What Is Ankylosing Spondylitis? Symptoms And Treatment

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Ankylosing Spondylitis

Ankylosing spondylitis is a disease that causes inflammation (swelling) of the spine, joints, and tissues surrounding the joints.

Over time, it can cause bridges to form in the bones of the spine, leading to restrictions in spinal movement and posture problems. Patients develop a stooped posture. If the ribs are affected, breathing difficulties may occur.

Can You Tell Me About The Complaints That Occur In Patients With Ankylosing Spondylitis?

Early symptoms of ankylosing spondylitis typically include pain and stiffness in the lower back and hips/thighs, which occurs in the morning or after periods of inactivity. The pain should gradually worsen and last for at least 3 months, and the stiffness should be worse in the morning or after rest and improve with movement. In addition, the pain should respond well to nonsteroidal anti-inflammatory drugs (NSAIDs).

Patients typically complain of a deep, dull pain that is difficult to localize. The pain initially occurs in the thighs and can spread to the hips or back of the thighs.

The pain in the right and left thighs is typically migratory. Low back pain is a very common complaint. Therefore, the diagnosis of the disease may be delayed for years. The average time it takes to diagnose after the complaints start is reported to be 5 years.

Sacroiliac joint involvement causes sacroiliitis, and asymmetric joint swelling/pain is observed, especially in the lower extremities. Pain can also occur at the entheses, such as heel pain and ankle pain, due to inflammation at the attachment sites of tendons, ligaments, and joint capsules to the bone.

The heel, costosternal joints, greater trochanters, ischial tuberosities, and spinous processes are the first areas to be affected. The disease can also start with joint complaints. It usually progresses with involvement of large joints such as the hip, knee, and shoulder.

Joint involvement is usually asymmetric. Hip involvement is usually bilateral, insidious in onset, and a major cause of disability. Repeated swelling can be seen in the knee joint. Jaw joint involvement can lead to decreased mouth opening and impaired chewing function.

In the advanced stages of the disease, spinal deformities develop, leading to restricted movement and posture abnormalities in the back, neck, and spine. The curvature of the back disappears, straightens, and forward flexion of the back and a forward head position develop.

Chest pain and decreased chest expansion capacity during respiration can occur in advanced stages.

In Summary

The pain is inflammatory in nature: there is pain and stiffness that lasts for more than half an hour, decreases with movement, and wakes the patient up at night, requiring them to move. Fatigue and tiredness are also present.

Involvement is more common in the area between the lumbar region and the hip bones, at the attachment points of tendons and ligaments to bone, in the cartilages of the ribs and sternum, and in the hip and shoulder joints. In women, the disease can start with neck and back pain, especially.

Diagnosis is delayed even further in women due to the mild course and slow progression of the disease.

What Areas Can Be Affected Outside The Spine In Ankylosing Spondylitis?

In addition to the spine and joints, other parts of the body can also be affected. The most common area of extra-articular involvement is the eyes.

  • Eyes: Acute anterior uveitis, which is an inflammation of the middle layer of the eye
  • Gastrointestinal tract: Inflammatory bowel disease, as well as asymptomatic enteritis
  • Heart: Aortitis, aortic insufficiency, conduction abnormalities
  • Lungs: Moderate restrictive lung function impairment, apical fibrosis
  • Nervous system: Spinal fracture (secondary to compression or instability), spinal cord compression, cauda equina syndrome, atlantoaxial subluxation
  • Kidneys: Secondary amyloidosis (4-9%), IgA nephropathy

Is There A Genetic Predisposition To Ankylosing Spondylitis?

This disease has a genetic predisposition. In patients, the HLA B27 test is positive in approximately 90% of cases. This rate is only 6-10% in the general population. It should be noted that HLA B27 positivity is not sufficient for diagnosis alone.

The test increases the likelihood of disease when positive, but HLA B27 is not a routine screening or diagnostic test. It is a helpful test for diagnosis if the patient’s history and physical examination suggest the disease, but the diagnosis cannot be clearly made with radiological findings.

Negative results of this test do not necessarily mean that the disease is not present. Clinical and radiological data may be compatible with ankylosing spondylitis, but the HLA B27 test may be negative.

When Should I Seek Medical Attention?

  • If you wake up with back or hip pain in the morning,
  • If your pain decreases with movement and you have complaints of stiffness lasting longer than 30 minutes,
  • If the pain wakes you up from your sleep,
  • If your pain decreases with exercise and worsens with rest,
  • If your pain has been going on for a long time,
  • If you have experienced joint swelling,

If you experience pain in different parts of your body (such as the heel, hip, or chest) even when you do not load them, you should definitely consult an appropriate specialist.

