How Treatments Differ for Inflammatory vs. Mechanical Back Pain

Inflammatory back pain occurs due to ankylosing spondylitis (AS) and other spondyloarthritides. AS is a type of inflammatory arthritis that starts in the joints and ligaments of your spine. When untreated, it can eventually cause fusion of the vertebrae of your lower spine.

AS typically causes lower back pain and pain in the hips. You may also notice that your symptoms get worse with rest and improve with activity.

The exact cause of AS is not known. Experts believe it may have to do with a combination of genetic and environmental factors that trigger AS to develop. For example, experts know that having the HLA-B27 gene increases the risk of developing AS, but it is not a guarantee you will develop the condition if you have that gene.

While inflammation is the underlying cause of inflammatory back pain, mechanical back pain starts in the spine, soft tissue, and disks of your back. Repetitive trauma and overuse are common causes of chronic lower back pain, second only to workplace injury.

AS is a chronic, progressive disease. It currently has no cure, but treatments can help slow progression and lessen the severity of symptoms.

You may also experience what is known as flares. Flares describe times when your symptoms worsen or intensify.

AS can cause the following symptoms to occur in your spine:

• stiffness
• posture changes
• immobility

Over many years, the process of healing and repair following inflammatory flares can lead to fusion of the spine. This typically occurs in severe cases of AS. It does not occur in everyone with the condition. If it does occur, it increases the risk of spinal fractures and further reduces mobility.

AS can affect more than just your spine due to the inflammatory nature of the condition.

Widespread inflammation can cause issues in other organs and tissues throughout the body, leading to potential issues that may include:

• skin rashes
• stiffness, pain, and inflammation in other joints, such as the knees, shoulders, feet, or ribs
• vision changes
• uveitis (eye pain from inflammation)
• trouble taking deep breaths (when the joints of the ribs become involved)
• loss of appetite
• weight loss
• loose bowel movements
• abdominal pain
• fatigue

Following appropriate treatment guidelines can help prevent complications from occurring, so it is important to figure out the source of your back pain if you’re not sure of the underlying cause.

Spine or back pain can be difficult for doctors to diagnose due to the complexity of the structure of the spine. Experts generally recommend doctors start with a review of personal and family medical history combined with a physical examination and imaging as needed.

In some cases, a doctor may be able to identify possible causes of mechanical back pain to help rule out other causes.

Doctors will typically look for certain red flags that may point to an inflammatory underlying cause, such as AS.

Some signs your back pain may be from AS and is not mechanical in nature include:

• pain onset occurs in people under age 35
• pain and stiffness worsen when at rest, such as sitting for long periods or overnight
• symptoms last for 3 months or longer
• use of nonsteroidal anti-inflammatory drugs (NSAIDs) effectively relieves pain and stiffness (occurs in most people with AS)
• pain and stiffness improve with exercise and physical activity

A doctor will need to rule out other causes of back pain. For example, mechanical back pain will typically improve with rest and will only cause short-lived pain in the morning.

A doctor may order additional imaging tests or blood tests. Since there is no single test that can point to AS, diagnosis may take a bit of time for a doctor to confirm.

Management for mechanical and inflammatory back pain differ. Getting a proper diagnosis can make a big difference in making sure you get the right treatment that will best help you.

Mechanical back pain has several potential treatment and management options, some with more evidence of effectiveness than others. These options include:

• NSAIDs, which are generally OK for short-term use
• opioids, which can relieve pain in the short term but are only recommended for severe back pain
• skeletal muscle relaxants, which may be good for acute pain but are also associated with adverse effects
• physical therapies, including massages, acupuncture, or physical therapy, with differing effectiveness levels
• injections
• surgical invention
• alternative treatments, including yoga and cognitive behavioral therapy

There is no evidence that acetaminophen or anticonvulsants are effective, and in fact they may prove detrimental.

Often, resting from activities that aggravate your pain will generally help it improve. You may not need prescription treatment if the pain is mild and does not interfere with daily activities.

Inflammatory back pain associated with AS will typically require medications to help:

• relieve symptoms
• prevent progression of the disease
• help maintain posture

Treatments may involve a combination of medications as well as physical therapy. In very severe cases, a doctor may recommend surgery to help repair damaged joints.

Possible medications a doctor may recommend include:

• over-the-counter or prescription NSAIDs
• Janus kinase (JAK) inhibitors to help block specific causes of inflammation
• biologics to help block inflammation
• injected corticosteroids to help with inflammation and pain

In addition to medical treatments, you can also help manage your AS symptoms with some lifestyle strategies. These can include:

• getting regular exercise or physical activity
• eating a nutritious, balanced diet
• taking steps to improve posture, such as using braces
• using assistive devices
• taking steps to manage stress and mental health needs through therapies and learning coping techniques
• quitting smoking, if applicable

Mechanical back pain often occurs due to repeated stress placed on the spine. Inflammatory back pain occurs due to the immune system creating inflammation. It’s often associated with AS.

While they can both be mild or severe, they require different treatments. Mechanical back pain often improves with rest and may not need additional treatments in mild cases. Inflammatory back pain will require treating the underlying cause of inflammation to help relieve symptoms and prevent disease progression.

Proper diagnosis is important for treatment. Doctors will typically need to review medical history and order imaging tests. They may also request additional testing as needed.