Ankylosing spondylitis is a chronic inflammatory disease that primarily affects the lower back and the spine, though it may occur in other parts of the body. This includes the hips, shoulders, and knees as well as the tendons and ligaments around the bones and joints. The disease is usually characterized by back pain and stiffness. The exact cause is unknown; some risk factors for the condition include having a family history of the disease, being male, and having certain genetic variations. Treatment options may include lifestyle changes, medications, surgery, and routine monitoring.
Approximately 350,000 people in the United States have this condition. The disease affects men more often than women. Symptoms may start in adolescence and are usually present by age 30. In some people, it can cause significant pain and disability for many years.
Ankylosing spondylitis is a type of inflammatory arthritis that causes inflammation of the joints between vertebrae of the spine and joints between the spine and pelvis. The disease may also cause inflammation in other body parts. Some inflamed areas may include the place where tendons and ligaments connect to bones, the joints between the spine and ribs, and joints in the hips, shoulders, knees, and feet. It commonly causes inflammation in the eyes as well.
While the ankylosing spondylitis worsens and inflammation progresses, new bones form as the body's way of attempting to heal. As a result, the body's vertebrae fuse. This forms syndesmophytes, or bony outgrowths; vertebrae stiffen and lose flexibility. This fusion may stiffen the rib cage, limiting lung function and contributing to other complications.
Symptoms of ankylosing spondylitis are varied and change over time. Early signs of the disease include pain and stiffness in the lower back and hips. The pain is often worse in the morning, at night, or following long periods of inactivity. Pain eventually progresses to the spine and other joints.
Advanced stages of this chronic disease include limited chest expansion, a severely stooped posture, a stiff spine, fatigue, lack of appetite, weight loss, eye inflammation, and bowel inflammation. There is no known cause of ankylosing spondylitis, but genetic factors play a role in the onset of the disease. This severe form of arthritis generally targets males between the ages of 16 and 40.
Complications resulting from the disease can include difficulty with standing and walking. This is because when the bones of the rib cage fuse, the ribs cannot move when a person breathes. As a result, the lungs fail to fully inflate. Other complications include heart problems and lung infections.
If a person suspects that he may have ankylosing spondylitis, he should contact his doctor. A physician can conduct a series of tests that feature x-rays, CT scans, MRI, or blood tests in order to determine if a person has the disease. Once a person is diagnosed with ankylosing spondylitis, a physician specializing in the condition will prescribe several treatments.
Treatments are designed to delay or prevent complications and spine deformities as a result of the inflammatory disease. It is best to begin receiving treatment in the early stages of ankylosing spondylitis before bones have the opportunity to fuse, thereby limiting mobility. Typical treatments provided to a patient include nonsteroidal anti-inflammatory drugs (NSAIDs). These medicines relieve inflammation, stiffness, and pain. Other medications are disease-modifying antirheumatic drugs (DMARDs), treatments used to attack inflammation of the joints in the legs, arms and tissues.
DMARDs have the ability to limit joint damage. Corticosteroids suppress inflammation and joint damage in severe cases. They are taken orally for a short period of time and may even be injected into a painful joint when necessary.
Tumor necrosis factor (TNF) blockers is another type of treatment favored by doctors to treat the disease. A TNF is a cell protein that acts as an inflammatory agent. TNF blockers block this protein and help lessen pain, stiffness, and swollen joints.
Finally, doctors may prescribe physical therapy to their patients. Physical therapy sessions may help to relieve pain and improve strength and flexibility within the body. Severe joint damage and pain may require surgery, although this is a rare occurrence.
Ankylosing spondylitis is a condition that affects about 0.5 percent of people of Western European descent. It is one of many types of arthritis. Research scientists believe that a combination of environmental, genetic, and immune system factors cause this condition. However, at this point, they aren't sure how these possible ankylosing spondylitis causes tie together.
Environmental, genetic, and immune system factors are believed to play a role in causing ankylosing spondylitis; however, it is not clear how these factors specifically cause the condition. Certain risk factors can increase a person's chances of developing ankylosing spondylitis. These include such things as being male and having a certain gene variation.
