Inflammatory low back pain: How to treat it?

Article reviewed and approved by Dr. Ibtissama Boukas, physician specializing in family medicine 

Back pain is common, it's a fact. Sudden movements, lifting of loads, "bad posture, all of these factors are considered “mechanical” causes of low back pain. But do you know inflammatory low back pain?

Far less common, far more pernicious, this condition unlike mechanical low back pain occurs when your OWN immune system attacks the joints surrounding your spine.

How to recognize inflammatory back pain? Are there any particular symptoms, or medical tests that would help you clarify the diagnosis? And most importantly, are there treatments available for those who suffer from this disorder?

This article covers all the aspects surrounding inflammatory low back pain, from the diagnosis to the various treatments available, without forgetting to provide you with several tips to apply on a daily basis to relieve pain and improve your quality of life. 

Definition of inflammatory back pain

 

When we talk about low back pain, we often refer to so-called “mechanical” back pain. This type of back pain causes structural changes in the spine and surrounding tissues.

The resulting pain is usually aggravated by excessive and prolonged movement, and is relieved by relative and temporary rest. Fortunately, most cases eventually resolve on their own.

 

It is when the pain persists that we come to ask ourselves questions. For example, we often associate the fibromyalgia to chronic lower back pain. But there are other conditions responsible for the persistent pain. Inflammatory back pain is one of them.

What happens in the presence of inflammatory low back pain? Essentially, a systemic inflammatory reaction is believed to be triggered at the spine, related joints, and entheses. Several inflammatory mediators induce chronic changes responsible for lower back pain and other observed symptoms.

The cause? Granted, the question is legitimate, but I'm afraid the answer will disappoint you. Unfortunately, we do not currently know the real cause of many inflammatory diseases. Some theories mention hereditary and genetic causes.

 

Be that as it may, one can observe a degeneration at the level of the column, until observing a fusion of vertebrae and a risk of vertebral compaction ou vertebra fracture. Due to the chronic inflammatory process, other health problems can also be observed, such as inflammation of the eyes (uveitis), or heart problems. 

 

Recognize the symptoms

 

It is important to understand that the symptoms, when considered individually, are not sufficient to conclude that there is inflammatory disease.

There are, however, symptoms that should alert you. The first is night pain. If pain wakes you up frequently at night (while you're resting!), there's something wrong.

Another frequently encountered symptom is morning stiffness. Sylvain, one of my patients suffering from ankylosing spondylitis, claims to have to wait 30 minutes every morning so that his back “unlocks”, and he can function. 

Finally, the response to physical exercise is a major factor in differentiating between mechanical and inflammatory low back pain. As mentioned previously, pain of mechanical origin seems to lessen with relative rest. On the contrary, the symptoms seem to improve with physical activity in the presence of inflammatory low back pain.

Other symptoms observed may be:

• Lower back pain that does not improve within 3 months. Rather, the condition progresses and seems to get worse over time.
• Pain often described as "deep", "dull", "diffuse", "throbbing".    
• Pain that alternates from side to side, or sometimes radiates to the legs. (If the pain alternates from one place to another, it is difficult to conclude to a precise lesion at the level of the back!).
• Periods of pain peaks followed by periods of remission
• Pain and inflammation in the region of the sacroiliac joints
• Loss of mobility in the lumbar region and in the hips
• Joint pain and stiffness in general (ankle, knees, ribs, etc.)
• Other inflammatory condition (uveitis-inflammatory disease affecting the eye, psoriasis, irritable bowel syndrome, etc.)

Obviously, this greatly affects the quality of life people with inflammatory low back pain. In concrete terms, patients complain on a daily basis of:

• Morning pain and stiffness
• Poor sleep quality
• Chronic fatigue
• Appearance Concerns
• Fear of the future prognosis
• Medication Side Effects
• Difficulty working (many work stoppages)

 

Clinical, biological and radiological examinations

Imagine that it sometimes takes up to 5-10 years (on average, 7 years!) before diagnosing inflammatory low back pain! But why? On the one hand, the patient, often young, frequently minimizes his pain, and thinks that this is a normal situation that will pass with time.

Is it denial? Maybe. Anyway, I frequently hear people say that they gave up consulting because they thought their pain was due "to their work, their lack of physical activity, their recent move, or even simple lumbar stiffness!” 

