Ankylosing spondylitis is part of the group of autoimmune diseases and, like many others, does not have an established cause. However, it is known that there may be a genetic component involved.
In ICD-10 (International Disease Code), ankylosing spondylitis is found by codes M08.1 and M45.
The true cause of ankylosing spondylitis is unknown.
However, there is a suspicion that it has a genetic component , since a genetic marker – a protein called HLA-B27 – has been found in about 90% of patients with the disease.
This genetic marker refers to a certain type of white blood cell, but it is not present in all patients, just as the presence of the marker does not mean that the person will develop the disease.
In fact, it is known that, of people with HLA-B27, only 20% end up having ankylosing spondylitis.
There is also evidence that the disease is more common in white (Caucasian) people and within certain families .
This all reinforces the idea that it is a genetic problem, although there are suspicions that the disease is triggered in people susceptible to other factors, such as an infection.
Despite this, parents with AS need not worry about their children: the chance that they will develop the disease is only 15%.
In fact, there are more than 60 genes being studied that may have something to do with this and other diseases.
Even with all this mystery, there is a well-known hypothesis among researchers, although it has not been proven.
Many believe that ankylosing spondylitis begins when the defense of the intestines falls and certain bacteria end up in the bloodstream and, in addition to causing an infection, are still able to change the way the immune system responds.
From there, it starts to attack the body itself, initiating the process described previously.
The main risk factors for ankylosing spondylitis are believed to be:
- Being HLA-B27 positive (the human leukocyte antigen, or HLA-B27, is a group of genes generally identified in patients);
- Have a family history of the disease;
- Suffer from frequent gastrointestinal infections.
Symptoms of ankylosing spondylitis
Like any autoimmune disease, symptoms can vary widely from person to person.
Back pain, especially in the lower back, is the main symptom of ankylosing spondylitis, as well as several other diseases.
This pain has the main characteristic of appearing during the morning, preventing the person from getting up easily, and being oscillating, that is, coming and going, disrupting everyday life.
So, if you have back pain and are suspicious of AE, stay calm!
There are great possibilities your pain has another source, and you don’t have to worry, just remember to go to the doctor to have a correct diagnosis as soon as possible.
It is worth remembering that ankylosing spondylitis is an insidious disease, that is, its symptoms start slowly and gradually.
For this reason, it is common for people to think that it is nothing too much and take too long to go to the doctor, which, in turn, is detrimental to the prognosis.
Some symptoms that accompany ankylosing spondylitis are:
Low back pain, back pain and sciatica are the main types of pain that can be felt with AS. Low back pain refers to lower back, back pain and sciatica to the sciatic nerve path, that is, at the level of the buttocks and thighs.
Talalgias, which are pain in the heels, can also occur.
Stiffness is characterized by difficulty in moving and, in the case of AS, is concentrated in the spine. This symptom can be more noticeable in the morning, upon waking up, and after periods of rest.
To be characterized as a symptom of the disease, it must last at least 30 minutes, but it can last up to a few hours.
Tendonitis is inflammation in the tendons – tissue that connects a muscle to the bone -, characterized by swelling and pain.
In the case of ankylosing spondylitis, it occurs more frequently in the Achilles tendon (calcaneal tendon) and in the rotulian tendon (which is in front of the knee).
As the disease progresses, arthritis may cease to be confined to the axial skeleton and move to the appendicular skeleton (limbs), where there may be arthritis in the knees, elbows, hips and shoulders.
Weakness and fatigue
In addition to pain, disabling sensations of weakness and fatigue are frequent.
Inflammation in the eyes
In some people, eye inflammation is the first manifestation of the disease. They can occur at different levels (uveitis, iridocyclitis or iritis) and cause pain and redness.
Inflammation of the skin
Some patients may also end up suffering from psoriasis, an inflammatory skin disease characterized by reddish lesions with dry, thick scales, accompanied by itching.
Inflammation in the intestine
Known as colitis, inflammation in the intestine in some patients may be related to ankylosing spondylitis.
At the base of the spine, there is a sacroiliac joint, which connects the sacrum bone with the ilium.
One of the first manifestations of ankylosing spondylitis may be sacroiliitis, which is the inflammation of that joint, causing symptoms such as severe pain and fever.
Other symptoms related to ankylosing spondylitis are:
- Swelling in the joints of the shoulders, knees and ankles;
- Difficulty to fully expand the chest;
- Low fever;
- Loss of movement or lower mobility of the spine;
- Unintentional weight loss.
