Juan Agustin Solerand Fares Haddadexplain the causes and management options
There are many and diverse causes of back pain, including trauma, prolapsed intervertebral discs, damage to the ligaments, degener- ative disease, spondylolysis, spondylolisthesis, inflammatory arthritis and infection.
Athletes are more than averagely susceptible to back pain because of the volume of physical activity that they do and the specific stresses that particular sports may impose. It has been estimated that 5-10% of all athletic injuries are related to the lumbar spine, most of them the result of a traumatic event. The young athlete who presents complaining of low back pain without a history of trauma is a cause for concern; these individuals are usually young, fit men, so ankylosing spondylitis may not be high on the list of differentials and an accurate diagnosis may be delayed.
Ankylosing spondylitis (AS) is a generalised chronic inflammatory disease that for the most part affects the axial skeleton and sacroiliac joints. The main symptoms are pain and stiffness and decreased mobility in the spine; and, to a lesser degree, involvement of peripheral joints. An important feature of AS is enthesitis, or inflammation of the tendinous, ligamentous or joint capsule insertions into bones. The therapist should bear this in mind, as these clients may also complain of problems with the Achilles tendon or the soles of their feet (plantar fasciitis).
We do not understand what causes the disease or why it disproportionately affects young men. It has a prevalence of up to 0.2% in Western Europe and North America, though it is lower among Japanese and Black Africans. There is a strong association with the HLA-B27 gene (which can be identified with a simple blood test). Approximately 1-2% of all people who are positive for HLA-B27 develop AS, rising to 15-20% of those who have an immediate family relation with AS. There does not appear to be any relationship between AS and type or intensity of sport practised.
The abnormality is twofold. Inflammation of the synovial membrane of the vertebral facet joints and the sacroiliac joints causes destruction of the articular cartilage and surrounding bone. The costovertebral joints are also affected, leading to a decrease in mobility of the thoracic cage and consequential respiratory problems. There is also inflammation of the intervertebral discs, sacroiliac ligaments, symphysis pubis, upper sternum and bony insertion of large tendons. Calcium deposits across the surface of the discs give rise to small bony ridges linking adjacent vertebral bodies. When many vertebrae are affected, the spine may become rigid. AS can be associated with other conditions. Approximately two out of five sufferers will develop an inflammation of the iris and its attachment to the outer wall of the eye, the uvea: iritis and/or uveitis. Symptoms include blurry vision together with sharp pain and a red, inflamed eye. It is important to seek urgent medical advice and treatment for this condition.
The heart can also occasionally be affected in the form of a leaky heart valve or electrical conduction problems, although these are rarely noticed by the client. For this reason the active client should be assessed for heart problems by a physician.
The lungs themselves do not tend to be affected. However, the joints of the ribs can get involved and cause problems with chest expansion. Clients may find deep breathing, sneezing or coughing painful. In advanced forms of the disease, the total volume of the thoracic cage may be so reduced as to make breathing more difficult. It would be wise to ask the client to avoid smoking as this can create more difficulties in breathing and cause lung problems such as infections.
AS can occur on its own or together with other abnormalities seen in various systemic inflammatory conditions such as Reiter’s syndrome (with inflammation of the urethra and the iris), psoriasis, Crohn’s disease or ulcerative colitis of the bowel. It is important to remember, however, that suffering from AS does not predispose the individual to any of these conditions.
The most striking feature of AS is the early onset of symptoms, usually between the ages of 15 and 25, although it can be as late as 40. These symptoms are back pain and stiffness, especially in the early morning or after inactivity. Over time the pain may become more continuous and other symptoms may show, such as general fatigue, night pain, pain in other joints, night sweats, feeling feverish, stooping (which increases over time) and a very stiff spine.
Clinical examination should begin with evaluation of the spinal curvature, range of motion and degree of pain-free range of motion with the patient standing. The whole of the spine and surrounding tissues should be palpated and reproducible painful movements documented. The pelvis and hips should be examined, including range of motion and presence of fixed flexion deformities. However, there may be little to be seen, particularly in the early stage, apart from slight loss of lumbar lordosis and diffuse tenderness to the spine and sacroiliac joints.
In advanced cases the patient has a typical posture with loss of the normal lumbar curvature, increased thoracic curvature (kyphosis) and a forward thrust of the neck. The hips and knees are slightly flexed and with time may become fixed in this position. As the condition and stiffness progress, the whole spine may become completely ankylosed (fused), sometimes in positions of great deformity.
X-rays are rarely used in the initial stages and then only to rule out serious medical conditions. They may show erosion of the sacroiliac joints as an early manifestation. On the vertebrae, there may be ‘squaring’ of the bodies; calcium deposition in the ligaments produces bony growths that bridge adjacent vertebral bodies, giving the spine a characteristic appearance of a bamboo tree, the ‘bamboo spine’.
Diagnosis is often delayed because more common causes of back pain are usually considered first, such as mechanical back pain, facet joint dysfunction, etc. Blood tests may reveal a raised ESR, positive HLA-B27 gene in up to 90% of cases, and a negative rheumatoid factor.
AS has no cure at present so treatment is directed at relieving or controlling the symptoms, mainly pain and inflammation.
It is extremely important that the client should maintain exercise and an active lifestyle. In particular they must be taught how to maintain a proper posture and learn exercises to preserve spinal mobility. A vicious circle of pain and poor posture can occur because of a tendency for the affected individual to flex forwards when experiencing pain in the spine. Education can help them to break this impulse.
Two helpful exercises are:
Wall stand: the client places their back against a wall with their heels about 10cm from the wall. The shoulders and buttocks should be close to, and if possible, touching the wall. Do not ask the patient to strain. Hold for 5 seconds, relax and repeat.
Prone lie:the client lies prone on a firm surface. A pillow can be placed under the chest and a folded towel on the forehead, if unable to lie flat. It is advisable to do this when the body is warm.
Swimming, dancing and exercises to improve muscle tone, strength and flexibility are ideal, but rapid twisting movements should be avoided. The most important thing for the client to understand is that rest is not advisable as it will increase their stiffness. Contact sports such as rugby or hockey should be avoided: when the disease progresses and the spine starts to fuse, there is always a risk of spinal fracture. For the same reason, sports carrying a higher risk of falls (such as skiing or horseback sports) are best avoided.
It may be worth considering using a heat retainer, as it is important not to let the painful areas and muscle groups get cold. Deep tissue massage, ultrasound, passive stretching, heat/ice and acupuncture may all have a role to play in reducing pain and maintaining mobility.
Surgery is an option to correct gross deformities of the spine, but these are extensive procedures that must be thoroughly discussed with the orthopaedic spinal surgeon or neurosurgeon. Joint problems such as fixed flexion deformities can be resolved by total hip replacement.
The progression of AS is highly variable. Many patients will not go on to develop all the advanced features of the disorder. For the keen young athlete, this may be a great cause for optimism, offering many the chance of continued participation in their sport, albeit possibly at a reduced level.
Drezner JA, Herring SA ‘Exercises in the Treatment of Low-Back Pain’ The Physician and Sportsmedicine2001 Vol 29 No 8 Kataria RK, Brent LH, ‘Spondylo- arthropathies’ American Family Physician 2004 Vol 69 No.12
Kronberg J, Small E, ‘Tackling Back Pain in a Young Athlete’ Contemporary Pediatrics (www.contemporarypediatrics. com, first published Nov 2005)