Inflammatory Back Pain: Integrated Approaches in Physical Therapy, Nursing, and Laboratory Management
Abstract
Background: Inflammatory Back Pain (IBP) is a clinical syndrome characterized by chronic axial spinal pain, distinct from mechanical back pain. It is strongly associated with seronegative spondyloarthropathies (SpA) like ankylosing spondylitis and, if unmanaged, can lead to progressive structural damage and significant morbidity.
Aim: This article aims to delineate the integrated, multidisciplinary approach required for the effective diagnosis, management, and long-term care of IBP. It emphasizes early recognition to prevent irreversible complications and improve patient outcomes.
Methods: Management involves a coordinated strategy combining early rheumatologist referral, pharmacotherapy (NSAIDs, biologic DMARDs like TNF or IL-17 inhibitors), and non-pharmacologic interventions. The latter includes structured physical therapy, patient education, and lifestyle modifications. Diagnosis relies on clinical criteria (e.g., chronicity, morning stiffness, improvement with exercise), supported by laboratory tests (HLA-B27, inflammatory markers) and advanced imaging (MRI).
Results: A multidisciplinary approach effectively controls symptoms, preserves spinal mobility, and improves quality of life. However, under-diagnosis and delayed treatment can lead to complications including osteoporosis, fractures, spinal deformity, and increased cardiovascular risk. Early intervention is critical for a favorable prognosis.
Conclusion: Successful management of IBP hinges on an interprofessional model integrating specialist medical care, targeted pharmacotherapy, structured rehabilitation, and patient education to mitigate disease progression and systemic complications.
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References
Zhao J, Chen J, Yang TH, Holme P. Insights into the pathogenesis of axial spondyloarthropathy from network and pathway analysis. BMC Syst Biol. 2012;6 Suppl 1(Suppl 1):S4.
Chyuan IT, Chen JY. Role of Interleukin- (IL-) 17 in the Pathogenesis and Targeted Therapies in Spondyloarthropathies. Mediators Inflamm. 2018;2018:2403935.
Weisman MH. Inflammatory back pain: the United States perspective. Rheum Dis Clin North Am. 2012 Aug;38(3):501-12.
Braun J, Inman R. Clinical significance of inflammatory back pain for diagnosis and screening of patients with axial spondyloarthritis. Ann Rheum Dis. 2010 Jul;69(7):1264-8.
Thomas GP, Duan R, Pettit AR, Weedon H, Kaur S, Smith M, Brown MA. Expression profiling in spondyloarthropathy synovial biopsies highlights changes in expression of inflammatory genes in conjunction with tissue remodelling genes. BMC Musculoskelet Disord. 2013 Dec 15;14:354.
Hamilton L, Macgregor A, Warmington V, Pinch E, Gaffney K. The prevalence of inflammatory back pain in a UK primary care population. Rheumatology (Oxford). 2014 Jan;53(1):161-4.
Lau IS, Gun SC, Yeap SS, Mohd Zain M, Mohd Yusoof H, Sargunan S, Yahya F. Algorithm for the referral of patients with inflammatory back pain from primary care in Malaysia. Malays Fam Physician. 2021 Jul 22;16(2):2-6.
Tam LS, Wei JC, Aggarwal A, Baek HJ, Cheung PP, Chiowchanwisawakit P, Dans L, Gu J, Hagino N, Kishimoto M, Reyes HM, Soroosh S, Stebbings S, Whittle S, Yeap SS, Lau CS. 2018 APLAR axial spondyloarthritis treatment recommendations. Int J Rheum Dis. 2019 Mar;22(3):340-356.
Parameswaran P, Lucke M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 4, 2023. HLA-B27 Syndromes.
Taurog JD, Richardson JA, Croft JT, Simmons WA, Zhou M, Fernández-Sueiro JL, Balish E, Hammer RE. The germfree state prevents development of gut and joint inflammatory disease in HLA-B27 transgenic rats. J Exp Med. 1994 Dec 01;180(6):2359-64.
Tiwana H, Natt RS, Benitez-Brito R, Shah S, Wilson C, Bridger S, Harbord M, Sarner M, Ebringer A. Correlation between the immune responses to collagens type I, III, IV and V and Klebsiella pneumoniae in patients with Crohn's disease and ankylosing spondylitis. Rheumatology (Oxford). 2001 Jan;40(1):15-23.
Thatayatikom A, Modica R, De Leucio A. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jan 16, 2023. Juvenile Idiopathic Arthritis.
Ajene AN, Fischer Walker CL, Black RE. Enteric pathogens and reactive arthritis: a systematic review of Campylobacter, salmonella and Shigella-associated reactive arthritis. J Health Popul Nutr. 2013 Sep;31(3):299-307.
Baeten D, Kruithof E, De Rycke L, Boots AM, Mielants H, Veys EM, De Keyser F. Infiltration of the synovial membrane with macrophage subsets and polymorphonuclear cells reflects global disease activity in spondyloarthropathy. Arthritis Res Ther. 2005;7(2):R359-69.
Brandt HC, Spiller I, Song IH, Vahldiek JL, Rudwaleit M, Sieper J. Performance of referral recommendations in patients with chronic back pain and suspected axial spondyloarthritis. Ann Rheum Dis. 2007 Nov;66(11):1479-84.
Rudwaleit M, van der Heijde D, Landewé R, Listing J, Akkoc N, Brandt J, Braun J, Chou CT, Collantes-Estevez E, Dougados M, Huang F, Gu J, Khan MA, Kirazli Y, Maksymowych WP, Mielants H, Sørensen IJ, Ozgocmen S, Roussou E, Valle-Oñate R, Weber U, Wei J, Sieper J. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis. 2009 Jun;68(6):777-83.
