Arthritis and Ankylosing Spondylitis
Ankylosing spondylitis is a type of arthritis that affects the spine. Ankylosing spondylitis symptoms include pain and stiffness from the neck down to the lower back. The spine's bones (vertebrae) may grow or fuse together, resulting in a rigid spine. These changes may be mild or severe, and may lead to a stooped-over posture. Early diagnosis and treatment helps control pain and stiffness and may reduce or prevent significant deformity
Who Is Affected by Ankylosing Spondylitis?
Ankylosing spondylitis affects about 0.1% to 0.5% of the adult population. Although it can occur at any age, spondylitis most often affects men in their 20s and 30s. It is less common and generally milder in women and most common in Native Americans.
What Are the Symptoms of Ankylosing Spondylitis?
The most common early symptoms of ankylosing spondylitis include:
- Pain and stiffness. Constant pain and stiffness in the low back, buttocks, and hips that continue for more than three months. Spondylitis often starts around the sacroiliac joints, where the sacrum (the lowest major part of the spine) joins the ilium bone of the pelvis in the lower back region.
- Bony fusion. Ankylosing spondylitis can cause an overgrowth of the bones, which may lead to abnormal joining of bones, called "bony fusion." Fusion affecting bones of the neck, back, or hips may impair a person's ability to perform routine activities. Fusion of the ribs to the spine or breastbone may limit a person's ability to expand his or her chest when taking a deep breath.
- Pain in ligaments and tendons. Spondylitis also may affect some of the ligaments and tendons that attach to bones. Tendonitis (inflammation of the tendon) may cause pain and stiffness in the area behind or beneath the heel, such as the Achilles tendon at the back of the ankle.
Ankylosing spondylitis is a systemic disease, which means symptoms may not be limited to the joints. People with the condition also may have fever, fatigue, and loss of appetite. Eye inflammation (redness and pain) occurs in some people with spondylitis. In rare cases, lung and heart problems also may develop.
What Causes Ankylosing Spondylitis?
Although the cause of ankylosing spondylitis is unknown, there is a strong genetic or family link. Most, but not all, people with spondylitis carry a gene called HLA-B27. Although people carrying this gene are more likely to develop spondylitis, more than 75% of these people never develop the disease.
How Is Ankylosing Spondylitis Diagnosed?
The diagnosis of ankylosing spondylitis is based on several factors, including:
- Findings of an physical exam
- X-rays of the back and pelvis
- Measurements of the chest when breathing
- Results of lab tests
How Is Ankylosing Spondylitis Treated?
There is no cure for ankylosing spondylitis, but there are treatments that can reduce discomfort and improve function. The goals of treatment are to reduce pain and stiffness, maintain a good posture, prevent deformity, and preserve the ability to perform normal activities. When properly treated, people with ankylosing spondylitis may lead fairly normal lives. Under ideal circumstances, a team approach to treat spondylitis is recommended. Members of the treatment team typically include the patient, doctor, physical therapist, and occupational therapist. In patients with severe deformities, osteotomy and fusion can be done.
- Physical and occupational therapy. Early intervention with physical and occupational therapy is important to maintain function and minimize deformity.
- Exercise. A program of daily exercise helps reduce stiffness, strengthen the muscles around the joints and prevent or minimize the risk of disability. Deep breathing exercises may help keep the chest cage flexible. Swimming is an excellent form of exercise for people with ankylosing spondylitis.
- Medications. Certain drugs help provide relief from pain and stiffness, and allow patients to perform their exercises with minimal discomfort. Nonsteroidal anti-inflammatory drugs (NSAIDs) -- such as ibuprofen, naproxen, and aspirin -- are the most commonly used drugs for spondylitis treatment. In moderate to severe cases, other drugs may be added to the treatment regimen. Disease modifying anitrheumatic drugs (DMARDs) -- such as methotrexate -- can be used when NSAIDs alone are not enough to reduce the inflammation, and help to prevent joint stiffness and pain. In addition, the relatively new drugs Enbrel and Remicade have been FDA approved for treating ankylosing spondylitis. A similar drug, Humira has also been shown to improve the pain and stiffness of ankylosing spondylitis.
