Topic Overview
What is ankylosing spondylitis?
Ankylosing
spondylitis (say "ang-kill-LOH-sing spawn-duh-LY-tus") is a long-term form of
arthritis that most often occurs in the
spine. It can cause pain and stiffness in the low
back, middle back, buttocks, and neck, and sometimes in other areas such as the
hips, chest wall, or heels. It can also cause swelling and limited motion in
these areas. This disease is more common in men than in women.
There is no cure, but treatment can control symptoms and prevent the
disease from getting worse in most cases. Most people are able to do their
normal daily activities and can still work.
This disease can cause
several other problems. You may have redness and pain in the colored part of
your eye (iritis). You also may have trouble breathing as your
upper body begins to curve and your chest wall begins to stiffen.
What causes ankylosing spondylitis?
The cause is
unknown, but it may run in families. Most people with ankylosing spondylitis
are born with a certain
gene, HLA-B27. But having this gene does not mean that
you will get the disease.
Research suggests that bacterial
infections and your environment may have roles in causing this disease.
What are the symptoms?
This disease causes mild to
severe pain in the low back and buttocks that is often worse in early morning.
Some people have more pain in other areas, such as the hips or heels. The pain
usually gets better slowly as you move around and are active. Ankylosing
spondylitis most often begins anywhere from the teenage years through the 30s.
It gets worse slowly over time as swelling of the ligaments,
tendons, and joints of the spine causes the bones of the spine to
join, or fuse, together. This leads to less range of movement in the neck and low
back.
As the spine fuses and stiffens, the neck and low back lose
their normal curve. The middle back curves outward. This can keep you in a
bent-forward position and may make it hard for you to
walk.
As the small joints that connect the ribs and collarbone to
the breastbone get inflamed, you may find that it’s harder for you to breathe.
Other parts of the body, such as your eyes and your other joints, may also
swell. Sometimes the disease affects the lungs, the heart valves, the digestive
tract, and the major blood vessel called the aorta.
How is ankylosing spondylitis diagnosed?
The early
signs of this disease—dull pain in the low back and buttocks—are common. Your
doctor will ask about your symptoms and if they have become worse over time.
Your doctor will also ask if you have a family history of this joint disease or
others like it.
Your doctor may do several tests if he or she
thinks that you have ankylosing spondylitis. You may have an X-ray, a test for
the HLA-B27 gene, or an
MRI of the
sacroiliac joints.
The clearest sign of
the disease is a change in the sacroiliac joints at the base of the low back.
This change can take up to a few years to show up on an X-ray.
How is it treated?
Treatment includes exercise and
physical therapy. These will help reduce stiffness so that you can stand up
straighter and move around better. Your doctor will also give you medicine for
pain and swelling.
Because people with ankylosing spondylitis are
at a higher risk for spinal cord injury, it’s important that you wear a seat
belt every time you drive or ride in a car.
You will need to get
regular eye exams to check for inflammation in your eye, called iritis. You may
use a device such as a cane to help you walk and to help reduce stress on your
joints.
Surgery for the spine is rarely needed. You may want to
think about hip or knee replacements if you have severe arthritis in those
joints.
There is no cure for this disease. But early diagnosis and
treatment can help relieve pain and stiffness and allow you to keep doing your
daily activities for as long as possible.
Frequently Asked Questions
Learning about ankylosing spondylitis: | |
Being diagnosed: | |
Getting treatment: | |
Ongoing concerns: | |
Living with ankylosing spondylitis: | |
Symptoms
Ankylosing spondylitis is inflammation
primarily of the joints of the spine. But it can also involve inflammation of
the eye, other joints—especially those in the hips, chest wall, and around the
heels—and, on occasion, the shoulders, wrists, hands, knees, ankles, and feet.
Although it is unusual, ankylosing spondylitis can also cause changes such as
thickening of the major artery (aorta) and the valve in the heart
called the
aortic valve.
If the inflammation
continues over time, it will lead to scarring and permanent damage. In some
people the disease is mild and progresses slowly, and symptoms may never become
severe. Other people may have a more aggressive disease process.
Whether ankylosing spondylitis gets worse depends on a number of things
such as how old you were when the disease began, how early it was diagnosed,
and what joints are involved. It's too early to tell yet, but experts hope
that early treatment with newer medicines will slow or minimize the
inflammation, prevent scarring, and limit the progression of the disease.
Mild or early ankylosing spondylitis
Ankylosing
spondylitis usually starts with dull pain in the low back and back stiffness.
Some people with ankylosing spondylitis have "flares" of increased pain and
stiffness that may last for several weeks before decreasing again.
