What is Ankylosing Spondylitis
Ankylosing Spondylitis (AS) is a form of arthritis that affects the joints of the spine as well as other joints. Commonly Spondylitis causes inflammation in the spine or vertebra. Often AS involves an inflamed sacroiliac (SI) joint, where the spine joins the pelvis.
Although a form of arthritis, it falls into the auto immune disease category as well.
In some people, and unfortunately Tucker is one of these, the disease affects other joints as well.
The areas most commonly affected are:
- The joint between the base of your spine and your pelvis
- The vertebrae in your lower back
- The places where your tendons and ligaments attach to bones, mainly in your spine, but sometimes along the back of your heel
- The cartilage between your breastbone and ribs
- Your hip and shoulder joints
- Studies have shown that hip involvement typically is more common in younger people when the symptoms first begin. Unfortunately it often carries with it a much more severe prognosis (course of the disease).
As ankylosing spondylitis worsens and the inflammation persists, new bone forms as part of the body’s attempt to heal. This new bone gradually fuses the affected joints together. Those joints become stiff and inflexible. Fusion can also stiffen your rib cage, restricting your lung capacity and function.
Progression of AS
Some with severe disease will experience severe pain and stiffness over multiple areas of the body for long periods of time. AS can be very debilitating, and in some cases, lead to deformity and disability.
Clinical Features of AS
Peripheral joints, such as the shoulders, hips, and feet may be affected. The younger the age of onset, the more likely the hip will be involved. Hip involvement leads to fixed flexion deformities, where it is not possible to straighten the hip thus adversely affecting posture and gait. Due to restriction of hip movement help may be needed with putting on shoes and socks
AS does not only affect joints. The disease is systemic, causing fatigue and other disorders. Eye problems (Acute anterior uveitis) occur in 25% of cases. This presents with eye pain, photophobia and blurred vision. Interaction between the systemic complications of AS (e.g. Crohn’s disease, anaemia, frequent eye disease, Reiter’s syndrome and colitis) will greatly increase the disabling effects of AS.
Breathlessness on exertion may occur in severe cases due to reduced chest expansion following fusion of the joints in the ribs (costochondritis). The earlier the chest is involved in the disease the greater will be the reduction of chest expansion.
Less common but very significant, are heart problems affecting the aortic valve.
If the hips are involved, or severe neck involvement is present, the functional prognosis is much worse, often resulting in extensive incapacitating deformities.
Although neck involvement is fairly common in AS, in advanced or severe cases the neck (cervical spine) may rarely become fused in a flexed position making forward vision difficult. Neurological involvement affecting the upper limbs may also occur, causing weakness and loss of grip.
Treatments for AS
The key to effective control of AS is early diagnosis, and a program of preventative exercises and activity designed to keep the spine as mobile as possible for as long as possible. Chest expansion is also encouraged. Physical and Occupational Therapy is vital to analyze the specific patient and develop a planned course of activities to maintain independence and decrease pain and fatigue.
Water therapies and exercises are the treatment of choice for movement due to less gravity on the affected, already damaged joints.
It is essential that this program of exercise, education and lifestyle management is commenced (and continued with) before the ankylosing process of spinal fusion has started. Eventually the spine will fuse, even with therapy, but disability is likely to be less severe if the spine can be allowed to fuse in the erect or upright position.
Failure to control pain and maintain prescribed activity will lead to irreversible forward bending (kyphosis) of the spine, with marked disability.
When the inflammation of AS is active, morning pain and stiffness may be too severe to permit active and effective exercise. In this situation, pain control and reduction of inflammation and fatigue with Non Steroidal Anti Inflammatory Drugs (NSAIDS) may help exercise compliance and engagement in daily activities.
Newer therapies such as Disease Modifying Anti Rheumatic Drugs (DMARDs) and Biological Agents may also be used in moderate or severe disease. These may reduce the severity of disease progression.
Injections of steroids into peripheral joints or structures may also be needed to reduce inflammation and increase function.
Wrist and/or finger splints are sometimes required if the hands are involved.
Surgery may be required where there is severe hip, knee or shoulder restriction. Hip surgery may be particularly helpful in restoring functional independence, and reducing the need for difficult spinal surgery. However, very occasionally, spinal surgery may be required in cases of severe curvature of the spine.