Ankylosing Spondylitis
1. Introduction
Ankylosing spondylitis (AS) is a general term for forms of inflammatory arthritis. You may also see this called axial spondylarthritis (AxSpA).
It is a painful, progressive form of inflammatory arthritis and mainly affects the lower back, which tends to present with certain signs and symptoms as detailed below (3). You should seek medical advice if you also have a current, or history of, inflammatory bowel disease (Crohn’s disease or ulcerative colitis), psoriasis or uveitis (red/painful eye). Uveitis has been shown to present in up to 30% of patients diagnosed with axial spondylitis (4).
Frequently Asked Questions
- Ankylosing spondylitis (AS) is a long-term condition in which the spine and other areas of the body become inflamed.
- Ankylosing spondylitis is a rare condition and affects less than 0.5% of the adult population in the UK (1).
- Moderately.
- The condition is not curable and it is important that if you believe you have the symptoms of ankylosing spondylitis that you see your GP who may refer you to see a specialist.
- With the right rehabilitation and medical approach, this condition can be managed well.
- Age – it most commonly begins between 20 and 30 years of age, with 90-95% of people aged less than 45 years when diagnosed (6).
- Gender – around twice as many men have ankylosing spondylitis compared with women (7).
- People with an immediate family history of similar conditions (2).
- Slow or gradual onset of low back pain and stiffness which is constant and persists for more than 3 months.
- Improvement within 48 hours of taking NSAIDs – ibuprofen or naproxen for example.
- Improvement with movement.
- Buttock pain (2).
- Seek advice from your GP/physiotherapist.
- Exercises prescribed by your physiotherapist can maintain mobility.
- Maintain a good sitting and sleeping posture with a firm chair and mattress.
- Depending on the severity of your ankylosing spondylitis symptoms, your doctor may need to give you a combination of medications to help you with the pain, stiffness and inflammation.
- Using hot and/or cold (ensuring that the skin is protected) may help relieve pain.
- Support networks such as Nass can be very useful (3).
- Unfortunately, this is a long-term condition and is not curable however, there are many things you can do to help manage the symptoms.
- Good management can reduce the effect of the condition on your ability to perform normal daily activities.
- Continue reading for more information and links to useful resources.
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
- Tends to present in younger adults (aged under 45).
- Slow or gradual onset of low back pain and stiffness which is constant and persists for more than 3 months.
- Waking during the second half of the night because of your symptoms.
- Current or past psoriasis.
- Current or past arthritis.
- Current or past enthesitis (inflamed joints/tendons, commonly heels).
- Improvement within 48 hours of taking NSAIDs – ibuprofen or naproxen for example.
- Improvement with movement.
- Buttock pain (2).
3. Causes
Ankylosing spondylitis is a form of inflammatory arthritis. This happens when the body’s immune system (which is meant to keep us well by fighting infection) starts to cause inflammation in the joints and the area around them, causing damage. Why this happens is not fully understood, but research shows that it can run in families (3).
An immediate family history/first-degree relative with ankylosing spondylitis (including psoriatic arthritis or rheumatoid arthritis) raises the suspicion of having this condition. If you are unsure, your musculoskeletal physiotherapist or GP may get an understanding by asking questions about your symptoms (but do not worry if you cannot remember exactly).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing ankylosing spondylitis. It does not mean everyone with these risk factors will develop symptoms.
- Gender – men are more likely to develop ankylosing spondylitis than are women.
- Age – onset generally occurs in late adolescence or early adulthood.
- Your heredity- most people who have ankylosing spondylitis have the HLA-B27 gene. But many people who have this gene never develop ankylosing spondylitis.
5. Prevalence
Each year, a GP may only see one person presenting with new-onset ankylosing spondylitis, making it a challenge to diagnose (3). Cases of ankylosing spondylitis are believed to range from 0.05% to 0.23% in the general population (1).
6. Assessment & Diagnosis
Before further investigations, your musculoskeletal physiotherapist will assess for many of the signs/symptoms associated with ankylosing spondylitis as outlined above.
