Ankylosing spondylitis
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}} Ankylosing spondylitis (AS) is a chronic, painful, progressive inflammatory arthritis primarily affecting spine and sacroiliac joints, causing eventual fusion of the spine; it is a member of the group of the autoimmune spondylarthropathies with a probable genetic predisposition. Complete fusion results in a complete rigidity of the spine, a condition known as bamboo spine.
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Signs and symptoms
The typical patient is a young man of 15-30 years old with chronic pain and stiffness in the lower part of the spine. Males are affected by ankylosing spondylitis three times more than women. Younger patients may experience knee pain even at very young ages (3 years old), commonly misinterpreted as simple rheumatisms. Recurring aphtae may also be experienced and are part of typical AS symptoms. Fatigue is also a widely spread symptom.
In 40% of cases, ankylosing spondylitis it is associated with iridocyclitis (anterior uveitis) causing eye pain and photophobia (increased sensitivity to light). Other less common complications are ulcerative colitis, psoriasis and Reiter's disease.
Osteopenia or osteoporosis of AP spine, causing eventual compression fractures and a back "hump" if untreated.
Organs affected by AS, other than the axial spine, are the hips, heart, lungs, heels, and other areas (peripheral).
Diagnosis
The diagnosis of AS is done by X-ray studies of the spine, which show characteristic spinal changes and sacroiliitis. Other options for effective diagnosis are tomography and magnetic resonance of the sacroiliac joints.
During acute inflammation periods, AS patients will usually show an increased values of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).
Variations of the HLA-B gene increase the risk of developing ankylosing spondylitis. Those with the HLA-B27 variant are at highest risk of developing the disorder. HLA-B27, demonstrated in a blood test, is occasionally used as a diagnostic, but does not distinguish AS from other diseases and is therefore not of real diagnostic value. Over 95% of people with AS are HLA-B27 positive, although this ratio varies from population to population (only 50% of African American patients with AS possess HLA-B27, and it is close to 80% among AS patients from Mediterranean countries).
Unattended cases normally lead to knee pain, resulting in a fair assumption of normal rheumatism.
Pathophysiology
AS is a systemic rheumatic disease, and about 90% of the patients are HLA-B27 positive. HLA-DR and IL1ra are also implicated in ankylosing spondylitis. Although specific autoantibodies cannot be detected, its response to immunosuppresive medication has prompted its classification as an autoimmune disease.
Hypotheses on its pathogenesis include a cross-reaction with antigens of the Klebsiella bacterial strain (Tiwana et al. 2001). Particular authorities argue that elimination of the prime nutrients of Klebsiella (starches) would decrease antigenemia and improve the musculoskeletal symptoms. On the other hand, Khan (2002) argues that the evidence for a correlation between Klebsiella and AS is circumstantial so far, and that the efficacy of low-starch diets has not yet been scientifically evaluated. Similarly, Toivanen (1999) found no support for the role of klebsiella in the etiology of primary AS.
Epidemiology
The sex ratio is 3:1 for men:women. In the USA, the prevalence is 0.25%, but as it is a chronic condition, the number of new cases (incidence) is fairly low.
Therapy
No cure is known for AS, although treatments and medications are available to reduce symptoms and pain.
Physical therapy and exercise, along with medication, are at the heart of therapy for ankylosing spondylitis. Physiotherapy and physical exercises are clearly preceded by medical treatment in order to reduce the inflammation and pain, and commonly followed by a physician. This way the movements will help in diminish pain and stiffness, while exercises in an active inflammatory state will just make the pain worse.
Medication
There are three major types of medications used to treat ankylosing spondylitis.
- NSAIDs such as aspirin, ibuprofen, indomethacin, naproxen and COX-2 inhibitors, which reduce inflammation and pain. These drugs tend to have a personal response to the pain and inflammation, although commonly used anti-inflammatory drugs like nimesulide are less effective than others;
- DMARDs such as methotrexate, sulfasalazine, and corticosteroids, used to reduce the immune system response through immunosuppression;
- TNFα receptors such as etanercept, infliximab and adalimumab (also known as biologics), are effective immunosuppressant on AS as on other autoimmune diseases;
TNFα blockers have been shown shown to be the best promising treatment, slowing the progress of AS in the majority of clinical cases. They have also been shown to be highly effective in treating not only the arthritis of the joints but the spinal arthritis associated with AS.
Note on TNFα blockers: TNFα blockers are constituted by proteins that are effective immunosuppressants. This means that treatments with these drugs increase the risk of infections. For this reason, the protocol for any of the TNF-α blockers include a test for tubercolosis (like Mantoux or Heaf) before starting taking any drug. In case of recurrent infections, like even recurrent sore throats, the therapy may be suspended due to the involved immunosuppression.
Surgery
In severe cases of AS, surgery can be an option in the form of joint replacements, particularly in the knees and hips. Surgical correction is also possible for those with severe flexion deformities (severe downward curvature) of the spine, particularly in the neck, although this procedure is considered risky.
Physical therapy
- Physiotherapy has shown to be of great benefit to AS patients;
- Swimming is one of the preferred exercises since it involves all muscles and joints in a low gravity environment;
- Slow movements exercises like stretching, yoga, tai chi;
- Any physical movement like, jogging, Pilates method, etc.
Alternative medicine
Although the effectiveness of alternative medicines has not been proved by any clinical trial, some patients find some relief in adding these alternative treatements to the medicaments and physical exercises:
- Diet: Starch free diet (Ebringer et al, 1996), london diet, paleolithic diet;
- Acupuncture.
Prognosis
AS can range from mild to progressively debilitating, and from medically controlled to refractive.
Famous patients
Well known sufferers of AS include:
- Mötley Crüe guitarist Mick Mars
- former England cricket captain Mike Atherton
- former Australian cricketer Michael Slater
- British comedian Lee Hurst
- Canadian radio personality Mike Stafford
- Norwegian Prime Minister Jens Stoltenberg
- chess player Vladimir Kramnik
- Former author and "Saturday Review" editor Norman Cousins
- Former Scottish snooker player Chris Small.
See also
- NASC, the AS patients' federation
- NIAMS, the National Institute of Arthritis and Musculoskeletal and Skin Diseases
References
- Ebringer A, Wilson C. The use of a low starch diet in the treatment of patients suffering from ankylosing spondylitis. Clinical Rheumatology 1996 Jan;15 Suppl 1:62-66. PMID 8835506.
- Khan MA. 2002. Ankylosing spondylitis: The facts. Oxford University Press. ISBN 0192632825.
- Tiwana H, Natt RS, Benitez-Brito R, Shah S, Wilson C, Bridger S, Harbord M, Sarner M, Ebringer A. Correlation between the immune responses to collagens type I, III, IV and V and Klebsiella pneumoniae in patients with Crohn's disease and ankylosing spondylitis. Rheumatology (Oxford) 2001;40:15-23. PMID 11157137.
- Toivanen, Paavo, et al. "Somatic Serogroups, Capsular Types, and Species of Fecal Klebsiella in Patients with Ankylosing Spondylitis" Journal of Clinical Microbiology, September 1999, p. 2808-2812, Vol. 37, No. 9.
External links
National organizations
Support groups
- KickAS.org (online community; support and information)cs:Bechtěrevova nemoc
de:Spondylitis ankylosans fr:Spondylarthrite ankylosante it:Spondilite anchilosante nl:Ziekte van Bechterew no:Bekhterevs sykdom pl:Zesztywniające zapalenie stawów kręgosłupa tr:Ankilozan spondilit