Then, many physicians issue the diagnosis of non-specific chronic low back pain to patients who present for persistent back pain. Frustrating, I know. Back pain is so frequent and widespread that it is trivialized. Big mistake!

Finally, the diagnosis as such is very difficult to make. This is due to the fact that there is no precise and unique diagnostic test that automatically concludes that there is inflammatory low back pain.

Can you imagine having to wait 7 years before getting a diagnosis!? Imagine the impact on the quality of life of people affected! And as low back pain also affects the professional activity of those affected, this will inevitably have an impact on society in the long term.

Let us now discuss the various examinations that can be used to conclude that there is inflammatory damage to the spine. You will likely be referred to a rheumatologist if inflammatory low back pain is suspected. Here are the different clinical, biological or radiological tests to which you will be subjected:

Physical examination

When a low back pain patient presents to the clinic, the healthcare professional will often start with a medical history, followed by clinical tests. Here are the elements that will lead the doctor to suspect inflammatory low back pain, and to push the investigation further:

• Symptoms suggestive of possible inflammatory involvement (as discussed previously)
• On physical examination, observation of a decrease in the range of motion of the spine (in particular lateral inclinations and rotations of the trunk, as well as the hips in certain cases)
• Gradual change in standing posture (hunched forward)
• Sacroiliac tests positive 
• Pain on palpation of enthesitis site

Blood tests

If deemed necessary, a doctor may also order a blood test. In the case of inflammatory low back pain, one could observe:

• HLA-B27 antigen positive. It is a genetic factor present in nearly 90% of patients with inflammatory conditions such as ankylosing spondylitis. (ATTENTION! A positive test is not necessarily synonymous with inflammatory low back pain)
• An increase in sedimentation rate, indicative of inflammation
• A C-Reactive Protein (CRP) elevated, signifying the presence of inflammation in the body

ATTENTION! A positive blood test is not necessarily synonymous with inflammatory low back pain. Some people who do NOT have inflammatory low back pain may, for example, have the HLA-B27 gene. In short, we cannot rely exclusively on blood tests to conclude that there is inflammatory low back pain.

Medical imaging

 

It is not uncommon for a doctor to ask the patient to have a medical imaging in order to clarify the diagnosis. In the case of inflammatory low back pain, the x-ray is rarely accurate. This means that if we observe a sacroiliitis radiological, it considerably increases the probability of inflammatory damage.

Thus, an MRI is much more relevant to detect sacroiliitis characteristic of certain spondyloarthritis. As with blood tests, it must be realized that a negative MRI (that is to say that shows no lesion) does not necessarily mean that there is no inflammatory low back pain. This is called a “false negative” in technical terms.

Although not routinely prescribed, another test to clarify the diagnosis is a bone scan. Again, a negative examination does not exclude a diagnosis of inflammatory disease.

 

Reaction to anti-inflammatories

 

Another interesting way to determine if the patient suffers from inflammatory low back pain is simply to prescribe nonsteroidal anti-inflammatory drugs. After all, if taking these drugs significantly relieves the symptoms, one might suspect that the back pain is potentially of inflammatory origin.

 

 

Possible diagnoses of inflammatory low back pain

 

Inflammatory back pain is most often related to a condition called “ankylosing spondylitis”. However, there are other possible diagnoses that can reproduce similar symptoms. These pathologies can either come from an inflammatory attack, or from another condition: 

 

• Psoriatic arthritis
• Inflammatory stomach disease
• Enteropathic arthropathy
• Juvenile idiopathic arthritis
• Reactive arthritis
• Lower back pain of visceral origin
• Achievement of spinal cord or ponytail
• Osteomyelitis
• Cancer cause
• Cancer or tumor 
• Bacterial infections
• fibromyalgia
• Scheuermann's disease
• osteoporosis

I dare to hope that you now understand why it is better not to self-diagnose by doing a quick search on Google!

 

 

Treatment: What to do? (9 tips)

 

What to do in the presence of inflammatory low back pain? It's simple. First and foremost, don't wait forever, otherwise the condition will become chronic.

The biggest challenge in the presence of inflammatory low back pain is to diagnose the disease early, before it causes irreversible damage. Indeed, the faster the treatment, the more we will be able to slow down the progression of the disease, in addition to improving the quality of life of those affected.

Speaking of quality of life…Here are 9 tips to apply daily to relieve symptoms, prevent acute episodes, and stay active.

