Episode 29: Why Back Pain is Not Just Wear and Tear

Most of the time long-standing pain is due to wear and tear or, in medical terminology, degenerative changes or degenerative disc disease.

Join me for a fascinating interview with Dr. Poddubnyy, where we discuss more rare causes of back pain that doctors often overlook. 

If you have any questions for Dr. Karmy, feel free to email us at karmychronicpain@gmail.com

Follow our social media:
Instagram
https://www.instagram.com/karmychronicpain?igsh=cHZycXdzeGhqN2Zn
Facebook
https://www.facebook.com/profile.php?id=61550237320641&mibextid=dGKdO6

Learn more about pain management treatments offered at our clinic: https://karmyclinic.com/

Transcript

0:00

the main symptom of spondyloarthritis being back pain is a problem that results into large diagnostic delay. The mean diagnostic delay in western countries, including Canada and Western Europe, is nowadays about five years. Meaning that people living with inflammatory and very well treatable condition. They run from doctor to physiotherapies, to chiropractor to whoever. Without getting appropriate help. We were working on this problem very intensively, in the past 20 years. The main thing here is how to recognize a person with a high probability of inflammatory disease involving spine among all the patients with chronic back pain. And we tested many strategies, screening and referral strategies, what came out. And my bottom line of, all these efforts is it should be relatively simple. Hello, this is Dr. Karmy for Chronic Pain Chronicles, and today with us we have Dr. Dennis Poddubnyy. He is a rheumatologist at University of Toronto with, uh, long experience in both, clinical practice and research, and he's got any specific interest in the field because there's many rheumatological disorders is Seronegative, Spondyloarthropathies. Hello, Dr.  Poddubnyy. Hello, and thank you for having me today. So just in a way of introduction, how did you choose and rheumatology as your field of endeavor? It's not as sexy as neurosurgery. It's not as lifestyle friendly as dermatology. So why rheumatology? Oh rheumatology is probably the most exciting field of internal medicine. And I decided to go to internal medicine relatively earlier already in the medical school. It is it is an intellectual challenge and specifically rheumatology is one of the rare disciplines where you need to be really an internal medicine specialist because we're dealing with conditions involving immune system and immune system is everywhere and immune system can affect any organ in the human body. And the conditions where we're working with they may affect people from. Very young adult adults to elderly people. So it is huge spectrum in terms of manifestations and in terms of age structure. Okay. So it's a intellectual challenge. Absolutely. Okay, so let's maybe meander a little bit into the specific topic today. And I think there's a spec, a reason actually why I felt it was very interesting. And the topic is spondyloarthropathies. One of the reasons, uh, I find this particular disorder interesting is that ma majority of inflammatory joint disorders primarily involve joints like knees, ankles, hands, wrists, et cetera. Which is, fairly distinctive pattern. But the thing about seronegative spondyloarthropathies is that they involve the spine as their primary target. And unlike other areas. The vast majority of back pain is caused by degenerative problems degenerative disc disease, osteoarthritis of facet joints. And so I always suspect that there's a lot of patients with, uh, ankylosing spondylitis and other arthropathies that get missed. Because in clinical practice, if 99% of back pain is degenerative, then it's almost anytime you see a patient, you assume it's just degenerative problem. And you treat it as such, which I suspect means that you're going to miss a lot of patients with ankylosing spondylitis. Any thoughts on that? Is there a way that somebody can get a sense that maybe this is not your garden variety degenerative disc disease, that there's an inflammatory condition going on? Yes. Very good. I'm very glad you touch upon this topic. So this is a problem which persists already for many years, and the main symptom of spondyloarthritis being back pain is a problem that results into large diagnostic delay. The mean diagnostic delay in western countries, including Canada and Western Europe, is nowadays about five years. Meaning that people living with inflammatory and very well treatable condition. They run from doctor to physiotherapies, to chiropractor to whoever. Without getting appropriate help. We were working on this problem very intensively, in the past 20 years. The main thing here is how to recognize a person with a high probability of inflammatory disease involving spine among all the patients with chronic back pain. And we tested many strategies, screening and referral strategies, what came out. And my bottom line of, all these efforts is it should be relatively simple. So primary care provider person dealing with chronic back pain should recognize relatively easily who belongs to a rheumatologist at least once. And this is relatively easy. This is a situation where chronic back pain started at younger age between 20 and 40, and where back pain has some inflammatory characteristics, meaning this is back pain that worsens with rest, improves with exercise happens at night, especially in the second half of the night, and is accompanied by prolong morning stiffness upon waking up so that this is a relatively simple. The strategy that may bring you to an idea, this may be an inflammation behind