Management of Chronic Low Back Pain in Ankylosing Spondylitis within the Framework of a Biopsychosocial Approach

Abstract

Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease affecting the spine, with chronic lower back pain being one of its most common manifestations. Although the disease has been addressed within a biomedical model for many years, current literature reveals that chronic pain is a multifaceted condition that cannot be explained solely by inflammation and structural damage. In this context, the biopsychosocial model is gaining more acceptance as a holistic approach to understanding the experience of chronic pain. The biopsychosocial model suggests that pain perception is influenced not only by biological processes but also by psychological factors and socio-environmental variables. In particular, central sensitization, neuroplasticity changes, and chronic inflammatory processes are key mechanisms explaining the chronicity of pain in AS. The aim of this review is to examine the effectiveness of physiotherapy-based interventions in chronic low back pain in AS by evaluating it within the framework of a biopsychosocial model. The literature shows that exercise-based approaches have significant effects on reducing pain intensity, increasing functional capacity, and improving quality of life. Furthermore, it is reported that psychological factors and individual patient characteristics influence treatment response, and therefore a multidisciplinary approach plays a role in clinical success.

Keywords

• Ankylosing spondylitis
• chronic low back pain
• biopsychosocial model
• physiotherapy
• exercise

Ethical Statement

Since this study is a literature review, it does not require ethical committee approval.

Biyopsikososyal Yaklaşım Çerçevesinde Ankilozan Spondilitte Kronik Bel Ağrısı Yönetimi

Abstract

Ankilozan Spondilit (AS), omurgayı tutan kronik inflamatuvar bir romatizmal hastalık olup en sık bulgularından biri kronik bel ağrısıdır. Hastalığın uzun yıllar biyomedikal model çerçevesinde ele alınmasına karşın, güncel literatür kronik ağrının yalnızca inflamasyon ve yapısal hasarla açıklanamayacak kadar çok boyutlu yapıya sahip olduğunu ortaya koymaktadır. Bu bağlamda biyopsikososyal model, kronik ağrı deneyiminin anlaşılmasında bütüncül bir yaklaşım olarak daha fazla kabul görmektedir. Biyopsikososyal model, ağrı algısının yalnızca biyolojik süreçlerden değil; aynı zamanda psikolojik faktörler ve sosyal çevresel değişkenlerden etkilendiğini ortaya koymaktadır. Özellikle santral sensitizasyon, nöroplastisite değişiklikleri ve kronik inflamatuvar süreçler, AS’de ağrının kronikleşmesini açıklayan temel mekanizmalardır. Bu derlemenin amacı, AS’de kronik bel ağrısını biyopsikososyal model çerçevesinde değerlendirerek fizyoterapi temelli müdahalelerin etkinliğini incelemektir. Literatür, egzersiz temelli yaklaşımların ağrı şiddetini azaltma, fonksiyonel kapasiteyi artırma ve yaşam kalitesini iyileştirme üzerinde anlamlı etkiler sağladığını göstermektedir. Ayrıca psikolojik faktörler ve bireysel hasta özelliklerinin tedavi yanıtını etkilediği ve bu nedenle multidisipliner yaklaşımın klinik başarıda rol oynadığı bildirilmektedir.

Keywords

• Ankilozan spondilit
• kronik bel ağrısı
• biyopsikososyal model
• fizyoterapi
• egzersiz

Ethical Statement

Bu çalışma literatür derlemesi niteliğinde olduğundan etik kurul onayı gerektirmemektedir.

References

1. Ashton-James, C. E., Anderson, S. R., Mackey, S. C., & Darnall, B. D. (2022). Beyond pain, distress, and disability: The importance of social outcomes in pain management research and practice. Pain, 163(3), e426-e431. https://doi.org/10.1097/j.pain.0000000000002404
2. Bittar, M., & Deodhar, A. (2025). Axial Spondyloarthritis: A Review. JAMA, 333(5), 408-420. https://doi.org/10.1001/jama.2024.20917
3. Chen, H.-H., Chen, Y.-M., Lai, K.-L., Hsieh, T.-Y., Hung, W.-T., Lin, C.-T., … Chen, Y.-H. (2020). Gender difference in ASAS HI among patients with ankylosing spondylitis. PloS One, 15(7), e0235678. https://doi.org/10.1371/journal.pone.0235678
4. Correia, J. C., Waqas, A., Assal, J.-P., Davies, M. J., Somers, F., Golay, A., & Pataky, Z. (2023). Effectiveness of therapeutic patient education interventions for chronic diseases: A systematic review and meta-analyses of randomized controlled trials. Frontiers in Medicine, 9, 996528. https://doi.org/10.3389/fmed.2022.996528
5. Crombez, G., Veirman, E., Van Ryckeghem, D., Scott, W., & De Paepe, A. (2023). The effect of psychological factors on pain outcomes: Lessons learned for the next generation of research. Pain Reports, 8(6), e1112. https://doi.org/10.1097/PR9.0000000000001112
6. Danilov, A., Danilov, A., Badaeva, A., Kosareva, A., Popovskaya, K., & Novikov, V. (2025). State-of-the-Art Personalized Therapy Approaches for Chronic Non-Specific Low Back Pain: Understanding the Mechanisms and Drivers. Pain and Therapy, 14(2), 479-496. https://doi.org/10.1007/s40122-025-00706-w
7. Ding, X., Li, D., Zhang, J., Wang, S., Luo, Z., & Wu, Z. (2026). Factors associated with kinesiophobia in patients with rheumatic and musculoskeletal diseases: A systematic review. Joint Bone Spine, 93(4), 106029. https://doi.org/10.1016/j.jbspin.2025.106029
8. Dougherty, P., & Beehler, G. (2025). Biopsychosocial management of chronic lower back pain: The role of manual therapy and behavioral health co-management. Frontiers in Musculoskeletal Disorders, 3. https://doi.org/10.3389/fmscd.2025.1646096

