Microsoft word - ankylosing spondylitis.docx

Copyright Bradley Whale 2011. No unauthorised reproductions. www.bradleywhale.co.uk Ankylosing Spondylitis


What is ankylosing spondylitis?

Ankylosing spondylitis is a form of chronic inflammation of the spine and the sacroiliac
joints. The sacroiliac joints are located in the low back where the sacrum (the bone directly
above the tailbone) meets the iliac bones (bones on either side of the upper buttocks).
Chronic inflammation in these areas causes pain and stiffness in and around the spine. Over
time, chronic spinal inflammation (spondylitis) can lead to a complete cementing together
(fusion) of the vertebrae, a process referred to as ankylosis. Ankylosis leads to loss of
mobility of the spine.
Ankylosing spondylitis is also a systemic disease, meaning it can affect other tissues
throughout the body. Accordingly, it can cause inflammation in or injury to other joints
away from the spine, as well as to other organs, such as the eyes, heart, lungs, and kidneys.
Ankylosing spondylitis shares many features with several other arthritis conditions, such
as psoriatic arthritis, reactive arthritis, and arthritis associated with Crohn's disease and
ulcerative colitis. Each of these arthritic conditions can cause disease and inflammation in
the spine, other joints, eyes, skin, mouth, and various organs. In view of their similarities
and tendency to cause inflammation of the spine, these conditions are collectively referred
to as "spondyloarthropathies." Ankylosing spondylitis is considered one of the many
rheumatic diseases because it can cause symptoms involving muscles and joints.
Ankylosing spondylitis is two to three times more common in males than in females. In
women, joints away from the spine are more frequently affected than in men. Ankylosing
spondylitis affects all age groups, including children. The most common age of onset of
symptoms is in the second and third decades of life.
What causes ankylosing spondylitis?
This is the science bit but basicly it is geneticly inherited.
The tendency to develop ankylosing spondylitis is believed to be genetically inherited, and
the majority (nearly 90%) of patients with ankylosing spondylitis are born with the
HLA-B27 gene. Blood tests have been developed to detect the HLA-B27 gene marker and
have furthered our understanding of the relationship between HLA-B27 and ankylosing
spondylitis. The HLA-B27 gene appears only to increase the tendency of developing
ankylosing spondylitis, while some additional factor(s), perhaps environmental, are
necessary for the disease to appear or become expressed. For example, while 7% of the
United States population have the HLA-B27 gene, only 1% of the population actually have
the disease ankylosing spondylitis. In Northern Scandinavia (Lapland), 1.8% of the
population have ankylosing spondylitis while 24% of the general population have the

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HLA-B27 gene. Even among HLA-B27-positive individuals, the risk of developing
ankylosing spondylitis appears to be further related to heredity. In HLA-B27-positive
individuals who have relatives with the disease, their risk of developing ankylosing
spondylitis is 12% (six times greater than for those whose relatives do not have ankylosing
spondylitis).
Recently, two more genes have been identified that are associated with ankylosing
spondylitis. These genes are called ARTS1 and IL23R. These genes seem to play a role in
influencing immune function. It is anticipated that by understanding the effects of each of
these known genes researchers will make significant progress in discovering a cure for
ankylosing spondylitis.
What are the symptoms of ankylosing spondylitis?

