Focus on an overlooked cause of back pain

September 2013

It’s estimated that 20% of the UK adult population suffer from chronic back pain and between 60 and 80% of the UK population report back pain at some point in their life. Approximately 6-9% of UK adults consult their GP about low back pain each year.  Despite a very generic label “back pain”, in the hands of the appropriate healthcare professional a specific name, cause and course of treatment may be available to help manage your condition. 

As many back pain sufferers will know, the pain and loss of function can be debilitating and gruelling.  Unlike a limb, it’s almost impossible to isolate your back from day-to-day movement and activities - a simple cough or sneeze can take you by surprise and have you leaping in pain.  Other activities that support a general feeling of ‘wellbeing’ like recreational interests, social interaction, active parenthood and being able to work and earn can also be affected – this may create additional psychological problems.

 Consultant Rheumatologist Dr Karl Gaffney treats patients with a range of back problems and has a special interest in a condition known as Ankylosing Spondylitis (AS) or axial Spondyloarthropathy (SpA). If you or someone you know is suffering from chronic back pain… please read on.

What is Ankylosing Spondylitis (AS)? - “AS is an inflammatory condition of the spine which causes pain, stiffness, disability and deformity”. It is estimated that 200,000 people suffer from AS in the UK, a figure that is around twice the number of people with multiple sclerosis, however the vast majority of the general public knows very little about it and many patients don’t even know that they have the condition.

Ankylosing means fusing together and spondylitis means inflammation of the spine. Most patients will have the inflammation but not necessarily progress to develop ankylosis. It usually begins in adolescence or early adulthood, a critical period in terms of education, work and the establishment of social frameworks and relationships – hence it’s something to be aware of in early life to help avoid later-life problems.

“AS is characterised by back pain of fluctuating severity, which can lead to increasing spinal damage  and deformity”.  Minimizing the effects of disease progression and complications requires early recognition, careful long term monitoring and prompt appropriate treatment. Fifty per cent of patients also experience inflammation and damage to other parts of the body including the eyes (iritis), bowels (colitis), skin (psoriasis) and hips.

So, what should I look out for? - “Most patients with AS present with back or buttock pain – usually lower or mid-back, and sometimes resembling sciatica. The symptoms and signs of AS may be difficult to distinguish from other more common types of back pain. The key features to look out for are: 

  • Gradual onset of back pain and stiffness - often being most severe at night, first thing in the morning and following periods of rest/immobility
  • Disturbed sleep due to pain causing sufferers to get out of bed in the night to move around so as to improve their back pain and stiffness
  • Pain which improves with activity and worsens at rest

“Apart from the above related symptoms, other disorders commonly associated with AS include:

  • Iritis - inflammation of the eye
  • Psoriasis - a common skin disease characterised by thickened patches of inflamed, red scaly skin
  • Inflammatory bowel disease

“Symptoms of AS usually begin between the ages 20 to 40 years and can often go undiagnosed for a long time.  A recent study undertaken by Dr Gaffney identified there is an average delay of 8.5 years between the onset of symptoms and diagnosis of AS in the UK.  This delay in diagnosis and treatment can have a significant impact on the long-term outcome.

“Since many people with AS are neither deformed nor have obvious joint abnormalities, especially in the early course of the disease, much of the burden of living with AS is invisible.  The spectrum of severity means that although many people with AS live active and rewarding lives, others experience progressive spinal pain and immobility.  The effects on lifestyle and interpersonal relationships are only now being recognised.  Work disability is a major problem with more than 50% of affected individuals suffering work instability.  In addition, one-third of people with AS give up work before normal retirement age and another 15% reduce or change their work because of AS. 

Does making an early diagnosis make any difference? “Until recently, the benefits of making a diagnosis have been perceived as being modest at best. Early diagnosis, allows early access to expert treatment, specialised physiotherapy (including hydrotherapy, and open-access for flare-ups) and consideration of biological therapies which have revolutionised the treatment for severe disease.

What’s likely to happen if my GP thinks I have AS? – “Initially, you should be referred to a Rheumatologist to confirm the diagnosis.  Acquiring a diagnosis usually requires an MRI scan and blood tests. X-rays are usually unhelpful as they are usually normal within the first 5 years following symptom onset. Your consultant will liaise with other professionals within the team as necessary – radiologists to report/evaluate the scans, a specialist physiotherapist and trained nurses, ophthalmologists (iritis), dermatologists (psoriasis), gastroenterologists (inflammatory bowel disease).

“Depending on when the diagnosis is made and how severe your condition is, much of your treatment may be conservative.  Anti-inflammatory drugs may be prescribed and simple lifestyle changes advised along with a tailored exercise regime agreed between you, your consultant and a physiotherapist. This is all that many patients need to stay well.  Biological treatment (anti-TNF) may be prescribed for severe cases.  TNF promotes inflammation and therefore anti-TNF treatments work in reverse and attempt to redress the balance by reducing inflammation which in turn reduces the pain and improves function.  Surgery may be needed for patients with severe hip arthritis or spinal deformity. Approximately 12-15% will need a hip replacement during the course of their disease and 1-2% spinal corrective surgery.

Dr Karl Gaffney, Consultant Rheumatologist is medical adviser and trustee to the National Ankylosing Spondylitis Society (NASS) and Chair of the British Society for Rheumatology Guidelines group for biologics in AS. For further information, please visit or

The content of this page is provided for general information only.  It should not be treated as a substitute for the professional medical advice of your doctor or other healthcare professionals.

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