Managing rib pain in Axial Spondyloarthritis (including Ankylosing Spondylitis)



Axial Spondyloarthritis (axial SpA), including Ankylosing Spondylitis, can cause pain at the front of your chest (where your ribs join the chest bone) and at the back (where your ribs join your spine). Even when your condition is generally well controlled, flare ups can occur and rib pain can be really debilitating.

There are various different techniques to help reduce rib pain, but as each axial SpA flare can behave very differently, it's helpful to have different methods written down so you can try each one and find what works for you. It's all about having a variety of 'tools' in your 'axial SpA toolbox'.


Before I begin, I want to emphasise that if you're struggling to manage your flares, please speak to your rheumatology team for specific advice and help. This blog will give some ideas on self-care techniques, but it's not a substitute for individual advice from your health team. If you have any tips for rib pain that I haven't discussed, please do share in the comments for others. The National Axial Spondyloarthritis Society helpline and website are also fantastic for advice and support.






Heat or ice

One of the most soothing things can be applying heat or ice to the painful area. Use a heat pad/wheat bag or ice pack, wrapped in a tea towel, onto the area for 10 minutes. You can repeat this frequently, but don't apply heat or ice directly to the skin.

A hot bath or shower can be very soothing for the muscles surrounding the rib cage. If you find cold is more effective, then use the shower head on a cool setting directly onto the painful area for a minute or so.


Rest and movement

It can seem counterintuitive with axial SpA, but frequent rests can be very beneficial when your ribs are flaring. I recommend regular, short rests between periods of activity to reduce your rib pain, while still allowing for any fatigue you're experiencing. Resting for long periods can feel nice at the time, but will only add to the pain and stiffness in your ribcage. In the long-term, keeping active will maintain strength in the muscles surrounding your back and ribs, which can help support the joints.





Exercise

Gentle mobility exercises can be really helpful during a flare up. Over time you will gradually learn the amount of stretching and exercise your joints will tolerate during a flare, so start gently and build up slowly.

Some of the best exercises are while seated:

1. Gently tilt your body to the side to reach your hand to the floor. Repeat on the other side.
2. Gently turn your body, relaxing your neck and shoulders as you look behind you as far as comfortable. Repeat on the other side.
3. Flow between looking up towards the ceiling and arching your back, then looking down to the floor and relaxing forward.

All of these movements should be comfortable and shouldn't aggravate the pain. It's best to try these movements when you're not flaring first, so you know where your comfortable range is.


Short-term adaptations

During a flare, you may wish to avoid reaching high overhead or down to the ground where possible. Ask someone to move things onto counters to avoid over-stretching frequently. If you're generally quite mobile, I would recommend only adapting your home during a flare; day-to-day activities are really important to keep you flexible and mobile.


Reduce the pressure on your rib cage

If you have severe pain in your ribs, then this will seem very obvious, but avoid tight clothing that puts pressure around your ribcage.

When travelling in the car, use a memory foam seat belt cover to cushion the area that crosses your rib cage, but still allowing the seat belt to be effective in an emergency.

When sitting on a sofa, use plenty of soft cushions behind you to keep you upright and avoid slumping.

Bra fitting: It's important to be professionally measured to ensure you're wearing the correct size bra. If a standard bra is too uncomfortable, then try a sports bra or bralette where the pressure is distributed differently.




Gentle massage

You can use the palm of your hand or your fingertips to gently massage the muscles of your neck, shoulders and around your ribs. I recommend doing this for short periods, but often, so you don't overdo it and make the areas more tender. If the areas around your ribs are too sensitive to touch, then avoid massaging them and just use ice or heat to help relieve the tenderness.




Swimming/Floating

Floating in water (in a bath or swimming pool) can be very effective at relieving pain around joints. If you're able to, gentle swimming is an excellent exercise for the muscles around the joints while it doesn't jar the joints themselves.


Pain relief


This is something to speak to your rheumatology team about so you can form your own plan. I recommend writing down what pain medication works best for you at different times. For example, for the beginning of a flare, some simple painkillers can be helpful. Whereas during a severe flare, some topical pain relief or anti-inflammatories can be helpful. Creating this plan when you're feeling well will help reduce the stress if you feel a flare coming. Most importantly, have it written down and remember to check it when you’re flaring. When you’re in a lot of pain, it’s really easy to forget what’s been recommended to help.


Sleeping position

Many people report disrupted sleep when their ribs are flaring because it's difficult to find a position that doesn't apply pressure to the ribs. For short periods, some people find lying on their back with a couple of cushions to prop them up works well. I also recommend lying on your side with a pillow between your arms resting in front of you and a pillow between your legs. If this is particularly helpful, it can be worth buying a full body pillow (like this) because individual pillows can move about easily and disrupt your sleep further.


Prevention


There are some ways you can reduce the likelihood of a rib flare or help reduce how frequently they occur. Firstly, it's important to identify what triggers them for you so you can make alterations. For example, I find slumping on the sofa for a long time increases the likelihood of rib pain- so I make sure I sit upright with a cushion behind my back and do the gentle stretches I described earlier to keep my back moving while I'm watching a film. I do slump occasionally, but I've found I can tolerate it more when I do it less frequently.

To help identify triggers, you can use a simple 'symptom diary'. Jot down each day roughly what symptoms you're experiencing, your activity and your food intake. Sometimes over time you can see a pattern develop. Do not get too worried about keeping a detailed diary and I would recommend having a break from doing this every now and then, otherwise it can feel a little overwhelming.




Strengthening


Strengthening the muscles around your back and rib cage can help prevent episodes of pain. It's also essential for the long-term management of axial SpA. A great exercise to start with is a wall press (essentially a press-up against a wall). As you do the movement, really focus on squeezing your shoulder blades together to strengthen this area.

Diaphragm breathing can help stiffness or reduced movement in your ribcage. Lie on your back and place one hand on your sternum (chest bone) and one hand on your stomach. As you breathe in, try to breathe right down into your stomach, so your lower hand rises and your lower ribs expand. Your lower hand should relax down as you breathe out and contract your abdominal muscles.

NASS have a great exercise on their YouTube channel, showing how to use your arms to increase the movement.

Hydrotherapy is an excellent exercise for the whole body, so check with your local hospital if they run sessions.

Not only is it a great strengthening exercise, it's also great fun... singing! I am no singer, so I enjoy blasting out something that's vaguely like a tune when I'm driving on my own. I wouldn't inflict that on anyone else, but the benefits for the strength/mobility of my ribs, my lung capacity and also my mood are noticeable. Why not give it a go?


I hope you've found my top tips helpful. Please do leave a comment below if you have any techniques that work for you. Sometimes the simplest change can have huge differences when living with axial SpA, so it's worth trying things out and finding what works for you.




About Zoë:

Zoë Clark is an osteopath trained at the British College of Osteopathic Medicine in London.

Practicing in Howe, near Norwich (01508 558373) and at The Space Burston, near Diss (07543 557746).

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