Ankylosing Spondylitis

What is Ankylosing Spondylitis?

Ankylosing spondylitis is a disease that causes pain and stiffness in the back, neck, and sometimes hips and heels. It begins with inflammation around the bones in the spine or in some joints. Later, it can sometimes cause the bones in the spine to fuse together.

What are the symptoms of ankylosing spondylitis?

The most common symptom is pain in the low back. This pain usually:

• Starts in early adulthood, usually before the age of 45
• Comes on slowly
• Lasts for more than 3 months
• Is worse after resting, such as first thing in the morning
• Feels better with movement

The back might also become less flexible. This can make it harder to do things like bend forward to put on socks or shoes. It can also lead to a "hunchback" posture over time.
Other symptoms might include:

• Pain or arthritis in other joints, such as the hips or shoulders
• Pain or swelling in other parts of the body, such as the elbows, heels, or ribs
• Feeling tired and not well

In some cases, ankylosing spondylitis can lead to other problems, such as:

• Inflammation of part of the eye – This is called "iritis" or "uveitis," and causes eye pain and blurry vision.
• Problems with the spinal cord – Ankylosing spondylitis makes it more likely that the bones in the neck or back will break. This can sometimes happen even from a very small fall or accident. If these bones break, the spinal cord can be injured. • Problems with the way the heart valves work
• Breathing problems – Some people have stiffness between the ribs and spine. This can make it harder to breathe deeply and to exercise.
• Inflammation of the inside of the intestines, which usually does not cause any obvious symptoms

Is there a test for ankylosing spondylitis?

There is no one test that can tell if you have ankylosing spondylitis. But your doctor or nurse should be able to tell if you have it by learning about your symptoms, doing an exam, and using imaging tests to look at your bones and joints.

Is there anything I can do on my own to feel better?

Yes. You can reduce the chance that your condition will cause problems if you:
• Stop smoking – If you smoke and have ankylosing spondylitis, you will be more likely to have breathing problems. Quitting smoking can help with this.
• Exercise – Exercise can help prevent some of the stiffness caused by ankylosing spondylitis. Follow your doctor's instructions for exercising and stretching.
• Get plenty of calcium and vitamin D – This can help to keep your bones from getting weak.
• Use a thin pillow – Sleeping on a thick pillow can cause neck problems in people with ankylosing spondylitis.

How is ankylosing spondylitis treated?

Treatment depends on your symptoms and how severe your condition is. The goal of treatment is to relieve your symptoms, help you do your normal activities, and keep your condition from causing other problems.

Exercise is an important part of treating ankylosing spondylitis. Some people work with a physical therapist (an exercise expert) to learn the best way to exercise. You might do stretches and gentle exercises to strengthen your muscles. It is especially important to work on your posture. That's because ankylosing spondylitis can cause the head to tilt forward in a "hunchback" posture. Special exercises can help prevent this.

Many people with ankylosing spondylitis also take one or more medicines. These might include:

• NSAIDs – This is a large group of medicines that includesibuprofen (sample brand names: Brufen ) andnaproxen (sample brand names: Naprosyn). These medicines can help relieve pain and stiffness.
• Other medicines – There are other medicines that can help treat symptoms and keep ankylosing spondylitis from getting worse. Your doctor or nurse will decide which medicines are best for you.

Surgery can help some people with severe ankylosing spondylitis. For instance, some people have hip replacement surgery to replace a bad hip joint.

What will my life be like?

Ankylosing spondylitis can make it hard to do simple things, such as getting dressed, getting up from a sitting position, and looking from side to side. You might need help from family or friends.

If the bones in your spine have fused together, you could be at risk of serious neck or back injury. To reduce the chances that you will get hurt:

• Remove loose rugs, electrical cords, and any clutter that could make you trip
• Do not drink a lot of alcohol or take sleeping pills
• Avoid contact sports and other activities that might cause injury
• Always wear a seatbelt while riding in a car.

OVERVIEW OF SPONDYLOARTHRITIS

Spondyloarthritis (SpA) is a family of arthritis- associated diseases. The most common diseases in this group are ankylosing spondylitis (AS) and nonradiographic axial SpA (nr-axSpA).

