Spondyloarthritis – Ankylosing Spondylitis
Types, causes, symptoms, complications, diagnosis and treatment
Things You Need to Know About Ankylosing Spondylitis
What is Spondyloarthritis? What are the types of Spondyloarthritis?
Spondyloarthritis, also known as spondylitis or spondyloarthropathy, is a group of closely related rheumatic diseases that primarily affect joints and enthesis (ligaments and tendons). It is characterized by inflammatory back pain as well as pain and inflammation of the neck, intestine, pelvis, eyes and large joints in the body.
Spondyloarthritis is an umbrella term which is largely associated with the spine, however, it also includes problems related to inflammation of other areas in the body. The most common conditions of spondyloarthritis are:
- Ankylosing spondylitis is the inflammation and ankylosis (new bone formation) of the spine resulting in inflammatory back pain.
- Reactive arthritis is the inflammation of joints, skin, eyes, bladder, genitals and mucous membrane that follows after an infection in the intestine or urinary tract. Usually, the symptoms are not permanent and they subside in 3 to 12 months. In some cases, patients may develop chronic arthritis.
- Psoriatic arthritis is the inflammation and ankylosis of spondylitis in the spine and small joints in hands and feet with skin-related symptoms of psoriasis.
- Enteropathic arthritis is characterized by the spine and joint symptoms along with inflammation of the intestine which is associated with inflammatory bowel diseases.
- Juvenile spondyloarthritis: Children with spondyloarthritis (identified with prominent enthesitis) have more peripheral involvement especially in the lower extremity.
- Undifferentiated spondyloarthritis: Spondyloarthritis that does not fit into any of the above types are categorized here.
According to the newer SpA classification system, spondyloarthritis is classified into:
- Axial spondyloarthritis (AxSpA): It is a broad category that includes people with or without characteristic inflammatory changes of the sacroiliac joints (joints linking the lowest part of the spine to the pelvis) in X-ray.
- – Radiologic AxSpA: Spondylitis wherein the sacroiliac changes are prominent on X-ray. Almost all cases of ankylosing spondylitis belong in this category.
- – Non-radiologic AxSpA: Spondylitis without characteristic sacroiliac changes on X-ray.
- Peripheral spondyloarthritis (pSpA): This term covers inflammation in joints and/or tendons outside the spine or sacroiliac joints, such as joints in the hands, wrists, elbows, shoulders, knees, ankles, and feet.
What is ankylosing spondylitis?
Ankylosing spondylitis (AS) is a type of arthritis, which primarily affects the spine and cause inflammatory back pain. The condition also affects the joints in the shoulders, hips, ribs, heels and other joints. It is a systemic disease, which means that it is not just limited to bones and joints. AS causes inflammation of spinal joints (vertebrae) leading to severe and chronic pain, stiffness and discomfort.
“Ankylosis” is the formation of new bone tissue in the spine which causes sections of the spine to fuse in a fixed and immobile position. The spine becomes less flexible over time and results in a hunched forward posture.
What causes ankylosing spondylitis (AS)?
There are no specific known causes for AS, however, genetic factors seem to be involved in over 90% of the people with AS have gene HLA-B27.
What are the signs and symptoms of ankylosing spondylitis?
Early signs and symptoms of ankylosing spondylitis include pain and stiffness, particularly in lower back and hips (sacroiliac joint), especially during early mornings or after long periods of inactivity. The stiffness, inflammation and pain can be seen in other joints of the body. The shoulders, neck, hips, ribs, heels and small joints of hands and feet may be involved.
Systemic features like weight loss, fever, fatigue and inflammation are common.
Enthesitis: Inflammation of ligaments, tendons and capsules attached to the bone, mainly in the spine, sometimes in the back of the heel (Achilles tendon), also, the cartilage between the breastbone and ribs is a common symptom.
What are the risk factors for ankylosing spondylitis?
Some risk factors for ankylosing spondylitis are –
- Gender: It is less common and less severe in females.
- Age: as develops in late adolescence to early adulthood with the peak onset in the age range from 20 to 30 years.
