Diagnosis and Classification of Spondyloarthropathies

Original Editor - Jess Bell Top Contributors - Jess Bell

Introduction

Spondyloarthropathy is a chronic form of inflammatory arthritis which affects around 0.5-1.5 percent of the Western population.[1] It is a family of diseases, which includes axial spondyloarthritis (also known as ankylosing spondylitis), psoriatic arthritis, reactive arthritis, enteropathic arthritis and undifferentiated arthritis. These conditions affect both the axial and peripheral skeleton and have various extra-articular features.[2][3]

Diagnosis of spondyloarthropathy is a complex process and must be given by a specialist (i.e. a rheumatologist).[4] However, because of the complexities in identifying these conditions, diagnosis is often delayed.[5] For instance, axial spondyloarthritis often goes undiagnosed for five to ten years from symptom onset.[6] This is significant because early diagnosis of axial spondyloarthritis results in better outcomes in terms of disease activity, function, spinal mobility and radiographic damage, as well as better response to treatment.[5]

Significantly for physiotherapists, a prior diagnosis of mechanical back pain has been found to be an independent factor related to delays in diagnosis.[5] It is, therefore, necessary to be able to differentiate between mechanical and inflammatory back pain. For more information on differentiating these types of pain, please click here.

Various classification systems exist to improve early detection of spondyloarthropathy. This page will explore, in particular, the ASAS classification for axial spondyloarthritis, which classifies spondyloarthritis as either axial (radiographic or non-radiographic) or peripheral,[1] as well as the CASPAR criteria for psoriatic arthritis.

The following video provides insight from patients on the impact of delayed diagnosis of axial spondyloarthritis.

[7]

The next video discusses the diagnosis of inflammatory back pain from a medical perspective.

[8]

Axial Spondyloarthritis

Axial spondyloarthritis is the prototypic form of spondyloarthropathy.[4] The modified New York Classification Criteria (mNYCC) was previously used to diagnose axial spondyloarthritis.[2] The mNYCC includes clinical and radiological criteria:[9]

Radiological Criteria
Appearance of sacroiliac joints on x ray are given a grade of 0 to 4:
  • Grade 0 = normal
  • Grade 1 = suspicious changes
  • Grade 2 = minimal definite changes
  • Grade 3 = distinctive changes
  • Grade 4 = ankylosis (fusion of bones)
To meet the radiological criteria for axial spondyloarthritis, a patient has:

Grade 2, 3 or 4 sacroiliitis on both sides

OR

Grade 3 or 4 sacroiliitis on one side

As well as meeting the radiological criteria, the patient must fulfil at least one of the following clinical criteria:[9]

Clinical Criteria
  • Low back pain for at least 3 months, which is improved by exercise, but not by rest
  • Limitation in flexibility of lumbar spine
  • Reduction in chest expansion

However, structural damage is estimated to take between six and ten years to develop from symptom onset[10] and in some cases, it may not develop at all.[11] Thus, the mNYCC is unable to detect patients with early signs of axial inflammation.[10] This has added to the delay in diagnosis of axial spondyloarthritis.[2][4]

ASAS Criteria

The creation of the Assessment of Spondyloarthritis International Society Axial Spondyloarthritis (ASAS) classification criteria in 2009 has been considered a positive step forwards for research on spondyloarthropathy.[2] This classification criteria has, for the first time, enabled earlier identification of axial spondyloarthritis through magnetic resonance imaging (MRI).[2]

The ASAS also created another subgroup of axial spondyloarthritis, labelled non-radiographic spondyloarthritis (nrAxSpA). A diagnosis of nrAxSpA can be given patients who fulfil certain criteria, but who do not have radiographic sacroiliitis.[12]

It is, however, important to note that these criteria are not diagnostic in themselves. The clinician still needs to consider the whole picture.[4]

The 2009 ASAS criteria essentially incorporates two arms, an imagining arm and a clinical arm. The criteria are as follows:[12]

Patients who have had back pain for more than 3 months, with an age of onset less than 45 years, as well as:
Imaging Arm OR Clinical Arm
Sacroiliitis on imaging (i.e. active (acute) inflammation on MRI that is highly suggestive of sacroiliitis or definite radiographic sacroiliitis according to mNYCC)

PLUS

1 or more feature of spondyloarthropathy

Positive HLA-B27

PLUS

2 or more features of spondyloarthropathy

ASAS features of spondyloarthropathy are:

