Douleurs inflammatoires du dos / spondylarthrite axiale

• Use culturally safe, trauma- and violence-informed care. Explain why questions matter, seek permission before sensitive topics, and adapt communication to the patient’s language, identity, culture, disability and previous health care experiences (Public Health Agency of Canada, 2018).
• Informations sociodémographiques : age, sex, gender identity, language, living arrangement, occupation, education, caregiving responsibilities, health literacy, supports and communication or access needs.

Primary concerns

• Symptom onset and course: age at onset; duration; gradual or sudden onset; first episode or recurrence; location and spread; current severity; morning stiffness; waking during the second half of the night; improvement with movement; response to rest; buttock pain, including alternating sides; and change over days, weeks and months.
• Response to anti-inflammatory medication: whether back pain improved within 48 hours of a non-steroidal anti-inflammatory drug when previously taken, including dose, duration, benefit and adverse effects. This history can support recognition but does not establish or exclude the diagnosis.
• Peripheral and extra-musculoskeletal features: current or previous acute anterior uveitis; psoriasis or nail change; inflammatory bowel disease or persistent gastrointestinal symptoms; peripheral joint swelling; heel or other enthesis pain; dactylitis; and recent genitourinary or gastrointestinal infection.
• Symptoms and functioning: pain, stiffness, fatigue, sleep, mobility, self-care, household activities, work or school, caregiving, sexual activity, physical activity, recreation, social participation and strategies used to manage symptoms.
• Revue des systèmes corporels : constitutional symptoms; eyes; skin and nails; gastrointestinal and genitourinary; cardiovascular and respiratory; neurological; musculoskeletal and bone health; sleep; and mood symptoms that may indicate an extra-musculoskeletal manifestation, comorbidity or alternative condition.
• Family and diagnostic history: first-degree relatives with axial spondyloarthritis, psoriasis, uveitis, reactive arthritis or inflammatory bowel disease; previous rheumatology assessment; documented diagnosis; HLA-B27, C-reactive protein and erythrocyte sedimentation rate results; and available radiographs or MRI reports.
• Trauma, falls and bone health: recent trauma, including low-impact events; new or focal spinal pain; osteoporosis or low bone density; previous fragility fracture; spinal fusion or marked kyphosis; falls; balance concerns; and fear of falling.
• Health and lifestyle: cardiovascular, respiratory, metabolic, neurological and mental health conditions; infection history; pregnancy or reproductive considerations when relevant; physical activity; sleep; nutrition; tobacco, alcohol and substance use; and immunization status when known.
• Medication and treatment history: current and previous non-steroidal anti-inflammatory drugs, biologic or targeted drugs, corticosteroids, analgesics and supplements; adherence; benefit; adverse effects; infection or monitoring concerns; previous rehabilitation, exercise and hands-on care; and what helped, did not help, caused harm or was difficult to continue.
• Patient perspective: understanding of the condition, priorities, preferences, cultural context, acceptable risk, confidence, concerns, expectations and previous experiences of care.
• Social determinants of health: housing, income, food security, discrimination, social support, caregiving, transportation, digital access and availability or affordability of medical care, rehabilitation and physical activity (Public Health Agency of Canada, 2026).
• Flag review: check Red Flags and refer to the separate fixed Orange Flags and Yellow Flags modules when relevant.

Outcome measures

• Use a small set that reflects the person’s priorities, disease activity, functioning and participation. Record the version and conditions of testing so repeated results are comparable.
• Patient-specific functioning: Patient-Specific Functional Scale (PSFS).
• Disability and participation: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0).
• Qualité de vie : WHOQOL-BREF.
• Axial spondyloarthritis symptoms and functioning: the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Functional Index (BASFI) can support repeat monitoring when the measures fit the clinical question.
• Disease activity in shared medical care: the Ankylosing Spondylitis Disease Activity Score (ASDAS) can be used when a current C-reactive protein or erythrocyte sedimentation rate result and the required patient ratings are available.
• Symptoms and performance: a consistent pain and stiffness rating, fatigue and sleep measure, plus a repeatable mobility, balance or endurance task selected for the person’s goals and safety.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