- Affected bones of the low back, middle back,
hips, or neck may become painful, stiff, and limited in motion. Pain tends to
increase slowly over a period of weeks or months, and it is often hard to point
to exactly where the pain is. Stiffness is usually worse in the morning and
usually lasts for more than one hour. Pain is often noticeable in the early
morning hours of sleep, such as between 3 a.m. and 6 a.m. Physical activity
often helps decrease pain and stiffness.
- Some people feel tired as
the disease progresses. This tiredness comes from the body fighting the
inflammatory process that is part of ankylosing spondylitis and also from
ongoing stiffness and pain.
- The colored part of the eye (iris) may become inflamed. This inflammation, called
iritis, occurs in about 25 to 30 out of 100 people who have
ankylosing spondylitis.1 Symptoms of iritis include
redness and pain in the eye and sensitivity to light.
Severe or advanced ankylosing spondylitis
If, over
time, the inflammation continues, it will lead to scarring and permanent
damage.
- Scarring in the
spine causes the joints of the spine to grow together
(fuse, or "ankylose").
- As the
bones fuse, back pain will gradually go away, but the spine will remain very
stiff and unable to bend. The fused spine is more likely to break (fracture) if
injured, especially the neck (cervical spine).
- Changes in the spine can cause problems with balance, safety, and mobility. The upper
spine can curve forward until eventually the person has a hard time looking
straight ahead. Also, as the spine loses its natural curves, it becomes hard to
balance while standing and walking, especially if the hips are also
affected.
- Breathing can become difficult as the upper
body curves forward and the chest wall stiffens. Severe ankylosing spondylitis
can also cause scarring of the lungs (pulmonary fibrosis) and an increased risk of lung infection. This can cause even
greater problems in smokers, because their lungs are already more prone to lung
infection and scarring.
- Scarring in the eye can lead to permanent
visual impairment and glaucoma.
- In rare cases, the heart muscle
can become scarred and the heart valves may become
inflamed. The heart may be unable to pump properly
(heart failure). The main artery leading from the heart
(aorta) can also be affected by becoming inflamed and
enlarged near where it leaves the heart.
- Bowel inflammation is
sometimes linked with ankylosing spondylitis.
- The kidneys can be
affected by taking
medicines over a long period of time.
- Some people who have
ankylosing spondylitis for many years develop
cauda equina syndrome from scarring around the nerves
at the end of the spinal cord. This condition can cause loss of feeling in the
saddle area of the groin and legs. It can also cause problems with bowel and
bladder control and sexual activity. Talk to your doctor if you start having
problems controlling your bowels or bladder.
The stiffening of the chest can feel like the discomfort
or "heaviness" of a heart attack. Ankylosing spondylitis can also cause the
heart to work less efficiently.
If you have any symptoms of heart
or lung problems—including heaviness of the chest or pain with deep
breathing—talk to a doctor right away to make sure you don't have any serious
heart or lung problems. For more information on heart and lung problems, see
the topics
Heart Attack and Unstable Angina and
Pleurisy.
Ankylosing spondylitis is one disease in a group of joint diseases called the
spondyloarthropathies (say
"spon-dill-o-ar-THROP-a-thees"). These include
psoriatic arthritis, reactive arthritis (Reiter's syndrome), and enteropathic arthritis (joint
problems linked with
inflammatory bowel disease). Although inflammation of
the spine also occurs in these other conditions, it is less common and less
severe than the inflammation that occurs in ankylosing spondylitis.
Exams and Tests
Your doctor will use a medical history,
physical exam, and X-ray to diagnose
ankylosing spondylitis.
By asking
questions about your medical history, your doctor can evaluate your symptoms.
Most people with ankylosing spondylitis have back pain with four or five of the
following characteristics:
- Begins before the age of about
35
- Starts and gets worse gradually
- Persists for at
least 3 months
- Is linked with morning stiffness that usually
lasts for more than one hour
- Improves with exercise
Your doctor will want to know whether you have any family
members who have ankylosing spondylitis or a related joint disease. Many people
with ankylosing spondylitis have a family member with the same condition. He or
she may also ask whether you have had ongoing diarrhea, abdominal (belly) pain,
multiple infections of the
cervix (in women) or
urethra (more common in men),
psoriasis, or inflammation of the eye chamber (uveitis). These could be clues to having a condition
other than ankylosing spondylitis.
You will have a physical exam
to see how stiff your back is and whether you can expand your chest normally.
Your doctor will also look for tender areas, especially over the points of the
spine, the pelvis, the areas where your ribs join your breastbone, and your
heels. You may experience chest pain and stiffness with ankylosing
spondylitis.
