Ankylosing Spondylitis (AS) is a chronic (long-term) type of inflammatory arthritis that causes stiffness and pain in the back. Spondylitis means inflammation of the spine and ankylosing means the fusion or melding of two bones into one. Chronic inflammation causes the spine to become stiff and inflexible.
AS is an autoimmune disease, meaning that it is caused by the body’s immune system making a mistake and attacking its own healthy cells and tissues. The reason why it does this is not well understood. When the body’s immune system is “activated” and attacking the spine and joints, it can make a person feel very tired, similar to when they have the flu.
AS is called a systemic rheumatic disease because it can affect other parts of the body (eyes, lungs, bowels, etc). It is very important that AS is assessed and treated as early as possible. This prevents further damage that can ultimately have crippling effects, and can reduce the risk of other problems associated with chronic inflammation, such as heart disease.
The most common symptom of Ankylosing Spondylitis (AS) is back pain and stiffness. It’s common for different people to show different symptoms, and experience different levels of discomfort and reduced mobility. Some people with AS live for years thinking they only have a stiff back, without realizing they might have a serious autoimmune disease like AS.
Most people with AS noticed the first signs and symptoms of the disease in their late teens to early 30s, but it can strike at any time.
With AS, back pain and stiffness is usually worse in the morning or after periods of inactivity, such as sitting for a long time. Unlike other back injuries and conditions, the morning pain and stiffness can get better with certain exercises and activities.
Over time, the inflammation caused by AS can eventually evolve from its starting point to the rest of the spine. It can also evolve to other areas of the body like the hips, shoulders, and sometimes the knees. In some people, the tendons surrounding the joints at the back of the heels (Achilles) or under the bottom of the feet (plantar fasciitis) may become inflamed.
People with AS can have inflammation in one or both eyes, called iritis. Some people with AS also have inflammation in the bowel (colitis).
When the body’s immune system is “activated” and busy attacking the spine and joints, it can make a person feel very tired, similar to when they have the flu.
The chronic (long-term) inflammation caused by AS is not good for the body. It can increase the risk of heart disease and make other health conditions worse.
Ankylosing Spondylitis (AS) is best diagnosed by a rheumatologist, a type of doctor that specializes in arthritis and autoimmune disease. To diagnose AS, they will take a careful and complete history and perform a thorough physical examination. Based on this information, the doctor will likely order tests like blood tests and scans to confirm their diagnosis.
Common Tests to Diagnose AS
Blood tests that look for inflammation: AS is an inflammatory arthritis so these tests are expected to have abnormal results. Common tests include a Complete Blood Count (CBC), Erythrocyte Sedimentation Rate (ESR), and C-Reactive Protein (CRP).
Blood tests that look for a Genetic Marker: Over 90% of Caucasians with AS will be positive for a gene called HLA-B27. However, as HLA-B27 is also present in about 6% of this population, so doctors and patients need to be careful interpreting the results of this test. A positive HLA-B27 test does not mean there is AS. The result of this test must be taken in context of other test results.
X-Rays: Plain x-rays of the pelvis, hips, spine, and other joints are often very useful in diagnosing AS. A challenge with x-rays is that they may look normal in patients in very early stages of disease.
Magnetic Resonance Imaging (MRI): MRI imaging has advanced significantly in recent years and provides useful imaging for the diagnosis of AS. Not everyone needs an MRI because in many cases x-rays are clear enough.
Medical Tip for MRI: A regular MRI is not useful in Ankylosing Spondylitis. The MRI should be done with T2 Weighted STIR Images or T1 Post Gadolinium Enhanced Images to look for inflammation.
Bone Scan: Bone scans can sometimes be suggestive of AS but they are not useful to confirm a diagnosis. Bone scans can be abnormal for a number of reasons and can be misleading. Doctors consider the results in context of other test results.
Ankylosing spondylitis occurs when the body’s immune system begins to attack its own joints for reasons that are not yet understood. The joints between bones in the spine and/or the joints between the spine and the pelvis (called the sacroiliac or “SI” joints) are usually the first targets of this immune attack.
The immune system’s attack causes inflammation in the spine. The body then tries to repair itself by growing new bone. The body’s inflammation and self-repair process works great to help heal minor injuries like a sprained ankle. Unfortunately in AS, this healing process is misguided. It can lead to bone growth across joints, connecting two bones together. If AS is left untreated, joints in the spine and pelvis can become completely fused. This can cause considerable stiffness and pain. It can also lead to disfigurement (a “hunched” posture, or a “hump” back), and changes in gait (how a person walks).
Like many other diseases, it is thought that genetics has a role to play in who gets AS. About 9 out of 10 people with AS have a gene called HLA-B27. But, having the HLA-B27 gene doesn’t guarantee that someone will get AS. Many people have this gene and don’t ever develop AS. Having the gene just means that there is a higher chance of getting AS.
