in patients with longstanding axial spondyloarthritis (axSpA) and controls with back pain (nonspondyloarthritis [non-SpA]). METHODS: Consecutive outpatients with chronic back pain (axSpA or non-SpA), were prospectively recruited. Any previous NSAIDs were withdrawn 2 days before study start (baseline). Back pain was assessed using a numerical rating scale (NRS; range 0-10) starting at 2 hours after baseline and several times thereafter up to 4 weeks. "Any response" to NSAIDs was defined as improvement of back pain on the NRS > 2 units, and "good response" as improvement > 50%, compared to baseline. RESULTS: Among 233 patients included, 68 had axSpA (29.2%) and 165 had non-SpA back pain (70.8%). The mean age was 42.7 (SD 10.7) vs 49.3 (SD 11.1) years, symptom duration 15.1 (SD 11.1) years vs 14.6 (SD 11.9) years, and pain score 5.9 (SD 2.3) vs 6.3 (SD 2.0), respectively. Overall, of patients with axSpA or non-SpA back pain, 30.9% vs 29.1% of patients showed any response and 23.5% vs 16.4% of patients showed a good response after 4 weeks, respectively (P value not significant). No differences were found in the rapidity of response or between subgroups of patients based on demographics, including different stages of axSpA. CONCLUSION: No major differences in the response to NSAIDs were found between patients with axSpA and those with non-SpA with longstanding chronic back pain. The item in the Assessment of SpondyloArthritis international Society classification criteria on "response to NSAIDs" needs more study.

Does the intensity of pain and disability affect health-related quality of life of older adults with back pain? Multilevel analysis between Brazil and Netherlands: a cross-sectional study of the BACE consortium.

BACKGROUND: The prognosis of back pain (BP) in the older adults is less favorable than in younger adults and progress to adverse outcomes and consequent worsening of health-related quality of life (HRQoL). The present study aimed to verify the association between BP intensity, disability and HRQoL in older adults residents in Brazil and Netherlands, and to evaluate whether the country of residence influences the associations. METHODS: Data were collected from 602 Brazilian and 675 Dutch participants with a new episode of BP from the Back Complaints in Elders (BACE) consortium. For the present study, a cross section was used. Pain intensity and disability were assessed using the Numerical Rating Scale (NRS) and the Roland-Morris Disability Questionnaire (RMDQ), respectively. HRQoL was assessed using the Short Form Health Survey (SF-36) quality of life questionnaire. Age, sex, and education were descriptive variables. Pain intensity (NPS score) and country were the independent variables and quality of life assessed by each SF domain - 36 was the dependent variable. Analysis of models at the individual level was performed to verify the association between pain and disability, also HRQoL in Netherlands and Brazil in the total sample. The multilevel model was used to verify whether the older adults person's country of residence influenced this relationship. RESULTS: The average age of the participants was 67.00 (7.33) years. In the total sample, linear regression analysis adjusted for sex and age showed a significant association between BP intensity scores and HRQoL, for all domains. There was no association between disability and HRQoL. In the multilevel analysis, there was an association between BP intensity and HRQoL in all domains and an association between the country of residence and HRQoL, influencing the effect of pain, in all domains, except for the physical functioning. CONCLUSION: Socioeconomic and cultural aspects of different countries can affect the perception of the elderly about their HRQoL in the presence of BP. Pain and disability in Brazilian and Dutch older adults ones are experienced differently in relation to their HRQoL.

A lower frequency of inflammatory back pain in male patients with ankylosing spondylitis compared with female patients.

In routine rheumatology practice, we noticed that a significant number of male ankylosing spondylitis (AS) patients did not experience inflammatory back pain (IBP). Based on this observation, we aimed to investigate the prevalence of IBP in male AS patients and compare it to that in female patients. Patients with AS who fulfilled the modified New York criteria were subjected to a face-to-face interview with a standardized questionnaire that addressed the IBP components based on the Berlin criteria. The study also included 63 patients with chronic mechanical back pain (MBP). Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels were measured, and Bath Ankylosing Spondylitis Disease Activity, Function, and Metrology Indexes (BASDAI, BASFI, and BASMI) were evaluated in patients with AS. There were 181 patients with AS (124 males, mean age 41.2 years; 57 females, mean age 44.6 years) and 63 patients with MBP (28 males, mean age 47.2 years; 35 females, mean age 43.5 years). The prevalence of IBP was found to be 87.7% in female and 66.1% in male patients with AS (p = 0.002). The specificity of the criteria was determined to be high both in females (85.7%) and males (89.2%). Female patients with AS had higher BASDAI levels than males (p = 0.048), but no difference was found in BASFI, BASMI, or serum CRP levels between genders. A considerable proportion of male patients with AS did not experience IBP, although they had similar CRP levels compared with females.

