World Arthritis Day: A case of ankylosing spondylitis

There’s a lot of research on therapeutic alliance because the relationship that you have with your healthcare provider can determine the success of your treatment. Research has shown that the relationship you have with your chiropractor can predict the success of your recovery. With this in mind, it’s not surprising that a poor working relationship can lead to poor recovery.

Today, we are going to go through an article written by Bethany Dawson about her experience with ankylosing spondylitis. In doing so, we hope you can take away something to apply to your own pain management.

Do not mistake temporal sequence as causation

As humans, one of the things we tend to do is to look for the problem. We are almost hardwired to ask “why”, and we think that having clarity of what is wrong is necessary for a successful recovery. This is often untrue.

In Bethany’s case, she started experiencing pain after a skin tumour removal. Because of the sequence of events, it may make sense to assume her pain was caused by the surgery. Well, it wasn’t. And making the assumption could have definitely worsen her condition.

In clinical practice, we often see patients ascribing their pain to a car accident ten years ago. Yes, it may be true that the pain you experienced then was from the accident. But 10 years later? No, it’s highly likely, almost possible, for your pain today to be the result of that car accident.

To put that in context, it’s like how the rooster may crow at dawn before sunrise. Does that mean the sun rises because of the rooster’s crowing? No.

If we can put our assumptions aside and attempt to look at your pain experience as it is, you are way more likely to get successful results from your recovery.

I don’t know if I am better because of your treatment

Yesterday, I asked a client about how she is going in her recovery. If 0% was no change and 100% is a full recovery, where is she today?

It is early days and she replied that she is 10-20% better. She was also very quick to add that she wasn’t sure if the change was coming from our time together.

This is really interesting because as humans we tend to peg meaning to our experiences, even though there may not be any. When I asked the question, on how far along she’s getting, I didn’t mean how much better she was from the treatment she is receiving from us. I merely wanted to know if she was better (or not).

With the client, I also asked what was the activity she was doing when she experienced a certain tingling in her arms. She mentioned that she was working on the computer when she experienced it. She also added that she don’t think computer use was causing her tingling.

Again, in asking that question we weren’t trying to find a causative reason for her symptom experience. We were only trying to contextualise her symptom experience.

As she move along in her recovery, and as we collect more data about how her symptoms behave, a pattern would eventually emerge.

For most parts, single time-point data is not enough for us to make any meaningful assumptions. We ask questions so we can collect information on a patient’s symptom experience as it is. They are usually non-meaningful at the start but with more time and with more testing, we do eventually see that a pattern would emerge.

So, it really circles back to being able to observe your symptoms as it is.Without trying ascribe any meaning to it. Without trying to explain a mechanism for it.

The less assumptions we make, the better your recovery.

Your pain is all in your head!

The way Bethany described the mindfulness encounter from the doctors seem to suggest as if her pain was 100% in her head. You probably won’t like what I am about to say but I am going to say it anyways: Your pain is indeed 100% in your head.

In fact, all pain is 100% in your head. Pain science is very clear that pain is a perception. It is something that can only occur in your brain. There is no such thing as pain signals (not to be confused with nociception) in your body, and pain is 100% an interpretation of various conscious and subconscious stimuli.

There you go. Your pain is 100% in your brain.

If you are not entirely convinced, you can watch the infamous rubber hand experiment video above. There are three things that you should be aware of:

1. The person did experience real pain.
2. It is possible for a person to experience pain in the absence of damage (i.e., the pain experience is created by your brain).
3. There was no attempt to “trick” the person. He was fully aware that the rubber hand is not his real hand. But yet his cognitive ability was not able to overwrite the pain he experienced.

Of course this is just a fun experiment. There are tons of research on the rubber hand illusion that is done in a scientifically controlled environment. These research clearly demonstrate that pain can occur without damage. It also shows that our brain can be confused to create pain.

Mindfulness can help you navigate your pain experience

I really don’t think Bethany should have “dissed” the mindfulness suggestion. If the doctor or healthcare provider conveyed it poorly, then the problem is with the clinician. Not with mindfulness.

To be clear, mindfulness is not a first-line treatment for chronic pain. Exercise + education is still the preferred treatment. In terms of psychological interventions, cognitive behavioural therapy is also considered a first-line treatment for lower back pain. It’s super important to acknowledge that psychological interventions do have a role in persistent pain management.

