Ankylosing spondylitis is a chronic inflammatory
form of arthritis affecting mainly, the spinal joints. The important feature
of this condition is the involvement of the joints at the base of the spine
where the spine joins the pelvis - the sacroiliac joints. As a result of
swelling and irritation of the vertebral joints, it causes pain and stiffness
in the back and a bent posture. The inflammation may eventually make the
vertebrae fuse together.
Does this condition cause a lot of pain?
Some people may just experience episodes of transient
back pain. Others may experience long standing and severe back pain that
leads to differing degrees of spinal stiffness. Almost always, the problem
is characterized by acute painful episodes followed by periods when the
pain settles.
What are the symptoms of ankylosing spondylitis?
The most common symptom of Ankylosing spondylitis
is chronic low back pain, which comes on without any apparent cause. The
pain is usually worse in the morning. Soon after waking up, a person may
feel stiff and sore. It may take 30 minutes to several hours for the stiffness
to pass off. The back pain is usually dull and diffuse rather than sharp
and localised.
The most common site of pain is deep within the buttock, on one side, or
on both sides. Inflammation of the tendons and ligaments that connect and
provide support to joints can lead to pain and tenderness in the ribs, shoulder
blades, hips, thighs, shins, heels and along the bony points of the spine.
When the pain starts in the hip, knee, or shoulder-joint, it could be mistaken
for some other form of arthritis.
The condition may begin with mild fever, loss of appetite and general discomfort.
There could be pain, watering, or redness of the eyes, with blurred vision
and increased sensitivity to bright light. The person may complain of a
feeling similar to having a handful of sand thrown in the eye.
The pain itself is due to the inflammation of the joints.
To avoid the pain, a person may stoop forward, because, bending backwards
could be uncomfortable. To feel comfortable, a person may also curl up while
in bed.
What will happen if the condition is left unattended?
If the inflammation is not treated, it could
cause small bony outgrowths from the edges of the vertebrae, which ultimately
extend from one vertebra to the next. This can cause stiffness and immobility
between the vertebrae. Involvement of just two vertebrae can limit function.
Further involvement could lead to progressive disability.
Greater potential disability can occur if Ankylosing spondylitis affects
the hips, knees or shoulders. The joints could be damaged, the pain causing
a limitation in mobility. The end stage of this hip damage is frequently,
a need for total hip joint replacement.
Does Ankylosing Spondylitis have anything to do with the
heart?
Although it is quite uncommon, sometimes, the
portion of the aorta near the heart may be involved. The doctor may listen
to the heart sounds and ask for further investigations if necessary.
How common is ankylosing spondylitis?
Ankylosing spondylitis is three times more common
in men than in women. It typically affects young people between the ages
of 15 and 30. In very young people it may present differently, with pain
around the heels, knees and hips, rather than pain originating in the spine.
It is uncommon for this condition to begin after a person is 40.
What causes ankylosing spondylitis? Is this
a hereditary condition?
The exact cause of Ankylosing spondylitis is unknown.
Ankylosing spondylitis appears to be a hereditary problem because, one
of the inherited tissue types, HLA-B27, of the Human Leucocyte Antigen
(HLA) system, is found in approximately 93% of people with this condition,
but only in 6% of the general population. People with this antigen seem
to be predisposed to Ankylosing spondylitis.
How is Ankylosing spondylitis diagnosed?
The doctor will be able to diagnose Ankylosing spondylitis
by learning about the history of the onset of pain, the areas that have
been affected and the times of the day when pain is worst.
In young people, the presence of tender points at specific locations around
the feet, heels, knees and hips can be indicative of this condition.
Since the problem often affects young men, who are active, it is sometimes
misdiagnosed as low back pain due to mechanical stress and strain.
The sacroiliac joints on the right and left sides in the buttock area are
the joints that are most often involved. X-ray evidence of changes in these
joints may take some time to occur. So, while an x-ray picture in the early
stages of the problem may not show any changes, over time, changes can be
observed in X-ray pictures of the joints and the vertebrae.
There is no specific blood test to diagnose Ankylosing spondylitis. But
a blood ESR could show whether an inflammation is present in the body.
A physical examination will help the doctor determine the limitation of
movement of the spine and various joints.
What is the treatment for Ankylosing Spondylitis?
At present, there is no cure for Ankylosing spondylitis.
The most important thing is to follow some steps to lessen the pain and
maintain movement and function. Treatment is designed with this in mind.
The earlier a person contacts the doctor, the better the chance of avoiding
disability or deformity. The family physician may refer a person to a Rheumatologist.
If the eyes are affected, the person may also need to consult an eye specialist
or ophthalmologist.
Oral Medication
The most common type of medicine used to treat ankylosing spondylitis is
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). These drugs help reduce
the pain and swelling of the joints and decrease stiffness. However, they
do not prevent further joint damage. The common examples of NSAIDS are Nimesulide,
Ibuprofen, Diclofenac, Aspirin etc.
