We’ve been talking lots about low back pain lately, however, most of the time when we see low back pain in a clinical setting it is referred to as “non-specific” low back pain.

This basically means there is no underlying cause or incident that can be attributed to the patient’s pain, yet they are still undergoing a painful experience.

Part of our clinical intake and decision making should be able to point us in the right direction when the pain isn’t non-specific, especially if the patient is experiencing one of the red flags of low back pain. Some of these can be difficult to differentiate as there is usually a little bit of overlap between symptoms and really narrowing it down can present its own challenges, especially if you’re trying to prevent a patient from catastrophizing about their pain.

One of these situations is a condition called “Ankylosing Spondylitis” and the symptoms have some overlap with other red flags, so it’s crucial we are able to differentiate between this and other conditions, if for no other reason than to refer out to the appropriate health care professional for the person to get the proper care.

Signs, Symptoms & History

Ankylosing Spondylitis is an inflammatory rheumatic disease that traditionally affects young people and usually becomes noticeable around 26 – 28 years old, with men being affected more than women by a 2:1 ratio and they may have more structural changes than women.

While it is generally recognized around 26, 80% of affected patients are diagnosed under the age of 30 and only 5% develop the condition above the age of 45 (some important things to take note of with your intake).

This condition falls under a group of spondyloarthritides, of which there are five different conditions:

• Ankylosing Spondylitis.
• Psoriatic Spondyloarthritis.
• Reactive Spondyloarthritis.
• Spondyloarthritis associated with inflammatory bowel disease.
• Undifferentiated Spondyloarthritis.

Regardless of which subtype a person has the main thing that occurs is inflammatory back pain starting with sacroiliitis and inflammation occurring in other spots on the spine along with some peripheral arthritis (usually lower limb) and in rare cases, causes issues with organs.

Generally, the symptoms start with a dull pain deep in the gluts and/or low back accompanied by stiffness in the morning that lasts for a few hours. It improves with movement but comes back with rest. Within a few months, the pain becomes persistent, felt on both sides and gets worse at night. The spinal stiffness and loss of mobility come on as a result of inflammation and the resulting damage caused by the disease. Some of the damage is due to bone remodeling and bone loss because of the inflammation involved.

The cause of the disease is unknown, but one of the predisposing factors related to getting this is the gene HLA B27, (not that you’ll be able to know if your patient has this) in fact, 90-95% of those diagnosed with AS (ankylosing spondylitis) are positive for this gene with the risk of developing the disease around 5% in those positive for the gene and even higher for relatives of patients, however, most of the HLA B27 positive people remain healthy.

Now, I realize a lot of that just sounded like a bunch of sciencey talk (which it kind of was) but how does it all apply clinically?

Well, what we need to look out for is:

• Low back pain and stiffness for longer than three months, which is relieved by exercise, but not with rest.
• Restriction of lumbar ROM with flexion/extension as well as side-bending.
• Restriction of chest expansion in comparison to others of the same age and sex (not 100% sure how you would measure this).
• Sacroiliitis identified through imaging.

The use of MRI is what usually identifies the sacroiliitis because of its ability to see active inflammation along with structural damage to the bones and cartilage that can be seen, which hopefully catches the disease early. However, the MRI alone isn’t en0ugh for a diagnosis. It is better diagnosed if at least three clinical, laboratory (gene testing), or imaging results are positive. Clinically  we would look for:

• Morning stiffness longer than 30 minutes.
• Improvement in back pain with exercise, but not with rest.
• Waking due to back pain during the second half of the night.
• Alternating buttock pain.

This is where our understanding of the red flags of low back pain comes in to play. Low back pain greater than six weeks and for those older than 18 are red flags due to a tumor, infection, or a rheumatological disorder. If the person has no history of cancer, the tumor is quite unlikely, and if there is no reason to suspect an infection, well… that leaves us with rheumatological issues that we may need to refer the patient to a doctor for further diagnosis.

Exercise And Massage Treatment

Our goals for treatment should be to reduce symptoms, minimize spinal deformity, disability, and in reviewing research there is one topic that continually comes up as a non-pharmaceutical treatment for AS…exercise!

There are many similarities between rheumatoid arthritis (RA) and AS, but some similarities are still present, so, much of the research revolves around RA instead of AS. It is recommended for people to get 30 minutes of moderate intensity exercise per week (brisk walking is suggested) 3 days a week, or the equivalent of 90 minutes/week. However, this can include dynamic exercise to improve muscle strength and aerobic endurance.

