Ankylosing spondylitis, AS, Back Pain.

Back pain is typically one of those aches that worsens when you bend or walk and feels better when you rest or recline. 

But That’s not the case with ankylosing spondylitis. This inflammatory disease causes pain and stiffness in your lower back and hips — especially in the morning or after prolonged periods of not moving. 

Ankylosing spondylitis (AS) is a form of arthritis that causes inflammation in the joints in your spine, or vertebrae. As the disease progresses, it impacts the sacroiliac joints (which connect the base of your spine and your pelvis), and can lead to severe and chronic pain, stiffness, and discomfort in your lower back and hips.

Inflammation may also occur in the connective tissue in your spine where tendons and ligaments attach to bone (caused the entheses); in the cartilage between your breastbone and ribs; the back of your heel; as well as your hip and shoulder joints.

Ankylosing Spondylitis Symptoms and Red Flags

1. Chronic pain and stiffness in the lower back where your spine meets your pelvis

Ankylosing spondylitis causes chronic pain that can come and go. You might experience periods of flares and stiffness, and other times when you don’t feel pain as acutely. The symptoms may ease up or disappear for a period of time, but they ultimately return.

2. Pain that gets worse with inactivity or sitting still for long periods, such as while you sleep

When your back pain occurs because your immune system is attacking your joints, inflammatory cells and proteins accumulate in the fluid in your joints. When you don’t move your joints for a long time, such as during a marathon work meeting or while you sleep, those inflammatory chemicals settle and make your pain worse.

This is why people with AS feel better when they are active. 

3. Pain that gets better from a hot shower

Similarly to exercise and activity improving AS back pain, a hot shower or a heating pad often helps inflammatory back pain feel better too. The hot water helps loosen up the inflammatory chemicals in your spine and other joints, temporarily relieving symptoms.

4. ‘Alternating buttock pain’

This is one of those symptoms where you know it if you have it. Your pain feels like it moves from side to side in your lower back near your rear end. “Alternating buttock pain” can make it hard to sit still, like during a long stretch of time at work at your desk, or during a movie.

5. Pain in your ribcage, such as when you exhale

AS can also cause inflammation at the point where your rib cage connects with your breastbone and spine. This can make it ache or hurt when you exhale. If your ribcage gets very stiff, you might be limited in how much your chest can expand, making it harder to breathe.

6. Pain in your heel or foot

Another prominent feature of AS is that it causes inflammation of the entheses, which is where ligaments and tendons attach to bones. A common location is by your Achilles tendon at the back of your heel, though this can occur throughout the body. Sometimes people call these areas “hot spots.” Your doctor may check for pain and tenderness at various hot spots during your visits. When you get inflammation in your feet from AS, it can hurt badly enough to affect your ability to walk.

7. Pain in your jaw

Jaw inflammation isn’t as common in AS as the above symptoms, but it can still occur in a smaller number of patients. Your jaw might ache or hurt when you eat.

8. Fever

AS occurs because your immune system is overactive and is attacking your body’s own joints. An overactive immune system can cause what doctors call “systemic” symptoms in addition to pain and swelling. A low-grade fever that lingers or comes and goes can be a sign of ankylosing spondylitis.

9. Diarrhea, bloating, or other GI symptoms

There is genetic overlap between AS and inflammatory bowel diseases like ulcerative colitis and Crohn’s disease, which is why these diseases tend to co-occur in patients. About 10 percent of AS patients develop IBD, but even people without an official IBD diagnosis experience inflammation in the gastrointestinal tract that can cause bloating, diarrhea, and other GI symptoms. If your lower back pain occurs with GI upset, that could be a red flag that your pain is inflammatory in nature.

10. Uveitis, or eye redness and inflammation

In some people with AS, the symptom that sends them to seek treatment isn’t related to back or hip pain — it’s eye redness. Uveitis, or inflammation of the part of the eye called the uvea, occurs in as many as 30 percent of people with AS. In many cases, it can be very painful. Your eyes may feel extremely sensitive to sunlight, and treatment like eye drops for pinkeye won’t improve things. 

