Background:
Significant delays in diagnosis have been reported for patients with Axial Spondyloarthrtis (AxSpA) worldwide, with Norway having among the largest reported delay (mean: 10.6 years). Delayed diagnosis is associated with increased disease severity and worse outcomes for these patients. Several causes of this delay have been proposed, one being a lack of awareness of AxSpA by primary care medical professionals, such as physiotherapists.

Objectives:
To investigate Norwegian physiotherapists’ abilities to identify AxSpA and their choice of referral of these patients. Further, we investigated factors associated with correct identification of AxSpA as a possible diagnosis and correctly choosing to refer the patient for further investigations. Additionally we explored physiotherapists comfort levels with referral of patients for further investigations, and how seriously they felt medical doctors took their inquiry.

Method:
An online survey distributed in social media and professional networks was used to collect data. The survey consisted of demographic questions and vignettes presenting 4 patients with low back pain. Two vignettes were designed to represent patients with possible AxSpA. Data analysis consisted of descriptive statistics and estimated odds ratios as measures of association between demographic factors and correctly identifying AxSpA and correct referral.

Results:
149 participant responses were analyzed. 79% (95% CI, 71%-84%) identified AxSpA as a possible diagnosis in vignette 1, but only 23% (95% CI, 17%-31%) in vignette 4. Most, but not all would correctly refer these patients for further diagnostic examinations. Right to refer (OR: 5.30; 95% CI, 2.15-13.07) , an >50% caseload of low back pain patients (OR: 4.92; 95% CI, 2.11-11.46), and a master’s degree (OR: 2.49; 95% CI, 1.08-5.74) were associated with correct identification of AxSpA and referral. The majority reported to be comfortable with referral of patients with suspected underlying pathology, and appriximately half (49%) felt that medical doctors took their referral/conferral seriously, to either a large degree or a very large degree.

Conclusion:
Physiotherapists in Norway are an essential primary care health profession in the examination and management of patients with low back pain, and are responsible for identifying patients suspected of having an underlying disease. Diagnostic delays for AxSpA are long, and our findings indicate that physiotherapists are an important target for information about AxSpA as a disease, its heterogenous clinical presentation and strategies for referral of these patients in an attempt to improve the situation.