Diseases in the SpA family fall into one of two groups, axial SpA and peripheral SpA, but some patients have both axial and peripheral features:

• Axial SpA – These conditions involve the spine. AS and nr-axSpA are both types of axial SpA. Sometimes these patients also have involvement of joints in the arms and legs.
• Peripheral SpA – These conditions affect the joints of the arms and legs, fingers and toes, and heels. Some of these people have psoriatic arthritis, reactive arthritis, or arthritis associated with inflammatory bowel disease (ulcerative colitis or Crohn disease).

This topic discusses the symptoms, diagnostic tests, treatment, and complications of axial spondyloarthritis (axSpA).

AXIAL SPONDYLOARTHRITIS SPECTRUM OF SEVERITY

All people with axial spondyloarthritis (axSpA) share the common feature of back pain. However, there is a wide spectrum in terms of the severity of the disease:

• At one end of the spectrum are people who, on X-ray, do not show any changes in the sacroiliac joints (the joints that connect the bottom of the spine to the pelvis) or the vertebrae (the bones of the spine). This is callednonradiographic axial SpA (nr-axSpA); "nonradiographic" means not visible on X-ray. A more sensitive test, usually magnetic resonance imaging (MRI), is needed to detect changes in the sacroiliac joints in these patients.
• Over time, some people in the nr-axSpA category develop signs of radiologic changes, especially of the sacroiliac joints. Once the sacroiliac joints are clearly affected on X-ray, a person is said to haveankylosing spondylitis (AS).
• At the other end of the spectrum, in some people with ankylosing spondylitis (AS), the sacroiliac joints as well as the vertebrae become fused into what doctors call a "bamboo spine."

Many people with nr-axSpA do not go on to have AS, and many people with AS do not advance to "bamboo spine." The same treatments are effective in both nr-axSpA and AS.

AXIAL SPONDYLOARTHRITIS SIGNS AND SYMPTOMS

The most common symptom of axial spondyloarthritis (axSpA) is pain in the lower back. Some people also have pain, stiffness, and limited mobility outside the spine, such as in the hips, knees, and heels..

Spinal pain — Spinal pain, almost always in the lower back, is usually the first and most common symptom of axSpA. The pain generally has some of the following characteristics:

• Begins in early adulthood (before 45 years of age)
• Has a gradual onset (rather than sudden onset after an acute injury or a disc problem)
• Lasts longer than three months
• Is worse after rest (eg, in the morning)
• Improves with activity
• Wakes you up in the second half of the night
• Can cause morning stiffness lasting more than 30 minutes
• Can be associated with buttock pain that alternates between the left and right sides

Limited spinal flexibility — Limited flexibility of the back and neck is more severe in ankylosing spondylitis (AS) than with nonradiographic axial SpA (nr-axSpA). In AS, the degree of inflexibility ranges from minor to complete inflexibility. Limitations in flexibility of the back and neck can make it hard to do normal daily activities, such as putting on shoes and stockings. The most serious consequence is developing an irreversible head-forward "hunchback" posture. More normal posture can often be maintained by regularly performing posture training exercises. You can test yourself for a hunchback posture by standing against a wall, with your back and heels touching the wall. Normally it is possible to touch the wall with the back of the head while keeping the chin parallel to the floor. If you cannot touch the wall with the back of the head, this indicates that you have a significant head-forward hunchback posture. If you are not already doing physical therapy and posture training to help with this, your doctor can help you get started.

Other symptoms -Other symptoms of axSpA can include:

• Fatigue and sleeplessness – Inflammation in axSpA can affect the entire person, causing fatigue and sleeplessness.
• Anxiety and depression – These problems sometimes affect people with axSpA.
• Hip pain – Arthritis of the hips is relatively common in AS, but much less so in nr-axSpA. Hip arthritis can cause pains in the groin or buttocks or difficulty walking.
• Heel pain – A common area of inflammation is the heel. This can cause pain at the back of the heel (Achilles tendinitis) and in the sole of the foot (plantar fasciitis).
• Shoulder pain – Inflammation of the tendon and bone may cause shoulder pain and limited mobility of the affected shoulder(s).
• Arthritis in other joints – Pain, stiffness, and swelling of other joints may occur. Arthritis may affect a single joint (monoarthritis) or a few joints (oligoarthritis). This is mainly seen in the hips, knees, ankles, heels, and feet.
• "Sausage-digits" – Sausage-shaped swelling can affect one or several toes and fingers.
• Other organs – Body systems other than the joints can be affected

The combination of symptoms varies from person to person. The diagnosis of AS or nr-axSpA must be made by a clinician and cannot be made using an itemized checklist.."