these symptoms and this person should go at least once to, to rheumatologist for an appropriate evaluation. It is still no, no guarantee that this person will have an inflammatory condition. Even typical inflammatory back pain can be caused by mechanical problems such as degenerative disc disease with modic lesions on MRI. But this simple strategy, chronic inflammatory back pain in young adults would help you to increase the probability of exo spondyloarthritis. From one to 5% across all cases with chronic back pain to 30 to 40%, meaning the rheumatologist would need to see about two to three patients with back pain to to make a diagnosis of spondyloarthritis in one case. So obviously starts out with just suspecting it. If you don't think it, you'll never diagnose it. And then, potentially there could be some screening tests or maybe more specific diagnostic tests that could be done. There's a whole range of them. Everything from blood work like HLAB 27 to x-rays of sacro IC joints to MRI scans a any thoughts on what the best approach is? So this is a part that is normally done in the rheumatology practice. The issue still is that we do not have allusive tests. So HLA B 27 you mentioned is a genetic marker, which is positive in 80 to 90% of cases with Axial spondyloarthritis, but it is also positive in about 9% in the general population. And if you go up north you will see even higher. Background prevalence of this genetic marker inflammatory markers in the blood. They're positive in about 40 to 50% of the cases, and we often rely a lot on the imaging. It many years, it used to be X-rays, but x-rays, they demonstrate already advanced structural changes nowadays, the golden standard of visualization of inflammation in the sacroiliac joints in the spine is MRI. And MRI improved the diagnostic a lot. So nowadays we can diagnose this disease very early, of course, if the patient is referred to us early. But very broad use of MRI resulted nowadays to another problem. So we were starting with long diagnostic delay. We were working on shortening the diagnostic delay. We are in a good way, but now we are running into an issue of over diagnosing excess spondyloarthritis. And the reason for this is that some changes we see on MRI, especially bone marrow edema on MRI, in the sacroiliac joints and in the spine may well be induced by mechanical changes. So mechanical degenerative changes and this is a big issue, which was not that clear about 20 years ago when first criteria were published and everybody was so happy. Hey, we can diagnose this. This is that. Early we see bone marrow edema, it must be axial spondyloarthritis. And now we're coming to a more differentiated approach. We know how the spondyloarthritis typical bone marrow edema should look like. And we have also good idea how mechanical induced bone marrow edema looks like. But it is a learning curve, and it is not easy. And we try to educate nowadays, not only radiologists, but also our colleagues rheumatologists. Because rheumatologists, at the end of the day, they're responsible for the diagnosis. And if the diagnosis is not correct, if it is osteoarthritis in the sacroiliac joints causing bone marrow edema. There won't be a good effect from treatment options we're using, including most advanced ones biologics and targeted synthetic disease modifying anti matic drugs. So let's maybe move on to talking then a little bit about the treatment. One of the important reasons, from what I understand in diagnosing these conditions isn't just opportunity to control the pain better, but also these systemic conditions and they cause inflammations in other organs. And so by treating ankylosing spondylitis, you could may not just be treating the pain, you may also be protecting some of these other organs. The one that comes to mind is eyes. So what are the organs can ankylosing spondylitis affect and does treatment protect those organs? Yeah. There are several specific negative effects of of inflammation and there are also some overall non-specific effects. So what you mentioned the eye. Uveitis is a typical manifestation of spondyloarthritis, but it can be also gut with development of inflammatory bowel disease and it can be skin. So psoriasis is also a part of the overall, uh, clinical presentation. And not to forget inflammation has multiple negative effects on human health overall. And that includes increased cardiovascular risk and includes increased risk of cancer and related mortality. So controlling inflammation, we literally increase the life expectation. We decrease the cardiovascular risk, we decrease risk of getting a cancer, especially of lymphomas because of uncontrolled inflammatory activity. Is there studies to suggest that actually treating patients with ankylosing spondylitis prolongs their life or reduces chances of some of these disorders? Yes. There are clinical trials showing that. Application of potent anti-inflammatory treatments. And that includes even simple nonsteroidal anti-inflammatory drugs. It increases cardiovascular risk. You may remember that there was a big story around cardiovascular risk increase with NSAIDs. It is, it may be true in primary non-inflammatory conditions such as osteoarthritis, but in ankylosing spondylitis,, there is a big study, population based study that showed that actually there are protective. So it sounds like treatment is not just about symptom control, it's actually about your general health. Which sort of brings me to my next question, and that is, obviously there's degrees of severity of ankylosing spondylitis. So does every patient with ankylosing spondylitis needs a