Ankylosing Spondylitis – Low Back Pain
In today’s blog article we are going to be discussing a particular cause of back pain known as Ankylosing Spondylitis (AS).
AS is an autoimmune condition and is a form of chronic inflammatory arthritis that primarily affects the joints of the spine, pelvis and large peripheral joints including the shoulders and hips.
As an inflammatory arthritis, AS is characterised by recurrent bouts of exacerbation and remission, where an individual will experience flare ups of pain and dysfunction, that will progressively settle. It affects males more commonly than females and usually presents between the ages of 15-45.
AS is an autoimmune disease which means it occurs as a result of an overactive immune system. Instead of attacking foreign bacteria or viruses that enter the body, the immune system will start attacking its own healthy tissue in and around the joints which leads to inflammation and pain.
As healing occurs this inflammation can lead to increased bone production around the joints, particularly in the spine, which can lead to permanent stiffness, and in severe cases even fusion, in the vertebra of the back and neck.
This progression is rare when AS is detected and treated early.
The exact cause of AS remains unknown and both genetic and environmental factors are suspected to have an influence. Unlike many other types of back pain it is generally not related to your job, activities or an acute injury.
It is widely accepted that family history and genetics play a large part in a person’s likelihood of developing the condition.
There is a gene, called HLA-B27, that is associated with AS. Almost nine out of 10 people with AS test positive for this gene. However HLA-B27 is present in 8% of the general population, including healthy people without AS. As the presence of this gene doesn’t automatically lead to the development of AS, other factors are thought to be involved.
AS starts with inflammation arising in cartilaginous joints. These inflammatory cells invade the insertion points of the cartilage the intervertebral discs and the bones of the vertebra. As damage is caused, our immune system attempts to repair the damage and fills these areas with scar tissue which eventually turns into bone.
Where this affects the intervertebral discs, bone formation occurs between our vertebra which gives the vertebra a ‘squared’ appearance and can lead to fusion (Ankylosis).
Ankylosis, ‘abnormal stiffening and immobility of a joint due to fusion of the bones’, usually takes years to occur and may not occur at all.
The disease progressively occurs over 3 subjective stages with most people remaining in stage 1 or 2 and never progressing to stage 3.
The stages are defined as follows:
1. Sacroiliac joint (SIJ) pain (on one or both sides) which may refer into the posterior thigh. Pain is relieved by movement and episodes tend to be relatively infrequent à often mistaken for non-specific low back pain or sciatica.
2. Pain extends into the lumbar, thoracic and cervical regions with significant stiffness following periods of immobility. Symptoms tend to be most apparent first thing in the morning and the individual may experience chest pain with coughing and deep breathing.
3. Significant ankylosis (fusion) occurs with the SIJ’s, lumbar and cervical regions. Discomfort varies from constant to intermittent and can be a dull ache or a sharp pain. Individual experiences severe stiffness and weakness in spinal muscles.
Symptoms of AS vary between people but things to be aware of are:
· Pain and stiffness in the back, buttocks or neck that started gradually for no reason
· Symptoms worse after rest (for example, in the early morning) and relieved with exercise
· Pain when arching backwards of sideways
· Extreme tenderness over the spine (spinous processes)
· Pain in tendons (which connect muscles to bones) and ligaments (which connect bones to each other), often felt as pain at the front of the chest, back of the heel or underneath the foot.
· Fatigue (extreme tiredness)
Symptoms may change from day to day and can become more intense. When this happens, it is known as an ‘exacerbation’ phase or acute flare up. Flares can be very unpredictable and can come on with little warning.
It is common for people to initially dismiss the pain from AS as a common back complaint and therefore fail to seek treatment. Early intervention is important in the management of AS as the earlier treatment starts the better the outcomes in terms of restricting movement loss.
AS is usually diagnosed by your therapist, they will assess your symptoms and complete a physical examination to assess your range of movement. You will then be referred to your GP for blood tests to measure levels of inflammation in your system and x-rays of your spine are normally completed to assess the state of the joints and see if there is any ankylosis - but these tests can all be normal in the early stages.
If AS is suspected or confirmed then your therapist or GP will refer you to a rheumatologist, a doctor who specialises in systemic inflammatory conditions. The rheumatologist will generally start you on anti-inflammatory medication based on symptom management with the goal of maintaining mobility and function.
Currently, there is no cure for AS. However, treatment for AS has improved dramatically, with new medicines that are extremely helpful in managing pain for the condition. A rheumatologist will usually work in conjunction with your physiotherapist to put together a plan that works to manage pain and range of motion. This will include treatment such as soft tissue therapy and intervertebral joint mobilisations to maintain motion accompanied with a specific exercise program which will address muscle weakness, improve posture and maintain flexibility of the spine.
3 tips to help manage your AS:
1. See a therapist ASAP. They can diagnose AS and make sure you get the correct treatment. Sooner is better, as catching the disease in the early stage results in less movement loss.
2. Learn more about your condition – knowing as much as possible about your AS means that you can make informed decisions about your healthcare and play an active role in managing it.
3. Keep yourself as healthy as possible. That applies for eating healthier, exercising or moving more and especially taking care of your mental health, stress and anxiety can aggravate your symptoms and make you feel worse.
So that’s a brief summary of what Ankylosing Spondylitis is how it occurs. It’s important to remember that there is no cure for AS and it is a condition that needs to be managed on an ongoing basis.
If you have any questions or comments, please email us at firstname.lastname@example.org and we will be happy to answer them for you.
If you suffer with persistent low back or hip pain, feel free to call us on (08) 9486 8653 and our therapists will be happy to chat with you about the best management plan.