Because mindfulness is a second-line treatment (or adjunctive treatment), it comes fair and evidence-based to use it in conjunction with exercise + education. We do prescribe mindfulness practice in our recovery programme.

We find that it helps clients with their awareness. They also reduce ruminating behaviours. These benefits definitely do complement their exercise therapy.

Most importantly, mindfulness practice fits into our empowerment model. Whereby the graduates of our recovery programme, is able to continue to engage in mindfulness practice on their own even after the programme. Furthermore, evidence-based mindfulness content and practice tracks from renowned institutions are available for free online.

In essence, if you are willing to put in the time and effort, mindfulness is a free resources that can help you with your pain! Free! 100% no charge. Isn’t that wonderful?

Not being taken seriously for being female

This is definitely wrong. No doctors, chiropractors, or any healthcare providers should be discounting what their patients say on the basis of their sex. Both sex bias and gender bias are unacceptable, and clinicians should really actively work to be aware of this.

The unfortunate truth is that sex bias does happen. Not just in clinical setting but also in workplaces. In well discussed in organisational psychology literature. And it also affects women in medicine.

There is really not much to say about this other than that I am sorry that it happened to her. I also wish for anyone of you who experienced this to find better healthcare in the future.

In clinical practice, we do have poor responders to treatment. As long as you spent enough time in practice, you will realise there are cases that are genuinely more severe, and experience poorer treatment outcomes compared to other clients. Interestingly for us, the two clients with extremely poor treatment responses and with pain experiences that don’t match their MRI findings, blood tests, etc, are males.

Her “ankylosing spondylitis” diagnosis is questionable

bamboo spine, ankylosing spondylitis
One of the signs of ankylosing spondylitis is named “bamboo spine”. It is when you can see extra bone growth on the sides of the vertebral bodies. They are laid down from segment to segment, given a wavy appearance that looks like a bamboo. Normal spines do not have the wavy appearance.

Based on what we read about her case and also what she shared in a TEDx talk, her diagnosis is contentious.

No, I am not saying that she is overplaying her pain. I am also not saying that she doesn’t have ankylosing spondylitis. I am saying that there is no evidence to actually support that she does.

In her TEDx talk, she mentioned having a non-radiographic ankylosing spondylitis diagnosis. This means there is nothing on x-rays, MRIs, or blood tests that support her diagnosis. So, for all we know, she may not even have ankylosing spondylitis.

Of course she is not my client so I cannot say that she definitely do not have it. There’s also not enough case history or medical history for me to “diagnose” her. What I am pointing out is that it is questionable.

So, it does make sense that her previous healthcare providers didn’t think of ankylosing spondylitis in their diagnostic workup. In fact, I wonder if the rheumatologist who diagnosed her did so so she can have closure about her pain.

Research does show that having a diagnosis, even if it is wrong, can help a patient make sense of their pain experience. With that in mind, improve their pain outcomes.

She is only 23 now.. Maybe she does have ankylosing spondylitis, and the radiological signs will show up as she reaches her 40s. Who knows.

Either way, I am happy that she found closure. I am also happy that she is doing amazing work advocating for people with chronic pain.

How should I approach my own pain treatment?

The gist of it, in my professional opinion, is to work with someone whom you can trust. Having said that, your healthcare provider is not there to make you happy. So, it is entirely possible that your trusted chiropractor is saying what you don’t want to hear.

When in doubt, ask your choice of practitioner on the research that supports their claim. If they are unable or unwilling to do so, I suggest changing your chiropractor.

Feel free to check out our Google reviews. Our clients, even those with decades of pain, have very good results to report from working with us. Sure, we cannot promise you that you will definitely recovery from working with us.

What we can promise you, however, is a fair shot at finding true freedom from pain. To find out more, drop us a message via the form below.


Frustrated by the lack of results-driven and ethical chiropractic clinics in Singapore, Chiropractor Jesse Cai found Square One Active Recovery to deliver meaningful and sustainable pain solutions.

Our goal? To make our own services redundant to you.

*We do not offer temporary pain relief such as chiropractic adjustments, dry needling, or any form of soft tissue therapy.