AB0718 IDENTIFYING AXIAL SPONDYLOARTHRITIS IN THE UNITED STATES: A POSSIBLE ROLE FOR CHIROPRACTORS
Authors: Atul Deodhar, Shireesh Bhalerao
Journal: Annals of the Rheumatic Diseases (2019)

<h3>Background</h3> Approximately 19% of the general population in the United States has chronic back pain (CBP), with 5%-6% of these cases classified as inflammatory back pain (IBP).<sup>1</sup> according to the US National Health and Nutritional Examination Survey, ≈ 15% of patients with IBP have axial spondyloarthritis (axSpA),<sup>1,2</sup> which can cause irreversible structural damage in the spine, loss of function, and a decreased quality of life. The diagnosis of axSpA is commonly missed, as patients seek care for back pain (BP) from a variety of non-rheumatology providers, including chiropractors.<sup>3</sup> Overall, nearly 50% of patients seek chiropractic care for BP.<sup>4</sup> However, not much is known about the prevalence of different types of BP (acute, chronic, IBP, and BP due to axSpA) in patients seeking chiropractic care in the United States. <h3>Objectives</h3> To investigate the types of providers sought by patients with BP and the prevalence of acute BP, CBP, IBP, and axSpA in patients with BP seeking chiropractic care in the United States. A secondary objective was to investigate how frequently chiropractors refer patients with BP to a rheumatologist. <h3>Methods</h3> PubMed literature searches were performed for all English language articles published through December 2017 to determine which providers are sought by patients with BP as well as the percentage of patients with BP being referred to a rheumatologist following chiropractic consultation. Search terms included "chiropractic," "chiropractor," "axial spondyloarthritis," "ankylosing spondylitis," "inflammatory back pain," "chronic back pain," "acute back pain," "low back pain," "sacroiliac joint," "sacroiliac pain," "back pain epidemiology," "rheumatologist," and "rheumatology." the full text of relevant articles was evaluated for specific data and BP statistics in this care setting. <h3>Results</h3> Only 7 articles that described the types of providers sought by patients with BP were identified (Table 1). Among patients with BP, 7%-45% sought chiropractic care; 26%-70% sought care from general practitioners, and 3%-37% sought care from rheumatologists. Patients who sought chiropractic care were mainly white, female, aged &lt; 65 years old, and of higher socioeconomic and education status. Patients with CBP seeking rheumatologic care had a mean duration of CBP of 14-28 years and were mostly women (56%; age range, 41-50 years)<sup>5</sup>; of these, 1% were referred to a rheumatologist by chiropractors for symptoms suggestive of SpA.<sup>5</sup> Data regarding the prevalence of different types of BP (eg, acute, CBP, IBP) in US chiropractic practices were not available. No articles describing axSpA in patients in chiropractic care were identified. <h3>Conclusion</h3> Chiropractors, as primary spine care providers in the United States, are playing an increasingly larger role in the diagnosis and treatment of BP, with 7%-45% of patients with BP seeking chiropractic care. However, there are conflicting data on the types of BP treated by chiropractors in the United States. Nonetheless, since approximately 15% of patients with IBP have axSpA,<sup>1,2</sup> it is very likely that many patients seeking care from chiropractors in the United States have undiagnosed axSpA. This reveals a need for a systematic investigation for the presence of axSpA among patients being treated by chiropractors. Specific educational strategies targeted to chiropractors should be applied to increase awareness of axSpA and achieve early referral to rheumatologists for these patients. <h3>References</h3> [1] Weisman MH, et al. Ann Rheum Dis. 2013;72:369-373. [2] Reveille JD, et al. Arthritis Care Res (Hoboken). 2012;64:905-910. [3] Danve a, et al. Clin Rheumatol. 2018Dec26. [Epub ahead of print]. [4] Beliveau PJH, et al. Chiropr Man therap. 2017;25:35. [5] Deodhar a, et al. Arthritis Rheumatol. 2016;68:1669-1676. <h3>Disclosure of interests</h3> Atul Deodhar Grant/research support from: abbVie, amgen, Eli Lilly, GSK, Janssen, Novartis, Pfizer, and UCB, Consultant for: abbVie, amgen, BMS, Eli Lilly, Janssen, Novartis, Pfizer, and UCB, Shireesh Bhalerao: None declared