What is ankylosing spondylitis?

>>>What is ankylosing spondylitis?<<<

Spine inflammation

Ankylosing spondylitis (AS) is a painful, often progressive and potentially debilitating chronic inflammatory condition that tends to affect young people, mainly men, in their late teens and twenties.1 It is commonly referred to as arthritis of the spine.

What is ankylosing spondylitis 

AS initially begins with persistent lower back pain and stiffness which over time, become progressively worse, particularly at night as a result of local inflammation of the soft tissue supporting bone.1

The symptoms include:

  1. Slow or gradual onset of back pain and stiffness over weeks or months, rather than hours or days (seldom an acute back pain)
  2. Early-morning stiffness and back pain, wearing off or reducing during the day with movement
  3. Feeling better after exercise and feeling worse after rest
  4. Sleep disturbance due to pain, particularly second half of the night
  5. Arthritis, in large joints, especially the legs, together with pain in the joints of the lower back particularly at night or on waking
  6. Persistence of above symptoms for more than three months
  7. Fatigue
  8. Pain relieved for a time after a shower or bath
  9. Symptoms begin typically in late teens or 20’s
  10. Associated conditions:
  • Iritis (or uveitis) which is inflammation of part of the iris within the eye; and conjunctivitis which causes red, gritty and painful eyes
  • Inflammatory Bowel Syndrome (chronic inflammatory disease of the gut)Diagram to show what happens to the spine due to ankylosing spondylitisInflammation occurs where ligaments or tendons are attached to the bone causing damage at the site of attachment. When the healing process begins, new bone develops replacing the elastic tissue of the ligaments or tendons.1,2

    Recurrence of this inflammatory process leads to further new bone formation which gradually results in the restriction of joint movement. When these disease processes occur in the spine, irreversible damage is caused as the vertebrae (joints of the spine) become fused together.1,2

AS varies between individuals in the way it progresses and symptoms will differ in severity, however most patients will experience flare-ups of inflammation periodically. 2 Disease progression can lead to fusion of the spine; causing loss of mobility and loss of function. In advanced stages of the disease or severe cases that are left untreated, spinal mobility and flexibility may become so reduced that the patient becomes progressively stooped (bent-over) making it increasingly difficult for the individual to move freely and carry out their usual daily activities.2,3 AS can lead to decreased daily activity, loss of work productivity and reduced quality of life in those affected. 1

Peripheral inflammationAlthough AS is a form of arthritis which primarily affects the spine, other joints and organs of the body can also be affected such as the hips, shoulders, knees, eyes, lungs, bowel, skin, and heart.2 Up to 40 per cent of people with AS will at some point develop a severe inflammation inside one or both of their eyes, this is known as iritis or uveitis and it causes redness and blurred vision. 2,3

AS sometimes overlaps with other conditions including reactive arthritis, psoriasis and inflammatory bowel disease. These overlapping conditions exist under the umbrella term ‘spondyloarthritis’.3,4

References  

1. Sieper J. et al. Ankylosing spondylitis: an overview. Ann Rheum Dis. 2002;61(Suppl III):iii8-iii18

2. National Ankylosing Spondylitis Society. Guidebook for `Patients: A Positive Response to Ankylosing Spondylitis. March 2007

3. Elyan M, Khan MA. Diagnosing Ankylosing Spondylitis. Rheum. 2006:33 (Suppl 78):12-23

4. Sieper J, Braun J. Clinician’s Manual on Ankylosing Spondylitis. London: Current Medicine Group.

>>>What causes ankylosing spondylitis?<<<

The cause of AS is poorly understood but it is believed that genetic, environmental, bacterial and immune-related factors may be involved.1 96 per cent of white western patients carry a protein called the human tissue leukocyte antigen B27 (HLA-B27) which is found on the surface of white blood cells suggesting that there is a genetic link.2

AS most commonly affects men, typically striking in their late teens and twenties, however anyone from either sex can be affected at any age.2

In Europe it is thought that approximately 1 in 200 people suffer from AS.4,5,6  However, the exact prevalence of AS is not known due to wide geographical variations seen within the population, prevalence estimates range from 0.1 to 1.4 per cent.1,4,6

References  

1. Sieper J. et al. Ankylosing spondylitis: an overview. Ann Rheum Dis. 2002;61(Suppl III):iii8-iii18

2. National Ankylosing Spondylitis Society. Guidebook for `Patients: A Positive Response to Ankylosing Spondylitis. March 2007

4. Sieper J, Braun J. Clinician’s Manual on Ankylosing Spondylitis. London: Current Medicine Group.

5. Akkoc N, Khan MA. Overestimation of the prevalence of ankylosing spondylitis in the Berlin study: comment on the Braun article by Braun et al (letter). Arthritis Rheum. 2005;52:4048-9

