Ankylosing Spondylitis

What is Ankylosing Spondylitis?

Ankylosing spondylitis (AS) is a type of inflammatory arthritis that primarily affects the spine or back. In AS, the joints and ligaments along the spine become inflamed. The inflammation produces pain and stiffness that usually begins in the lower back or buttocks, and may progress into the upper spine, chest and neck. Over time, the joints and bones (vertebrae) may grow together (fuse), causing the spine to become rigid and inflexible. Other joints, such as the hips, shoulders and knees may also be affected. AS is a systemic disease, which means it may affect organs.

Ankylosing Spondylitis Causes

The cause of ankylosing spondylitis is unknown, but genes and heredity play an important role. Scientists have discovered a gene called HLA-B27 that is found in about 90 percent of Caucasians with AS but only 8 percent of Caucasians without AS, suggesting this gene plays an important role in disease development. Some evidence suggests that AS may be triggered by an infection. Studies have focused on several bacteria that may influence the development of AS.

Who’s Affected by Ankylosing Spondylitis?

Nearly half a million people in the United States are affected by AS. The disease is more common in men than in women. Ankylosing spondylitis may develop in childhood, and boys are more likely to have it than girls. When children develop ankylosing spondylitis, symptoms usually begin in the hips, knees or heels and later progress to the spine. This disease occurs more often in Caucasians, Asian and Hispanic populations.

Ankylosing Spondylitis Symptoms

The first sign of AS is inflammation in the areas where the lower spine joins the pelvis. This frequently occurs between the ages of 17 and 35.

The most common early symptoms of AS are:

• Chronic pain and stiffness in the lower back, buttocks and hips (usually develops slowly over several weeks or months)
• Pain and stiffness that worsens during periods of rest or inactivity and improves with movement and exercise
• Back pain during the night or early morning
• Feeling very stiff in the morning

AS Long-Term Effects

Over time, pain and stiffness may progress to the upper spine and even into the rib cage and neck. Ultimately, the inflammation can cause the sacroiliac and vertebral bones to fuse or grow together. When the bones fuse, the spine loses its normal flexibility and becomes rigid. The rib cage also may fuse, which can limit normal chest expansion and make breathing more difficult. Inflammation and pain also can occur in the hips, shoulders, knees, ankles, toes and fingers, which may limit mobility. The heels may be affected, making it uncomfortable to stand or walk on hard surfaces.

Smokers who have ankylosing spondylitis (AS) have more spinal damage than non-smokers with the same level of disease activity. Having the disease is also linked to an increased risk of heart disease and stroke.

The disease can cause fever, loss of appetite, fatigue and inflammation in the lungs, heart and eyes. Eye inflammation (called iritis or uveitis) occurs in more than one-fourth of people with AS. Iritis causes redness and pain in the eye that worsens with exposure to bright light.

Ankylosing Spondylitis Diagnosis

The symptoms of AS often resemble other forms of arthritis such as psoriatic arthritis, arthritis associated with inflammatory bowel diseases (such as Crohn’s disease or ulcerative colitis) or reactive arthritis. Seeing a doctor, preferably a rheumatologist, early for an accurate diagnosis is very important.

To diagnose AS, the doctor will rely on medical history, physical examination of joints and spine, imaging tests of the pelvis and also blood tests to check for the HLA-B27 gene. Having the HLA-B27 gene doesn’t mean someone has AS; but it is a clue that may support the diagnosis. Many people have the HLA-B27 gene and don’t have AS.

Ankylosing Spondylitis Treatment

Treatment for AS focuses on reducing pain and stiffness, preventing deformities and allowing for the continuation of normal activities. The options include:

Analgesics

The doctor may recommend over-the-counter analgesics (pain relievers) such as acetaminophen (Tylenol) or prescribe an opioid analgesic such as tramadol (Ultram).

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

NSAIDs are the recommended first-line treatment for AS. They help relieve the symptoms – pain and stiffness – that come with this condition. NSAIDs that may be used to treat AS include over-the-counter drugs, such as ibuprofen (Advil) and naproxen (Aleve), as well as the prescription drugs indomethacin, diclofenac or celecoxib.

Disease-modifying Antirheumatic Drugs (DMARDs)

DMARDs can alter the course of AS. Some patients who don’t respond well to NSAIDs may be given a traditional DMARD such as sulfasalazine to reduce pain and swelling of the small joints of the hands or feet. Biologics, short for biologic response modifiers, are a subset of DMARDs. Biologics are the preferred treatment for patients with high disease activity that doesn’t respond well to NSAIDs. They work to control disease at the cellular level. There are several different forms of biologics; the one that works best with AS is called a tumor necrosis factor (TNF) inhibitor or, sometimes, an anti-TNF agent. Tumor necrosis factor is a substance found in cells that causes inflammation. Four biologic agents are currently approved to treat AS: infliximab, etanercept, adalimumab and golimumab.

