Ankylosing Spondylitis – Types, Symptoms, Causes and Treatment

Overview 

Spondylarthritis comprises a group of conditions where arthritis occurs in joints of the spine and peripheral joints. Patients present with back pain, which improves with activity and worsens with rest. They may have swelling, pain, and stiffness in other joints. The following conditions are part of the Spondylarthritis spectrum: Ankylosing Spondylitis, Psoriatic Arthritis, Reactive Arthritis, Enteropathic Arthritis, and Undifferentiated spondyloarthritis.

What is Ankylosing Spondylitis? 

Ankylosing Spondylitis (AS) is chronic inflammatory arthritis affecting the spine (sacroiliac joints and spine), peripheral joints, enthuses (attachment of tendons to bones), and extra-articular sites such as eyes, heart, lungs, and bowel, which leads to functional decline and disability. The age of onset is usually second to the third decade (before 45 years), and it is more common in men. Patients present with back pain, which is worse on rest and improves with activity, early morning stiffness lasting for over 30 minutes, and occasionally pain and swelling of the large joints of limbs. 

Patients may also present with other symptoms such as red eyes, blood in stools, or breathing difficulty. Over time, patients with AS develop reduced movements of the cervical and lumbar spine. A strong association with the HLAB27 gene is seen in 90% of patients with AS. HLAB27 is present in roughly 6% of the normal population. You should consult a Rheumatologist if you have persistent back pain, which is worse in the morning or after periods of rest, reduced mobility of neck and spine, other joint pains, or any of the symptoms mentioned above.

The condition causes inflammation that slowly causes small bones in the body to fuse. It can cause inflexibility to the spine by fusing the vertebrae to where a permanent hunch can develop if left untreated.

A major concern regarding AS is its effects on the ribs. The ribs can fuse, causing a lack of movement in the upper chest cavity where the lungs are located. This can lead to adverse respiratory conditions.

Types of Ankylosing Spondylitis

Ankylosing spondylitis differ based on pain, side effects, and the part of the body affected.

Symptoms of Ankylosing Spondylitis

The earliest symptoms of the condition manifest as stiffness and pain in the following areas:

• Back
• Hips

As the condition worsens, it is common to experience fatigue and increasingly severe pain. The condition can deteriorate or improve over time and is even known to stop at irregular periods.

The condition most commonly affects the following parts of the body:

• Vertebrae of the lower back
• Hips
• Joints found between your pelvis and spine.
• Ligaments and tendons in your heels or spine
• Shoulder joints
• The cartilage on the ribs and the breastbone

When should you see a doctor?

You should seek medical help if you experience lower back pain that increases gradually. It is also important to see your healthcare advisor if the back pain wakes you up at night or is the most intense in the mornings just after you wake up. Visit your doctor if the pain is a lot worse even after rest.

Seek an ophthalmologist’s opinion immediately if your eye is red, or the image is blurry, or you experience light sensitivity or an inflamed eye.

Request an appointment at Apollo Hospitals

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How to prepare for the Doctor’s visit? 

Your rheumatologist will ask you questions about your symptoms, examine you, and order investigations, including blood tests like ESR, CRP, and HLAB27 and X-rays of the spine and pelvis to arrive at a diagnosis. Your Rheumatologist will discuss the best treatment options and expected outcomes with you. Treatment options may include tablets, injectable medications, joint injections, Vitamin D and calcium supplementation, exercises, and others.

Newer treatment options for AS include TNF-alpha inhibitors like infliximab and etanercept, which are available in India. You will also need some regular ongoing treatment to control your pain. Learning strategies to cope with your pain, balancing your activities and rest periods, and eating a healthy balanced diet is also essential. Discuss your difficulties with your rheumatologist and seek help when needed.

Causes of Ankylosing Spondylitis

While the cause of ankylosing spondylitis is yet unknown, most doctors agree genetics play a big role in the development of this condition. People with the HLA-B27 genes have a higher chance of developing AS.

Risk factors for Ankylosing Spondylitis

The risk factors for AS are:

• Gender: Ankylosing spondylitis affects men more than women.
• Age: The disease usually presents itself during adolescence or early adulthood.
• Genetics: People born with the HLA-B27 genes have a higher risk of developing AS.
• Family history: The risk of developing AS increases if you have family members who have this condition, even if you don’t have HLA-B27 genes.

Treatment for Ankylosing Spondylitis

Ankylosing spondylitis can be treated with the help of a combination of the following treatments:

1. Non-steroidal anti-inflammatory drugs–Drugs like Naproxen and Indomethacin are anti-inflammatory drugs prescribed to help manage and control inflammation.
2. TNF–The second stage of treatment is a tumor necrosis factor blocker, a biological medication that attacks the protein that causes inflammation in the body. This medication is administered through an IV. These therapies have been newly introduced in the medical industry and have been extremely effective in providing relief to patients suffering from ankylosing spondylitis and its conditions. These newly invented drugs can offer a specific and targeted approach to decrease and stop inflammation compared to the old treatments. Yet, these treatments are not prescribed to every patient with ankylosing spondylitis. It is specific only for those patients who do not find relief from anti-inflammatory drugs and physiotherapy exercises.  

