Back Pain- Inflammatory versus Degenerative

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I see quite a few inflammatory arthritis patients as part of my practice. That includes patients with inflammatory back pain. Of course many of my patients also have degenerative arthritis related lower back pain. This video is meant to help people understand the difference between inflammatory and degenerative arthritis related back pain, diagnostic differences, and treatment differences.


One of the most common musculoskeletal issues that we see in our society is back pain. I want to discuss how to differentiate between inflammatory back pain and degenerative back pain. It’s important for a number of reasons. Back pain is a humongous problem in our society. Roughly 75% of people in Western societies will have some version of back pain at some point in their life. It’s important to differentiate between inflammatory versus degenerative back pain because the etiologies are very different, the treatments are very different, and even the prognosis can be different as well. From a cost standpoint, if we can make a correct diagnosis and get an individual on the right treatment path and algorithm, we have a better chance of bending the cost curve, rather than spending time on the wrong treatments.

There are very distinct diagnoses that cause inflammatory back pain versus degenerative back pain. The classic diagnoses for inflammatory back pain include ankylosing spondylitis, inflammatory bowel disease related sacroiliitis lower back pain as well as psoriatic arthritis. There’s a number of other conditions, but those are really your core three inflammatory back pain conditions. The cause of inflammatory back pain is related to autoimmune conditions meaning the individual’s immune system is miscommunicating, recognizing it’s own joints and other organs frequently as foreign and basically attacking them. This then leads to inflammation which then results in pain and damage, restriction of range of motion and eventually functional disability.

The prevalence of inflammatory back pain is still relatively less common, essentially ankylosing spondylitis makes up less then one percent of the population. Inflammatory bowel disease related back pain, again, less than one percent. Psoriatic arthritis is a bit more common, psoriatic arthritis affecting the lower back is less common however. So all told, around two percent of the population could have inflammatory back pain.

The presentation is really key here. The presentation for inflammatory back pain is pain that is very definitively worst first thing in the morning, worse with rest, and generally better with low impact physical activity. So a classic description would be someone with significant stiffness first thing in the morning, lasting for more than one hour. That’s fairly classic for inflammatory back pain. It will also be pain that will wake them up at nighttime or wake them up very early in the morning with pain.

Examination findings in an early stage might be limited, but the classic findings would be tenderness over the sacroiliac joints. Also there is a maneuver called a FABER’s test where essentially you externally rotate the hip and it creates pain in the sacroiliac joint area. There’s also the Schober’s test where you can actually get a sense for range of motion in the sacrum and sacroiliac joints to see if there is any restriction. Typically you see that as this condition progresses, not so much early on.

The diagnoses for degenerative back pain are the ones people are more familiar with.  This includes facet joint osteoarthritis, strain of the soft tissues including ligaments or muscles in the lower back, a pinched nerve in the lower back from foraminal stenosis and spinal stenosis. These are all very interrelated conditions that can occur primarily after a prior injury or chronic stress that then leads to chronic instability, due to weakness of some of the soft tissue structures, which then eventually leads to a progressive degenerative process including stressing the facet joints, the nerves and some of the other soft tissue structures. The cause is very clearly instability or trauma that progresses. The lifetime prevalence of degenerative back pain is up 70 to 75% of our population at some point of their lifetime.

Presentation is classically pain that is worse with certain activities depending on the condition. Different types of motion will make the pain worse and rest generally makes it better. So in general, degenerative back pain will be very definitively worse with activity and better first thing in the morning and with rest. Examination findings will vary, however, frequently provocative maneuvers can make things worse as well as significant tenderness and findings of subtle instability based on how you position an individual to see if it stresses the back or not.

In terms of some of the other objective findings, labs in inflammatory back pain can sometimes be abnormal, meaning sometimes your inflammatory parameters like sedimentation rate and C-reactive protein can be elevated. This is not true in all inflammatory back pain patients, but in some it can be found. The classic antibody, the HLA-B27 test, can be positive in some people. Again, not 100% and so the labs should not determine a diagnosis of inflammatory back pain, but they can help to confirm.