How well can the clinician appraise the patient's perception of the severity and impact of their back problem?

PURPOSE: A main concern of patients with back problems is pain and its impact on function and quality of life. These are subjective phenomena, and should be probed during the clinical consultation so that the physician can ascertain the extent of the problem. This study evaluated the agreement between clinicians' and patients' independent ratings of patient status on the Core Outcome Measures Index (COMI). METHODS: This was an analysis of the data from 5 spine specialists and 108 patients, in two centres. Prior to the consultation, the patient completed the COMI. After the consultation, the clinician (blind to the patient's version) also completed a COMI. Concordance was assessed by % agreement, Kappa values, Bland-Altman plots, Spearman rank, Intraclass Correlation Coefficients and comparisons of mean values, as appropriate. RESULTS: Agreement regarding the "main problem" (back pain, leg/buttock pain, sensory disturbances, other) was 83%, Kappa = 0.70 (95%CI 0.58-0.81). Moderate/strong correlations were found between the doctors' and patients' COMI-item ratings (0.48-0.74; p < 0.0001), although compared with the patients' ratings the doctors systematically underestimated absolute values for leg pain (p = 0.002) and dissatisfaction with symptom state (p = 0.002), and overestimated how much the patient's function was impaired (p = 0.029). CONCLUSION: The doctors were able to ascertain the location of the main problem and the multidimensional outcome score with good accuracy, but some individual domains were systematically underestimated (pain, symptom-specific well-being) or overestimated (impairment of function). More detailed/direct questioning on these domains during the consultation might deliver a better appreciation of the impact of the back problem on the patient's daily life.

Is complementary medicine and diagnosis associated among spinal patients in the secondary sector: a cross-sectional study.

PURPOSE: The services defined as complementary and alternative medicine/healthcare (CAM) are used to varying degrees according to the nature of the health problem, and musculoskeletal disorders, in particular, often lead to the use of CAM. Chronic pain is often cited as a reason for using CAM, and it is also the cardinal symptom of patients with back pain referred for specialist care. However, previous studies do not consider the heterogeneity of back pain when examining the use of CAM. Thus, this study aimed to explore the associations between CAM use and clinical findings incl. ICD-10 diagnostic codes in such a context. METHODS: In a cross-sectional study, a logistic regression analysis examined associations between CAM use and clinical findings at a public outpatient spine department. Chi-squared test examined the association between self-reported reasons for CAM use and the diagnostic groups. RESULTS: Of the 432 patients in the study population, 23.8% reported using CAM within 12 months prior to clinical assessment. CAM use was associated with being female and of younger age. Seeking CAM was not associated with clinical findings nor diagnosis, and no statistically significant association between the reasons for seeking CAM and the diagnostic groups was described. CONCLUSIONS: Among patients referred to specialist care for back pain, this study provides no evidence that the spinal condition should be expected to lead to the use of CAM. Only the individual demographic findings, specifically age and gender, were associated with CAM use.

How well do participants in clinical trials represent the U.S. population with chronic neck or back pain?

BACKGROUND: Randomized clinical trials (RCTs) are the gold standard for assessing treatment effectiveness; however, they have been criticized for generalizability issues such as how well trial participants represent those who receive the treatments in clinical practice. We assessed the representativeness of participants from eight RCTs for chronic spine pain in the U.S., which were used for an individual participant data meta-analysis on the cost-effectiveness of spinal manipulation for spine pain. In these clinical trials, spinal manipulation was performed by chiropractors. METHODS: We conducted a retrospective secondary analysis of RCT data to compare trial participants' socio-demographic characteristics, clinical features, and health outcomes to a representative sample of (a) U.S. adults with chronic spine pain and (b) U.S. adults with chronic spine pain receiving chiropractic care, using secondary data from the National Health Interview Survey (NHIS) and Medical Expenditure Panel Survey (MEPS). We assessed differences between trial and U.S. spine populations using independent t-tests for means and z-tests for proportions, accounting for the complex multi-stage survey design of the NHIS and MEPS. RESULTS: We found the clinical trials had an under-representation of individuals from health disparity populations with lower percentages of racial and ethnic minority groups (Black/African American 7% lower, Hispanic 8% lower), less educated (No high school degree 19% lower, high school degree 11% lower), and unemployed adults (25% lower) with worse health outcomes (physical health scores 2.5 lower and mental health scores 5.3 lower using the SF-12/36) relative to the U.S. population with spine pain. While the odds of chiropractic use in the U.S. are lower for individuals from health disparity populations, the trials also under-represented these populations relative to U.S. adults with chronic spine pain who visit a chiropractor. CONCLUSIONS: Health disparity populations are not well represented in spine pain clinical trials. Embracing key community-based approaches, which have shown promise for increasing participation of underserved communities, is needed.

