Axial Spondyloarthritis

Axial spondyloarthritis is a type of inflammatory arthritis that primarily affects the spine, causing chronic back pain and stiffness, often beginning in young adults or even teenagers. While there is no cure, a range of treatments and lifestyle approaches can help manage symptoms and maintain quality of life.

Table of contents

• What Is Axial Spondyloarthritis?
• Types of Axial Spondyloarthritis
• Who Can Be Affected?
• Causes and Genetic Factors
• Symptoms and How They Affect the Body
• Diagnosis
• Treatment Options
• Living with Axial Spondyloarthritis
• Outlook and Long-Term Management

What Is Axial Spondyloarthritis?

Axial spondyloarthritis, also called axSpA, is a type of inflammatory arthritis that mainly affects the joints in your spine, chest, and pelvis. These areas make up what doctors call your axial skeleton^[1]. The word “inflammatory” means that your immune system is overactive or not working properly, which causes swelling and damage in your joints and soft tissues^[1].

What makes axial spondyloarthritis different from other types of arthritis is that it can affect other parts of your body beyond your joints. People with axSpA might also experience eye inflammation, digestive problems like diarrhea, or other symptoms that may seem unrelated to joint pain^[1].

Over time, if left untreated, axial spondyloarthritis can cause the bones of your spine to grow together or fuse. This process is called ankylosis, and it can make your spine stiff and hard to move^[5]. The fusion can also lead to weakening of the bones in your spine, known as osteoporosis, which increases the risk of a broken bone in your spine^[1].

AS, ankylosing spondylitis, non-radiographic axial spondyloarthritis, nr-axSpA, radiographic axial spondyloarthritis, r-axSpA

• Spine
• Pelvis
• Sacroiliac joints
• Chest
• Hips
• Shoulders
• Ribs

Types of Axial Spondyloarthritis

Axial spondyloarthritis is an umbrella term that includes two main types, based on whether damage to the spine and joints can be seen on X-rays^[2].

The first type is called ankylosing spondylitis, also known as AS or radiographic axial spondyloarthritis. In this form, damage to the sacroiliac joints (where your spine connects to your pelvis) and the spine can be seen clearly on X-ray images^[2].

The second type is non-radiographic axial spondyloarthritis, or nr-axSpA. People with this form have similar symptoms and inflammation, but the damage does not show up on X-rays. However, inflammation may be visible on a more detailed imaging test called an MRI^[2]. Around 7 in 10 people with non-radiographic axial spondyloarthritis have visible inflammation on an MRI, while 3 in 10 may not show inflammation on MRI despite having symptoms^[4].

These two forms are considered parts of the same disease, and both share many genetic and symptom features. However, there are some differences. Ankylosing spondylitis is more common in men than in women, with a ratio of about 2 to 1. In contrast, non-radiographic axial spondyloarthritis affects men and women equally^[2][12].

Who Can Be Affected?

Anyone can develop axial spondyloarthritis, but it is relatively rare. The condition affects about 1 in 100 people worldwide, or around 3 million people in the United States^[1][6].

Axial spondyloarthritis usually begins in people younger than 40 years old, often starting during the teenage years or 20s^[1][2]. In fact, it is one of the most overlooked causes of persistent back pain in young adults^[19].

The condition occurs equally in males and females overall. However, as mentioned earlier, the specific type called ankylosing spondylitis is more common in men, while non-radiographic axial spondyloarthritis affects both sexes equally^[1].

Axial spondyloarthritis tends to run in families, suggesting a strong genetic component^[2].

Causes and Genetic Factors

The exact cause of axial spondyloarthritis is not fully understood. However, researchers believe that people with certain genes may develop the condition when they are exposed to triggers such as a virus, bacteria, or other environmental factors^[2].

Most people with axial spondyloarthritis carry a gene called HLA-B27^[1][3]. This gene is strongly associated with the disease. However, having the HLA-B27 gene does not mean that a person will definitely develop axSpA. In fact, many people who have this gene never develop the condition^[1][2]. On the other hand, some people develop axial spondyloarthritis even without having the HLA-B27 gene or a family history of the disease^[1].

In addition to HLA-B27, other genetic factors related to how the immune system works and certain inflammatory pathways in the body, such as those involving proteins called interleukin-23 and interleukin-17, are also believed to play a role in the disease^[7].

Symptoms and How They Affect the Body

The most common symptom of axial spondyloarthritis is chronic back pain, which means pain lasting three months or longer^[1]. This pain is not caused by an injury or a mechanical problem like a slipped disk or muscle spasm. Instead, it is caused by inflammation^[1].