Tests related to ankylosing spondylitis
include:
- X-rays of the
spine and pelvis to check for bone changes (bony erosions, fusion, or
calcification of the spine and
sacroiliac joints). Certain changes in the sacroiliac
joint confirm the diagnosis of ankylosing spondylitis, but those changes can
take several years to develop enough to show on X-ray.
MRI and
CT scan are more sensitive than X-ray. If no changes
to the sacroiliac joints show on the X-ray but your doctor still suspects
ankylosing spondylitis, an MRI or CT scan may allow an earlier diagnosis.
Ultrasound is being studied as a way to diagnose
ankylosing spondylitis earlier.
- Blood tests. These may include:
- C-reactive protein (CRP) or sedimentation rate (sed rate) to look for inflammation.
- Rheumatoid factor or antinuclear antibody test (ANA) to look for other types of arthritis or illness.
- A
genetic test, which may be done
to determine the presence of a
gene (HLA-B27) that is often linked with
ankylosing spondylitis. Many people who have the HLA-B27 gene will not develop
ankylosing spondylitis, so having this test will not confirm whether you have
the condition. But the test results can be helpful if your symptoms and
physical exam have not clearly pointed to a diagnosis.
Treatment Overview
Treatment for
ankylosing spondylitis focuses on relieving pain and
stiffness, reducing
inflammation, keeping the condition from getting
worse, and enabling you to continue daily activities. Early diagnosis and
treatment may reduce pain, stiffness, inflammation, and deformity.
Talk with your doctor about the best treatment approach for your
condition. A consultation with a
rheumatologist is often recommended, especially to
confirm the diagnosis and lay out a treatment plan. Your
family medicine physician or
internist can treat mild cases, or you may be referred
to a rheumatologist,
orthopedist, or
physiatrist.
Initial treatment
Initial treatment for
ankylosing spondylitis may include:
- Education, so you know what you can expect as
ankylosing spondylitis progresses and how you can minimize problems that can be
caused by your condition.
- Conditioning and strengthening exercises, to maintain mobility and control pain. People who exercise
regularly find they have less pain and stiffness than those who are less
active.
- Nonsteroidal anti-inflammatory drugs (NSAIDs), to relieve
pain and stiffness, reduce inflammation, and help with physical therapy. Some
people seem to get more benefit from daily NSAIDs than from taking NSAIDs just
when they notice symptoms. Talk to your doctor about using NSAIDs for
ankylosing spondylitis, including how much to take and how often to take it.
- Physical therapy, to maintain proper posture, and deep
breathing exercises, to enhance lung capacity. A physical therapist can also
help you learn to use heat and cold to help control your pain and stiffness.
Heat can help with relaxation and pain relief, and cold can help decrease
inflammation.
- Assistive devices such as canes or
walkers, which allow you to be physically active while reducing stress on
joints.
- Alternative therapies such as
yoga or
acupuncture, which may help relieve pain and improve
quality of life.
Talk with your doctor about your job. People who have
ankylosing spondylitis feel better if they stay active and exercise regularly.
So a job that is physically demanding—such as a job that requires lots of heavy
lifting—could increase your symptoms.
Ongoing treatment
If initial treatment does not
sufficiently reduce the pain and inflammation linked with
ankylosing spondylitis, and as your condition
progresses, ongoing treatment may include:
- Conditioning and strengthening exercises, to maintain mobility and control pain. People who exercise
regularly find they have less pain and stiffness than those who are less
active. In addition to general conditioning and strengthening, walking and
swimming are good activities for people with ankylosing spondylitis. Some
people continue to participate in sports also. Talk to your doctor or physical
therapist about activities that will help you and that you will
enjoy.
- Medicine. Doctors usually will first recommend
nonsteroidal anti-inflammatory drugs (NSAIDs) to
reduce pain and inflammation. But you may need other, stronger medicines.
- Corticosteroids, which are similar to natural hormones
produced in the body, help reduce inflammation. Corticosteroids injected into
stiff, painful joints may be helpful.1 Corticosteroids are generally used for joints such as the hips, not for the joints of the spine.
- Disease-modifying antirheumatic drugs (DMARDs)
such as sulfasalazine and methotrexate may help relieve pain in joints other than the spine and pelvis.
- Drugs known as "biologic agents" or "anti-TNF-alpha" drugs
reduce inflammation by blocking a
protein called tumor necrotizing factor (TNF), which
causes inflammation.
- Physical therapy, to help you keep
good posture, and deep breathing exercises, to enhance your lung capacity. A
physical therapist can also help you learn to use heat and cold to help control
your pain and stiffness. Heat can help with relaxation and pain relief, and
cold can help decrease inflammation.