  • Inflammatory back pain
  • Arthritis
  • Enthesitis (heel) (i.e. inflammation of the site where tendons / ligaments insert into bone)
  • Uveitis (inflammation of the uvea)
  • Dactylitis (whole digit swelling)
  • Psoriasis
  • Chron’s / colitis
  • Good response to NSAIDs
  • Family history of spondyloarthropathy
  • HLA-B27 positive
  • Elevated CRP

Peripheral Spondyloarthritis

In 2011, the ASAS criteria was extended to better include peripheral manifestations of the disease.[13] Psoriatic arthritis, reactive arthritis, and enteropathic arthritis are largely considered peripheral conditions, although there may be some features that overlap with axial spondyloarthritis (radiographic and non-radiographic) and vice versa.[14] To be classified as having peripheral spondyloarthritis, a patient must have either:[13]

Arthritis OR enthesitis OR dactylitis, and fulfil one of the two following categories:
One or more of the following: OR Two or more of the following:
  • Uveitis
  • Psoriasis
  • Chron's / ulcerative colitis
  • Preceding infection
  • HLA-B27 positive
  • Sacroillitis on imaging
  • Arthritis
  • Enthesitis
  • Dactylitis
  • Previous inflammatory back pain
  • Family history of spondyloarthritis

This criteria was found to have a sensitivity of 77.8 percent and a specificity of 82.9 percent.[13]

Psoriatic Arthritis

Like axial spondyloarthritis, diagnosing psoriatic arthritis is challenging.[15][16] This is significant as even a six-month delay from initial symptoms to the first rheumatology appointment can contribute to peripheral joint erosions and poorer long-term physical function.[15] While various classification systems have been used to identify psoriatic arthritis, the 2006 Criteria of the Classification of Psoriatic Arthritis (CASPAR)[17] has helped to increase recognition of this condition by medical practitioners.[16] The CASPAR tool has been been found to have a specificity of 98.7 percent and sensitivity of 91.4 percent. The criteria is defined as follows:[17]

A patient must have inflammatory articular disease (joint, spine or entheseal) PLUS fulfil 3 or more of the following 5 categories:
  1. Evidence of current psoriasis, a personal history of psoriasis or a family history of psoriasis
    • Current psoriasis is defined as psoriatic skin or scalp disease, identified by a rheumatologist or dermatologist, which is present today
    • A personal history of psoriasis is defined as a history of psoriasis obtained from either the patient, family physician, dermatologist, rheumatologist, or other qualified health care provider
    • A family history of psoriasis is defined as a history of psoriasis in a first or second-degree relative, based on patient report
2. Typical psoriatic nail dystrophy including, onycholysis, pitting and hyperkeratosis, which can be observed on physical examination
3. A negative test for rheumatoid factor
4. Either current dactylitis or a history of dactylitis
5. Radiographic evidence of juxta-articular new bone formation, which appears as poorly defined ossification near joint margins (excluding osteophyte formation) on hand or foot x-rays

NB: The presence of current psoriasis is assigned two points, while all other clinical features are assigned one point.

Recognition and Referral of Spondyloarthropathy

Diagnosis of spondyloarthropathy is made by a specialist, but it is important for physiotherapists to be able to detect and refer patients who may present with concerning features to the appropriate services. The "NICE Guidelines on Spondyloarthritis in over 16s" remind clinicians in cases of suspected spondyloarthropathy that:[18]

  • Symptoms of spondyloarthritis can be diverse and difficult to identify
  • Signs and symptoms may be musculoskeletal (i.e. inflammatory back pain, enthesitis, dactylitis) or extra-articular (i.e. uveitis, psoriasis)
  • Risk factors include recent genitourinary infection and a family history of spondyloarthritis or psoriasis
  • Axial spondyloarthritis affects a similar number of women as men
  • It can occur in individuals who are not HLA-B27 positive
  • It may be present even if there is no evidence of x-ray

These guidelines recommend referral to a rheumatologist for suspected axial spondyloarthritis if a patient has had low back pain for more than three months that started before the age of 45 years as well as FOUR or more of the following criteria:[18]

  • low back pain that started before the age of 35 years - this increases the likelihood that the patient's back pain is due to spondyloarthritis when compared to low back pain that started between the age of 35 and 44 years
  • pain / symptoms that wake the patient during the second half of the night
  • buttock pain
  • pain that improves with movement
  • pain that improves within 48 hours of taking non-steroidal anti-inflammatory drugs (NSAIDs)
  • patients who have a first-degree relative with spondyloarthritis
  • patients who have current or past arthritis
  • patients who have current or past enthesitis
  • patients who have current or past psoriasis

If three of the additional criteria are present, NICE Guidelines recommend that an HLA‑B27 test is performed. If this test is positive, the patient would need to be referred to a rheumatologist for assessment.[18]

The full NICE Guidelines on when to refer patients with suspected spondyloarthropathy are available here.

