Back Pain and Axial Spondyloarthritis (axSpA): Symptoms, Diagnosis and Treatment
When is back pain more than just back pain?
Back pain is very common. In the UK, the chance of experiencing an episode of back pain during your lifetime is almost 60%. Whilst most cases are caused by muscular strain or mechanical problems, chronic back pain in young adults can sometimes be a sign of an underlying inflammatory condition called axial spondyloarthritis (axSpA).
The type of back pain associated with axial spondyloarthritis is known as inflammatory back pain and behaves very differently from the mechanical back pain that most people experience.
In the vast majority of cases, back pain is mechanical in nature and settles with time, movement and simple treatments. However, in a minority of people, persistent inflammatory back pain can be a symptom of axial spondyloarthritis.
What is axial spondyloarthritis (axSpA)?
Axial spondyloarthritis is an autoimmune condition in which the body's immune system mistakenly attacks healthy tissues, causing inflammation in the joints of the spine and sacroiliac joints.
Inflammation affecting the sacroiliac joints is known as sacroiliitis, and it is one of the characteristic features of axial spondyloarthritis. Other areas of the body can also be affected.
This inflammation can lead to pain, stiffness (particularly in the morning or after periods of rest) and loss of mobility. If left completely untreated, it can progress and cause significant loss of mobility as joints in the spine become damaged and begin to fuse together.
Who is affected by axial spondyloarthritis?
Axial spondyloarthritis affects up to 1% of the population and most commonly develops before the age of 45.
Historically, we thought it affected men more commonly, but we now know that it can affect men and women equally.
I have heard the term ankylosing spondylitis. Is it the same thing as axial spondyloarthritis?
Ankylosing spondylitis is the historic name given to the condition when doctors identified certain changes on X-rays.
As we have become better at diagnosing the condition earlier, these X-ray changes are not always present. Modern treatments can also prevent the disease progressing to this stage.
Axial spondyloarthritis is now used as the umbrella term and includes both people who have X-ray changes and those who do not. Patients previously diagnosed with ankylosing spondylitis fall within the broader spectrum of axial spondyloarthritis.
Why does axial spondyloarthritis occur?
The truth is we do not really know, but it is likely to be caused by a combination of genetic and environmental factors.
A gene called HLA-B27 is associated with the condition. Among people of White ethnicity who are diagnosed with axial spondyloarthritis, around 85% carry this gene. This association is slightly lower in South Asian populations and lower still in Black populations, where approximately 50% of patients carry the gene.
It is important to understand that this is only an association. Being positive for the gene does not mean you have axial spondyloarthritis. Similarly, if you do not carry the gene, it does not mean you do not have the condition.
Does axial spondyloarthritis run in families?
There is a genetic component to axial spondyloarthritis, which means it can sometimes run in families.
Having a close family member with axial spondyloarthritis, ankylosing spondylitis, psoriasis, inflammatory bowel disease or uveitis may increase your risk of developing the condition. However, many people diagnosed with axSpA have no known family history.
Similarly, carrying the HLA-B27 gene does not mean you will develop the disease. It is simply one factor that may increase the likelihood.
What are the symptoms of axial spondyloarthritis (AxSpa)?
The main symptom is chronic back pain, usually lasting more than three months. This is typically felt in the lower back or buttocks and is often described as a deep ache.
The symptoms of inflammatory back pain often develop gradually over months or even years and are frequently mistaken for ordinary muscular back pain.
The pain is usually worse in the early morning and can sometimes wake you from sleep. Many people notice that symptoms are at their worst during the second half of the night or first thing in the morning.
Stiffness is also a hallmark symptom. Sometimes patients tell me they feel as though they have aged ten years in the space of a few months. The stiffness usually lasts for more than 30 minutes in the morning and can make simple activities, such as getting out of bed and getting dressed, feel difficult.
Unlike mechanical back pain, people with axial spondyloarthritis often find that exercise and stretching improve their symptoms. Many of my patients remain active for this reason and do not like sitting still for prolonged periods.
