Podcast: Arthritis & Back Pain-Part 1: What's Causing your Back Pain?

Four out of five people will experience lower back pain at some point in their lives — and much of it can be arthritis-related. In part one of this two-part episode a rheumatologist shares insights into common causes of arthritis-related back pain. Scroll down for show notes and full transcript.

This episode was brought to you in part by AbbVie, Bristol Myers Squibb and Janssen.

Millions of people suffer with chronic back pain. In fact, four out of five people will experience lower back pain at some point in their lives — and many of the causes can be arthritis-related. The physical, social and mental impacts can be devastating — leading to increased depression and anxiety.

In this episode our guest host, Cristina Schaefer, who was diagnosed with rheumatoid arthritis 18 years ago welcomes our guest expert, rheumatologist Vivian Bykerk, BSc, MD, FRCPC. Dr. Bykerk shares insights into common causes of arthritis-related back pain. 

Cristina Schaefer (Houston, TX)
Read More About Cristina

Vivian Bykerk, BSc, MD, FRCPC (New York City, NY)
Read More About Dr. Bykerk

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Full Transcript:
Released 9/26/2023

PODCAST OPEN:            
You’re listening to the Live Yes! With Arthritis podcast, created by the Arthritis Foundation to help people with arthritis — and the people who love them — live their best lives. If you’re dealing with chronic pain, this podcast is for you. You may have arthritis, but it doesn’t have you. Here, learn how you can take control of arthritis with tips and ideas from our hosts and guest experts. 


Cristina Schaefer:
Welcome to the Live Yes! With Arthritis podcast. Today, I'm your host, Cristina Schaefer. You may have heard me on the episode about tackling arthritis challenges for patients of color. I was diagnosed with rheumatoid arthritis 18 years ago and have been a longtime volunteer with the Arthritis Foundation, in both local roles in the Houston area and nationally. 

Today, we'll be talking about back pain and arthritis. Millions of people experience chronic back pain. In fact, four out of five people will experience lower back pain at some point in their lives, and many of the causes can be arthritis-related. In addition to the physical toll it takes, chronic back pain can cause social, mental and sometimes financial impacts that can be devastating. 
In this two-part episode of the Live Yes! With Arthritis podcast, we'll explore insights into common causes of arthritis-related back pain. And to help us do just that, we welcome our guest expert, Dr. Vivian Bykerk. Dr. Bykerk is a rheumatologist at the Hospital for Special Surgery in New York. Welcome to the podcast, Dr. Bykerk. 

Dr. Vivian Bykerk: 
Thank you. I’m happy to be here. 

Cristina Schaefer:
We are very happy to have you. Dr. Bykerk, can you tell us a little bit about yourself and your expertise? 

Dr. Vivian Bykerk: 
Well, I'm a clinical rheumatologist and a clinical investigator. I do a lot of research in inflammatory arthritis. And so, that involves both inflammation directly involving the spine, but more often, inflammation or pain in the back as a result of having a form of inflammatory arthritis. 

Cristina Schaefer:
What are the most common types of arthritis that can cause back pain? And how are they different? And also, what symptoms do they involve besides back pain? 

Dr. Vivian Bykerk: 
Back pain is incredibly complex. I'm going to try and simplify it. If we spoke of inflammation in the spine, the most common, really only, cause is something that we call spondyloarthropathy, or spondyloarthritis, or SpA for short. And what that really means is an inflammation involving elements in the spine, anywhere from the neck to the base of the spine to the joints where the pelvis knits together, called the sacroiliac joints. And that is not an immune-mediated form of arthritis. It can be seen on its own. And it can be seen in the context of having psoriatic arthritis and some other forms of arthritis.  

Children can get it. It's typically starting in the in the 30s or 40s, but anywhere from 20s to 50s is not uncommon. And it's treatable. The other forms of arthritis, the majority will be what we call osteoarthritis. Many call it degenerative arthritis. It's not so much immune-mediated. Really, the cause is a secondary inflammation. Because the joints, or components of the spine, are wearing out. 

Cristina Schaefer:
So, what do all of these have in common, these different types of arthritis? 

Dr. Vivian Bykerk: 
Any form of arthritis in the spine, obviously, will cause stiffness. It'll limit function. It will cause pain. But depending on the type of arthritis, one may experience pain at different times of day. One may experience improvement with activity, such as in SpA, or may be worsening with certain activities in terms of degenerative arthritis. 

And then keep in mind, if I had to say… Look at all back pain, arthritis probably accounts for maybe 20%, 30%. The rest of it is mechanical. It's how forces in our muscles and the angles that our spine sits in pulls off the actual normal angle of the spine, and then puts it out, so to speak. And you end up with pain, which may or may not last any long period of time. 

Cristina Schaefer:
Are there any other causes of back pain related to arthritis? 

Dr. Vivian Bykerk: 
So, disc disease is sort of a common reason for back pain. And disc disease, as you know, between each vertebra — each block, bony block in our spine — there’s a disc in between them. And they push into the spine and hold it in place. And when the disc wears out, or just degenerates, it becomes narrower, and so that can result in pain in different elements of the spine. 