Ankylosing spondylitis affects different people in different ways. Symptoms develop
gradually, may be mild or severe, and can come and go. They include:
• back pain and stiffness - this is worse at night and in the morning, and eases off • pain and swelling of your hip, knee or other joints • plantar fasciitis - pain under the heel of your foot • aching in your chest, around your ribs • feeling unwell or feverish and having night sweats • weight loss • tiredness The symptoms of ankylosing spondylitis are related to inflammation of the spine, joints, and other organs. Fatigue is a common symptom associated with active inflammation. Inflammation of the spine causes pain and stiffness in the low back, upper buttock area, neck, and the remainder of the spine. The onset of pain and stiffness is usually gradual and progressively worsens over months. Occasionally, the onset is rapid and intense. The symptoms of pain and stiffness are often worse in the morning or after prolonged periods of inactivity. The pain and stiffness are often eased by motion, heat, and a warm shower in the morning. Because ankylosing spondylitis often affects adolescents, the onset of low back pain is sometimes incorrectly attributed to athletic injuries in younger patients. Patients who have chronic, severe inflammation of the spine can develop a complete bony fusion of the spine (ankylosis). Once fused, the pain in the spine disappears, but the patient has a complete loss of spine mobility. These fused spines are particularly brittle and vulnerable to breakage (fracture) when involved in trauma, such as motor-vehicle accidents. A sudden onset of pain and mobility in the spinal area of these patients can indicate bone breakage. The lower neck (cervical spine) is the most common area for such fractures. Chronic spondylitis and ankylosis cause forward curvature of the upper torso (thoracic spine), limiting breathing capacity. Spondylitis can also affect the areas where ribs attach
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to the upper spine, further limiting lung capacity. Ankylosing spondylitis can cause
inflammation and scarring of the lungs, causing coughing and shortness of breath,
especially with exercise and infections. Therefore, breathing difficulty can be a serious
complication of ankylosing spondylitis.
Patients with ankylosing spondylitis can also have arthritis in joints other than the spine.
This feature occurs more commonly in women. Patients may notice pain, stiffness, heat,
swelling, warmth, and/or redness in joints such as the hips, knees, and ankles.
Occasionally, the small joints of the toes can become inflamed or "sausage" shaped.
Inflammation can occur in the cartilage around the breast bone (costochondritis) as well as
in the tendons where the muscles attach to the bone (tendinitis) and in ligament
attachments to bone. Some patients with this disease develop Achilles tendinitis, causing
pain and stiffness in the back of the heel, especially when pushing off with the foot while
walking up stairs. Inflammation of the tissues of the bottom of the foot, plantar fasciitis,
occurs more frequently in people with ankylosing spondylitis.
Other areas of the body affected by ankylosing spondylitis include the eyes, heart, and
kidneys. Patients with ankylosing spondylitis can develop inflammation of the iris, called
iritis. Iritis is characterized by redness and pain in the eye, especially when looking at
bright lights. Recurrent attacks of iritis can affect either eye. In addition to the iris, the
ciliary body and choroid of the eye can become inflamed; this is referred to as uveitis. Iritis
and uveitis can be serious complications of ankylosing spondylitis that can damage the eye
and impair vision and may require an eye specialist's (ophthalmologist) urgent care.
Special treatments for serious eye inflammation are discussed in the treatment section
below. (It should be noted that iritis and inflammation of the spine can occur in other forms
of arthritis such as reactive arthritis [formerly Reiter's syndrome], psoriatic arthritis, and
the arthritis of inflammatory bowel disease.)
A rare complication of ankylosing spondylitis involves scarring of the heart's electrical
system, causing an abnormally slow heart rate. A heart pacemaker may be necessary in
these patients to maintain adequate heart rate and output. The part of the aorta closest to the
heart can become inflamed, resulting in leakage of the aortic valve. In this case, patients
can develop shortness of breath, dizziness, and heart failure.
Advanced spondylitis can lead to deposits of protein material called amyloid into the
kidneys and result in kidney failure. Progressive kidney disease can lead to chronic fatigue
and nausea and can require removal of accumulated blood poisons by a filtering machine
(dialysis).



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What are treatment options for ankylosing spondylitis?

Painkillers and anti-inflammatories
Your GP or rheumatologist will usually advise you to try non-steroidal anti-inflammatory
drugs (NSAIDs) first, to help with your pain. NSAIDs will reduce inflammation and pain
so that you can keep active. You can buy some NSAIDs, such as ibuprofen (eg Nurofen),
from your pharmacist. Other NSAIDs, such as celecoxib, have to be prescribed by your
GP.
These medicines can have side-effects such as stomach pain or bleeding from the stomach.
Talk to your GP or pharmacist if you need to take NSAIDs regularly, and see your GP
immediately if you experience any pain that feels like indigestion while taking NSAIDs.
Always read the patient information leaflet that comes with your medicine.
If you can't take NSAIDs for any reason, your doctor may advise you to take another
painkiller, such as paracetamol, instead. Or, he or she may prescribe a medicine called a
proton pump inhibitor to take at the same time as an NSAID, to reduce your risk of
side-effects.
Your doctor can also prescribe corticosteroid injections, which he or she will inject into
joints (such as your knee) if they are very painful and swollen.

Disease-modifying anti-rheumatic drugs (DMARDs)
Depending on how severe your disease is, your rheumatologist may also prescribe
disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate or sulfasalazine.
These medicines are used for other types of arthritis that are due to inflammation (eg
rheumatoid arthritis). They work by changing the actual disease process of ankylosing
spondylitis. It may take some time before you notice any effect.

TNF-a inhibitors
If DMARDs have not helped relieve your symptoms, your rheumatologist may
recommend a type of medicine called a TNF-a inhibitor. Two of these medicines
(etanercept and adalimumab) are available on the NHS for people with ankylosing
spondlyitis. They are given by injection.