9. Dunn, M., Rushton, A. B., Mistry, J., Soundy, A., & Heneghan, N. R. (2024). The biopsychosocial factors associated with development of chronic musculoskeletal pain. An umbrella review and meta-analysis of observational systematic reviews. PLOS ONE, 19(4), e0294830. https://doi.org/10.1371/journal.pone.0294830
10. Exarchou, S., Lindström, U., Askling, J., Eriksson, J. K., Forsblad-d’Elia, H., Neovius, M., … Jacobsson, L. T. (2015). The prevalence of clinically diagnosed ankylosing spondylitis and its clinical manifestations: A nationwide register study. Arthritis Research & Therapy, 17(1), 118. https://doi.org/10.1186/s13075-015-0627-0
11. Fernández-Morales, C., Cardero-Durán, M. de los Á., Albornoz-Cabello, M., & Espejo-Antúnez, L. (2025). How Do Fear-Avoidance and Catastrophizing Pain Beliefs Affect Functional Status and Disease Activity in Axial Spondyloarthritis? Medicina, 61(6), 1039. https://doi.org/10.3390/medicina61061039
12. Garrido‐Cumbrera, M., Bundy, C., Navarro‐Compán, V., Makri, S., Sanz‐Gómez, S., Christen, L., … Poddubnyy, D. (2021). Patient‐Reported Impact of Axial Spondyloarthritis on Working Life: Results From the European Map of Axial Spondyloarthritis Survey. Arthritis Care & Research, 73(12), 1826-1833. https://doi.org/10.1002/acr.24426
13. Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133(4), 581-624. https://doi.org/10.1037/0033-2909.133.4.581
14. Ghio, D., & Peters, S. (2024). The value of social relationships in the biopsychosocial model of pain. British Journal of Pain, 18(6), 448-449. https://doi.org/10.1177/20494637241297274
15. Gravaldi, L. P., Bonetti, F., Lezzerini, S., & De Maio, F. (2022). Effectiveness of Physiotherapy in Patients with Ankylosing Spondylitis: A Systematic Review and Meta-Analysis. Healthcare, 10(1), 132. https://doi.org/10.3390/healthcare10010132
16. Ho, E. K.-Y., Chen, L., Simic, M., Ashton-James, C. E., Comachio, J., Wang, D. X. M., … Ferreira, P. H. (2022). Psychological interventions for chronic, non-specific low back pain: Systematic review with network meta-analysis. https://doi.org/10.1136/bmj-2021-067718
17. Hossain, M. N., Lee, J., Choi, H., Kwak, Y.-S., & Kim, J. (2024). The impact of exercise on depression: How moving makes your brain and body feel better. Physical Activity and Nutrition, 28(2), 43-51. https://doi.org/10.20463/pan.2024.0015
18. Kebapcilar, L., Bilgir, O., Alacacioglu, A., Yildiz, Y., Taylan, A., Gunaydin, R., … Sari, I. (2010). Impaired hypothalamo-pituitary-adrenal axis in patients with ankylosing spondylitis. Journal of Endocrinological Investigation, 33(1), 42-47. https://doi.org/10.1007/BF03346548
19. Kieskamp, S. C., Paap, D., Carbo, M. J. G., Wink, F., Bos, R., Bootsma, H., … Spoorenberg, A. (2022). Central sensitization has major impact on quality of life in patients with axial spondyloarthritis. Seminars in Arthritis and Rheumatism, 52, 151933. https://doi.org/10.1016/j.semarthrit.2021.11.006
20. Kovačević, I., Pavić, J., Filipović, B., Ozimec Vulinec, Š., Ilić, B., & Petek, D. (2024). Integrated Approach to Chronic Pain—The Role of Psychosocial Factors and Multidisciplinary Treatment: A Narrative Review. International Journal of Environmental Research and Public Health, 21(9), 1135. https://doi.org/10.3390/ijerph21091135
21. Li, T., Liu, Y., Sheng, R., Yin, J., Wu, X., & Xu, H. (2020). Correlation Between Chronic Pain Acceptance and Clinical Variables in Ankylosing Spondylitis and Its Prediction Role for Biologics Treatment. Frontiers in Medicine, 7. https://doi.org/10.3389/fmed.2020.00017