- Assistive devices
such as canes or walkers, which allow you to maintain physical activity while
reducing stress on joints.
- Alternative therapies such as
yoga or
acupuncture, which may help relieve pain and improve
quality of life.
Your doctor will treat complications of ankylosing
spondylitis as they occur. For example,
iritis may be treated with medicines that can help
reduce inflammation of the eye, such as
corticosteroids and
mydriatic eyedrops.
Treatment if the condition gets worse
In rare
cases, you may need surgery to replace joints that are severely damaged by the
inflammation of
ankylosing spondylitis. The most common surgery done
is
hip replacement surgery. Spine surgery is done in a
very small number of people who have ankylosing spondylitis. If there is
loosening of the top two vertebrae in the neck and there are signs of pressure
on the spinal cord such as numbness or clumsiness in the hands or arms, a
surgeon may permanently join (fuse) the two vertebrae together. In very rare
cases, spinal surgery may be done to straighten a part of the spine that has
become severely curved, but the surgery is risky and cannot restore motion.
Because ankylosing spondylitis is a lifelong condition, other
treatment may include
complementary and alternative medicine therapies,
which can reduce symptoms, help manage pain, and improve quality of life.
Complementary and alternative medicine is the term for a wide variety of health
care practices that may be used along with or in place of standard medical
treatment. These therapies may include
yoga and
acupuncture.
Even if your symptoms are
under control, you should see your doctor (often a
rheumatologist) every year to watch for and treat any
complications. People with hip symptoms and perhaps those whose disease started
in their teens may be at risk for a more severe progression of ankylosing
spondylitis.
Home Treatment
If you have been diagnosed with
ankylosing spondylitis, there are steps that you can
take at home to help reduce pain and stiffness and allow you to continue daily
activities. These steps include:
- Educating yourself. Learn all you can about
your condition and know what complications to watch for. This will help you
control your symptoms and stay more active.
- Taking pain relievers
such as
nonsteroidal anti-inflammatory drugs (NSAIDs) to
reduce pain. If NSAIDs do not relieve your pain, try acetaminophen. Heat, such
as warm showers or baths or sleeping under a warm electric blanket, may also
reduce pain and stiffness.
- Exercising regularly. This reduces pain
and stiffness and helps maintain fitness and mobility of the spine, chest, and
joints. Your doctor may recommend
physical therapy to get you started on an exercise
program.
- Deep breathing exercises can improve or
maintain lung capacity.
- Swimming as part of your exercise program
helps to maintain chest expansion and movement of the spine without jarring the
spine. Breaststroke is especially good for chest expansion.
- You
should avoid contact sports, because joint fusion may make your spine more
likely to fracture as the disease progresses. Your doctor may approve of other
activities such as golf and tennis. Check with your doctor before you add any
new activity.
- Maintaining proper posture and chest expansion.
Good posture is important because it can help prevent
abnormal bending of the spine. Maintaining chest expansion may help prevent
problems such as lung infection (pneumonia). It's a good idea to lie on your
stomach a few times each day to keep your spine and hips extended. For
sleeping, choose a firm mattress and a small pillow that supports your neck.
Try to lie flat on your back to sleep. If it's comfortable for you, you can
also sleep part of the night on your stomach.
- Using
assistive devices such as canes or walkers. Your local
chapter of the Arthritis Foundation, your physical therapist, or a medical
supply company may be able to help you find assistive devices in your area.
- Taking steps to protect yourself in the car, such as always using
a seat belt. Joints that are inflamed or damaged can easily be injured in an
accident. If your neck is becoming stiff, your doctor may advise you to wear a
soft neck brace when you ride in the car, to prevent injury in case of an
accident.
- Avoiding smoking, to prevent serious breathing
problems and lung scarring. Lung damage from smoking, combined with
decreased chest expansion and the lung infections that sometimes go with
ankylosing spondylitis, can seriously limit your ability to breathe freely.
- Seeing your doctor (often a
rheumatologist) at least once each year, to check on
your condition and watch for any complications. Catching complications early
and treating them can prevent further problems.
- Having regular eye
exams by an
ophthalmologist, to check for inflammation of the
colored part of the eye (iritis).
- Talking with your doctor about your job. People who have ankylosing
spondylitis feel better if they stay active and exercise regularly. So a job
that is physically demanding—such as a job that requires lots of heavy
lifting—could increase your symptoms.
- Joining a support group. For
more information, call the Spondylitis Association of America toll-free at
1-800-777-8189, or visit the association's website at
www.spondylitis.org.
