The fourth BRITSpA Annual Scientific meeting took place on 12th and 13th September 2018 in Birmingham. The scientific programme for this meeting was developed independently by this year's meeting chairmen Raj Sengupta and Karl Gaffney and the Executive Committee of BRITSpA. CPD accreditation was awarded to all delegates and speakers. Dr Tom Williams from the Royal United Hospitals Bath NHS Foundation Trust has written an insightful summary of this year's meeting's sessions.
In his role as NASS Chief Executive Officer, Dr Dale Webb discussed the ways NASS are attempting to identify current shortcomings in care for axSpA patients and support quality improvement by:
-Increasing knowledge of effective care and what’s needed to deliver this.
-Creating performance benchmarks as drivers of quality improvement.
-Building the will to improve care by engaging the public, political and healthcare decision-makers.
NASS welcome the NICE quality standards but these are not currently matched by policy levers to effect positive change. In particular there remains a poor understanding of the patient view of high quality care, reasons for variation in care and the impact of axSpA on mental health. Current NASS initiatives include:
-Establishing an All-Party Parliamentary Working Group to work with NICE and hold providers to their quality standards.
-Engagement with other specialties who have overlap with axSpA eg Back Pain Plus campaign.
-Championing excellence by identifying high performing care arrangements across all sectors, disseminate best practice and support innovation, with the aim of developing axSpA Centres of Excellence.
Dale recognised the anxiety that the last of these ideas in particular may cause for some clinicians and centres, however emphasised that the aim of the axSpA Centres of Excellence would be to support other centres in driving quality improvement as opposed to centralising services.
Dr Stefan Siebert gave an overview of the objectives and methods for the BAxSIC, which is a prospective, longtitudinal, observational, multi-centre early axSpA cohort. The primary objectives are to assess the impact of delay to diagnosis on axSpA patients along with the impact of diagnosis on natural history, work, pain, fatigue, co-morbidity and functional outcome. Secondary objectives are to identify early predictors of disease outcome and the impact of biologic use.
The BSR National Clinical Audit of Early Inflammatory Arthritis provides a potential resource for recruiting an early back pain cohort, with patients providing contact e-mail addresses and indicating their willingness to participate in further studies such as BAxSIC . Patients who consent to recruitment will be asked to complete questionnaires at baseline, 6 months and 12 months, at which point they will be asked again for consent to continue 6-monthly questionnaire completion thereafter.
Stefan was keen to emphasise the importance recruiting early inflammatory back pain patients to the audit, getting their e-mail addresses and asking whether they would be willing to be contacted about further studies, such as BAxSIC.
This year’s shortlisted abstracts came from Portsmouth, Norfolk and Norwich and Bath. Read more here.
The 2018 BRITSpA Abstract Winner was Charles Bridgewood from the University of Leeds for his abstract entitled:
“An Entheseal Innate Immune Cell Biological basis for differential efficacy of PDE4 and IL-23 pathway blockade between Psoriatic Disease and Rheumatoid Arthritis”
Dr Anushka Soni gave a gave a comprehensive overview of the complex mechanisms of chronic pain in axSpA and comparable long-term conditions. In particular she emphasised the non-linear relationship between nociception and pain, and highlighted the frequency and relevance of neuropathic and nociplastic pain. To illustrate this, she noted that OA patients receiving total knee replacement with high pre-operative levels of neuropathic pain had poorer post-operative outcomes.
Novel imaging techniques, such as functional brain MRI, are improving our understanding of these complex mechanisms and has highlighted a “pain matrix” involving multiple discrete areas of the brain. Anushka also highlighted the important role that clinicians can play in conditioning patients with chronic pain prior to interventions- patients who understand the purpose and expected outcome of an intervention for their chronic pain (eg initiation of an analgesic medication) are more likely to achieve a positive response to it. Changing the patient’s focus from their chronic pain to a more functional, task-orientated view can also result in improved levels of pain.
