Common back pain may be the symptom of a more serious problem. Aznim Ruhana Md Yusup finds out more
JUST as Jean (not her real name) was starting university, she began experiencing inexplicable pain in her lower back.
“I couldn’t even get up from bed in the morning,” she recalls. “I had to slowly turn to one side and use my hand to push myself up.”
She thought it was a bone-related problem, so she went to see an orthopaedic specialist. Jean underwent numerous tests — X-rays, MRI scans and even a biopsy. It was determined later that her pain had nothing to do with her bones but rather the joints in her spine.
Referred to a rheumatologist, she was diagnosed with ankylosing spondylitis, a form of spinal arthritis. As per standard treatment, she was prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) i.e. painkillers but it wasn’t very effective.
“I’m currently on biologics and I self-inject every two weeks. It really helps reduce inflammation; otherwise the pain is a nightmare. Right now it is under control so it doesn’t really affect my life,” she says.
“I still feel exhausted sometimes, so I will just lie in bed. My parents think I’m just being lazy. But that’s because they don’t understand how tiring it can get. At work, I feel stiffness around my neck and shoulder so I do some stretching when I need to.”
SPINE ISSUE
“Ankylosing spondylitis involves primarily the spine. But more than that, it affects the joints in the spine,” explains associate professor Dr Sargunan Sockalingam, a rheumatologist at University Malaya Specialist Centre.
The first joints to become affected are in the lower spine. Without medical intervention, the whole spine can become fused, leading to what is known as a bamboo spine because of how it looks in an X-ray.
“The spine is remarkably flexible, but with ankylosing spondylitis, it loses its flexibility and becomes like a pipe. The worst case scenario is zero movement of the spine, so bending and turning the head will be a problem,” he explains.
“To compensate, the body begins to stoop so patients will have difficulty looking up. These conditions actually qualify them as a disabled person.”
According to statistics, there are around 300,000 people with ankylosing spondylitis in the country. But only 50,000-60,000 have been diagnosed and treated, says Dr Sargunan.
The rest are very much in pain. He adds: “We can take care of the pain with painkillers. It’s a bad sign when there is no more pain because it means the joint is totally damaged.”
MISSED SIGNS
The problem with misdiagnosing ankylosing spondylitis is that the presenting symptom is both common and easy to treat. Back pain is an everyday complaint and it’s usually dealt with using painkillers and advice to take it easy.
But this approach is only effective if it’s mechanical back pain, says Dr Sargunan. Mechanical back pain has a trigger, meaning it is caused by an activity and will get worse if the activity continues.
Ankylosing spondylitis is due to inflammatory back pain, which doesn’t necessarily have a trigger. “It’s when a person is not doing anything, such as sleeping or sitting down and they try to get up, that’s when they experience pain,” he says.
“After some time, as they move around, the pain is lessened. That’s the feature of inflammatory back pain.”
The disease affects young people, who first experience symptoms in their teens. Unlike other arthritis diseases, men are more likely to be affected than women, though this is no consolation for female sufferers like Jean.
Patients will be dependent on painkillers for the rest of their lives, which isn’t ideal, but it does help keep the pain and inflammation at bay. The other aspect of treatment is physiotherapy, such as core strengthening exercises and swimming.
“The disease is progressive and there’s no cure,” says Dr Sargunan. “But we can try to delay or reduce the speed at which it progresses so to a certain extent NSAIDs do work.”
NEW TREATMENT
In recent years, patients have a new drug option called biologics. According to medical website WebMd, biologics are genetically-engineered proteins derived from human genes that are designed to inhibit specific components of the immune system which play pivotal roles in fuelling inflammation.
“It’s very exciting for us because we’ve moved from just having NSAIDs to the biologic drugs called anti-TNF, and now we have another agent which is Interleukin 17a,” says Dr Sargunan.
“A wider range of options means that if patients are diagnosed early, we can slow down the process of the disease and they can get back to normal.”
However, biologics are very costly, between RM30,000 and RM50,000 a year. Guidelines state that patients are put on NSAIDs first to see if they work, before they advance to biologics.
Since ankylosing spondylitis affects younger people, it’s vital that patients are diagnosed and treated in a timely manner so they can continue to be productive. It’s not just a matter of economics, but also necessary to their sense of self.
“The disease affects their work, but what’s important is that people around them understand that they need to work to be complete. Sympathy works to a certain extent but what’s important is understanding their limitations,” says Dr Sargunan.
“They may be limited in one thing but very good in another. That’s the support we expect from society.