Bisphosphonates
Bisphosphonates (eg, pamidronate) affect bone metabolism and are usually used to prevent
or treat osteoporosis (thin bones). However, they are also sometimes used in the treatment
of ankylosing spondylitis. They are also given by injection. Your rheumatologist may
prescribe these if he or she thinks these medicines will help you.
Physical Therapy
Physical therapy for ankylosing spondylitis includes instructions and exercises to maintain
proper posture. This includes deep breathing for lung expansion and stretching exercises to
improve spine and joint mobility. Since ankylosis of the spine tends to cause forward
curvature, patients are instructed to maintain erect posture as much as possible and to
perform back-extension exercises. Patients are also advised to sleep on a firm mattress and
avoid the use of a pillow in order to prevent spine curvature. Ankylosing spondylitis can

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involve the areas where the ribs attach to the upper spine as well as the vertebral joints, thus
limiting breathing capacity. Patients are instructed to maximally expand their chest
frequently throughout each day to minimize this limitation.
Exercise programs are customized for the individual patient. Swimming is preferred, as it
avoids jarring impact of the spine. Ankylosing spondylitis need not limit a patient's
involvement in athletics. Patients can participate in carefully chosen aerobic sports when
their disease is inactive. Aerobic exercise is generally encouraged as it promotes full
expansion of the breathing muscles and opens the airways of the lungs.
Inflammation and diseases in other organs are treated separately. For example,
inflammation of the iris of the eyes (iritis or uveitis) may require cortisone eyedrops (Pred
Forte) and high doses of cortisone by mouth. Additionally, atropine eyedrops are often
given to relax the muscles of the iris. Sometimes injections of cortisone into the affected
eye are necessary when the inflammation is severe. Heart disease in patients with
ankylosing spondylitis may require a pacemaker placement or medications for congestive
heart failure.
Cigarette smoking is strongly discouraged in patients with ankylosing spondylitis, as it can
accelerate lung scarring and seriously aggravate breathing difficulties. Occasionally,
patients with severe lung disease related to ankylosing spondylitis may require oxygen
supplementation and medications to improve breathing.
Patients may need to modify their activities of daily living and adjust features of the
workplace. For example, workers can adjust chairs and desks for proper postures. Drivers
can use wide rearview mirrors and prism glasses to compensate for the limited motion in
the spine.

Heat/Cold
Applying heat to stiff joints and tight muscles can help reduce pain and soreness. Applying
cold to inflamed areas can help reduce swelling. Hot baths and showers can also help
provide relief.

Surgery
In severe cases of AS, surgery can be an option in the form of joint replacements,
particularly in the knees and hips. Surgical correction is also possible for those with severe
flexion deformities (severe downward curvature) of the spine, particularly in the neck,
although this procedure is considered risky. Click here to learn more about surgery in our
Patient Resources section.
Other Symptom Management Tools
Alternative treatments such as massage and using a TNS unit (electrical stimulators for
pain) can also aide in pain relief. Maintaining a healthy body weight and balanced diet can
also aide in treatment.

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What is in the future for patients with ankylosing spondylitis?

Ankylosing spondylitis and each of the spondyloarthropathies are areas of active research.
The relationship between infectious agents and the triggering of chronic inflammation is
vigorously being pursued. Factors that perpetuate "autoimmunity" are being identified.
The characteristics of the gene marker HLA-B27 are being further defined. In fact, there
are now known to be seven different subtypes of HLA-B27.
The impact of the recent discovery of the two additional genes associated with ankylosing
spondylitis (described above under "Causes") cannot be overstated. As more about the
precise mechanisms these genes use to influence the immune system is understood, the
discovery of a cure will be possible. Moreover, results of ongoing research will lead to a
better understanding and treatment of the entire group of diseases collectively known as
spondyloarthropathies.

Ankylosing Spondylitis At A Glance

• Ankylosing spondylitis belongs to a group of arthritis conditions which tend to cause chronic inflammation of the spine (spondyloarthropathies). • Ankylosing spondylitis affects males two to three times more commonly than • Ankylosing spondylitis is a cause of back pain in adolescents and young adults. • The tendency to develop ankylosing spondylitis is genetically inherited. • The HLA-B27 gene can be detected in the blood of most patients with ankylosing • Ankylosing spondylitis can also affect the eyes, heart, lungs, and occasionally the • The optimal treatment of ankylosing spondylitis involves medications that reduce inflammation or suppress immunity, physical therapy, and exercise.

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