Ankylosing Spondylitis

Ankylosing spondylitis is a long-term inflammatory disease that primarily affects the spine and can cause pain, stiffness, and reduced mobility. While there is no cure, various treatments and lifestyle approaches can help manage symptoms, improve quality of life, and potentially slow disease progression.

Table of contents

• What is Ankylosing Spondylitis?
• Common Symptoms
• Causes and Risk Factors
• How is it Diagnosed?
• Treatment Options
• Possible Complications
• Living Well with Ankylosing Spondylitis

What is Ankylosing Spondylitis?

Ankylosing spondylitis, also called axial spondyloarthritis, is a type of inflammatory disease that mainly affects the spine. The condition causes inflammation of the joints in the spine, called vertebrae, which can lead to severe pain and discomfort over time^[1]. In more advanced cases, this inflammation can cause some of the bones in the spine to fuse together, making the spine less flexible and potentially leading to a hunched posture^[1].

The hallmark feature of ankylosing spondylitis is the involvement of the sacroiliac joints during the disease progression. These joints are located at the base of the spine, where the spine joins the pelvis^[2]. The sacroiliac joints are some of the biggest joints in your body, and you use them every time you move or shift your hips^[3].

There are two types of axial spondyloarthritis. When the condition is found on X-ray, it is called ankylosing spondylitis. When the condition cannot be seen on X-ray but is found based on symptoms, blood tests, and other imaging tests such as an MRI, it is called nonradiographic axial spondyloarthritis^[1].

Ankylosing spondylitis is a chronic inflammatory disease that can cause inflammation in the spinal joints, peripheral joints, digits, and entheses (the places where tendons attach to bones)^[4]. While it primarily affects the spine, it can also affect other joints, including the shoulders, hips, and knees^[3].

Common Symptoms

Early symptoms of ankylosing spondylitis might include back pain and stiffness, especially in the lower back and hips. These symptoms may be worse in the morning or after periods of inactivity^[1]. Neck pain and fatigue also are common^[1]. Symptoms can come and go over time^[1].

Lower back pain due to sacroiliitis (painful inflammation in your sacroiliac joints) is the most common symptom of ankylosing spondylitis^[3]. This pain can spread to other areas. You might experience hip pain, pain in your buttocks, neck pain, or abdominal pain^[3].

Other ankylosing spondylitis symptoms can include stiffness or trouble moving your hips and lower back, especially first thing in the morning or after you’ve been resting in one position for a long time. Many people with the condition experience fatigue (feeling tired all the time), shortness of breath, losing their appetite or having unexplained weight loss, diarrhea, skin rashes, and vision problems^[3].

Symptoms of ankylosing spondylitis typically originate in the lower back and buttocks and develop gradually over a period of months to years. These symptoms tend to worsen in the early morning hours, causing sleep disturbance in many patients. Pain and stiffness will tend to improve with stretching and physical activity and worsen with prolonged inactivity^[6].

Sometimes the condition affects other parts of the body, including the eyes (known as iritis or uveitis), which affects 25 to 35 percent of cases^[4]. Inflammatory bowel disease can affect up to 50 percent of individuals, and psoriasis occurs in approximately 10 percent^[4].

Causes and Risk Factors

Ankylosing spondylitis is an autoimmune disease. Autoimmune diseases happen when your immune system attacks your body instead of protecting it^[3]. Experts aren’t certain what causes ankylosing spondylitis, but studies have found that specific genetic mutations are closely linked to having the condition. Genetic mutations are changes to your DNA sequence that happen when your cells divide to make copies of themselves^[3].

There are more than 60 mutated genes that might cause ankylosing spondylitis. One example is the human leukocyte antigen-B (HLA-B27) gene^[3]. More than 90 percent of white people who have ankylosing spondylitis also have a mutated HLA-B27 gene^[3]. Among individuals who are HLA-B27 positive, the prevalence of ankylosing spondylitis is approximately 5 to 6 percent. In the United States, the prevalence of HLA-B27 varies among ethnic groups: 7.5 percent among non-Hispanic Whites, 4.6 percent among Mexican-Americans, and 1.1 percent among non-Hispanic Blacks^[4].

Anyone can develop ankylosing spondylitis, but certain groups of people are more likely to have it. People younger than 40 are at higher risk, with more than 80 percent of people with ankylosing spondylitis experiencing their first symptoms before age 30^[4]. The condition occurs more frequently in men than women (2 to 1)^[6]. People who have a close biological relative with ankylosing spondylitis, especially a biological parent, are also at higher risk^[3].

People with certain health conditions are more likely to have ankylosing spondylitis, including those with Crohn’s disease, ulcerative colitis, and psoriasis^[3].

How is it Diagnosed?