• Consent and comfort: explain the purpose and sequence, obtain consent, respect privacy, offer a chaperone when appropriate and adapt the assessment to communication, trauma history, symptom irritability and patient preference.
• Safety before movement: check for recent trauma, new severe focal pain, neurological change, systemic illness and fracture risk. Do not force spinal movement when fracture, instability, cord compression or serious infection is possible.
• Observation générale : distress, posture, spinal alignment, kyphosis, head position, breathing pattern, gait, transfers, movement confidence and visible assistance or mobility aids.
• Vital signs when indicated: temperature, heart rate, blood pressure, respiratory rate and oxygen saturation when acute illness, infection, medication effects or cardiorespiratory limitations are plausible.
• Mobilité de la colonne vertébrale : active movement quality and tolerance in the cervical, thoracic and lumbar regions; selected repeatable measures such as modified Schober, lateral spinal flexion, occiput-to-wall or tragus-to-wall distance and chest expansion when they are safe and useful. Avoid treating a single mobility measure as diagnostic.
• Sacroiliac, hip and regional assessment: hip movement and symptoms, buttock or pelvic pain, lower-limb movement and adjacent regions that may contribute to the presentation. Provocation findings are interpreted with the whole history and do not diagnose inflammatory disease.
• Articulations et enthèses périphériques : swelling, warmth, movement, tenderness and current or previous patterns of peripheral arthritis, heel or other enthesitis and dactylitis.
• Skin, nails and eyes: visible psoriasis or nail change when within scope and with consent. A painful red eye, light sensitivity or visual change follows Red Flags rather than a routine eye examination.
• Examen neurologique : strength, sensation, reflexes, gait and upper motor neuron or nerve-root findings when symptoms, trauma or the differential diagnosis indicate. New bladder, bowel or saddle sensory changes follow Red Flags.
• Functioning and physical capacity: patient-prioritized tasks, sit-to-stand, walking, balance, strength, cardiorespiratory tolerance and breathing expansion, selected according to goals, safety and baseline ability.
• Investigations and imaging: review available HLA-B27, C-reactive protein and erythrocyte sedimentation rate results and imaging reports. For suspected axial spondyloarthritis, medical assessment commonly begins with an anteroposterior pelvic or sacroiliac-joint radiograph; sacroiliac-joint MRI without contrast may follow when radiographs are nondiagnostic. Normal results do not always exclude disease, and routine scheduled repeat radiographs are not used solely to monitor stable disease (American College of Rheumatology, 2026; NICE, 2017).
• Repeat and adapt: repeat focused findings and the selected outcome measures to review change, test the working presentation and decide whether rehabilitation, medical assessment or rheumatology follow-up needs to change.

Recognition and referral framework

This framework supports recognition and rheumatology referral; it is not a diagnostic or classification rule.

• Entry pattern: low back pain began before age 45 years and has lasted longer than 3 months. Rheumatology referral is indicated when four or more of the following are present: onset before age 35 years; waking during the second half of the night; buttock pain; improvement with movement; improvement within 48 hours of a non-steroidal anti-inflammatory drug; a first-degree relative with spondyloarthritis; or current or previous arthritis, enthesitis or psoriasis (NICE, 2017).
• Three features: when exactly three features are present, HLA-B27 testing can help guide referral; a positive result supports rheumatology referral (NICE, 2017).
• Persistent suspicion: do not rule out axial spondyloarthritis because the feature count is lower, HLA-B27 is negative, inflammatory markers are normal or radiographs are normal. Repeat assessment and arrange rheumatology input when clinical suspicion persists or when psoriasis, inflammatory bowel disease, uveitis or new spondyloarthritis features emerge (NICE, 2017).

Working clinical presentations

These presentations can overlap or change. They organize assessment and shared care but do not replace rheumatology diagnosis or disease-activity assessment.

• Possible axial spondyloarthritis: an inflammatory back pain pattern or associated spondyloarthritis features are present without a confirmed diagnosis. Use the referral framework and safety-netting above.
• Established non-radiographic axial spondyloarthritis: rheumatology has diagnosed axial spondyloarthritis without definite radiographic sacroiliitis. Symptoms, MRI findings and inflammatory markers can vary over time.
• Established radiographic axial spondyloarthritis: definite radiographic sacroiliitis is documented. Mobility limitation, kyphosis, reduced chest expansion, osteoporosis and fracture risk may require added attention.
• Peripheral or extra-musculoskeletal involvement: arthritis, enthesitis, dactylitis, uveitis, psoriasis or inflammatory bowel disease is part of the current picture and needs coordinated specialty care.
• Stable or low-activity disease with rehabilitation needs: medical disease control is stable, while stiffness, deconditioning, mobility, posture, fatigue, work or participation goals remain suitable for rehabilitation.
• Active, flaring or inadequately controlled disease: increasing inflammatory symptoms, repeated flares, worsening disease-activity scores or reduced participation indicate review of medical control and adaptation of rehabilitation.
• Mixed or alternative presentation: mechanical back or hip pain, nerve-root symptoms, fibromyalgia, infection, fracture or another condition may coexist with or better explain the current symptoms. Revisit the differential diagnosis and Red Flags.

Base care on the working presentation, medical disease control, safety, patient priorities, context and response. Active rehabilitation and shared rheumatology care form the foundation.

Education, self-management and participation

• Understanding the condition: explain that axial spondyloarthritis is a chronic inflammatory condition with a variable course, and that rehabilitation works alongside medical treatment. Discuss the difference between symptom change and control of inflammation in plain language (Canadian Rheumatology Association, 2026; Ramiro et al., 2023).
• Reliable information: the Canadian Spondylitis Association axial spondyloarthritis fact sheets can support discussion and self-management. Match information to the person’s questions, language and health literacy.
• Participation and pacing: use patient-defined goals and flexible pacing for work or school, caregiving, sleep, travel, driving, sexual activity and recreation. Balance movement breaks and activity with short-term recovery during flares rather than prolonged inactivity.
• Safety knowledge: review the uveitis, infection, neurological and post-trauma fracture features in Red Flags. Make clear how immunosuppressive treatment, marked kyphosis, spinal fusion, osteoporosis or falls can change the urgency of assessment.

