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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Symptoms of ankylosing spondylitis

The symptoms of ankylosing spondylitis (AS) vary greatly from person to person, but they usually take a long time to develop. In some cases, symptoms can take three months to develop fully, although they can take several years.

The symptoms of ankylosing spondylitis usually start during early adulthood or in the later teenage years. The symptoms may come and go, and get better or worse over many years.

The main symptoms of ankylosing spondylitis are:

  • back pain and stiffness
  • buttock pain
  • inflammation (swelling) of the joints (arthritis)
  • painful inflammation where tendons or ligaments attach to bone (enthesitis)
  • fatigue (extreme tiredness)

If you have ankylosing spondylitis, you may not develop all of the symptoms listed above. The symptoms are explained in more detail below.

Back pain and stiffness

Back pain and stiffness are usually the main symptoms of ankylosing spondylitis. If you have ankylosing spondylitis you may find that:

  • your pain gets better with exercise but not with rest
  • your back is particularly stiff in the morning, lasting for more than 30 minutes after you start to move around
  • you wake up in the second half of the night with pain and stiffness
  • you have pain in your buttocks, which can sometimes be on one side and sometimes on the other

Arthritis

As well as causing symptoms in your back and spine, ankylosing spondylitis can cause arthritis in your hip, knee and other joints. The main symptoms associated with arthritis are:

  • pain on moving the joint
  • tenderness when the joint is examined
  • swelling
  • warmth in the affected area

See the Health A-Z topic about Arthritis for more information.

Enthesitis

Enthesitis is painful inflammation where a bone is joined to:

  • a tendon (a tough cord of tissue that connects muscles to bones), or
  • a ligament (a band of tissue that connects bones to bones)

Common sites for enthesitis are:

  • at the top of the shin bone
  • behind the heel
  • under the heel
  • at the ends of the ribs

If your ribs are inflamed, you will feel chest pain, and you may find it difficult to expand your chest when breathing deeply.

Fatigue

Fatigue is a common symptom of untreated ankylosing spondylitis. It can make you feel tired and lacking in energy.

Data from: http://www.nhs.uk/Conditions/Ankylosing-spondylitis/Pages/Symptoms.aspx

 ankylosing spondylitis acupuncture

Overview
A rheumatologist is commonly the type of physician that will diagnose ankylosing spondylitis, since they are doctors who are specially trained in diagnosing and treating disorders that affect the joints, muscles, tendons, ligaments, connective tissue, and bones. A thorough physical exam including x-rays, individual medical history, and a family history of AS, as well as blood work including a test for HLA-B27 are factors in making a diagnosis.

Physical Exam
The overall points taken into account when making an AS diagnosis are:

  • Onset is usually under 35 years of age.
  • Pain persists for more than 3 months (i.e. it is chronic).
  • The back pain and stiffness worsen with immobility, especially at night and early morning.
  • The back pain and stiffness tend to ease with physical activity and exercise.
  • Positive response to NSAIDs (nonsteroidal anti-inflammatory drugs).

A physical examine will entail looking for sites of inflammation. Thus, your doctor will likely check for pain and tenderness along the back, pelvic bones, sacroiliac joints, chest and heels. During the exam, you doctor may also check for the limitation of spinal mobility in all directions and for any restriction of chest expansion.

Other symptoms and indicators are also taken into account including a history of iritis or uveitis (inflammation of the eye), a history of gastrointestinal infections (for example, the presence of Crohn’s Disease or ulcerative colitis), a family history of AS, as well as fatigue due to the presence of inflammation.

The Hallmark of AS & X-rays vs. MRI
The hallmark of AS is involvement of the sacroiliac (SI) joint (see figure to the upper right). The x-rays are supposed to show erosion typical of sacroiliitis. Sacroiliitis is the inflammation of the sacroiliac joints. Using conventional x-rays to detect this involvement can be problematic because it can take 7 to 10 years of disease progression for the changes in the SI joints to be serious enough to show up in conventional x-rays.

Another option is to use MRI to check for SI involvement, but currently there is no validated method for interpreting the results in regards to an AS diagnosis. Also, MRI can be cost prohibitive.

Blood Work & the HLA-B27 Test
First, HLA-B27 is a perfectly normal gene found in 8% of the caucasian population. Generally speaking, no more than 2% of people born with this gene will eventually get spondylitis.

Secondly, it is important to note that the HLA-B27 test is not a diagnostic test for AS. Also, the association between AS and HLA-B27 varies in different ethnic and racial groups. It can be a very strong indicator in that over 95% of people in the caucasion population who have AS test HLA-B27 positive. However, only 50% of African American patients with AS possess HLA-B27, and it is close to 80% among AS patients from Mediterranean countries.