 

1. Incorporate therapeutic exercises into your routine

Obviously, kinesitherapy (physiotherapy) sessions are strongly recommended in case of inflammatory low back pain. We mentioned earlier that thephysical exercise generally relieved symptoms, even more than with mechanical low back pain. A health professional can therefore guide you and adjust the therapeutic exercises according to your condition.

Here are some exercises that can be prescribed to improve mobility, and promote a straighter posture. They can, for example, be carried out in the morning to participate in the “morning unlocking”. If the pain is too great in the morning, you can adjust the intensity of the exercises, or simply perform them when you are better:

Deep breathing (diaphragmatic)

 

Note: In addition to improving lung capacity, this deep breathing exercise will also open up the rib cage and ribs. The thoracic range of motion should be adjusted, especially in the presence of ankylosing spondylitis where the ribs are affected.

1. Lie on your back (ideally in an environment conducive to relaxation!) 

2. Place one hand on the chest and the other on the stomach. The hand placed on the chest should not move, because we want to focus only on the abdomen. 

3. Inhale through your nose, expanding your stomach like a balloon. 

4. At the end of the inhalation, hold your breath for 2 seconds 

5. Then exhale slowly, taking the air out through your mouth until complete exhalation. 

6. Repeat ten times, going slowly. 

7. The progression would be to open the rib cage by breathing more deeply. You can also put a weight on your belly that will serve as resistance.

  

Chest extension

 

1. Sit down with your head and back straight.
2. Grab the back of your neck with your hands, keeping your elbows pointing forward (as shown).
3. In the same movement, bring the elbows up, the back extended and the head backwards.
4. Slowly return to the initial position.
5. Repeat about XNUMX times, taking breaks as needed.

 

Thoracic rotation

 

1. Sit on a chair, and place a stick behind your back as shown.
2. In the same movement, turn the trunk by adding a slight pressure thanks to the stick.
3. Hold the comfortable twisting position for 20 seconds.
4. Return to an initial position, then repeat the process on the other side.
5. Do 3 sets in total.

Lumbar extension

Note: A prerequisite for performing this exercise is to be able to stand on your elbows without pain or uncomfortable radiation in the leg.

1. Lie on your stomach and place your hands on either side.
2. In the same movement, push with the hands so as to raise the upper trunk without contracting the gluteal muscles.
3. Climb up to the tolerated amplitude, then return to the initial position.
4. Repeat ten times, taking breaks as needed.

This exercise is taken from the McKenzie method. It is used more for lumbar problems of mechanical origin, but can allow an increase in mobility in extension. 

2. Consider taking medication

It is true that nobody likes to take drugs (me first!). On the other hand, in the case of inflammatory low back pain, the pros and cons must be weighed before making a decision. Obviously, your best ally in this process is your doctor.

Medication adherence is important because untreated inflammatory low back pain can progress to spinal deformities and even fractures. Obviously, the doctor will adjust the doses and the duration according to the personal condition of his patient. For example, some people do not tolerate NSAIDs for the irritation they cause in the stomach.

We usually start with the prescription of non-steroidal anti-inflammatory drugs (NSAIDs) for 2-4 weeks to assess their effectiveness. The objective of AINSI is not necessarily to treat the source of the problem, but rather to control the symptoms, and to slow down the progression of the disease.

If NSAIDs prove ineffective, the doctor may prescribe TNF inhibitors with the aim of controlling regional inflammation, and thus slowing down the evolution of inflammatory pathologies. On the other hand, it should be known that these drugs are expensive, restrictive, and expose to sometimes serious adverse effects (such as infections and tuberculosis).

In terms of invasive treatments (infiltration or surgery), unfortunately they will not be able to correct the source of the problem. For example, infiltrations (such as sacroiliac infiltrations) can help relieve pain in the buttock. As for surgery, it is indicated only if the inflammatory low back pain progresses to the point of creating deformities or subluxations.

 

3. Consider natural products

Admittedly, homeopathy is not backed by solid scientific evidence. But the fact remains that many patients suffering from inflammatory low back pain say they are relieved by some natural products, gels, ointments and even grandmother's remedies!

The most important thing is that you tell your doctor about any product consumed. Indeed, the risk of interaction with the drugs prescribed by your doctor is not to be underestimated, and could cause adverse reactions. A homeopath can also guide you if you ever consider this therapeutic option. 

