What is Ankylosing Spondylitis?
Ankylosing spondylitis (AS) is a long-term condition that mainly affects the spine, causing inflammation and results in various symptoms. Key signs of this disease involve constant back pain and an increasingly stiff spine. AS often affects the spine and joint areas, including the sacroiliac joints (where your lower spine and pelvis connect), and can impact fingers and other connection points between muscles and bones.
AS has a significant impact on spine movement and can lead to abnormal body posture. It’s also common for people to experience pain in their buttocks and hips. Other associated problems include arthritis outside the spine, inflammation at the points where tendons or ligaments attach to bones, and swollen fingers or toes (also known as “sausage digits”).
Besides the impact on joints and bones, AS can affect other parts of the body. Up to half of the people with AS may develop inflammatory bowel disease. Eye inflammation (acute anterior uveitis) and skin condition psoriasis are also seen in 25%-35% and around 10% of AS cases, respectively.
Furthermore, those with AS have an increased risk of heart diseases, likely because of the inflammation linked with AS. Lung problems are also related to AS as restricted spine movement and reduced chest expansion can lead to breathing issues.
Lastly, people with AS are more likely to fracture their vertebrae (spine bones) and experience other serious risks including a condition with abnormal movement between the first two vertebrae, spinal cord injuries, and, although rare, a severe condition caused by compression of the nerve roots (cauda equina syndrome).
What Causes Ankylosing Spondylitis?
The exact cause of ankylosing spondylitis (AS), a type of arthritis, is mostly mystery. However, research has found a link between the likelihood of having AS and the presence of a certain human protein called the human leukocyte antigen (HLA)-B27. Among individuals who carry this protein, around 5-6% have AS.
In the United States, the frequency of this protein varies among different ethnic groups. A study from 2009 revealed that 7.5% of non-Hispanic Whites, 4.6% of Mexican-Americans, and 1.1% of non-Hispanic Blacks carry the protein.
Risk Factors and Frequency for Ankylosing Spondylitis
Ankylosing spondylitis (AS) often affects people under the age of 40. In fact, about 80% of people with AS start showing symptoms before they turn 30. Fewer than 5% of people are diagnosed with AS after 45 years old. Men are more likely to have AS compared to women. If a family member has AS, your chances of developing it are higher.
- Ankylosing spondylitis (AS) usually shows up in those under 40 years old.
- About 80% of AS patients start noticing symptoms before reaching 30 years old.
- Less than 5% of diagnoses occur in those older than 45.
- AS is more common in men than in women.
- If a relative has AS, your risk of getting it increases.
Signs and Symptoms of Ankylosing Spondylitis
Ankylosing spondylitis, or AS, is a disease that affects the entire body and can involve several organ systems. It generally presents with back pain that is of an “inflammatory” nature. This means that it has certain features that help doctors identify it. It’s important for doctors to conduct a thorough examination of the entire body when AS is suspected.
Particular pain features that suggest inflammation include:
- Starting before the age of 40
- Beginning slowly and subtly
- Improving with physical activity
- Not getting better with rest
- Worsening at night but getting better after getting up
Patients with AS can also experience stiffness in the spinal area, reduced mobility, and changes in posture, especially an exaggerated curvature of the back (known as hyperkyphosis).
Because AS can involve several areas of the body, medical professionals will look out for both musculoskeletal symptoms (related to the muscles and the skeleton) and extra-articular features (symptoms outside the joints). Hence, a detailed medical history is taken to check for associated conditions like skin disease psoriasis, inflammatory bowel disease, and eye inflammation uveitis, among others, which may be linked with AS.
Testing for Ankylosing Spondylitis
In cases of ankylosing spondylitis (AS), lab tests can support a diagnosis but don’t provide definite answers. Around 50% to 70% of patients with active AS often have increased levels of inflammation-related proteins. Medical imaging, particularly x-rays and MRIs, can provide clues about AS, especially in the spine and sacroiliac joints. X-rays can show changes in the joints, ranging from subtle to severe degradation. Over time, the joints may show erosion, hardening, and fusion. MRI can provide more detailed views, including detecting inflammation-related changes. However, MRI findings can also occur in people without AS.
Treatment Options for Ankylosing Spondylitis
The treatment goals for Ankylosing Spondylitis (AS) are predominantly designed to relieve pain and stiffness, maintain spine mobility and functionality, and avoid spinal complications. Non-medication treatments include regular exercise, posture training, and physical therapy.
