Bridging the Gap Between Symptom Onset and Diagnosis in Axial Spondyloarthritis.

OBJECTIVE: To evaluate a stratified screening process for the early identification of axial spondyloarthritis (SpA) with consideration of the following: 1) wait times from primary care to rheumatology screen, 2) incremental precision and accuracy from primary care to rheumatology screening, and 3) diagnostic delay. METHODS: Adults with low back pain attending primary care at low back pain clinics prospectively underwent a primary standardized clinical screening. Patients with low back pain of >3 months who experienced symptom onset at age <50 years were referred for a comprehensive secondary screening by a physical therapist with advanced rheumatology training. At secondary screening, patients with features of inflammation were classified as being at a low, medium, or high risk for axial SpA versus no risk for axial SpA. Precision and accuracy of this screening strata were measured against a rheumatologist with expertise in axial SpA. RESULTS: Overall, 405 patients underwent primary and secondary screening in the present study. The study cohort had a mean ± SD age of 36.9 ± 9.9 years, and 55% were women. HLA-B27 was present in 14.4% of patients. Median wait time from primary screening to secondary screening was 15 days. Axial SpA risk assignment by rheumatologist was 64.9% for no risk or low risk for axial SpA and 35.1% for medium risk or high risk for axial SpA. The best combination of sensitivity (68%), specificity (90%), positive predictive values (80%), and negative predictive values (84%) was evident in the secondary screening. In this cohort, 15.6% of patients received a final diagnosis of axial SpA. Median low back pain duration from symptom onset to diagnosis was 2 years for nonradiographic axial SpA and 7 years for ankylosing spondylitis. CONCLUSION: A stratified interprofessional screening process can facilitate rapid diagnosis of persistent low back pain with high precision and accuracy in patients who have axial SpA.

Advancing Early Identification of Axial Spondyloarthritis: An Interobserver Comparison of Extended Role Practitioners and Rheumatologists.

OBJECTIVE: To compare clinical impression and confidence of extended role practitioners (ERP) with those of rheumatologists experienced in axial spondyloarthritis (axSpA) according to (1) evaluation of patients with chronic back pain assessed for axSpA; and (2) magnetic resonance imaging (MRI) recommendation for further investigation of these patients. METHODS: Patients with ≥ 3 months of back pain and age of onset < 45 years were referred for axSpA evaluation. An ERP assessed consecutive patients and recorded standardized clinical information in written form. Three rheumatologists subsequently evaluated each patient based on the recorded information. Patients were classified as having axSpA or mechanical back pain based on clinical and investigative findings. Level of confidence was noted for classification and MRI indication. Agreement between assessors was evaluated using percentage agreement and κ coefficient. RESULTS: Fifty-seven patients were assessed. Interobserver agreement of clinical impression for all raters was moderate (κ = 0.52). Agreement of clinical impression between ERP and rheumatologists ranged between 71.2% (κ = 0.41) and 79.7% (κ = 0.57). Agreement of clinical impression among rheumatologists ranged from 74.1% (κ = 0.49) to 79.7% (κ = 0.58). All rater agreement for MRI indication was fair (κ = 0.37). ERP agreement with rheumatologist for MRI recommendation ranged from 64.2% (κ = 0.32) to 75% (κ = 0.48). Agreement for MRI indication among rheumatologists ranged from 62.9% (κ = 0.27) to 74% (κ = 0.47). Confidence in clinical impression was similar among all practitioners. CONCLUSION: ERP with specialty training in inflammatory arthritis demonstrate clinical impressions comparable with those of rheumatologists in the assessment of axSpA. Incorporation of such roles into existing models of care may assist in early detection of axSpA.

Practice patterns of canadian physiotherapists mobilizing patients with external ventricular drains.

PURPOSE: To describe current mobilization practices of Canadian physiotherapists when treating patients with external ventricular drains (EVDs). METHODS: A quantitative, descriptive, cross-sectional study design using an online questionnaire via SurveyMonkey. An email invitation and questionnaire link was distributed in March 2010 to physiotherapists currently working with this patient population in Neurosurgical Centres across Canada. RESULTS: Respondents were 25 physiotherapists (21 full-time, 2 part-time, and 2 who did not disclose work status) working in 5 different provinces who treated ≥1 patient/month with an EVD (n=9). Slightly more than half of respondents had ≤10 years' clinical physiotherapy experience (n=14); the remainder had >10 years' experience (n=11). The majority of respondents indicated that they felt comfortable mobilizing patients with EVDs (n =19) and that it was safe to do so (n=20). Clinical experience (n=23) and safety concerns (n=25) were most commonly cited as guiding practice. More experienced physiotherapists were more likely to use out-of-bed mobilization practices. Regardless of experience, the majority of physiotherapists (20/25) ranked intracranial pressure (ICP) as the most important factor and saturation of oxygen (Spo2) as the least important factor to consider before mobilization. CONCLUSIONS: Canadian physiotherapists are mobilizing patients with EVDs, and the intensity level of their mobilization practices appears to be related to their experience level. Data from the current study may be used in developing future best-practice guidelines for the mobilization of patients with EVDs.

Objectif : Décrire les méthodes actuelles de mobilisation pratiquées par les physiothérapeutes canadiens qui traitent des patients avec des drains ventriculaires externes (DVE). Méthodes   : Étude transversale descriptive quantitative basée sur un questionnaire en ligne administré via SurveyMonkey. Une invitation électronique comportant un lien vers le questionnaire a été distribuée en mars 2010 aux physiothérapeutes qui travaillent actuellement avec cette population dans les centres de neurochirurgie du Canada. Résultats : Les répondants étaient 25 physiothérapeutes travaillant (21 à temps plein, 2 à temps partiel, 2 qui n'ont pas révélé leur statut) dans cinq provinces différentes qui ont traité ≥1 patient/mois au moyen de DVE (n=9). Un peu plus de la moitié des répondants comptaient ≤10 ans d'expérience de la physiothérapie clinique (n=14); les autres en comptaient >10 (n=11). La majorité des répondants ont indiqué se sentir à l'aise de mobiliser cette population (n=19) et qu'il était sécuritaire de le faire (n=20). L'expérience clinique (n=23) et les préoccupations en matière de sécurité (n=25) ont été les facteurs mentionnés le plus souvent comme guide de pratique. La plupart des physiothérapeutes chevronnés étaient plus susceptibles d'utiliser des méthodes de mobilisation hors du lit. Sans égard à l'expérience, la majorité des physiothérapeutes (20/25) a classé la pression intracrânienne (PIC) comme facteur le plus important et la saturation en oxygène (Spo2) comme facteur le moins important dont il faut tenir compte avant la mobilisation. Conclusions : Les physiothérapeutes canadiens mobilisent les patients en utilisant le DVE et l'intensité de leurs méthodes de mobilisation semble liée à leur expérience. Les données tirées de l'étude en cours pourront servir à établir de futurs guides de pratique clinique sur la mobilité des patients au moyen de DVE.