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The Reason Behind Your Back Pain and Inflammation

Exploring nr-AxSpA as the Cause

What Is Non-Radiographic Axial Spondyloarthritis?

If you’re commonly coping with back pain and inflammation, you owe it to yourself to identify the cause of the discomfort — especially if it’s affecting everyday activities like cooking, staying active, or doing your job. Identifying the reason is the first step to finding the right treatment!

One potential cause, often unheard of and often undiagnosed or misdiagnosed, is non-radiographic axial spondyloarthritis (nr-AxSpA). It is a type of arthritis that causes inflammation in the spine and in the area where the spine connects to the hips (your sacroiliac (SI) joints). While less common, it does affect over 3 million adults in the United States, and there are hallmark signs and symptoms that point to it.

The name of the condition is quite a mouthful, but its meaning is straightforward. Let’s break it down.

  • “Non-radiographic” means that while there are symptoms, x-rays do show damage or inflammation.
  • “Axial” means that the condition affects the axial skeleton — the hip bones, chest, and spine.
  • "Spondyloarthritis" generally refers to several distinct diseases that affect the joints, tendons, and ligaments, including psoriatic arthritis and axial spondylitis, amongst others. These diseases can be distinguished by some of their symptoms. However, they do share symptoms like joint inflammation, particularly in the lower back and hip joints.

Although nr-AxSpA causes invisible symptoms, the condition is no less severe than other types of arthritis. In fact, the disease burden is similar, causing pain, fatigue, and stiffness, and negatively affecting quality of life. The good news is that most people respond well to treatment, which can relieve symptoms and their associated burden.

Symptoms to Look Out For

Several tell-tale nr-AxSpA symptoms can manifest in several areas of the body, so there are factors you can look out for to rule the condition in or out. Explore each below. You should consult with your doctor in either case, especially if your symptoms aren’t manageable or tolerable.

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Lower Back Pain

 Lower back pain is common, often at night, in the morning, or after sitting for too long. It improves with movement and activity and most commonly occurs in late adolescence and early adulthood — before age 40.

Navigating Diagnosis

Visiting your healthcare provider and advocating for care — in person or through a telehealth call — is one of the best steps you can take to begin relieving symptoms, whether or not they align with those of nr-AxSpA.

If you suspect you have nr-AxSpA or another form of inflammatory arthritis, you can bring up your suspicions and your doctor can dig deeper. In some cases, he or she may refer you to a specialist called a rheumatologist, whose focus is diagnosing and treating diseases that affect the joints, muscles, and bones. Even if you don’t suspect nr-AxSpA, it’s in your best interest to work with your doctor to find the root cause of your pain and find a solution.

Unfortunately, there is no single test that can make a definitive nr-axSpA diagnosis. Your doctor will rely on various testing methods, including information from you about clinical symptoms, your medical and family history, a physical exam, bloodwork, and imaging. You can expect the following.

Symptom Assessment

Your doctor will likely ask you a series of questions about when your symptoms started, what time of day they occur, how long they last, and more. Do your best to be clear, honest, and specific in your answers. You may even want to track your symptoms before your appointment. Your doctor can use the information to make a proper diagnosis.

Take a look at the questions in the assessment below for a glimpse of what you may be asked and how your doctor may interpret the information. Remember, your doctor will holistically look at all the information you provide, along with additional information from exams and imaging. Answering yes or no to any of the questions below does not confirm or rule out a diagnosis and should not be considered medical advice.

Question 1

Is back pain the only symptom you experience?

  • Yes
  • No
Question 1 of 6

Medical and Family History

In addition to asking questions about your symptoms, your doctor will want more information about your personal medical history, which includes current and past medical conditions, any medications or supplements you are taking, and any surgeries you may have had. He or she will also want to know your family’s health history. Having relatives with certain inflammatory diseases, such as axial spondyloarthritis, uveitis, reactive arthritis, and psoriatic arthritis, may mean you are more likely to have nr-axSpA.

Physical Exam

Your doctor will likely perform a physical exam that includes an assessment of swollen joints, fingers, and feet. Your doctor will also check your eyes and skin to look for signs of inflammation, such as swelling, redness, burning, or skin rashes.

If you are meeting your doctor through a telehealth call, findings will likely come from a combination of questions and assessment over video chat.

Bloodwork

Blood work can determine if there is inflammation in the body. It can also reveal the presence of the HLA-B27 gene, which is associated with many spondyloarthritis conditions. Having the gene does not necessarily mean you have nr-AxSpA, but if you already have signs of the condition, having it means you more likely might.

Imaging

Your doctor may use magnetic resonance imaging (MRI), currently the gold standard for diagnosing nr-AxSpA. An MRI can show areas of inflammation in the SI joints long before the disease progresses enough for damage to be seen on x-rays. If the MRI does not show abnormalities, nr-AxSpA can be ruled out. At that point, your doctor will assess what else could be causing your symptoms. Some may be living with peripheral spondyloarthritis but not axial spondyloarthritis, for example, or related conditions like ankylosing spondylitis, other inflammatory conditions, or back pain unrelated to a condition may be at play.