Back pain from axSpA has some specific features that help distinguish it from other types of back pain. The pain often develops slowly over weeks or months, rather than suddenly^[2][4]. It tends to feel better when you exercise or move around, but gets worse when you rest or stay still for a long time^[1][3]. The pain is often worse at night or in the early morning, and morning stiffness is very common^[1][2]. The discomfort may spread to your hips or buttocks^[1].

Children with axial spondyloarthritis may first experience pain in the hips, knees, or heels before noticing back pain^[2].

In addition to back pain, people with axSpA may experience pain, swelling, redness, and warmth in other areas such as the toes, heels, ankles, knees, rib cage, shoulders, neck, and upper spine^[2]. Inflammation can occur where tendons and ligaments attach to bones, a condition called enthesitis^[1][4]. Swelling of entire fingers or toes, known as dactylitis, can also happen^[1].

Other common symptoms include extreme tiredness or fatigue, loss of appetite, and feeling feverish with night sweats^[2][4].

Axial spondyloarthritis can also affect other parts of the body beyond the joints. The eyes can become inflamed, a condition called uveitis or iritis. This causes dryness, pain, redness, sensitivity to light, and vision problems^[1][2][3]. Some people develop skin conditions such as psoriasis^[1]. Inflammation in the digestive tract can cause abdominal pain and diarrhea^[2]. Although less common, the heart and lungs can also be affected. Inflammation may involve the aorta, the largest artery leading to the heart, and people with axSpA have an increased risk of heart attack and stroke^[2].

Over time, repeated cycles of inflammation followed by healing can lead to new bone formation. When this happens in the spine, individual bones called vertebrae can fuse together^[4][5]. This fusion makes the spine less flexible and can result in a hunched posture. If the joints in the chest are affected, it may become harder to take deep breaths^[5].

Diagnosis

Getting a correct diagnosis of axial spondyloarthritis can take time. The main symptoms, such as back pain and stiffness, are common complaints that can be confused with other, less serious conditions like non-specific chronic low back pain^[7]. In fact, more than half of patients remain undiagnosed for at least five years^[19].

To diagnose axial spondyloarthritis, your doctor will start by reviewing your medical history and performing a physical exam to check your overall health^[1][3]. They may ask about the pattern of your back pain, whether it improves with exercise, and if you have other symptoms such as eye inflammation or digestive problems.

Blood tests are commonly used to look for signs of inflammation in your body, such as a protein called C-reactive protein. Your doctor may also test for the HLA-B27 gene, which is often present in people with axSpA^[1][3]. However, having this gene does not confirm the diagnosis, and not having it does not rule out the disease.

Imaging tests are an important part of the diagnosis. X-rays of the spine can show changes such as damage to the sacroiliac joints, called sacroiliitis, which is a key sign of axial spondyloarthritis^[1][3]. However, X-ray changes may only become visible after years of ongoing inflammation^[7]. For this reason, doctors often use MRI scans, which can detect inflammation in the spine and joints much earlier than X-rays^[1][7].

Doctors can diagnose axial spondyloarthritis based on symptoms, blood tests, and imaging findings, even if X-rays do not show visible damage. If you have typical symptoms but no X-ray changes, your doctor may diagnose non-radiographic axial spondyloarthritis^[1].

Treatment Options

There is no cure for axial spondyloarthritis, but effective treatments are available to help relieve symptoms, manage pain, and possibly slow down the progression of the disease^[1][5].

Treatment usually involves a combination of physical therapy, exercise, medications, and lifestyle changes^[14].

Physical Therapy and Exercise

Keeping active is one of the most important parts of managing axial spondyloarthritis. Regular exercise can improve your posture, maintain the range of movement in your spine, and reduce pain and stiffness^[3][13]. In fact, back pain caused by axSpA tends to get worse when you have been sitting or lying down for a long time, but improves with movement^[18].

A physiotherapist can work with you to create an exercise program that suits your needs. This may include group exercise classes, individual exercise routines, or hydrotherapy, which involves exercising in warm water^[13]. Swimming, Pilates, yoga, and tai chi are also excellent options for maintaining flexibility and relieving pain^[9][16].

In addition to stretching and flexibility exercises, it is important to include cardiovascular exercise that gets your heart rate up, as well as strength training^[9].

Medications

Medications play an essential role in treating axial spondyloarthritis for most people. The type of medication your doctor prescribes will depend on the severity of your symptoms and how well you respond to treatment.

