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Background Axial spondyloarthritis (axSpA) is commonly mistaken as chronic mechanical back pain. Delayed diagnosis averages 5-8 years with impacts on effective and timely management, outcomes and quality of life. Research on diagnostic delay suggests that a lack of recognition of inflammatory back pain and possible axSpA has been a contributing factor. Published referral criteria including NICE guidance (2017) and quality standards (2018) on spondyloarthritis in over-16s highlight the importance of earlier diagnosis and were developed to support earlier recognition and referral of suspected axSpA in primary care settings. This aim of this study was to investigate the occurrence of referral for musculoskeletal physiotherapy care and treatment prior to diagnosis of axSpA and to evaluate levels of recognition. Methods A retrospective review was undertaken of all patients diagnosed with axSpA who had been referred to and received physiotherapy care within nine physiotherapy services prior to diagnosis (1990-2016). Unrecognised axSpA was taken as the individual referred for and receiving three or more episodes of physiotherapy prior to diagnosis. Data was obtained on assigned diagnostic codes, number of episodes of physiotherapy care and contacts per episode. Results Two hundred and sixty three (263) people diagnosed with axSpA (age range 17-69 years) had been referred by a GP and received physiotherapy care prior to their diagnosis. Within this axSpA population, 103 (44%) had received 3 or more musculoskeletal physiotherapy assessments and episodes of care. Number of treatment contacts within each care episode ranged from 3 (47 people) to 58 contacts (1 person) [median=11 contacts-10 people]. Average time from initial physiotherapy care episode to date of diagnosis was 6.4 years (range=0.3-12.8 years, median=8.8 years). The most common assigned diagnostic code was back pain (49.6%), followed by shoulder (11.1%), knee (8.5%), neck (7.7%), ankle/foot (4.3%), tendonitis (4.2%), joint pain (3.4%), osteoarthritis (3.4%) and sacroiliac joint (2%). Analysis indicates that in nearly half of individuals who came to be diagnosed with axSpA, features of inflammatory back pain and possible axSpA were not recognised on at least six or more assessment occasions by either referrers or treating clinicians. Conclusion This study illustrates the extent of unrecognised axial spondyloarthritis referred to and missed in musculoskeletal clinical practice. This lack of recognition highlights the importance of professional education on signs, symptoms and risk factors for axSpA to support earlier diagnosis and treatment. Screening for and recognition of inflammatory back pain and other features for when to suspect and refer for possible axSpA in assessments of people with back pain need to be part of routine musculoskeletal clinical practice. Further research into contributors to diagnostic delay and the most effective education strategies to support earlier recognition of axSpA is needed. Disclosures C. McCrum: Honoraria; Novartis. K. Kenyon None. J. Cleaton None.

O21 Unrecognised inflammatory back pain: a retrospective review of people presenting to musculoskeletal physiotherapy with undiagnosed axSpA