How does ankylosing spondylitis evolve?
What if you discovered that, in fact, that morning back pain could be the beginning of the fusion of your vertebrae?
It starts sneakily in the lower back and goes up the entire spine.
Over time, the pain increases and the stiffness becomes more evident, until it reaches a point where you can no longer ignore it and go to the doctor.
There, you are diagnosed with ankylosing spondylitis. But what does that really mean ?
At first, it is important to know that spondylitis is an autoimmune disease , that is, it originates from a malfunction of the immune system.
For some reason, the body’s defense cells begin to attack healthy tissues as if they were invaders.
In the case of AS, the intervertebral joints undergo an inflammation process, which causes antibodies to join in these locations.
This is where the ankylosing part comes in : the antibodies, in an attempt to repair the non-existent damage, end up calcifying parts that should not undergo this process, such as the intervertebral joints.
The joints of the vertebrae are composed, in part, of a flexible fibrous substance, which allows movement.
As soon as these parts are calcified, flexibility and, consequently, the ability to move are lost. And that is not even the worst yet.
As if the loss of movements was not enough, calcification also ends up joining one vertebra with the other, resulting in a true fusion of vertebrae.
With that, the spine starts to bend to keep all the vertebrae together, characterizing a false hump.
This situation can cause the ribs to put pressure on the lungs and the heart, causing difficulties in breathing.
Fortunately, most of the current cases do not reach this point. With the treatments available, it is possible to postpone the total fusion of the vertebrae for a long time, although it is not possible to prevent it completely.
It all depends on the way the body responds to treatment.
When, unfortunately, the patient does not receive the appropriate treatment or there is no expected response, the inflammations can spread outside the axial skeleton – affecting peripheral joints like that of the knees – and even outside the joints, reaching the eyes, intestine and skin.
It is worth remembering that the disease does not progress in the same way for everyone and, therefore, not all AE stories will be similar to this.
Even so, it is important to be aware of the signs, as we will see when we talk about symptoms.
What organs and tissues are affected by the disease?
Because it is a systemic disease, ankylosing spondylitis also affects other organs and tissues in addition to the spine.
Sometimes this happens some time after the first manifestations of inflammation in the spine, at other times the symptoms appear simultaneously. You never know when the other tissues will be affected.
Find out which tissues are affected and how it manifests:
The most classic symptom of AS is spinal involvement, characterized by pain and morning stiffness. This usually starts at the sacroiliac joints, where the pelvis (pelvis) and the spine come together.
It doesn’t stop there: other joints can be affected as well.
Hips, knees, shoulders and ankles are the most frequently affected. The good thing is that, by treating the inflammation in the spine, all of these are treated as well.
Not infrequently, bones become more sensitive and painful, especially the heel (heel) and ischia (butt bone). In these cases, comfortable shoes and chairs are essential.
Inflammation in the eyes, such as uveitis and iritis, are common in patients with AS. In fact, 1 in 7 patients is affected. These inflammations should be reported to the doctor and treated as soon as possible, as they can cause permanent damage to vision.
The skin can also be affected by inflammation of AS, the most common being in the form of psoriasis.
Inflammation in the intestine, called colitis, is related to ankylosing spondylitis in some patients. In fact, there are hypotheses in which the disease is triggered by intestinal infections, that is, the intestine can be a key point for the development of the condition.
Heart and lungs
Rarely, the heart valves are affected by the disease, resulting in inflammation and consequent malfunction. The lung can also be affected by creating fibrosis in the upper part. It is worth remembering, however, that these complications are very rare.
A bundle of nerves comes out of the brain and passes through the spine. It is called the spinal cord. These nerves are responsible for the sensations and the ability to move parts of the body.
When the inflammation reaches the intervertebral discs of the spine, they can end up compressing the nerves that pass through there. This results in pain, numbness, muscle weakness and even paralysis.
How is the diagnosis made?
Do you go to the doctor often, do a battery of tests and never get a concise diagnosis?
Although this is very annoying, it can be normal: the diagnosis of any autoimmune disease is made difficult since the symptoms, in general, can have many causes that are not necessarily related to dysfunctions of the immune system.
Therefore, it is common for the doctor, usually a general practitioner, to order several tests and test each hypothesis before referring you to a rheumatologist, the doctor specializing in musculoskeletal and rheumatological diseases, often with an autoimmune background.
Unfortunately, in many cases, the diagnosis can take years.
