Inflammatory Back Pain
Axial spondyloarthritis (axial SpA) is a type of chronic inflammatory arthritis that mainly affects the spine and sacroiliac joints. You may have heard of it by a previous name - Ankylosing Spondylitis. It is characterized by pain and stiffness in the lower back, which may worsen with rest and improve with physical activity. Inflammatory back pain (IBP) is the most common symptom of axial SpA and is a diagnostic criterion for the disease. In this post, we will discuss the causes, symptoms, diagnosis, and treatment options for inflammatory back pain.
Causes of Inflammatory Back Pain
Inflammatory back pain is caused by inflammation in the spinal column and sacroiliac joints. The exact cause of this inflammation is not known, but it is believed to be related to the body's immune system attacking its own tissues. There is also a genetic component to the disease, as it is more common in people with certain genes. Environmental factors, such as smoking and infections, may also play a role in triggering the disease. Having other inflammatory conditions such as psoriasis, uveitis, inflammatory bowel disease, or dactylitis will increase your doctor’s suspicions that your back pain may be inflammatory.
Symptoms of Inflammatory Back Pain
The most common symptom of inflammatory back pain is pain and stiffness in the lower back, which may worsen with rest and improve with physical activity. The pain is typically dull and aching and may be present on one or both sides of the back. Other symptoms may include:
Pain and stiffness in the buttocks and hips
Tendon pain (Patella, Achilles, plantar fascia)
Morning stiffness that lasts for more than 30 minutes
Reduced flexibility in the spine
Swelling and tenderness in the joints
Diagnosis of Inflammatory Back Pain
The diagnosis of inflammatory back pain is based on a combination of clinical features, imaging studies, and laboratory tests. The diagnostic criteria for axial SpA include the presence of IBP, which is defined as back pain that starts before the age of 45 and lasts for more than three months, along with one or more of the following:
Reduced spinal mobility
Sacroiliitis on imaging studies
HLA-B27 positivity
Family history of axial SpA
Imaging studies that may be used to diagnose axial SpA include X-rays, magnetic resonance imaging (MRI), and computed tomography (CT) scans. These tests can reveal structural changes in the sacroiliac joints or the spine. Blood tests may also be performed to look for signs of inflammation, such as an elevated C-reactive protein (CRP) level.
Treatment of Inflammatory Back Pain
The treatment of inflammatory back pain depends on the severity of the symptoms and the underlying cause of the inflammation. The goals of treatment are to reduce pain and stiffness, improve mobility, and prevent joint damage. Treatment options may include:
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
NSAIDs are the first-line treatment for inflammatory back pain. They work by reducing inflammation and relieving pain. Commonly used NSAIDs include ibuprofen, naproxen, and diclofenac. NSAIDs should be taken with caution, as they can cause side effects such as stomach ulcers and kidney damage. Therefore, it is important to take NSAIDs as directed by a healthcare professional.
Disease-Modifying Antirheumatic Drugs (DMARDs)
DMARDs are a type of medication that can slow down the progression of inflammatory back pain. They work by suppressing the immune system and reducing inflammation. Commonly used DMARDs for axial SpA include methotrexate, sulfasalazine, and leflunomide.
Biologic Therapy
Biologic therapy is a type of medication that can target specific molecules in the immune system that are responsible for causing inflammation. Biologics are usually given by injection or infusion and can provide significant relief from symptoms. Commonly used biologics for axial SpA include tumor necrosis factor (TNF) inhibitors, such as adalimumab, etanercept, and infliximab. Other biologics that may be used include interleukin-17 (IL-17) inhibitors, such as secukinumab and ixekizumab, and interleukin-23 (IL-23) inhibitors, such as ustekinumab.
Physical Therapy
Physical therapy can help improve mobility and reduce pain in people with inflammatory back pain. A physical therapist can create a customized exercise program that includes stretching and strengthening exercises to improve flexibility and muscle strength. They may also use manual therapy techniques, such as massage or joint mobilization, to reduce pain and improve joint mobility.
Lifestyle Changes
Lifestyle changes can also be helpful in managing inflammatory back pain. These may include:
Quitting smoking
Eating a healthy diet
Getting regular exercise
Managing stress
It is worth noting that while inflammatory back pain is a common symptom of axial SpA, not everyone with the condition will experience it. Some people may have symptoms that primarily affect other joints, such as the hips or shoulders. Therefore, it is important to consult with a healthcare professional if you are experiencing any symptoms that may be related to axial SpA.
Early diagnosis and treatment of inflammatory back pain are crucial in preventing joint damage and preserving mobility. The average timeframe for diagnosis is 5-6 years! as so often inflammatory back pain gets misdiagnosed as more common types of lower back pain. If left untreated, inflammation in the spine and sacroiliac joints can lead to permanent damage, which can cause disability and a reduced quality of life.
As always, thanks for reading.
Here is a list of articles for further reading
Braun J, Sieper J. Ankylosing spondylitis. Lancet. 2007;369(9570):1379-1390. doi:10.1016/S0140-6736(07)60635-7
Rudwaleit M, van der Heijde D, Landewé R, et al. The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis. 2011;70(1):25-31. doi:10.1136/ard.2010.133645
Ward MM, Deodhar A, Gensler LS, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019;71(10):1599-1613. doi:10.1002/art.41042
Dagfinrud H, Kvien TK, Hagen KB. Physiotherapy interventions for ankylosing spondylitis. Cochrane Database Syst Rev. 2008;(1):CD002822. doi:10.1002/14651858.CD002822.pub3