11. Psoriasis

Psoriasis is an autoimmune disorder characterized by red, silvery scaly plaques on the skin (though there are different kind of psoriasis and psoriasis symptoms can present differently). Up to 30 percent of people with psoriasis also develop joint pain and other symptoms, which is a separate disease called psoriatic arthritis. But psoriasis can also co-occur with AS. If someone has axial involvement, which means pain and inflammation is occurring in the spine, and mild psoriasis, then they have both psoriasis and AS. 

12. Fatigue

The inflammation throughout your body also causes fatigue, which some AS patients say is as bad as, if not worse than, the pain and stiffness. Fatigue is more than feeling tired from too little sleep; it’s like you’re too weak and exhausted to function like your usual self. The tiredness feels physical, not just mental. 

In more severe cases of AS, new bone forms in the spine as part of the body’s attempt to heal from the inflammation. The extra bone bridges the gap between vertebrae, reducing flexibility in your back. Eventually, bone grows at the sides of the vertebrae, causing sections of the spine to fuse together and become immobile, which can reduce your ability to turn your head, stand up straight, or bend. Bony fusions can also stiffen your rib cage, making it tough to take deep breaths.

Less often, fusion of the spine can cause it to curve forward, resulting in a hunched-forward posture.

There’s no cure for ankylosing spondylitis, but treatments — including medication (such as non-steroidal anti-inflammatory drugs, or NSAIDS, and biologics) and physical therapy — can lessen pain and stiffness, and possibly slow the progression of the disease.

Ankylosing Spondylitis Treatment

Your GP and rheumatologist may prescribe medications to help control the inflammatory part of the disease. As well as seeing your GP or rheumatologist for check-ups, your physiotherapist plays an important role in helping you manage your ankylosing spondylitis.

PHASE I – Pain Relief

Your physiotherapist will use an array of treatment tools to reduce your pain and inflammation. These include heat, electrotherapy, acupuncture, de-oading taping techniques, and soft tissue massage.

PHASE II – Restoring Normal ROM & Posture

As your pain and inflammation settle, your physiotherapist will turn their attention to restoring your normal joint range of motion, muscle length, neural tissue mobility and resting muscle tension.

Treatment may include joint mobilisation and alignment techniques, massage, muscle stretches and neurodynamic exercises, plus acupuncture, trigger point therapy or dry needling. Your physiotherapist is an expert in the techniques that will work best for you.

PHASE III – Restore Normal Muscle Control & Strength

Researchers have discovered the importance of your muscle recruitment patterns with a normal order of: deep, then intermediate and finally superficial muscle firing patterns in normal pain-free people. Pain has an unfortunate side effect of ‘switching off’ your deep ‘core muscles’. Your physiotherapist will assess your muscle recruitment pattern and prescribe the best exercises for you specific to your needs.

PhysioWorks has developed a “Core Stabilisation Program” to assist their patients to regain normal muscle control. Please ask your physio for their advice.

PHASE IV – Restoring Function and Return to Activity

During this stage of your rehabilitation is aimed at returning you to your desired activities. Everyone has different demands for their bodies that will determine what specific treatment goals you need to achieve. For some, it is simply to walk around the block. Others may wish to run a marathon or return to a labour-intensive activity. Your physiotherapist will tailor your rehabilitation to help you achieve your own functional goals.

PHASE V – Long-Term Management

Ankylosing spondylitis is a condition that requires constant management. Sticking to a regular stretching plan specific to your stiffness helps to get the most out of your body. Your physiotherapist will set you up with an appropriate stretching programme, will monitor your symptoms and make any adjustments to the programme as necessary.

The best advice is to keep active. Regular physical activity is one of the most effective treatments for AS. It is important to engage in a regular stretching program every day and do at least 30 minutes of moderate exercise on most days of the week.

Symptoms may come (flare) and go (remission) for many years. For others, the symptoms and disability may gradually worsen over time.

Generally, people with AS can continue to work and perform daily activities, although certain changes may have to be made to allow a variety of positions and movements throughout the day.

Physiotherapy helps to provide pain relief and improve stiffness. Your physiotherapist can also provide you with a personalised exercise programme to help you manage your condition.

