A frequently misdiagnosed condition may be to blame

Nearly everyone experiences low back pain at one time or another. For many people, the pain is brought on by heavy lifting, a bad sleep position or twisting the wrong way. For others, it may be age-related osteoarthritis.

But for a significant number of back pain sufferers, the pain becomes chronic (occurring daily for months to years) and can be due to a condition known as ankylosing spondylitis (AS), a form of arthritis that causes painful inflammation of the spinal joints (vertebrae). Less often, pain also occurs in other parts of the body, such as the shoulders and hips — or even the jaw or small joints of the hands.

AS — most often referred to simply as spondylitis — is typically diagnosed before the age of 40, but the condition may go undetected or misdiagnosed until the patient is much older.

If spondylitis progresses, the inflammation can lead to new bone formation that causes the spine to fuse (a condition known as ankylosis) in a forward-stooped position. This occurred in Pope John Paul II, who suffered from AS.

Why do so many cases of spondylitis escape notice? For some patients, the back pain and stiffness caused by spondylitis are so mild or intermittent that the condition doesn’t become a problem until later in life. For example, I recently diagnosed a man in his 70s who had spondylitis, but his back pain had become severe only recently.

Spondylitis also can go undiagnosed because most patients — as well as many health-care professionals — are unfamiliar with the condition. Few people know that back pain (often accompanied by fatigue and morning back stiffness that gets better with activity) can be due to spondylitis, but estimates show that the condition affects at least one in every 500 adults, making it nearly as common as rheumatoid arthritis.

What you need to know…

MORE THAN JUST BACK PAIN

The chronic inflammation caused by spondylitis can lead to other potentially serious complications. For example, up to 40% of people with spondylitis suffer from inflammation of the eye (iritis), which can result in pain and sensitivity to light. The condition is treated with corticosteroid eyedrops to ease the inflammation.

In addition, some people with spondylitis develop inflammation just below the aortic valve (the aorta transports blood from the heart to the rest of the body). This chronic inflammation can interfere with the heart’s rhythm and/or cause the aortic valve to become leaky (aortic ­insufficiency), a condition that may require surgical valve replacement.

Recent research: Patients with spondylitis have more aortic stiffness (due to inflammation) than those without the back condition, according to a recent study. Stiffness in an artery raises the risk for high blood pressure and blood vessel damage.

In other spondylitis cases, the cartilage around the ribs may become inflamed, causing a painful condition known as costochondritis. The ribs may eventually fuse to the spine, which limits the chest’s ability to expand and may aggravate an existing lung disease, such as asthma or bronchitis, and raise the risk for spinal fracture.

GETTING THE RIGHT DIAGNOSIS

Spondylitis is difficult to diagnose — primarily because it progresses so slowly. It often takes up to 10 years from the time a patient first feels the twinges of back pain before the inflammation shows up on an X-ray.

Ask your doctor about: Getting a magnetic resonance imaging (MRI) scan if spondylitis is suspected. A telltale sign of spondylitis is inflammation of the sacroiliac joints, located in the low back. But X-rays do not always detect this inflammation in the early stages of the condition.

Spondylitis is primarily caused by hereditary factors, especially a genetic marker known as HLA-B27, which is present in more than 90% of people who have spondylitis. However, only about one in 20 people with HLA-B27 develop spondylitis or a related disease.

Certain gastrointestinal conditions, such as Crohn’s disease and ulcerative colitis, also have been associated with spondylitis.

Although no cure is yet available, recent advances in treatment have been successful in reducing the pain and inflammation associated with the disease.

BEST MEDICATION OPTIONS

Many people with spondylitis are able to control the pain with over-the-counter nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil) or naproxen (Aleve). Others may require the use of a prescription drug known as a TNF-alpha inhibitor, such as infliximab (Remicade), etanercept (Enbrel) or adalimumab (Humira).

Caution: The FDA recently issued a warning about increased risk for fungal infection in people who take these TNF-alpha inhibitors.

These medications, which often are used for rheumatoid arthritis, can eliminate the inflammation of spondylitis but won’t prevent the spinal fusion associated with ankylosis.

Latest treatment advances: The FDA recently approved the use of golimumab (Simponi), another TNF-alpha inhibitor, for the treatment of spondylitis. Studies show that the drug works at least as well as other TNF-alpha inhibitors, and it is taken less often than those other drugs. Certolizumab (Cimzia), another drug in the same class, was recently approved for treatment of rheumatoid arthritis and is expected to be studied as a treatment for spondylitis.

GET SERIOUS ABOUT EXERCISE

Daily exercise — even if it’s only five to 10 minutes of gentle stretching — is crucial in the treatment of spondylitis. Many studies have shown that spondylitis patients who exercise regularly experience less pain and better functioning than patients who do not get regular exercise.

Best types of exercise include…

Conditioning. Aerobic workouts, such as swimming, are especially effective at decreasing pain and stiffness.

Helpful: If you have trouble turning your head to breathe while swimming, try a snorkel and mask.

Spinal extension. These exercises loosen up the spine and prevent stiffness.

One to try: While on all fours, arch your back like a cat and hold until you feel a good stretch. Then let your back sway or sag downward toward the floor, while lifting up your head and buttocks. Repeat three to five times daily.

Range-of-motion for the neck. Moving the neck can help guard against the stiffness caused by spondylitis.

What to do: Pull in your chin and shift your gaze to your chest. Return to the starting position, then tip your head backward as far as you comfortably can. Repeat three to five times daily.