- Surgery. Artificial joint replacement surgery may be a treatment option for some people with advanced joint disease affecting the hips or knees.
n addition, people with spondylitis are urged to not smoke or chew tobacco products because of the increased risk of lung problems and reduced ability to expand the rib cage. Certainly, all of the other reasons why doctors discourage smoking also apply here as well.
People with spondylitis are encouraged to sleep on a firm mattress with the back straight. Placing large pillows under the head is discouraged, since it may promote neck fusion in the flexed position. Similarly, propping the legs up on pillows should be avoided because it may lead to hip or knee fusion in the bent position. Choose chairs, tables, and other work surfaces that will help avoid slumping or stooping. Armchairs are preferred over chairs without arms.
Since those with ankylosing spondylitis could easily hurt their rigid necks or backs, special care should be taken to avoid sudden impact, such as jumping or falling.
Symptoms & Types Understanding Back Pain - Symptoms What Are the Symptoms of Back Pain?
Most people have experienced back pain sometime in their life. The causes of back pain are numerous; some are self-inflicted due to a lifetime of bad habits. Other back pain causes include accidents, muscle strains, and sports injuries. Although the causes may be different, most often they share the same symptoms.
The symptoms for back pain are:
- Persistent aching or stiffness anywhere along your spine, from the base of the neck to the hips.
- Sharp, localized pain in the neck, upper back, or lower back -- especially after lifting heavy objects or engaging in other strenuous activity.
- Chronic ache in the middle or lower back, especially after sitting or standing for extended periods.
- Back pain that radiates from the low back to the buttock, down the back of the thigh, and into the calf and toes.
- Inability to stand straight without having severe muscle spasms in the low back.
Call Your Doctor About Back Pain If:
- You feel numbness, tingling, or loss of control in your arms or legs. This may signal damage to the spinal cord.
- The pain in your back extends downward along the back of the leg. You may be suffering from sciatica.
- The pain increases when you cough or bend forward at the waist. This can be the sign of a herniated disc.
- The pain is accompanied by fever, burning during urination, or strong-smelling urine. You may have a bacterial urinary tract infection.
- You have urine or fecal incontinence.
- You have dull pain in one area of your spine when lying in or getting out of bed. If you are over 50 you may be suffering from osteoarthritis.
Diagnosis & Tests
- Because many different conditions may cause back pain, a thorough medical history will be performed as part of the examination. Some of the questions you are asked may not seem pertinent to you but are very important to your doctor in determining the source of your pain.
- Your doctor will first ask you many questions regarding the onset of the pain. (Were you lifting a heavy object and felt an immediate pain? Did the pain come on gradually?) He or she will want to know what makes the pain better or worse. The doctor will ask you many questions referring to the “red flag” symptoms. He or she will ask if you have had the pain before. Your doctor will ask about recent illnesses and associated symptoms such as coughs, fevers, urinary difficulties, or stomach illnesses. In females, the doctor will want to know about vaginal bleeding, cramping, or discharge. Pain from the pelvis, in these cases, is frequently felt in the back.
- To ensure a thorough examination, you will be asked to put on a gown. The doctor will watch for signs of nerve damage while you walk on your heels, toes, and soles of the feet. Reflexes are usually tested using a reflex hammer. This is usually done at the knee and behind the ankle. As you lie flat on your back, one leg at a time is elevated, both with and without the assistance of the doctor. This is done to test the nerves, muscle strength, and assess the presence of tension on the sciatic nerve. Sensation is usually tested using a pin, paper clip, broken tongue depressor, or other sharp object to assess any loss of sensation in your legs.
- Depending on what the doctor suspects is wrong with you, the doctor may perform an abdominal examination, a pelvic examination, or a rectal examination. These exams look for diseases that can cause pain referred to your back. The lowest nerves in your spinal cord serve the sensory area and muscles of the rectum, and damage to these nerves can result in inability to control urination and defecation. Thus, a rectal examination is essential to make sure that you do not have nerve damage in this area of your body.