Of course in degenerative back pain, abnormal labs are really not an issue. If someone has a very high elevated inflammatory parameter and degenerative back pain, consider other potential etiologies as well. As an example, bone metastases if someone has cancer or a history of cancer, or infectious cause should be considered if a high level of inflammation is found on labs.

In contrast imaging is key here. In inflammatory back pain, the classic imaging used to be X-rays, in which someone who has progressive disease over years develops fusion of the spine. This does not occur early on. What you will see early on, however, is inflammation in the sacroiliac joints. This is really best seen under MRI where you can see bone marrow edema in the sacroiliac joints which is called sacroiliitis. There is a question in the medical literature of imaging negative inflammatory arthritis, which is a challenging diagnosis to make strictly based on symptoms and lack of other findings.

Degenerative back pain, of course, is very well understood in terms of what you will see on imaging. Whether that is arthritic changes in the facet joints or slight shifting of the vertebra indicative of chronic instability these can be seen on xray. Some other things you can see on MRI would include foraminal stenosis, where the nerves coming out of the spine are pinched. In addition, a really subtle finding, not always described by radiology would also be multifidus muscle atrophy in a degenerative spine, which is an indication of a slight pinched nerve in the lower back as well.

It’s important to note that inflammatory back pain patients are just as common, probably even more common, to also develop degenerative back pain issues as well. So frequently, in inflammatory back pain patients, you’ll find that they also have findings of degenerative disc disease or degenerative joint disease. It’s important to recognize that a person’s back pain, if they have something like ankylosing spondylitis, a component of it might be inflammatory, but a component may also be degenerative and should be treated appropriately as well.

First line treatment will be very similar with both of these conditions, namely very intensive and purposeful core strengthening, hip strengthening, working on range of motion, doing everything you can to help support the areas that are stressed, chronically inflamed, and unstable. In addition, utilizing certain over the counter supplements can be helpful as well. Glucosamine chondroitin in general can help 50% of people with degenerative. Omega-3 and tumeric/curcumin are low level anti-inflammatory supplements that are low risk, can help with pain in people with arthritis, and are also worthwhile trying. If the over-the-counter supplements can minimize the utilization of narcotics and chronic anti-inflammatory medications, that is worth trying as well. If that’s not adequate, then the escalation of treatment will differ between these two conditions.

For inflammatory back pain, treatment escalation typically utilizes some kind of medication like a biologic medication to help control the systemic inflammation that’s driving this condition. That is certainly worthwhile trying. If a person has really just very inflamed one sacroiliac joint, it can be worthwhile trying an injection, whether that’s an injection of a steroid or with alpha-2-macroglobulin, which is an autologous biologic from a person’s own blood.

Escalating treatment in degenerative back pain generally should be considered with injections if they’re failing conservative management. Rather than utilizing steroid injections, some other options would include, utilizing a person’s own blood and platelets, which can help to strengthen the soft tissue structures, treat the arthritic facet joints, and even reduce the inflammation and pain from a nerve if that has been pinched as well.

So the escalation of treatment is different depending on the etiology of the back pain.  That is key because if you want to put an individual down the right path for treatment, you want to make sure you have the right diagnosis first and then appropriately escalate treatment in the correct way based on the actual etiology of the condition.

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Keys to Early Rheumatoid Arthritis diagnosis

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What are the keys to make an early diagnosis of rheumatoid arthritis? This is an important topic for a number of reasons. As a clinical rheumatologist, this is important because this is one of the big conditions that I see and treat, and one that if we can catch people at an early stage, we can make a humongous difference in their life. The good thing is that in the medical community in general, there’s been a progressive awareness of catching this condition early in terms of the importance of it, and today I want to really highlight some of the key ways that you can make an early diagnosis. 