22. Liang, H., Xu, L., Tian, X., Wang, S., Liu, X., Dai, Y., … Chen, W. (2020). The comparative efficacy of supervised- versus home-based exercise programs in patients with ankylosing spondylitis: A meta-analysis. Medicine, 99(8), e19229. https://doi.org/10.1097/MD.0000000000019229
23. Linton, S. J., & Shaw, W. S. (2011). Impact of psychological factors in the experience of pain. Physical Therapy, 91(5), 700-711. https://doi.org/10.2522/ptj.20100330
24. Lo, C. N., Wong, N. E. J. W., Ho, S., Ang, E. J. H., & Leung, B. P. L. (2025). Evaluating the Effects of Exercise on Inflammation Markers in Musculoskeletal Pain: A Systematic Review and Meta-Analysis. Sports, 13(6), 168. https://doi.org/10.3390/sports13060168
25. Mamatha, H., Bhat, K. M. R., Said, O. H., & Prasanna, L. C. (2024). A comparative imaging analysis of paraspinal muscles in healthy individuals and patients with chronic low back pain. Translational Research in Anatomy, 37, 100319. https://doi.org/10.1016/j.tria.2024.100319
26. Mescouto, K., Olson, R. E., Hodges, P. W., & Setchell, J. (2022). A critical review of the biopsychosocial model of low back pain care: Time for a new approach? Disability and Rehabilitation, 44(13), 3270-3284. https://doi.org/10.1080/09638288.2020.1851783
27. Narendra Reddy, K., Sabu, N., Pandey, N., Raut, A., Joag, K., & Patil, P. (2021). Anxiety and depression among patients with axial spondyloarthritis. European Journal of Rheumatology, 9(1), 8-13. https://doi.org/10.5152/eurjrheum.2021.21022
28. Ni, W., Kuang, X., & Zhu, Z. (2025). Pain Chronicity and Relief: From Molecular Basis to Exercise-Based Rehabilitation. Biology, 14(9), 1116. https://doi.org/10.3390/biology14091116
29. Nijs, J., Malfliet, A., & Nishigami, T. (2023). Nociplastic pain and central sensitization in patients with chronic pain conditions: A terminology update for clinicians. Brazilian Journal of Physical Therapy, 27(3), 100518. https://doi.org/10.1016/j.bjpt.2023.100518
30. O’Dwyer, T., O’Shea, F., & Wilson, F. (2014). Exercise therapy for spondyloarthritis: A systematic review. Rheumatology International, 34(7), 887-902. https://doi.org/10.1007/s00296-014-2965-7
31. Öz, N., Özer, A., & Duruöz, M. T. (2025). Central Sensitization and Its Role in Persistent Pain Among Spondyloarthritis Patients on Biological Treatments. Medicina, 61(2), 319. https://doi.org/10.3390/medicina61020319
32. Park, S. J., Lee, R., Yoon, D. M., Yoon, K. B., Kim, K., & Kim, S. H. (2016). Factors associated with increased risk for pain catastrophizing in patients with chronic neck pain. Medicine, 95(37), e4698. https://doi.org/10.1097/MD.0000000000004698
33. Pathan, E. M. I., & Inman, R. D. (2017). Pain in spondyloarthritis: A neuro-immune interaction. Best Practice & Research. Clinical Rheumatology, 31(6), 830-845. https://doi.org/10.1016/j.berh.2018.07.003
34. Quartana, P. J., Campbell, C. M., & Edwards, R. R. (2009). Pain catastrophizing: A critical review. Expert review of neurotherapeutics, 9(5), 745-758. https://doi.org/10.1586/ERN.09.34
35. Rinaudo, C. M., Van de Velde, M., Steyaert, A., & Mouraux, A. (2025). Navigating the biopsychosocial landscape: A systematic review on the association between social support and chronic pain. PLOS One, 20(4), e0321750. https://doi.org/10.1371/journal.pone.0321750
36. Shahid, A., Mushtaq, H. S., & Azfar, S. M. (2017). Spontaneous bilateral quadriceps rupture in a patient with ankylosing spondylitis: A case report. JPMA. The Journal of the Pakistan Medical Association, 67(1), 150-152.
37. Spinoni, M., Di Gesto, C., Porpora, M. G., & Grano, C. (2026). The Role of Catastrophizing in Enhancing Pain Interference and Depressive Symptoms in Endometriosis: A Longitudinal Examination. European Journal of Pain (London, England), 30(1), e70198. https://doi.org/10.1002/ejp.70198