- Doctors can use several tests to "look inside you" to get an idea of what might be causing the back pain. No single test is perfect in that it identifies the absence or presence of disease 100% of the time.
- The medical literature is very clear: If there are no red flags, there is little to be gained in imaging acute back pain. Because about 90% of people have improved within 30 days of the onset of their back pain, most doctors will not order tests in the routine evaluation of acute, uncomplicated back pain.
- Plain x-rays are generally not considered useful in the evaluation of back pain, particularly in the first 30 days. In the absence of red flags, their use is discouraged. Their use is indicated if there is significant trauma, mild trauma in those older than 50, people with osteoporosis, and those with prolonged steroid use. Do not expect an x-ray to be taken.
- Myelogram is an x-ray study in which a radio-opaque dye is injected directly into the spinal canal. Its use has decreased dramatically since MRI scanning. This test is now usually done in conjunction with a CT scan and, even then, only in special situations when surgery is being planned.
- Magnetic resonance imaging (MRI) scans are a highly sophisticated test and, as such, are very expensive. The test does not use x-rays but very strong magnets to produce images. Their routine use is discouraged in acute back pain unless a condition is present that may require immediate surgery, such as with cauda equina syndrome or when red flags are present and suggest infection of the spinal canal, bone infection, tumor, or fracture.
- MRI may also be considered after 1 month of symptoms to rule out more serious underlying problems.
- MRIs are not without problems. Bulging of the discs is noted on up to 40% of MRIs performed on people without back pain. Other studies have shown that MRIs fail to diagnose up to 20% of ruptured discs that are found during surgery.
- MRI may also be considered after 1 month of symptoms to rule out more serious underlying problems.
- Electromyogram or EMG is a test that involves the placement of very small needles into the muscles. Electrical activity is monitored. Its use is usually reserved for more chronic pain and to predict the level of nerve root damage. The test is also able to help the doctor distinguish between nerve root disease and muscle disease.
Treatment & Care''
Back pain may be constant or sudden, mild or debilitating. Get the facts on back pain treatments, including medication, exercise, and chiropractic care.
Understanding Back Pain - Diagnosis and Treatment How Is Back Pain Diagnosed?
Before a doctor can begin treating back pain, he or she may do tests to diagnose what is causing the patient's back pain. Unless you are totally immobilized from a back injury, your doctor probably will test your range of motion and nerve function and touch your body to locate the area of discomfort.
Blood and urine tests will make sure the pain is not due to an infection or other systemic problem. X-rays are useful in pinpointing broken bones or other skeletal defects. They can sometimes help locate problems in connective tissue. To analyze soft-tissue damage magnetic resonance imaging (MRI) scans may be needed. X-rays and imaging studies are not usually indicated for first time back pain due to an overuse type injury, and are generally used only for checking out direct trauma to the back, back pain with fever, or nerve problems such as weakness or numbness in the arms or legs. To determine possible nerve or muscle damage, an electromyogram (EMG) can be useful.
Because back pain stems from a variety of causes, treatment goals are pain relief and restored movement. The basic treatment for relieving back pain from strain or minor injury is rest. An ice pack can be helpful, as can aspirin or another nonsteroidal anti-inflammatory drug (NSAID) to reduce pain and inflammation. After the inflammation subsides, applying heat can soothe muscles and connective tissue.
Long-term bed rest, which is considered greater than 72 hours, is not only no longer considered necessary for most cases of back pain, it is actually potentially harmful, making recovery slower and potentially causing new problems. In most cases, you will be expected to start normal, nonstrenuous activity (such as walking) within 24 to 72 hours. After that you should begin controlled exercise or physical therapy. Physical therapy treatments may employ massage, ultrasound, whirlpool baths, controlled application of heat, and individually tailored exercise programs to help you regain full use of the back. Strengthening both the abdominal and back muscles helps stabilize the spine. You can prevent further back injury by learning -- and doing -- gentle stretching exercises and proper lifting techniques, and maintaining good posture.
