THU0723-HPR Nice guidance on spondyloarthritis: recommendations supporting recognition and referral by physiotherapists & podiatrists
Authors: C. McCrum
Journal: Annals of the Rheumatic Diseases (2018)

<h3>Background</h3> Physiotherapists and podiatrists are key to earlier diagnosis of spondyloarthritis (SpA) and have an essential role in assessing for signs, symptoms and risk factors in people with joint, tendon or back pain. Spondyloarthritis can be a challenge to recognise and often mistaken as chronic back pain or unrelated tendon and joint problems. Symptoms can move around, flare and settle, and links between back pain, peripheral problems and extra-articular conditions can be missed. <h3>Objectives</h3> This presentation raises awareness of recent NICE guidelines on Spondyloarthritis<sup>1</sup> and provides an overview of recommendations on recognition and referral relevant for physiotherapists and podiatrists. <h3>Methods</h3> The guideline was developed using standard NICE guideline methodology. Quality ratings of evidence applied GRADE methods based on quality of available evidence for assessed outcomes. When standard methodology could not be applied, customised quality assessments provided narrative summaries or customised GRADE tables. Recommendations were developed by a multispecialty development group which included people with SpA and review by stakeholder organisations informing the final version. <h3>Results</h3> NICE guidance offers recommendations for suspecting axial and peripheral presentations and when to refer to rheumatology for assessment. These are based on the evidence for signs, symptoms and risk factors that increase the likelihood that a person may have SpA. The guidance highlights that SpA can occur with negative HLA B27, normal inflammatory markers and not to exclude SpA based on any one sign, symptom or test result. Referral is recommended for suspected axial spondyloarthritis with back pain lasting &gt;3 mths with onset before 45 years of age plus four or more additional features: Onset before 35 years; Woken second half of night by symptoms; Buttock pain; Improves with movement; Improves within 48 hours of taking NSAIDs; First-degree relative with SpA or psoriasis; Current/past enthesitis; Current/past psoriasis; Current/past uveitis plus psoriasis or if HLAB27 positive).<sup>1 2</sup> Morning stiffness lacked specificity as a referral criterion for axial SpA however prolonged morning stiffness remains important in suspecting inflammatory disease. Referral is recommended for suspected peripheral SpA if a person presents with dactylitis; or with persistent or multiple-site enthesitis (inflammation at tendon/ligament attachment to bone) without apparent mechanical cause plus if any of the following: back pain without apparent mechanical cause; current/past psoriasis, inflammatory bowel disease or uveitis; first degree relative with SpA or psoriasis; or symptom onset following gastrointestinal or genitourinary infection. <h3>Conclusions</h3> Recognising possible signs, symptoms and risk factors of spondyloarthritis is an essential aspect of clinical practice for clinicans assessing musculoskeletal probblems. Recent NICE guidance offers advice on suspecting SpA and when to refer to rheumatology for assessment to support earlier diagnosis, treatment and reduce the significant impacts of these conditions. <h3>References</h3> [1] NICE. (2017) Spondyloarthritis in over 16s: diagnosis and management. www.nice.org.uk/guidance/ng65 [2] Haroon M, et al. Ann Rhuem Dis2015;74(11):1990–5. <h3>Acknowledgements</h3> Dr Carol McCrum was on the guideline development committee and has a NICE Fellowship to raise awareness and support implementation of these guidelines <h3>Disclosure of Interest</h3> None declared