Research has shown that people with certain risk factors are more likely than others to develop ankylosing spondylitis. A risk factor is anything that increases a person's chances of developing a disease. Having risk factors for ankylosing spondylitis does not guarantee that a person will develop the condition -- it is not a "cause" of the disease per se; it just increases a person's chances of developing it.
Some of these risk factors include:
Having a family history of ankylosing spondylitis
Possessing certain genetic factors
Being male
Being in adolescence or early adulthood
Having certain infections.
Family History
About 20 percent of people with ankylosing spondylitis also have a family member with the condition.
Genetic Factors
Scientists have identified certain genes that increase a person's chances of developing ankylosing spondylitis. For example, variations of the HLA-B gene increase the risk of developing the condition. The HLA-B gene provides instructions for making a protein that plays an important role in the immune system. HLA-B27, one variation, is found in about 95 percent of Caucasians with ankylosing spondylitis. It is also found in about 50 percent of African Americans with the condition.
Although many people with ankylosing spondylitis have the HLA-B27 variation, most people with this version of the gene never develop the disorder. It is not known how HLA-B27 increases the risk of developing ankylosing spondylitis.
Other genes are believed to affect the chances of developing ankylosing spondylitis and influence the progression of the disease. Some of these genes likely play a role in the immune system, while others may have different functions. Researchers are working to identify these genes and clarify their role in causing ankylosing spondylitis.
Age and Gender
Ankylosing spondylitis occurs twice as often in men as in women, and symptoms of the disease tend to be more severe in men. It is typically diagnosed in adolescence or early adulthood. (Most people are diagnosed with the disease between the ages of 17 and 35.)
Infections
Researchers think that infections with a virus or bacteria may increase a person's chances of developing ankylosing spondylitis. There also seems to be an increased risk in people who have recurrent urinary tract infections or bowel infections. This does not mean that ankylosing spondylitis is contagious. Researchers think the infection somehow triggers the condition in those people who are already susceptible to it because of their genetics.
In many cases, ankylosing spondylitis will begin with back pain, back stiffness, loss of flexibility, and bony tenderness. The disease may also cause arthritis in the shoulders, hips, and other joints. In up to 40 percent of people with the condition, signs and symptoms of ankylosing spondylitis may include episodes of eye inflammation called acute iritis; such episodes require immediate medical attention.
Ankylosing spondylitis is a condition that primarily affects the spine. It is a form of chronic inflammatory arthritis characterized by back pain and stiffness. These ankylosing spondylitis symptoms typically appear in adolescence or early adulthood. They often vary significantly from one person to another, and not everyone with the condition will experience serious symptoms or have spinal fusion.
Almost all cases of ankylosing spondylitis can periodically show up, or flare, and then get better. Unfortunately, there is no way for the healthcare provider to know what ankylosing spondylitis symptoms a particular person will have and whether or not these symptoms will flare.
The earliest symptoms of ankylosing spondylitis result from inflammation of the joints between the base of the spine (the sacrum) and the hipbones (the ilia). These joints are called sacroiliac joints, and inflammation in this region is known as sacroiliitis. The disorder also causes inflammation of the joints between vertebrae, which is called spondylitis.
This inflammation often results in early ankylosing spondylitis symptoms that include:
Back pain (most often lower back pain, although upper back pain or neck pain is possible)
Back stiffness
Some loss of flexibility
Bony tenderness.
Pain associated with ankylosing spondylitis may:
Develop gradually over many months
Worsen in the morning (or after long periods of rest)
Improve with activity
Wake a person up during the second half of his or her sleep
Usually be on both sides (although in the beginning it may alternate from one side to the other).
Back or neck stiffness is also worse in the morning and typically lasts at least 30 minutes.
Ankylosing spondylitis can involve other joints as well, including the:
Shoulders
Hips
Joints in the limbs (although this is not as common), including the ankle, elbow, knee, heel, and fingers.