Physical activity and exercise

• Individualized active program: options include spinal and hip mobility, posture and extension work, deep breathing and chest expansion, progressive strengthening, aerobic activity, balance, gait and practice of valued activities. Select the starting level and progression from current disease activity, mobility, fracture risk, cardiovascular health, goals and response (American College of Rheumatology, 2026; NICE, 2017; Zhang et al., 2025).
• Format and supervision: supervised, group, home, recreational, aquatic, yoga, tai chi or mixed formats can be used when they are safe, acceptable and feasible. Supervision can help with learning, progression and adherence, especially with active disease, marked restriction, deconditioning or low confidence (American College of Rheumatology, 2026; NICE, 2017).
• Flares and changing capacity: reduce load, range, duration or complexity when symptoms or fatigue rise, while retaining tolerable movement when safe. Rebuild toward usual activity as the flare settles and coordinate medical review when the change is substantial or persistent.

Hands-on and symptom-relieving care

• Spinal manipulation: do not use spinal manipulation for adults with axial spondyloarthritis because of the potential for harm, particularly when structural change, spinal fusion or osteoporosis is present (American College of Rheumatology, 2026).
• Short-term symptom relief: heat, cold, comfortable positioning, gentle soft-tissue care, acupuncture or transcutaneous electrical nerve stimulation can be used when safe and acceptable and when they help a defined symptom or activity goal. Stop when benefit is absent or symptoms worsen, and do not use passive care in place of exercise or medical disease control.

Psychological, social and interdisciplinary support

• Coping, sleep and mood: clear information, graded activity, sleep support and psychologically informed rehabilitation can address fear, distress, low confidence or unhelpful avoidance. Persistent or severe mental health needs are coordinated with the appropriate provider.
• Interdisciplinary care: rheumatology coordinates inflammatory disease management. Primary care and rehabilitation can work with ophthalmology, dermatology, gastroenterology, pharmacy, occupational therapy, mental health, bone-health and cardiovascular services according to the current manifestations and goals (American College of Rheumatology, 2026; Ramiro et al., 2023).
• Access and feasibility: transportation, cost, housing, language, technology, work demands, caregiving and service availability can shape the plan. Select options the person can use and revisit barriers when participation is difficult.
• Tobacco support: connect people who use tobacco with acceptable cessation or reduction support and frame the discussion around overall health, cardiovascular risk and possible association with structural progression, without blame.

Medication coordination

• Medical treatment: non-steroidal anti-inflammatory drugs and, when indicated, biologic or targeted drugs are medical options. Selection, monitoring and changes remain with the rheumatologist or another authorized prescriber. Coordinate when symptoms limit rehabilitation, benefit appears inadequate, adverse effects occur, infection is suspected, or monitoring and immunization questions arise (Canadian Rheumatology Association, 2026; American College of Rheumatology, 2026).

Monitoring and reassessment

• Agree on a reassessment point based on safety, disease activity, goals, care being tried, patient needs and access rather than a fixed visit schedule.
• Repeat the small outcome set recorded at baseline and review pain, stiffness, fatigue, sleep, mobility, functioning, participation, relevant examination findings, benefits, harms, treatment burden and progress toward patient-defined goals.
• Continue what is useful and acceptable; adapt or stop what is not; and revisit the working presentation, differential diagnosis, medical disease control, referral or shared care when progress differs from expectations or new safety concerns emerge.

• Expected course: axial spondyloarthritis is chronic and its symptoms and disease activity can fluctuate. Some people maintain high levels of activity and participation, while others develop persistent symptoms, mobility restriction or structural change. Non-radiographic and radiographic categories do not determine an individual’s future course (Canadian Rheumatology Association, 2026; Ramiro et al., 2023).
• Factors associated with a less favourable course: higher disease activity or C-reactive protein, existing syndesmophytes or other structural damage, smoking, hip involvement, fracture or osteoporosis, comorbidity and barriers to timely care may be associated with greater long-term impact. These are group-level associations, not certain individual predictions (American College of Rheumatology, 2026; Ramiro et al., 2023).
• Potential supports for recovery: coordinated rheumatology care, control of inflammation, feasible regular physical activity and exercise, support for tobacco reduction or cessation, work and daily-activity adaptations, and attention to extra-musculoskeletal disease, bone health, cardiovascular health, sleep and mood may support functioning and participation (Canadian Rheumatology Association, 2026; American College of Rheumatology, 2026; NICE, 2017).
• Discussing prognosis: explain the variable course without promising an outcome or timeline. Use the person’s current disease activity, health, repeated outcomes and goals, discuss uncertainty plainly, and update the outlook as the condition and context change.