6. Braun J. et al. Ankylosing spondylitis. Lancet 2007; 369:1379-90

>>>Getting a diagnosis<<<

It is important to get an accurate diagnosis early in the disease course. This is because AS progresses over time and so the earlier the condition is diagnosed and treated the better the outcome for the patient and their ability to continue with the activities they enjoy.3

Due to low awareness and poor recognition of AS, amongst both the general public and healthcare professionals, diagnosis may be delayed by

as much as eleven years after the initial onset of symptoms.3

If you think that you have some or all of the typical symptoms described here we recommend that next time you visit your primary care physician you print off the symptom checklist and discuss the symptoms that you are experiencing with them.

Print off the AS symptom checklist.

There is no direct test to diagnose AS. Your primary care physician is likely to carry out an examination of your back and possibly a pelvic x-ray, and either start treatment or refer you to a rheumatologist if AS is suspected or confirmed.2

References  

2. National Ankylosing Spondylitis Society. Guidebook for `Patients: A Positive Response to Ankylosing Spondylitis. March 2007

3. Elyan M, Khan MA. Diagnosing Ankylosing Spondylitis. Rheum. 2006:33 (Suppl 78):12-23

>>>Treating ankylosing spondylitis<<<

Treating AS

There is no cure for AS however there are a number of treatment options available, as outlined below, to help reduce the pain and stiffness experienced by sufferers, thus improving general well-being.2

In addition to taking medication it is vital to maintain good posture and a regular exercise routine (e.g. swimming) as this will help prevent the spine from “stiffening up”. Physiotherapy is an important part of managing AS and can greatly influence the outcome of the condition.2

www.nass.co.uk/public/exercises.htm

Anti-Inflammatory Drugs

In the first instance a primary care physician or rheumatologist may advise taking Non Steroidal Anti-Inflammatory Drugs (NSAIDs), such as ibuprofen, which can provide symptomatic relief by reducing pain and inflammation.1 Paracetamol is often suggested as an alternative treatment if sufferers experience side effects with NSAIDs.2

Disease-Modifying Anti-Rheumatic Drugs

In some AS patients, inflammation of joints excluding the spine (such as the hips, knees, or ankles) may develop.1 Inflammation in these joints may not respond to anti-inflammatory drugs alone and the addition of disease-modifying anti-rheumatic drugs (DMARDs) such as sulphasalazine or methotrexate may be considered.7These drugs arecommonly used to treat rheumatoid arthritis and affect the underlying disease process.

Biologics

Biologics are a relatively new form of treatment which are similar to human or animal proteins, unlike other typical medicines which are made by combining chemicals. Biologics work by targeting the underlying inflammatory processes involved in conditions such as AS. Biologics have been demonstrated to be highly effective for the treatment of AS by reducing inflammation and improving spinal mobility in addition to slowing disease progression.1,7 Biologics are usually administered by injection.2

One class of biologics, known as TNF-inhibitors, works by blocking the inflammation caused by specific molecules in the immune system known as tumour necrosis factor (TNF).  TNF plays an important role in the inflammation process and patients with AS have increased levels of TNF in their body. Currently there are three TNF-inhibitor drugs which target TNF approved in Europe for the treatment of AS.4, 7

The route of treatment is assessed for each individual patient but is usually dependent on the severity of symptoms and the location of the inflammation (i.e. whether the inflammation is within the spine only or whether it is present in the peripheral joints outside the spine too).4

References  

1. Sieper J. et al. Ankylosing spondylitis: an overview. Ann Rheum Dis. 2002;61(Suppl III):iii8-iii18

2. National Ankylosing Spondylitis Society. Guidebook for `Patients: A Positive Response to Ankylosing Spondylitis. March 2007

4. Sieper J, Braun J. Clinician’s Manual on Ankylosing Spondylitis. London: Current Medicine Group.

7. Braun J. et al. International ASAS consensus statement for the use of anti-tumour necrosis factor agents in patients with ankylosing spondylitis. Ann Rheum Dis. 2003;62:817–824

>>>Living with ankylosing spondylitis?<<<

If AS is well managed sufferers should be able to continue to carry out normal daily activities. However, some sufferers may have to cope with varying degrees of pain, sleep disturbance, sick leave and functional problems with everyday tasks such as driving.1 It is important to get an accurate diagnosis early in the disease course and start treatment before the condition progresses.

References  

1. Sieper J. et al. Ankylosing spondylitis: an overview. Ann Rheum Dis. 2002;61(Suppl III):iii8-iii18

Download the information on this page.
Download the AS symptom checklist.

Data from: http://eu.back-in-play.com/back-pain-and-as/what-is-ankylosing-spondylitis.aspx

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