Conference Coverage

Around 10% of back pain patients referred by chiropractors have undiagnosed SpA



– Over 10% of patients referred by chiropractors to rheumatology had undiagnosed spondyloarthritis, with axial spondyloarthritis being the most common, according to new data. The U.S. study was aimed at understanding what proportion of back pain patients have undiagnosed spondyloarthritis.

The study also found that the most common cause for which patients see chiropractors is neck/cervical pain.

Atul Deodhar, MD, MRCP, rheumatologist and medical director of rheumatology clinics at Oregon Health & Science University, Portland, was senior author of the poster that was presented at the 13th International Congress of Spondyloarthritides.

Dr. Atul Deodhar, Oregon Health & Science University, Portland

Dr. Atul Deodhar

“In the U.S., many people with back pain go to chiropractors, but many chiropractors are not aware of axial spondyloarthritis [axSpA] terminology, and very little – if anything – is published in chiropractic literature, “ he said in an interview.

He remarked that the study highlighted the need to develop a better strategy to identify undiagnosed patients, because the yield found in their study was poor (13%). “Patient-reported spondyloarthritis criteria are often poor, and do not match rheumatologist-inquired history,” he noted, adding that, “inflammatory back pain is in fact a poor ‘entry point.’ ”

Ulrich Weber, MD, rheumatologist from the Practice Buchsbaum in Schaffhausen, Switzerland, commented on the findings, saying he often receives delayed referrals from chiropractors, so “it would be very useful if patients could be more easily and accurately identifiable via this route, but the problem is chiropractors do not have a specific training to spot spondyloarthritis.”

He added that he welcomed the study but noted, “the criteria used to identify patients in this study are broad and I’d worry that it would inundate our rheumatology practice. There remains a real need for a good method of identifying the patients.”

Referral to rheumatology

Back pain is highly prevalent in the general population, with a global mean lifetime prevalence of 38.9%. Chiropractors treat many patients with back pain of unknown cause.

“In this study, we wanted to see what percentage of patients in chiropractic practice have undiagnosed axial spondyloarthritis, and what are the common complaints. Our hypothesis was that chiropractors may be missing such patients,” Dr. Deodhar explained.

Dr. Deodhar and colleagues recruited chiropractors from four different parts of the city of Portland into the study. “We think Portland, Oregon, is a typical U.S. city, and our results could be generalized. However, this is our impression alone,” he remarked.

Adults, under the age of 45 years who attended a participating chiropractic clinics between November 2020 and November 2021 for chronic back pain and without a prior diagnosis of spondyloarthritis were eligible for inclusion.

If the patient reported at least one feature of spondyloarthritis in the screening questionnaire they were referred to a rheumatologist for a diagnostic assessment. This assessment involved taking history by telephone, both laboratory tests and imaging, and the patients were categorized as radiographic axSpA, nonradiographic axSpA, peripheral SpA, or no SpA.

The screening questionnaire included the following examples: If the patient was under 45 years and had chronic pain in back, hip or buttocks, then they were asked for more information including whether their pain was gradual (insidious) in onset; if the pain started before the age of 40; and if the pain improved with physical activities or movements. Use of drugs was investigated including whether the pain improved significantly with NSAIDs and whether the patient has current or past heel pains, particularly when waking up in the morning. They were also asked if they have experienced skin psoriasis. Other questions were asked about the presence of uveitis, iritis, family history of psoriasis, inflammatory bowel disease, or ankylosing spondylitis, and whether the patient had unexplained joint pains plus joint swelling.


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