The pain may partially respond to anti-inflammatory medications, but it rarely disappears completely. Over time, other areas can also be affected, including the upper back, neck and hips.
You may also experience other symptoms:
- Swelling and stiffness in other joints or tendons. Achilles tendon pain and knee tendon pain are common.
- Skin psoriasis, often appearing as a flaky, silvery rash on the elbows, knees or groin.
- Episodes of eye inflammation (uveitis).
- Bowel symptoms, including abdominal pain, cramps and bloody diarrhoea.
What is inflammatory back pain?
One term you may come across when researching axial spondyloarthritis is inflammatory back pain.
This is the type of back pain caused by inflammation within the joints and tissues around the spine. It behaves very differently from the mechanical back pain that most people experience at some point in their lives.
Inflammatory back pain typically:
- Starts before the age of 45.
- Comes on gradually rather than after an injury.
- Improves with movement and exercise.
- Feels worse after periods of rest.
- Causes morning stiffness that lasts longer than 30 minutes.
- Can wake you during the second half of the night.
This pattern of symptoms is often one of the biggest clues that there may be an underlying inflammatory condition such as axial spondyloarthritis.
When should I see a doctor about back pain?
Most back pain is mechanical and improves with time, exercise and simple pain relief. However, there are certain features that should prompt you to seek medical advice.
You should consider seeing a doctor if:
- Your back pain has persisted for more than three months.
- You regularly wake in the early hours because of pain.
- You experience significant morning stiffness lasting more than 30 minutes.
- Exercise improves your symptoms but resting makes them worse.
- You have psoriasis, inflammatory bowel disease or a history of uveitis.
- A close family member has been diagnosed with ankylosing spondylitis or axial spondyloarthritis.
Unfortunately, axial spondyloarthritis is often diagnosed later than it should be. Many patients are initially told they have mechanical or muscular back pain because they are otherwise young and healthy. Recognising the symptoms early can help people access treatment sooner and achieve better outcomes.
How is axial spondyloarthritis diagnosed?
Firstly, it is a clinical diagnosis. This means you need to see a rheumatologist, such as myself.
Rheumatologists are specialists in diagnosing and treating conditions such as axial spondyloarthritis, ankylosing spondylitis and other inflammatory forms of back pain.
A rheumatologist will take a detailed history, discuss your symptoms and perform an examination. We also use blood tests and imaging, such as X-rays and MRI scans, to help support the diagnosis.
Tests usually include:
- HLA-B27 and CRP blood tests to assess for inflammation in the body and check for the gene association discussed earlier.
- MRI of the sacroiliac joints and the whole spine. Most people develop changes that are visible on MRI within the sacroiliac joints near the base of the spine. However, some patients develop inflammation elsewhere in the spine. Scanning the whole spine helps us understand where inflammation is present and how active it is. It can also show signs of previous inflammation, even when symptoms have improved.
MRI scans are particularly useful because they can detect inflammation before permanent damage becomes visible on X-rays.
A note about MRI scans:
MRI scans are extremely useful for identifying inflammation within the sacroiliac joints and spine. However, it is important to understand that no single test can diagnose axial spondyloarthritis on its own.
Occasionally, patients have symptoms strongly suggestive of axial spondyloarthritis but their MRI scan does not show obvious inflammation. In these situations, rheumatologists look at the overall clinical picture, including symptoms, examination findings and blood tests, rather than relying on any one investigation in isolation.
Is axial spondyloarthritis (AxSpa) treatable?
The great thing about reaching a diagnosis is that this is a very treatable condition.
Like any autoimmune disease, it cannot currently be cured. However, there are many effective treatments available that can help control symptoms and prevent progression.
At diagnosis, we discuss a treatment plan aimed at putting the condition into remission. The goal is to help you return to a full quality of life and enjoy the activities you did before your symptoms began.
What does treatment for axial spondyloarthritis look like?
Treatment focuses on three main strategies:
Physiotherapy and exercise
This remains the cornerstone of treatment and has done for many years. Research consistently shows benefits in pain, fatigue and overall function. Supervised physiotherapy tends to be more effective than exercising alone, but both can help.