That's a very common problem, particularly with aging, and for some, it's probably genetic. The disc wear-and-tear, when the actual inside of the disc extrudes out and pushes on the nerve, or the spinal canal, you can get nerve pain associated with it. And that's very painful. 

Cristina Schaefer:
Are there any other causes that you want to mention? 

Dr. Vivian Bykerk: 
I mean, there's rare conditions. There's something called DISH. It can be confused with forms of SpA, such as ankylosing spondylitis, which everyone hasn't heard of. But if you do a little Google search, you'll find it fast enough. Because DISH is really Forestier's disease. Or Diffused Idiopathic Skeletal Hyperostosis is what it stands for. And basically, it's a condition where there's a lot of calcification, and some inflammation of the ligaments around the discs, and even beyond. But not close to, not exactly, in the spine. And that's often confused for ankylosing spondylitis. But that condition occurs at older age typically. 

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Cristina Schaefer:
Because the back can affect so many parts of the body, head to toe really. What are some of the predominant symptoms that you should look for that could be arthritis in the back? 

Dr. Vivian Bykerk: 
I think if you're a patient and you're wanting to know, "Is my arthritis potentially in the back?" Pain and stiffness would be two common ones, and they would pretty much be close to the back. If it's in the sacroiliac joints, it will be felt under the buttock. If it's in the lower spine, it may be felt directly in the lower spine. Or it may be what we call referred off to the outer buttocks. 

The mid-spine, which can be affected in ankylosing spondylosis, more often in women than men, that may be a first place for it. If it's inflammatory, the pain will be kind of in the middle of your back and may even travel a bit around the back to the sides of the ribs. 

And this concept of referred pain really refers to our brain's inability to perfectly identify where the pain's coming from. Neck pain, for instance, can be felt over the tops of the shoulders, or the high-upper chest, or even up into the head. And it's still due to an arthritic condition in the neck, cervical spine. 

Cristina Schaefer:
Is a tingling sensation a symptom? 

Dr. Vivian Bykerk: 
Tingling is a nerve symptom. It implies there's a compression of a nerve or intermittent compression of a nerve. We can see that in disc disease. But sometimes we see it because there's so much spasm due to pain in the muscles around the affected area — that the nerves going through the muscles might actually be compressed. And this is a common phenomenon that happens in the neck. So, you think it's coming from the neck, but it might actually be transient due to muscle spasms. So, we can see tingling that comes and goes in those scenarios. 

So, if there's a burning pain or a numbness that goes below the elbows or below the knees, that can be related to the neck and lower spine respectively. Because there is a significant compression on where the nerves are coming out of the spine. 

Cristina Schaefer:
For people living with chronic pain, I can imagine that some of this pain and stiffness can be very easy to maybe almost overlook or write off as just, "I'm in pain every day, and this is just how I live." How is arthritis in the back typically diagnosed? 

Dr. Vivian Bykerk: 
First of all, to address the, "This is pain and stiffness, and it's my life," I wouldn't take that attitude. I think there's always something that can be done. How do we decide, whether it's arthritis or a consequence, let's say related to arthritis, say more mechanical? 

First of all, we'll often perform a physical examination. We'll take a history. We'll ask about tingling. We'll ask about referred pain. We'll ask about anything that could cause a problem in the spine. It's really rare, but cancer could. It's usually in someone who might have had cancer already. We call those the red flags. Rarely, it's an infection. So, we're always looking for extremely rare but serious problems. We have to make sure that isn't there. 

Then we start to figure out, "OK, what kind of arthritis might be causing this? Or is this mechanics due to another problem?" And it certainly can be a mixed picture. The inflammatory arthritis that we typically see with ankylosing spondylitis, or SpA, conditions, sometimes psoriatic arthritis, that's sort of characteristically: an aching pain. 

It's worse in the morning. It can wake people up at 3:00 or 4:00 in the morning, and they need to go put heat on it. Or have a hot shower to relieve it. And there is stiffness, prolonged stiffness, over 45 minutes to an hour, in the spine.  

Now, contrast that to the degenerative types of arthritis. That still can cause pain. It can still wake you up when you roll over at night. It can still be kind of stiff in the morning. But the stiffness lasts less long, typically 15, 20 minutes. You stretch it out. But then you sit again. Or you take a nap. And that stiffness is right back. It's hard to tell them apart. But you use the other cues, like age. Is there a family history? Does the person have psoriasis? What else is going on? It's sort of a big picture kind of diagnosis. 

We also image. So, we can do an MRI of the spine and of the sacroiliac joints or any part of the spine. And we will see certain characteristic features if it's a variation of SpA, where the ligaments that insert into various aspects of the spine or around the SI joints look inflamed; and the bone near that looks inflamed. We might see erosions in the sacroiliac joints. 

That's very different from wear and tear arthritis, degenerative arthritis, where we would see maybe extrusion of the inside of a disc pushing on something. Or we'll see the discs being narrowed. Or we'll see, what we call the posterior elements of the spine — in other words, the back part of the spine — where there are little joints that keep holding your spine together. They may be worn out. They could even be inflamed. Treatment can involve injecting those. 