NSAIDs reduce pain when taken in a low dose, and relieve inflammation when
taken at a higher dose. Though the various NSAIDs, taken in full doses,
usually have the same levels of anti-inflammatory effect, different individuals
may experience different levels of relief from one medicine or other. It
is important to take the right dosages to avoid stomach irritation, heartburn
and ulcers. It may be advisable to take antacids or other drugs with the
advice of the doctor, to avoid such problems.
A group of drugs called disease-modifying anti-rheumatic drugs (DMARDs)
can also stop Ankylosing spondylitis from becoming worse, but they may take
about two to six months before they begin to make a difference in the pain
and swelling. DMARDs act on the processes causing the inflammation, but
do not reverse permanent joint damage. The most common of them are gold
salts, methotrexate, sulfasalazine and hydroxychloroquine. A DMARD is usually
prescribed in addition to an NSAID or prednisolone. Side effects may include
mouth sores, diarrhea and nausea. More serious side effects include liver
damage, and excessive lowering of white blood cell count, which causes increased
susceptibility to infections. The blood platelet count could also be affected,
which affects the blood clotting mechanism.
Injections
Cortisone is a steroid that reduces inflammation and swelling. It is a hormone
produced naturally by the body. Corticosteroids are man-made drugs that
closely resemble cortisone. Sometimes, a doctor may choose to inject a corticosteroid
into an affected joint or ligament, to bring short-term relief, in the case
of severe pain and inflammation. This can provide immediate relief for a
tender, swollen and inflamed joint. However, repeated or longterm use of
corticosteroids can weaken the cartilage and remove the minerals from the
bone, thereby weakening the joint further. So, the doctor may use them only
when they are most needed.
In most cases, the medication does not result in total relief from pain.
The doctor and the person affected will have to work out which drug brings
about the best relief from pain and inflammation.
Exercise
Exercise is the most important activity for successful long-term management
of Ankylosing spondylitis.
The main aims of the exercise program are:
To maintain or restore spinal mobility
To maintain or improve posture
To maintain chest expansion.
A person could take the guidance of a physiotherapist to learn an exercise
program that includes a range of motion exercises for the neck, mid back
and low back, which should be done daily. A person could concentrate on
a range of motion exercises, on particular areas that are troublesome. For
example, if the neck is painful and prone to stiffness, the person should
do gentle mobility exercises to maintain movement of the neck.
Strengthening exercises should be done to increase the muscle power of extensors
or back muscles, which keep a person upright and erect. This will reduce
the tendency to stoop forward and become stiff in this position. Gentle
stretching exercises are important, to prevent stiffness and postural changes.
To maintain the chest expansion and rib mobility, a physiotherapist may
also teach some breathing exercises. Swimming and walking encourage good
posture. Strenuous physical activity may not be advisable, because of the
risk of fracturing the spine, due to the stiffness in the back, caused by
Ankylosing spondylitis.
Since most people with Ankylosing sponydiltis are stiff in the morning,
this may not be the ideal time to do the exercises. If there is pain, a
warm bath could be taken prior to exercising.
Hot or Cold Fomentation
Heat helps to reduce pain and stiffness, by relaxing aching muscles and
increasing circulation to the area.
There is some concern that heat may worsen the symptoms in an already inflamed
joint.
Fomentation or even a hot shower can give good relief from pain.
Cold compresses help to lessen the pain and swelling in a joint.
Protect Your Joints
Joints should be protected from excess mechanical stress due to daily tasks.
The following techniques should be kept in mind.
Alternating heavy or repeated tasks with easier tasks or breaks (pacing),
reduces the stress on painful joints and allows weakened muscles to rest.
Pacing and planning are some ways to deal with fatigue.
Positioning joints wisely helps a person to use them in ways that avoid
extra stress. Larger, stronger joints should be used to carry loads. For
example, one can use a shoulder bag instead of a hand-held one. The back,
arms and legs should also be used safely, to avoid stress on joints. For
example, a heavy load should be carried close to the body. One should avoid
retaining the same posture for a long period of time.
Using devices, such as canes, raised chairs, grips and reaching aids, can
help make daily tasks easier and falls could be avoided.
It is important for people with Ankylosing spondylitis to sleep on a firm
supportive surface, to maintain good spinal alignment. After all, most people
spend one third of a 24-hour day in bed. The neck should be supported with
special neck supports or pillows.
It is important to observe the posture maintained during the day. For example,
whether a person sits upright, or has to stoop over to look at the computer,
whether the person stands erect and so on. Working positions should be adjusted
to maintain a good posture.
It is important to keep the back straight and avoid a tendency to slump
forward, even if that feels more comfortable.
Relaxation
Relaxing the muscles around an inflamed joint reduces pain.
Deep breathing exercises, music, meditation, etc can all help a person relax
and achieve a positive outlook, thereby giving a feeling of greater control
over the arthritic condition.
Surgery
Surgery such as total 'hip joint replacement', may be contemplated if the
damage is very bad. The doctor will be the best judge to make the decision.
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