Arthritis in the hips and shoulders occurs in up to 35 percent of people and can cause early symptoms of ankylosing spondylitis.
The main symptoms associated with arthritis are:
pain on moving the joint
tenderness when the joint is examined
swelling
warmth in the affected area
As ankylosing spondylitis progresses, back movement can gradually become limited as the bones of the spine (vertebrae) fuse together. Joint stiffness or a limited range of motion in certain joints is called "ankylosis." This may make it difficult to perform certain activities, like putting on shoes and socks.
Over time, ankylosing spondylitis can affect the joints between the spine and ribs, restricting movement of the chest and making it difficult to breathe.
Ankylosing spondylitis affects the eyes in up to 40 percent of cases, leading to episodes of eye inflammation called acute iritis. Acute iritis causes:
Eye pain
Blurred vision
Redness
Excessive tearing
Increased sensitivity to light (photophobia).
Acute iritis requires immediate medical attention. Healthcare providers treat it with medicines, and usually it improves within three months. Sometimes, eye problems occur before the joint symptoms.
Rarely, ankylosing spondylitis can also result in serious complications involving the heart and lungs. The most common problem in the heart in such cases is a leaking aortic valve (aortic regurgitation). This can eventually cause congestive heart failure symptoms. Lung problems associated with ankylosing spondylitis can include slowly progressive fibrosis of the upper part of the lungs (pulmonary fibrosis).
Some people experience a thinning of their bones during the early stages of ankylosing spondylitis. Weakened vertebrae may crumble, increasing the severity of your stooped posture. Vertebral fractures sometimes can damage the spinal cord and the nerves that pass through the spine.
A person with ankylosing spondylitis may also experience fever, excessive tiredness, muscle aches or pain, a decrease in red blood cells (anemia), and weight loss. These systemic symptoms are more common in children with ankylosing spondylitis than they are in adults with the condition.
It is also possible for a person with ankylosing spondylitis to have bowel inflammation, which can be associated with Crohn's disease or ulcerative colitis.
There is no cure for ankylosing spondylitis (AS), but treatment is available. It aims to:
relieve your symptoms
prevent your symptoms from interfering with your daily life
slow the process of stiffening of your spine
Ankylosing spondylitis is a chronic (long-term) condition, but most people who are affected by it are fully independent and lead relatively normal lives.
If your doctor thinks you have ankylosing spondylitis, they may prescribe medicines to control your symptoms. You will probably be referred to a rheumatologist (a specialist in conditions that affect the bones, muscles and joints).
The rheumatologist will advise you and your doctor about continuing your treatment using:
physical treatments, such as physiotherapy (where physical methods, such as exercise and manipulation, are used to improve your symptoms and wellbeing)
medication to control the pain and relieve the symptoms
These treatments are described in more detail below.
Physical activity and exercise are very important for effectively treating ankylosing spondylitis effectively. Keeping active can improve your posture and your range of spinal movement, as well as preventing your spine from becoming stiff and painful.
As well as keeping active, physiotherapy is a key part of treating ankylosing spondylitis. Your rheumatologist will be able to refer you to a physiotherapist (a healthcare professional who is trained in using physical methods of treatment). They can advise you about the best ways to exercise. They can also draw up an exercise program that is suitable for you.
If you have ankylosing spondylitis, the type of physiotherapy that may be recommended may include:
a group exercise program, where you exercise with other people
an individual exercise program – you are given exercises to do by yourself
massage – your muscles and other soft tissues are manipulated to relieve pain and improve movement (the bones of the spine should never be manipulated as this can cause injury in people with ankylosing spondylitis)
hydrotherapy – you exercise in water (usually a warm, shallow swimming pool or a special hydrotherapy bath); the weight of the water helps to improve your circulation (blood flow), relieve pain and relax your muscles
electrotherapy – electric currents or impulses (small electric shocks) make your muscles contract (tighten), which can help ease pain and promote healing
Some people prefer to swim or play sport to keep flexible. This is usually fine, although some daily stretching and exercise is also important (see below).
