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AS is… …more than just a pain in the butt.

From Joint Efforts

Ali was 20 when he first experienced lower back pain and stiffness. The symptoms were most noticeable in the morning but tended to fade away by mid morning. He could not remember any strain or trauma that started the pain but it just never
went away completely. Although Ali did speak to his friends about this discomfort, they all put it down to strain from football practice. He went to his doctor and was given some painkillers, which relieved the pain when he took them, but the pain returned when he stopped the painkillers. There were times when the pain generally got better, but at
other times it got much worse.

By the time he hit 30, his back had stiffened to the point that Ali was unable to move his back properly. He had lost a considerable amount of what medical professionals would refer to as “range of motion”.

Little did he know it at that time, but Ali had joined the ranks of greats such as Pope John Paul II, golfer Ian Woosnam and
Taiwanese musician Jay Chou, all of whom – along with Ali – have been diagnosed with Ankloysing Spondylitis, or AS in short. Also known as “Bekhterev’s disease” as well as “Marie- Strumpell disease”, AS is from the Greek words “ankylos” or
“stiff” and “spondylos” or “vertebrae”, hence Ali’s inability to move due to the gradual stiffening vertebrae of his spine.
AS is a form of spondyloarthritis; a chronic, inflammatory arthritis and autoimmune disease that mainly affects joints in
the spine and the sacroilium in the pelvis. Untreated AS can cause fusion of the vertebrae of the spine resulting in complete rigidity, a condition also known as “bamboo spine”. The effects of ankylosing spondylitis This disease ranges from mild to progressively debilitating.

Cases that have been diagnosed early can be medically controlled. While some patients vacillate between periods of active inflammation to periods of remission, others never have times of remission and experience chronic inflammation and pain. Sometimes, AS can be misdiagnosed as normal rheumatism, and in the long-term, untreated AS may result in osteopenia or osteoporosis causing compression fractures and a back “hump”. Typical signs of AS that has progressed are the visible formation of syndesmophytes (a kind of bone outgrowths of the spine) on X-Rays and abnormal bone outgrowths similar to osteophytes (small round lumps of extra bone that grow around joints, the body’s attempt to compensate for existing bone and ligament degeneration due to age or injury) affecting the spine.

Apart from the axial spine and other related joints, the organs most commonly affected by AS are the heart, lungs, eyes, colon and kidneys. Other complications are aortic regurgitation (faulty blood flow into the left ventricular chamber of the heart due to an “incompetent” aorta) Achilles tendinitis, AV node block (a disease in the electrical system of the heart that can cause lightheadedness, fainting and palpitations) and amyloidosis (a variety of conditions in which amyloid proteins are abnormally deposited in organs and/or tissues).

Signs and symptoms

Contrary to rheumatoid arthritis that affects more women than men, especially women in their 40s and above, the typical AS patient is a young male, aged 20-40. In patients under the age of 18, AS is relatively likely to cause pain and swelling of the large limb joints, particularly the knee. AS in pre-pubescent children can cause swelling and pain in the ankles and feet, where calcaneal spurs may also develop.

Symptoms first appear with chronic pain and stiffness in the lower back, and often, pain in one buttock or the back of the thigh from the sacroiliac joint. The course of AS varies greatly from person to person and its symptoms can sometimes occur in children or older men. Another common symptom is generalized fatigue and nausea. The pain cause by AS is usually dull and diffused, rather than localized, being worse in the mornings and during the night, but may be improved by a warm shower or light exercise. Pain is more severe with rest, but improves with physical activity.

Over the course of month or years, the stiffness and pain can spread up the spine and into the neck with tenderness spreading to the ribs,shoulder blades, hips, thighs and even the heels as well. Men are more affected by AS than women by a ratio of about 3:1. Also, the disease takes a more painful course in men than it does in the women who have it.

About 40 percent of AS cases are associated with inflammation of the eye – iridocylitis and uveitis – that cause redness, eye pain, vision loss, floaters and photophobia. Approximately 90 percent of AS patients express the HLA-B27 genotype. In other words, there appears to be a strong genetic association, although only five percent of people with the HLA_B27 genotype contract the disease.

