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[T1297]Treatment For Ankylosing Spondylitis

by Jonathan Blood Smyth, Jon

The inflammatory arthritis diseases or spondyloarthropathies include various diseases such as Ankylosing spondylitis, the arthritis of bowel disease, reactive arthritis and the arthritis associated with psoriasis. The typical linking features of these diseases are enthesitis (an inflammation at the bone/ligament junction) and the presence of HLA B27, a gene on white blood cells. The inflammation at the entheses can develop into fibrosis and eventually to fusion of the joints from bone formation.
AS is the commonest of the spondyloarthropathies and its occurrence varies with the occurrence of the HLA B27 gene in the population, AS being less common in the tropics and more common in northern European countries. 0.1 to 1.0% of people are affected but this varies with latitude and is more common in white people. About 1-2% of people with the HLA B27 gene actually develop AS but this becomes 15-20% likelihood if they have a first degree relative with the disease.
Three males to every one female is the ratio of patients with Ankylosing spondylitis, as female patients may have much less obvious symptoms and so be missed from the diagnosis. Young men are the commonest presenting group with most consulting a doctor before they are 40 and up to 20% before they are sixteen years old. 25 years is the average age that someone goes down with the symptoms and is uncommon to find a diagnosis of AS in a person over fifty. It is easily overlooked as it can look like mechanical back pain if care is not taken. On questioning how they are in the morning, a typical answer is very stiff.
The presentation of Ankylosing spondylitis is similar but different from that of mechanical low back pain due to the inflammatory nature of AS:
Back pain and stiffness in the morning, lasting at least half an hour or more The back pain and stiffness are improved by exercising Resting worsens the stiffness and pain Pain is worse later in the night Thirty to fifty percent of patients exhibit other joint symptoms Fatigue is typical Systemic inflammatory affects include fever, loss of weight and unwellness.
Physiotherapy examination of the spine in an AS patient usually uncovers significantly reduced ranges of spinal movement from normal, with perhaps a reduced lumbar lordosis and an increased thoracic curve. Neck movements may also be limited in later stages and a reduction in chest expansion noted due to rib joint involvement. Peripheral symptoms occur in around a third of patients and the physio will palpate the tender areas, searching for evidence of enthesitis in the insertions of the Achilles tendon and plantar ligament of the foot. These are areas of high mechanical stress and commonly affected.
The physiotherapist initially notes the postural changes which have occurred in an AS patient such as any spinal deformities, round shoulders, bent knees or an increased cervico-thoracic curve and poking chin posture. The physio will record ranges of movement of the spine and include the neck, thorax and lumbar ranges, also assessing any peripheral joints which may be affected. Any entheses which are reported as painful are palpated to confirm the presence of an inflammatory process, and if the AS is very active then the physiotherapist might also find effusions in the joints, perhaps with a feeling of unwellness, night sweats and poor rest.
Physiotherapy starts with treating active enthesis sites with ice, ultrasound and gentle stretches, with insoles useful in the foot. Routine range of movement exercises for the whole spine and affected joints are taught with concentration on getting to end range at each time. This targets the antigravity movements such as lumbar and thoracic extension, thoracic rotations and neck rotation and retraction. Patients are also taught to rest in good positions to avoid encouraging the typical deformities, such as on a firm mattress with just one pillow, or lying on the front regularly. Hydrotherapy is a very helpful and popular way of maintain joint ranges and patients need to keep up self treatment over the long term.

Ankylosing spondylitis (AS) is a chronic, systemic, inflammatory form of arthritis that preferentially affects the spine leading to limitation of spine movement. The cause of AS is not fully known, but there is a strong genetic predisposition associated with a genetic marker called the human leukocyte antigen (HLA)-B27.

AS usually begins with back pain and stiffness in the late teen years and early adulthood due to inflammation of the sacroiliac joints (the joints that join the spine to the pelvis) and the spine. AS also has a tendency for affecting sites where ligaments attach to bone. When inflammation affects these areas, the condition is called "enthesitis."

The most common joints outside of the spine and sacroiliac joints to be affected are the hip and shoulder joints. Other joints such as the knee, wrist, ankle, and elbow can also be involved. Some patients may develop eye inflammation termed "acute anterior uveitis".

Involvement of the heart and lungs, while rare, can be a complication. There may also be an association with psoriasis or inflammatory bowel disease.

Males are affected twice as often as females. Onset of symptoms after age 45 is unusual. Roughly, 15% of patients have disease onset during childhood.

The earliest symptom can be a dull pain in the buttock region. This occurs as a result of sacroiliac joint involvement. Some patients may have radiation of pain down the upper part of the back of the thigh and be misdiagnosed as having sciatica.

The pain at first may be one-sided and intermittent. It may also alternate, first in one buttock and then the other, but the pain, over time, becomes persistent and involves both sides.

The low back area becomes stiff and painful. This may be accompanied by tenderness along the spine and in the sacroiliac joints.

The back symptoms tend to worsen after prolonged periods of rest so that a patient will say their worst times are late at night and early in the morning. The symptoms improve with physical activity or exercise and worsen with rest.

