Ankylosing Spondylitis

Ankylosing spondylitis: a comprehensive guide to understanding and managing this inflammatory disease

Ankylosing spondylitis is a chronic inflammatory disease that primarily affects the spine. Although this condition is lifelong, it is entirely possible to manage symptoms effectively and maintain a good quality of life with the right treatment. Understanding this disease and knowing how physical activity can help is an essential step toward better control of your symptoms.

What is ankylosing spondylitis?

Ankylosing spondylitis is a chronic inflammatory disease of the spine. It is part of a group of diseases called spondyloarthropathies, which affect the joints of the spine and sometimes other joints in the body. This condition is characterized by phases of inflammation that can lead, over time, to progressive fusion of the vertebrae if not properly managed.

The term ankylosing refers to ankylosis, which means fusion of the joints. However, with modern treatments and appropriate management, progression to this fusion can be significantly slowed or even prevented in many people.

Who is at greater risk of developing ankylosing spondylitis?

This disease has specific demographic characteristics that distinguish it from other conditions affecting the back. The disease usually appears in people in their thirties, and symptoms almost always appear before the age of 40. This characteristic distinguishes ankylosing spondylitis from mechanical or degenerative lower back pain, which is more common in older people.

Men are two to three times more likely to be affected by this disease than women, although the condition can affect both sexes. The chances of having this disease are around 1 to 2% in the general population. The presence of a gene called HLA-B27 significantly increases the risk of developing this condition, although not everyone who carries this gene will develop the disease.

A family history of ankylosing spondylitis is also a risk factor. If a close family member has the disease, your risk of developing it is higher than in the general population.

What are the symptoms of ankylosing spondylitis?

It is important to understand that ankylosing spondylitis does not always cause symptoms continuously. Symptoms may come and go throughout life, with periods of remission between inflammatory episodes. This flare-up pattern is characteristic of the disease.

Common symptoms

The most common symptoms include lower back pain that has been present for at least three months. This prolonged duration is an important diagnostic criterion. The pain has specific characteristics that distinguish it from other types of back pain.

The pain improves with exercise and worsens with rest. This characteristic is the opposite of mechanical pain, which generally worsens with activity. The pain is often present at night and in the morning for the first 30 minutes, then improves during the day with movement. This prolonged morning stiffness is a classic sign of inflammation.

Stiffness in the spine can, over time, lead to the development of hyperkyphosis of the spine, i.e., a very rounded back. This postural deformity can be prevented or minimized through regular exercise and good inflammation control.

It is common to experience pain in one or both buttocks, corresponding to inflammation of the sacroiliac joints that connect the sacrum to the pelvis. This alternating buttock pain is characteristic of ankylosing spondylitis.

Other possible symptoms

Some people may also experience other symptoms of the disease. Pain in several other joints may appear at the same time for no apparent reason. The hips, knees, and shoulders are sometimes affected.

Excessive fatigue is frequently reported by people with ankylosing spondylitis. This fatigue is linked to chronic inflammation and can significantly affect quality of life. Extra-articular manifestations may sometimes occur, such as inflammation of the eye called uveitis, or gastrointestinal problems.

What are the serious symptoms to watch out for?

The presence of certain signs and symptoms should prompt you to seek immediate medical attention at the emergency room or from a doctor. These red flags are rare but important to recognize.

Severe weakness or paralysis in one or both legs requires immediate medical attention. Similarly, significant or complete loss of sensation in one or both legs must be evaluated quickly. Recent loss of balance when walking or significant new incoordination are also cause for concern.

New difficulties in controlling urine or stool, as well as a loss of sensation in the genital area or when wiping after a bowel movement, may indicate serious nerve compression. These symptoms constitute medical emergencies.

It is reassuring to know that these serious symptoms are present in less than 1% of cases of lower back pain. In most cases, although the pain can be very unpleasant, the condition improves with appropriate treatment.

What are the causes of ankylosing spondylitis?

The exact cause of ankylosing spondylitis remains unknown, although research has identified several contributing factors. There appears to be a significant genetic influence in the development of this disease. The HLA-B27 gene is present in approximately 90% of people with the disease, although many people who carry this gene never develop the disease.

The disease is thought to result from an interaction between genetic predisposition and environmental factors, possibly infections or other triggers that activate the immune system abnormally. The immune system then attacks the tissues of the spine, causing the chronic inflammation characteristic of the disease.

This disease is different from conditions such as Forestier's disease, which also causes stiffness in the spine but is not inflammatory in nature.

How is ankylosing spondylitis diagnosed?

The diagnosis of ankylosing spondylitis is based on several complementary factors. The history of symptoms is crucial, particularly the inflammatory nature of the pain (worse at rest, better with movement), prolonged morning stiffness, and age of onset before 40 years of age.

The clinical examination assesses spinal mobility, checks for tenderness in the sacroiliac joints, and identifies other signs of inflammation. Certain medical imaging tests may be necessary to confirm the diagnosis. X-rays or MRIs of the sacroiliac joints may show signs of inflammation or structural changes.