If you are under 45 and have had back pain for more than 3 months, and have 4 or more of the above-mentioned signs/symptoms, your physiotherapist or GP may consider sending you to a rheumatologist. A rheumatologist is a specialist in conditions affecting muscles and joints; they will carry out further tests that may include X-ray or MRI, with or without blood tests.
The tests can help to differentiate between forms of ankylosing spondylitis, which include:
- Ankylosing spondylitis (AS) – where there are visible changes to your spinal X-ray, mainly inflammation to your sacroiliac joint (one or both). Sometimes the presence of a specific gene in your blood called HLA-B27.
- Non-radiographic axial spondyolarthritis – where there are no changes in X-ray, but visible inflammation following an MRI scan (5).
7. Self-Management
There is no cure for this condition however, treatment is available to relieve symptoms and help prevent its progression, as well as learning to self-manage. Your musculoskeletal physiotherapist will answer your queries regarding your condition, assess your posture and periodically measure your flexibility, especially of your back, neck, trunk and hips. They will also suggest useful strategies for managing your activity levels so that you are able to control your symptoms. Regular reassessment will ensure you are maintaining health, fitness and function, and will allow for changes to be made to your treatment programme.
8. Rehabilitation
Research is clear that remaining active within limitations will help manage your ankylosing spondylitis symptoms. Aerobic exercises such as walking, swimming and cycling will help improve/support your flexibility, strength, and overall fitness. Any exercise you decide to undertake needs to be regular, consistent and kept up over the long term. So, it is important to choose something you enjoy.
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at helping patients diagnosed with AS. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Ankylosing Spondylitis
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme focuses on improving/maintaining the range of movement within the hips and spine. It is important not to further irritate your symptoms and to pace yourself. We suggest you carry these exercises out daily prior to progressing onto the next stage of rehabilitation when your pain and function allows. This should not exceed any more than 4/10 on your perceived pain scale.
- 0
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- 8
- 910
This is the next progression. More focus is given to progressive loading of the lower back and hips. It remains important not to further irritate your symptoms and pace yourself as you progress into doing these exercises so always progress as able. This should not exceed any more than 4/10 on your perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This programme is a further progression with challenging progressive loading of the lower back and hips. It remains important not to further irritate your symptoms and pace yourself as you progress into doing these exercises. This should not exceed any more than 4/10 on your perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from a further assessment to ensure you are making progress and to establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage your condition.
11. Other Treatment Options
Medication – often you will be started with the lowest effective dosage of NSAIDs, such as ibuprofen or naproxen, to fight the inflammation, along with protective medication for your stomach. If your rheumatologist thinks that you have a form of severe active axial spondylitis then they may start you on medications known as disease-modifying anti-rheumatic drugs (DMARDS) to slow down the disease progression. However, please note that DMARDS is an umbrella term for several medications which come under this category (3).
Surgery – this is not recommended unless your symptoms are significantly affecting the quality of your life and worsening/progressing despite optimal conservative treatment as outlined above (3).
12. Links for Further Reading
References
- NICE. (2016). TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis. Technology appraisal guidance [TA383]. National Institute for Health and Care Excellence.
- BMJ. (2017). Guidance for primary care: Identifying and referring Spondyloarthritis.
- NICE Guidelines. (2017). Spondyloarthritis in over 16s: diagnosis and management https://www.nice.org.uk/guidance/ng65/chapter/Recommendation.
- Gouveia, E.B., Elmann, D. and Morales, M.S.D.Á. (2012). Ankylosing spondylitis and uveitis: overview. Revista brasileira de reumatologia, 52(5), 749-756.
- NICE Guidelines. (2019). Ankylosing spondylitis. https://cks.nice.org.uk/topics/ankylosing-spondylitis/#!diagnosisSub.
- Sieper, J. and Poddubnyy, D. (2017). Axial spondyloarthritis. Lancet 390 (10089), 73-84
- Dean, L.E., Jones, G.T. and MacDonald, A.G. (2014). Global prevalence of ankylosing spondylitis. Rheumatology 53(4), 650-657.
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