Since there is no single blood test for AS, laboratory work may not be of much help. A simple ESR (erythrocyte sedimentation rate), also known as sed rate, is commonly an indicator of inflammation. However, less than 70% of people with AS have a raised ESR level.

Finally, there is no association with ankylosing spondylitis and rheumatoid factor (associated with rheumatoid arthritis) and antinuclear antibodies (associated with lupus).

Data from: http://www.spondylitis.org/about/as_diag.aspx

Most Common Symptoms
It is important to note that the course of ankylosing spondylitis varies greatly from person to person. So too can the onset of symptoms. Although symptoms usually start to appear in late adolescence or early adulthood (ages 17-35), the symptoms can occur in children or much later.

Typically, the first symptoms of AS are frequent pain and stiffness in the lower back and buttocks, which comes on gradually over the course of a few weeks or months. At first, discomfort may only be felt on one side, or alternate sides. The pain is usually dull and diffuse, rather than localized. This pain and stiffness is usually worse in the mornings and during the night, but may be improved by a warm shower or light exercise. Also, in the early stages of AS, there may be mild fever, loss of appetite and general discomfort. It is important to note that back pain from ankylosing spondylitis is inflammatory in nature and not mechanical. For more information on mechanical vs. inflammatory back pain, please click here.

The pain normally becomes persistent (chronic) and is felt on both sides, usually persisting for at least three months. Over the course of months or years, the stiffness and pain can spread up the spine and into the neck. Pain and tenderness spreading to the ribs, shoulder blades, hips, thighs and heels is possible as well.

Note that AS can present differently at onset in women than in men. Quoting Dr. Elaine Adams, “Women often present in a little more atypical fashion so it’s even harder to make the diagnoses in women.” For example, anecdotally we have heard from women with AS who have stated that their symptoms started in the neck rather than in the lower back.

Varying levels of fatigue may also result from the inflammation caused by AS. The body must expend energy to deal with the inflammation, thus causing fatigue. Also, mild to moderate anemia, which may also result from the inflammation, can contribute to an overall feeling of tiredness.

Other Symptoms
In a minority of individuals, the pain does not start in the lower back, but in a peripheral joint such as the hip, ankle, elbow, knee, heel or shoulder. This pain is commonly caused by enthesitis, which is the inflammation of the site where a ligament or tendon attaches to bone. Inflammation and pain in peripheral joints is more common in juveniles with AS. This can be confusing since, without the immediate presence of back pain, AS may look like some other form of arthritis.

Many people with AS also experience bowel inflammation, which may be associated with Crohn’s Disease or ulcerative colitis.

AS is often accompanied by iritis or uveitis (inflammation of the eyes). About one third of people with AS will experience inflammation of the eye at least once. Signs of iritis or uevitis are: Eye(s) becoming painful, watery, red and individuals may experience blurred vision and sensitivity to bright light. Click herefor more information on the complications of AS, including iritis/uveitis.

Advanced Symptoms
Advanced symptoms can be chronic, severe pain and stiffness in the back, spine and possibly peripheral joints, as well as lack of spinal mobility because of chronic inflammation and possible spinal fusion.

Data from: http://www.spondylitis.org/about/as_sym.aspx

The ‘growing pains’ that could cripple you for life

The ‘growing pains’ that could cripple you for life
By ISLA WHITCROFT
UPDATED: 00:14 GMT, 30 November 2010

Paul Curry’s teenage years were blighted by what doctors insisted were growing pains. Not just the odd sharp stab or ache that many youngsters suffer, but attacks that were so severe he was often bedridden for days.
‘The pain was dull, gnawing deep inside both hips,’ says Paul, 28, from Durham. ‘It was excruciating.

‘The first time it happened I was 13 and mad about sport, particularly rugby. I assumed — as did my parents — it was growing pains or a sporting injury and so would go away.’

At risk: Young males are most likely to suffer from Ankylosing Spondylitis(AS), a progressive rheumatic disease that causes inflammation around joints

Unfortunately, over the next few years not only did the pain worsen, but the attacks became more frequent and lasted longer.

‘Sometimes I could cope by taking painkillers, but other times I’d be in bed for days, screaming with pain,’ says Paul.

Over the next few years, his parents took him to see his GP several times. He diagnosed growing pains and said it was ‘something Paul would grow out of’.

A consultant orthopaedic ­surgeon, to whom Paul was referred privately at the age of 16, then pronounced he was suffering from Sherman’s disease, a mild condition that causes a slight curvature of the upper spine.

‘He said that by the time I was 21 I’d have grown out of it. In the meantime, I was to keep taking painkillers,’ he says.