Exercise
The National Ankylosing Spondylitis Society (NASS) provides detailed information about different types of exercise that may help you to effectively manage your condition.
However, if you are in doubt, get advice from your physiotherapist or rheumatologist before taking up a new form of exercise or sport.
Alongside physiotherapy, you will also probably be prescribed medication. The different types of medications that you may be prescribed include:
painkillers
tumor necrosis factor (TNF) blockers
bisphosphonates
disease-modifying anti-rheumatic drugs (DMARDs)
corticosteroids
These are described below.
Your doctor may prescribe painkillers to manage your condition while you are being referred to a rheumatologist. The rheumatologist may continue prescribing painkillers, although not everyone needs them, at least not all the time. The first type of painkiller that is usually prescribed is a non-steroidal anti-inflammatory drug (NSAID).
Non-steroidal anti-inflammatory drugs (NSAIDs)
As well as helping to ease pain, non-steroidal anti-inflammatory drugs (NSAIDs) will also help to relieve inflammation (swelling) in your joints. Therefore, they are usually an effective treatment for ankylosing spondylitis. Examples of NSAIDs include:
ibuprofen
naproxen
diclofenac
When prescribing NSAIDs, your doctor or rheumatologist will try to find the one that suits you best and the lowest possible dose that relieves your symptoms. Your dose will be monitored and reviewed as necessary.
Cautions
NSAIDs may be unsuitable for you if you:
have asthma – a condition that causes the airways of the lungs (the bronchi) to become inflamed
have high blood pressure (hypertension)
have kidney or heart problems
have, or have previously had, stomach problems, such as a peptic ulcer
are pregnant
are also taking other medications, such as aspirin or warfarin (medicine to stop your blood clotting)
Paracetamol
If NSAIDs are unsuitable for you, an alternative painkiller, such as paracetamol, may be recommended.
Paracetamol rarely causes side effects and can be used in women who are pregnant or breastfeeding. However, paracetamol may not be suitable for people with liver problems or those who are dependent on alcohol (have an alcohol addiction).
Codeine
If necessary, as well as paracetamol, you may also be prescribed a stronger type of painkiller called codeine. Codeine can cause side effects including:
nausea (feeling sick)
vomiting (being sick)
constipation (an inability to empty your bowels)
drowsiness, which could affect your ability to drive
If your symptoms of ankylosing spondylitis cannot be controlled using painkillers or exercising and stretching, a tumor necrosis factor (TNF) blocker may be recommended for you. TNF is a chemical that is produced by cells when tissue is inflamed.
TNF blockers are given by injection and work by preventing the effects of TNF. This helps reduce the inflammation in your joints that is caused by ankylosing spondylitis. Examples of TNF blockers include:
adalimumab
etanercept
Side effects
Side effects from adalimumab and etanercept include:
reactions at the site of the injection, such as redness or swelling
infections, which can be severe, such as tuberculosis (an infection of the lungs) or septicaemia (blood poisoning)
nausea (feeling sick)
abdominal (tummy) pain
headache
TNF alpha blockers are a relatively new form of treatment for ankylosing spondylitis, and their long-term effects are unknown. However, research into the use of TNF blockers for treating rheumatoid arthritis (a type of arthritis that makes your joints feel stiff and can leave you feeling tired and unwell) is providing clearer information about their long-term safety.
If your rheumatologist recommends using TNF blockers, the decision about whether they are right for you must be discussed carefully, and your progress will be closely monitored. The main reason for this is that TNF blockers interfere with the immune system (the body's natural defense system).