Surgery

Surgery is needed only if the disease has caused nerve damage in the spine or if joint damage is severe.

Massage

Many patients find that soft tissue massage therapy is beneficial to assist your pain relief, muscle relaxation and swelling reduction.

Acupuncture

Acupuncture can be helpful for the relief of your pain. If you are interested in trying some acupuncture, many of our therapists are trained in acupuncture. 

Weight-Loss

Carrying excessive body weight puts extra load on your joints and muscles, which predisposes you to increased pain.

General Exercise

General exercises are very important to keep your body moving. If you have a specific activity that you enjoy, please ask your physiotherapist if that activity will be beneficial to your long-term health.

For this particular injury, other patients have benefited from the following activities: hydrotherapy, pilates, yoga, walking, swimming, cycling, or tennis.

Exercise Helps Ankylosing Spondylitis

Most people with AS say pain improves after exercise or activity.

The best time to exercise: when you wake up. “Morning stiffness is very common with AS.” Start with flexibility and range-of-motion exrcises, and continue to stay active and exercise throughout the day.

The types of exercises your physical therapist may recommend include:

Posture training: Practicing good posture techniques helps you avoid slouching forward so you reduce the amount of strain on your spine.

Flexibility exercises: Gentle range-of-motion and stretching exercises help keep the spine and other joints from getting stiff, improve mobility in your joints, and help keep your back flexible.

Deep-breathing exercises: The goal is to expand your chest so you can breathe better.

Strengthening exercises: Making your back and core muscles stronger can help maintain proper posture and keep your body stable. Strengthening back muscles also provides better support to bones and joints, which may reduce pain.

Balance exercises: “Loss of balance is seen in advanced AS.” Poor posture can make you less steady on your feet, which can increase your risk of falling when you walk.

Aquatic exercises: Water aerobics can help decrease joint pain and improve mobility.  

Stretches Exercises to Help Ankylosing Spondylitis Pain

If you’re new to exercise, always talk to your doctor before starting. Your physical therapist can make sure the exercises are safe for you. Start slowly and move gently. And if any activity increases joint pain, and if pain continues for several days after exercise, it’s time to stop. Talk to your doctor about what pain is normal and when it’s a sign of something more serious.

The following stretches and exercises were recommended:

1. AS Exercise: Back Against a Wall

Maintains posture

Stand against a wall, with your heels and buttocks touching the wall.

Squeeze your shoulder blades together.

Hold for 5 seconds, then relax. Repeat.

2. AS Exercise: Prone Lying

Improves posture

Lie on your stomach.

Slowly prop yourself up on your elbows so your chest is off the ground.

If you’re able, straighten your arms.

Hold for 10 to 20 seconds, then return to start position. Repeat.

3. AS Exercise: Seated Thoracic Extension

Stretches chest muscles

Sit upright in a chair, with your feet flat on the floor.

Place your hands behind your head for support, with your elbows out to the sides.

Keeping your head still, slowly roll the top of your spine over the back of the chair.

Hold for 5 to 10 seconds, then return to start position. Repeat.

4. AS Exercise: Quadricep Stretch

Stretches the front of your thigh

Lie on your stomach.

Loop a strap, belt, or sheet around the top of one foot.

Gently pull the strap over your shoulder until you feel a stretch through the muscle.

Hold for 10 to 20 seconds, then return to start position. Repeat on the other side.

 

5. AS Exercise: Seated Figure Four Stretch

Improves hip mobility

Sit upright in a chair, with your feet flat on the floor.

Lift your right leg and place your right foot on top of your left thigh, just above your knee.

Keeping your spine as straight as possible, slowly hinge forward. For a deeper stretch, apply gentle pressure on the right thigh.

Hold for 10 to 20 seconds, then return to start position. Repeat on the other side.

 

6. AS Exercise: Plank

Helps stabilize your core

 

Planks

Lie on your stomach with your forearms on the floor and elbows directly below your shoulders.

Tighten your stomach muscles and lift your hips off the floor.

Squeeze your buttock muscles, and left your knees off the floor.

Keep your body straight, without letting your pelvis sag toward the floor.

Hold for 10 to 20 seconds, then return to start position. Repeat.