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Could Probiotics Help Relieve Arthritis Symptoms Like Back Pain?

gut health back pain probiotics for ankylosing spondylitis and rheumatoid arthritisThe health of the gut has a profound effect on overall health and well being but you might not have previously connected gut health and arthritis symptoms like back pain. In a new review researchers have looked at how gut microflora’s influence on our immune system may point to a novel way of preventing and treating arthritis. Could popping a probiotic help reduce back pain, with the only side effects being better all-round health?

People with ankylosing spondylitis and rheumatoid arthritis may have already heard that evidence is mounting to suggest the involvement of the microbiome in causing their condition. A bacterial cause of arthritis presents a potential route to treat and prevent the disease, offering hope for many thousands, if not millions of people worldwide.

The bacteria that we carry around in our gut, and elsewhere in the body, have the capacity to influence genetic expression, inflammation, vitamin synthesis, energy metabolism, weight control, and a range of other processes that play a role in immune function and, therefore, autoimmune spine conditions like ankylosing spondylitis and rheumatoid arthritis.

A Predisposition to Rheumatoid Arthritis

Since the late 1970s, rheumatoid arthritis has been connected to differences in the histocompatability complex (HLA) region, with HLA-Dw4 being more common among people with the disease. The involvement of HLA-DRB1 genes began to be investigated in order to further understand how genetics influences RA risk. RA risk is certainly connected to our genes, as twin studies have found, but not necessarily as strongly as one may think (there is a 13% concordance for monozygotic twins vs. 3.5% for dizygotic twins).

As not everyone with a specific genotype develops RA scientists have realised that lifestyle, dietary, and environmental factors can influence gene expression (known as epigenetics) and alter a person’s likelihood of developing a disease or condition for which they are predisposed. RA also appears to be strongly connected to periodontal disease, with those treated for periodontitis having decreased severity of RA activity. Gum infection with Prevotella intermedia and Porphyromonas gingivalis has also been linked to infection of the synovial fluid, suggesting that the infection may initiate or maintain RA inflammation.

Genetics and the Development of Rheumatoid Arthritis and Ankylosing Spondylitis

Genetics also influences spondyloarthritis (SpA) development, including ankylosing spondylitis, undifferentiated SpA, reactive arthritis, psoriatic arthritis, and arthritis accompanying inflammatory bowel diseases. HLA-B27 is especially linked to the development of ankylosing spondylitis, accounting for some 30% of heritabliity overall.

Patients with active ankylosing spondylitis (AS) have been found to have a higher level of antibodies to the bacterium Klebsiella pneumoniae compared to people with RA, those who are healthy, and those with inactive AS. One possible explanation for this is an effect on monocyte proliferation, i.e. immune response to endotoxins, of HLA-B27.

Gut Dysfunction in Patients with AS and RA

Up to 66% of patients with SpA have been found to have subclinical gut inflammation, with AS patients found to have an absence of CD14+ macrophages and a large increase in CD163+ (M2) macrophages. Inflammatory bowel disease occurs in around 6.5% of patients presenting with SpA and no symptoms of IBD. Gut inflammation has also been correlated with worse disease progression in AS patients, including increased inflammation on MRI and increased oedema in the bone marrow of the sacroiliac joint (where the spine meets the pelvis).

Given all of these links between the gut, the microbiome, inflammation and spine disease, does it make sense to incorporate probiotics into a treatment plan for ankylosing spondylitis and/or rheumatoid arthritis?

Probiotics, AKA friendly bacteria, are microorganisms that have beneficial effects on the body. These include helping with the breakdown of food, synthesising vitamins and other substances in the intestinal tract, preventing colonisation by pathogenic organisms, maintaining urinary and gut pH, and even reducing the production of pro-inflammatory substances.

Benefits of Probiotics for Arthritis

Specific strains of friendly bacteria are especially helpful at combating infection with pathogens often encountered in hospitals, making them useful for those undergoing spine surgery or other procedure. They can help regulate digestion and bowel movements, reducing the incidence of constipation after back surgery or diarrhoea associated with antibiotics taken to minimise the risk of infection after back surgery. Probiotics can also reduce bloating, which may have some benefit for maintaining good posture.

The probiotic Lactobacillus casei has been seen in studies in rats to lower arthritis scores and levels of pro-inflammatory cytokines, even having a greater effect than indomethacin. A similar effect was seen in recent study of L. casei in human patients with RA who also had lower levels of proinflammatory cytokines, namely tumour necrosis factor-alpha, interleukin-6, and interleukin-12. These RA patients also had significantly decreased disease activity scores, and the benefits of probiotics appear to be connected to suppression of the type II collagen-reactive effector function of Th1-type cellular and humoral immune responses involved in arthritic inflammation.

A study of probiotics in inactive ulcerative colitis and active ankylosing spondylitis found that Lactobacillus acidophilus and Lactobacillus salivarius significantly reduced disease activity. These benefits were not seen in a 12-week follow-up study however.

Clearly more research needs to be done to ascertain the benefits of probiotics for rheumatoid arthritis, ankylosing spondylitis and other sources of back pain. In the meantime, the observed benefits of probiotics, and the relative safety of these supplements, certainly suggests that they can be worthwhile for people with these health conditions, regardless of whether they have a direct effect on the disease itself.


Mohamed K. Bedaiwi, Robert D. Inman. Microbiome and Probiotics: Link to Arthritis. Curr Opin Rheumatol. 2014;26(4):410-415.

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