Ankylosing spondylitis (AS) is a term used to describe a form of arthritis which mainly affects the joints in the spine. However, it may affect other parts of the body, for example the hips, shoulders, knees or ankles.
AS is a chronic (i.e. continuing, long-lasting) condition. However, with early diagnosis and proper management, the pain and stiffness of AS can be minimized and the deformity considerably reduced.
AS causes inflammation outside the joint where the ligaments and tendons are attached to the bone. It usually affects the little joints between the vertebrae of the spine and tends to reduce the movement which takes place at these joints, causing stiffening.
The spine or backbone is made up of 24 bones (vertebrae) and 110 joints (Figure 1). There are 3 main sections; the cervical or neck section, which is the most mobile, the thoracic or chest section and the lumbar section. Below the lumbar section is the sacrum, which fits into the pelvis. AS usually starts at the sacro-lilac joints which lie between the sacrum and the pelvis.
What Causes Ankylosing Spondylitis?
The cause is not yet known, but there is a hereditary factor as occasionally, more than one family member can have this condition.
AS is not infectious, and neither can it be caused by athletic activity or injury. Sometimes, the initial symptoms may follow unusual exertion or strain and this may be blamed at first, but it is not the cause of AS.
Who Gets Ankylosing Spondylitis?
AS unusually affects young people between 13 and 35 years old, but may appear in the older age group. Typically, it affects young males, but can occur in women as well.
The early symptoms vary, but pain and stiffness in the lower back and around the hips are common. Back troubles however, are some of the commonest complaints seen by doctors. The most common cause of backache is “back strain,” which can happen at any age. A “slipped disc” is another example. In older people, wear and tear problems often affect the back. Diagnosis is made by listening to your symptoms and examining you.
Although the early symptoms commonly affect the lower spine, other areas of the spine may be affected. In a few cases, the first complaint may not be in the back at all, but in the hip or knee. The symptoms are particularly worse in the early morning and tend to wear off through the day. Unlike the common mechanical low back pain, which improves with rest, the pain and stiffness of AS are relieved by exercise and are worse after not moving, for example, in the morning after lying in bed all night. Some patients may have other symptoms, for example, chest pain. This does not come from the heart, but from the joints between the ribs and breast bone. Breathing exercises will help maintain the mobility of the ribcage. Iritis (inflammation of the iris which forms the pupils of the eye) occasionally occurs, so if you suddenly develop a red eye, please see your doctor immediately. There are other rare complications which can affect the heart, lung and nervous system, but these affect less than one patient in a hundred.
AS is a condition that waxes and wanes with time, so there will be periods when one has more pain and stiffness and other periods when they are less troublesome. AS is a systemic condition and can affect the whole body and hence, when AS is active, a person may experience fever, loss of appetite and feel constantly tired.
If any of these symptoms continue for more than two months, you should see a doctor.
AS is often very difficult to diagnose in the early stages or in mild cases. The diagnosis can be confirmed by X-rays, but because the changes may take several years to appear, it may not be possible to make a definite diagnosis initially. Your doctor may also carry out some blood tests, which may point to a diagnosis.
AS does not follow the same course in everyone. In the early stages the symptoms may come and go, but in most people they ultimately become more persistent. Your lower back may become stiff and painful, and the same can happen to the upper part of your back and neck as well. It is, therefore, very important to maintain a good posture and prevent a stooped (bent) spine.
AS is a chronic disease and there is currently no preventive measure or cure for it. There is no special diet, but do not get overweight.
Early accurate diagnosis and appropriate treatment may minimize years of pain and disability because with successful management, it is often possible to minimize spinal deformity and slow down the progressive loss of mobility of the spine and other affected joints.
The objectives of treatment are to reduce pain and stiffness, maintain erect posture and preserving mobility.