So, why is making an early diagnosis important? Well, without a doubt, if you can catch this condition early, you can prevent progression of the condition to more erosive and permanent damage level of disease. That is important because longer term it means that specific individual will have less pain, and better function, and without a doubt if you can catch people in an early stage and treat them appropriately early on, you can actually prevent disability and functional decline as well. So not only is this a huge deal for this one individual patient, but really a huge deal for the overall medical system and even society at large. In addition if you can reduce chronic systemic inflammation, long-term you get a lot of other benefits as well. There is a very clear understanding that in rheumatoid arthritis these individuals have much higher rates of cardiovascular disease as well long-term. The thinking is that chronic inflammation left unchecked is what leads to that progressive cardiovascular disease. And there is limited but early evidence that if you can reduce chronic inflammation in RA patients, that you can actually reduce the cardiovascular burden in these individuals longer term as well. 

There are a number of keys when it comes to diagnosis. There are a lot of subtle things to look for and these are some highlights that I think are really essential when you’re catching somebody at an early stage.  Without a doubt, hand and feet symptoms are very key in rheumatoid arthritis patients. Now the reality is that these individuals can have inflammatory arthritis in any joint in the body, but prominent hand and feet symptoms are really pathognomonic for this condition. Having symptoms on both sides is another classic tell, although at an early stage you may not have bilateral findings, it may just be unilateral. Pain that is classically worse first thing in the morning and better with activity, is again another sign of an inflammatory arthritis.  

Symptoms that have been greater than six weeks is important in differentiating between acute self limited conditions and more chronic long term conditions such as rheumatoid arthritis. It is helpful to catch them even earlier than that, but understand that there are some other disease mimickers that can present as acute inflammatory arthritis whether that is an actual infected joint, or if that’s just a reactive arthritis, meaning the body’s reaction to either an infection, or a medication that can lead to an inflammatory arthritis. Those conditions are typically short-term, while, rheumatoid arthritis is really classically long-term. 

On examination, there are subtle things that you can see, but the classic findings are swollen, warm, and tender joints. Now the challenge is that at an early stage some of those findings may not actually be present. For someone who sees and treats a lot of joint conditions, you can catch some findings of early inflammatory arthritis that are relatively mild and subtle findings, that don’t become quite as obvious later on. Some subtle things on examination that you may be able to catch, even if an individual doesn’t have flagrantly swollen and tender joints, include difficulty making a full grip with their hand. In addition, you may notice that as you squeeze their hands or their feet, that they’ll have tenderness as well.  These are very subtle signs that someone may have an inflammatory arthritis, something that isn’t quite as obvious as what you might see later on. 

There are a number of other things that are helpful in this diagnosis as well.  Labs can be helpful, but the reality is that at an early stage of diagnosis, antibody testing can be negative in 50% of patients, includeing the rheumatoid factor and the CCP antibody. Longer term, 25% of these individuals can be antibody negative. That’s important because while the antibody testing are helpful in order to confirm diagnosis, that’s not actually how you make a diagnosis of inflammatory arthritis. Inflammatory arthritis is really diagnosed based on do you see evidence of inflammation in the joints on exam or on imaging.  Moreover, the classic inflammatory lab parameters including sedimentation rate and C-Reactive Protein, may or may not correlate with disease activity. In some people they do, in some people they don’t. Again, it’s a disease marker that can be helpful, but should not fully rule out someone from having an inflammatory arthritis if you have other symptoms and signs objectively on exam that indicate an active inflammatory arthritis. 

Regarding imaging, the imaging study that I think is most useful for rheumatoid arthritis, and inflammatory arthritis in general, is Diagnostic Musculoskeletal Ultrasound. For physicians who are dedicated to musculoskeletal health and wellness, in terms of caring for those conditions, musculoskeletal ultrasound is essentially our stethoscope. Without it, you only get a limited picture.  Physical examination is helpful, but ultrasound can pick up a lot of very subtle findings of inflammatory arthritis, including very subtle effusions in the joints that you can not necessarily pick up on examination at an early stage. In addition, ultrasound can pick up what’s called “Power Doppler Uptake”, which is a sign of more aggressive inflammation than just having fluid in the joints. It is a very key diagnostic factor, but in addition a very key prognostic factor, because if you have some of these finding it can indicate a risk for more progressive disease. 