AXIAL SPONDYLOARTHRITIS RISK FACTORS

Ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (nr-axSpA) are usually diagnosed in young adults between the ages of 20 and 30 years.
The disease can be more common in certain families. For example, a person's risk of developing axSpA increases if a first-degree relative (parent, sibling, or child) has axSpA. The presence of a gene called human leukocyte antigen (HLA)-B27 also increases the risk of developing axSpA.
Smoking is the single most important risk factor you can change for developing more severe disease. If you are a smoker and have been diagnosed with axial spondyloarthritis (axSpA), you should try to quit as soon as possible. Your health care provider can help you make a plan to quit.

AXIAL SPONDYLOARTHRITIS DIAGNOSIS

Ultimately, the diagnosis of axial spondyloarthritis (axSpA) must be made by an experienced clinician and is based upon a combination of symptoms, physical examination, blood tests, and imaging tests such as X-ray and magnetic resonance imaging (MRI). Based on the results, a clinician can assign a degree of probability to whether axSpA is causing your symptoms. The diagnosis cannot be made by ticking a checklist.
For some people, observations for months or years might be necessary before a clinician can be confident of the diagnosis. In general, axSpA should be considered if you have daily back pain for more than three months that starts before the age of 45, especially if this back pain is predominantly present in the morning and improves after movement.

• Blood tests — There are no blood tests that, by themselves, can definitively diagnose or exclude axSpA. However, testing for the presence of one particular type of the human leukocyte antigen (HLA) gene, HLA-B27, can be helpful in certain people. AxSpA is less likely in a person with a negative test for HLA-B27 who is white and of European descent. Tests for proteins called "acute phase reactants" are sometimes helpful but are not diagnostic for axSpA; these tests, which are markers of inflammation in the body, include C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) tests.

• Imaging tests — People with axSpA develop characteristic changes in the sacroiliac joints. These are the joints that connect the base of the spine (sacrum) to the large pelvic bone (ilium) on both sides. In ankylosing spondylitis (AS), these changes can be seen on radiograph (X-ray) images.

Imaging tests such as MRI detect the disease earlier than plain X-rays. In nonradiographic (nr)- axSpA, findings suggesting inflammation in the sacroiliac joints may be present on MRI when the X-rays are negative. The interpretation of both the X-ray and the MRI requires training and, to a certain extent, is observer-dependent. Two clinicians might not agree on the same X-ray or MRI. Imaging tests should always be interpreted in the context of the symptoms, physical examination, and blood tests.
In people already diagnosed with AS, radiographs of the vertebrae are also useful in assessing the degree of structural damage to the spine.

TREATMENT OF AXIAL SPONDYLOARTHRITIS

The treatment approaches to ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (nr-axSpA) are similar. A number of treatments are available; the selection is tailored for each individual, based on the characteristics and severity of the disease. Treatment may include some or all of the following:

• Physical therapy, exercise, and posture training- It is best to start exercising as soon as possible after being diagnosed with axSpA and to continue exercising regularly. Exercise should be part of the treatment program for everyone with axSpA. It can include home exercises, individual or group exercise with a physical therapist, or individual physical therapy treatments. It can be "land-based" or in a pool, with or without additional therapies. Optimally, you should be evaluated and given instructions by a physical therapist and be monitored periodically.
The minimum exercise program includes core strengthening and should also contain cardiovascular exercises, isometric strengthening (exercising muscles while holding a position rather than through motion), breathing, stretching, and dynamic movements.
Because axSpA can lead to the spine becoming "frozen" in an awkward posture, posture training is very important. Modern sedentary life often involves sitting in a slumped posture in front of a computer, which causes shortening of the muscles at the back of the thighs, tilting of the hips forward, weakening of the muscles of the upper back, and a tendency to bend and hold the neck and head too far forward. A vigorous posture training program should be aimed at compensating for these issues.

