Nonradiographic axial spondyloarthritis (nr-axSpA) is a type of inflammatory arthritis that affects your spine and sacroiliac (SI) joints. Unlike its better-known counterpart, ankylosing spondylitis (AS), nr-axSpA doesn’t cause joint damage that’s visible on X-ray images. But that doesn’t mean it’s any less likely to cause disruptive symptoms like pain and stiffness.
People with nr-axSpA experience “inflammatory back pain, meaning pain that’s typically worse with rest or after sleeping, and better with activity like exercise,” explains Jean Liew, MD, an instructor and spondyloarthritis researcher in the division of rheumatology at the University of Washington in Seattle.
This form of pain and stiffness also tends to respond to nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil) or naproxen (Aleve). But over-the-counter drugs often aren’t enough to keep nr-axSpA under control, so it’s important to get a proper diagnosis and receive treatment under the supervision of a doctor — usually a rheumatologist, an expert in arthritis and other diseases affecting your joints, muscles, and bones.
Here are nine ways to help relieve pain and stiffness if you have nr-axSpA — both on your own, and as part of your doctor-supervised treatment.
1. Take an NSAID With Caution
NSAIDs are considered a first-line treatment for nr-axSpA, but that doesn’t mean they’re all the same or that they’re risk-free. Talk to your doctor before taking any NSAIDs, including over-the-counter products. If over-the-counter drugs aren’t controlling your pain, your doctor may be able to prescribe a prescription NSAID that does the job better.
But “if you’re being prescribed an NSAID already by your doctor, you should not mix that with one that you’re taking” on your own, Dr. Liew cautions. That’s because too high of a combined dose of these drugs can lead to gastrointestinal (GI) problems, including stomach bleeding and ulcers.
And NSAIDs may also raise your risk for kidney problems and cardiovascular disease in the long run, so using them alone for pain control may not be the best strategy. If you already have GI, kidney, or heart problems, “then you really have to proceed with caution and talk to your doctor about that,” Liew explains. “They may have to do additional monitoring of your blood pressure or kidney numbers to make sure you’re not overdoing it.”
2. Try Physical Therapy
A physical therapist is more than just a specialized personal trainer. Physical therapists are trained to help you address different aspects of your health condition — including pain, stiffness, and limited mobility — through exercises as well as manual manipulation, heat or cold therapy, and other techniques.
Some physical therapists have specialized training in arthritis and other musculoskeletal conditions, so getting a referral from your rheumatologist may be the best way to find one with the right skill set. Your physical therapist will then evaluate your condition and how it responds to different treatment techniques, and come up with a personalized program for you.
But “indefinite physical therapy isn’t always an option” for people with nr-axSpA, says John Miller, MD, an instructor of medicine in the division of rheumatology at Johns Hopkins Medicine in Baltimore. Often that’s because of limitations related to cost and insurance coverage, but it may also be impractical for many people to attend more than a few sessions. “You hope with those sessions the patient can learn good stretching techniques and exercises to help with mobility, and incorporate them into daily activities,” Dr. Miller notes.
3. Get Serious About Exercise
Exercise is considered one of the main treatments for nr-axSpA, along with drug therapy, according to the most recent treatment guidelines, published in August 2019 in the journal Arthritis & Rheumatology. This recommendation is “constant, no matter if your disease is super-active or well-controlled,” Liew says.
Unfortunately, “there’s not a lot of data on what’s the best type of exercise,” says Miller. “People have looked at stretching and aerobic exercise and weight lifting,” with each showing positive results in some people, he notes. “I think it’s very individualized.”
Liew says there’s some evidence that “guided exercise is probably better than if you took it on yourself,” but this may be simply because classes and guided training programs often motivate people to actually get moving. In the end, she says, “anything that gets you moving that you can do on a regular basis is what I’d recommend.”