If back pain keeps you from normal daily activities, your doctor can help by recommending or prescribing pain medications. Over-the-counter painkillers such as Tylenol, aspirin, or ibuprofen can be helpful. Your doctor may prescribe prescription strength anti-inflammatories/pain medicines or may prefer to prescribe combination opioid/acetaminophen medications such as Vicodin or Percocet. Some doctors also prescribe muscle relaxants. But beware, these medications have their main effect on the brain, not the muscles, and often cause drowsiness.
If your primary doctor isn't able to help you control back pain, he/she may refer you to a back specialist or a pain specialist. Sometimes these doctors will use injections of steroids or anesthetics to help control the pain. In cases where there is a herniated disc or pinching of the nerve from the spinal cord, surgery may be indicated. For those patients with long-standing back pain and nerve damage, some newer treatments have been developed recently to help with the treatment of pain. One of these is radiofrequency ablation, a process of delivering electrical stimulation to specific nerves to make them less sensitive to pain, or by delivering enough electricity to actually destroy the nerve to prevent further pain. A similar type of procedure that delivers heat to a herniated disc can shrink the disc so that it no longer bulging onto the nerve root causing pain. Other medicines such as antidepressants and anticonvulsants are sometimes prescribed to help with pain related to irritated nerves.
Knowing the cause of the pain and fixing the problem if possible should be primary in the course of your treatment, however.
Some physicians advocate using a transcutaneous electrical nerve stimulator (TENS), although whether TENS is clearly helpful for back pain has not been resolved. Electrodes taped to the body carry a mild electric current that helps relieve pain.TENS is not painful and may be effective therapy to mask pain such as diabetic neuropathy. However, TENS for chronic low back pain is not effective and cannot be recommended, the American Academy of Neurology (AAN) now says.
Surgery for nonspecific back pain is a last resort. In cases of persistent pain from extreme nerve damage, rhizotomy -- surgically severing a nerve -- may be necessary to stop transmission of pain to the brain. Rhizotomy can correct the symptoms caused by friction between the surfaces in a spinal joint, but it doesn't address other problems, such as herniated discs.
Chiropractors have a role in the treatment of back pain. The U.S. Agency for Healthcare Research and Quality recognizes spinal manipulation by chiropractors and osteopaths as effective for acute low-back pain. Its effectiveness for treating chronic back pain is less well established. Some researchers suggest that early chiropractic adjustments for acute back pain may prevent chronic problems from developing. Other doctors warn against some chiropractic manipulations, particularly those that involve rapid twisting of the neck.
Osteopathic treatment is likely to combine drug therapy with spinal manipulation or traction, followed by physical therapy and exercise.
Acupuncture may bring moderate to complete back pain relief for many sufferers. It can be used alone or as part of a comprehensive treatment plan that includes medications and other bodywork. Clinical achievements, along with positive research results, prompted the National Institutes of Health (NIH) to declare acupuncture a reasonable treatment option for those suffering low back pain.
If you consult a psychotherapist for cognitive behavioral therapy (CBT), your treatment may include stress management, behavioral adaptation, education, and relaxation techniques. CBT can lessen the intensity of back pain, change perceptions about levels of pain and disability, and even lift depression. The NIH considers CBT useful for relieving low back pain, citing studies that show CBT to be superior to routine care and placebo.
Other comprehensive behavioral programs have shown similar success, with participants able to lessen the amount of medication they needed while improving their outlook and pain-related behavior.
If lower back pain is related to muscle tension or spasm, biofeedback can be effective for lessening pain intensity, decreasing drug use, and improving quality of life. Biofeedback may help you train your muscles to respond better to stress or movement.
The Alexander Technique, Pilates, and the Feldendkrais Method are all specialized forms of body work that help you learn to move in a more coordinated, flexible, and graceful manner. They may help reduce pain and can relieve stress. Some of the postures of yoga may help diminish low back pain, improve flexibility, strength, and sense of balance. Yoga is good for stress reduction and can help with the psychological aspects of pain.
Aquatic therapy and exercise can also improve flexibility and decrease pain for those with chronic low back problems. The unique properties of water make it an especially safe environment for exercising a sore back; it provides gentle resistance, comfort, and relaxation.