Inflammatory Back Pain / Axial Spondyloarthritis

• Apply cultural awareness and trauma-informed care principles.
  Acknowledge prior healthcare experiences, prolonged diagnostic journeys, and potential impacts on trust, engagement, and expectations.
• Sociodemographic information: 
• Age (typical onset <45 years), gender, sex, race/ethnicity, family history of spondyloarthritis or related inflammatory conditions.
• Main complaint: 
  • Where is the pain located? (low back, buttocks, alternating sides, thoracic or neck involvement)
  • When did symptoms begin, and were they gradual or sudden in onset?
  • How long have symptoms been present (>3 months)?
  • What is the pattern of stiffness, particularly in the morning (duration >30 minutes)?
  • Do symptoms improve with movement or exercise and worsen with rest?
  • Is pain present at night, particularly in the second half of the night?
  • What activities aggravate or relieve symptoms?
  • Are there fluctuations or flares over time?
• Associated musculoskeletal symptoms:
  Peripheral joint pain or swelling, enthesitis (e.g., heel, Achilles, plantar fascia), hip pain, reduced spinal mobility.
• Extra-articular features:
  History of uveitis/iritis, psoriasis, inflammatory bowel disease, dactylitis, or inflammatory heel pain.
• Body systems review: Neurologic, cardiovascular (including chest wall pain), genitourinary, gastrointestinal, musculoskeletal, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
• Health, lifestyle, and history: Prior diagnoses of back pain or arthritis; previous investigations; response to NSAIDs (rapid and marked response); current and past medications; physical activity levels; diet; sleep disturbance; smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment.
• Functional and participation context:
  Impact on work, school, caregiving, physical activity, and daily participation; variability across days; effects of symptom flares.
• Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, social support; access to primary care, rheumatology, imaging, and rehabilitation.
• Previous treatments and responses: Document prior pharmacologic and non-pharmacologic treatments, effectiveness, and adverse effects.
• Beliefs and expectations: Assess patient understanding of inflammatory versus mechanical back pain; expectations regarding diagnosis, long-term management, and role of exercise and medication. 
• Flag considerations: Identify red, orange, and yellow flags for potential referrals.

​​Outcomes Assessments: Prioritize approaches aligned with inflammatory disease impact and participation.

• Pain: Use pain scales (e.g., NRS) and diagrams.
• Function and Participation: Evaluate impact on daily activities (BASFI, PSFS, WHODAS).
• Recovery: Use Self-rated recovery scales.
• Quality of Life: Assess using tools such as SF-12.
• Work/school Status: Monitor return to activities.
• Sleep quality: Assess using tools such as PSQI.
• Individual Goals: Set SMART goal setting (Specific, Measurable, Achievable, Relevant, Timely).
• Patient Feedback: Gather and integrate patient experience and satisfaction.

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.

• General observation:
  Posture, spinal alignment, movement behaviour, willingness to move, and overall stiffness, particularly after rest.
• Spinal mobility:
  • Assess active range of motion of the cervical, thoracic, and lumbar spine.
  • Note global or segmental restriction, especially reduced lumbar flexion and extension.
  • Compare movement quality and symptom response rather than absolute range values.
• Chest expansion:
  Observe and, where appropriate, measure chest expansion during deep inspiration, particularly if thoracic involvement is suspected.
• Hip examination:
  • Screen hip range of motion, particularly internal rotation and flexion.
  • Identify hip pain or restriction that may contribute to functional limitation or suggest hip involvement in axSpA.
• Peripheral joints and entheses:
  Assess for swelling, tenderness, or reduced range of motion in peripheral joints.
  Palpate common enthesis sites (e.g., Achilles tendon, plantar fascia, costosternal junctions) for localized tenderness.
• Neurologic screening:
  Perform a brief neurologic screen to exclude neurologic compromise (strength, sensation, reflexes) when indicated.
• Functional assessment:
  Evaluate tolerance to functional tasks such as sit-to-stand, walking, bending, and sustained postures.
  Observe symptom response to movement versus rest.
• Response to movement:
  Note whether symptoms improve with repeated movement or gentle activity, which supports an inflammatory pain pattern.

Physical examination findings in axSpA may be subtle or absent in early disease. A normal examination does not exclude inflammatory pathology. The examination should guide timely referral and co-management, rather than delay specialist assessment when clinical suspicion is high.

Clinical presentation of axSpA is characterized by inflammatory spinal pain patterns, functional limitation, and fluctuating disease activity. Presentations evolve over time and may vary widely between individuals. Symptoms should be interpreted in the context of age at onset, duration, and response to activity rather than imaging findings alone.

Typical Presentation

• Chronic back pain lasting >3 months with onset before age 45
• Inflammatory pain pattern:
  • Gradual onset
  • Improves with movement or exercise
  • Worsens with rest or inactivity
  • Prominent morning stiffness (>30 minutes)
  • Night pain, particularly in the second half of the night
• Functional limitations: Reduced tolerance for prolonged sitting, standing, or static postures; difficulty with bending or rotation; reduced participation in work, physical activity, or recreation
• Fatigue, often disproportionate to activity level

Axial and Regional Involvement

• Low back and buttock pain (often alternating sides)
• Thoracic or cervical spine stiffness or pain
• Hip involvement, which may significantly affect function and prognosis

