Top tips on Spondyloarthritis with Danny Murphy
1. What is Spondyloarthritis?
Spondyloarthritis (SpA) is the term for the family of diseases which affects both the joints and entheses; the enthesis is the site where tendons and ligaments join to bone. SpA can predominantly affect the back and pelvis, which is known as Axial Spondyloarthritis (Ax-SpA) or can mainly affect peripheral joints (peripheral SpA).
2. Who is at risk of Ax-SpA?
Certain groups of patients are at higher risk of developing Ax-SpA. These include patients with a personal or family history of:
- Psoriasis, or psoriatic nail disease
- Inflammatory Bowel Disease
Patients with a family history of Ax-SpA are also at increased risk.
3. What should make me suspect Ax-SpA?
There are some hallmark symptoms and signs which can help differentiate inflammatory back pain due to Ax-SpA from mechanical pain:
- Pain which is insidious in onset
- Pain which eases with exercise, or worsens with rest
- Early morning stiffness of longer than 30 minutes
- Nocturnal pain
- Persistent pain affecting tendon or ligament insertions
- Atraumatic joint swelling, or swelling of a whole digit.
4. I am concerned that a patient may have Ax-SpA. What investigations should I request?
The key features of Ax-SpA are clinical. Investigations such as X-rays and blood tests in patients suffering with Ax-SpA are often normal; you should not, therefore, exclude Ax-SpA based on a normal investigation result.
5. Whom should I refer?
NICE guidelines suggest that if a person has low back pain that started before the age of 45 years, which has lasted for longer than 3 months, then referral should be considered if 4 or more of the following are present:
- Low back pain that started before the age of 35 years
- Waking during the second half of the night because of symptoms
- Buttock pain
- Improvement with movement
- Improvement within 48 hours of taking non-steroidal anti-inflammatory drugs (NSAIDs)
- A first-degree relative with Ax-SpA current or past arthritis, current or past enthesitis, or current or past psoriasis.
If exactly 3 of the additional criteria are present, perform an HLA-B27 test. If the test is positive, consider referral. You can find further details about recognition and referral here.
6. How is Ax-SpA managed?
Non-steroidal anti-inflammatory drugs (NSAIDs) are well-tolerated and effective in reducing pain and stiffness in Ax-SpA; there is some evidence they may reduce the possibility of spinal fusion (ankylosis).
Disease-modifying anti-rheumatic drugs (DMARDs) are not effective in treating spinal pain or reducing damage in spinal disease.
7. What other drugs might secondary care prescribe?
Several classes of biologic drugs are effective in treating Ax-SpA; these are used if NSAIDs fail to control symptoms.
8. What about non-pharmacological management?
All patients with axial disease should be referred to a specialised rheumatology physiotherapy service; holistic care should include advice about appropriate weight loss, exercise and smoking cessation.
Depression & anxiety in Ax-SpA are common and associated with increased levels of pain and fatigue; patients should be screened opportunistically.
9. My patient with SpA is suffering with a flare. How can I help?
Flares can be managed effectively with increased doses of NSAIDs and analgesia. Gentle stretching, heat or TENS machines can help manage pain.
Increased stiffness is a common component of a flare. Patients should be encouraged that stretching and exercise will not cause damage and can help limit symptoms.
10. I’m keen to improve how I manage SpA. How can I implement change?
How high is the level of awareness about Ax-SpA amongst your colleagues and patients? Could the recent NICE guidelines be discussed at a practice education meeting? Could your practice newsletter include information about the symptoms or signs of Ax-SpA?
Identifying patients with Ax-SpA is difficult. Could you develop or use a template for the assessment of patients with back pain, which includes a reminder of the referral criteria?
Hear from the digital team
You’ve probably noticed that there have been some big changes on the new Versus Arthritis website. The Digital Team has been working to make sure all the information which we’ve moved over from the old Arthritis Research UK and Arthritis Care websites is up to date and dedicated to our professional audiences. The layout of the new website has changed a little but you will still find all the information you need in one place. If you are struggling, the search function on the Arthritis Research UK website is still working and will point you to the new website, if needed.
The main reason we’ve got a new look is to enable us to better showcase our collective work, provide a helpful resource to all of our audiences and to make sure you have the information you need. To add to this, functionality of the website has also been improved by making all pages available to view on different platforms, like tablets and mobiles. Over the next few months you’ll notice the website evolve as we continue to develop it further.
Hear from the research team
Through our pushing frontiers in health research funding call, we aim to fund research that will be directly relevant to people with arthritis and whose outputs lead to a positive change to relevant health services.
One of our grants awarded through this scheme was to Dr Celia Gregson at the University of Bristol. She is using large anonymised clinical datasets to assess hip fracture services, including how care is delivered in emergency departments, on wards, in operating theatres, and during rehabilitation. This is because, despite national guidelines, variation in care is seen across hospitals in the UK due to how health services organise hip fracture care. Findings will inform future commissioning and service planning priorities, provide reports for every hospital in England and Wales, and inform development of a new toolkit, which will be maintained by the National Osteoporosis Society.
Watch this space for more information about other projects we have funded through the scheme.
Hear from the health intelligence team
The Public Health England Fingertips musculoskeletal (MSK) diseases profile tool was updated in December 2018. The update included one new indicator (on MSK and co-morbidity) to the profiles and an update of three existing indicators. Further details of this update can be found here.