• Safety issues- A fused, immobile, inflexible spine is more easily fractured than a normal spine. Because of the increased risk of serious spinal injury from even minor falls or other accidents, people with axSpA with an inflexible spine should take care to avoid such mishaps. Safety measures you can take include the following:

• Limit the amount of alcohol you drink. Narcotic pain-relieving drugs (such as codeine) and sedatives (sleeping pills) should be used cautiously, if at all, since these also increase the risk of falling.
• Modify your home to decrease your risk of falling. Shower or tub grab-bars and nightlights decrease the chance of a fall. Remove or secure loose rugs, and keep walkways free of clutter, electrical cords, and other things that could be tripped over.
• Take precautions in the car. Seatbelts reduce the risk of injury in a car crash and should always be worn while driving or riding in a vehicle. A wraparound rearview mirror can improve visibility while driving if you cannot turn your head and neck.
• To avoid developing deformities of the neck, use a thin, rather than thick, pillow for sleeping.
• If you have an inflexible spine, avoid contact sports and other high-impact activities.
• Perform fall-prevention exercises as part of your exercise program.

• Diet — There are no special dietary recommendations for axSpA other than maintaining a healthy diet. There is a lack of evidence for benefit from the intake of probiotics.

Medications

Nonsteroidal antiinflammatory drugs — Nonsteroidal antiinflammatory drugs (NSAIDs) are commonly used to control pain and stiffness. NSAIDs need to be taken on a regular basis for several weeks before their maximum effect can be judged. If one NSAID is not effective, your doctor might try another one.

Opioids — Opioids (narcotics) are a group of medications that can relieve pain in certain situations. Opioids can cause side effects, some of which can be serious. They can also lead to misuse and addiction in some people. In general, people with axSpA and chronic pain shouldnotuse opioids. You should only take them if your clinician has prescribed them after a detailed discussion about their relative risks and benefits.

Sulfasalazine and methotrexate —Sulfasalazine is a disease-modifying antirheumatic drug (DMARD) that may be prescribed for people with axSpA who also suffer from peripheral arthritis (affecting joints outside the spine). This drug provides some relief of arthritis symptoms but is not helpful for axial (spine) symptoms. It may be given along with NSAIDs. Methotrexate might also be effective for peripheral arthritis but is not for axial symptoms

Anti-tumor necrosis factor therapy — A group of medicines known as anti-tumor necrosis factor agents (anti-TNF agents or TNF inhibitors) are often effective in the treatment of axSpA. Examples of anti-TNF medications include infliximab, etanercept, adalimumab, certolizumab pegol, and golimumab. People who do not respond to one anti-TNF treatment may respond to another. Improvement in symptoms is common and may occur within a few weeks of starting the drugs.
Not every person with axSpA needs anti-TNF therapy. In general, people with active disease in the spine who have not responded fully to NSAIDs may be candidates
Your clinician may also recommend a glucocorticoid (cortisone-like drug) injection into painful or swollen peripheral joints before starting an anti-TNF drug if these areas continue to bother you despite using NSAIDs or DMARD therapy. The decision to use anti-TNF therapy depends upon several factors that should be discussed with your clinician.

Surgery — Hip or spine surgery may be beneficial in some people with axSpA. Surgical procedures may include one or more of the following:

• Total hip replacement (arthroplasty)
• Spinal surgery
• Wedge osteotomy

HOW DO I COPE WITH AXIAL SPONDYLOARTHRITIS?

Psychological well-being — In addition to physical symptoms, some people with axial spondyloarthritis (axSpA) also have feelings of sadness or frustration, and a sense that they are missing out on a lot of activities or letting people down. Brain imaging studies show that some people with ankylosing spondylitis (AS) even have changes in activities and structures of the brain associated with mood (happiness, sadness, etc).
There are two types of coping strategies. One is passive coping, in which you rely totally on medications or your clinicians for help. The other is active coping, in which you rebuild your psychological defense systems through approaches such as mindfulness, cognitive behavior therapy, and positive psychology
Physical limitations — AxSpA can affect daily life in various ways. Dressing, reaching, rising from a chair, getting up from the floor, standing, climbing steps, looking to the side or over the shoulder, exercising, and doing household and other work-related tasks can become more difficult as a result of the limited joint and spinal motion.