The patient’s history is the biggest clue to arrive at the diagnosis. Taking into account factors such as symptoms, age, family history and medical history, one can raise the hypothesis that the patient suffers from AS.
What is the test for ankylosing spondylitis?
When the disease is suspected, there are a number of tests that can be performed:
The first step in understanding the location and severity of pain is physical examination. In this, the doctor can ask the patient to try a variety of movements to check mobility .
Then, he can press on some regions of the body in an attempt to mimic and locate pain .
The main sites to be examined are the spine, the pelvis (pelvis) and legs. In addition, he can also ask the patient to try to take a deep breath in order to check if there is any difficulty in expanding the chest (rib cage).
The sting of the blood test can be painful, but it can help a lot in several diagnoses, precisely because it is an exam that does not require much from the patient.
It is worth mentioning that two of these tests are done, in fact, with the idea of ruling out the possibility of ankylosing spondylitis. Understand:
When there is inflammation, the amount of C-reactive protein in the blood increases. Therefore, a higher than expected result increases the chances of treating AE, while a normal result can be an indication to rule out this possibility.
Erythrocyte sedimentation rate (ESR)
You know that blood is not a homogeneous mixture, do you? This means that it is formed by several substances that do not mix and, if left in a container, its appearance changes.
Normally, in healthy people, the blood coagulates, that is, “dries up” and creates a peel to protect the injured area.
In the ESR test, an anticoagulant substance is added so that blood cannot clot and, instead, red blood cells (red blood cells) can settle.
The sedimentation process is one in which the solid separates from the liquid and settles on the bottom, more or less when we put too much sugar in the coffee and, at the end of the cup, there is a trail of sugar that has not been able to dissolve.
It turns out that, normally, erythrocyte sedimentation (erythrocyte sedimentation) is a little slow due to the physical properties of the particles themselves.
However, when there is an inflammation or infection, these properties are altered and the red blood cells settle to the bottom of the container much more quickly.
When the speed is within the expected, the diagnosis of AS can be ruled out.
However, when there are changes, it can mean that there is an inflammatory process, although there is no way to be sure which disease it is.
In some cases, you can order the test to check for the existence of the HLA-B27 gene.
This test can better clarify the possibilities of being ankylosing spondylitis, but it is not able to diagnose the problem itself, since several carriers of the gene do not get to develop the disease.
Another limitation is that this test is not accessible due to the costs.
It is worth remembering that HLA-B27 is more common in white patients with AS and black or oriental patients may not have the gene, but still suffer from the disease.
In addition, having the gene does not mean having the disease, there is only a greater likelihood of the diagnosis being that.
To complete the diagnosis, radiographs are essential. This is because they can show exactly where there is inflammation and highlight possible fusions that may have started.
X-rays are usually ordered from the sacroiliac joints, which connect the spine to the pelvis and tend to be the first to ignite in ankylosing spondylitis.
However, sometimes a simple radiograph is not able to capture the inflammation, usually because it is very early.
When X-rays do not reveal much, an MRI scan, which uses radio waves and a magnetic field to generate clearer images of the bones and surrounding tissues, may be ordered.
The only problem is that this exam is usually more expensive and less accessible to everyone.
Computed tomography (CT)
Another exam used is computed axial tomography, that is, a specific computed tomography of the axial skeleton.
On CT, several X-ray beams are capable of creating images in the form of “slices” of the body. This modality helps to detect inflammation and bone changes such as calcifications.
In order to check for phenomena such as tendonitis, an ultrasound may be requested. This examination consists of using an ultrasound (sound waves) to visualize certain tissues.
It is not uncommon for patients with AS to have osteoporosis at an early age and, therefore, bone densitometry can help in the diagnosis.
Bone densitometry measures the spaces between cells in the spongy tissue of the bone. Naturally, there are large spaces visible to the naked eye between cells in certain parts of the bone.
However, when these spaces are very large, the bones lose resistance and fracture more easily, a primary characteristic of osteoporosis.
Is ankylosing spondylitis curable?
Unfortunately, ankylosing spondylitis has no cure , but its progression can be slowed with available treatments.
Therefore, the treatment aims to reduce pain, preserve joint function and prevent deformities.
What is the treatment?