The best exercise is ultimately something you enjoy and can maintain long term. Exercise does not damage your joints, and both aerobic exercise and strength training are beneficial. A combination of the two is usually best.
Anti-inflammatory medications
Examples include ibuprofen and naproxen, although doctors often prescribe longer-acting anti-inflammatory medications such as etoricoxib.
These medications can be very effective, and around one-third of patients achieve good symptom control with anti-inflammatory treatment alone.
Advanced biologic therapies
Biologic therapies have transformed outcomes for patients with axial spondyloarthritis in recent years. These medications target specific parts of the immune system to reduce inflammation.
Examples include adalimumab, although several other biologic treatments are now available. Approximately 60-70% of patients respond well to these therapies.
Historically, these treatments were expensive, but as many have come off patent they have become increasingly accessible.
What are biologic therapies like?
Many people feel anxious when they first hear the term "biologic therapy", but in reality these medications have transformed the outlook for many patients with axial spondyloarthritis.
Most biologic medications are given as injections that can be administered at home, while some are given as infusions within a hospital setting. Your rheumatology team will discuss the most appropriate option for you based on your symptoms, lifestyle and medical history.
For many patients, these treatments significantly reduce pain and stiffness, improve quality of life and help prevent long-term joint damage.
Living with axial spondyloarthritis
Lifestyle measures can play an important role alongside medical treatment.
Maintaining regular physical activity, avoiding smoking, achieving a healthy weight and performing exercises recommended by your physiotherapist can all help improve symptoms and long-term outcomes.
Many patients find that a combination of appropriate medication, regular exercise and ongoing support from their rheumatology team allows them to continue leading full and active lives.
What is the prognosis for axial spondyloarthritis?
Axial spondyloarthritis is a chronic condition, but it is highly treatable. Modern therapies can provide significant symptom relief and help prevent long-term damage.
Many people with axial spondyloarthritis go on to lead active, fulfilling lives with appropriate treatment and support. Early diagnosis and treatment are particularly important, as they can significantly improve long-term outcomes.
It is also important to remember that the severe spinal fusion often seen in historical images of ankylosing spondylitis is now much less common. Earlier diagnosis, improved physiotherapy programmes and the development of biologic therapies have dramatically changed outcomes for many patients.
When should I seek urgent medical attention?
While most back pain is not caused by a serious medical condition, there are some symptoms that require urgent assessment.
You should seek immediate medical attention if you develop:
- New weakness in one or both legs.
- Loss of bladder or bowel control.
- Numbness around the genitals or buttocks.
- Unexplained weight loss.
- Persistent fevers or night sweats.
These symptoms may indicate a different underlying condition and should be assessed urgently.
Frequently Asked Questions
Can axial spondyloarthritis be cured?
At present there is no cure for axial spondyloarthritis. However, modern treatments can be very effective in controlling inflammation, reducing symptoms and preventing long-term damage.
Can I exercise if I have axial spondyloarthritis?
Absolutely. Exercise remains one of the most important parts of treatment. Most patients find that regular movement improves pain, stiffness and overall wellbeing.
Is axial spondyloarthritis hereditary?
There is a genetic component, and the condition can run in families. However, not everyone with a family history develops the condition, and many people diagnosed have no affected relatives.
Will I need an MRI scan?
Many patients will undergo MRI scanning as part of their assessment, particularly if X-rays are normal. Whether you need an MRI will depend on your symptoms, examination findings and previous investigations.
Can axial spondyloarthritis cause neck pain?
Yes. Although symptoms often begin in the lower back or buttocks, inflammation can affect other areas of the spine, including the neck.
Can axial spondyloarthritis be missed on an X-ray?
Yes. Many patients have symptoms for years before changes become visible on X-rays. This is one reason MRI scanning has become such an important tool for diagnosis.
Is axial spondyloarthritis the same as ankylosing spondylitis?
Ankylosing spondylitis is part of the axial spondyloarthritis spectrum. The term axial spondyloarthritis is now used more commonly because it includes people with the condition both before and after X-ray changes develop.