Inflammatory back pain: how to distinguish
Mechanical back pain - that which is associated with overload - behaves predictably: it appears after exercise, intensifies in the evening and subsides with rest. Inflammatory pain is the other way around, and this difference is so characteristic that in itself it gives reason to refer a person to a rheumatologist. It’s enough to calmly make out a few signs.
- Onset at a young age, usually before age forty, and gradual rather than after a specific episode
- The pain lasts longer than three months and does not go away at all
- Intensifies at rest and especially in the second half of the night, causing you to wake up and walk around the room
- Improved by movement and exercise, not by lying down
- Morning stiffness in the lower back lasts longer than thirty minutes, often an hour or more
- Responds well to anti-inflammatory drugs - relief is noticeable and rapid
- Can give alternately to one and the other buttock
There is a simple check that a person can do himself. If you have to get up at night because of pain, and after ten to fifteen minutes of walking it becomes easier and you manage to fall asleep again - this is very typical for inflammatory pain and not at all typical for osteochondrosis. The same applies to the morning: with mechanical pain, a person gets up rested and feels better in the evening, with inflammatory pain, he wakes up stiff, walks around for lunch and feels best in the active part of the day.
What else happens besides the back
Ankylosing spondylitis is not limited to the spine, and non-vertebral manifestations often occur before back pain becomes apparent. They are useful to know: they help put the picture together and explain why a patient is sometimes referred to an ophthalmologist or gastroenterologist for a diagnosis.
- Acute uveitis is inflammation of the uvea of the eye: sudden pain, redness, photophobia, fog before the eye. Usually one eye is affected and the condition requires immediate examination by an ophthalmologist
- Arthritis of large joints - most often hip, knee, ankle, usually asymmetrical
- Enthesitis - inflammation where tendons attach to bones: pain in the heel when taking the first steps in the morning, soreness of the Achilles tendon
- Dactylitis is a uniform swelling of the entire finger that looks like a sausage.
- Inflammatory bowel disease: prolonged diarrhea, blood in stool, abdominal pain
- Skin and nail psoriasis
- Restricted mobility of the chest: it expands less well when inhaling, breathing volume decreases
Heel pain deserves a special mention because it is almost always attributed to a heel spur. In a young person who also has low back pain at night, inflammation of the Achilles tendon or plantar fascia insertion is part of the overall picture and not an independent orthopedic problem. Treatment in this case is also general, aimed at the underlying disease.
How is the diagnosis made?
The basis of diagnosis is the clinical picture confirmed by imaging. There is an important feature here: x-rays show changes in the sacroiliac joints only years after the onset of the disease, so a normal x-ray in a young patient does not exclude anything. MRI sees active inflammation at the very beginning, and it has changed the approach to early diagnosis.
- Подробный расспрос: характер боли, её поведение ночью и при движении, длительность утренней скованности, заболевания глаз и кишечника, случаи diseases у родственников.
- Осмотр с оценкой подвижности позвоночника в разных плоскостях и измерением экскурсии грудной клетки — эти показатели фиксируются в цифрах и потом отслеживаются в динамике.
- МРТ крестцово-подвздошных сочленений — метод выбора на ранней стадии: показывает отёк костного мозга, то есть активное воспаление.
- Рентген таза — выявляет уже сформировавшиеся структурные изменения, полезен при большей длительности болезни.
- Анализы крови: СРБ и СОЭ как показатели воспалительной активности; при этом нормальные значения диагноз не отменяют.
- HLA-B27 — генетический маркер, повышающий вероятность диагноза, но не подтверждающий и не исключающий его сам по себе.
It’s worth mentioning separately about HLA-B27, because there is a lot of confusion around this analysis. It is positive in most patients with ankylosing spondylitis, but it also occurs in some healthy people who never get sick. There are two conclusions from this. A positive result without symptoms is not a diagnosis and is not a reason for treatment or concern. A negative result for typical inflammatory back pain does not remove the diagnosis, and in such a situation an MRI is needed, and not a refusal to further search.
Exercise is the primary treatment, not an adjunct.
