Healthy sleep is vital for having enough energy, thinking clearly, and managing everyday stresses confidently. Chronic unhealthy sleep patterns and/or insomnia can lead to and contribute to various health issues. This includes daytime fatigue, irritability, difficulty concentrating, delayed reaction time, constantly getting sick, and memory problems. Sleeping health problems can get worse with every night of poor rest. Injury Medical Chiropractic and Functional Medicine Clinic provide treatment, training, and tools to realign and relax the body and restore healthy sleep.
Sleeping Health Problems
Lack of sleep disrupts and slows down nerve impulses and transmissions throughout the body. This can lead to health problems that can include:
Excessive fatigue
Brain fog
Slow responses
Physical performance problems
Inability to remember
Low sex drive
Chronic illness
Over time the risk of developing a serious medical condition increases and can include:
Anxiety
Depression
High blood pressure
Diabetes
Weakened immune system
Stroke
Heart attack
Seizures
Staying On
There is some research that insomnia is associated with hyperarousal or the state of staying on. It often starts with a stressful event that sets off the body’s systems, causing the inability to relax completely. Body discomfort and pain symptoms can also present when the mind and body can’t relax. The entire body can tighten/stiffen, causing aches, soreness, and pain. Continuation of sleeping health problems of the cycle leads to more stress.
Chiropractic care, massage, and decompression therapy can help break the cycle. Breaking the process is necessary to help the body recover and rehabilitate properly. Treatment retrains the body to relax; stretching and pulling the muscles increases blood circulation, as well as advanced and improved brain signals telling the body to relax. A chiropractor will evaluate the individuals sleeping patterns and recommend various solutions. The benefits for individuals with sleep issues include:
Alleviates muscle tension.
Stimulates nerve circulation and blood flow.
Relaxes the whole body.
Enhances central nervous system function.
Relieves pain and discomfort.
A chiropractor will also provide the following:
Sleeping position recommendations.
Postural stretches and exercises.
Recommendations on supportive mattresses.
Ergonomics for work, home, and bed.
Chiropractic’s Evolution
References
Hale, Deborah, and Katherine Marshall. “Sleep and Sleep Hygiene.” Home healthcare now vol. 37,4 (2019): 227. doi:10.1097/NHH.0000000000000803
What Are Sleep Deprivation and Deficiency?https://www.nhlbi.nih.gov/health/sleepdeprivation#:~:text=Sleep%20deficiency%20is%20linked%20to,adults%2C%20teens%2C%20and%20children.
What Makes You Sleep? https://www.nhlbi.nih.gov/health/sleep-deprivation/body-clock
How Sleep Affects Your Health https://www.nhlbi.nih.gov/health/sleep-deprivation/health-effects
Riemann, Dieter. “Sleep hygiene, insomnia, and mental health.” Journal of sleep research vol. 27,1 (2018): 3. doi:10.1111/jsr.12661
Nerve irritation occurs when the nerves exiting the spine become irritated and sensitized. Also known as nerve gliding restriction, it is a condition whereby a nerve becomes irritated by inflamed swelling of structures close to the nerve, such as joints, ligaments, muscles, or discs, that have sustained an accumulative strain which results in swelling and inflammation. A thorough chiropractic assessment and examination can diagnose the extent of the irritation and develop a personalized treatment plan.
Nerve Irritation
When swelling and inflammation interfere with the nerve root, the nerve transmits signals to the brain to let it know there is a threat. The brain interprets these signals and creates a protective response to avoid worsening the damage to the nerve. The protective reactions vary from person to person but can include the following:
Muscle tightness and guarding
Aching sensation
Cramping
Radiating discomfort or pain
Pins and needles
Tingling
Numbness
Nerve root irritation also inhibits the body from recovering as fast as it should.
Nerve irritation is not to be confused with nerve root compression or radiculopathy. This is when the nerve becomes compressed/pinched, resulting in the loss of its functions like muscle strength and sensation. Sometimes individuals with nerve irritation can also experience increased neural tension. The nerves adapt to the mechanical loads placed on them through regular movements. Restrictions to neural mobility can cause symptoms to worsen along the pathway and distribution of the nerve.
The nervous system consists of the brain, spine, and nerve branches.
The branches, similar to electrical cables, cannot stretch.
Tension is generated when straightening out body areas, creating a pull and gliding of the nerve to the spinal cord.
