Ankylosing Spondylitis
Ankylosing spondylitis (AS) is a form of arthritis. It mainly
affects the lower back. Other joints and other parts of the
body are sometimes affected. Treatment includes regular exercise
and anti-inflammatory medication. The severity of AS varies
from mild to severe. It is mild or moderate in most cases.
What is ankylosing spondylitis?
Spondylitis means inflammation of the spine.
Ankylosing means bones tend to join together (fuse) across
a joint.
In ankylosing spondylitis (AS), the discs and ligaments of
the lower spine become inflamed. The discs and ligaments are
the strong tissues that connect the spinal bones (vertebrae)
together. The joints between the lower spine and the pelvis
(the sacro-iliac joints), and the small facet joints between
the vertebrae are also commonly affected. Inflammation around
the lower spine that persists long term can cause scarring
and may, over time, cause some of the vertebrae to fuse together.
In some cases, inflammation of joints (arthritis) outside
the spine, such as the hips and knees, and inflammation in
other parts of the body, such as the eye, also occurs.
Who gets ankylosing spondylitis?
AS usually develops in teenagers or young adults. It rarely
first develops after the age of 40. It is 5 times more common
in men than women. About 1 in 1000 people have AS.
What causes ankylosing spondylitis?
The cause of AS is not known. There is a strong genetic (hereditary)
part. Something may 'trigger' AS to develop in people who
have an inherited tendency to have it. The trigger is not
known.
What are the symptoms of ankylosing spondylitis?
Back pain - is the main symptom. It usually starts in your
lower back. You may think of it as just backache at first.
It typically becomes worse over several months. You may have
aching over your buttocks and down the back of your thighs.
Coughing or straining may make it worse. Rest does not make
it better. Instead, exercise usually eases the pain. The pain
tends to be worse first thing in the morning. Lying in bed
after waking is often uncomfortable. The pain tends to ease
as the day goes on. The middle (chest part) of your spine
may become affected. The joints between your ribs and the
spine may then become painful too.
Stiffness in your lower spine - can be quite severe first
thing each morning. It usually improves with exercise and
as the day goes on.
Other joints - are affected at some stage in about 1 in 3
cases. The most common are: the hips, knees, ankles and shoulders.
Affected joints can become painful, stiff and swollen.
Tendons and ligaments - may become inflamed and painful where
they attach to bones. Common examples (apart from the spinal
ligaments) are the Achilles' tendon where it attaches to the
heel and where the chest muscles attach to the ribs.
Inflammation of part of the eye (uveitis) - affects about
1 in 3 people with AS from time to time. Tell a doctor urgently
if you have AS and develop a painful eye. Treatment with eye
drops is best started as soon as possible after eye symptoms
begin.
Some other 'inflammatory' conditions - develop more commonly
than normal. For example, people with AS have a greater than
average chance of developing bowel inflammation (ulcerative
colitis or Crohn's disease) and skin inflammation (psoriasis).
General - some people with AS feel generally unwell with symptoms
of tiredness or depression. Weight loss or anaemia sometimes
occur.
Symptoms usually come and go. Flare-ups of inflammation causing
periods of pain and stiffness tend to occur from time to time.
If joints outside your spine are affected they tend to flare
up at the same time as back symptoms. The frequency, duration
and severity of flare-ups varies greatly from person to person.
In time, the mobility and flexibility of your spine may be
reduced. This occurs if the inflammation causes gradual 'fusion'
(joining together or ankylosis) of some of your vertebrae.
The number of vertebrae involved and the extent of any fusion
varies from person to person. A stooping deformity may occur
in severe cases.
What are the treatments for ankylosing spondylitis?
The aims of treatment are: to ease pain and stiffness, to
keep your spine as mobile and flexible as possible and to
limit the extent of any deformity.
EXERCISE AND POSTURE
Exercise is the most important treatment. It is vital to have
a good posture and a regular exercise routine. This helps
to keep a full range of spinal movement and to prevent your
spine from 'stiffening up'. Regular exercise is thought to
limit the extent of any spinal deformity that may develop.