Other Places To Get Help
Organizations
| American College of Rheumatology |
| 2200 Lake Boulevard NE |
| Atlanta, GA 30319 |
| Phone: | (404) 633-3777 |
| Fax: | (404) 633-1870 |
| Web Address: | www.rheumatology.org |
| |
The American College of Rheumatology (ACR) and the
Association of Rheumatology Health Professionals (ARHP, a division of ACR) are
professional organizations of rheumatologists and associated health
professionals who are dedicated to healing, preventing disability from, and
curing the many types of arthritis and related disabling and sometimes fatal
disorders of the joints, muscles, and bones. Members of the ACR are physicians;
members of the ARHP include research scientists, nurses, physical and
occupational therapists, psychologists, and social workers. Both the ACR and
the ARHP provide professional education for their members. The ACR
website offers patient information fact sheets about rheumatic diseases, about
medicines used to treat rheumatic diseases, and about care
professionals. |
|
| Arthritis Foundation |
| P.O. Box 7669 |
| Atlanta, GA 30357 |
| Phone: | 1-800-283-7800 |
| Web Address: | www.arthritis.org |
| |
The Arthritis Foundation provides grants to help find a
cure, prevention methods, and better treatment options for arthritis. It also
provides a large number of community-based services nationwide to make living
with arthritis easier, including self-help courses; water- and land-based
exercise classes; support groups; home study groups; instructional videotapes;
public forums; free educational brochures and booklets; the national, bimonthly
consumer magazine Arthritis Today; and continuing
education courses and publications for health professionals. |
|
| National Institute of Arthritis and Musculoskeletal and
Skin Diseases (NIAMS), National Institutes of Health |
| 1 AMS Circle |
| Bethesda, MD 20892-3675 |
| Phone: | 1-877-22-NIAMS (1-877-226-4267) toll-free |
| Phone: | (301) 495-4484 |
| Fax: | (301) 718-6366 |
| TDD: | (301) 565-2966 |
| Email: | niamsinfo@mail.nih.gov |
| Web Address: | www.niams.nih.gov |
| |
The National Institute of Arthritis and Musculoskeletal
and Skin Diseases (NIAMS) is a governmental institute that serves the public
and health professionals by providing information, locating other information
sources, and participating in a national federal database of health
information. NIAMS supports research into the causes, treatment, and prevention
of arthritis and musculoskeletal and skin diseases and supports the training of
scientists to carry out this research. The NIAMS website provides
health information referrals to the NIAMS Clearinghouse, which has information
packages about diseases. |
|
| Spondylitis Association of America |
| P.O. Box 5872 |
| Sherman Oaks, CA 91413 |
| Phone: | 1-800-777-8189
(818) 981-1616 |
| Email: | info@spondylitis.org |
| Web Address: | www.spondylitis.org |
| |
The Spondylitis Association of America (SAA) is a national
nonprofit organization. It is dedicated to the cure of ankylosing spondylitis and
related diseases such as spondyloarthropathy, psoriatic arthritis, reactive arthritis, and enteropathic arthritis through education, advocacy, awareness, and research. |
|
References
Citations
- Van der Linden S, et al. (2009). Ankylosing
spondylitis. In GS Firestein et al., eds., Kelley's Textbook of Rheumatology, 8th ed., vol. 2, pp. 1169–1189. Philadelphia: Saunders
Elsevier.
Other Works Consulted
- Braun J, et al. (2011). 2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitis. Annals of the Rheumatic Diseases, 70(6): 896–904.
- Braun J, Sieper J (2004). Biological therapies in
spondyloarthritides—The current state. Rheumatology,
43(9): 1072–1084.
- Braverman SE (2008). Ankylosing spondylitis. In WR Frontera et al., eds., Essentials of Physical Medicine and Rehabilitation, 2nd ed., pp. 605–608. Philadelphia: Saunders Elsevier.
- Gorman JD, et al. (2002). Treatment of ankylosing spondylitis by inhibition of tumor necrosis factor a. New England Journal of Medicine, 346(18): 1349–1356.
- Jaakkola E, et al. (2006). Finnish HLA studies confirm
the increased risk conferred by HLA-B27 homozygosity in ankylosing spondylitis.
Annals of the Rheumatic Diseases, 65(6):
775–780.
- McVeigh CM, Cairns AP (2006). Clinical review:
Diagnosis and management of ankylosing spondylitis. BMJ,
333(7568): 581–585.
Credits
| By | Healthwise Staff |
|---|
| Primary Medical Reviewer | Anne C. Poinier, MD - Internal Medicine |
|---|
| Specialist Medical Reviewer | Stanford M. Shoor, MD - Rheumatology |
|---|
| Last Revised | July 28, 2011 |
|---|
