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Ankylosing spondylitis – Basics for patient

Ankylosing means – Fusion.

Spondylitis means – Inflammation around spinal vertebra or in spine joints

Ankylosing spondylitis is a disease that usually starts with pain and inflammation in lower back region.  It is a type of arthritis.

 

Generally, it is believed that arthritis is a disease of old age. Rheumatology is a medical field that involves many types of arthritis. Rheumatologist is a doctor who detects these types of arthritic diseases and treats them. There are a lot of rheumatic diseases that one can develop at very young age. AS is such a disease.

 

Ankylosing spondylitis begins with swelling in the sacro-iliac joint, which is a part of spine joint  (Picture 1). There are two sacro-iliac joints in the body near each buttock region. This inflammation of sacro-iliac joint is known as sacro-ileitis. However, As patient can have inflammation of many other areas in spine to start with or later in the disease. Other joints of the body like knee, ankle etc may also be involved. It usually affects young males and females and disease usually starts before 45 years of age. It can also affect children and teenagers (< 16 years ) of age in a slightly different form. Males are more commonly affected than females. Occasionally, this disease can lead to fusion of spine vertebra (Picture 2).

Ankylosing spondylitis is a type of arthritis, which usually affects adolescents or young people and starts with back pain or hip pain. It is usually associated with pain and stiffness on prolonged rest, sleeping and while getting up in morning.

 

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The most common symptom of this is lower back pain (Figure 1).

This lower back pain usually

 

  • Starts before the age of 45
  • Builds up slowly over weeks
  • Lasts longer than 3 months
  • After resting, the pain and stiffness increases – like when lying/sleeping at night and while getting up in the morning
  • Pain and stiffness usually decreases with some activity or exercises

The commonest symptom of ankylosing spondylitis pain and stiffness in lower back or buttock region, which increases on rest (especially when lying down at night and getting up in morning) and decreases with activity (walking or exercise). Often, in early phases, a patient of Ankylosing spondylitis, can play sports or do exercises without problems, but can’t sleep in night due to back pain.

Other symptoms

  • Excess fatigue whole day
  • Pain, swelling and stiffness in other joints of the body – like hips, knee, ankle, shoulders, foot etc
  • Pain and swelling in other parts of body like heel (plantar fascitis), achilles tendon (back of the heel), side of the hips, pain in ribs / chest pain during breathing etc


This disease can be sometimes associated with some other problems/diseases like

  • Iritis / Uveitis – About 30 % of AS patients can have attacks of pain, swelling and redness in one or both eyes. This is often associated with blurred vision and clears with steroid drops. These attacks can be recurrent.
  • Inflammatory bowel disease – 5-20 % of AS patients have an associated bowel problem which is associated with pain in abdomen, bleeding in stools and diarrhoea. This bowel problems may start even before ankylosing spondylitis starts. There are two such disease, Ulcerative colitis and Crohn’s disease. These diseases are associated with inflammation or swelling in bowel, hence known as inflammatory bowel disease.

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There is no single test that can tell you have AS with 100 percent guarantee. But an arthritis specialist doctor, i.e. Rheumatologist, will check and do various tests to come to a diagnosis. They might do various blood tests, such as testing for HLA B27 gene, ESR (Erythrocyte sedimentation rate), CRP (C Reactive protein). They will also in most cases do an X ray and MRI of your back. Only after listening to your symptoms, history and taking all tests into account, a rheumatologist can make a proper diagnosis.  
There is no single test that can tell you have AS with 100 percent guarantee. A Rheumatologist diagnoses Ankylosing spondylitis by getting a complete picture from your history and a combination of various tests.
Read more : What is HLA b27 ? What does it mean ? Is it curable ?
Your rheumatologist doctor can tell you how severe your condition is after doing some scorings / tests. Some of the symptoms or reports that point to your disease being severe are the following:
  • Pain and stiffness are quite severe and increasing in intensity, they are affecting daily functioning.
  • Hip pain – Any ankylosing spondylitis patient with hip pain is likely to have severe disease
  • Increases ESR and CRP in blood reports is usually a sign that your disease is active
  • MRI continues to show inflammation or swelling even after preliminary treatment
Treatment of AS depends on your symptoms and depends on how active / severe your disease is. The goal of treatment is to silence or decrease symptoms, especially pain and stiffness, to help you do your normal activities. This also helps in preventing any future complications. Unfortunately, there is no permanent cure for the disease. Don’t worry, most patients can be controlled very well on todays medications. Exercise : Exercise is an important part of AS treatment. It is advisable to take therapy from physical therapists or physiotherapist to know the best exercises. Working on your posture is especially important because AS can lead to stooping posture in future and exercises help to prevent that (Picture 3). Surya-namaskar exercise (sun salutation) and swimming can also be very helpful as exercises.