Ankylosing spondylitis should be treated early and aggressively. The goal of treatment is to keep the spine flexible and the joints moving before the disease causes bones to fuse together. Once the damage from AS is done, it cannot be reversed with medicine. AS must be stopped before it damages the joints. Treatment can also help get affected joints back to moving smoothly as quickly as possible.
It is important for patients to attend their rheumatologist appointments regularly, and promptly get any blood tests or scans requested by doctors.
In general, treating AS has two important parts:
- Physical therapy and daily stretching can reduce stiffness in the back and improve overall mobility
- Medications that reduce pain, and improve function and mobility
A summary of all of the treatment options that can improve the lives of patients with AS follows:
Physical Therapy and Daily Stretching
Physical therapy has been shown to improve long-term outcomes for people with AS. It is an important part of an overall treatment plan. The right stretching and exercises can improve stiffness in the back, especially the kind that’s worse in the morning. Daily stretching and exercise can help improve posture and keep the joints in the back moving properly. It can also protect the joints by strengthening the muscles around them.
AS is linked to heart disease, so patients should also keep their blood pressure and cholesterol at healthy levels. For patients with diabetes, it’s important to keep blood sugar under control. Any smokers with AS should quit as soon as possible because smoking is known to worsen symptoms and can make the disease a lot more difficult to treat.
Surgical Treatment in Severe Cases
In the most severe cases of AS, the joints of the spine and/or the pelvis are so badly damaged that they fuse together and may require surgery to fix. Surgery often involves replacing a damaged joint with an artificial joint (most commonly the hip). Surgery can help people with severe, advanced AS by reducing pain, improving their mobility and restoring their functioning. Surgery of the spine is more complex and is usually reserved for patients with severe deformity due to AS.
Medications for AS fall into two broad groups. The first group is medications that help control the symptoms of AS. The second group of medications control the disease and prevent long-term damage. Before starting a new medication, patients should confirm if it has any interactions with alcohol, or any other medications, supplements, or alternative therapies that they take. No known natural remedies or complementary therapies that have been proven to help AS in any significant way.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Analgesics, and Corticosteroids (prednisone) are 3 groups of medications that help control AS symptoms. They can help make it easier to live with the disease.
Medications that Control Symptoms
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are medications that reduce the inflammation in the joints caused by AS. They can also help to reduce symptoms such as pain. There are about 20 different anti-inflammatory medications available, so if one doesn’t work for a particular patient, they can always try out another one with the guidance of their doctor.
Tip: It used to be thought that NSAIDs could alter the natural course of AS. However, newer research has not shown that this is true.
Analgesic medications only control pain. They do nothing to control the disease or to prevent further joint damage. Analgesics can range from common things like acetaminophen (Tylenol) to more potent narcotics like morphine.
Corticosteroids like prednisone can help control inflammation in some people. Usually, prednisone isn’t that effective for AS. However, in high doses for short periods of time it can be an effective medication to control the symptoms of AS. When used for long periods of time, prednisone can have side effects. A rheumatologist can help a patient understand the risks and benefits of this treatment as it applies to their AS.
Medications that Control AS and Prevent Long-term Damage
Biologics and Disease Modifying Anti-Rheumatic Drugs (DMARDs) are medications that can help control symptoms and prevent long-term damage.
Patients with AS whose pain and stiffness aren’t relieved by anti-inflammatory drugs can be treated by a group of medications called biologics. These medications are extremely effective and can make a big difference for people with AS. They work by disrupting aspects of the body’s inflammatory response.
A type of biologic called anti-TNF biologics were first introduced in 1998. Until that time, there were few other options for people with AS if anti-inflammatory medications weren’t enough to control their disease.
Today there are a number of available anti-TNF biologics including Humira, Remicade/Inflectra/Remsima, Enbrel, Cimzia, and Simponi. Newer biologics target other aspects of the inflammatory response, such as Cosentyx, which inhibits a signalling protein called IL-17.
If one biologic doesn’t work for a particular patient, a rheumatologist may suggest another.
Disease Modifying Anti-Rheumatic Drugs (DMARDs) have been traditionally used to treat rheumatoid arthritis (RA). They aren’t used as often in AS because they don’t work as well as they do for RA. As a general rule, common DMARDs like methotrexate or sulfasalazine don’t work to help symptoms in the back. However, DMARDs can be helpful in treating other swollen joints like the knees or hips if a patient’s AS is affecting them.
Living with AS
The pain and stiffness caused by AS can sometimes limit people’s normal activities, including work. There are many things people can do to lessen the impact of AS on their work and daily routine.
We recommend adjusting features of the workplace to help make working with AS easier. For example, people that sit for much of the day can adjust the position of chairs and desks for proper posture. Vehicle seats can be adjusted to make driving more comfortable and reduce stress on joints and affected tissues.