4. Experiment With Your Diet
When it comes to certain foods helping with or exacerbating pain and inflammation in nr-axSpA, “we hear it so frequently that it’s hard to say there isn’t something real there,” says Miller. But “there’s not a lot of data for dietary interventions,” he cautions, and “there may not be one diet” that’s best for everyone with the condition.
Miller says that some people report improvement — from subtle to dramatic — by cutting out dairy, gluten, or certain forms of carbohydrate. For people interested in this approach, he recommends making a single dietary change for two to three weeks and taking note of any changes in your symptoms. “If you do everything at once, you may feel better but not know what got you there,” he notes.
In addition, “if someone is overweight or obese, I’d recommend losing weight,” as part of a dietary intervention, says Liew. “The extra weight is not good for the joints,” and there’s some evidence that fat cells may directly contribute to inflammation, she adds.
5. Apply Heat as Needed
Putting a heating pad or hot water bottle on an area of pain or stiffness may offer short-term relief, according to Miller. “I don’t know how helpful warm compresses are in the long term,” he says, but many people report that they feel better in the moment when using them.
“I don’t think we have any trial evidence that heat therapy is better than no heat therapy” in a measurable way, says Liew. “But I also encourage people to try to find things that make them feel better.”
6. Consider Certain Supplements
There isn’t much evidence to support any benefit from taking dietary supplements for nr-axSpA, but as many as 95 percent of people with the condition are believed to have experimented with herbal and nutritional remedies, according to the Spondylitis Association of America.
Anecdotally, some people report improvements in pain and stiffness from supplements that are believed to help reduce inflammation, such as turmeric or omega-3 fatty acid supplements, like fish oil. But these and other supplements can carry side effects like stomach upset or blood thinning, so it’s important to talk with your doctor before taking them.
7. Try Massage or Acupuncture
Therapies like massage or acupuncture may be helpful at relieving pain and increasing feelings of well-being, but there isn’t much evidence to support them specifically for nr-axSpA, according to the Spondylitis Association of America.
Acupuncture, in particular, has been shown in studies to encourage the release endorphins, hormones that may cause immediate pain relief and even help improve functional outcomes in people with conditions that limit mobility. More studies are needed to confirm that these benefits apply to nr-axSpA.
If you decide to seek out massage therapy, talk to your doctor first, and make sure that your massage therapist knows about your condition and any areas of bone weakness or joint tenderness that shouldn’t have pressure applied to them.
8. Optimize Your Drug Treatment
If you experience ongoing pain and stiffness from nr-axSpA despite getting enough exercise and optimizing other areas of your lifestyle, you may need to reexamine your drug treatment. If you’re currently just taking an NSAID, that may mean switching to a different NSAID, or adding a biologic drug, such as a TNF inhibitor.
And if you’re already taking a biologic drug, talk to your doctor about whether it’s working as intended. You may be a candidate for switching to another drug, or you may need to discuss other options for pain relief.
“Even if you have access to biologics, a lot of people end up taking pain-specific medications, like opioids,” says Liew, “which indicates that even if we get a good handle on inflammation, there’s a lot of pain that’s not fully controlled.”
9. Look Into Other Conditions
Finally, ongoing pain may be related to a condition other than nr-axSpA that hasn’t yet been detected or diagnosed. “We sometimes see fibromyalgia syndrome overlapping with” nr-axSpA, says Miller. “If you don’t address that component, it takes longer to address fatigue and pain.”
It’s important to mention any new or changed symptoms at your doctor appointments, even if they appear unrelated to your nr-axSpA. That’s because they may be a clue that helps your doctor diagnose or better treat another condition.
This applies in particular to symptoms related to your mental health. Depression or anxiety may change your perception of pain, Miller says, and addressing those conditions may lead to improvement in nr-axSpA symptoms.
“We try to do as much as possible in talking about different coping mechanisms to deal with chronic illness,” he notes. “But there are definitely people who benefit from psychiatric or psychological evaluation.”