Many people may need to take one or more medicines for Ankylosing spondylitis:

NSAIDS (Non-steroidal, anti-inflammatory drugs) – This is a large group of medicines which include Ibuprofen (Sample Brand Name: Brufen) and Naproxen (Sample Brand Name: Naprosyn), Indomethacin (Sample Brand Name: Donica, Inmecin), Etoricoxib (Nucoxia, Arcoxia), Celecoxib etc. These medicines can help in relieving pain. Though, called pain killers by general population, they are actually anti-inflammatories. Basically they help reducing pain, swelling and inflammation in patients with Ankylosing spondylitis patients.  If given in the correct amount and in the right way, then they can be very beneficial. Other medicines – There are other medicines (Sulfaslazine – Saaz, Methotrexate – Folitrax), Biological injections – Infliximab (Sample Brand Name: Remicade) ; Adalimumab (Sample Brand Name: Humira, Exemptia); Etanercept (Sample Brand Name: Enbrel, Intacept, Etacept), Secukinumab (Cosentyx, Scapho) which can help in treatment of symptoms and prevent complications. Your doctor or nurse will decide which medicines are best for you. Read more : Is it safe to have biologics for Ankylosing spondylitis ?
The following answer is a very short reply to above question. For more detailed answer, you can read this article – Can Ayurveda or homeopathy cure my Ankylosing spondylitis ? There is no evidence that ayurveda or homeopathy has any specific treatment for Ankylosing spondylitis. Allopathy treatment in AS has advanced with very good research in last 30 years. For example : A drug called Humira (adalimumab), used in Ankylosing spondylitis has been researched in at least 30,000 patients, approved in more than 90 countries and has been used by at least 10 Lakh (1 million) people worldwide for various problems (For data see references below). Another drug called Remicade (infliximab) has been used in more than 26 lakh (2.6million) patient’s worldwide. This is old data for just for two drugs used in AS. One cannot even imagine the recent data available for these & other drugs. There has been no specific research in ayurveda or homeopathy for AS. Most drugs used in these streams are age-old drugs without any proven benefit in AS. Avoid people who claim to give guarantees and cure the disease, as these people are usually fake. Ayurvedic medicines with bhasm’s and gold powder can permanently damage the liver, nerves or kidneys. Also, many ayurvedic and homeopathy medicines are unlabeled in India. There is no way for a patient to know what they contain. Also, if you don’t take a proper proven treatment, it might lead to complications (as given below in section: What if I don’t take treatment in AS)
A patient with AS can take the following precautions
  • Stop Smoking – If you smoke and you have AS, it is more likely to make your disease worse and more likely to cause respiratory problems. Quitting smoking can help you control the disease.
  • Eat healthy. There is no need for any diet or stop anything in patients with ankylosing spondylitis.
Read more about diet and arthritis in this article : Why you should not stop eating chana dal (or other lentils) in increased uric acid and arthritis ?
  • Exercise – Physiotherapy / Exercise – Follow your physiotherapist’s doctor’s instructions for exercise and stretching. Stretch regularly at work.
  • Get Calcium and Vitamin D in the right amount – it can help to protect your bones from being weak. Your rheumatologist will help you with knowing what is the right intake for you.
  • Get as much information as you can, exact knowledge about the disease will help you to avoid wandering from the right treatment. Don’t fall into traps of people claiming to cure your AS, in some patients AS goes silent on its own. That doesn’t mean somebody has cured it.
  • Continue regular follow ups with your Rheumatologist who is an arthritis specialist.

How will ankylosing spondylitis affect my future life ?

As Ankylosing spondylitis often starts in teenagers or young adults, its affects their study and high earning years. The chronic pain can be frustrating for many in these important years. The good news is that, in today’s era, with very good treatment, most people with AS can have a reasonably good life .

30-50% of AS patients generally do not have very serious or severe symptoms. They can mange life with intermittent ant-inflammatories and exercises alone. Also, some times you might have a different arthritis called reactive arthritis and might be labelled as ankylosing spondylitis. This is actually quite a common occurrence in a developing country like India, where most people with arthritis don’t see rheumatologist (Read below on why the two are often confused with each other). The good thing about reactive arthritis is that it usually subsides in three months.

In many patients disease can have periods of activity and inactivity. When their disease flares / becomes active they have pain and might have to take necessary medications. In many such patients with intermittent complaints, disease often goes into silence between this flare episodes.

In 30-70% of the population the disease can be very active. Such patients have difficulty managing their lives smoothly. If such patients don’t take proper treatment they might have fusion of spine or damage to hips. So always try to follow your treating rheumatologist’s advice.

 

 

 

  • AS patients with very active disease can have fusion in spine vertebra with forward stopping posture in future.
  • Active AS patients not taking proper treatment can have hips or other joints damaged, which can give chronic pain and walking difficulties. Such patients might need hip replacements at a young age.
  • Some AS patients can have recurrent inflammatory attacks in eye, known as iritis or uveitis. If not treated properly it may cause complications in eye.
  • In AS patients, who have had spine fusion and very active disease, their spines can be very stiff from outside and weak from inside (thin internal bone structure). This can make them very prone to spine fractures even with minor falls. They should always consult respective doctors, if they have had a fall and continuous pain.
  • Very rarely, chronic AS patients can develop loosening one of the heart valves causing it to leak. This usually happens in AS patients who have had disease for more than 20-40 years.

 

Most of above AS complications are avoidable or treatable, provided they take proper treatment. So please have regular follow-up with your treating doctor.

Yes, it is certainly possible. Both male and female AS patients can conceive normally and there is no increased risk of anything to the baby. In the modern era, most young AS patients can have normal pregnancies with healthy babies. However, one has to tell their doctor if they are planning a pregnancy. Certain drugs need change / planning before pregnancy planning begins. Do not wait till you or your partner gets pregnant, tell your rheumatologist even when you are thinking of same. They will guide and adjust medications. For females, it is better to plan pregnancy when your disease is controlled and your rheumatologist is happy for you to plan the same.

References

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