This is the most unexpected statement for patients, and it is accurate: with ankylosing spondylitis, regular physical therapy affects the outcome no less than medications. Inflammation gradually leads to ossification of the ligaments and fusion of the vertebrae, and the whole future life depends on the position in which the spine is fixed. If a person maintains extension and mobility on a daily basis, the back will largely maintain function. If he spares his back and tries to move less, a bent posture is formed, which is subsequently impossible to change.
- Daily spinal extension and stretching exercises, at least half an hour, preferably in two sets
- Separately, breathing exercises to maintain chest mobility
- Swimming as an optimal form of exercise: relieves the spine and forces all muscle groups to work
- Sleep on a flat surface, low pillow, periodically lie on your stomach to prevent flexion position
- Control of posture throughout the day, regular breaks during sedentary work with warm-up every hour
- Quitting smoking: it accelerates the progression and worsens lung function, which is already impaired in this disease
- Be careful with impact sports and any situations with a risk of back injury
It is useful to understand what exactly regular gymnastics allows you to avoid. When a flexion position is formed, a person cannot straighten up, looks at the floor, it is difficult for him to drive a car and cross the road, and the volume of breathing decreases so much that this in itself becomes a problem. Surgical correction of such deformity is possible, but this is a large and complex procedure. Half an hour of exercise every day is an incomparably lower price, and you need to pay it precisely when your back still bends, and not when it stops.
Drug treatment and observation
Drug therapy solves two problems: relieve pain and suppress inflammation to slow down structural changes. The scheme is built in stages - from simple to complex, with an assessment of the result at each stage.
- Нестероидные противовоспалительные препараты — первая линия. При этой diseases они работают особенно хорошо, а при высокой активности принимаются регулярно, а не только при боли, по схеме, которую определяет врач.
- При недостаточном эффекте двух препаратов этой группы в течение достаточного срока рассматривается переход к следующей ступени.
- Генно-инженерные биологические препараты — при сохраняющейся активности. Они существенно изменили прогноз заболевания за последние два десятилетия.
- Препараты базисной группы имеют смысл главным образом при поражении периферических суставов, но не при изолированном поражении позвоночника.
- Локальные инъекции глюкокортикоидов в отдельные суставы или зоны энтезитов по показаниям. Длительный приём гормонов внутрь при этой diseases неэффективен.
- Регулярная оценка активности, подвижности позвоночника и лабораторных показателей — обычно раз в несколько месяцев.
Before starting biological therapy, latent tuberculosis and viral hepatitis must be excluded - this is a standard and non-discussed part of the preparation, especially important in a region with a high prevalence of tuberculosis. In the future, the control is repeated according to the schedule, and if there is any increase in temperature during such therapy, you need to contact your doctor and not wait.
Work, life and long-term perspective
The course of the disease varies greatly among different people: for some it remains mild and has almost no effect on life, for others it requires active therapy for years. However, the general pattern can be clearly seen - earlier treatment and constant gymnastics give noticeably better back function after ten and twenty years. Many household solutions are simple and cost little.
- Organize your workspace so that the monitor is at eye level, and not below - this keeps your neck from bending forward
- When working sedentarily, get up and stretch every hour, rather than wait until the evening
- Choose a moderately hard mattress and a low pillow; sleeping on a high pillow with this disease is especially undesirable
- Avoid work that requires prolonged bending or heavy lifting.
- Quitting smoking is one of the few measures that affects the rate of progression
- Do not delay a visit to the ophthalmologist if there is redness and pain in the eye: uveitis can be treated quickly, but requires timely onset
- Remember that if the mobility of the neck and chest is significantly limited, you need to warn the anesthesiologist in advance before any operation
It is also worth mentioning how the disease is perceived by others. A young person who appears healthy but sleeps poorly, gets up groggy and asks for exercise breaks often faces misunderstandings at work and at home. Meanwhile, night pain and many hours of stiffness are not an exaggeration, but a typical manifestation of an active disease. Having an open conversation with your employer and being able to get up and stretch during the day usually solves the problem better than trying to endure it.