Inflammatory Back Pain

What is inflammatory back pain?

Back pain is very common. Around 6% of adults in the UK suffer from chronic low back pain, meaning pain lasting longer than 3 months.  This represents almost 3 million people based on a UK adult population of 49.5 million.

In the majority of these cases the pain is said to be ‘mechanical’ – that is, related to the way the muscles, ligaments, discs and bones work together.  For around 5% of those with chronic low back pain, the pain is due to inflammation in the spine. 

It is important to be able to distinguish inflammatory pain from mechanical pain, as the treatment is very different. In the early stages, however, this can be difficult.

What are the symptoms of inflammatory back pain?

Typically, inflammatory back pain:

• Starts before the age of 40 years.
• Has been present for at least 3 months.
• Has come on slowly over time.
• Is worse in the mornings.
• Causes stiffness in the mornings lasting for at least 30 minutes (stiffness is perhaps best described as the sort of aching you get the day after heavy exercise).
• Improves with exercise, and is worse with rest.
• Improves with anti-inflammatory drugs (e.g. ibuprofen).
• Can wake people from sleep, often in the second half of the night.
• Can often cause pain in the buttocks, but rarely pain shooting down the leg (sciatica).

Spondylo….what?

Inflammatory back pain is the main symptom of a group of conditions called the spondyloarthopathies (SpA).  These affect the spine, joints, tendons, ligaments and occasionally the internal organs, and they can be associated with other conditions, particularly psoriasis (a scaly skin rash), inflammatory bowel disease (Crohn’s disease and ulcerative colitis) and uveitis or iritis (inflammation of the eye). 

The SpA include: ankylosing spondylitis; reactive arthritis; psoriatic arthritis and enteropathic arthritis. 

The cause of SpA is not certain. It is thought that, for most people with the condition, their genetic make-up puts them at risk but the disease is actually triggered by something in the environment (e.g. an infection such as food poisoning).

What will the future hold for me?

We know that in a proportion of people the symptoms of inflammatory back pain will go away in time, and they will never develop a SpA. In other people the inflammation will progress and  they will go on to develop ankylosing spondylitis. 

What we do not know is why some people fall into the first group and others into the second. We hope that research into these conditions will answer this question, and result in new treatments that switch off inflammation in the spine at an early stage.

Will tests help to make a diagnosis?

Yes and no. The single best test for a person with suspected inflammatory back pain is a Magnetic Resonance Imaging (MRI) scan of the sacro-iliac joints (the junction between the spine and the pelvis) and sometimes the spine as well. The MRI scan is a non-invasive medical test that detects early inflammation, long before changes become apparent on x-ray. In fact, it can take up to10 years for damage to become visible on a normal x-ray.

Your doctor will probably take blood to check ESR and CRP levels. These are markers of inflammation which can be high in inflammatory back pain, but are often normal. Another blood test which is frequently performed is for a gene called HLA-B27. People who carry the HLA-B27 gene are much more likely to develop ankylosing spondylitis than those who do not, but this is by no means inevitable. In the UK around 7% of people have the HLA-B27 gene, but less than a tenth of them will develop SpA. 

As tests can be difficult to interpret, and SpA are notoriously difficult to diagnose in the early stages, it is recommended that all patients with inflammatory back pain are referred to a rheumatologist for assessment.

What treatments are available for inflammatory back pain?

Anti-inflammatory drugs (e.g. ibuprofen or diclofenac) improve pain and stiffness, but do not prevent inflammation in the spine progressing. They can sometimes irritate the stomach lining, so should be taken after food. Other drugs (e.g. anti TNF drugs) are available if patients develop ankylosing spondylitis or another SpA.

Exercise is probably the most important way of managing inflammatory back pain. If the diagnosis is confirmed, you should be referred to a physiotherapist who will design an exercise programme to strengthen the back muscles and reduce stiffness in the spine. Part of this programme might involve hydrotherapy (exercises performed in a warm shallow pool).  Although physiotherapy is helpful, the most important thing is to get into the habit of doing your exercises once or twice a day at home.

See www.nass.co.uk/public/exercises.htm for some useful exercises.

Will changing my lifestyle help?

There is little proof that diet has much impact, though one small study has suggested that omega-3 fatty acids (found naturally in oily fish and linseed oil) help to reduce general back pain symptoms when taken at a high dose. There are no studies in people specifically with inflammatory back pain. 

People with inflammatory back pain tend to notice an improvement when they are active, so you may already be exercising. If not, a physiotherapist can advise you on the best programme.  

Another important lifestyle measure is to avoid smoking.  We know that people with ankylosing spondylitis who smoke do worse in the long term than those who do not.