Exercise may also ease back pain. A physiotherapist will usually
advise. The advice may include the following.
When sitting, keep your back straight and erect. Move your
neck and back frequently. This may require changes to chair,
desk or work routines.
Every day lie face down for 20 minutes before getting out
of bed. Do this again before going to sleep. This helps to
stop the tendency for the spine to become fixed in a stooped
position.
Sleep on a firm bed, preferably with a board under the mattress.
Exercises to maintain the full range of movement of your spine.
Breathing exercises to help maintain the full movement of
your ribcage.
Exercises should become a routine part of life. Aim for about
2-4 hours of exercise per week. Swimming is an excellent additional
exercise.
MEDICATION
Anti-inflammatory painkillers
An anti-inflammatory painkiller is usually prescribed to use
when symptoms flare up. They reduce inflammation and ease
pain. However, they do not alter the course of the disease.
An important part of these medicines is to ease pain so you
can do regular exercises without much discomfort.
There are several different brands of anti-inflammatory painkillers.
If one does not suit, another may be fine. Side effects sometimes
occur with these medicines.
Stomach pain and bleeding from the stomach are the most serious.
The risk of this is higher if you are over 65 or have had
a duodenal or stomach ulcer. Stop taking the medication and
see a doctor if you develop stomach symptoms.
You may not be able to take anti-inflammatory painkillers
if you have asthma, high blood pressure, kidney failure or
heart failure.
Ordinary painkillers
Painkillers such as paracetamol may be sufficient if symptoms
are mild between flare-ups. You can also taker paracetamol
in addition to an anti-inflammatory for top-up pain relief.
Other medication
A specialist may advise other medication if symptoms become
severe. This is more likely to be needed if joints outside
your spine become inflamed.
An injection of steroid medication directly into a badly
inflamed joint is sometimes needed to ease symptoms.
Other pain relieving medication may be tried. For example,
low dose antidepressants have a pain relieving effect separate
to their action on depression.
Some medicines that are used to reduce joint damage in rheumatoid
arthritis have also been shown to help in AS. For example,
sulphasalazine and methotrexate. They seem to work best if
non-spine joints are affected. They do not appear to help
much if the spine alone is affected. A specialist may advise
one in severe cases.
OTHER TREATMENTS
TENS machines are sometimes used to ease pain. (These give
tiny electrical currents into the affected area).
Heat, for example a hot shower, may help to ease pain, particularly
each morning.
Other physiotherapy treatments may help. For example, some
people find regular massage soothing.
About 1 in 20 people with AS need hip replacement surgery
at some stage as the hip sometimes becomes badly affected.
Rarely, surgery is needed to correct a severe spinal deformity.
What is the outlook (prognosis) for people with ankylosing
spondylitis?
Although there is no cure for AS, the outlook is good. After
an initial period of inflammation, the disease often settles
down. Flare-ups of symptoms are commonly mild or moderate
and not frequent.
About 9 in 10 people with AS have a good quality of life,
remain fully independent and develop little or no disability.
Most people with AS are able to work full time for the whole
of a normal working life. Heavy manual work may become difficult
though.
In most cases, episodes of arthritis outside the spine and/or
eye inflammation do not occur or only occur now and again.
In a minority of cases these problems outside the spine recur
frequently or become severe.
Regular exercise and medication keep symptoms away or much
reduced in most cases. However, about 1 in 10 people with
AS have a severe form of the disease and may become quite
disabled over time.
Further help and information
This leaflet is only a brief introduction to AS. For further
help and information contact:
The National Ankylosing Spondylitis Society
PO Box 179, Mayfield, East Sussex, TN20 6ZL
Tel: 01435 873 527 Web: www.nass.co.uk/
Arthritis & Rheumatism Campaign - ARC
Copeman House, St Marys Court, St Marys Gate, Chesterfield,
Derbyshire, S41 7TD.
Tel: 01246 558033 Web: www.arc.org.uk
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