Ankylosing Spondylitis
Ankylosing Spondylitis (AS) is a chronic (long-term) type of inflammatory arthritis that causes stiffness and pain in the back.
Ankylosing means the fusion or melding of two bones into one. Spondylitis means inflammation of the spine. Chronic inflammation causes the spine to become stiff and inflexible.
Ankylosing Spondylitis belongs to a family of diseases called the seronegative spondyloarthropathies that also includes psoriatic arthritis, enteropathic arthritis and reactive arthritis.
Systemic Autoimmune Disease
Ankylosing Spondylitis is an autoimmune disease. This means that it is caused by the body’s immune system attacking its own healthy cells and tissues by mistake. The reason why it does this is not well understood.
Ankylosing Spondylitis is called a systemic rheumatic disease because it can also affect other parts of the body including the eyes, lungs, and bowels.
Importance of Early Treatment
It is very important that Ankylosing Spondylitis is diagnosed and treated as early as possible.
Treatment prevents damage that can have crippling effects over time, and can reduce the risk of other problems associated with chronic inflammation such as heart disease, and the worsening of other health conditions.
Understanding Ankylosing Spondylitis
Ankylosing Spondylitis has a number of possible symptoms but the most common is back pain and stiffness.
It’s common for different people to show different symptoms, and experience different levels of discomfort and reduced mobility.
Most people with Ankylosing Spondylitis notice the first signs and symptoms of the disease in their late teens to early 30s, but it can strike at any time.
Back Pain and Stiffness
Back pain and stiffness is the most common symptom of Ankylosing Spondylitis .
Some people with Ankylosing Spondylitis live for years thinking they only have a stiff back without realizing they might have a serious autoimmune disease.
Fatigue
When the body’s immune system is “activated” and busy attacking the spine and joints, it can make a person feel very tired, similar to when they have the flu.
Inflammation of the Spine, Hips, Shoulders, and Knees
Over time, the inflammation caused by Ankylosing Spondylitis can eventually evolve from its starting point to the rest of the spine.
It can also evolve to other areas of the body like the hips, shoulders, and sometimes the knees.
Inflammation in the Foot
In some people, the tendons surrounding the joints at the back of the heels (Achilles) or under the bottom of the feet (plantar fasciitis) may become inflamed.
Eye Inflammation (Iritis)
People with Ankylosing Spondylitis can have inflammation in one or both eyes, called iritis.
Bowel Inflammation (Colitis)
Some people with Ankylosing Spondylitis also have inflammation in the bowel, called colitis.
Ankylosing Spondylitis is best diagnosed by a rheumatologist, a type of doctor that specializes in arthritis and autoimmune disease.
To diagnose Ankylosing Spondylitis, they will take a careful and complete history and perform a thorough physical examination.
The doctor will likely order tests like blood tests, X-Rays, or an MRI to confirm their diagnosis.
Ankylosing spondylitis occurs when the body’s immune system begins to attack its own joints for reasons that are not yet understood.
The joints between bones in the spine and/or the joints between the spine and the pelvis (called the sacroiliac or “SI” joints) are usually the first targets of this immune attack.
Why Bones Fuse Together
The immune system’s attack causes inflammation in the spine. The body then tries to repair itself by growing new bone.
The body’s inflammation and self-repair process works great to help heal minor injuries like a sprained ankle. Unfortunately in Ankylosing Spondylitis, this healing process is misguided. It can lead to bone growth across joints, connecting two bones together.
If Ankylosing Spondylitis is left untreated, joints in the spine and pelvis can become completely fused. This can cause considerable stiffness and pain. It can also lead to disfigurement (a “hunched” posture, or a “hump” back), and changes in gait (how a person walks).
Genetics
Like many other diseases, it is thought that genetics has a role to play in who gets Ankylosing Spondylitis.
About 9 out of 10 people with Ankylosing Spondylitis have a gene called HLA-B27. Having the HLA-B27 gene doesn’t guarantee that someone will get Ankylosing Spondylitis because many people have this gene who never develop the disease. Having the gene means that there is a higher chance of getting Ankylosing Spondylitis.
Ankylosing spondylitis should be treated early and aggressively. The goal of treatment is to keep the spine flexible and the joints moving before the disease causes bones to fuse together.
Once the damage from Ankylosing Spondylitis is done, it cannot be reversed with medicine. Ankylosing Spondylitis must be stopped before it damages the joints. Treatment can also help get affected joints back to moving smoothly as quickly as possible.
It is important for patients to attend their rheumatologist appointments regularly, and promptly get any blood tests or scans requested by doctors.
