Chronic Upper Back
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Ankylosing spondylitis is about three times more common in men than women. It commonly presents in the late teenage years or 20s, although can start as late as 45 years old.
The word spondylitis refers to inflammation of the spine; ankylosis means fusion or the melding of two bones into one.
If ankylosing spondylitis is not managed well, it can lead to permanent stiffening of the spine. New bone can grow around the spine, which results in the bones fusing together and limits movement. It also results in a characteristic stooped posture.What Causes Ankylosing Spondylitis?
The cause of ankylosing spondylitis is unknown, although appears to have a strong genetic link. This is particularly the case in people who carry what is known as the HLA-B27 gene.
Recently, two new genes (IL23R and ARTS1) have also been found to be associated with ankylosing spondylitis but the medical community is not yet sure what this means for passing on the condition.
Simply carrying the genes does not mean that you will definitely get ankylosing spondylitis, in fact, only one in eight carriers of the HLA-B27 gene ends up with the condition.
Ankylosing spondylitis usually presents without a specific cause, which makes it different from many common back pains. It does not seem to be caused by particular jobs or movements and is usually not the result of particular injuries, infections or other medical conditions.
What are the Symptoms of Ankylosing Spondylitis?
• Back pain / stiffness which came on gradually.
• Early morning pain / stiffness which reduces with movement.
• Pain/stiffness improves after exercise and is worse after rest.
• Sleep disturbance, particularly in the second half of the night.
• Persistence of the above symptoms for more than 3 months.
• Pain relieved for a time after a shower, bath or heat treatments.
• Inflammation of the iris, within the eye. This may include pain in the eye or brow region, pain associated with exposure to light, blurred vision or a reddened eye.
• The lining of the bowel may also be affected, causing symptoms of inflammatory bowel disease such as diarrhea and bloating.
How is Ankylosing Spondylitis Diagnosed?
If ankylosing spondylitis is suspected by your physiotherapist, you will be referred to your GP for further testing including blood tests and possibly imaging such as X-rays, MRI or a CT scan. Should the test results indicate possible ankylosing spondylitis, you are generally referred on to see a Rheumatologist who specialises in diagnosing the condition.
What is 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, deloading taping techniques, and soft tissue massage.
PHASE II – Restoring Normal ROM & Posture
As your pain and inflammation settles, 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 mobilization 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.
CARE Institute/Sabga Physiotherapy has developed a “Core Stabilization Program” to assist their patients to regain normal muscle control. Please ask your physiotherapist 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 be 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.
What Results Can You Expect?
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 personalized exercise programme to help you manage your condition.
Surgery is needed only if the disease has caused nerve damage in the spine or if joint damage is severe.
Many patients find that soft tissue massage therapy is beneficial to assist your pain relief, muscle relaxation and swelling reduction. Please ask your physiotherapist if you would benefit from a massage.
Acupuncture can be helpful in the relief of your pain. If you are interested in trying some acupuncture, many of our therapists are trained in acupuncture. Please ask for their advice.
Carrying excessive body weight puts extra load on your joints and muscles, which predisposes you to increased pain.
General exercises are very important to keeping your body moving. If you have a specific activity that 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.
Braces and Products
Heat packs are often a wonderful way of easing away stiffness and pain associated with ankylosing spondylitis.
In Scheuermann’s disease, one side (the back) of the vertebral body grows normally and the front grows more slowly or abnormally. This leads to a vertebra with a distinct wedge shape. This in turn leads to an increase in the bend in your upper back called an increased dorsal kyphosis.
Along with this wedging of the vertebra there is also a change to the interface between the disc and the vertebra called endplate irregularities. Some of the disc then pushes into the vertebra and these are called Schmorl’s nodes and are typically seen on an X-Ray.
These Schmorl’s nodes are present for life but are do not appear to cause any problems in the future. People may have an X-Ray when they are older for an unrelated condition and find that they have Schmorl’s nodes but have never experienced back pain.What Causes Scheuermann’s Disease?
Scheuermann’s disease has a familial tendency and no clear gender predilection. It’s cause is unknown, but appears to be multifactorial.
Factors include: juvenile osteoporosis, malabsorption, infection, endocrine disorders and biomechanical factors including a shortened sternum.
What are the Symptoms of Scheuermann’s Disease?
Scheuermann’s disease usually causes pain in and around the thoracic spine. It can also lead to an increased thoracic or mid/upper back kyphosis (bend). This can then lead to some restriction in range of movement especially into extension (bending backwards).
The pain can be made worse by activity including sports that require a lot of twisting, or forceful bending or arching backward such as gymnastics, cricket or athletic field events.