The influence of breastfeeding factors on the prevalence of back and neck pain: data from an online survey.

BACKGROUND: Sometimes during breastfeeding women adopt positions that may cause problems with musculoskeletal system, resulting in back pain. The aim of this study was to determine the prevalence of lower back, upper back and neck pain in breastfeeding women and how this may be related to the act of breastfeeding. METHODS: An online survey within Poland was conducted among 395 breastfeeding women who were 1 to 48 months postpartum and were divided into two groups; "no back pain" and "back pain present". The measurement tools used included an original questionnaire, the International Physical Activity Questionnaire (IPAQ), a Numerical Pain Rating Scale (0-10), and the Roland-Morris Disability Questionnaire. Pearson's chi-squared tests, Mann-Whitney U tests, Student's t-tests, and Kruskal-Wallis ANOVA tests were used to compare the groups. RESULTS: It was found that 84% of breastfeeding mothers suffered from back pain at least once a month. Pain was experienced at least once a week in the cervical, thoracic and lumbosacral regions in 48%, 36%, and 66% of the women, respectively. A dysfunctional state was present in 27.6% of breastfeeding mothers who suffered from back pain. Mothers experiencing back pain spent significantly more time on single breastfeeding episodes (p < 0.05) and had an increased total time breastfeeding per day (p < 0.01) compared to mothers with no back pain. Neck pain was significantly less intense in mothers preferring to breastfeed in a lying position as compared to mothers preferring a sitting position in a chair or an armchair (p < 0.05). CONCLUSIONS: This survey of Polish breastfeeding mothers revealed a very high prevalence of lower back, upper back and neck pain. The amount of time spent on breastfeeding and the choice of body position for breastfeeding were important factors differentiating the prevalence and intensity of the pain. It is recommended that breastfeeding mothers do not extend the single-feeding time in the adopted position beyond the required time. It is of utmost importance to choose a breastfeeding position in which all parts of the mother's body are supported. To prevent neck pain, lying and semi-lying positions with head support are recommended.

Prevalence of undiagnosed axial spondyloarthritis in inflammatory bowel disease patients with chronic back pain: secondary care cross-sectional study.

OBJECTIVE: To elucidate the prevalence of undiagnosed rheumatology-verified diagnosis of axial spondyloarthritis (RVD-axSpA) in patients attending routine secondary care IBD clinics with chronic back pain. METHODS: Screening questionnaires were sent to consecutive patients attending IBD clinics in a university teaching hospital. Patients fulling the eligibility criteria (gastroenterologist-verified diagnosis, 18-80 years old, biologic therapy naive, no previous diagnosis of axSpA); and a moderate diagnostic probability of axSpA [self-reported chronic back pain (CBP) >3 months, onset <45 years] were invited for rheumatology assessment. This included medical review, physical examination, patient reported outcome measures, human leucocyte antigen B27, C-reactive protein, pelvic radiograph and axSpA protocol magnetic resonance imaging. A diagnosis of RVD-axSpA was made by a panel of rheumatologists. RESULTS: Of the 470 patients approached, 91 had self-reported CBP >3 months, onset <45 years, of whom 82 were eligible for clinical assessment. The prevalence of undiagnosed RVD-axSpA in patients attending IBD clinics in a secondary care setting, with self-reported CBP, onset <45 years is estimated at 5% (95% CI 1.3, 12.0) with a mean symptom duration of 12 (s.d. 12.4) years. CONCLUSION: There is a significant hidden disease burden of axSpA among IBD patients. Appropriate identification and referral from gastroenterology is needed to potentially shorten the delay to diagnosis and allow access to appropriate therapy.

