Learning outcomes:
• Develop awareness of the clinical presentation of axial spondyloarthritis, research evidence on diagnostic delays and impacts, and importance of screening for spondyloarthritis in musculoskeletal assessments.
• Develop knowledge of signs, symptoms and risk factors for axial spondyloarthritis, role of blood tests and imaging in suspicion, and guidance on referral to rheumatology.
• Gain practical skills in history-taking and clinical examination for suspected spondyloarthritis and associated extra-articular manifestations, skin and nail examination, and structuring a good referral.

Description:
Spondyloarthritis is a group of inflammatory conditions that mimic common musculoskeletal problems. Delays in diagnosis average up to 8-9 years for many people (1), because it is often not recognised in assessments(2,3). Screening for suspected spondyloarthritis (SpA) and when to refer onto rheumatology needs to be a core skill of musculoskeletal clinicians(4,5).
Musculoskeletal clinicians are key to early diagnosis and reducing the significant impacts of this inflammatory disease. Spondyloarthritis can be challenging to recognise and often mistaken as chronic mechanical low back pain or unrelated tendon and joint problems(4,5). Research shows that the inflammatory disease links between persistent back pain, peripheral problems and extra-articular inflammatory manifestations are often missed in clinical practice(2).
Knowing features that raise suspicion of spondyloarthritis and when to refer onto rheumatology is an important aspect of musculoskeletal practice. Research also indicates that musculoskeletal clinicians report a lack confidence and awareness in screening for axial spondyloarthritis (3,6), added to by a paucity of literature on axial SpA in musculoskeletal professional literature(7).
NICE (2017) has developed guidance to support earlier recognition, diagnosis, treatment and other important considerations with SpA. This is supported by increasing research, international campaigns and the development of increasing resources to support earlier diagnosis(8,9).
This course aims to enable clinicians to develop clinical knowledge and skills to screen for suspected spondyloarthritis within musculoskeletal assessments and when to refer to Rheumatology. It will also outline research and resources available to support their clinical practice in screening for these conditions.

Symposium format:
Chair – Dr Carol McCrum will introduce the symposium .and provide an outline of the sessions and practical activities.

Presenter 1- Will Gregory, Consultant Physiotherapist in Rheumatology, will introduce the and relevance of screening for Axial Spondyloarthritis in musculoskeletal assessment. Will then will discuss research showing the global issue of delayed diagnosis and the importance of early recognition of axial spondyloarthritis to enable early intervention and better outcomes. Patient perspectives on the impact of axial spondyloarthritis and of delayed diagnosis will be given through research on patient experiences and video accounts of experiences. The session will close with an overview of the Rheumatology Physiotherapy Specialist Capabilities Framework: Screening in Musculoskeletal Settings that outlines required inflammatory knowledge and skills of musculoskeletal clinicians.

Presenter 2- Eliza Steen, Advanced Practice Physiotherapist in Spinal Assessment Service, will discuss her research on the awareness, confidence and knowledge of physiotherapists of axial spondyloarthritis across a range of roles and settings. She will discuss findings on the lack of recognition of features of axial spondyloarthritis within back pain presentations, the consequences and need for supporting screening skills for this inflammatory disease in musculoskeletal clinical practice.

Presenter 3- Dr Carol McCrum, Consultant Physiotherapist in Rheumatology, will lead interactive talks outlining the latest research on signs, symptoms and risk factors for axial spondyloarthritis, features of inflammatory back pain, and when to suspect axial spondyloarthritis. She will discuss blood tests, imaging and interpretation concerning axial spondyloarthritis. Carol outline referral criteria provided by NICE Guidance on Spondyloarthritis (2017) and involve participants in using other resources to support when to refer for possible axial spondyloarthritis. There will be interactive quizzes and question and discussion time across the session.

Presenter 4- Hannah Chambers will lead practical sessions on screening for axial spondyloarthritis, including: history-taking, case studies and clinical-reasoning vignettes to support knowledge and skills on suspicion and referral through group workshops; practical session on questioning on extra-articular manifestations; skin examination; axial and peripheral physical examination skills; features of good referral letter. The session will close with post-workshop quiz on awareness, confidence and knowledge of screening for axial spondyloarthritis.

Chair- Dr Carol McCrum will host a panel Q&A and then summarize key learning and close.

Implications/Conclusions:
Axial spondyloarthritis has often been missed across multiple assessments of back pain, joint and tendon problems in people’s journey to diagnosis. Resulting impacts on disease outcomes, quality of life, complications, psychological health and workability can be devastating. Early recognition and referral is key. Screening for axial spondyloarthritis in back, tendon and joint problem presentations needs to be a core musculoskeletal skill.

References
1.Gregory WJ et al.(2022)Survey of Diagnostic Delay in Axial Spondyloarthritis Across Two National Health Service(NHS) Rheumatology Services.Cureus,30;14(3):e23670
2.McCrum C et al.(2019)Unrecognised Masquerader:Retrospective review of people presenting to musculoskeletal physiotherapy with undiagnosed spondyloarthritis.Physiotherapy,105,e102.
3.Stee, E, Cairns,M, McCrum,C(2021)Physiotherapist’ awareness, knowledge and confidence in screening and referral of suspected Spondyloarthritis:Survey of UK clinical practice.Musculoskeletal Care.
4.McCrum C(2019)Appraisal of Clinical Practice GuidelineJournal of Physiotherapy,65(4),242.
5.McCrum C(2019)Editorial -When to suspect spondyloarthritis.Musculoskeletal Science and Practice,41(iii),
6.McCrum, C.(2020)Delaying Diagnosis: inflammatory back pain and other features of suspected spondyloarthritis rarely featured in musculoskeletal health professions literature. Rheumatology,22(Supp_2)
7.MacMillan,A et al.(2021)Masterclass: Axial spondyloarthritis for osteopaths and manual therapists.IntJOsteopMed(41)45-56.
8.Rheumatology_Physiotherapy_Capabilities_Framework_vFINAL_Interactive.pdf (macpweb.org)