Sadly, Paul, from Durham, didn’t have Sherman’s disease, but Ankylosing Spondylitis (AS), a progressive rheumatic disease that causes inflammation around bone joints and ligaments.

Left untreated, this causes bone erosion, which stimulates the immune system into a healing process. This, in turn, produces an overgrowth of bone, which leads to the fusion of bones such as the spine and hips and eventually immobility. The damage is irreversible.

Some 400,000 Britons are affected by AS, with symptoms usually appearing between the ages of 25 and 34 — though ­teenagers and older people can be affected.

Unfortunately, like Paul, many sufferers are mis-diagnosed — with devastating consequences.

Today, at 28, Paul is racked with constant pain. The discs in the lower half of his spine have fused, as have his hip and pelvic joints.

Three vertebrae at the top of his neck are also affected and this once super-fit teenager counts himself lucky if he walks without using a stick.
At night, his joints stiffen and spasm and he is dependent on a daily dose of morphine.

Late diagnosis: Paul Curry’s crippling condition was not spotted until his 20s

Not surprisingly, in the past, the condition has left Paul feeling depressed.

‘I still get distressed about what might have been had I been properly diagnosed early on,’ says Paul who, after getting a degree in business management, had to move back in with his parents because he is often confined to bed for days at a time.

Despite spending thousands of pounds on specialists over the years, Paul wasn’t diagnosed until he was 26, when an astute physiotherapist recognised his symptoms and advised him to see a rheumatologist.

‘She examined me and said she was almost certain I had AS,’ says Paul.

‘Blood tests and an MRI scan confirmed this. It was a scary diagnosis, but an utter relief that at last I knew what I was dealing with.’

Shockingly, the average delay in diagnosing the condition is ten years, according to a survey for the National Ankylosing Spondylitis Society (NASS).

‘There is a lack of awareness of the condition and how to distinguish the symptoms from other causes such as back pain,’ says Dr Andrew Keat, consultant rheumatologist at Northwick Park Hospital, Harrow, Middlesex, and a specialist in AS.

‘Unfortunately, the very people who suffer most from the ­condition — young males — are also the ones who tend to be the most active,’ he says.

‘Therefore, it’s easy to write off their symptoms as being a sporting injury or even just growing pains.’

The main distinguishing ­symptom is inflammatory joint pain, which comes on slowly and usually occurs in the lower back or hips. Crucially, it improves with exercise and worsens with inactivity, meaning it’s often severe at night.

‘These symptoms should be a red light to your GP that ­inflammation is occurring,’ says Dr Keat. ‘If anti-inflammatories don’t help after a few weeks, the symptoms need further investigation by a rheumatologist.’
There is no one simple test, says Dr Keat.

‘We look at family history, symptoms, make a physical examination and take blood tests for signs of inflammation. X-rays rarely show the condition so an MRI scan is essential,’ he says.

Ironically, once the condition is diagnosed, treatment is ­usually effective — with anti-inflammatories such as ibuprofen and exercise, as movement discourages the fusion process.

Exercise can make a significant difference, as Liz Ledger proves. Now 28, she had severe hip pains from the age of 17; these were also blamed on growing pains.

‘I lost count of how many health professionals I saw,’ says Liz, a sales and marketing ­manager from Bristol.

However, she worked out that the pain receded when she ­exercised and over the years she has devised a routine that kept it manageable.

But by her mid-20s the pain was increasingly severe. Finally, in October 2007, she suffered a flare-up that left her bed-bound.

‘I dragged myself to the GP and insisted that I wasn’t ­leaving without a referral to a rheumatologist.’

An MRI scan and blood test confirmed AS; her first four ­vertebrae had fused and there were signs of fusion in the hips and pelvic joints.

Her condition is being managed by anti-inflammatories and pain-killers. She does cycle classes, body conditioning and gentle running six days a week.
‘It’s a commitment, but it means the difference between mobility and immobility,’ she says.

‘AS can be a devastating ­condition, but one positive thing is that the sufferer can actually help themselves,’ says Jane Skerrett of the NASS.

‘The earlier a patient gets on to a suitable exercise regimen the better.’
The charity has launched an exercise guide, developed by a rheumatologist and physiotherapists, that contains a full ­fitness programme as well as advice.

Despite his pain, Paul makes sure he always does gentle stretching and walking. And ­having recently married, he remains optimistic and is keen to start a family.

Liz, who was diagnosed earlier in the disease cycle, is also upbeat. ‘I recently completed a half-marathon,’ she says.

‘Now I’m back at work and have a social life. Exercise has given me control of this disease.’

Data from: dailymail.co.uk