Psychiatric disorders, diagnosed in psychiatric clinics, in patients with back pain: A cohort study.

Aims: The aim of this study was to evaluate whether patients with a non-specific back pain disorder are more likely to be diagnosed with a psychiatric disorder than patients with a specific back pain disorder (such as a herniated disc or inflammatory back disorder). Methods: This was a retrospective cohort study using Danish registries. Results: Our study population included 24,518 patients younger than 61 years and 12,274 patients older than 61 years. In both subpopulations, 60% had a non-specific back pain diagnosis (BPD). In the younger subpopulation, 2.1% of the patients with a non-specific BPD and 1.3% of the patients with a specific BPD had a psychiatric diagnosis within one year of their BPD. In the older subpopulation, 0.6% of patients had a psychiatric diagnosis in both BPD groups. The most frequent psychiatric diagnoses were stress-related disorders. In the younger subpopulation, patients with non-specific back pain had a higher risk of being diagnosed with a psychiatric disorder than patients with specific back pain (adjusted odds ratio 1.56, 95% confidence interval 1.25-1.94). The type of BPD had no effect on the risk of having a psychiatric diagnosis among older patients. Conclusions: Patients with a non-specific back pain disorder younger than 61 years were more likely to be diagnosed with a psychiatric disorder than patients with a specific back pain disorder. We recommend that spine specialists pay special attention to patients younger than 61 years with a back pain disorder to prevent them from developing a psychiatric disorder.

Values derived from patient reported outcomes in spine surgery: a systematic review of the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state.

PURPOSE: While patient reported outcome measures (PROMs) define value in spine surgery, several values such as minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) help guide the interpretation of PROMs and identify thresholds of clinical significance. Significant variation exists in reported values and their calculation, so the primary objective of this study was to systematically review the spine surgery literature for metrics of clinical significance derived from PROMs. METHODS: We conducted a query of PubMed/MEDLINE and Scopus databases from inception to January 1, 2023, for studies that derived quantitative metrics (e.g., SCB, MCID, PASS) from PROMs in the setting of spine surgery with minimum 1-year follow-up. Details regarding the specific PROMs were collected including which PROM was measured, whether anchor- or distribution-based methods were utilized, the specific calculations, and the recommended value for a given PROM based on all evaluated calculations. RESULTS: Thirty-seven studies of 21,780 patients were included. The most commonly evaluated PROM-derived value was the MCID (n = 28), followed by PASS (n = 6) and SCB (n = 4). Twenty-one studies only utilized anchor-based calculations, 15 utilized both anchor-based and distribution-based methods, and one only utilized distribution-based calculations. The most commonly evaluated legacy PROMs were the Oswestry Disability Index (ODI) (N = 11, MCID range 4-20) and visual analog scale back pain (N = 5, MCID range 0.5-4.6). All 10 studies that derived SCB or PASS utilized the receiver operating characteristic methods. Among the six studies deriving a PASS value, four only evaluated ODI, identifying PASS ranging from 5 to 22. CONCLUSION: While calculated measures of clinical significance such as MCID, PASS, and SCB exist, significant heterogeneity exists in the current literature. Current shortcomings include a wide variability of reported value thresholds across the literature, and limited applicability to more heterogenous patient populations than the targeted cohorts included in published investigations. Continued investigations that apply these methods to heterogenous, large-scale populations can help increase generalizability and validity of these measures. LEVEL OF EVIDENCE: III.

Impact of mental health components on the development of back pain in young adults with adolescent idiopathic scoliosis.

BACKGROUND: Back pain occurs commonly in adults and is multifactorial in nature. This study aimed to assess the prevalence and intensity of back pain during young adulthood in subjects with adolescent idiopathic scoliosis (AIS), as well as factors that may be associated with its prognosis. METHODS: Subjects with AIS aged 20-39 treated conservatively were included in this study. Patient-reported outcome measures in adulthood involved episodes of back pain, and scales of self-image, depression, anxiety, and stress. Additionally, pain, self-image, and mental health scores were retrieved at the first clinic consultation. Occurrence of back pain was defined as a numeric pain rating scale ≥ 6. RESULTS: 101 participants were enrolled. The prevalence of back pain in the lifetime, past 12 months, past 6 months, past 1 month, past 7 days, and past 24 h were 37%, 35%, 31%, 27%, 23%, and 20%, respectively. Male, self-image, and depression were significant associated factors for the development of back pain at all time points. Furthermore, the analyses of the initial presentation of participants have shown that participants with back pain in adulthood were characterised by poor self-image and mental health during their adolescence. CONCLUSION: The present study addressed the natural history of back pain in young adults with conservatively treated AIS. Psychological makeup has been shown to constitute the development of back pain and is strongly hinted as an early sign of having back pain in adulthood among subjects with AIS.