When nerve irritation occurs, signals are sent to protect the body, brain, spine, and branches.
Causes
Most commonly, nerve irritation occurs when a structure adjacent to the nerve; this could be a joint, ligament, and/or muscle that accumulates strain and becomes dysfunctional, swollen, inflamed, and/or spasms resulting from protective guarding.
Mild nerve irritation can include accumulated strain from postural overload and swelling from a minor tear in an adjacent ligament.
Often nothing shows as a problem on an MRI scan.
Severe nerve irritation can include disc herniation and shows up on an MRI scan; surgery could be required in some cases.
Symptoms
Stiffness
Tightness
Aches
Pains
Persist even after days of rest, stretching, targeted exercises, avoiding movements, etc.
Stretching feels good at first, but the pain returns or worsens a few hours later or the next day.
The irritation blocks the effective recovery of muscle, joint, tendon, and ligament discomfort symptoms.
Chiropractic Care
Treatment involves various therapies and strengthening the supporting structures while relaxing and releasing tight structures to avoid recurring injuries. Chiropractic care realigns the spine, corrects joints that have shifted out of place, helps to regulate the nervous system’s function, and relieves irritation and inflammation. Whether in the form of an adjustment, traction, or guided exercise, all systems in the body are moved closer to a balanced state. This includes the:
Nervous system
Immune system
Respiratory system
Circulatory system
Endocrine system
Skeletal system
All help support the body’s self-healing process and increase the nervous system’s function.
The chiropractic team will guide the patient through the rehabilitation process to get back to full strength.
Peroneal Nerve Irritation
References
Ellis, Richard F, and Wayne A Hing. “Neural mobilization: a systematic review of randomized controlled trials with an analysis of therapeutic efficacy.” The Journal of manual & manipulative therapy vol. 16,1 (2008): 8-22. doi:10.1179/106698108790818594
Gibson, William, et al. “Transcutaneous electrical nerve stimulation (TENS) for neuropathic pain in adults.” The Cochrane database of systematic reviews vol. 9,9 CD011976. 14 Sep. 2017, doi:10.1002/14651858.CD011976.pub2
O’Shea, Simone D et al. “Peripheral muscle strength training in COPD: a systematic review.” Chest vol. 126,3 (2004): 903-14. doi:10.1378/chest.126.3.903
Rozmaryn, L M et al. “Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome.” Journal of hand therapy: official Journal of the American Society of Hand Therapists vol. 11,3 (1998): 171-9. doi:10.1016/s0894-1130(98)80035-5
Sipko, Tomasz, et al. “Mobility of cervical spine and postural equilibrium in patients with spinal overload syndrome.” Ortopedia, traumatologia, rehabilitacja vol. 9,2 (2007): 141-8.
Bruxism is an abnormal jaw clenching or grinding of the teeth, either while awake or during sleep. This can cause neck and shoulder tension caused by excess pressure on the neck and jaw muscles. Individuals may not realize they have bruxism until a dentist notices excess wear and tear or a chiropractor examines their symptoms. Bruxism can play a role in temporomandibular disorders. Doctors and dentists agree that factors like stress increase the likelihood of jaw clenching. Dentists usually recommend a mouth guard to prevent grinding. Chiropractic care, massage, and decompression therapy can relieve symptoms, release and relax the muscles, realign the spine, and restore function.
Bruxism
There is awake bruxism and sleep bruxism. A tight jaw generates tension extending to the neck, shoulder, and upper back muscles. Over time, that excess strain irritates the joints, causing inflammation. Jaw clenching and teeth grinding can lead to health issues like damaged teeth, neck, shoulder, and upper back pain symptoms, and tension headaches.
Symptoms
Signs and symptoms can include:
Face, jaw, neck, and upper back aches, tightness, and soreness.
Tired or tight jaw muscles.
Headaches that start in the temples.
What feels like earache pain symptoms.
Damage from clenching on the inside of the cheek.
Increased tooth sensitivity.
Teeth that are loose, flattened, chipped, or fractured.
Sleep problems.
Risk Factors
Emotional tension – Stress, anxiety, frustration, and anger.
An unhealthy lifestyle – smoking, excess drinking, caffeine, etc., disrupts brain and cardiovascular functions.