What Are The Causes Of Ankylosing Spondylitis?

The exact cause of the disease is unknown. Genetic effects arising from HLA B27 are in the foreground. It is thought to develop as a result of immune responses to triggering environmental factors in people with genetic predisposition.

Recent infections can trigger the onset of the disease. It can be triggered especially after infections such as gastroenteritis (intestinal infection), urinary tract infection, and sexually transmitted diseases.

What Are The Risk Factors For Ankylosing Spondylitis?

  • Gender: more common in men than women
  • Age: onset in late adolescence or early adulthood
  • Genetics: HLA-B27 positivity

How Is Ankylosing Spondylitis Diagnosed?

For the diagnosis of ankylosing spondylitis, a good history and physical examination are essential. If the findings suggest the disease, the necessary tests are requested. Because the disease can run very differently, a patient-specific path is followed.

The patient’s past history should be investigated for whether he/she has had previous painful periods, whether the pain is periodic, whether the pain is shifting, whether there is morning stiffness, family history, history of previous eye inflammation, joint swelling, tendon inflammation, history of recent infection, history of rheumatism in himself/herself or in his/her family (psoriasis, Behçet’s disease, Crohn’s disease, ulcerative colitis disease, etc.), response to non-steroidal pain relievers, and elevation in laboratory tests (CRP and sedimentation rate). The patient’s recent medication use should also be investigated.

Although rare, sacroiliitis and inflammatory low back pain can develop due to the use of certain medications or due to a deficiency of certain vitamins.

It is very important for patients to communicate with their doctor. Because in this disease, sometimes the complaints start very mildly and it takes time for the complaints to become clear.

It may not be the right approach to investigate this disease with pain that has only been present for a week, as tests performed before the findings are fully established may lead us to a misdiagnosis.

 

Many of our patients have concomitant lumbar disc herniation and receive lumbar disc herniation treatment as the cause of pain. It is necessary for the patient to monitor the character and change of the pain and inform his/her doctor about it. It is important to stay under the follow-up of a specialist doctor in this regard for accurate diagnosis.

According to the patient’s clinical presentation, laboratory examinations and imaging methods are required for diagnosis and follow-up. In rheumatological diseases, tests are usually requested in stages, and the need for a new test is determined by reviewing the data obtained.

Sometimes we can follow our patients for a while with medication and/or physical therapy, and observe their complaints to see if further testing is needed.

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Would You Like To Talk About The Treatment Of Ankylosing Spondylitis?

There is currently no cure for ankylosing spondylitis. The main goal of treatment is to reduce pain and stiffness, preserve and improve function and mobility, prevent disability, improve quality of life, and prevent structural damage.

With treatment, symptoms improve and the progression of the disease slows down. Treatment includes medication, patient education, and exercise. The first step in treatment is the use of non-steroidal anti-inflammatory drugs (NSAIDs). Your doctor will prescribe the right medication for you according to your condition and any underlying diseases.

Treatment also involves a stepwise approach to transitioning to different medications. In recent years, the disease can be controlled with biological agents used in treatment. It takes time to determine which drug will be effective, and drugs can have different effectiveness from person to person.

In addition, every drug used can have side effects, and close monitoring of potential drug side effects in patients is required.

What Is The Goal Of Exercise In Ankylosing Spondylitis?

  • To keep the spine flexible
  • To prevent stiffness, slow the progression if formed
  • To keep the chest moving
  • To maintain good posture
  • To stretch tight muscles
  • To strengthen weak muscles
  • To improve physical function

Exercise is essential in the treatment of patients.

The basic exercises that should be taught to patients with ankylosing spondylitis are joint range of motion and stretching exercises, including full extension and rotation exercises of the cervical spine, dorsal and lumbar extension exercises, trunk rotation exercises performed lying down or standing on the knees, cat-cow exercises, and breathing exercises. Recreational activities and aerobic exercises are also recommended in addition to these.

What Would You Like To Say About Complementary Medicine And Dietary Recommendations In The Treatment Of Ankylosing Spondylitis? 

In recent years, complementary medicine methods (such as cupping therapy (hijama), hirudotherapy, acupuncture, and ozone therapy) have become a part of my treatment plan for pain and functionality.

In addition, as the effect of nutrition on pain has come to the fore more and more in recent years, nutritional recommendations and dietary supplements are also among my recommendations.

However, the need for further research on these issues is undeniable.

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Doç. Dr. Saliha Eroğlu Demir

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