How is Scheuermann’s Disease Diagnosed?
A simple plain X-Ray is usually sufficient to diagnose Scheuermann’s Disease with it showing the classic wedging of the thoracic vertebrae and sometimes the Schmorl’s Nodes. MRI will show additional detail.
What is Scheuermann’s Disease Treatment?
PHASE I – Pain Relief & Protection
Managing your pain is the main reason that you seek treatment. In truth, it was actually the final symptom that you developed and should be the first symptom to improve.
Scheuermann’s Disease inflammation it best eased via ice therapy and techniques or exercises that deload the inflamed structures.
Your physiotherapist will use an array of treatment tools to reduce your pain and inflammation. These include: ice, electrotherapy, acupuncture, deloading taping techniques, soft tissue massage.
Your doctor may recommend a course of non-steroidal anti-inflammatory drugs such as ibuprofen or pain relievers such as paracetamol.
You will need to avoid heavy loading of your thoracic spine and strong bending exercises such as crunches or sit ups.
PHASE II – Restoring Normal ROM, Strength
As your pain and inflammation settles, your physiotherapist will turn their attention to restoring as much range of movement as you can. It is important to regain as much extension as you can.
It is also important to restore or improve the muscles that control the movement and posture in your back. Your physiotherapist will assess your muscle recruitment pattern and prescribe the best exercises for you specific to your needs.
Please ask your physiotherapist for their advice.
PHASE III – Restoring Full Function
There is no reason why people can not return to full activity including all sports but they may need guidance on returning to activity that involves twisting or strong bending. You will also need to be progressed through exercises to regain sport or activity specific strength as the period of rest can lead to a lot of deconditioning.
PHASE IV – Preventing Future Dysfunction
There are some things that you can do to reduce your chances of having any problems in the future. Maintaining good flexibility in your back and keeping the core muscles strong so that you maintain better posture and good control over the vertebra will all help to limit any future problems.
What is Your Prognosis?
The pain from active Scheuermann’s Disease will eventually pass and for the majority of people they will have no further trouble from their thoracic vertebrae. Some people will have reduced range of movement and if the disease caused significant kyphosis (bend) then they can get ongoing postural issues.
For more information please contact your physiotherapist.
Other Treatment Options for Scheuermann’s Disease
Sometimes a posture brace is used to help keep the back in as much extension as possible. This works to remind you where your back should be and encourage the correct muscles to work.
Surgery for Scheuermann’s Disease
Rarely the amount of wedging of the vertebra is so great that surgery to restore a better position for the thoracic spine is required. This only occurs it the disease process is significant. Your Physiotherapist will be able to monitor the amount of flexion that you have and if it appears to be increasing to greatly an orthopaedic surgeon may need to make an assessment.
If you have any questions please seek the advice of your physiotherapist.
The goal of physiotherapy in treating adults, therefore, is to address back pain, posture and muscle strength. Heat, electrical stimulation and massage have been proven helpful in alleviating the pain of scoliosis. In addition, soft tissue manipulation may help improve alignment and flexibility but cannot halt the progression of the disease. Exercises to strengthen muscles also form part of the physiotherapy program. Aquatic exercises are especially helpful as the buoyancy of the water helps improve flexibility, posture and balance and relieve pain.
In idiopathic adolescent scoliosis, therapy may focus on bracing to prevent progression of the disease. A custom-fitted brace may be appropriate, which fits from the armpits to the hips. The child or parent is taught to put on and take off the brace and is given a wearing schedule, usually 22-23 hours a day.
For the child whose scoliosis is the result of a neurological disorder, therapy is much more complex. Special seating and/or mobility devices may be needed. Training in posture, coordination and gait may be necessary as well as exercises to promote flexibility and strength. The child may also be fitted with a brace and will be trained in the normal wearing procedure.
Physical therapy treatment ddress the problems identified during the patient evaluation. Conservative treatment is utilized unless there is significant vascular compromise, motor loss or as long as the patient is improving.8 Surgical treatment typically includes resection of first rib, scalenotomy or clavicular resection, but should be used as a last resort.
Physical therapy treatment is specifically directed to the structures involved the. The treatment goal is to increase the space of the thoracic outlet and reduce the pressure upon the nervous and vascular structures.
The conservative treatment program includes the following basic principles.
1. Postural correction/modification;
2. Stretching tight musculature/relieving muscle tension;
3. Increasing the mobility of the first/second ribs and clavicle;
4. Strengthening weak muscles;
5. Diaphragmatic breathing and relaxation instruction.