38. Taurog, J. D., Chhabra, A., & Colbert, R. A. (2016). Ankylosing Spondylitis and Axial Spondyloarthritis. The New England Journal of Medicine, 374(26), 2563-2574. https://doi.org/10.1056/NEJMra1406182
39. Timmers, I., Quaedflieg, C. W. E. M., Hsu, C., Heathcote, L. C., Rovnaghi, C. R., & Simons, L. E. (2019). The interaction between stress and chronic pain through the lens of threat learning. Neuroscience and biobehavioral reviews, 107, 641-655. https://doi.org/10.1016/j.neubiorev.2019.10.007
40. Uçar Baytaroğlu, İ. M., & Karahan, A. Y. (2025). Effectiveness of a mobile respiratory trainer (AiroFit PROTM) in ankylosing spondylitis: A randomized controlled trial. Annals of Medicine, 57(1), 2582913. https://doi.org/10.1080/07853890.2025.2582913
41. van Dijk, H., Köke, A. J. A., Elbers, S., Mollema, J., Smeets, R. J. E. M., & Wittink, H. (2023). Physiotherapists Using the Biopsychosocial Model for Chronic Pain: Barriers and Facilitators—A Scoping Review. International Journal of Environmental Research and Public Health, 20(2), 1634. https://doi.org/10.3390/ijerph20021634
42. Vergne-Salle, P., & Bertin, P. (2021). Chronic pain and neuroinflammation. Joint Bone Spine, 88(6), 105222. https://doi.org/10.1016/j.jbspin.2021.105222
43. Weiß, M., Jachnik, A., Lampe, E. C., Gründahl, M., Harnik, M., Sommer, C., … Hein, G. (2024). Differential effects of everyday-life social support on chronic pain. BMC Neurology, 24, 301. https://doi.org/10.1186/s12883-024-03792-z
44. Wilson, N., Liu, J., Adamjee, Q., Di Giorgio, S., Steer, S., Hutton, J., & Lempp, H. (2023). Exploring the emotional impact of axial Spondyloarthritis: A systematic review and thematic synthesis of qualitative studies and a review of social media. BMC Rheumatology, 7(1), 26. https://doi.org/10.1186/s41927-023-00351-w
45. Yang, K., Gong, Y., Geng, Z., Xu, X., Yan, S., Zhang, H., … Liu, H. (2025). Correlates of depression, anxiety, and stress among patients with ankylosing spondylitis. Advances in Rheumatology, 65(1), 14. https://doi.org/10.1186/s42358-025-00439-6
46. Yu, C., Guo, L., Gao, X., Shen, X., Ma, X., Li, J., … Cai, J. (2026). Exercise prescription for axial spondyloarthritis: A systematic review and meta-analysis of randomized controlled trials. Frontiers in Medicine, 13, 1783569. https://doi.org/10.3389/fmed.2026.1783569
47. Yu, K.-C., Lo, L.-Y., Lin, M., Cheung, Y., & Wong, S.-S. (2021). A preliminary study of an online pain management programme for patients with ankylosing spondylitis. Counselling and Psychotherapy Research, 21(1), 227-236. https://doi.org/10.1002/capr.12314
48. Zhang, M., Liang, Z., Tian, L., Han, Y., Jiang, X., Li, Y., … Liu, T. (2025). Effects of Exercise Therapy in Axial Spondyloarthritis: A Systematic Review, Meta-analysis, and Meta-regression of Randomized Trials. Archives of Physical Medicine and Rehabilitation, 106(1), 113-123. https://doi.org/10.1016/j.apmr.2024.06.005
49. Zheng, J.-X., Zhang, X.-F., Liu, S.-H., Ye, F., Ji, S.-G., & Wen, X.-Z. (2024). Exercise Therapy Research in Ankylosing Spondylitis-Induced Back Pain: A Bibliometric Study (2004-2023). Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, 30, e943196. https://doi.org/10.12659/MSM.943196
50. Zhou, L., Li, T., Wu, X., Lu, H., Lin, L., Ye, L., … Xu, H. (2021). Assessment of Neuropathic Pain in Ankylosing Spondylitis: Prevalence and Characteristics. Pain and Therapy, 10(2), 1467-1479. https://doi.org/10.1007/s40122-021-00310-8
51. Zhu, W., He, X., Cheng, K., Zhang, L., Chen, D., Wang, X., … Weng, X. (2019). Ankylosing spondylitis: Etiology, pathogenesis, and treatments. Bone Research, 7, 22. https://doi.org/10.1038/s41413-019-0057-8