To diagnose ankylosing spondylitis, your healthcare professional may ask about your medical history, family history, and symptoms. Your healthcare professional also may perform a physical exam to check your posture, flexibility, and areas of pain or stiffness. You also may be asked to take a deep breath to see if you have trouble expanding your chest^[8].

X-rays can check for changes in joints and bones, which can be a sign of ankylosing spondylitis. However, changes that appear on X-ray might take years to develop, and early disease might not show on X-ray images^[8]. MRI uses radio waves and a strong magnetic field to provide more detailed images of bones and soft tissues. MRI scans can detect nonradiographic axial spondyloarthritis earlier in the disease process, but MRI scans are much more expensive^[8].

There are no specific lab tests to identify ankylosing spondylitis. Certain blood tests, including erythrocyte sedimentation rate (also called sed rate) and C-reactive protein (CRP), can check for markers of inflammation, but many different health issues can cause inflammation^[8]. Blood can be tested for the HLA-B27 gene, but many people who have the gene don’t have ankylosing spondylitis, and people who don’t have the HLA-B27 gene can have the disease^[8].

The 1984 Modified New York classification criteria has been generally accepted for both research and clinical purposes. It requires at least one clinical manifestation and at least one radiographic parameter. Clinical manifestations include three months or more of inflammatory back pain that improves with exercise and is worsened by rest, limitation of lumbar motion in both frontal and sagittal planes, and limitation of chest expansion compared to the normal population^[6].

Treatment Options

There is no cure for ankylosing spondylitis, but treatments can lessen symptoms, manage pain, and possibly slow down the progression of the disease^[1]. The goal of treatment is to relieve pain and stiffness, maintain flexibility, and prevent or slow changes to the spine. Ankylosing spondylitis treatment works best when it’s started early before permanent damage is done^[8].

In most cases, treatment involves a combination of exercises carried out individually or in groups to reduce pain and stiffness, physiotherapy (where physical methods such as massage and manipulation are used to improve comfort and spinal flexibility), and medicine to help relieve pain and reduce inflammation^[5].

Medications

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen sodium (Aleve) and ibuprofen (Advil, Motrin IB, others), are the medicines healthcare professionals most commonly use to treat axial spondyloarthritis. As well as helping ease pain, NSAIDs can help relieve swelling in your joints^[9]. Sometimes high doses of NSAIDs are needed to maintain relief from symptoms. This can pose a problem because NSAIDs can cause significant side effects, especially in the gastrointestinal tract^[11].

If NSAIDs are unsuitable for you or if you need extra pain relief, an alternative painkiller such as paracetamol may be recommended. If necessary, you may also be prescribed a stronger type of painkiller called codeine^[9].

If your symptoms cannot be controlled using NSAIDs and exercising and stretching, anti-tumor necrosis factor (TNF) medicine may be recommended. TNF is a chemical produced by cells when tissue is inflamed. Anti-TNF medicines are given by injection and work by preventing the effects of TNF, as well as reducing the inflammation in your joints caused by ankylosing spondylitis^[9]. These powerful biologic drugs target tumor necrosis factor, a protein that causes inflammation^[13].

Monoclonal antibodies, such as secukinumab and ixekizumab, may be offered to people with ankylosing spondylitis who do not respond to NSAIDs or anti-TNF medicine, or as an alternative to anti-TNF medicine. This type of treatment works by blocking the effects of a protein involved in triggering inflammation^[9].

JAK inhibitors are a type of medicine that may be offered to people with ankylosing spondylitis who do not respond to anti-TNF medicine or cannot take it. They work by blocking enzymes (proteins) that the immune system uses to trigger inflammation. They’re taken as tablets^[9].

Corticosteroids have a powerful anti-inflammatory effect and can be taken as injections by people with ankylosing spondylitis. If a particular joint is inflamed, corticosteroids can be injected directly into the joint^[9].

Physical Therapy and Exercise

Keeping active can improve your posture and range of spinal movement, along with preventing your spine from becoming stiff and painful. As well as keeping active, physiotherapy is a key part of treating ankylosing spondylitis^[5]. Exercise is essential for everyone with arthritis, but it’s even more vital in ankylosing spondylitis. It can dramatically relieve pain and stiffness and is the only way to maintain flexibility, strength, and normal posture^[13].

A physiotherapist can advise about the most effective exercises and draw up an exercise programme that suits you. Types of physiotherapy recommended include a group exercise programme where you exercise with others, an individual exercise programme with exercises to do by yourself, and hydrotherapy (exercise in water, usually a warm, shallow swimming pool or a special hydrotherapy bath)^[5].

Swimming and other exercises that extend the back such as Pilates, yoga, and tai chi are great ways to maintain mobility and relieve pain. But don’t limit yourself to stretching. Cardio exercise that gets your heart rate up and strength training are also important^[19].