Peripheral and Extra-Articular Manifestations

• Peripheral arthritis (asymmetric, lower limb predominance)
• Enthesitis (e.g., Achilles tendon, plantar fascia, costosternal junctions)
• Dactylitis
• Extra-articular features such as uveitis, psoriasis, or inflammatory bowel disease

Early or Non-Radiographic Disease

• Symptoms may be present despite normal plain radiographs
• Physical examination findings may be minimal
• MRI may demonstrate active inflammation, but clinical suspicion should guide referral even in the absence of imaging abnormalities

Atypical or Delayed Presentations

• Less prominent morning stiffness or night pain
• Mixed mechanical and inflammatory features
• Higher prevalence of peripheral symptoms, fatigue, or pain amplification
• More common in women and older adults, contributing to diagnostic delay

Clinical presentations in axSpA are heterogeneous and dynamic. Ongoing reassessment is essential to monitor disease impact, guide rehabilitation, and determine the need for escalation or co-management.

Approach to Conservative Management

Conservative management is a core and lifelong component of care for individuals with inflammatory back pain and axial spondyloarthritis and should be initiated early, alongside appropriate medical management. International clinical practice guidelines consistently emphasize that exercise and patient education are foundational.

Management should be individualized, progressive, and sustained, with the primary goals of:

• controlling symptoms,
• preserving spinal mobility and physical function,
• supporting participation in work, physical activity, and daily life,
• preventing long-term disability.

Conservative care should be delivered within a shared-care model, integrated with rheumatology and primary care, rather than as episodic or short-term treatment.

Education and Self-Management

Education is a cornerstone of axSpA management and should be provided early and reinforced over time.

Key elements include:

• Clear explanation of axSpA as a chronic inflammatory condition distinct from mechanical back pain
• Reassurance regarding the safety and necessity of regular physical activity
• Education on symptom fluctuation, disease activity, and long-term management expectations
• Support for self-management strategies, including pacing, flare management, sleep hygiene, stress management, and smoking cessation (smoking is associated with worse outcomes)

Education should promote active patient engagement and shared decision-making, rather than reliance on passive treatments.

Exercise Therapy (Core, First-Line Intervention)

Exercise therapy is strongly recommended for all individuals with axSpA, regardless of disease stage or imaging findings.

Established standards of care support:

• Regular, lifelong exercise participation
• Programs that include:
  • spinal mobility and posture exercises,
  • strengthening of trunk and hip musculature,
  • aerobic conditioning,
  • functional and balance training as needed

Exercise programs should be:

• Individualized and progressive
• Adapted to disease activity, symptoms, and functional goals
• Delivered through supervised, group-based, or home-based formats depending on access and preference

No single exercise modality has been shown to be superior. Adherence and long-term engagement are more important than exercise type.

Supervised Rehabilitation

Supervised rehabilitation may be beneficial, particularly for:

• individuals with higher disease activity,
• reduced mobility or function,
• difficulty initiating or maintaining independent exercise programs.

Focus on:

• optimizing movement quality and spinal mobility,
• addressing deconditioning and movement avoidance,
• supporting confidence with physical activity.

Manual Therapy

Manual therapy may be used as a short-term adjunct to support symptom relief and movement confidence.

• It should not replace active exercise
• It should be used cautiously during periods of high disease activity
• Evidence supports only adjunctive use, not stand-alone treatment

Medications (Role of Conservative Care in Context)

While pharmacologic management (e.g., NSAIDs, biologic therapies) is directed by medical providers, conservative care plays a key role in:

• supporting adherence to medical treatment,
• monitoring functional response and participation,
• identifying inadequate response requiring medical reassessment.

Exercise and rehabilitation remain essential even when pharmacologic disease control is optimal.

Multidisciplinary and Long-Term Care Considerations

• Conservative management should be coordinated across providers to ensure continuity of care
• Long-term follow-up should emphasize maintenance of physical activity and function, not discharge after symptom improvement
• Rehabilitation strategies should adapt across the lifespan and disease course

Risk and Prognostic Factors

Prognosis in axSpA is heterogeneous and is influenced by inflammatory burden, structural progression risk, lifestyle factors, and access to timely diagnosis and effective treatment.

Factors commonly associated with worse outcomes (pain, function, progression, or participation):

• Higher disease activity and persistent inflammation (ongoing symptoms and elevated inflammatory markers when present)
• Hip involvement and more extensive axial symptoms
• Smoking (associated with worse disease outcomes and greater structural damage risk)
• Reduced physical activity / deconditioning and prolonged sedentary behaviour
• Delayed diagnosis and delayed access to appropriate specialist care
• Psychosocial factors that reduce adherence to long-term management (e.g., low self-efficacy, depression/anxiety, high fear of movement)
• Barriers to care (limited access to rheumatology, supervised exercise, or consistent follow-up)

Factors commonly associated with better outcomes:

• Early recognition and rheumatology co-management when axSpA is suspected
• Sustained, structured exercise participation (long-term adherence is key)
• Smoking cessation and risk-factor modification
• Effective control of inflammation (medical management) paired with rehabilitation to preserve function and participation

Prognosis

• Rehabilitation should be framed as lifelong function maintenance and participation support, not a short episode of care.
• axSpA is typically a long-term condition with fluctuating disease activity. Many individuals achieve good function and participation with early diagnosis, appropriate medical care, and sustained exercise.
• Some individuals develop persistent pain, functional limitation, and structural progression over time. This risk is higher when inflammatory activity remains uncontrolled, when hip involvement is present, and in people who smoke.