Medications
Chiropractic Care for Jaw Clenching
If there is a jaw clenching or grinding issue, it is recommended to see a dentist for a professional diagnosis. Then a chiropractor can develop a personalized treatment plan that utilizes massage and decompression therapy to re-position the jaw, stretch, release and relax the muscles. They will recommend exercises to strengthen and maintain the relaxed jaw muscles and awareness exercises to help identify triggers and prevent clenching.
Jaw Exercises
References
Capellini, Verena Kise, et al. “Massage therapy in managing myogenic TMD: a pilot study.” Journal of applied oral science: Revista FOB vol. 14,1 (2006): 21-6. doi:10.1590/s1678-77572006000100005
Kuhn, Monika, and Jens Christoph Türp. “Risk factors for bruxism.” Swiss dental journal vol. 128,2 (2018): 118-124.
Nishida, Norihiro et al. “Stress analysis of the cervical spinal cord: Impact of the morphology of spinal cord segments on stress.” The journal of spinal cord medicine vol. 39,3 (2016): 327-34. doi:10.1179/2045772315Y.0000000012
Ohayon, M M et al. “Risk factors for sleep bruxism in the general population.” Chest vol. 119,1 (2001): 53-61. doi:10.1378/chest.119.1.53
Santos Miotto Amorim, Cinthia, et al. “Effectiveness of two physical therapy interventions, relative to dental treatment in individuals with bruxism: study protocol of a randomized clinical trial.” Trials vol. 15 8. 7 Jan. 2014, doi:10.1186/1745-6215-15-8
It is a common scenario, whether sitting or standing when we need to bend down or forward, and suddenly there is a sharp sting on one side of the low back. The sensation can cause the knees to buckle. So we stand up slowly to assess the condition and realize it is almost impossible to stand completely straight and even harder to bend forward. So we sit back down to try and relieve the pressure. It helps a little, but the injury has caused the back muscles to spasm and get tighter and tighter. When we try to get up, there can be one big or several mild to severe electrical shock sensations traveling through the back. A severely over-rotated vertebrae could be the cause and require chiropractic care, massage, and/or decompression therapy.
Over Rotated Vertebrae
The spinal column is made of 26 interconnected vertebrae. When in motion, each vertebra moves, and as the torso rotates, the spine must rotate as well. The spine can move in several ways, including:
Bending
Rounding forward.
Extending or arching backward.
Twisting
Tilting sideways uses some of the same muscles when twisting.
Although the spine can move in various directions, there are limits to how far it can and should go. For example, when bending forward to lift an object, an individual can unknowingly over-extend and over-rotate vertebrae. This is where the risk of injury increases. A rotational injury of the spine occurs when the torso turns too far, and the spinal cord can’t handle it. This can stretch the ligaments in the spine to the point of snapping, causing the facet joints to dislocate. Ligament strains and facet dislocations are two of the most common rotational spine injuries.
Complications
An over-rotated vertebrae injury can also lead to complications that include.
Chronic Pain
Spinal nerve damage can lead to chronic pain conditions.
Mobility Problems
Mobility problems are common following an injury of the spine.
This comes from damage to the nerves that innervate the legs, causing weakness and coordination problems.
Pressure Ulcers
Numbness following a spine injury can cause individuals not to notice pressure ulcers developing.
These can lead to infections and could require hospitalization.
Individuals accumulate tension and/or weakness in the oblique abdominal muscles and other trunk muscles that can lead to chronic tightness and weakness, affecting movement and decreasing the range of motion.
Chiropractic Treatment Plan
Depending on the time and severity of the injury, a personalized treatment plan may consist of the following:
Chiropractic mobilization to release the spasms and reset the spine.
Rest
Facet Syndrome Treatment
References
Janssen, Michiel M A, et al. “Pre-existent vertebral rotation in the human spine is influenced by body position.” The European spine journal: official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society vol. 19,10 (2010): 1728-34. doi:10.1007/s00586-010-1400-3
Kruger, Erwin A et al. “Comprehensive management of pressure ulcers in spinal cord injury: current concepts and future trends.” The Journal of spinal cord medicine vol. 36,6 (2013): 572-85. doi:10.1179/2045772313Y.0000000093
Passias, Peter G et al. “Segmental lumbar rotation in patients with discogenic low back pain during functional weight-bearing activities.” The Journal of bone and joint surgery. American volume vol. 93,1 (2011): 29-37. doi:10.2106/JBJS.I.01348
Shan, X., Ning, X., Chen, Z. et al. Low back pain development response to sustained trunk axial twisting. Eur Spine J 22, 1972–1978 (2013). https://doi.org/10.1007/s00586-013-2784-7
Cue sports use a cue stick to strike billiard balls off and around a pool or equivalent table. The most common game is pool. Although these are not contact sports, various musculoskeletal injuries can manifest. Therefore, it is recommended to know the common injuries so that they can be self-treated or treatment can be sought before the condition worsens. Injury Medical Chiropractic and Functional Medicine Clinic can relieve symptoms, rehabilitate the body, and restore mobility and function.