Some of the other imaging studies such as X-rays, qre not as helpful at an early stage. X-rays in someone who’s had long standing disease can eventually show erosions, but at an early stage will not and is not as helpful. MRI is the most sensitive study when it comes for looking for subtle inflammatory arthritis, but the reality is if you weigh the cost associated with MRI versus ultrasound versus the slight increase in sensitivity for picking up inflammatory arthritis, ultrasound still works out as being the better imaging modality. 

What are the next steps that you should take if a diagnosis of rheumatoid arthritis is suspected or inflammatory arthritis is detected. Without a doubt, a rapid referral to rheumatology is necessary, and again that’s because if you can get disease modifying treatment started at an early stage, you can prevent progression of this condition. Now the reality is that that referral should be within two weeks, and if it’s taking more than a month, think about having a conversation with your local rheumatologist to encourage them to see that individual a little bit earlier. In terms of medications, there are classic meds that are used, anti-inflammatory medications, Nsaids, ibuprofen, Advil, Aleve, Celebre. realistically these should be minimized long-term. While these have been classically used in abundance, and overused in our inflammatory arthritis patients, they should be minimized due to many many side effects. Steroids, while they have a ton of long-term side effects, short-term usage to help control inflammation as it’s decided what disease modifying treatment to use is okay, and it’s appropriate to give an individual quick acting relief, as well as help them to function better. 

Without a doubt, getting started on a disease modifying treatment is the most important first step when it comes to treating rheumatoid arthritis. Methotrexate is the classic medication at this stage. There can sometimes be an argument made for people that have mild inflammatory arthritis to utilize a milder medication like Plaquenil, but Methotrexate is still first line, and then relatively quickly escalating to a biologic medication, which are stronger and generally do a better job if someone is failing Methotrexate. 

Long-term there are other things that patients can do as well, including focusing on an anti-inflammatory diet, which includes a relatively low carbohydrate diet, avoiding refined sugars, minimizing red meat, and being a bit more plant based. Supplements such as Omega 3 in high dosage, as well as Turmeric and Curcumin can help with inflammatory arthritis as well as pain.  Certainly exercise as tolerated to maintain muscle strength, and mobility is key in inflammatory arthritis as well. 

That’s the basics, that’s how you make a quick diagnosis in terms of catching someone who may have an early rheumatoid arthritis diagnosis, some subtle examination findings, classic symptoms, labs may or may not be absolutely correct and correlating, but a rapid referral to a Rheumatologist to then help make a more firm diagnosis utilizing more modern imaging technologies including diagnostic musculoskeletal ultrasound.  And an emphasis of getting that individual plugged in and starting treatment early is key for improving this condition, improving their life, and making a big difference. 

To learn more about arthritis, tendinitis, back pain, musculoskeletal injuries, and non surgical treatment options, see the following options:
-Chicago Arthritis Blog.
-Regenerative Medicine Report Podcast.
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Non Surgical Treatment Options for Knee Osteoarthritis

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Today’s blog is a high-level, but significant overview, of what are the significant, non-surgical treatment options available for knee osteoarthritis. So, knee osteoarthritis is without a doubt one of the most common things that I see every single day in the clinic, and it’s significant enough where there’s quite a few different treatment options available. It’s a matter of understanding what works, what doesn’t work, what’s worthwhile for patients to pursue, and what, as physicians, can we really offer to maximize the health and wellness for our patients. 

There are a couple of very initial things that every single individual that has knee osteoarthritis should be focused on before they even start getting treated from a medical perspective. Without a doubt, if there is any degree of excess body weight, weight loss and getting to an ideal body weight is of critical emphasis. Every pound that’s reduced can help reduce the weight on the knees by three to four pounds, so that can be significant in terms of reducing pain. If an individual has to lose 10 pounds, that’s a significant amount of stress reduction on the knees. 