RCT’s showed how exercise was most effective in physical function and spinal mobility for patients with AS, more specifically supervised exercise was even more effective, and pool exercises were more popular than land based.  One study showed that a combination of self and manual mobilization at home helped with chest expansion, posture, and spinal mobility. 

Another study on the effectiveness of group exercise was done with one group who was supervised and the other was given the exercises/movements as homecare. The results showed a positive influence on the duration of morning stiffness, chest expansion, and overall well being after intensive supervised exercise classes, however, the home exercise group didn’t really show much improvement. It is believed that part of the reason for this is the psychosocial factors that come with being around other patients with similar problems and the education given in the classes. I would venture to assume there is a certain amount of motivation that comes with being in a group to actually “do” the exercises as well (part of the reason I push myself at CrossFit a lot harder than I do in the gym alone). The combined group exercise has also been shown as a more cost-effective treatment compared to standard treatment alone (use of NSAIDs). 

So, what does this all mean for us as massage therapists? 

Well, a lot actually, and in a positive way. Quite often “complementary and alternative treatments” are recommended in conditions like this and well… we just happen to be one of those treatments. When we look at what’s recommended, there aren’t any clinically controlled trials (although here is a case study that looks positive) on our effectiveness, but massage is shown to be SAFE! However, it is recommended when looking at acupuncture and chiropractic manipulations under the same light to view them with caution, so SAFE is GOOD.

As we have discussed so many times on this blog we also have an opportunity (and a responsibility) to look at the biopsychosocial aspects of what could be affecting our patients with AS. Since this generally happens at a younger age when people are typically in their most productive stage of life, there is a general fear around work disability which can be a contributor to the persons pain. This is one aspect where educating on how exercise can help prevent progression of the disease can be a valuable tool during treatment. One of the other issues is a lack of energy and fear of joint damage around exercise, which gives us another opportunity.

When we look at many of the exercises used in the studies we mention, they used: stretching, mobilization and strengthening for the back, aerobic, along with postural and respiratory exercises. While exercise may not be in all of our scopes, we generally, can do stretching during treatment and can also do active and passive range of motion (which is essentially mobilization). Not only is this part of the recommended exercises, but it’s also an opportunity for us to reinforce that movement and exercise is safe and promote resilience in their dealing with the condition. If exercise is in your scope, use the opportunity to go for a walk with your patient (they may need your reassurance and support to do this), do some active movement, some repeated motions to increase mobility, and above all reassure them this is not only safe, but beneficial!

 

Here is some information I would like anyone with back pain to know. Whether it is the first time you have had back pain or you have had it for ages.

I would love others to contribute to building up this information as it is certainly not definitive. So if you are a clinician or have had back pain please email me if you have something to add ben@cor-kinetic.com

This has also been turned into a downloadable PDF so you can share with colleagues, patients or anyone you feel it may help. Please click Back Pain Share Pdf to get it!

Back Pain Information

• Back pain is normal. Up to 20% of people are likely to get some each year and a whopping 80% of us will get some back pain in our lifetime, in fact, it would abnormal not to get back pain.
• Back pain can last up to 6 weeks – this may be longer than you anticipated. So if it has been going on for a bit there is no need to unduly worry. Lots of pains only last a number of days but it is still normal for it to last longer.
• Although we all know someone who has had long term persisting back pain that has caused lots of problems it is actually somewhere between 10% and 25% of people with back pain that lasts longer than normal. So you have good odds it won’t last longer than 6 weeks.
• Back pain is no different to any other pain in our bodies such as shoulder, ankle or knee pain although people do tend to worry more about it.
• Pain itself is normal and nothing to be scared of. It is a protective mechanism that has evolved to help us out. You would not want to live without it!
• Pain is not good at reflecting the physical state of our back or any body part. We can have lots of pain without significant damage. Think about getting a paper cut or a bee sting. They can hurt like hell but don’t really damage us.

Diagnosis

Diagnosis can often be challenging with back pain although I know that people often want an answer. We don’t always need a definitive answer to help you.

Here is what we do know:

• The vast majority of back pain is not serious, in fact around 99%. The 1% is mostly fractures, can include cancer, but these a pretty rare occurrences.
• Around 10% can be pinned down to a specific tissue diagnosis such as a disc or a nerve.
• These statistics mean that it is unlikely to be a ‘slipped disc’ or a nerve problem and people often throw these terms around as causes without really knowing this for sure. This can often be unhelpful.
• Therapists have some tests to tell if the problem is in that 10%. These include clinical tests for the nerves and nerve roots as well as muscle strength, sensation and reflex tests.
• It is very difficult to make a diagnosis from an MRI alone. Lots of MRI findings also exist in people without pain, hence the need for a clinical exam to accompany a scan.
• MRI’s are not able to show us pain.
• So we often can’t pin it down to a specific tissue or pathology around 9 out of 10 times. There are lots of different tissues in a small space and if it is irritated or inflamed then it may affect more than one of the tissues.
• Inflammation is a good thing. It means the body is working well and doing its repair jobs.
• From a medical perspective, this type of back pain is often termed ‘non-specific’ and we should see this as a positive diagnosis as it means nothing serious is wrong. It could still hurt a whole lot though.
• The term ‘non-specific’ means the tissue, not non-specific to you or has no origin. YOUR PAIN IS ALWAYS REAL AND SPECIFIC.
• Non-specific pain often responds well to moving and although we cannot give an exact label does not mean we cannot give some ideas to help or a basic explanation about why you might have back pain.

Other Factors

• Lots of different factors (many which you may have not considered) can affect your back pain.
• This can mean that you feel your back pain has a life of its own but it may be that you have not been informed about or considered all of the potential contributing factors.
• These other factors can include abnormal sleep, lots of life stressors including work and family, feeling that the pain will never go and negative beliefs about your back and performing daily activities.
• Its probably not your spinal posture, your pelvic tilt, a teeny weeny muscle not firing or something needs to be put back into place causing your back pain. How do we know? We have studied this stuff to death.
• If you have been told this before it could mean your therapist is not up to date with the latest research in this area. You may have been given lots of opinions previously and it can often be confusing for you and hence the need to be aware of the scientific data in this area.

Treatment

• There are NO magic treatments for back pain that work for everybody, unfortunately.
• It might not be one singular problem but a few different things happening together. A minor pain might be exacerbated by other things that are making you a bit more sensitive.
• Your therapist should be able to give you some basic advice or point you in the direction of others who can if it needs more specialist help.
• Lots of different treatments can help in the short term, such as a few hours or days, but don’t simply put your recovery in someone else’s hands. This has been shown to often be worse in the long term.
• You may have to avoid aggravating activities in the short term but make sure you go back to doing them. Nothing should be off limits in the long term. Don’t let anyone tell you otherwise.
• People who feel they need to protect their backs can also have worse outcomes.
• Learning more about what helps you and what makes you worse is important to help you manage your back pain. Your therapists should help you do this.
• Movement and exercise might help.
• Unfortunately, there are no magic exercises for back pain. Find what you enjoy and just do it. This could be Pilates, strength training, a sport with friends or simply going for a walk in the park.
• Don’t feel you have to really push yourself to get stronger or fitter but it is good once in a while to exert yourself. This gets your body used to doing it.
• Moving and exercising can help us build confidence in our bodies and this might be key to recovery rather than fixing a physical problem.

Persisting Back Pain

• The common term for persisting pain is chronic pain, The term chronic does not mean ‘worse’ it is actually just a general term for pain that has gone on for longer than 3 months.
• How we respond to back pain might play a role in how long it lasts. If you change what you do in terms of activity such as avoiding things or think very negatively about your pain and your recovery
• We could see persisting back pain as our protective systems, in this case, pain, doing its job too well.
• Although pain is normal and a good thing, we could see it a lot like red wine. A little bit is great, but sometimes we can have too much of a good thing and it leaves us with a hangover.
• Persisting pain is currently seen as a problem of the protective system itself rather than simply reflective of the state of your body.
• The more we work the mechanisms that contribute to pain the stronger they can get. It’s a bit like working your bicep in the gym. Just like your muscles the protective system can adapt and get better at protecting you.
• Unfortunately, this means that the things that did not use to cause you pain now can do and may explain why you can be very sensitive to things that used to be normal.
• All of this does not mean you can’t get better but it is not as simple as finding an ‘off’ switch.

Clinicians Advice

• Sheren Gaulbert – Stay connected with people who matter in your life/engage in activities you value
• Karen Litzy – Don’t consider yourself broken or damaged goods
• Ash James – It’s often better to be at work than at home. You will move more, rest less, and get back to normal stuff sooner
• Kjartan Vibe Fersum – Important to have a shared plan (with your therapist) to move forward with
• Tom Goom – It’s good to experiment with movement, relax into it and see what helps pain and stiffness. Movement is medicine, and like medicine, it has a dosage, experimentation is needed to find the right dose for you
• Claire Higgins – Your back is designed to be strong. It can so easily be visualized by patients to be a stack of blocks which could be “crushed” or “topple” at any moment. Education on how our backs are super strong and to trust in them is important.
• Claire Higgins – Focus on the things which turn your pain down, restoring balance e.g. exercise, meeting friends for coffee, being in the great outdoors.