biologic agent. Yeah, very good. Very good question. Yeah. And very reasonable question because not every, everybody really need needs a biologic. So what we. Learned over many years that inflammation control is really crucial to prevent progression of the disease and to avoid long-term disease complications. Meaning that if we are able to control inflammatory activity. By simple measures such as nonsteroidal anti-inflammatory drugs, we don't need necessarily biologics and individual course of the disease varies a lot in some cases. It can be just a couple of flares in a year, which can be very well controlled by by NSAIDs. While in others we see uncontrolled inflammatory activity where we are forced to go to the next step and to use biological, another type of advanced anti inflammatory treatment. Oh so it sounds like it's a stepwise approach where if you can get by with less aggressive treatments you go there and if you can't, you gradually build it up. I guess what are the pros and the cons of current medications for treatment of  ankylosing spondylitis? It is always about risk management. So if we see no contraindication for the use of NSAIDs, such as diclofenac, naproxen, ibuprofen we go ahead and and use them. If we see contraindications, let's say history of gastric ulcers, bleeding in the past serious cardiovascular risk problems with kidneys then we go over this step rather quickly. And for as of biologics in general, the more we were using them the bigger is the evidence, how safe overall, this approach is on the long run. So at the beginning of biologics era 20 years ago, we were very much concerned about various risks, including risk of cancer and so on. But then large scale epidemiological studies demonstrated that actually it's not biologic that induces cancer. It is a disease. It is the inflammation, uncontrolled inflammation that increases the risk of cancer. And by applying anti-inflammatory medication. Actually, we mitigate this risk. What a state after all these years is a slight increase in infectious risk. Most of the people, they don't even see a personal increase of their risk because we are balancing immune system. And the immune system starts working against germs and not against the own body. But there are a few infections where we extremely cautious and these are chronic hidden infections which may reactivate if you release the break of the immune system. And this is specifically tuberculosis and hepatitis B. We learned how to manage this. We always screen for these infections before we start the medication. And in most of the cases, we are a able to initiate the treatment even if this chronic infection is present by applying some preventive measures. Obviously there's the things that doctors do and that makes can make a big difference. But are there things that patients can do themselves in terms of lifestyle that could help? Yes. Absolutely. And so far we were talking about non-pharmacological measures, but there is a huge spectrum of treatment options, which are non-pharmacological. So not related to drugs. What we know for sure is that smoking is really bad for inflammation. Smoker is a strong promoter of inflammatory activity. And we advise always in favor of not smoking, stopping smoking in the case of smoking behavior. Second thing we very often run a discussion about what to eat, what not to eat. So dietary intervention is not very well standardized. And clinical trials studies, epidemiological studies provided some heterogeneous results, but what came consistently out is that sugar, especially quick sugar and carbohydrates are in general associated with high inflammatory activities. So at least quick sugar soft rings this is something what we recommend to reduce. Another component is definitely in this condition, regular exercises. It is almost self-explanatory, but it is a extremely important component of treating inflammatory condition in the spine, which helps to preserve function long term. Starting point may be difficult. People report in increased pain at the beginning, but on the long run they benefit a lot. And I explain it very often to my patients that axial spondyloarthritis or ankylosing spondylitis is a feature of your body and it has a positive effect. It forces you to do everyday exercises till the end of your life. And thi this is something good and you need to keep on doing. And finally and I think it's a good breach to the topic of chronic pain. In some cases we apply our medication, we do some non-pharmacological intervention including exercises, education, and so on. But the pain persists and this is always a reason for us to look at some other factors potentially contributing to pain. And this is where. Some en environmental and social psychological factors do play a major role and specifically this anxiety, depression, and poor sleep that may contribute to the perception of having pain, chronic pain despite well-controlled inflammatory activity. I guess that sort of meanders into nociplastic pain. At least in my experience nociplastic pain, which essentially means pain not because a target is necessarily injured, but rather because the nervous system, which sends the pain signals, becomes hypersensitive and starts to send pain signals without really a good cause. In my experience, at least most of the time, there's a trigger for it. Whether that trigger, most commonly, honestly, is trauma, be it a car accident or some other type of injury. On occasion, it can be an infection. And I suspect in line with that it can also be a joint which might become inflamed. Perhaps inflammation is settled, but because there's