Those who find out they have AS while they’re still young can consider choosing work that isn’t physically demanding on their joints and back.
Exercise is important to overall health. It also helps keep the joints moving properly, and helps protect them by strengthening the muscles around them.
The level and amount of exercise people with AS can do depends on the activity of their disease.
Physical therapy has been shown to improve long-term outcomes in people with the AS. Exercise and stretching is an important part of a treatment plan for AS.
The right stretching and exercises can improve stiffness in the back, especially the kind that’s worse in the morning. It improves posture and helps ensure that the joints in the back are moving properly.
A trained arthritis physiotherapist is the best person to help design an exercise program tailored to the needs of patients with AS.
The following are some useful articles on exercising with arthritis:
Exercise and Arthritis: An article by arthritis physiotherapist Marlene Thompson
Exercising in a Flare: Another excellent article by Marlene Thompson on how to cope with flares through your exercise routine.
Alcoholic beverages are not an effective treatment for AS, and they can interact with many medications.
People with AS that plan on drinking should ask their doctor about possible negative interactions with the medications they take.
Some examples of medication that mixes poorly with alcohol includes, and is not limited to: the DMARDs methotrexate, Arava (leflunomide), and Imuran (azathioprine).
Smoking is not healthy for people with AS. It can make symptoms worse and harder to treat.
Research has shown that some arthritis medications do not work as well in people who smoke.
We recommend that smokers quit immediately to reduce the impact of their symptoms, improve the effectiveness of their medications, and improve their overall health.
Smoking significantly increases the risk of cardiovascular disease. The chronic (long-term) inflammation caused by rheumatic diseases like AS already increases this risk without a big extra boost from smoking.
Smoking can be especially harmful to patients whose upper spine is affected by their artritis. When the upper spine is inflamed and the bones begin to fuse together, it’s harder to breathe in deeply. Smoking makes this problem worse.
Travel is still possible when you have AS.
It is best for people with this disease to get organized well in advance of a trip to ensure a smooth, comfortable, and enjoyable time.
Check out our Travel Checklist page.
Though AS does not particularly cause a loss of sex drive, it can cause pain, fatigue and emotional hardships. These hardships risk creating barriers to sexual needs, ability, and satisfaction.
People with AS can take comfort knowing that sex and intimacy can be maintained. In many cases, it can help draw partners closer together, especially through improved communication.
For more information on intimacy and arthritis, a great book is: Rheumatoid Arthritis: Plan to Win by Cheryl Koehn, Taysha Palmer and John Esdaile.
Ankylosing Spondylitis (AS) has no effect on fertility. The chances of getting pregnant for people with AS are the same as with people that don’t have it. AS also has no known effects on the developing fetus or the newborn.
The two main issues doctors worry about with AS and pregnancy are:
Patients with AS might be treated with a number of medications that can affect pregancies including NSAIDs, anti-TNF biologics, and occasionally DMARDs. It is important for people with AS who want to become pregnant to discuss their medications with their doctor and create a pre-pregnancy plan. A plan is important for a number of reasons. For example, discontinuing a particular medication for safety of the newborn might cause AS to flare, so its wise to have a plan in place to handle these possibilities.
Any type of arthritis that affects the pelvis or the hips can make vaginal delivery difficult. It is important for those planning pregnancy to discuss delivery options with an obstetrician.
Women with AS are more likely to have caesarean sections than women without. The presence of significant spinal fusion may make an epidural difficult or impossible. If an epidural is not an option then other methods of pain control during delivery need to be discussed. The inability to administer an epidural would likely result in general anaesthesia for a c-section delivery.
Following the basics of healthy eating can help improve health and well-being in everyone, including those with AS. Keeping a healthy weight helps reduce the load on weight-bearing joints including the spine, hips, and knees, making it easier to live with the disease.
Unfortuantely, no special diet has ever been proven to significantly alter the course of AS or any other types of arthritis.
In addition, no known natural remedies or complementary therapies have been proven to help AS in any significant way.
People with AS should consult with their doctor to make sure that any supplements or alternative therapies they consume will not negatively interact with their medications.
Its very important for people with AS to attend regularly scheduled appointments with their rheumatologist, and promptly get any tests that are ordered by their doctors.
It is often very important that medications are taken exactly as prescribed. Patients should always talk to their doctor about any issues they experience, or if they would like to change anything.
Ankylosing Spondylitis is a chronic disease and a rheumatologist is the best partner in helping patients achieve the best quality of life possible.
RheumInfo Patient Tools
RheumInfo has created an online symptom assessment for AS patients to complete shortly before they visit their rheumatologist. The tool provides a summary report in PDF format that patients can show to their doctor at the start of their appointment. The report summarizes the patient’s overall condition so they can spend more time with their doctor, and get more value out of their visit.