Now What? How to Approach Your Mild or Early AxSpA
Pain and stiffness in the lower back that gradually worsened over a few months, followed by dull pain on one side, and difficulty getting mobile after waking up—these symptoms seemed bothersome but unconnected at first, but then they started to concern you. After you saw a doctor (or maybe a few), the cause of these challenges was identified: non-radiographic axial spondyloarthritis (nr-axSpA), the early or mild stage of axial spondyloarthritis (axSpA), a type of arthritis primarily affecting the spine.
According to the Spondylitis Association of America, nr-axSpA symptoms vary from person to person, but tend to include inflammatory back pain that gets worse over time and flares up mostly in the morning or the middle of the night. You could also have pain and stiffness in other parts of the body like the neck, hips, knees, and shoulders. Even your eyes can be affected, with sensitivity to light and skewed vision in one eye at a time.
Getting a diagnosis can be a relief, because it means you can start to focus on treatment, but how do you start the conversation about next steps? Here are four questions to ask your rheumatologist to help map out a treatment plan that may help prolong the progression of the condition into radiographic axial spondyloarthritis (r-axSpA), the later stage also known as ankylosing spondylitis—when damage to the joints is visible on X-rays.
What medical treatments should I be considering?
One of the most essential aspects of managing symptoms and slowing progression of nr-axSpA will be medication, which makes this a key topic for you and your doctor, says Harry Fischer, MD, a rheumatologist at Northwell Lenox Hill Hospital in New York City. That’s because as the condition progresses, your treatment will likely change as well. When symptoms are mild, you’ll be able to use over-the-counter anti-inflammatories to reduce stiffness and pain, but when those aren’t working well anymore, it’s helpful to transition to prescription medications like disease-modifying antirheumatic drugs (DMARDs) and biologics, which can change your body’s response to inflammation.
“Even if you’re at the point of using only over-the-counter medications, it’s very important to discuss long-term management with your doctor so you know what might be ahead,” Dr. Fischer says. “Part of that conversation will be getting information about what symptoms or situations would lead to the transition into different medication. That way, you can feel more informed and empowered as a patient.” For example, if your symptoms are leading to frequent sleep disruption, limiting your mobility and causing you to miss work often, that should prompt an appointment with your doctor about next steps for treatment, he adds.
Can exercise and physical therapy help?
The reason why you experience more symptoms of nr-axSpA first thing in the morning is because the condition worsens with immobility. For example, stiffness and pain when you wake up usually improves as you move and get ready for your day.
But although getting more physical activity is hugely important, that can be challenging, since the condition often also causes fatigue, says Ruth Chan, DO, a specialist in immunology and rheumatology at The Ohio State University Wexner Medical Center, in Columbus. Talk with your doctor about potential options that can address both: the lack of energy and motivation prompted by fatigue, and the reduced mobility that might come from symptoms like pain and stiffness.
In some cases, physical therapy (PT) may be the ideal first step, since a program can combine aerobic fitness, balance training, strength work, and stretching. Some PT is done in a pool, which can be particularly helpful for easing joint, tendon, and muscle tension caused by nr-axSpA, says Dr. Chan.
She also suggests speaking with your doctor about what signs might mean it’s time to change your exercise routine. For instance, if you’ve been running and you find yourself more fatigued than usual or your back pain is worsening, you may want to consider an alternative activity.
Does my diet play a role in progression?
There’s no special nutritional plan for nr-axSpA, but the Arthritis Foundation notes that eating anti-inflammatory foods, like the ones found in the Mediterranean diet, may help. That means plenty of fruits and vegetables, fatty fish like salmon, whole grains, and extra-virgin olive oil, while reducing consumption of red meat, sugar, and processed foods.
Preliminary research published in the journal Arthritis Research & Therapy looked at the diets of those with ankylosing spondylitis and found that when there wasn’t an adequate intake of fiber, marine omega-3 fatty acids, vitamin D, and selenium—all nutrients with anti-inflammatory properties—symptoms and progression were more likely. Meanwhile, adequate nutritional intake not only reduced inflammation and slowed progression of the condition, but also helped prevent issues like osteoporosis and atherosclerosis, which tend to make nr-axSpA more difficult to manage.
When talking with your doctor, consider asking for a referral to a registered dietitian or clinical dietitian who may be in the same health system, suggests Dr. Fischer. These professionals are well versed in putting together eating plans that are geared toward symptom reduction for specific conditions, including nr-axSpA.
What else should I pay attention to?
In addition to movement and nutrition, chat with your doctor about other meaningful lifestyle shifts that could help your condition. Some of these may even boost the effectiveness of your medication, because you’ll be controlling inflammation more effectively, notes Dr. Chan.
“The top behaviors to consider here are quitting smoking, focusing on quality sleep, and reducing stress,” she says. “All of these can add up to reduced inflammation overall, so it’s worth talking with your doctor about each of them.”
How can I tell if this is progressing?
Although a combination of medications and lifestyle habits can slow progression of nr-axSpA considerably, it’s still crucial to pay consistent attention to your symptoms and track them, says Dr. Fischer—for example, by keeping a health journal in which you write down when symptoms flare up. Note their intensity and duration, and what improved them. This will make it easier for you and your doctor to spot any patterns or trends and adjust your treatment accordingly.
“Think of discussions with your doctor as part of a health team meeting,” he suggests. “Even when your nr-axSpA is in an early or mild stage, you still benefit from thinking long-term and anticipating what might be coming up. A condition like this feels much less overwhelming when you’re informed and prepared.”
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