Surgery

Surgery is sometimes needed to repair significantly damaged joints or correct severe bends in the spine, but this is uncommon^[5]. Surgery may be required to replace a severely damaged hip joint or, rarely, to correct deformities of the spine^[7].

Possible Complications

People with ankylosing spondylitis have a higher risk of spinal fractures (broken bones in your spine)^[3]. The natural history of ankylosing spondylitis for some patients includes structural abnormalities of the spine from development of new bone formation. These syndesmophytes frequently bridge adjacent vertebrae, resulting in impaired spinal mobility. This process tends to be slow, but when it progresses can ultimately lead to complete spinal fusion or ankylosis (the so-called “bamboo spine”)^[6].

Other complications can include fused vertebrae (bones in your spine joining together), kyphosis (a forward curve in your spine), and osteoporosis (weakening of the bones)^[3][5].

Eye and vision issues like uveitis or light sensitivity can occur. Heart issues, including aortitis (inflammation of the aorta), arrhythmia (abnormal heart rhythm), and cardiomyopathy (heart muscle disease) are possible. Nerve damage can also occur^[3].

Ankylosing spondylitis is additionally linked to an increased risk of cardiovascular disease, which is believed to stem from the systemic inflammation present in individuals with the condition. Pulmonary complications are also associated with ankylosing spondylitis, as diminished chest wall expansion and limited spinal mobility can predispose individuals to a restrictive pulmonary pattern^[4].

Individuals with ankylosing spondylitis are at least twice as likely to experience vertebral fragility fractures. Additionally, they face an increased risk of atlantoaxial subluxation, spinal cord injury, and, rarely, cauda equina syndrome^[4].

With modern treatments, ankylosing spondylitis does not normally affect life expectancy significantly, although the condition is associated with an increased risk of other potentially life-threatening problems^[5].

Living Well with Ankylosing Spondylitis

Making some adjustments to your home and work environments and using an assistive device as necessary can help you to be more comfortable and get around more easily^[16]. Life with ankylosing spondylitis is easier when you learn ways to better deal with the pain, stiffness, and fatigue it can cause^[17].

Daily Activities

Do your cleaning and cooking at times when your pain is manageable and you’re not too fatigued. Start prepping your meals ahead of time. Take frequent breaks if you need them. Use a long-handled grabber in the kitchen, while doing laundry, or any other time you need to stretch and reach for things. Look for a lightweight, easy-to-handle vacuum cleaner. If you’re fatigued, sit down when doing kitchen prep work or folding clothes, but don’t sit for long stretches of time as that could make your fatigue worse. Don’t forget to delegate and ask for help around the house when your energy is low^[17].

Sleep

Your body needs sleep to be its best. Sleep loss due to pain or stiffness can mean worse symptoms the next day. Get the right mattress that is soft enough to spread your weight evenly but firm enough to hold your body in place. Sleep without a pillow or find one that’s thin to help keep your neck and spine aligned. Don’t sleep on your stomach as it puts too much pressure on your neck and back. Back sleeping is best. Use good sleep hygiene by keeping your bedroom dark and quiet and limiting caffeine and screen time before bed. Create a relaxing bedtime routine such as taking a warm bath or shower and doing some gentle stretches before bed^[17].

Posture

Do all you can to keep your spine straight. Sleep on a firm mattress or with a thin (or no) pillow under your head. Every day, practice standing against a wall with your heels, bottom, shoulders, and head touching the wall. Also, do all the posture exercises your physical therapist recommends^[19].

Diet

There’s no one diet for ankylosing spondylitis, but many people find that sticking with a healthy diet helps them feel better. Choose fresh vegetables, fruit, and whole grains. Limit red meat, sugar, soda, and other junk foods. If you’re having trouble figuring out a healthy way to eat on your own, ask your doctor for a referral to a dietitian who specializes in inflammatory disease^[19].

Smoking

If you smoke, quit. Smoking can make symptoms of ankylosing spondylitis worse, speed up joint damage, and make treatment less effective. The joints that allow your rib cage to expand can be attacked in ankylosing spondylitis, making breathing problems caused by smoking worse. Smoking makes it tough to stay active, which is a key part of treatment. It also increases the risk of other health problems that are common in inflammatory arthritis, especially heart disease^[19].

Stress Management

Living with a chronic disease is stressful. Find healthy ways to manage stress that work for you and your life. This can be whatever makes you feel calm, such as meditation, practicing yoga, taking walks in nature, spending time with your pets, or listening to music^[19].

Foot Care

People with ankylosing spondylitis sometimes get a painful condition called plantar fasciitis, which causes discomfort in the arch of your foot or in your heel. Always wear supportive, comfortable shoes. See a foot specialist (podiatrist) for custom insoles that fit into your shoes. Do gentle foot stretching exercises, such as rolling a tennis ball under the arch of your foot in every direction at least twice a day^[17].