Cue Sports Injuries
Sports medicine doctors say cue sports players suffer from sprains, strains, and fractures, among other injuries. Cue sports players are constantly:
Bending
Reaching
Twisting
Stretching their arms
Using their hands and wrists
Performing these constant movements and motions for extended periods increases the risk of sustaining injuries. Common symptoms include:
Inflammation
Warmth or heat in affected areas
Swelling
Tightness in the affected areas
Pain
Decreased range of motion
Injuries
Back and Waist
The posturing can cause individuals to tense their muscles, increasing the likelihood of injury. With all the bending, waist and back injuries are common. Back issues include:
Pinched nerves
Sciatica
Sprains
Strains
Herniated discs
Individuals with existing spine conditions or osteoarthritis have an increased risk of injury.
Shoulder, Arm, Wrist, Hand, and Finger
The shoulders, hands, wrists, and fingers are in constant use.
This can lead to overuse injuries affecting the muscles, tendons, ligaments, nerves, and bones.
Consistent stress can lead to sprains, strains, or bursitis.
Tendonitis
Tendonitis occurs when too much pressure is applied, causing tendons to inflame.
This could lead to swelling and pain and could lead to long-term damage.
Foot and Ankle
The feet can slip when stretching too far while setting up and taking a shot.
This injury usually happens when trying to balance on one foot.
Slipping can lead to a sprained ankle or something worse, like a torn ligament or fractured foot.
Chiropractic Care
Chiropractic adjustments combined with massage therapy and functional medicine can treat these injuries and conditions, relieving symptoms and restoring mobility and function. When the tendons, muscles, ligaments, and bones are properly aligned, recovery and rehabilitation progress faster. A chiropractor will also recommend stretching and exercise programs to help maintain the adjustments and prevent injuries.
Physical Therapy and Exercises
References
Garner, Michael J et al. “Chiropractic care of musculoskeletal disorders in a unique population within Canadian community health centers.” Journal of manipulative and physiological therapeutics vol. 30,3 (2007): 165-70. doi:10.1016/j.jmpt.2007.01.009
Hestbaek, Lise, and Mette Jensen Stochkendahl. “The evidence base for chiropractic treatment of musculoskeletal conditions in children and adolescents: The emperor’s new suit?.” Chiropractic & osteopathy vol. 18 15. 2 Jun. 2010, doi:10.1186/1746-1340-18-15
Orloff, A S, and D Resnick. “Fatigue fracture of the distal part of the radius in a pool player.” Injury vol. 17,6 (1986): 418-9. doi:10.1016/0020-1383(86)90088-4
The hip joint is a ball-and-socket joint composed of the femur head and a socket, which is part of the pelvis. The labrum is a cartilage ring on the socket part of the hip joint that helps keep joint fluid inside to ensure frictionless hip motion and alignment during movement. A labral tear of the hip is an injury to the labrum. The extent of the damage can vary. Sometimes, the hip labrum can have mini tears or fray at the edges, usually caused by gradual wear and tear. In other cases, a section of the labrum can separate or get torn away from the socket bone. These types of injuries are usually due to trauma. There are conservative hip labral tear tests to determine the type of injury. The Injury Medical Chiropractic and Functional Medicine Clinic team can help.
Symptoms
Symptoms are similar regardless of the type of tear, but where they are felt depends on whether the tear is in the front or the back. Common symptoms include:
Hip stiffness
Limited range of motion
A clicking or locking sensation in the hip joint when moving.
Pain in the hip, groin, or buttocks, especially when walking or running.
Night discomfort and pain symptoms when sleeping.
Some tears can cause no symptoms and can go unnoticed for years.