PROBLEMS OUTSIDE THE SPINE OR THE JOINTS

Among the possible clinical problems outside the spine and the joints, the most frequent is anterior uveitis. To a lesser extent, people with axial spondyloarthritis (axSpA) might suffer from psoriasis or inflammatory bowel disease.

• Anterior uveitis – Uveitis, or inflammation of part of the eye, is the most common axSpA- related problem that does not involve the joints. Anterior uveitis affects the iris (the colored part of the eye). It causes pain in the eye, blurring of vision, and light sensitivity. Uveitis requires immediate medical attention and treatment with eye medications. It is usually responsive to treatment with eye drops and often resolves within several months.
• Psoriasis – Psoriasis is a skin condition that might affect people with axSpA. In psoriasis, areas of the skin are thickened and red, and these may be covered with white or silvery scales. Sometimes the nails are involved.
• Inflammatory bowel disease – Crohn disease or ulcerative colitis, which is an inflammatory condition of the bowel, sometimes coexists with axSpA. Inflammatory bowel disease can cause abdominal pain or cramps, diarrhea, and bloody bowel movements. Also, shallow ulcerations in the lining of the bowels are observed in some people with axSpA. Such ulcerations do not usually cause any symptoms.
• Depression and fibromyalgia – Some patients with axSpA also develop depression, anxiety, and sometimes pain from fibromyalgia (a chronic disorder that causes widespread pain, fatigue, poor sleep, and poor concentration). These conditions should be evaluated and treated as well.
• Cardiovascular disease – There is a possibility that people with axSpA may have a higher risk for cardiovascular diseases such as heart attack. Because of this, it is a good idea to minimize other factors that may increase this risk. This includes avoiding smoking, leading a healthy lifestyle, and getting treatment for high blood pressure.

COMPLICATIONS OF LONGSTANDING ANKYLOSING SPONDYLITIS

The following complications may happen in people with advanced ankylosing spondylitis (AS), although they are rare.

• Spinal fractures and spinal cord injuries – Spinal fractures and spinal cord injuries are, respectively, 4 and 11 times more common in patients with AS than in the general population. Most of the acute fractures occur in the neck. Because a spine affected by AS is more easily fractured than a healthy spine, in many cases, injury can result from even a low-impact activity or incident. Patients with spinal cord injuries may have only minor initial neurologic symptoms such as neck pain, numbness, or weakness.
Any neck or spine injury requires immobilization, consultation with a doctor, and evaluation in an emergency facility. More than half of neck fractures in people with AS are undetectable by plain radiograph (X-ray). Computed tomography (CT) and magnetic resonance imaging (MRI) are more sensitive imaging techniques.
• Neurologic problems – Cauda equina syndrome is a rare complication that occurs in people with longstanding disease who have severe stiffening of the spine. The symptoms result from damage to many nerves in the lower back and include abnormal sensation and weakness of the lower extremities and difficulty with bladder and bowel control. Men may experience erectile dysfunction or impotence.
• Heart valve disease – The most serious problem that can affect the heart is a leaking aortic valve (aortic regurgitation), which can cause symptoms of heart failure, including leg or ankle swelling (edema) and shortness of breath during exercise or exertion. This requires monitoring and, in some cases, treatment with medications or even surgery.
• Pulmonary (lung) disease – Many people with AS are unable to fully expand the chest normally during breathing because of stiffness between the ribs and the spine. In some cases, there are actual changes in the lung tissues. This may or may not cause breathing problems.

Because the severity and outcome of axial spondyloarthritis (axSpA) vary tremendously from person to person, treatment must be tailored to each individual. However, everyone with axSpA can benefit from the following:

• Stop smoking cigarettes, if you smoke. People who smoke and have AS can have problems with their breathing. AS can limit the movement of the chest and can reduce the amount of air the lungs can hold.
• Maintain correct upright and sitting posture and participate in an exercise program.

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