Nonsteroidal anti-inflammatory drugs, or NSAIDs, are usually the first medications prescribed. They help ease pain and reduce swelling in your joints^[3][9]. Common examples include ibuprofen, naproxen, and diclofenac^[13].

If NSAIDs do not provide enough relief or if joints outside the spine are affected, your doctor may prescribe a medication called sulfasalazine^[9][13]. Another option is methotrexate, which is used in some cases^[3].

For people with more active disease or those who do not respond well to NSAIDs, a class of medications called biologics may be used. These are powerful drugs that target specific parts of the immune system to reduce inflammation. One type of biologic works by blocking a protein called tumor necrosis factor, or TNF. Examples include adalimumab, etanercept, infliximab, golimumab, and certolizumab^[3][9][13]. Another type of biologic blocks a protein called interleukin-17, or IL-17. Examples include secukinumab and ixekizumab^[3][9][13].

A newer class of medications called Janus kinase inhibitors, or JAK inhibitors, may also be prescribed for people who do not respond to anti-TNF drugs or cannot take them. JAK inhibitors are taken as tablets and work by blocking enzymes that the immune system uses to trigger inflammation^[12][13].

If a specific joint is very inflamed, your doctor may inject corticosteroids directly into the joint to quickly reduce swelling and pain^[3][13]. However, oral corticosteroids are not recommended for routine use in axial spondyloarthritis^[13].

For simple pain relief, paracetamol or codeine may be used if you cannot take NSAIDs or need extra help managing pain^[13].

Surgery

In rare cases, surgery may be needed to correct posture or repair damaged joints. However, surgery is not common in axial spondyloarthritis^[3][13].

Living with Axial Spondyloarthritis

Living with axial spondyloarthritis means making adjustments and finding ways to manage your condition day to day. Fortunately, there are many strategies that can help you stay active and feel better.

Self-Care and Lifestyle Habits

Certain lifestyle changes can make a big difference in managing your symptoms. If you smoke, quitting is one of the most important steps you can take. Smoking can make symptoms worse, speed up joint damage, and make treatment less effective. It also increases the risk of other health problems that are common in inflammatory arthritis, especially heart disease^[16][18].

Paying attention to your posture is also important. Try to keep your spine straight as much as possible. Sleep on a firm mattress with a thin pillow or no pillow under your head. Practice standing against a wall with your heels, bottom, shoulders, and head touching the wall, and do all the posture exercises your physiotherapist recommends^[16].

Getting enough sleep is essential. The back pain of axSpA may wake you up in the middle of the night, and lack of sleep can make you more sensitive to pain and increase fatigue. To improve your sleep, make sure you are taking your medications as directed, avoid caffeine late in the day, limit screen time before bed, and exercise during the day^[16].

Managing stress is another key part of living well with axial spondyloarthritis. Living with a chronic disease can be stressful, so find healthy ways to manage stress that work for you. This might include meditation, yoga, spending time in nature, or enjoying time with pets^[16].

Diet and Nutrition

While there is no specific diet for axial spondyloarthritis, 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^[16]. If you are 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 diseases^[16].

Emotional and Social Support

Adjusting to a diagnosis of axial spondyloarthritis can be difficult, especially for young adults who are just starting their careers, planning families, or building their lives. Learning that you have a chronic illness is challenging, but it is important to remember that you are not alone. With the right support and treatment, you can live a happy, full life with axSpA^[17].

Building a support network can make a big difference. This may include friends and family, but connecting with others who have the same condition can be especially helpful. Support groups, both in-person and online, can provide encouragement, practical advice, and a sense of community^[3][17].

It is also important to practice emotional self-care. Remember that your disease does not define you. Acknowledge and accept your feelings, but try not to let them weigh you down. Ask for help when you need it, but also feel free to say no if you do not want help. You may not be able to fully control your disease, but you can control how you think, react, and feel about it^[17].

Outlook and Long-Term Management

With today’s treatment options, most people with axial spondyloarthritis can lead normal, productive lives and have a normal lifespan^[3]. The key is to work closely with your doctor to create a treatment plan that is right for you, and to stay active and engaged in managing your health.

Long-term suppression of inflammation through treatment may help slow down or prevent the structural damage that can occur in the spine^[10]. Regular follow-up appointments with your doctor are important to monitor your condition and adjust your treatment as needed.

While axial spondyloarthritis is a chronic condition that requires ongoing management, advances in understanding the disease and new treatment options continue to improve outcomes for people living with this condition.