A Physio’s Guide to Early Identification of Axial Spondyloarthritis

Axial spondyloarthritis (axSpA) presents both a diagnostic and therapeutic challenge—one where physiotherapists are uniquely positioned to have a large impact on patient outcomes.

As primary care clinicians, physiotherapists often encounter patients experiencing persistent back pain long before a formal rheumatological diagnosis is made. Understanding the nuances of axSpA, from recognising inflammatory pain patterns to differentiating from mechanical causes, is essential not only for early identification but also for optimising long-term management. This blog will explore the vital role physiotherapists can play in early detection of axSpA—helping to facilitate timely referrals, support early intervention, and ultimately improve patient outcomes through collaborative care.

If you want in-depth knowledge on how to assess and manage axSpA as a physio–watch Dr. Julia Sewell’s full Masterclass HERE.

What is axial spondyloarthritis?

Axial spondyloarthritis (axSpA) is a chronic, inflammatory condition primarily affecting the spine and sacroiliac joints–it falls within the broader family of spondyloarthropathies, which share overlapping features like joint inflammation, enthesitis (inflammation where tendons attach to bone), and extra-articular manifestations such as psoriasis, inflammatory bowel disease, and uveitis (inflammatory eye disease).

AxSpA is typically classified into two categories:

• Radiographic axSpA (ankylosing spondylitis): where characteristic changes, such as sacroiliitis and spinal fusion, are visible on x-ray.
• Non-radiographic axSpA: where patients have clinical symptoms and MRI findings of inflammation without clear changes on x-ray.

While it’s not our role to formally diagnose axSpA on radiographs, developing a basic understanding of what you’re seeing can be extremely useful in grasping the overall condition. In this short clip from her Masterclass, Julia explains how to identify key features of radiographic axSpA and how they relate to clinical presentation:

Despite these differences, both forms can cause significant pain, stiffness, and functional impairment. Early recognition and intervention are key to slowing disease progression, improving outcomes, and ensuring patients receive appropriate specialist care. For people with ankylosing spondylitis, the average time from symptom onset to diagnosis is seven years—a delay that Dr. Julia Sewell says must be addressed and reduced.

What can we do as physios?

As some of the most common primary care clinicians people consult for back pain (along with General Practitioners), we play a large role in the early detection, management, and long-term care of patients with axSpA. Through thorough history-taking and targeted physical assessment, we are often the first to recognise signs of inflammatory back pain that differ from typical mechanical patterns. Our role includes identifying red flags, encouraging patients to seek further medical evaluation when axSpA is suspected, and facilitating timely referral to general practitioners or rheumatologists. Julia outlines a few screening questions to ask if you suspect your patient may have axSpA, as approximately 20-30% of people may also experience peripheral spondyloarthropathies, and this information can add to the overall clinical picture. See this short clip from her Masterclass:

When it comes to diagnosing axSpA, there are no specific diagnostic criteria and no single clinical test that confirms the diagnosis. Instead, diagnosis relies on a combination of clinical evidence, biochemical and serological findings, and radiographic evidence. As physiotherapists, we play a key role in contributing to the clinical evidence—where the subjective examination is absolutely integral. While formal diagnostic criteria don’t exist, Julia shares the classification criteria commonly used in research settings in this short video from her Masterclass:

In confirmed cases, we are part of the first-line care team for axSpA, working alongside Non-Steroidal Anti-Inflammatories (NSAIDs) to manage symptoms effectively. Physiotherapists are essential in delivering tailored exercise programs focused on maintaining spinal mobility, improving posture, reducing stiffness, building strength, and enhancing overall functional independence. While we have an important role to play in the management of axSpA, it’s still important to recognise that we do not influence or slow the underlying disease progression—this remains the role of immunosuppressive therapies prescribed by specialist physicians such as rheumatologists.

Wrapping up

Axial spondyloarthritis is a complex and often under-recognised condition where physiotherapists have the opportunity to make a real difference in reducing the gap between symptom onset and diagnosis. By staying alert to the clinical features of axSpA, advocating for our patients and facilitating early referrals, we can play a key role in addressing the condition early, and improving outcomes for our patients.

If you want to know all about how to detect, assess and manage axial spondyloarthritis as a physio, watch Dr. Julia Sewell’s full Masterclass HERE.