To learn all about natural products (and which ones to use for back pain), see the following article.

4. Keep your spirits up (easy to say, I know!)

 

“I can no longer live as I lived before. With my partner, on weekends we went out, we walked. Today, walking a kilometer is painful for me, my hips and knees hurt very quickly. During crises, I have the impression of living in the body of an elderly person.

Jennifer Massenot, patient with ankylosing spondylitis.

Inflammatory conditions are usually very difficult to live with morally. For these reasons, it is necessary avoid social isolation, and ask for help if needed. 

“I do not yet accept the disease and I have decided to make myself follow up with a psychologist. Waiting for it to pass, I don't think that's a good idea and then there's no shame in asking for help."  Karine

 

5. Quit smoking

 

According to some studies, smoking is responsible for an earlier onset of disabling symptoms, and an aggravation of inflammatory diseases such as ankylosing spondylitis.

Smoking is known to affect heart and lung function, in addition to fueling inflammation. From experience, I can also tell you that several of my patients have seen their pain decrease quitting smoking.

If you are a smoker, you have a more reason to quit!  

 

6. Choose the right bedding

 

Unfortunately, many patients with inflammatory low back pain complain of nocturnal pain. From experience, many have seen their symptoms improve somewhat by choosing adequate bedding. There is no solid evidence at this level, but the orthopedic pillows and semi-firm mattresses seem to help you sleep better at night. Try sleeping on a different surface, and see for yourself the impact on your pain!

As for the pillow, opt for an orthopedic memory foam pillow. To know the opinion of a health professional on this type of pillow, click here.

 

7. Decorate your home

 

As the spine is more fragile in the presence of inflammatory low back pain, this increases the risk of fracture in the event of trauma. Many patients furnish their homes with non-slip floor, shower or bath mats. Prevention is better than cure!

 

In addition, joint stiffness associated with inflammatory low back pain can affect sitting posture, especially when it comes to sitting on the toilet bowl. An easy adjustment would be to add armrests, or simply raise the seat.

 

8. Arrange your workstation

 

We discussed the myth of the "bad posture" in a previous article. On the other hand, many patients claim to feel more comfortable when they use an ergonomic chair, lumbar support, or even a standing desk.

On the other hand, never forget the basics, namely that prolonged sitting posture must be avoided by changing position as much as possible.

 

9. Consider a anti-inflammatory diet

 

It is obvious, many patients have seen a great improvement in their pain after changing their diet.

Of course, a nutritionist is best able to help you. But we can go by the logic that some foods increase the level of inflammation, while others can decrease it. Our goal will then be to limit the consumption of foods that increase the level of inflammation, as well as to consume foods that have a role to play against inflammation.

Here is a list of foods that have a role to play against inflammation (this list is far from exhaustive!). Keep this list in mind the next time you go to the supermarket:

Foods with a role to play against inflammation:

• -Spirulina (Wu et al 2016)
• -Curcumin or turmeric (Chin et al 2016)
• -Kale
• -Foods rich in omega-3
• -Low-starch vegetables (Sears et al 2015)
• -Nut
• -Olive oil
• -Tomatoes

Conversely, there are foods that can potentially increase the level of inflammation in the body. Here are some examples (again, this list is far from exhaustive!):

 

List of foods to avoid to possibly reduce your level of inflammation: (Sears et al 2015)

 

• -Saturated fats and artificial trans fats
• -Some foods rich in Omega-6
• -Foods high in sugar and fructose
• - Fries
• -Processed foods
• -Caffeine
• -Alcohol
• -Soft drinks
• - Excess red meat

If you're interested in the topic, there's a full article explaining the anti-inflammatory diet and its relationship to back pain. As a bonus, a 7 and 28-day food plan is offered, as well as a complete method called "The anti back pain diet".

To know everything about the anti-inflammatory diet, see the following article. 

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Conclusion

So! If you are reading these lines, I hope that you are now better able to diagnose the origin of your low back pain.

Admittedly, the diagnosis itself is complex, but certain tests and symptoms should give you an idea. A doctor can then guide you through the process, and prescribe the tests and examinations to clarify the situation.

Remember that the biggest challenge with inflammatory low back pain is diagnosing it early. Don't expect too much, and above all, don't let your back pain ruin your life!