Ankylosing spondylitis

[Melissa Tiessen]

Hi everyone,

Thanks for the opportunity to share this case for feedback. It’s a woman in her early 60’s, retired, married, two adult children. The client is on board with the role of anxiety in her symptoms, however still questions whether there is something structural going on. It seems to me that she has plenty of evidence for neuroplastic processes. But as a psychologist I don’t know enough about structural diagnoses to be as confident as she needs! So our main questions are:

(1) Role of ankylosing spondylitis?
Diagnosis of ankylosing spondylitis has been suggested to client, although been told unusual for such a late onset thus diagnosis not confirmed. Does have pattern of stiffness at night and early morning that improves over the day. (However lots of other indicators for neuroplastic pain – see below.)

(2) Role of increased risk for multiple myeloma?
A bit of an aside – but client has also been told she is at increased risk for multiple myeloma, given elevated blood marker. However still waiting to see a specialist, and not actually diagnosed with cancer.

Current symptoms (as described by client):

Stiffness and pain in lower back (sacrum), buttocks, upper legs. More pain in left SI joint. The sacrum pain came on rather suddenly in June 2022 after a day of lifting food, water, tables, etc. at a memorial service, followed by a long bike ride the following day when I was very uncomfortable. I am a very active person – the stiffness and pain is very uncomfortable especially in the morning but I keep moving which makes it better.

• Mostly achy pain .. feels like it’s in the muscles, not the joints except for more stabbing pain in left SI joint at times.
• I’ve previously had lower back spasms 4-5 times in my life – acute, can’t move properly for a few days. Takes 1-2 weeks to be moving properly again. Diagnoses at the time was SI joint dysfunction and disk problems.
• I’ve had stiffness in my back and legs and pain in buttocks for quite a few years but last June (2022) it got worse and was more in the sacrum area (as well as the SI joints) especially the left side.

What makes the pain better:
• after moving, stretching exercises.
• later in the day.
• once I get going I can walk all day (e.g. did 9 days of day-hiking in Rockies in July)
• road biking is ok for a few hours but I’m stiff and find it hard to stand up straight when I get off the bike.
• In winter I cross country ski – it’s usually ok but after a couple of hours I’m sore from bending forward.

What makes the pain worse:
• in night/early morning, sometimes it wakes me up and I have to stretch (child’s pose) to get comfortable.
• Very stiff and sore when I get out of bed. Sometimes I get a sharp feeling like an electric shock in the back, but I just have to be careful for a little while, ease into movement and then it’s ok.
• I try to just ignore it and get moving.
• can’t really lie on my stomach – back extension is very uncomfortable at any time of day
• after sitting for a while – usually very stiff to get up and stand up straight. Eg. working at a desk, car ride, sitting on a couch
• after bending for a while – eg. 2 hours in the garden is max, very uncomfortable
• standing with weight on one foot (e.g. putting socks on) causes more pain in left SI joint

History also of MGUS, cold urticaria, piriformis syndrome, chronic tendonitis in elbow for 2 years, frozen shoulder for 2 years, Barrett’s esophagus, insomnia and longstanding anxiety.

Some significant challenging health issues as a child (petit mal epilepsy) and younger brother’s congenital heart defects.

As an adult, significant stressors have included loss of parents, estrangement from brother, need to advocate for son’s learning disability, and son’s serious biking accident 2 years ago.

Multiple relevant personality traits – conscientious, hard on self, overly responsible, frequent worry, wanting to be good/liked, difficulty letting go, difficulty making decisions, cautious/shy, low self-esteem, and hypervigilance.

Assessments/treatments:
• Aug – Sep 2022 – osteopathic doctor said I had chronic spasticity in leg muscles & sacrum was out of alignment.
• Xray Sep 2022 (see below) – arthritis in spine and SI joints.
• Since Dec 2022 doing dynamic stretching exercises every morning until spring 2023 (since then not every day because I have been travelling a lot). The exercises really help me get moving. But it doesn’t change the stiffness/pain every morning and after sitting/bending.
• Saw a chiropractor in winter/spring 2023 – he did manual therapy on the muscles but did not improve anything. He did wonder about ankylosing spondylitis but didn’t think that was it.
• Physio therapist – spring 2023 – said pelvis was twisted. Gave exercises but didn’t notice any improvement.
• Massage treatments – no improvement, feels ok at the time except I’m not able to lie very long on my stomach so it’s not that comfortable.
• I have had blood and urine tests since developing cold urticaria in April 2022. There is a blood plasma irregularity that I don’t really understand .. they say I have a slightly elevated risk of developing multiple myeloma but I have not yet been able to have an appointment with a hematologist to explain it to me. (Rest of blood testing has been normal.)

Xrays in September 2022:

Lumbosacral spine and sacrum
• Diffuse multi-level anterior osteophytosis with slight reduction of the L2-L3, L3-L4, L4-L5 spaces attesting to spondylarthrosis.
• Preservation of the height of vertebral bodies and intervertebral spaces.
• No other specific lumbar bone damage.
• The study of the sacrum and coccyx is considered normal.

Pelvis and sacroiliac joints
• Sclerosis especially of the iliac side of the two joints.
• Joint space is preserved and joint surfaces remain relatively clean and regular.
• All suggesting mostly degenerative changes.
• No other bone or joint anomaly.

Any input is greatly appreciated! Thanks, Melissa

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