Diagnosis

There is no direct test to diagnose AS. The main diagnostic tools are clinical examination and X-Ray studies that show spinal changes and sacroilitis that are characteristic of AS. However, X-Ray is, in turn, not the best diagnostic tool as it generally only shows spinal abnormalities of the spine that has been suffering from AS for between eight to 10 years.
This means that a person diagnosed with AS with X-Ray would have had up to a 10-year delay in treatment for the condition. Options for earlier detection are tomography and magnetic resonance imaging, or MRI, of the sacroiliac joints, although the medical jury is still out on the reliability of these tests. A clinical measure, or medical test, for AS, on
the other hand, would be the Schober’s Test (see below).

Schober’s test, a way of diagnosing AS, assesses the amount of lumbar flexion. In this test a mark is made at the level of the posterior iliac spine on the vertebral column, approximately at the level of L5. The examiner then places one finger 5cm below this mark and another finger at about 10cm above this mark. The patient is then instructed to touch his toes. If the increase in distance between the two fingers on the patients spine is less than 5cm then this is indicative of a limitation of lumbar flexion. This test allows serial measurements for patients with progressive disease to be undertaken.

An AS patient going through an acute inflammatory phase of the disease might also be tested for blood concentration of
C-reactive protein (CRP) and an increase in the erythrocyte sedimentation rate (ESR), although the CRP and ESR rates in some AS patients do not increase during this phase. In 2007, researchers discovered that two genes, ARTS1 and IL23R also contribute to the cause of AS. Together with the HLAB27, these two genes account for roughly 70 percent of the overall incidence of the disease. Accordingly, a more accurate diagnosis of AS can be made if these three genes are detected. Two indexes have also been designed — the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Bath Ankylosing Spondylitis Functional Index (BASFI) – respectively to detect the degree of AS caused inflammation and to accurately assess a patient’s functional impairment due to the disease as well as improvements following therapy.
The BASDAI helps to diagnose AS by detecting factors such as HLA-B27 positivity, persistent buttock pain that stops with
exercise and X-Ray or MRI of the sacroiliac joint. The BASFI, on the other hand, is not usually used as a diagnostic tool, but a means of assessing a patient’s functional impairment due to the disease as well as improvements following therapy.

Treatment

Although there is no known cure for AS, there are available an array of treatments and medication that reduce the symptoms as well as pain caused by the disease. Ultimately, however, physical exercise or therapy lies at the heart of AS treatment. Normally, a physician would prescribe medication to the AS patient before the patient undergoes physiotherapy or an exercise regimen. Once the inflammation and pain are brought down by the medication, the patient undergoes physiotherapy or performs physician-prescribed exercises designed to diminish pain and to maintain the mobility of the joints. Physiotherapy is one of the most effective treatments of AS followed by swimming because it involves all muscles and joints in a low-impact, buoyant environment, as well as stretching, yoga, tai chi and Pilates. On the whole, moderate to high-impact exercises such as jogging are either not recommended or recommended with restrictions due to the jarring of affected vertebrae that can worsen pain and stiffness in some patients. Aside from exercise, experts in AS generally
believe that maintaining good posture can reduce the likelihood of a fused or curved spine that occurs in many people diagnosed with AS.

Generally, three major types of medication are used to treat AS: pain-relieving drugs; DMARDs, to reduce the immune
system response through immunosuppression; and TNFa blockers known as “biologics” also used as immunosuppressants.
Pain-relieving drugs come in two major classes: the antiinflammatory drugs that include NSAIDs such as ibuprofen,
phenylbutazone, indomethacin, naproxen and COX-2 inhibitors that reduce inflammation and pain, and opioid analgesics that have been proven effective in alleviating the type of chronic pain that AS patients generally have to endure.

The most promising AS treatment to date, however, are the TNFa blockers that have shown, in the majority of clinical cases, to slow the progress of AS, helping to reduce significantly pain and inflammation. However, aside from being very expensive, biologics seem to increase the risk of infections. In severe cases, surgery can be an option in the form of joint
replacements, especially of the hips and knees. Although considered highly risky, severe “flexion deformities”, or downward
curvature of the spine or neck can be corrected with surgery.

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