Background Previous studies in Ankylosing Spondylitis (AS) have reported delays in diagnosis (average 8-11 years delay). The recently published UK survey clearly shows inequalities in access to services in the UK1. Almost one-third of patients are not seen in rheumatology departments and therefore may be under-treated. This highlights a lack of awareness amongst the general public and healthcare professionals.
Objectives Our aim was to explore the current knowledge of general practitioners (GPs) with respect to mechanical (MBP) and inflammatory back pain (IBP).
Methods A questionnaire was devised to assess the approach and management of back pain in the community, undertaken by GPs attending a local educational meeting. Results were collated and analysed using Microsoft Excel.
Results Demographics:Of the 50 attendees, 43 questionnaires were completed with a response rate of 86%. 21% have a specialist interest in musculoskeletal medicine. Over 79% saw a minimum of five patients with back symptoms in a typical week. 51% felt most patients reviewed were Caucasian whilst 49% were of other ethnic minorities, predominately Asians (21%). Mechanical back pain: Only 40% of GPs were confident to diagnose MBP within the first consultation. The criteria GPs use to diagnose MBP include: pain aggravated by activity and relieved by rest (72%), sudden onset (53%) and age (44%). The majority (92%) treats MBP symptomatically without requesting any further imaging, in accordance with NICE guidelines. Whilst 5% carry out spinal x-rays or MRI scan. 65% would treat with non-steroidal anti-inflammatories (NSAIDs) and simple analgesics (60%). 75% of GPs manage MBP in the community and 26% only refer if clinical indication of bilateral radicular symptoms. Inflammatory back pain: When we explored the criteria used in routine practice to diagnose IBP we noted the following domains used: early morning stiffness >30 minutes (91%), insidious onset (63%), improvement with exercise (60%), age of onset <40 (60%) and response to NSAIDs (47%). Further enquiry into symptoms of inflammatory bowel disease (88%), psoriasis (81%) and uveitis (74%) would be performed routinely. GPs would organise CRP (91%), HLA B27 (21%) and MRI spine (19%). 67% would initially manage IBP with physiotherapy and NSAIDs. 30% would treat with NSAIDs alone. 79% would refer to a rheumatologist, with 88% within 2-4 visits by the patient to primary care. General: 79% had patients with back pain in employment. 93% would administer a sick note, usually of 2-4 week duration (72%). The majority of GPs only had between 1-2 AS patients within their practice and surprisingly only 14% were aware that the prevalence of AS is twice as common as multiple = “multiple” sclerosis.
Conclusions We observed from our survey that MBP is very well managed as per NICE guidelines in the community2. When prompted GPs are more confident in utilising set criteria to identify IBP. Although GPs have awareness of IBP, whether this is applied in routine clinical practice needs to be further investigated. It is crucial not only to educate GPs to recognise IBP in young men and women in their productive age group but also to raise awareness of the new treatment available to halt disease progress and disability.
Hamilton et al. Services for people with ankylosing spondylitis in the UK – a survey of rheumatologists and patients. Rheumatology 2011; 50: 1991-1998
CG88 Low back pain: NICE guidance - http://www.nice.org.uk/nicemedia/live/11887/44343/44343.pdf
Disclosure of Interest None Declared