Corticosteroids

Corticosteroid injections into the joint or surrounding tendons can provide relief as well. However, these treatments work best for patients with arthritis away from the spine; they don’t reduce pain and stiffness in the spine.

Surgery

Joint replacement surgery allows many people to regain the use of joints damaged by AS.

Ankylosing Spondylitis Self-Care

One of the best ways to take care of your health if you have ankylosing spondylitis is to take a proactive role in your own treatment – a process called self-management.  Here are some ways you can manage your disease, along with adhering to your medication program.

Engage in Physical Activity

Regular physical activity is the most important component of overall AS management. The goal is to prevent permanent stiffness and preserve the range of motion in your neck and back. Deep-breathing exercises and aerobic activities will help keep your chest and rib cage flexible. Swimming is a good option because it helps keep your spine, neck, shoulders and hips flexible. General strengthening and aerobic exercise can improve overall health and function in individuals with AS. Talk to a physical therapist who is experienced in treating people with arthritis about developing an exercise program to meet your needs.

Stop Smoking

AS can affect your lungs and rib cage, which may make breathing more difficult. Smoking will worsen any lung problems due to AS and is an important risk factor for osteoporosis (bone loss).

Maintain Good Posture

Maintaining proper body position is important to prevent joints from fusing in undesirable positions.

Take Advantage of Self-help Devices

Self-help devices may make your daily tasks easier. For instance, long-handled shoehorns and sock aids can help if your back or hips don’t bend easily. An occupational therapist can advise you about special aids or assistive devices.

Make Workplace Accommodations

Avoid lifting, stooping and remaining in cramped or bent positions. Maintain good posture by adjusting the height of your desk or computer monitor. Some people find it helpful to alternate between standing and sitting and using a cushion to support a painful back. If possible, pace your activities and arrange to take short rest periods throughout the day.

More About Ankylosing Spondylitis

The effects are especially damaging for men who smoke.

October 29, 2013 | By Jennifer Davis

Smokers who have ankylosing spondylitis (AS) have more spinal damage than non-smokers with the same level of disease activity, according to a new Dutch study presented at the American College of Rheumatology’s annual meeting in San Diego this week. The effect is especially strong among men and in earlier phases of the disease.

Ankylosing spondylitis is a type of inflammatory arthritis that primarily affects the spine, hips and sacroiliac joints (where the spine meets the pelvis). The disease can lead to fusion of the vertebrae (the bones that make up the spine) resulting in a loss of flexibility and chronic pain. AS is more common in men than women.

For this study, the researchers analyzed data from 127 AS patients (71 percent of participants were men) over the course of 12 years. Each participant received a physical exam and X-rays every other year. Disease activity was measured by a patient's self-evaluation along with their C-reactive protein level, a blood marker of body-wide inflammation. X-ray damage was scored by two independent reviewers.

The researchers found that disease activity at one point in time was linked to greater damage on X-rays two years later.

When the researchers looked at the effect of smoking on this relationship, they found that the effect of disease activity on X-ray damage was 5.5 times greater, compared to that of non-smoking AS patients. In other words, smoking means that the same amount of disease activity leads to much more damage two years later.

When the researchers looked at men and women separately, they found that the effect of disease activity on X-ray damage was more than 13 times greater (i.e. worse) among male smokers compared to female non-smokers. (The effect of disease activity on X-ray damage was roughly the same for male non-smokers and female smokers).

“The effect of inflammation [disease activity] on radiographic progression is different for men and women – it’s worse for men. So for male smokers, it is even worse,” explains lead author Sofia Ramiro, MD, a PhD candidate in the department of clinical immunology and rheumatology at the University of Amsterdam, in the Netherlands.

Disease activity also appears to have a higher impact on X-ray damage in earlier phases of AS: Smokers who had had the disease for less than 18 years had 3.4 times more X-ray damage compared to smokers who had had the disease for more than 18 years (and 8 times more damage compared to non-smokers who had had the disease for more than 18 years).

The researchers say these findings indicate that young, male patients with AS could develop less spinal damage and have better long-term outcomes if they stop smoking.

Can Smoking Trigger Autoimmunity in RA?

Eric M. Ruderman, MD, a professor of medicine in the division of rheumatology at Northwestern University Feinberg School of Medicine, in Chicago, says while considerable research has shown that smoking worsens the progression of rheumatoid arthritis, this is one of the first studies showing the same is true with ankylosing spondylitis.

“If you want to try and prevent people from having progression and damage on X-rays, you need to control disease activity,” says Dr. Ruderman. “Smoking has a huge effect. Independent of everything else, if you smoke you will have more progression on X-rays over time, which could affect your function.”

This study only shows a correlation between smoking and X-ray damage but it doesn’t explain the mechanism involved. Dr. Ruderman says it would be nice if future research looked at the effect of smoking cessation over time.

But he says even before that data is available, patients know enough about the harmful effects of smoking right now. “It’s one more reason there may be a benefit to stop smoking,” he says. “At least you potentially won’t do more damage.”