Hip Labral Tear Tests
A hip labral tear can occur anywhere along the labrum. They can be described as anterior or posterior, depending on which part of the joint is affected:
Anterior hip labral tears: The most common type of hip labral tear. These tears occur on the front of the hip joint.
Posterior hip labral tears: This type appears on the back of the hip joint.
Tests
The most common hip labral tear tests include:
The Hip Impingement Test
The Straight Leg Raise Test
The FABER Test – stands for Flexion, Abduction, and External Rotation.
The THIRD Test – stands for the Hip Internal Rotation with Distraction.
Hip Impingement Tests
There are two types of hip impingement tests.
Anterior Hip Impingement
This test involves the patient lying on their back with their knee bent at 90 degrees and then rotated inward towards the body.
If there is pain, the test is considered positive.
Posterior Hip Impingement
This test involves the patient lying on their back with their hip extended and their knee flexed and bent at 90 degrees.
The leg is then rotated outward away from the body.
If it results in pain or apprehension, it is considered positive.
Straight Leg Raise Test
This test is used on various medical conditions that involve back pain.
The test begins with the patient sitting or lying down.
On the unaffected side, the range of motion is examined.
Then the hip is flexed while the knee is straight on both legs.
The patient may be asked to flex the neck or extend the foot to stretch nerves.
The FABER Test
It stands for Flexion, Abduction, and External Rotation.
The test begins with the patient lying on their back with their legs straight.
The affected leg is placed in a figure four position.
The physician will then apply incremental downward pressure to the bent knee.
If there is hip or groin pain, the test is positive.
The THIRD Test
This stands for – the Hip Internal Rotation with Distraction
The test begins with the patient lying on their back.
The patient then flexes their knee to 90 degrees and turns it inward around 10 degrees.
The hip is then rotated inward with downward pressure on the hip joint.
The maneuver is repeated with the joint slightly distracted/pulled apart.
It is considered positive if the pain is present when the hip is rotated and diminished pain when distracted and rotated.
Chiropractic Treatment
Chiropractic treatment involves hip adjustments to realign the bones around the hip and up through the spine, soft tissue massage therapy to relax the muscles around the pelvis and thigh, targeted flexibility exercises to restore range of motion, motor control exercises, and strengthening exercises to correct muscular imbalances.
Treatment and Therapy
References
Chamberlain, Rachel. “Hip Pain in Adults: Evaluation and Differential Diagnosis.” American family physician vol. 103,2 (2021): 81-89.
Groh, M.M., Herrera, J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med 2, 105–117 (2009). https://doi.org/10.1007/s12178-009-9052-9
Karen M. Myrick, Carl W. Nissen, THIRD Test: Diagnosing Hip Labral Tears With a New Physical Examination Technique, The Journal for Nurse Practitioners, Volume 9, Issue 8, 2013, Pages 501-505, ISSN 1555-4155, https://doi.org/10.1016/j.nurpra.2013.06.008. (https://www.sciencedirect.com/science/article/pii/S155541551300367X)
Roanna M. Burgess, Alison Rushton, Chris Wright, Cathryn Daborn, The validity and accuracy of clinical diagnostic tests used to detect labral pathology of the hip: A systematic review, Manual Therapy, Volume 16, Issue 4, 2011, Pages 318-326, ISSN 1356-689X, https://doi.org/10.1016/j.math.2011.01.002 (https://www.sciencedirect.com/science/article/pii/S1356689X11000038)
Su, Tiao, et al. “Diagnosis and treatment of labral tear.” Chinese medical journal vol. 132,2 (2019): 211-219. doi:10.1097/CM9.0000000000000020
Wilson, John J, and Masaru Furukawa. “Evaluation of the patient with hip pain.” American family physician vol. 89,1 (2014): 27-34.
Non-radiographic axial spondyloarthritis or nr-axSpA and non-radiographic ankylosing spondylitis/AS are related. However, non-radiographic axial spondyloarthritis can present AS symptoms with active inflammation of the spine and sacroiliac/SI joints, causing back and hip pain but does not reveal joint damage on X-rays or MRIs. Injury Medical Chiropractic and Functional Medicine Clinic can explain what it means to have non-radiographic axial spondyloarthritis, how it can be managed, and what to do to prevent it from turning into ankylosing spondylitis.
