Many with Ulcerative colitis and Crohn’s disease suffer extra-intestinal manifestations, meaning symptoms that affect the body beyond the intestines. The most common are anemia, psoriasis, and specific forms of arthritis which are linked to IBD, mainly axial arthritis and ankylosing spondylitis (AS), which cause back pain in roughly 25% of patients.
What Causes Back Pain in Ulcerative Colitis?
In IBD, back pain is usually caused by axial arthritis (Spondyloarthritis) with inflammation in the axial joints (spine, chest, pelvis). This can, in severe cases, progress to ankylosing spondylitis.
Both axial arthritis and ankylosing spondylitis are driven by immune-mediated inflammatory responses, as opposed to the wear and tear usually associated with osteoarthritis.
Axial arthritis (spondyloarthritis) is more common in Crohn’s disease, but the condition can affect those with Ulcerative colitis. The condition impacts the sacroiliac joints that connect the pelvis and lower spine, causing pain and stiffness in the lower back, hips, and buttocks. The pain starts gradually and worsens over time, lasting for three months or more. Discomfort is worse in the morning, wearing off with time and movement. In fact, prolonged inactivity can actually exacerbate the pain.
You should see a rheumatologist immediately if you feel signs of axial arthritis, as the vertebrae of the spinal column can, in some cases, fuse together and greatly restrict your movement.
In cases where bone fusion occurs, axial spondyloarthritis can progress into ankylosing spondylitis (AS). Significant bone fusing can lead to restriction of rib movement, and you may struggle to take deep breaths.
Roughly 2-3% of IBD patients have ankylosing spondylitis, and 5-10% of AS cases are associated with IBD. But although a larger percentage of AS patients show subclinical gut inflammation, only a small population of these patients develop overt IBD. Research suggests a genetic component, and researchers have noted shared inflammatory pathways in gut and joint inflammation in AS, and in gut inflammation in AS and IBD.
Diagnosing Back Pain in Ulcerative Colitis
Diagnosing back pain in UC can pose somewhat of a challenge, as it could easily be caused by a strain or injury. It may also not occur to patients that their backache is connected to their IBD, especially because the back pain can develop years before the emergence of IBD.
If your doctor suspects axial arthritis of AS, they will conduct a physical exam and test the range of motion in the spine, and your ability to take deep breaths. They will also attempt to determine the exact location of the pain by moving your legs and pressing certain areas of your pelvis.
Radiographic tests such as an X-ray may be used to diagnose AS. If there is no evidence of inflammatory damage on the X-ray, your doctor may order an MRI scan to identify the condition.
Treating Back Pain in Ulcerative Colitis
Research shows that treating the underlying inflammatory bowel condition can greatly lessen the severity of axial arthritis, but will not resolve it or the back pain itself. Back pain requires a separate treatment that will not negatively impact the underlying condition, so you should work with a rheumatologist and a gastroenterologist to manage both conditions properly.
Many use ibuprofen or aspirin to manage back pain, but these nonsteroidal anti-inflammatory drugs (NSAIDs) are mostly advised against in UC as they can cause a flare-up of symptoms. Recent research suggests they may be safer in IBD than previously thought, but it is still best to consult your physician with the overall goal of limiting their use to short periods of time. A better option for IBD patients may be acetaminophen (Tylenol), which is a non-NSAID painkiller.
Heat therapy helps stretch the soft tissue around the spine, which can ease stiffness and increase your range of motion. When applied before physical therapy, the heat can help make exercise and movement more tolerable. The heat may also block the transmission of pain signals.
Some medications for axial arthritis and AS overlap with those for UC. These include corticosteroids and methotrexate. Biologics such as Humira, Cimzia, or Remicade may also be an option as well as some of the newer drugs from the Jak Kinase inhibitors family (Xeljanz, Rinvoq).
Physical therapy helps maintain physical function and manage symptoms. This may include frequent workouts, back exercises, and hip flexors, hip stabilizers, and stretching to improve strength, flexibility, joint movement, and posture.
Curcumin & Boswellia
Curcumin (Turmeric extract) and Boswellia are herbal compounds with naturally occurring anti-inflammatory activities. Curcumin modulates and affects several inflammatory pathways involved in rheumatoid arthritis and ankylosing spondylitis such as NF-κB, interleukin-1β, and TNF. Some of these are actually the target for many AS drugs. In clinical trials, curcumin has been found to improve overall arthritis symptom severity and pain.
The Arthritis Foundation recommends Boswellia for rheumatoid arthritis and osteoarthritis as it contains antiarthritic, anti-inflammatory, pro-apoptotic, and pain-relieving pharmacological properties. Boswellia has also been found to inhibit NF-κB activity, which is associated with the risk of AS, and suppresses interleukin-1β, which, according to one study, ‘trends’ in AS patients.
Vitamins & Minerals
Folic acid is vital for the formation of healthy cells in the body and may benefit those with UC-related back pain. Those suffering from AS have an increased risk of osteoporosis, so it’s important to get an adequate intake of calcium and vitamin D. It’s recommended to take these together, as vitamin D helps the body absorb calcium.
If you have UC and are unsure of the source behind your back pain, it’s best to see your doctor for diagnosis and treatment. Axial arthritis and AS require management to avoid extensive damage.