Here are a few biological therapies, known as anti-TNF drugs, that can help a recovering ankylosing spondylitis patient better than ever before: 

• Certolizumab pegol 
• Etanercept 
• Adalimumab 
• Golimumab 

Another type of biological therapy has been introduced, and it is known as “Secukinumab”, which also treats ankylosing spondylitis well. It is one of the new biological therapies, and it also works against reducing or decreasing inflammation. All the drugs mentioned here can be injected into the patient’s body. 

The patients, their families, partners, friends, or even relatives can learn how to inject these drugs so that they do not need to visit the hospital for injections. Also, you may note that the after-effects of these biological therapies will be monitored thoroughly by your doctors. They may ask you questions or give you a form, and using your answers, your doctor will assess the response to this treatment. 

Steroids 

Steroids can be given for short-term relief and as immediate treatment at the flare-up area, which is painful and heavily swollen. These medicinal steroids are also given as injections inside the muscle. They can treat painful tendons, such as your heels. It cannot be administered repeatedly to patients as regular treatment since these steroids have certain side effects. 

During your entire treatment, your doctor may give you an oral medication or a tablet that will contain a small quantity of steroids. These medicines will help you get over the pain and stiffness very effectively. However, if you use them for a longer period, you will start noticing a few side effects that weaken your muscles more than ever before. 

It is best to speak to your doctor about the risks and side effects you may face if you consume such tablets. The chances are your doctor will not prescribe these medicines. However, if they do, they will keep you informed about their effects. 

Physical Therapies 

This is yet another treatment proven to be effective against ankylosing spondylitis, along with medication. Physiotherapy is an important part that should be practiced to maintain the mobility and movements in your spine and other joints of your body. For physiotherapy, you need to consult a physiotherapist who can create a regimen for you according to your srequirement and intensity of ankylosing spondylitis. Your physiotherapist may also advise you to go for “Hydrotherapy”, also known as aquatic therapy. This therapy will help you target concentrated joints such as the hips, joints, and shoulders, and these will be performed in a warm-water pool. This therapy, combined with proper medication, has resulted in a positive impact on people. 

Surgery 

Usually, people suffering from ankylosing spondylitis do not need to undergo surgery. Many people who get a knee or hip replacement undergo such operations only if their joints are badly affected. If your doctor recommends surgery, remember it should be performed by a spinal surgeon. Surgery for this condition is rare, yet it takes place. It can leave a positive impact on a patient’s life.

• IL-7 – This biological medication is used to combat infections and reduces inflammation.
• Janus kinase inhibitor: TNF blockers and IL-7 can have some side effects like reactivating untreated tuberculosis. In such cases, a Janus kinase inhibitor can be prescribed. If you cannot take TNF blockers or IL-17 inhibitors, your doctor may suggest the Janus kinase inhibitor tofacitinib. This medicine has been approved for psoriatic arthritis and rheumatoid arthritis. Research is being conducted on its effectiveness for people with ankylosing spondylitis.

Along with medicines, doctors recommend physical therapy to keep your body strong and flexible, which goes a long way in warding off the pain. It is important to note that physical therapy should be given along with medical therapy, as neither works as standalone treatments for AS.

The rarest form of treatment for ankylosing spondylitis is surgery. It is performed only if the joint damage is severe and the joint needs to be replaced or if the pain cannot be managed.

Complications in Ankylosing Spondylitis

If Ankylosing spondylitis is not treated on time, it can lead to many complications:

Uveitis: A common complication because of untreated Ankylosing spondylitis. It is the inflammation of the eyes.

Heart issues: Ankylosing spondylitis can cause inflammation along the aorta,  can damage the aortic valve, and impair the heart’s functioning.

Compound fractures: Ankylosing spondylitis can thin bones during its early stages. The inflammation weakens the bones and can cause small compound fractures.

While these complications seem severe, they occur only if the condition is left untreated for a long time.

Coping with Ankylosing Spondylitis

You can do the following to cope with the disease:

• Use heat and cold compresses on the affected area
• Try keeping yourself fit and active
• Stretch regularly
• Avoid smoking
• Maintain good posture as much as possible

While these steps are not known to prevent the condition entirely, they can help manage and cope with the situation.

Conclusion

Ankylosing spondylitis is a painful autoimmune condition that could interrupt your daily life. In severe cases, or if it is not treated early, it can lead to serious conditions that can be life-threatening. Inflammatory back pain (pain better with activity and worse after rest like sleeping and early morning stiffness for over 30 minutes) in a young individual needs assessment by a rheumatologist if it persists for over 6 weeks.

It is crucial to seek help as soon as possible. Reach out to medical experts at leading medical care facilities like Apollo Hospitals for the best medical advice.

Frequently Asked Questions (FAQs)

What is an autoimmune disease?

An autoimmune disease is caused when the body mistakenly attacks itself. There are about 80 known autoimmune diseases, and ankylosing spondylitis is one of them.

Are there any home remedies for AS?

AS is treated with the help of an experienced medical professional. Many patients with the condition have reported that performing yoga regularly helps reduce the pain associated with this condition.

What foods should be avoided in AS?

Certain foods cause or aggravate inflammation. These include processed foods and foods high in sugar and trans fats. Avoid these foods and load up on fresh fruits and vegetables with whole grains and healthy fats.