NICE guidelines
The National Institute for Health and Clinical Excellence (NICE) has produced guidance about the use of these TNF blockers. NICE states that adalimumab and etanercept may only be used if:
your diagnosis of ankylosing spondylitis has been confirmed
your level of pain is assessed twice (using a simple scale that you fill in) 12 weeks apart and confirms that your condition is still active (has not improved)
your Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is tested twice, 12 weeks apart, and confirms that your condition is still active (BASDAI is a set of measures devised by experts to evaluate your condition by asking a number of questions about your symptoms)
treatment with two or more NSAIDs for four weeks at the highest possible dose has not controlled your symptoms
After 12 weeks of treatment with adalimumab or etanercept, your pain score and BASDAI will be tested again to see whether or not they have improved sufficiently to make continued treatment worthwhile for you. If they have, treatment with adalimumab or etanercept will continue and you will be tested every 12 weeks.
If there is not enough improvement after 12 weeks, you will be tested again after six weeks. If treatment with adalimumab or etanercept is still not effective, the treatment will be stopped.
If you cannot understand the BASDAI and pain tests, for example, because of a learning difficulty or because they are not available in a language you easily understand, it will be possible to assess the appropriateness and effects of TNF blocker drugs in other ways (an alternative method of assessment may be used).
Infliximab is an alternative TNF blocker that may be used to treat ankylosing spondylitis. However, it is not recommended by NICE. If you are currently taking infliximab, you should continue to do so until you and your rheumatologist decide that it is appropriate for you to stop.
Other new TNF blockers and similar medications are being developed and may be approved by NICE.
Bisphosphonates are usually used to treat osteoporosis (weak and brittle bones), which can sometimes develop as a complication of ankylosing spondylitis. Bisphosphonates may also be effective in treating ankylosing spondylitis, although the evidence is not entirely clear. They may be used if you also have osteoporosis.
Bisphosphonates can be taken by mouth (orally) as tablets or given by injection.
Disease-modifying anti-rheumatic drugs (DMARDs) are an alternative type of medication that is often used to treat other types of arthritis, such as rheumatoid arthritis. DMARDs may be prescribed for ankylosing spondylitis, although they are only beneficial if other joints are involved rather than the spine.
Two DMARDs have been studied for possible benefits in people with ankylosing spondylitis. Both may be helpful for inflammation of joints other than the spine, although neither seems to be helpful for spinal symptoms. They are:
sulfasalazine
methotrexate
Both are known to be effective for treating rheumatoid arthritis, but there is not currently enough evidence of the benefits of methotrexate for ankylosing spondylitis.
Sulfasalazine
Sulfasalazine can cause a number of side effects, such as:
nausea
vomiting
heartburn (when stomach acid leaks back up into your gullet)
serious skin reactions
Corticosteroid medicines (steroids) have a powerful anti-inflammatory effect and can be taken in various ways, for example as:
tablets (oral)
injections (parenteral)
If a particular joint is inflamed, corticosteroids can possibly be injected directly into the joint. Corticosteroids are sometimes used to treat other types of arthritis because they can reduce the pain, stiffness and swelling in a joint.
After the injection you will need to rest the joint for up to 48 hours (two days). It is usually considered wise to have a corticosteroid injection up to three times in one year, with at least three months between injections in the same joint. This is because corticosteroids injections can cause a number of side effects, such as:
inflammation in response to the injection
the skin around the injection may change color (depigmentation)
the surrounding tissue may waste away
a tendon (cord of tissue that connects muscles to bones) near the joint may rupture (burst)
Corticosteroids may also help to calm down painful swollen joints when taken as tablets. Occasionally, when pain and stiffness are severe, corticosteroids can be very helpful when given as an injection into your muscle (intramuscular injection).
If you have been diagnosed with ankylosing spondylitis, the self care advice that is outlined below may prove useful.
Make sure that you take the medicines that have been prescribed for you.
Make sure you do the stretches and exercises that your physiotherapist (a healthcare professional who is trained in using physical methods of treatment) recommends for you.
Make sure that you maintain a good posture when you are sitting and sleeping.
Do not smoke. As well as having a negative impact on your overall health, smoking is particularly risky for people with ankylosing spondylitis as it increases your risk of developing cardiovascular disease (conditions that affect the heart and blood flow, such as heart attacks).
Using hot or cold packs may help to relieve back and joint pain.