MSK conditions are the leading cause of pain and disability in England and account for one of the highest causes of sickness absence and productivity loss.
The musculoskeletal diseases profile has been designed to bring together data on a single platform, to enable the commissioning of high value musculoskeletal services. Data are provided in a user-friendly format to help local government and health services:
- understand the health needs of their populations
- see how many people are accessing services in their areas
- find out the cost and outcomes of services.
Hear from the involvement and services team
Whilst people enjoy, and get great benefits from, physiotherapy, it is often reported to us that they may not continue their exercises after group sessions are finished.
Our Services Coordinator for the East Midlands has been working with the physiotherapy team at Clay Cross Hospital in North Derbyshire to devise a model of delivering our modular self-management course alongside weekly physiotherapy sessions.
The sessions have been well received by both healthcare professionals and the participants and include topics on:
- Managing pain
- Living with arthritis
Our local Coordinator saw a need to support people to remain in contact with each other during and after completing their physiotherapy sessions, and organised regular informal meet ups with current and past session attendees to encourage networking and maintain motivation.
In January 2018 our volunteer-led Chesterfield Versus Arthritis community group was formed - affectionately called Clicky Knees and Creaky Hips. With support from the League of Friends, equipment was purchased for the group, allowing them to continue with their exercise programme.
This group of 20 + people now meets regularly to socialise and continue their physiotherapy exercises. Every person attending Clay Cross physiotherapy is also signposted to the group. The volunteer group leaders learn the exercise routines at the Clay Cross education group – some ongoing support is offered by the physiotherapy team in the form of information sheets and the occasional visit. Our volunteers show new people how the exercises are completed, provide information sheets and generally encourage everyone to continue exercising.
Following the success of the community group, we are now working with physiotherapists in the neighbouring Erewash CCG and several more across England (17 as of January 2019), delivering self-management information and supporting people to develop groups that offer longer term support for people with all types of arthritis.
If you would like more information please contact Debbie Holden at email@example.com.
Hear from the policy team
On 7 January 2019, NHS England published their Long Term Plan, which sets out a vision for the health service in England over the next five years.
The Long Term Plan recognised the growing prevalence of arthritis and musculoskeletal conditions in England, their impact on physical and mental health services and their link to obesity.
Three key elements of the plan which will impact people with arthritis are:
Ensuring joint replacement surgery within effective timescales
The majority of hip and knee replacements carried out in the NHS are for people with osteoarthritis. Delays in access to hip and knee replacements for those who need them can lead to deterioration in health and worse overall outcomes, ultimately costing the health and care system more.
Targets can play a big part in holding healthcare providers to account for providing care within a reasonable timescale for patients. That’s why it is so important to retain the right for patients to receive elective surgery – including hip and knee replacements - within 18 weeks of referral to treatment.
Whilst the Long Term Plan did not give a commitment to the 18-week target, it did include a measure to re-introduce fines for hospitals and Clinical Commissioning Groups (CCGs) who do not deliver surgery within 52 weeks, which will improve accountability in the short-term.
Supporting the mental health of people with arthritis and other long-term conditions
Mental health is a key priority in the Long Term Plan, and we were pleased to see a commitment to expanding Improving Access to Psychological Therapies (IAPT) services for people with long term conditions.
Arthritis and musculoskeletal conditions can have a huge impact on a person’s mental health, with depression and anxiety being more common for those in persistent pain. IAPT services aim to provide better treatment for people with anxiety and depression at an earlier stage.
We were pleased to see a commitment to expanding the number of physiotherapists working in primary care networks across England. This will help more people with a musculoskeletal condition to access services that are associated with better outcomes like restoring movement and function, without a GP referral.
Besides the areas we have highlighted here, the Long Term Plan includes a commitment to improving research in the NHS, with the aim that a million people will register to participate in health research by 2023/4. It also included commitments to more investment in primary and community care such as GP appointments and continued expansion of personalised care so that people can better manage their own health.
The Long Term Plan provides a starting point for improving health and care services for people with arthritis. The new commitments are important steps towards improving quality of life for people with arthritis and supporting them to live independently for longer.
However, much work is needed on the implementation of the Long Term Plan to put its commitments into practice.
Versus Arthritis is committed to working with NHS England and other partners to ensure that real progress is made for the 17.8 million people with arthritis and related conditions over the next ten years.
Start 2019 off with some education
Providing good musculoskeletal care for patients is about having the skills and confidence to make a positive diagnosis and explain what is happening to the patient. This ensures that when the patient leaves the consultation they feel empowered to self-manage.
Our Core Skills in Musculoskeletal Care workshops focus on the practical skills required in a 10-minute GP consultation. They are split into three sections: spine, lower limb and upper limb. The trainer will go through an example examination demonstration and explanation including a management plan, and small groups will be encouraged to practise this, with the aim of increasing confidence in helping patients self-manage.
A series of workshops will be delivered across the UK throughout 2019.
Is 2019 the year you aspire to become a leader?
MSK Champions Versus Arthritis
We’re delighted to announce that we’re now open for applications for the second round of the MSK Champions programme; a prestigious leadership development opportunity. Together with international business school Ashridge Executive Education, we have created a bespoke leadership initiative, which will support you to become a Champion of musculoskeletal care. You’ll join a galvanized community of role models and ambassadors who champion change and work together to improve musculoskeletal care across the whole of the UK.
Are you passionate about leading change in MSK care?
If so, applications for the second cohort are now live and the programme will start in June 2019.