The first course of treatment usually involves the regular, long-term use of non-steroidal anti-inflammatory drugs (NSAIDs). If these drugs aren’t providing enough relief, they can be used in combination with or replaced by tumor necrosis factor inhibitors (TNF-Is) such as adalimumab, infliximab or etanercept. A patient’s response to NSAIDs is typically evaluated after 4 to 6 weeks, and a response to TNF-Is evaluated after about 12 weeks.
While system-wide steroid drugs aren’t recommended for treating AS, steroid injections in specific areas may be considered for certain cases. Depending on how the disease presents in a patient, complications, and any non-joint-related symptoms of the disease, referrals to specialists may be needed. Rheumatologists can help to formally diagnose, manage, and monitor AS, while dermatologists, eye doctors, and digestive system specialists may assist with related non-joint-related symptoms of the condition.
What else can Ankylosing Spondylitis be?
When a doctor suspects a patient may have ankylosing spondylitis (AS), they need to rule out other diseases and conditions that show similar symptoms. These include:
- Mechanical lower back pain
- Lumbar spinal stenosis (a condition where the spaces within your spine are narrowed)
- Rheumatoid arthritis (a long-term autoimmune disorder resulting in inflammation of the joints)
- Diffuse idiopathic skeletal hyperostosis (DISH, a condition that causes some of the ligaments in your body to turn into bone)
Even though these conditions share some similarities with AS, doctors have to recognize their differences for an accurate diagnosis.
For instance, mechanical lower back pain and AS can be told apart by closely studying the symptoms. Mechanical back pain can occur at any age and feels better with rest, whereas AS normally arises before the age of 40 with symptoms that don’t improve with rest.
Lumbar spinal stenosis, characterized by a narrowing in the spinal column, may cause long-term back pain and stiffness in the morning, much like AS. However, it generally occurs in those above 60 years old, and doesn’t come with the other symptoms associated with AS.
Rheumatoid arthritis (RA) is a chronic joint inflammation disorder that may also cause long-term back pain and stiffness. This type of arthritis often causes painful swelling in the hands and feet, which is different from AS. Also, RA results in rheumatoid nodules, lumps beneath the skin that are not seen in AS.
Diffuse idiopathic skeletal hyperostosis (DISH) is a spine disorder that results in bone growth along the ligaments of the spine. Although it may cause changes in posture and back pain, similar to AS, it does not cause morning stiffness or improve with exercise but not with rest, unlike AS. Another major difference is that DISH does not result in sacroiliitis, inflammation of the sacroiliac joints, which is evident in AS.
What to expect with Ankylosing Spondylitis
People who develop ankylosing spondylitis (AS), a type of arthritis, at a young age might have worse physical conditions over time. However, it’s important to know that severe physical disability is rarely seen in people with AS. Most patients can keep up with a reasonable level of physical activity and live active and fulfilling lives.
Those who have a severe and long-term form of the disease have a higher risk of passing away compared to the average person. This increased risk of death is mostly due to complications related to heart disease.
Possible Complications When Diagnosed with Ankylosing Spondylitis
Ankylosing spondylitis (AS) is a condition that can cause various complications. These complications can be both within the joints (articular) and outside the joints (extra-articular). These complications can include:
- Chronic pain and disability
- A condition where the heart’s aortic valve doesn’t close properly (Aortic regurgitation)
- Scarring of the lungs (Pulmonary fibrosis)
- A condition affecting nerves in the lower spine (Cauda equina syndrome)
- Mental health issues (Mood disorders)
Recovery from Ankylosing Spondylitis
Exercise routines have been shown to be highly beneficial in helping people manage the condition known as ankylosing spondylitis. This includes managing pain, improving flexibility and mobility, and enhancing overall physical functions. Although there isn’t a single exercise plan that’s universally recommended for managing this condition, numerous studies have indicated improvements with a variety of exercise programs like home exercises and group therapy sessions.
One form of exercise, called hydrotherapy, is often mentioned for its heart health benefits and its power in managing pain for individuals with ankylosing spondylitis. Respiratory and postural exercises are also crucial for managing this condition because it can affect a person’s ability to breathe properly and maintain good posture.
Preventing Ankylosing Spondylitis
Teaching patients about their condition is important when they’re living with ankylosing spondylitis, a type of long-term arthritis. It’s crucial that they understand the ongoing nature of their health issue, are familiar with the medications used to treat it, and aware of any potential side-effects.
Stress should be put on the importance of regular exercise programs to ease symptoms. Physical therapy, including activities like water therapy and swimming, can be incredibly helpful to decrease symptoms, improve physical ability, and maintain overall fitness.
As ankylosing spondylitis may also impact the lungs, it’s very important to underline the need to stop smoking.