Dr Linda Dean focussed on the impact of AxSpA on occupational outcomes in both biologic-treated and biologic-naïve cohorts over 3 years. 62% of patients were in paid employment throughout follow-up, of whom 19% reported some absenteeism and 79% reported some presenteesim. Overall, AxSpA resulted in approximately 1.5 days per week of lost economic productivity. Absenteeism was the strongest predictor of future job loss. Absenteeism was predicted by previous presenteeism, along with having a physically demanding job and having peripheral joint arthritis. Presenteeism was predicted by high BASDAI, BASFI and fatigue scores, along with having a physically demanding job. Occupational outcomes were better in the biologic-treated versus biologic-naïve cohorts, equivalent to half a day per week of work productivity. These findings may help in developing the health economic case for treating AxSpA patients with biologic drugs.
Dr Joanna Shim reported on the impact of delay to diagnosis in BSRBR-AS (or more specifically the delay from symptom-onset to first review by a rheumatologist). Overall, the median delay to axSpA diagnosis in this cohort was 6 years, with a trend towards shorter delays over time. Patients with greater than 6 years delay were compared to those with less than 6 years delay in order to identify predictive factors and compare outcomes. Outcome measures at 12 months were not found to be significantly different between the 2 groups. Patients experiencing longer delays to diagnosis were more likely to have:
-mNY criteria x-ray evidence of Ankylosing Spondylitis
-a positive family history of AxSpA
-been HLA-B27 tested at some point
-a history of uveitis
-greater cumulative smoking and alcohol exposure
-more likely to be employed (no differences seen in rates of absenteeism and presenteeism)
-greater levels of chronic widespread pain (though not fulfil FMS classification criteria)
Dr Lesley Kay gave an overview of the BSR National Clinical Audit of Early Inflammatory Arthritis. She particularly highlighted the benefits this could have to provide departmental feedback on performance (available quarterly from January 2019 onwards) and in driving quality improvement. To this end it could assist with the NHS Getting It Right First Time (GIRFT) campaign, which aims to identify any unwarranted variation in quality or cost between departments. Lesley emphasised the need to ensure that we appropriately recruit axSpA patients to the audit.
Dr Edwin Lim presented the evidence for the usefulness of HLA-B27 testing in suspected axSpA patients. HLA-B27 likely accounts for about 25% of the heritability of axSpA, and the polygenic heritability of axSpA remains poorly understood.
HLA-B27 positive people are sixteen times more likely to develop axSpA than the general population, however without clinical context, its positive predictive value as a diagnostic test for axSpA is only approximately 5%. This increases significantly in the context of chronic lower back pain with young age of onset, and yet further if back pain is inflammatory in character.
HLA-B27 can be a useful prognostic as well as diagnostic risk marker, in that it is a predictor of positive response to biologic therapy and can be used in combination with other biomarkers to predict radiographic progression and extra-articular manifestations of axSpA.
What do patients mean by fatigue? – Nathan Pearson, Warwick
Patients with axSpA who report fatigue frequently describe a lack of predictability or clear trigger for fatigue, cognitive difficulties, a feeling of isolation and a tendency to ring-fence and prioritise work over personal and family life, potentially aggravating this symptom. Nathan Pearson argued that our current tools for measuring fatigue in axSpA, such as question 1 on BASDAI and FACIT score, do not adequately distinguish fatigue from energy levels, which patients frequently regard as separate entities. To address this, Nathan has been working with patients to develop a new axSpA-specific measure known as the Warwick axSpA Tiredness and Energy (WASTEd) questionnaire, details of which can be found elsewhere on the BRITSpA website:
Fatigue- science behind the symptoms and optimising management – Dr Neil Basu, Glasgow
Fatigue is the strongest predictive factor for work-related presenteeism and activity impairment in axSpA, however its causative mechanisms remain poorly understood. Dr Neil Basu gave an overview of what is known to date along with potential future developments to enhance our understanding of this topic.
Accepting their limitations, neuroimaging studies suggest that the medial pre-frontal cortex and inferior parietal lobule may be key central mediators of inflammation-derived fatigue. Computerised data modelling may help improve our understanding of the mechanisms of fatigue and device technology may in future allow for targeted therapeutic intervention in a manner analogous to the use of deep brain stimulation in neurodegenerative disorders like Parkinson’s disease. Neil also highlighted that 20% of axSpA patients fulfil FMS classification criteria, and that these patients:
-have poorer quality of life outcomes
-have higher BASDAI scores (in large part influenced by question 1 being related to fatigue)
-have greater levels of work disability
-are more likely to be prescribed a biologic drug for axSpA
Neuroimaging studies have revealed DMN-Insula activity in these patients, a finding which distinguishes from inflammation-mediated fatigue.