Non-Radiographic Axial Spondyloarthritis
Non-radiographic axial spondyloarthritis means there are early AS symptoms but have not developed enough joint inflammation or damage to show up on an X-ray or other form of imaging. Early evidence of joint inflammation includes blurring of the joint edges and localized regions of joint erosion. It can be difficult for physicians to see these subtle changes on an x-ray.
Ankylosing Spondylitis
Ankylosing spondylitis, or AS, is a form of inflammatory arthritis that affects joints in the spine and elsewhere.
It is a chronic, inflammatory, autoimmune disease.
Medical research is still ongoing to determine the exact cause, but a genetic component is believed to be contributing factor.
Around 85% of individuals with ankylosing spondylitis have inherited the HLA-B27 gene, which is associated with multiple autoimmune conditions.
In the early stages, individuals will present lower back pain around the sacroiliac joints or the joints that connect the spine to the pelvis.
Later stages have more obvious X-ray findings, like the fusing of the sacroiliac joints and the lower spine that takes place over time.
Joint inflammation can progress, causing permanent joint damage and spine rigidity.
Most individuals with the condition can manage their symptoms with NSAIDs, chiropractic care, physical and massage therapy, and range of motion exercises.
Stage 1
There is no evidence of spinal inflammation on x-rays.
MRI provides more detailed images of bones and may reveal bone marrow edema or accumulation of fluid in the structures of the spinal bones and joints.
Individuals with non-radiographic axial spondyloarthritis, you are here.
Stage 2
There is visible inflammation of the spinal joints on the x-ray.
The sacroiliac joints between the spine and the pelvis are the most affected.
Stage 3
Chronic inflammation of the joints has caused bone loss and permanent joint damage, resulting in spine rigidity.
Symptoms of Non-Radiographic Axial Spondyloarthritis
There are differences between back pain associated with muscle strain and arthritis. Back pain symptoms include:
Starts to present before age 40.
It has a gradual onset and can go unnoticed for years.
Improves with movement or activity.
Eases up throughout the day.
Starts up in the evening when resting.
Other symptoms include:
Joint stiffness
Swollen fingers
Heel pain
Bilateral buttock discomfort and pain
Slowing Progression
Progression from non-radiographic axial spondyloarthritis to ankylosing spondylitis occurs in 10% – 20% of individuals over a two-year period. Progression factors include genetics, gender, degree of joint damage, and level of inflammatory markers at the time of diagnosis.
Early diagnosis and treatment can slow the progression before significant joint damage with anti-inflammatory therapy, rheumatological therapy, and targeted exercise.
Work with a specialist like an orthopedic spine specialist and rheumatologist that understands the disorder and is up to date on the most recent treatment modalities.
Individuals with non-radiographic axial spondyloarthritis should expect to have serial X-rays to gauge the progression of the disease.
Staying healthy and active is recommended to slow the progression of nr-AxSpA and AS.
Recent medical advances and lifestyle adjustments can slow the progression in most cases.
axSpA
References
Six tips for living well with ankylosing spondylitis. Available at https://www.mayoclinic.org/diseases-conditions/ankylosing-spondylitis/in-depth/6-tips-for-living-well-with-ankylosing-spondylitis/art-20478753. Accessed 11/07/2022.
Ankylosing spondylitis. Mayo Clinic. Available at https://www.mayoclinic.org/diseases-conditions/ankylosing-spondylitis/symptoms-causes/syc-20354808. Accessed 11/05/2022.
D. J. Pradeep, A. Keat, K. Gaffney, Predicting outcome in ankylosing spondylitis, Rheumatology, Volume 47, Issue 7, July 2008, Pages 942–945, https://doi.org/10.1093/rheumatology/ken195
Kucybała, Iwona, et al. “Radiologic approach to axial spondyloarthritis: where are we now and where are we heading?.” Rheumatology international vol. 38,10 (2018): 1753-1762. doi:10.1007/s00296-018-4130-1
Michelena, Xabier, López-Medina, Clementina, and Helena Marzo-Ortega. “Non-radiographic versus radiographic axSpA: what’s in a name?”.” National Center for Biotechnology Information. October 14, 2020. https://doi.org/10.1093/rheumatology/keaa422
Swift D. Ankylosing spondylitis: disease progression varies widely. Medpage Today. Accessed 11/05/2022.Available at https://www.medpagetoday.com/rheumatology/arthritis/49096
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