In general, treating Ankylosing Spondylitis has two important parts:
- Physical therapy and daily stretching can reduce stiffness in the back and improve overall mobility
- Medications that reduce pain, and improve function and mobility
A summary of all of the treatment options that can improve the lives of patients with Ankylosing Spondylitis follows:
Physical Therapy and Daily Stretching
Physical therapy has been shown to improve long-term outcomes for people with Ankylosing Spondylitis. It is an important part of an overall treatment plan.
The right stretching and exercises can improve stiffness in the back, especially the kind that’s worse in the morning.
Daily stretching and exercise can help improve posture and keep the joints in the back moving properly. It can also protect the joints by strengthening the muscles around them.
Lifestyle Improvements
Ankylosing Spondylitis is linked to heart disease, so people with Anklyosing Spondylitis should keep their blood pressure and cholesterol at healthy levels.
For patients with diabetes, it’s important to keep blood sugar under control.
Smokers with Ankylosing Spondylitis should quit as soon as possible because smoking is known to worsen symptoms and can make the disease a lot more difficult to treat.
Surgical Treatment for Severe Cases
In the most severe cases of Ankylosing Spondylitis, the joints of the spine and/or the pelvis are so badly damaged that they fuse together and may require surgery to fix.
Surgery often involves replacing a damaged joint with an artificial joint (most commonly the hip).
Surgery can help people with severe, advanced Ankylosing Spondylitis by reducing pain, improving their mobility and restoring their functioning.
Surgery of the spine is more complex and is usually reserved for patients with severe deformity due to Ankylosing Spondylitis.
Medications
Medications for Ankylosing Spondylitis fall into two broad groups:
- Medications that control the symptoms of Ankylosing Spondylitis. These include NSAIDs, analgesics (painkillers), and corticosteroids like prednisone.
- Medications control the disease and prevent long-term damage. These include biologics and DMARDs (Disease Modifying Anti-Rheumatic Drugs).
Before starting a new medication, patients should confirm if it has any interactions with alcohol or any other medications, supplements, or alternative therapies that they take.
There are no known natural remedies or complementary therapies that have been proven to help Ankylosing Spondylitis in any significant way.
NSAIDs
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are medications that reduce the inflammation in the joints caused by Ankylosing Spondylitis. They can also help to reduce symptoms such as pain.
There are about 20 different anti-inflammatory medications available, so if one doesn’t work for a particular patient, they can always try out another one with the guidance of their doctor.
It used to be thought that NSAIDs could alter the natural course of Ankylosing Spondylitis. However, newer research has shown that this is NOT true.
Analgesic Medications
Analgesic medications only control pain. They do nothing to control the disease or to prevent further joint damage.
Analgesics can range from common things like acetaminophen (Tylenol) to more potent narcotics like morphine.
Corticosteroids
Corticosteroids like prednisone can help control inflammation in some people.
Usually, prednisone isn’t that effective for Ankylosing Spondylitis. However, in high doses for short periods of time it can be an effective medication to control the symptoms of Ankylosing Spondylitis .
When used for long periods of time, prednisone can have side effects. A rheumatologist can help a patient understand the risks and benefits of this treatment as it applies to their Ankylosing Spondylitis.
Biologics
Patients with Ankylosing Spondylitis whose pain and stiffness aren’t relieved by anti-inflammatory drugs can be treated by a group of medications called biologics.
Biologic medications are extremely effective and can make a big difference for people with Ankylosing Spondylitis. They work by disrupting aspects of the body’s inflammatory response.
A type of biologic called anti-TNF biologics were first introduced in 1998. Until that time, there were few other options for people with Ankylosing Spondylitis if anti-inflammatory medications weren’t enough to control their disease.
Today there are a number of available anti-TNF biologics including Humira, Remicade (also known as Inflectra and Remsima), Enbrel, Cimzia, and Simponi. Newer biologics target other aspects of the inflammatory response, such as Cosentyx or Taltz, which inhibits a signalling protein called IL-17.
If one biologic doesn’t work for a particular patient, a rheumatologist may suggest another.
DMARDs
Disease Modifying Anti-Rheumatic Drugs (DMARDs) have been traditionally used to treat rheumatoid arthritis (RA). They aren’t used as often in Ankylosing Spondylitis because they don’t work as well as they do for Rheumatoid Arthritis.
As a general rule, common DMARDs like methotrexate or sulfasalazine don’t work to help symptoms in the back.
However, DMARDs can be helpful in treating other swollen joints like the knees or hips if a patient’s Ankylosing Spondylitis is affecting them.