Wang Z, Du M, Li J, Shi D, Wang H, Li H, Guo H. Clinical study of Tongdu Shujin decoction in the treatment of ankylosing spondylitis with cold-dampness obstruction type: Study protocol for a randomized controlled trial. Medicine (Baltimore). 2023 Feb 10;102(6):e32852.
Aboobacker S, Kurn H, Al Aboud AM. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jun 20, 2023. Secukinumab.
van der Heijde D, Ramiro S, Landewé R, Baraliakos X, Van den Bosch F, Sepriano A, Regel A, Ciurea A, Dagfinrud H, Dougados M, van Gaalen F, Géher P, van der Horst-Bruinsma I, Inman RD, Jongkees M, Kiltz U, Kvien TK, Machado PM, Marzo-Ortega H, Molto A, Navarro-Compàn V, Ozgocmen S, Pimentel-Santos FM, Reveille J, Rudwaleit M, Sieper J, Sampaio-Barros P, Wiek D, Braun J. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017 Jun;76(6):978-991.
Smolen JS, Schöls M, Braun J, Dougados M, FitzGerald O, Gladman DD, Kavanaugh A, Landewé R, Mease P, Sieper J, Stamm T, Wit M, Aletaha D, Baraliakos X, Betteridge N, Bosch FVD, Coates LC, Emery P, Gensler LS, Gossec L, Helliwell P, Jongkees M, Kvien TK, Inman RD, McInnes IB, Maccarone M, Machado PM, Molto A, Ogdie A, Poddubnyy D, Ritchlin C, Rudwaleit M, Tanew A, Thio B, Veale D, Vlam K, van der Heijde D. Treating axial spondyloarthritis and peripheral spondyloarthritis, especially psoriatic arthritis, to target: 2017 update of recommendations by an international task force. Ann Rheum Dis. 2018 Jan;77(1):3-17.
Malik TF, Aurelio DM. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Mar 6, 2023. Extraintestinal Manifestations of Inflammatory Bowel Disease.
Wahl EC, Smith D, Sesto M, Boissonnault W. Differential diagnosis of a patient with low back and toe pain. J Man Manip Ther. 2013 May;21(2):81-9.
Verhagen AP, Downie A, Maher CG, Koes BW. Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review. Pain. 2017 Oct;158(10):1860-1868.
Wong JJ, Côté P, Sutton DA, Randhawa K, Yu H, Varatharajan S, Goldgrub R, Nordin M, Gross DP, Shearer HM, Carroll LJ, Stern PJ, Ameis A, Southerst D, Mior S, Stupar M, Varatharajan T, Taylor-Vaisey A. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain. 2017 Feb;21(2):201-216.
Kroon FP, van der Burg LR, Ramiro S, Landewé RB, Buchbinder R, Falzon L, van der Heijde D. Non-steroidal anti-inflammatory drugs (NSAIDs) for axial spondyloarthritis (ankylosing spondylitis and non-radiographic axial spondyloarthritis). Cochrane Database Syst Rev. 2015 Jul 17;2015(7):CD010952.
Wang R, Ward MM. Epidemiology of axial spondyloarthritis: an update. Curr Opin Rheumatol. 2018 Mar;30(2):137-143.
Chaudhary SB, Hullinger H, Vives MJ. Management of acute spinal fractures in ankylosing spondylitis. ISRN Rheumatol. 2011;2011:150484.
Moltó A, Etcheto A, van der Heijde D, Landewé R, van den Bosch F, Bautista Molano W, Burgos-Vargas R, Cheung PP, Collantes-Estevez E, Deodhar A, El-Zorkany B, Erdes S, Gu J, Hajjaj-Hassouni N, Kiltz U, Kim TH, Kishimoto M, Luo SF, Machado PM, Maksymowych WP, Maldonado-Cocco J, Marzo-Ortega H, Montecucco CM, Ozgoçmen S, van Gaalen F, Dougados M. Prevalence of comorbidities and evaluation of their screening in spondyloarthritis: results of the international cross-sectional ASAS-COMOSPA study. Ann Rheum Dis. 2016 Jun;75(6):1016-23.
Mundwiler ML, Siddique K, Dym JM, Perri B, Johnson JP, Weisman MH. Complications of the spine in ankylosing spondylitis with a focus on deformity correction. Neurosurg Focus. 2008;24(1):E6.
Lee SH, Lee EJ, Chung SW, Song R, Moon JY, Lee SH, Lim SJ, Lee YA, Hong SJ, Yang HI. Renal involvement in ankylosing spondylitis: prevalence, pathology, response to TNF-a blocker. Rheumatol Int. 2013 Jul;33(7):1689-92
Walker C, Biasucci LM. Cardiovascular safety of non-steroidal anti-inflammatory drugs revisited. Postgrad Med. 2018 Jan;130(1):55-71.
Shim YK, Kim N. [Nonsteroidal Anti-inflammatory Drug and Aspirin-induced Peptic Ulcer Disease]. Korean J Gastroenterol. 2016 Jun 25;67(6):300-12.
Lassiter, William, Beenish S. Bhutta, and Abdallah E. Allam. "Inflammatory back pain." In StatPearls [Internet]. Statpearls Publishing, 2024.
Authors
Copyright (c) 2024 Ahmed Moner Alqerafi, Mohammad Abdullah Mubarak Almarwan, Khaled Alnashmi F Alanazi, Mohammed Yahya Abdu Rayyani, Thikrayat Mohammed Alaithan, Fahad Sulaiman Almousa, Fozeh Menhy Alrewily, Albandari Sulaiman A Al Nafisah, Maryam Thalab Salman Al Dhafery, Salem Mushari Saleh Al Dughman, Aysha Ali Hamoud Alsalman, Zainab Haider Alsharfa, Manal Abdullah Ali Aldosari
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