What are the complications of ankylosing spondylitis?
Scarring and fusion of vertebrae: The hallmark feature of ankylosing spondylitis is the fusion of bones along the spine over time. In severe cases, as a part of the body’s healing mechanism, new bone is formed to bridge the gap between vertebrae. This scarring tissue eventually fuses the vertebrae, leading to stiffness and forward hunched posture.
The fusion can cause stiff rib cage, making deep breathing difficult for the patient, leading to reduced lung capacity and function.
Compression fractures: The weakened vertebrae can crumble; vertebral fractures can put pressure on the spinal cord and nerves passing through the spine.
Eye inflammation: Painful red eyes, inflammation, severe photophobia (sensitivity to light) or blurred vision.
Heart: Inflamed aorta and distorted aortic valve, this affects the blood supply to the body.
How is ankylosing spondylitis diagnosed?
- Medical history
- Physical Examination: It is advised to visit a doctor as soon as early signs and symptoms are apparent. During the physical examination, the doctor would test the range of motion in the spine by asking the patient to bend in different directions. Tenderness, stiffness and new bone formations can be felt by palpation along the spine. The doctor may ask you to deep breathe to check for difficulty in breathing upon chest expansion.
- In case of inflammation and photo-sensitivity in eyes, an ophthalmologist must be consulted immediately.
- Imaging Tests:
- – X-rays help the doctor look for changes in bones and joints, though the visible signs of the disease might not be evident in the earlier stages.
- – MRI gives detailed images of bones and soft tissues in the earlier stages of ankylosing spondylitis.
- Lab Tests:
- – There are no specific lab tests to diagnose ankylosing spondylitis. However, blood tests for markers of inflammation can be done.
- – Tests to check the presence of HLA-B27 gene may be done, though not everyone with defective gene gets affected by the disease, it may be done as a precaution.
How is ankylosing spondylitis treated?
Depending on the signs and symptoms and the medical condition of the patient, ankylosing spondylitis may be managed conservatively or surgically.
- Symptomatic management with medication – Non-Steroidal Anti Inflammatory Drugs (NSAIDs)/pain killers give relief from inflammation, pain and stiffness.
- Surgery is usually not required in most AS cases,the however, doctor might suggest this option when the patient is in a progressed stage where the pain is severe. Repair or replacement of damaged joints (hip/knee) and tendons may be done.
What are the lifestyle modifications needed in ankylosing spondylitis?
- Therapy: Physical therapy has proven to be the most effective in AS. Exercises are designed to improve the flexibility and range of motion. Stretching exercises and strength-building exercises are recommended for improving posture and strength. Proper sleep and walking positions, abdominal and back strengthening exercises are designed to improve or avoid the hunched forward posture and maintain upright position in the patient. Deep breathing exercises are recommended as well.
- Swimming is recommended as a choice of exercise as it has shown a good result in patients with AS. It helps in reducing pain and improving the posture and breathing.
- Regular massage with warm oils followed by fomentation provides relief from inflammation and pain.
- The patient is advised to be active throughout the day. Follow a healthy and balanced diet.
- Good posture practices.
- It is best to avoid smoking as tobacco aggravates the condition.
- The course of the disease can change overtime with the support of patient’s family and friends, along with the support of the doctor.
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- Mayo Clinic. Ankylosing spondylitis. Available at: https://www.mayoclinic.org/diseases-conditions/ankylosing-spondylitis/symptoms-causes/syc-20354808. Accessed on 15thMarch 2018.
- National Institute of Arthritis, musculoskeletal and skin diseases. Ankylosing spondylitis. Available at: https://www.niams.nih.gov/health-topics/ankylosing-spondylitis. Accessed on 15th March 2018.
- US National Library of Medicine National Institute of Health. Ankylosing spondylitis. Available at: https://medlineplus.gov/ency/article/000420.htm. Accessed on 15thMarch 2018.
- Spondyloarthritis: A Family of Related Diseases. Available at: https://www.spondylitis.org/Types-of-Spondylitis Accessed on 18th March 2018.