It's sort of complicated, but those are what we'll look for. We will image and look. And obviously, if there are nerve symptoms, we will be looking at whether or not there are elements of the spine, or buildup of bone spurs, that are pushing on nerves or pushing on the spinal cord itself. 

Cristina Schaefer:
How does arthritis-related back pain affect daily life? 

Dr. Vivian Bykerk: 
You know, pain, any pain, any chronic pain, if severe enough, will be working on your brain in the background, while you're asleep and during the day. So, it will tire you out. It will give you difficulty in focusing and completing tasks. You will be less inclined to move, which of course is the last thing that should happen. You should be getting up and moving, walking, but you don't want to, because it hurts. 

So, really the biggest impacts are fatigue, stiffness, difficulty with function and difficulty with doing one's, what we call, social participation. Doing one's job, caring for family, participating in social events, hanging out with friends. People pull away from all those things. Their lives get smaller when that pain is bad. Then you can end up with less movement, weight gain. There's an inclination to eat less nourishing foods, and then it becomes this sort of general health issue. 

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Cristina Schaefer:
We like to look at social media and post questions on social media on the Arthritis Foundation accounts. We'll pose questions to the audience related to the topic at hand. And we posted, "How does back pain affect your daily life?" Dr. Bykerk, I just wanted to share some of these responses with you and see your thoughts on them. 

Hurricane Liz Chronicles said, "Having ankylosing spondylitis means being in pain all day, every day. My back pain stops me from being with my family and friends. It means I miss out on a lot of stuff." 

Dr. Vivian Bykerk: 
Yeah, that totally makes sense. As I said, there's five, we call them health domains, that are impacted. And she's describing both function and social participation, not to mention what it means to be in chronic pain. 

Cristina Schaefer:
Lexi 1927 said, "I always have back pain, every day. I don't remember when I didn't have back pain." 

Dr. Vivian Bykerk: 
Again, and I think that brings up an important point: People kind of get used to it. If you give someone a chronic painful condition, after a year, they will describe the pain as slightly less than they might have at the very beginning, because they have adapted to it. Depending on how bad it is, they're able to tolerate it slightly better. They've also made adaptions in their lives, so that it doesn't get worse. 

Nonetheless, you know, I think anybody who has that kind of pain warrants being seen by a specialist and trying some of the new therapies out there now. They're very effective. And they should reduce pain substantially in conditions like ankylosing spondylitis or psoriatic arthritis-related spondylitis. 

Cristina Schaefer:
And one more comment that we had on social media, from KK Everyday 82. They said, "Waking up a lot at night" affects them not sleeping well, "which affects my day, and I have long-term health issues." 

Dr. Vivian Bykerk: 
And we certainly touched on that in our questions. The long-term health issues, as I said: You have pain. You don't want to move. You don't sleep well. Your energy is low. You don't go out for walks. You don't go out. 

The pain affects general health by virtue of how it limits life. And it's usually weight gain that's a problem. And then, of course, you can end up with a lot of metabolic problems: heart disease, high cholesterol, hypertension or high blood pressure, central obesity, where you gain weight, we'll call it lower tummy fat, which is an inflammatory kind of fat. So, you know, trying to target pain is incredibly important. 

Walking is proven to be one of the best exercises for back pain, no matter the cause. Exercise pretty much helps all of these forms of back pain. Even if it's in water, even if it's very gentle, even if it's yoga. There is an exercise out there people can do, almost always. I won't say always, but almost always, and that's an important way to tackle, living in pain. 

And just because you're too tired and too sore to do it doesn't mean you shouldn't try. I always say, "Just try. Go for two minutes, five minutes. See what you can do." Inevitably, people can do 15. When weight becomes an issue, I say, "If you can put in 30 minutes of walking a day, and I don't care if it's 10 minutes three times a day, if you can put that in, you can keep off 15 pounds." And so, you can imagine how to expand that thinking if you're trying to improve your general health. 

Cristina Schaefer:
Very good. What are the top three takeaways that you'd like people to take from this episode? 

Dr. Vivian Bykerk: 
Obviously, inflammatory arthritis is important to diagnose because it's treated differently. But most back pain is not inflammatory arthritis. It's related to degenerative issues, but more likely to weakness and mechanical issues. So, you need a team to help you diagnose it and look after it. And you need to use your best self-discipline to get moving. 
Cristina Schaefer:
Well, thank you, Dr. Bykerk, for your time today. 

Dr. Vivian Bykerk: 
You're welcome. Thank you for having me. 

Our special two-part series about arthritis and back pain is brought to you in part by AbbVie, Bristol Myers Squibb and Janssen. Tune in for part two to hear about strategies and treatments to take control of arthritis-related back pain. This podcast is also made possible in part because of the generosity of our donors. Thank you for pitching in. 

The Live Yes! With Arthritis podcast is independently produced by the Arthritis Foundation. This podcast aims to help people living with arthritis and chronic pain live their best life. People like you. For a transcript and show notes, go to Subscribe and rate us wherever you get your podcasts. And stay in touch! 

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