permanent changes in the nervous system, the pain just stays there. What percent of the patients do you think with, uh, ankylosing spondylitis and perhaps other rheumatological disorders develop this nociplastic pain component? Yeah. This is a very good point and I and my view on the things is uh, very similar to yours. I think this understanding of various mechanisms of pain is coming now to rheumatology because a few years ago. We were really obsessed with finding new treatment targets because we saw in daily clinical practice, but also in clinical studies that we are not reaching 100% of clinical response. And the idea was a few years ago that we just don't have the proper targets, immunological targets. So we're not good controlling in inflammatory activity, but nowadays with multiple treatment targets which could be addressed and multiple drugs available. We're getting to an understanding that there might be other sources of pain, and in most of the cases when we see a person with axial spondyloarthritis or with psoriatic arthritis, where, there are no swollen joints. There is no inflammation in MRI, but there is pain. We need to assume that the pain is not related to inflammation in most of the cases. That is indeed nociplastic pain. We are working right now International initiatives on the development of the concept of difficult to manage axial spondyloarthritis and psoriatic arthritis. And this concept covers exactly this patient profile where you apply anti-inflammatory treatment, but that there are persisting symptoms still bothering patient. And there are several studies. Which applied those criteria retrospectively in the Netherlands in Greece, in Germany. And most recently we did also study in Toronto spondylitis clinic. We see that about 10% of, uh, patients with axial spondyloarthritis would fulfill this criteria, and for most likely, they have indeed a nociplastic pain that bothers them. In psoriatic arthritis this percentage can vary from clinic to clinic. In Toronto, we run a big clinic with many longstanding patients. And I would estimate the proportion of patients with substantial nociplastic pain component a little bit higher than an X-L-S-P-E. It, it is about 20% but it is also related to the fact that we are seeing more severe patients then community-based rheumatologists will, would be doing. So perhaps to end this where is the field going? I guess is what are the likely treatments of the future? I think that inflammation is a very loosely thrown around tur and I suspect there's many different pathways of inflammation. And I think inflammation is blamed from everything from cancer to osteoarthritis, to rheumatoid arthritis, yet the treatment for a great deal. So there's probably many different types of inflammation and perhaps, fine tuning would cause some progress. There's a lot of talk about microbiome and perhaps the bacteria that live in our bowels and particular perhaps have an impact on the level of inflammation. Not to mention things like crispr vagal stimulation for rheumatoid arthritis. That seems to be vogue right now. So where do you think the field is going? I. Yeah. Very good. Point indeed. We're coming to an understanding that there might be some different mechanisms in, in chronic inflammation, in longstanding disease. In general there is a huge overlap in the efficacy between all the drugs we're using nowadays, all the biologics, they are more or less similarly effective. But this efficacy ends when it comes to chronic longstanding inflammation. And within this spectrum of difficult to treat difficult to manage disease, there is a small proportion of people with truly treatment refractory disease. And there is a suspicion that there might be a role of some other cell types, including so-called fibroblasts, producing fibrous tissue. It is , right now matter of clinical research. Otherwise you are right. Microbiota is a topic and there are very interesting study from cancer research showing that your gut bacteria can actually define whether you would be responsive to one or another type of cancer treatment. So we're looking into this also with respect to the biological response and non-response. But overall I think that we are pretty good in our ability to control relevant inflammatory activity. And now the field is moving and should be moving in a direction of addressing residual symptoms, so rheumatologists should become aware that patient's symptoms, especially pain, may not be directly related to inflammation. And once inflammation is controlled, there is something to do about symptoms bothering the person. And we need to characterize this pain and we need to find ways of addressing this, whether it is a pharmacological treatment or whether it is non-pharmacological treatment methods. Yeah, for instance we heard recently about very promising results related to pain reprocessing therapy. Dr. Foolan is working on this. And yeah we're very interested in this topic because otherwise we don't have much to offer to our patients. And I think , we need to work with pain specialists very close to achieve our holistic goal of having a patient's free from inflammation, but also free from pain. Alright, and then that we will end. Thank you Dr. Poddubnyy for taking the time to speak to us. Thank you. Thank you very much. Disclaimer, when it comes to your health, always consult with your own physician or healthcare provider for personalized advice and guidance. The information provided in this podcast is for educational and informational purposes only and should not be considered medical advice or a substitute for professional medical care.