If you have ankylosing spondylitis, you may also have an increased risk of developing cardiovascular disease. Cardiovascular diseases include:
heart disease – your heart's blood supply is blocked or interrupted by a build-up of fatty substances in the coronary arteries (the blood vessels that supply blood to the heart)
stroke – a serious medical condition that occurs when the blood supply to the brain is interrupted
deep vein thrombosis (DVT) – where blood clots develop in one of the deep veins in your body, usually in your legs
Your rheumatologist (specialist in treating muscle and joint conditions) will be able to advise you about any lifestyle changes you should make to minimize your risk of developing a cardiovascular disease. These changes may include:
giving up smoking (if you smoke)
losing weight (if you are overweight or obese)
taking more regular exercise
keeping any other conditions that you may have under control, such as diabetes (a long-term condition caused by too much glucose in the blood) or high blood pressure (hypertension)
In a study, Dr Alan Ebringer, a famous rheumatologist and researcher based in London, found that a low starch diet helps in reducing the accompanying inflammation. This observation, though debatable, holds true for some patients. Dr Ebringer kept some of his patients on a low-starch, high protein diet for about nine months, and the inflammation in these patients was considerably reduced after a period of time. He had also noted in the research that klebsiella bacteria, that were found in the stool samples of many AS patients, could be the cause of ankylosing spondylitis in a majority of people having the disease. A low starch diet fights this bacteria, thus reducing its number. The diet proposed by Dr Alan Ebringer is renowned by the name London AS diet. The diet is based on the intake and avoidance of the following food items:
Patients should increase consumption of foods that are rich in protein and fiber, and low in fat:
Vegetables and fruits
Dairy products based on milk, and eggs
Nuts, peas and beans
Fish and meat
As per the London AS diet, patients should limit the intake of:
Rice
Potatoes
Bread and bread products
There is no specific diet for ankylosing spondylitis; in patients certain foods can trigger a change in symptoms, i.e, either the symptoms will subside, or worsen. Patients should keep a note of any such notable changes and discuss them with their physician to design a diet plan. The patient should adhere to the following guidelines, as far as food is concerned.
In arthritis or spondylitis, there is weakening of bones, and people who have spondylitis are at a higher risk of developing osteoporosis. Thus foods that have a high amount of calcium and vitamin D should be consumed by people with this disease.
Patients should try to avoid foods like pizzas, spaghetti, white bread, macaroni, cakes, puddings, and pies.
Alcohol is also not safe for bone health, and the consumption of alcohol should thus be restricted or limited by patients.
Drink lots of water, around 8-10 glasses per day.
Sodium, sugar, should be consumed in restriction.
Some foods can help you in reducing the inflammation that accompanies any form of arthritis. Below, we have tabulated the chief anti-inflammatory foods that you should ideally consume.
|
Vegetables |
Vegetables like green leafy vegetables, broccoli, cabbage and asparagus should make up a big part of your diet. |
|
Fruits & Nuts |
It is advised, you should have at least five portions of fruits daily. Plums, papaya, apples are good anti-inflammatory fruits. Nuts like hazelnuts, almonds, pecans and walnuts are best for patients with ankylosing spondylitis |
|
Others |
Eating dairy products also works in favor of reducing inflammation, especially eggs and products based on milk. Similarly, the consumption of tuna, salmon, brown rice, oregano, ginger, whole grain cereals and cod is also encouraged. |
There are some foods which should be necessarily avoided as they might aggravate the symptoms. The patient should keep a check on the consumption of junk food and rich sugary desserts as they might worsen the symptoms. There should also be a restriction on the consumption of alcohol, because alcohol impedes the absorption of vital nutrients and vitamins. Likewise, you should avoid consumption of citrus fruits, tomatoes, potatoes, products with a high amount of chili and pepper, coffee, and high fat dairy products.
There aren't any strict diet restrictions for patients of ankylosing spondylitis. However, for some relief from the pain, the consumption of some foods should be avoided and some foods should be increased. Patients should also exercise as it helps in reducing the stiffening of joints and facilitates smooth movement.