In a somewhat related fashion, improving the biomechanics is also essential. Strengthening, via either physical therapy or with a trainer or on one’s own, in particular, focusing on hip and core strengthening. The reality is that the knee, the hip, the back, the ankle, these are all connected in a very finely-coordinated motion that we’ve developed over thousands, if not tens of thousands of years. The way that we live in modern society is we’re too sedentary. Sitting too much leads to many people, if not most people, having some degree of hip weakness and core weakness. In the normal course of daily activity, walking, gait, running patterns, then leads to excess stress on the knees. The normal transfer from the trunk and hips down to the knees because of that weakness leads to more stress on the knees. Anything that can help to strengthen the hip and the core can also help with knee arthritis-related pain as well. 

Also essential is improving posture and symmetry. This may sound relatively minor, but the reality is that we all have a slight degree of asymmetry from one side to the other side. We all have slight deviations in posture from the ideal. Those slight deviations, when applied over months to years to decades, leads to more stress on individual body parts including the knees. Trying to correct those kind of issues is of essential importance as well. Egoscue is a nationwide clinic that has a focus on posture-related stuff and I think that’s very helpful also. 

Additional things that can be tried even before you get into my office would include maximizing joint healthy supplements that we know can help with osteoarthritis pain. That incudes glucosamine chondroitin, which can help roughly 50% of people that take that. Omega-3 can help with the mild degree of inflammation that you see in osteoarthritis as well. And turmeric, which has curcumin, can also help in terms of pain and some of the mild inflammation that you see in osteoarthritis. The benefit of these is that if that means an individual requires less pain medication, less anti-inflammatory medication, and that allows them to function more, do a bit more exercise, maintain their strength, reduce their weight. These are low-risk supplements. I like the idea of utilizing those in place of chronic anti-inflammatory medications. Other complementary treatments, including chiropractic, acupuncture, massage, and other low-risk options that can help with pain relief are certainly worthwhile trying for knee osteoarthritis. 

Despite the above treatments, if an individual is still having pain in their knees, what’s next? From a non-surgical standpoint, the traditional injections include steroid injections or viscosupplementation injections, or gel injections. I’m not a fan of steroid injections for wear-and-tear arthritis for a number of reasons. Number one is that they’re short-lived in terms of benefit. Number two, they have the potential, if utilized too often, to actually damage cartilage, bone, and soft tissue.  In addition, they don’t even help with improving things like stability and other other key physiologic issues that affect the knee. 

Viscosupplementation injections can help in mild to moderate osteoarthritis. They tend to be a mild treatment option but are low-risk and can help as well. The next set of injections that I think are worthwhile really thinking and focusing on for knee osteoarthritis are orthobiologic treatments. 

While this discussion is not about surgery, it is useful to understand the a few issues regarding knee surgery. Total knee replacement is a separate discussion, of course, and I think most knee osteoarthritis patients can be treated relatively well with the potential to avoid total knee replacement, but there is that need in some people. Arthroscopy, however, is one of the most common knee surgeries done for knee osteoarthritis. The reality is that there are multiple studies showing that routine knee arthroscopy, or a clean out surgery, is no better than just physical therapy. This is not recommended by the largest orthopedic professional associations. It’s actually not even allowed in certain countries where they try to manage healthcare costs because there’s no evidence that it’s of significant benefit in most people compared to just improving biomechanics via physical therapy. 

A better option are the orthobiologic treatment options. Orthobiologics essentially means, ortho meaning related to the musculoskeletal system and biologics meaning treatments that are coming from cell-based treatments and biologic tissues. There are a number of different options. What’s nice about orthobiologic treatment options is number one, they can help with pain, they can help with inflammation, they are generally autologous, meaning coming from oneself, and so they are low-risk in terms of infection and reactions. In addition, besides treating pain, utilized in an appropriate fashion, they can actually help improve stability and function as well. You can do that because under image-guidance, you can inject orthobiologic treatments into tendons and ligaments. And if you can improve the chronic laxity, degenerative laxity, that occurs in a degenerative knee osteoarthritis condition, you can actually improve the stability in that knee joint as well, which will improve function and it will improve pain as well. 

