Ankylosing Spondylitis symptoms, causes, and treatments

What is Ankylosing Spondylitis (AS)? 

AS is a type of auto-immune disease that causes arthritis in the spine usually starting from lower back and spreading all the way to the neck and sometimes peripheral joints. “Ankylosis” means fused joints or other hard tissue. “Spondylitis” means inflammation of the spinal joints or vertebrae. It is a life-long condition and in severe cases it can cause a permanent hunched spine.

What are the common symptoms of AS?

• Lower back and/or hip pain and stiffness
• Over time the symptoms may spread to other areas of the body. Pain typically worsens after periods of rest and inactivity, which may cause some people to experience more pain during the middle of night or prolonged sitting. Usually, moving and exercises improve pain.
• Pain, stiffness and inflammation in other joints such as ribs, shoulders, knees or feet.
• Difficulty taking deep breaths if the joints connecting ribs are affected. 
• Vision changes and eye pain due to uveitis, i.e. inflammation of the eye.
• Fatigue or feeling very tired.
• Loss of appetite and weight loss.
• Skin rashes, in particular psoriasis.
• Abdominal pain and loose bowel movements.                          (https://www.niams.nih.gov/health-topics/ankylosing-spondylitis) 

What are the causes of getting AS?

Researchers aren`t sure what triggers the development of AS, however they have found a gene called human leukocyte antigen – B (HLA-B27) linked to the disease. Mutation or change in this gene may be the cause of getting AS. 

What are the risk factors of getting AS?

AS affects less than 1% of the U.S. population. One of the main risk factors for getting AS is having the HLA-B27 gene. Most people who have the gene don`t get AS, while those who don`t have the gene can also get AS. 

Chances of getting AS are more likely if 

• Male at birth
• Age is under 40 (about 80% cases begin around age 30) 
• Have a close family member with AS

Having another auto-immune disease may also increase chances of getting AS for e.g. having 

• Crohn`s disease
• Ulcerative colitis 
• Psoriasis                                                                                            

How is AS diagnosed?

Patient history about joint pain including duration, location, intensity, aggravating and relieving factors is taken. Detailed medical history of the patient and the family are taken into consideration. Physical examination of the patient is performed covering joint mobility assessment, inflammatory marker assessment, relevant special tests for the Musculo-skeletal region are performed to arrive at a differential diagnosis. 

To confirm the hypotheses, imaging such as X-rays or MRI scanning are recommended. Additionally, lab tests such as blood test to detect HLA-B27 and presence of other inflammatory markers can confirm the diagnosis of AS. 

Evidence of sacroiliitis on imaging, whether radiographic or magnetic resonance imaging, is considered a major inclusion criteria for AS according to the Assessment of Spondyloarthritis International Society (2009) axial spondyloarthritis criteria. A standardized plain radiographic grading scale exists for sacroiliitis. This scale ranges from normal (0) to most severe (IV) AS, as stated below.

• Grade 0 – Normal SI joint width, sharp joint margins
• Grade I – Suspicious margins 
• Grade II – Sclerosis, some erosions 
• Grade III – Severe erosions, pseudo dilation of the joint space, partial ankylosis
• Grade IV – Complete ankylosis (https://www.ncbi.nlm.nih.gov/books/NBK470173/) 

What are the key treatments for AS?

The aims of treatment for AS are: 

• Relieve symptoms
• Help maintain proper posture, flexibility and strength
• Halt or slow disease progression

The aims of treatment are achieved with the following:

• Medication includes one or more of the following: 
  • Over the counter anti-inflammatory medication or prescription non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen sodium (Aleve) and ibuprofen (Advil) are used. It is safer to take doctor`s advise before taking medication to avoid side effects like intestinal bleeding. 
  • If NSAIDs don`t work, the doctor may prescribe other class of medication such as Tumor Necrosis Factor (TNF) blocker like Humira, Cimzia, Enbrel or Interleukin-17 (IL-17) inhibitor like Cosentyx or Taltz. 
  • A type of disease modifying drug such as Janus kinase (JAK) inhibitor such as Xeljanz or Rivoq can also be prescribed.
  • Corticosteroids can help decrease inflammation and provide a degree of immediate pain relief. (https://www.mayoclinic.org/diseases-conditions/ankylosing-spondylitis/diagnosis-treatment/drc-20354813) 
• Physical therapy and exercises aim at:
  • Pain relief with the help of various modalities like hot or cold packs, transcutaneous electrical nerve stimulation, Russian currents and grade 1 joint mobilizations.
  • Strengthen neck and back muscles which improves spinal posture and stability.
  • Improve core and abdominal muscle strength to support to axial skeleton and peripheral body movements.
  • Improve postural awareness and self-management. 
  • Improve sleeping position to adapt to disease progression. (https://www.niams.nih.gov/health-topics/ankylosing-spondylitis/diagnosis-treatment-and-steps-to-take) 
• Surgery: Most people with AS don`t require surgery, but if the disease is in advanced stage there may be candidates for joint replacement to help regain movement of severely damaged e.g. hip joint. Laminectomy to decompress the spine and osteotomy to realign the body posture can be recommended in severe disability. 
• Lifestyle changes and alternative remedies: 
  • There is little scientific evidence that probiotic supplements can benefit those with AS. Some people find mind-body movements such as yoga, Tai-chi or Pilates to be helpful. 
  • Keeping healthy weight ensures that the spinal and lower extremity joints aren`t under as much stress. 
  • Diet rich in Omega-3 fatty acids may help. Watching for certain dietary triggers will help prevent flare-ups. Plenty of bright colored fruits and vegetables intake helps anti-inflammation and anti-oxidant properties. Adequate hydration helps flush accumulated toxins out of the body. 
  • Quitting smoking will help reducing additional inflammation and retard disease progression.
  • Managing stress with massage, yoga, meditation, mindfulness and counselling will also help to slow disease progression. 
  • Getting enough sleep ensures adequate healing and muscle relaxation.

Making time for exercises daily helps most cases of AS to prevent disease advancement. 

Improve and maintain joint flexibility.