Blood tests may be performed to check for markers of inflammation such as C-reactive protein and sedimentation rate, as well as the HLA-B27 gene. However, a negative result for this gene does not rule out the diagnosis.

It is important to note that medical imaging is not relevant in 99% of cases of ordinary back pain. For ankylosing spondylitis, tests are indicated when the clinical picture suggests this specific condition.

When should you see a physiotherapist for ankylosing spondylitis?

You should consult a physical therapist if you have symptoms as described above, or if your doctor has already ruled out any other causes for your pain. Physical therapy for lower back pain plays a central role in managing this condition.

You do not need to see a doctor before consulting a physical therapist. Physical therapists are front-line professionals who can assess your condition and refer you to other health care professionals if necessary. If your condition requires you to see a doctor, your physical therapist will be able to tell you and refer you appropriately.

What physiotherapy treatments are available for ankylosing spondylitis?

Your physical therapist will first conduct a comprehensive assessment to determine your limitations. This assessment examines several key elements. The mobility of your spine will be tested to identify segments that are less mobile. The slippage of your nerves will be evaluated to see if they are contributing to your symptoms.

Your postural habits will be observed to identify positions that could contribute to the progression of kyphosis. The quality of your movements will be analyzed to identify inefficient movement patterns. Your strength and stability will be measured to assess your muscles' ability to support your spine.

Based on the results of this assessment, your physical therapist will use different therapeutic approaches. Joint mobilization and manipulation of your back joints and nerves can reduce pain and improve movement. These manual techniques help maintain spinal mobility.

Specific exercises will be prescribed for you to do at home. Stabilizing muscle exercises strengthen the deep muscles that support your spine. Extension and thoracic mobility exercises are particularly important for preventing the progression of kyphosis. Strength and endurance exercises maintain overall body function.

Your physical therapist will also teach you how to balance your daily activities and leisure time to optimize the management of your condition. You will receive personalized advice on your posture and movements.

It is important to understand that there is no cure for ankylosing spondylitis, as it is a disease that will always be present. However, with the right treatment, the symptoms associated with the disease can be managed very well or even eliminated, even though the disease is still present. Many people with the disease lead active and fulfilling lives.

What can you do at home for ankylosing spondylitis?

The most important advice is not to remain completely immobile for long periods of time, as you will be stiffer and in more pain afterward. Immobility is particularly harmful in this inflammatory condition, where movement helps reduce pain and maintain mobility.

The best thing to do is to be active. If you are sedentary, start by taking regular walks and doing mobility exercises for your back, while respecting the pain each day. If you are already active, continue with activities that do not cause too much pain. Regular exercise is considered one of the pillars of treatment for ankylosing spondylitis.

Chest extension and mobility exercises are particularly beneficial in counteracting the disease's natural tendency to cause kyphosis. Swimming is often recommended because it provides a full-body workout without stressing the joints. Adapted yoga and Pilates can also be beneficial for maintaining flexibility.

If you see no improvement despite your efforts, you should consult a physical therapist for a professional evaluation and a personalized exercise program.

Conditions associated with ankylosing spondylitis

Ankylosing spondylitis can coexist with other conditions.Lumbar osteoarthritis can develop in joints that compensate for ankylosed segments. Lumbar facet syndrome can contribute to pain.

Lumbar disc herniation and lumbar radiculopathy can occur in people with ankylosing spondylitis, although they are less common than in the general population due to spinal stiffness.

The importance of exercise in managing ankylosing spondylitis

Regular exercise is absolutely essential in managing ankylosing spondylitis. Unlike other conditions where rest is sometimes recommended, physical activity is a first-line treatment for this disease. Exercise helps maintain spinal mobility, strengthen the muscles that support it, reduce pain and stiffness, and improve respiratory function.

A comprehensive exercise program should include stretching and mobility exercises to maintain flexibility, strengthening exercises to support the spine, cardiovascular exercises for overall health, and breathing exercises, as chest stiffness can affect lung capacity.

Getting help for ankylosing spondylitis

If you suffer from back pain with the characteristics described in this article, our physical therapists can help you understand your condition and develop a personalized exercise program. A comprehensive assessment will identify your specific limitations and develop a treatment plan tailored to your needs.

Early and regular treatment is essential to maintaining a good quality of life with ankylosing spondylitis. Make an appointment today to begin your journey toward better management of your condition.

Sources

Wenker KJ, Quint JM. Ankylosing spondylitis.

Zhu W, He X, Cheng K, Zhang L, Chen D, Wang X, Qiu G, Cao X, Weng X. Ankylosing spondylitis: etiology, pathogenesis, and treatments. Bone Research. 2019 Aug 5;7(1):1-6.

Sieper J, Braun J, Rudwaleit M, Boonen A, Zink A. Ankylosing spondylitis: an overview. Annals of the rheumatic diseases. 2002 Nov 1;61(suppl 3):iii8-18.

McVeigh CM, Cairns AP. Diagnosis and management of ankylosing spondylitis. Bmj. 2006 Sep 14;333(7568):581-5.