Summary

While classification systems exist to aid the identification of spondyloarthropathy, there is no gold standard for diagnosis of this family of conditions. Because of the complexities and variety of symptoms, diagnosis of these conditions can be lengthy and delayed.[4]

Diagnosis is made based on the patient’s history, clinical examination, laboratory tests, imaging, and an index of suspicion around spondyloarthropathy.[4]

References

  1. 1.0 1.1 de Winter JJ, van Mens LJ, van der Heijde D, Landewé R, Baeten DL. Prevalence of peripheral and extra-articular disease in ankylosing spondylitis versus non-radiographic axial spondyloarthritis: a meta-analysis. Arthritis Res Ther. 2016; 18(1): 196.
  2. 2.0 2.1 2.2 2.3 2.4 Dubreuil M, Deodhar AA. Axial spondyloarthritis classification criteria: the debate continues. Curr Opin Rheumatol. 2017; 29(4): 317-322.
  3. Ehrenfeld M, Infection and spondyloarthropathies. In: Shoenfeld Y, Agmon-Levin N, Rose NR editors. Infection and autoimmunity. Elsevier B.V. 2015. p745-57.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 Martey C. Diagnosis and Classification of Spondyloarthropathies Course. Physioplus 2020.
  5. 5.0 5.1 5.2 Seo MR, Baek HL, Yoon HH, Ryu HJ, Choi HJ, Baek HJ, Ko KP. Delayed diagnosis is linked to worse outcomes and unfavourable treatment responses in patients with axial spondyloarthritis. Clin Rheumatol. 2015; 34(8): 1397-405.
  6. Braun J, Sieper J. Early diagnosis of spondyloarthritis. Nature clinical practice rheumatology. october 2006 vol 2 no 10  : 2C
  7. National Axial Spondyloarthritis Society. Ankylosing Spondylitis (axial spondyloarthritis) AS Getting your diagnosis. Available from: https://www.youtube.com/watch?v=_ojkHgiN3rQ [last accessed 16/11/2020]
  8. AJMCtv. Accurately Diagnosing Axial Spondyloarthritis. Available from https://www.youtube.com/watch?v=eRd3xAu9kYw&t=1s [last accessed 18/11/2020].
  9. 9.0 9.1 van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. Arthritis Rheum. 1984; 27(4): 361-8.
  10. 10.0 10.1 Deodhar A. Axial spondyloarthritis criteria and modified NY criteria: issues and controversies. Clin Rheumatol. 2014; 33(6): 741-7.
  11. Mease PJ, Heijde DV, Karki C, et al. Characterization of Patients With Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis in the US-Based Corrona Registry. Arthritis Care Res (Hoboken). 2018; 70(11): 1661-1670.
  12. 12.0 12.1 Slobodin G, Eshed I. Non-Radiographic Axial Spondyloarthritis. Isr Med Assoc J. 2015; 17(12): 770-6.
  13. 13.0 13.1 13.2 Rudwaleit M, van der Heijde D, Landewé R, Akkoc N, Brandt J, Chou CT, Dougados M, et al. The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis. 2011; 70(1): 25-31.
  14. Hauk L. Spondyloarthritis: NICE Releases Guidelines on Diagnosis and Treatment. Am Fam Physician. 2017; 96(10): 677-678.
  15. 15.0 15.1 Haroon M, Gallagher P, FitzGerald O. Diagnostic delay of more than 6 months contributes to poor radiographic and functional outcome in psoriatic arthritis. Ann Rheum Dis. 2015; 74(6): 1045-50.
  16. 16.0 16.1 Ocampo D V, Gladman D. Psoriatic arthritis. F1000Res. 2019; 8 :F1000 Faculty Rev-1665.
  17. 17.0 17.1 Taylor W, Gladman D, Helliwell P, Marchesoni A, Mease P, Mielants H; CASPAR Study Group. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum. 2006; 54(8): 2665-73.
  18. 18.0 18.1 18.2 Spondyloarthritis in over 16s: diagnosis and management. London: National Institute for Health and Care Excellence (UK); 2017 Jun. PMID: 32049469.