Exercises and Physical Therapy
Regular exercises are of fundamental importance in the successful long-term management of AS. They help maintain or improve posture, chest expansion and spine mobility, they improve health status, and they prevent or minimize deformity. Doing some recreational exercises at least 30 minutes per day and back exercises at least 5 days a week will improve your health status. Stretching and strengthening exercises are needed to keep the muscles strong and the spine mobile and erect, and to retain good range of movements of joints. Swimming is perhaps the best form of exercise because it uses all the joints and muscles. Suitable sports include non – contact sports including badminton, tennis or golf. If there is too much stiffness or pain to exercise comfortably, a hot bath or shower will help ease the pain and tension so that exercises can be done.
There is no drug that will cure AS, but most minimize pain and help maintain mobility and function.
Non – steroidal anti – inflammatory drugs (NSAIDs) will reduce pain and inflammation. You must take the full anti-inflammatory dose of NSAIDs during the active phase of the disease. They will relieve the stiffness and pain and therefore allow the person to exercise regularly. The commonest side effect is indigestion, so should always be taken on a full stomach. Other side effects are possible, so let your doctor know if you have problems.
(b) COX-2 Selective Inhibitors
These are newer forms of NSAIDs which cause less indigestion and other gastro-intestinal complaints. However, there are not more effective than traditional NSAIDs and are associated with other possible side effects.
Disease modifying anti – rheumatic drugs (DMARDs) are sometimes used in AS patients who have progressive disease not controlled by other measures.
Sulphasalazine and methotrexate are used with good effect especially for patients with peripheral (non – spine) disease. However, they have little effect on the on – going spinal inflammation. For more information on these drugs, please see the “Medication for Rheumatoid Arthritis” leaflet.
Another class of DMARDs are the tumour necrosis factor alpha (TNFa) inhibitors. There are 3 available in Malaysia, adalimumab, etanercept and infliximab. They are given either by injection under the skin (subcutaneously) or by drip into a vein (intravenously). Although they are very effective especially for the spinal disease, they are also very costly. For more information on these drugs, please see the “Medication for Rheumatoid Arthritis” leaflet.
If the AS is very active and the stiffness troublesome, you may need to take time off to rest. This does not mean keeping still in bed, because this will hasten the stiffening of the spine. So even a spell of rest from work means that you need to continue to do exercises for your back, chest and limbs to keep them supple.
Your bed should be firm. If you have an internally sprung mattress, get a suitable board to put between the mattress and the bed frame. Even when the painful active phase of AS is passed, it is important to keep a firm bed in order to prevent any tendency for spinal curvature.
When you are in bed, it is important that you should lie quite flat on your back; some of the time you should practice lying on your front. “Prone lying”, as it is called, is best done for twenty minutes before rising in the mornings, and twenty minutes before going to bed at night.
At first you may not be able to tolerate more than five minutes at a time, or may need a pillow under your chest. But with practice, as the spine relaxes, it will become easier. If you make a habit of this, it will help prevent your back and hips becoming bent. It may, of course not be practical every day but it is better to devote some time to it than nothing at all.
A person with AS should be aware of posture at all times. It is important to keep the spine straight and to stay as erect as possible. Pay special attention to the position of your back when at work so that you do not stoop. Hardback, upright chairs are far better for your posture that low, soft, upholstered chairs. If you sit at a desk or bench, see that the seat is at proper height and do not sit in one position for too long without moving your back.
Corsets and braces are hardly ever helpful, and can make the AS worse. It is better to develop your own muscles, and keep a straight back by natural means.
Pregnancy in women with AS provides no special problem for the mother or baby. However, in contrast with some other forms of arthritis, the condition does not subside during pregnancy. The babies are usually born by the normal route, but occasionally, a caesarean operation is necessary if the hip joints become stiff.
AS sufferers are capable of doing a wide variety of jobs and many have very successful professional and business careers. An ideal occupation is one which allows periods of sitting, standing and walking. Occupations involving prolonged stooping and back strain may worsen symptoms.
AS is a chronic illness with no known cure as yet. The effects of AS can be controlled or minimized by regular mobilizing exercises, good posture and proper medication. By following the individualized programme, the chances of AS interfering with an active, functional life are kept to a minimum.