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!