Spondylodiscitis-a cohort analysis of its identification and management.

PURPOSE: Discitis represents infection of the intervertebral disc and osteomyelitis of the adjacent end plates. Classically, patients present with fever and back pain. Varied presentations and lack of adherence to guidelines lead to great variation in its identification and management. The primary objective of this study was to conduct a cohort analysis, assessing the identification and management of discitis, in a busy secondary orthopaedic centre. METHODS: A retrospective study was conducted, of cases diagnosed and treated for discitis, in a secondary orthopaedic department, within the UK from January 2017 to October 2019. During this time period, all patients who underwent magnetic resonance imaging (MRI) spine were identified. Patients with MRI-proven discitis were then added into the study. RESULTS: A total of 152 MRIs showed radiographic features of discitis. Of these, only 38 had a clear clinical correlation. Back pain was the most common presenting complaint followed by fever. The commonest site of involvement was vertebral levels L5 and S1. All patients had baseline bloods, and most, but not all, had blood cultures taken. Staphylococcus aureus was the most frequently isolated, causative organism. The mainstay of treatment was intravenous flucloxacillin, with most patients requiring a minimum of six weeks. CONCLUSION: Our study has helped define the population of patients presenting with discitis, in a busy secondary orthopedic center. Analyzing over two years of data has provided us with valuable insight into the most appropriate diagnostics and management for discitis.

A clinical decision support system in back pain helps to find the diagnosis: a prospective correlation study.

The aim of this study is to show the concordance of an app-based decision support system and the diagnosis given by spinal surgeons in cases of back pain. 86 patients took part within 2 months. They were seen by spine surgeons in the daily routine and then completed an app-based questionnaire that also led to a diagnosis independently. The results showed a Cramer's V = .711 (p < .001), which can be taken as a strong relation between the tool and the diagnosis of the medical doctor. Besides, in 67.4% of the cases, the diagnosis was concordant. An overestimation of the severity of the diagnosis occurred more often than underestimation (15.1% vs. 7%). The app-based tool is a safe tool to support healthcare professionals in back pain diagnosis.

[Multiprofessional treatment approach in chronic back pain]. / Multiprofessioneller Behandlungsansatz bei chronischen Rückenschmerzen.

International guidelines recommend involving various professions and disciplines at an early stage in the event of chronic back pain. In connection with this, terms such as multiprofessional or interprofessional interventions are often mentioned without a uniform idea of what they mean. This article is intended to provide an overview of multiprofessional interventions for patients with chronic back pain and the integration into a meaningful interdisciplinary and interprofessional multimodal treatment concept. This is illustrated in a biopsychosocial pillar model, which should be pursued for each patient individually.

[Internal differential diagnoses in acute back pain : An internal perspective on the possible causes of acute back pain]. / Internistische Differenzialdiagnosen bei akuten Rückenschmerzen : Eine internistische Perspektive zu den möglichen Ursachen von akuten Rückenschmerzen.

The majority of patients with acute back pain have no serious underlying disease; however, many internal diseases can be manifested as acute or chronic back pain. Therefore, in the assessment of patients with back pain the clinical history and clinical examination are important in order to detect indications for a possible underlying disease. Particularly red flags that indicate an acute or life-threatening disease should not be missed. In most cases where such red flags, risk factors or clinical indications are not present, no systematic search for internal underlying diseases is necessary. This article summarizes the most relevant differential diagnoses and clinical indications as well as warning symptoms.

[Lower Back Pain - Specific or Non-Specific?] / Rückenschmerzen.

Lower Back Pain - Specific or Non-Specific? Abstract. Lower back pain is a challenge. A diagnosis that is as accurate as possible is significant for both the treating physician and the patient. With a precise examination, it is often possible to narrow down even the less specific back pain (the so-called "non-specific back pain") and assign it to a clinical syndrome.

[The role of structure-modifying agents in the treatment of back pain].