The back symptoms also worsen with exposure to cold or dampness. Some patients have fleeting aches and pains or tender spots that can lead to a misdiagnosis early on of fibromyalgia.

Sometimes, the first symptom can be pain and stiffness in the middle part of the spine (thoracic region) or even the neck. Sometimes chest pain may be more of a symptom than low back pain.

Eye inflammation in the form of anterior uveitis is the most common non-joint feature of AS. This complication occurs in 25%-40% of patients at some time during their disease.

Clinical examination may or may not be helpful in the early course of the disease. The physician should examine the sacroiliac joints and the entire spine, including the neck. Chest expansion (the ability to move the chest with a deep breath) along with range of motion of the hip and shoulder joints should be measured. A search for signs of enthesitis can be helpful in making an early diagnosis of AS. The areas to search for enthesitis include the spinous ligaments, pelvis, front chest wall, bottom of the heels, back of the heels (Achilles tendon), outside of the hips, and the front of the knees just below the kneecap. This area is called the tibial tubercle.

The muscles along the spine may also be tender.

As the disease progresses, the spine becomes stiffer leading to loss of mobility in all directions. Chest movement also becomes more restricted.

Spinal deformities slowly progress and make the spine more rigid. Some patients may develop osteoporosis. If osteoporosis accompanies the rigidity, then a particularly dangerous situation develops because this rigid osteoporotic spine is very susceptible to fracture even after minor trauma.

The diagnosis of AS is based on physical exam and confirmed by imaging procedures. Symptoms, family history, and the joint exam are the most important tools early on.

X-ray evidence of AS may not be evident early in the course of the disease. Patients may need to undergo magnetic resonance imaging (MRI). MRI can detect subtle inflammatory changes in the sacroiliac joints and other areas of enthesitis early on HLA-B27 typing can be helpful in cases where AS is suspected but the diagnosis remains uncertain.

In cases where AS suspected, the HLA-B27 test may allow the presumptive diagnosis of AS to be made.

However, the presence of HLA-B27 should not be used to diagnose AS in the absence of other supporting history and physical exam evidence.

Dr. Muhammad Khan, the world's foremost expert in AS, has flatly stated that, "HLA-B27 testing is inappropriate in patients with back pain or arthritis in whom neither the history nor the physical examination suggests the presence of AS. A positive result in this clinical situation would still not permit the diagnosis of AS to be made because up to 8% of the general population possesses this gene."

Laboratory tests measuring inflammation are of limited value. Elevation of erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) occurs in about 70% of patients with active AS. The problem is that there is not a good correlation between the elevation in these blood tests and disease activity.

It may be that the increases in ESR and CRP reflect the presence of active arthritis in joints outside of the spine. Normal ESR or CRP does not exclude the presence of clinically active AS.

Successful treatment of AS requires a combination of non-drug as well as appropriate drug therapies.

Patient education is important and should include a life-long program of regular stretching and range-of-motion exercise. Smokers should be encouraged to stop smoking.

Use of non-steroidal anti-inflammatory drugs (NSAIDs) is often helpful. Traditional disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, leflunomide (Arava), and sulfasalazine (Azulfidine), are not useful for the treatment of disease restricted to the spine. They may be helpful in patients where peripheral joint arthritis or enthesitis is present.

Tumor necrosis factor (TNF) inhibiting agents, etanercept (Enbrel), adalimumab (Humira), and infliximab (Remicade) are very effective in treating AS patients.

MRI studies have shown that TNF-inhibitors are capable of resolving severe inflammation in the spine as well as in peripheral joints. Whether these drugs can prevent structural damage remains to be seen.

As with all forms of arthritis that require immunosuppressive therapy, close supervision of the patient is mandatory.

Surgery may be required for cases of AS that don't respond to medical therapy. Joint replacement, in the case of peripheral involvement, and corrective spinal surgery may be needed.

Fortunately, today, quicker diagnosis and more aggressive medical intervention have reduced the need for surgical solutions.

One other note of caution... In patients with significant neck involvement and rigidity, intubation for general anesthesia is extremely difficult and dangerous. These patients should notify the anesthesiologist in cases of elective surgery. They should also wear an ID bracelet advising of their condition.

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Both Jonathan Blood Smyth & Nathan Wei are contributors for EditorialToday. The above articles have been edited for relevancy and timeliness. All write-ups, reviews, tips and guides published by EditorialToday.com and its partners or affiliates are for informational purposes only. They should not be used for any legal or any other type of advice. We do not endorse any author, contributor, writer or article posted by our team.

Jonathan Blood Smyth has sinced written about articles on various topics from . Jonathan Blood Smyth is a Superintendent at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking a. Jonathan Blood Smyth's top article . to your Favourites.

Nathan Wei has sinced written about articles on various topics from Arthritis Pain, Health and Arthritis Signs. Nathan Wei, MD FACP FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland. He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine. For more info:. Nathan Wei's top article generates over 550000 views. to your Favourites.