Non-pharmacological approaches to fatigue – Dr Jane Martinadale, Wrightington
Dr Jane Martindale presented a case-based discussion highlighting the available non-pharmacological approaches for fatigue management. “Reducing Arthritis Fatigue (RAFT)” provides an example of a tailored approach for patients with rheumatic diseases such as axSpA. Jane emphasised the facilitative role that clinicians can have for problem-solving, goal setting and expectations management, all of which are integral to allowing successful self-management of fatigue.
Dr Andrew Keat led the Annual General Meeting (AGM) where an update on the charity’s financial status was presented by the Treasurer, Professor Karl Gaffney, together with an update on the website (Dr Raj Sengupta), current research activities (Dr Stefan Siebert) and membership (Professor Alex Bennett).
At the end of the AGM Dr Andrew Keat communicated the BRITSpA audience his decision to stand down as chair, having been Inaugural Chair since the earliest discussions which led to the founding of BRITSpA. He also assured the Society of a bright and progressive future by introducing his successor to the Chair, the previous vice-chair Dr Helena Marzo-Ortega.
Helena gave a vote of thanks and presented the retiring Chair with a substantial gift voucher, a framed photo of the Inaugural Executive Committee members and CME attendance certificate for this year’s ASM! Andrew thanked her, the membership and the other Executive Committee members for their support on this most rewarding venture, their warm applause and most generous presents.
Mel Martin presented the challenge of engaging patients with self-management from her perspective as a senior advanced physiotherapy practictioner. Her presentation highlighted the many complex barriers to self-management that patients encounter and the fact that patient compliance with physical activity recommendations is poor compared to their compliance with medications. Adherence is influenced by a triad of capability, motivation and opportunity. Clinicians can support axSpA patients to overcome these barriers by ensuring that they have an appropriate, personalised physical activity programme, focussing on barriers to adherence with it and evaluating its effects in exactly the same way as we would with medical interventions. Mel suggested a useful “RULE” acronym for practical tips in supporting patient self-management:
-Resist the urge to solve problems for the patient
-Understand their needs
Dr Pedro Machado presented a summary of the recommendations which will be included in the MRI consensus statement. These will recommend that the whole spine and SIJs should be imaged in all patients with suspected AxSpA, with a minimum of a sagittal spinal view with extended lateral coverage, and coronal-oblique views of the SIJs. This should include T1-weighted images to look for structural lesions (such as erosions or fatty infiltration) and a fat-suppressed, fluid-sensitive sequence (eg STIR) to identify active disease (eg bone marrow oedema).B
This abstract was also presented at EULAR in June 2018. For more information read here.
Dr Helena Marzo Ortega gave a comprehensive review of the new developments in axSpA over the past year. Highlights included:
-T1-weighted MRI imaging was found to be non-inferior to x-ray when identifying many of the structural SIJ lesions seen in axSpA (erosions, joint space change, overall appearance, though not sclerosis), when compared to a “gold standard” of CT scanning (though noting that in this study the images were read by expert reviewers).
-There remains a significant burden of under-diagnosed axSpA in patients presenting with Acute Anterior Uveitis.
-Young healthy athletes (especially hockey players) can exhibit bone marrow oedema on MRI in a similar distribution to axSpA.
-The GESPIC cohort has emphasised the relevance of radiographic progression in axSpA, in that structural damage and active disease both influence functional limitation.
-Gensler et al have demonstrated that NSAIDs have a dose-related synergistic effect in preventing radiographic progression in anti-TNF treated axSpA patients. Celecoxib seemed to be the most effective NSAID for this purpose in their study.
-ABILITY3 has looked at the safety of continuing versus withdrawing Adalimumab for maintaining remission in non-radiographic axSpA. Nearly all patients in the withdrawal group flared eventually with a mean time to flare of 4 months. Adalimumab was frequently less effective when re-introduced for this group than it had been originally.
-The rate of pre-term births is slightly higher in axSpA patients than healthy controls, though no evidence of increased foetal loss was seen.