Relieving Symptoms

If your doctor concludes a nr-AxSpA diagnosis, rest assured that there are treatments that can help relieve symptoms and improve your quality of life. And while it may understandably feel overwhelming to be diagnosed with a new condition, you may also feel a sense of relief knowing the reason behind your symptoms and knowing you can now take proven steps to alleviate them.

Lifestyle Improvements

Your everyday lifestyle habits can affect your symptoms, but there are things you can do to improve them and help yourself feel better. You can:

  • Quit Smoking: If you smoke, take time to research resources that will help you quit. Studies have shown tobacco can worsen nr-AxSpA symptoms.
  • Eat Healthy: Managing nr-AxSpA doesn’t call for a specific diet, but a balanced diet will help you control your weight and avoid inflammation-inducing options like fried foods.
  • Keep Moving: Consistent activity can ease nr-AxSpa back and joint pain. Simple stretches and swimming in particular have been shown to help.
  • Try Physical Therapy: Scheduled sessions will keep you consistently active, and a trained PT will teach you specific exercises designed to relieve pain and retain good range of motion.

Medications

Medication treatment for nr-AxSpA focuses on addressing pain, reducing inflammation, and slowing down disease progression. There are several classes of drugs your doctor will consider when treating symptoms and slowing down the disease.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

  • Benefits: NSAIDs reduce inflammation and relieve pain. They are usually highly effective in treating early disease.
  • How They’re Administered: NSAIDs are packaged as oral pills or capsules, whether you get them over-the-counter (OTC) at your local pharmacy or prescribed by your doctor.
  • Side Effects: Despite offering quick relief, NSAIDs take a few weeks to achieve full treatment benefits. It is important to note that they can have serious side effects, especially when taken in high doses for long periods of time. These include GI troubles, stomach ulcers and bleeding, kidney and liver damage, and an increased risk for stroke or heart attack. Make sure you follow your doctor’s advice when taking NSAIDs. Once your disease is better controlled, he or she will likely recommend you take these drugs on an as-needed basis.
  • Your Options: OTC options include ibuprofen and naproxen. Prescription options include meloxicam and celecoxib. Which NSAID works best for treating nr-AxSpA varies from person to person, so it’s important to work with your doctor and be mindful of efficacy and side effects as you begin taking them.

Biologics: TNF Inhibitors

  • Benefits: Biologic drugs that inhibit TNF proteins have been shown effective in treating nr-AxSpA. Once TNF is blocked, inflammation, pain, swelling, stiffness, and fatigue usually improve.
  • Available Options: There are five different TNF inhibitors used for nr-AxSpA treatment. It’s best to discuss the options with your doctor. Work together and talk about administration, side effects, efficacy, and why he or she prefers one option over the other.
  • How They’re Administered: Available options differ in administration. Some are infusions that require a visit to the doctor’s office, others are under-the-skin injections that you can give yourself from the comfort of your own home. The options also differ in how often they’re given. Discuss and consider the requirements associated with each option to help determine which you’ll likely comply with most.
  • Side Effects: Side effects of TNF inhibitors include injection site reactions, such as burning and itching, and increased risk for infections, like tuberculosis and fungal-type infections. Additionally, long term use of TNF inhibitors can increase the risk for some cancers, including skin cancer and lymphoma.

Biologics: IL-17A, IL-12, and IL23 Inhibitors

  • Benefits: Biologic drugs that inhibit pro-inflammatory proteins such as interleukin (IL)-17A, IL-12, and IL-23 can significantly improve disease signs and symptoms. 
  • Available Options: There are multiple options available, with more on the way (Cosentyx is expected to gain FDA approval for nr-AxSpA in 2020). It’s best to discuss them with your doctor. Work together and talk about side effects, efficacy, and why he or she prefers one option over the other.
  • How They’re Administered: All options in this category are injected under the skin. Your doctor will teach you the safest and most effective ways to inject yourself. Follow his or her instructions and make sure to stay compliant with treatment so that you get the best results.
  • Side Effects: Similar to other biologics, side effects include injection site reactions, such as burning and itching, and increased risk for infections, like tuberculosis and fungal-type infections.

Intra-Articular Corticosteroid Injections

  • Benefits: These injections inhibit inflammatory cell production to relieve pain and local inflammation. 
  • How They’re Administered: The steroids are injected directly into the joint space of a painful, inflamed joint every three months or longer.
  • Side Effects: Long-term corticosteroid use is known to progressively damage joints, so the option is never considered a sole treatment. The injections are also associated with infections and local site reactions.

Consider your doctor your partner as you research your diagnosis and explore treatments. For the best experience, come prepared with questions so that you feel prepared and empowered during your discussions.

Working With Your Doctor

The doctor discussion guide below outlines a few questions you might want to ask. Print it out or save it to keep handy during your appointment. It comes with nr-AxSpA-related vocabulary words you might hear your doctor use or you might want to use to better express yourself.

As you start treatment, it’s important to stay in touch and communicate any frustrations you’re experiencing — whether it’s side effects or lack of results. Your doctor can tweak your treatment plan, offer solutions, or explain the reasons behind the delays you’re experiencing so that you can have the best treatment experience possible.