In terms of orthobiologic treatments, there are a number of different ones that are available right now. There are three very common ones that you may hear about. Platelet-rich plasma is probably the most common one that’s used at this time. This is essentially a treatment where you take a quantity of blood from an individual, from a blood draw, concentrate that down into a high concentration of one’s own platelets and then inject that into the tissue that needs to be treated. Whether that’s just a joint or the soft tissue structures as well, the data out there shows that this is a better treatment option than the viscosupplementation or gel injections. It gives not only more pain relief, it gives longer-lasting pain relief. This is a good moderate-level treatment option for knee osteoarthritis. I’ve had good results even in more advanced knee osteoarthritis. But certainly, a fairly reliable treatment option for mild-to-moderate knee osteoarthritis. 

You can then escalate to what’s called bone marrow aspirate concentrate-derived stem cells. This is essentially a treatment where you take an individual’s own bone marrow from the back of their iliac crest over their pelvis, concentrate that down into a very high-concentrate of a number of different cellular materials, including mesenchymal stem cells, hematopoietic stem cells, and a number of other cell lines and growth factors which can then be injected into the joint, soft tissue, bone, and other parts of that degenerative knee condition. This is a good option for moderate to more advanced knee osteoarthritis. In my experience, but also in the published literature, this is a treatment option that can work in even advanced knee osteoarthritis. It’s not uncommon that patients come in and say that they’ve been told that they have bone on bone knee arthritis based on a X-ray, and yet when you have them flex and extend their knee, they are able to still get pretty good range of motion. That kind of individual can still respond quite well in terms of pain, in terms of reducing chronic inflammation, in terms of improving function, and maintaining a high-quality life as well. 

The last one to mention are the birth cord fluid treatment options that people are hearing about. That includes amniotic fluid and umbilical cord fluid. These have been miscategorized as stem-cell treatments. The reality is that multiple sources have looked at whether there are any live cells in these products and the reality is that there are no significant live cells in these products in order to be sold in the United States. And that’s because, for safety reasons, in order to be utilized by physicians in patients, since it’s a foreign material, these are processed in a manner that essentially kills off all the cells and then, when it’s rehydrated to be used at the bedside, it will further kill off any remaining cells that were able to survive that initial screening process. While the birth cord fluid products are not a true stem-cell treatment, because they don’t have any live cells, they do have growth factors and they’re likely equivalent to a platelet-rich plasma injection, except coming from somebody else. These treatments can still be helpful, but I still think those first two options, platelet-rich plasma and bone marrow aspirate concentrate stem cells, are better orthobioligic treatment options. 

That is really just scratching the surface but it’s a pretty good high-level overview in terms of what’s available from a non-surgical treatment standpoint. The reality is that compared to where we were 10 years ago, we’ve really come light years forward.  With ongoing data collection efforts, and now results being published in the peer-reviewed literature showing effectiveness of these treatments. As time goes on, you will be hearing more and more about these treatments. They have a legitimate use. They need to be regulated in a appropriate way professionally, but these are good treatment options for knee osteoarthritis and for people that have chronic pain, knee pain that’s preventing them from functioning at a higher level. These are excellent treatment options to consider in anyone who has knee osteoarthritis.


To learn more about arthritis, tendinitis, back pain, musculoskeletal injuries, and non surgical treatment options, see the following options:
-Chicago Arthritis Blog.
-Regenerative Medicine Report Podcast.
-Follow us on our Social Media Channels.
Siddharth Tambar is a physician at Chicago Arthritis and Regenerative Medicine, where his mission is to improve your pain and function, allowing you to do the activities you enjoy with the people you care about.
This is accomplished with various non surgical modalities to treat musculoskeletal and orthopedic conditions, including using your own blood and stem cells to treat arthritis, tendinitis, injuries, and back pain.

 

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