BACKGROUND: Back pain is currently one of the most urgent problems within pain syndromes. Inadequate treatment of nonspecific back pain, even with a relatively favorable prognosis, leads to its chronicity and decreases the patient's quality of life. The most common cause of vertebrogenic dorsopathies is spinal osteochondrosis. The etiopathogenetic basis of spinal osteochondrosis is degenerative and dystrophic changes in the intervertebral discs involving adjacent vertebrae, joints, and ligaments. Considering the experience of many years of using chondroprotective therapy in clinical practice, we performed an observational study using Ambene Bio to assess the change of pain severity over time in patients with osteochondrosis and back pain. AIM: To study the change in the severity of pain and its components in patients with back pain during therapy with Ambene Bio combined with standard therapy (NSAIDs and muscle relaxants). MATERIALS AND METHODS: Fifty-one patients with chronic lower back pain lasting more than 3 months were included in the study. CONCLUSION: The study results confirmed the high efficacy of Ambene Bio in patients with dorsopathies with an alternating treatment regimen (10 IM injections 2 mL every other day).

Diagnostic delay is common for patients with axial spondyloarthritis: results from the National Early Inflammatory Arthritis Audit.

OBJECTIVES: Updated guidelines for patients with axial SpA (axSpA) have sought to reduce diagnostic delay by raising awareness among clinicians. We used the National Early Inflammatory Arthritis Audit (NEIAA) to describe baseline characteristics and time to diagnosis for newly referred patients with axSpA in England and Wales. METHODS: Analyses were performed on sociodemographic and clinical metrics, including time to referral and assessment, for axSpA patients (n = 784) recruited to the NEIAA between May 2018 and March 2020. Comparators were patients recruited to the NEIAA with RA (n = 9270) or mechanical back pain (MBP; n = 370) in the same period. RESULTS: Symptom duration prior to initial rheumatology assessment was longer in axSpA than RA patients (P < 0.001) and non-significantly longer in axSpA than MBP patients (P = 0.062): 79.7% of axSpA patients had symptom durations of >6 months, compared with 33.7% of RA patients and 76.0% of MBP patients. Following referral, the median time to initial rheumatology assessment was longer for axSpA than RA patients (36 vs 24 days; P < 0.001) and similar to MBP patients (39 days; P = 0.30). Of the subset of patients deemed eligible for early inflammatory arthritis pathway follow-up, fewer axSpA than RA patients had disease education provided (77.5% vs 97.8%) and RA patients reported a better understanding of their condition and treatment. CONCLUSION: Diagnostic delay in axSpA remains a major challenge despite improved disease understanding and updated referral guidelines. Disease education is provided to fewer axSpA than RA patients, highlighting the need for specialist clinics and support programmes for axSpA patients.

A clinical tool to identify older women with back pain at high risk of osteoporotic vertebral fractures (Vfrac): a population-based cohort study with exploratory economic evaluation.

BACKGROUND: osteoporotic vertebral fractures (OVFs) identify people at high risk of future fractures, but despite this, less than a third come to clinical attention. The objective of this study was to develop a clinical tool to aid health care professionals decide which older women with back pain should have a spinal radiograph. METHODS: a population-based cohort of 1,635 women aged 65+ years with self-reported back pain in the previous 4 months were recruited from primary care. Exposure data were collected through self-completion questionnaires and physical examination, including descriptions of back pain and traditional risk factors for osteoporosis. Outcome was the presence/absence of OVFs on spinal radiographs. Logistic regression models identified independent predictors of OVFs, with the area under the (receiver operating) curve calculated for the final model, and a cut-point was identified. RESULTS: mean age was 73.9 years and 209 (12.8%) had OVFs. The final Vfrac model comprised 15 predictors of OVF, with an AUC of 0.802 (95% CI: 0.764-0.840). Sensitivity was 72.4% and specificity was 72.9%. Vfrac identified 93% of those with more than one OVF and two-thirds of those with one OVF. Performance was enhanced by inclusion of self-reported back pain descriptors, removal of which reduced AUC to 0.742 (95% CI: 0.696-0.788) and sensitivity to 66.5%. Health economic modelling to support a future trial was favourable. CONCLUSIONS: the Vfrac clinical tool appears to be valid and is improved by the addition of self-reported back pain symptoms. The tool now requires testing to establish real-world clinical and cost-effectiveness.