More detailed description about ankylosing spondylitis

Ankylosing spondylitis can appear at any age; however, it most commonly affects young men in their 2nd and 3rd decade of life. Men generally run a higher risk, as the disease is 2-3 times more common in men than in women. Approximately 1% of the white population is affected. There are vast racial differences reflecting different genetic influences. Native Americans are commonly affected while the Japanese and the African blacks practically never see this disease.

Reasons for disease development

Despite extensive efforts aimed at discovering the main cause of disease, it remains unknown. Immunological processes most certainly play a major role. The disease usually starts as an enthesitis. Enthesitis is an inflammation of that part of the joint where muscle tendons attach to the bone. Many immune cells (macrophages, lymphocytes) gather here (most commonly vertebrae) and start producing various inflammatory mediators. Due to the longstanding inflammation, permanent and irreversible joint changes result, especially in the area of the spine.

Genetics plays an important role in ankylosing spondylitis, as does the familial predisposition. Patient's relatives run a 16-fold higher risk of developing the disease than representatives of the general population. Furthermore, it is an established fact that carriers of HLA-B27 are 50 times more commonly affected than non-carriers. HLA stands for human leukocyte antigen. It is a type of protein located on the outer cell membrane and is person-specific. The immune system uses the HLA system to differentiate between the self and the foreign cells; this system goes awry in autoimmune diseases. Ankylosing spodylitis is also a case of inability to recognize the body's own cells.

Symptoms

The initial symptom is usually lower back pain which improves on physical activity but remains while at rest. Problems arise also at night and in the morning with the so called morning stiffness. The flexibility is decreased due to joint pain which disappears on "warming up". An important sign is also the progressive reduced flexibility of the spine. Women experience similar symptoms although in a much milder form, making it possible for the disease to go unnoticed.

In addition to articular problems, extra-articular problems may also appear including eye inflammation, intestinal problems as well as other disorders affecting the blood vessels, lungs, heart and prostate.

Diagnosis

Internationally recognized criteria are utilized to make the diagnosis. It is especially important to determine whether the person is a HLA-B27 carrier. Clinical tests which show reduced joint flexibility and disease progression are also in use, of which the chest extensor test and spinal mobility test are the most important ones. An x-ray of the skeleton can also reveal typical changes.

Prevention

Since the cause and mechanism of the appearance of ankylosing spondylitis are unclear, the disease cannot be prevented. With the use of daily physical and breathing exercises the patients may maintain and improve the flexibility of the spine and slow down the appearance of irreparable damage in the joints. Since this disease tends to further advance the spinal curvature, patients should be encouraged to keep an upright posture and regularly perform exercises for the spine. Sleeping on a hard pillow by keeping the head low is recommended.

Breathing exercises

Ankylosing spondylitis also affects the joints where the ribs articulate with the upper portion of the spine; thus, the ability to breath may worsen. Breathing exercises for maximal thoracic expansion are recommended because they minimize the respiratory limitation. Smoking is strongly discouraged for it stimulates scarring of the lungs which further worsens breathing difficulties. Some patients with advanced lung disease additionally require oxygen therapy and medications to improve the respiratory function.

Physical therapy

Physical therapy must be tailored according to the needs of each individual patient. Swimming is most beneficial for the spine. In the periods of disease remission, we recommend mainly aerobic exercises that stimulate breathing. Falls represent an additional chance of injury to the spine and their prevention is of utmost importance. Therefore, patients must avoid the consumption of alcohol, narcotics and sedatives, as well as certain activities characterized by sudden changes of body posture.

Patients who are professional drivers have special rear-view mirrors in place that increase the visual field, since the ability to turn one's head is compromised by the disease as well.

Therapy

Early detection and treatment of the disease is recommended because the patients are more responsive to medications early on in the course of the disease. There is no cure for this disease; however, therapy may reduce inflammation and the faulty immune system response. Thus, the disease progression is slowed down. Non-steroidal anti-inflammatory drugs (NSAIDs) are used to reduce the inflammation and pain. An anti-inflammatory drug from the coxib group (celecoxib, valdecoxib, etoricoxib) may be prescribed for patients who have ulcers or who have suffered stomach or duodenal bleeding episodes, because these medications are less aggressive on the intestinal mucosa.

During the periods of high disease activity, sulfasalazine or methotrexate that belong to the group of immunomodulators are employed. Sulfasalazine tends to reduce inflammation in the peripheral joints. If this drug also fails to improve the patient's condition, methotrexate may be instituted. Corticosteroids, despite their anti-inflammatory action, are rarely used in the treatment of this disease. When the inflamed joint is unresponsive to other therapy, corticosteroids may be applied directly into the joint or administered in the form of methylprednisolone infusion. A long-term corticosteroid therapy of ankylosing spondylitis is not recommended due to the many side effects-- a cataract may ensue, the skin becomes thinner; in addition, osteoporosis, frequent infections and diabetes mellitus appear.

A severe course of disease

In recent years, therapy with biological drugs has become an option, especially in patients with a more severe course of disease (infliximab, etanercept, adalimumab). If a patient does not show improvement on a certain drug, a different biological drug should be tried with this patient.

In the presence of extensive changes in the joints, surgery becomes an option as well; most often, a total hip endoprosthesis is required. Spinal surgery also becomes necessary at times, especially in the cases of spinal cord and nerve compression.

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