A multidisciplinary team must be responsible for the treatment, since inflammations can affect several tissues. The professionals who can assist in this task are:
- Rheumatologist: treats the disease itself;
- Physiotherapist: helps with exercises to improve pain and prevent loss of mobility;
- Occupational therapist: assists with rehabilitation in case of severe limitations;
- Ophthalmologist: treats inflammation in the eyes;
- Gastroenterologist: treats inflammation in the intestine.
It is worth remembering that the treatment is done mainly by means of medications.
However, medications alone will not be enough to guarantee a good quality of life in the long term and, therefore, treatment must accompany significant changes in habits.
In addition to drug treatment, the patient can do:
Physiotherapy and occupational therapy
There are two types of therapy that work together to keep the patient as independent as possible: physical therapy and occupational therapy. Although they are often confused, these two therapies have different approaches.
While physical therapy is focused on movement and the prevention of loss of mobility, occupational therapy seeks alternatives so that the patient can manage on his own in the best possible way.
In physical therapy, the patient will learn exercises and techniques that he must perform every day to prevent calcification of the spine.
In addition, some of these exercises can help improve posture and reduce some pain.
In occupational therapy, the patient will, together with the therapist, choose equipment and alternatives so that he can lead a life without major complications.
It is the case of choosing a wheelchair, equipment to improve mobility at home, ways to rearrange the environments that the patient frequents so that he does not need to stop studying / working or doing things alone.
Diet and exercise
While a balanced diet and exercise are beneficial for everyone, patients with AS should also maintain these two habits. That’s because there are several exercises that help to deal with pain and stiffness.
Stretches can help maintain movement for longer in the long run, strength-building exercises help keep muscles strong to support inflamed joints.
An idea that appeals to many is the possibility of exercising in the water, as it can help with movement and pain.
It is very important that an exercise routine is defined together with a doctor or a qualified professional, as certain exercises and techniques can be more harmful than helping.
Ultimately, surgeries may be necessary.
It may seem daunting at first, especially since they are surgeries that directly affect the bone structure, but some of them may be totally worthwhile, since they can help in the recovery of mobility of certain joints.
The most frequent type of surgery is arthroplasty. In it, damaged joints are replaced with metal, plastic or ceramic prostheses. In general, they are performed on the knees and the hip joint.
In cases where the vertebrae fuse, some people can rarely have an osteotomy. This procedure consists of straightening the spine by cutting and realigning the vertebrae.
Because it moves directly on the spine, close to the spinal cord, it is considered a very high-risk surgery and can only be done by doctors who have a lot of practical experience.
Medicines for ankylosing spondylitis
Because it is an inflammatory disease, it is understood that the treatment is done with anti-inflammatory drugs, right? The problem is that, unfortunately, this method is not always effective for everyone.
However, research is being done all the time and, nowadays, there are new drugs used to treat AS that can help a lot of patients who do not respond well to anti-inflammatory drugs.
It is extremely important that medical follow-up is carried out to determine the best treatment for each case, since each organism responds in a different way.
In addition, only the doctor will be able to tell you the best combination of drugs in order to avoid problems such as dangerous drug interactions.
Non-steroidal anti-inflammatory drugs
Non-steroidal anti-inflammatory drugs are non-hormonal drugs used to fight inflammation. They work by blocking substances called prostaglandins, which are synthesized at the site of inflammation and cause even more pain and swelling.
When anti-inflammatory drugs reach these tissues, they inhibit the production of these substances, relieving symptoms.
Some examples of non-steroidal anti-inflammatory drugs are:
- Diclofenac Sodium ;
- Diclofenac Cholestyramine ;
- Ibuprofen ;
- Acetylsalicylic acid ;
- Naproxen .
These are anti-inflammatory drugs that can be purchased without a prescription, but there are many others that need a prescription and can help with the problem.
Remembering that it is essential to talk with the doctor to find the best anti-inflammatory for your case.
A type of anti-inflammatory that is widely used in the treatment of arthritis are specific inhibitors of the cyclooxygenase 2 enzyme, such as celecoxib.
In the long run, anti-inflammatory drugs can have serious side effects . It is of utmost importance that anyone who takes anti-inflammatory drugs for a long time has medical monitoring.
Corticosteroids are a type of anti-inflammatory that simulates the action of cortisone, a class of anti-inflammatory substances synthesized naturally by the body. Administration can be done either through injections or pills.
In general, injections bring faster results, as they are applied directly to inflamed sites: sacral iliac joints, knee and hip joints. However, they should not be done directly on the spine.
Disease-modifying antirheumatic drugs (DMARDs)
If anti-inflammatory drugs are not working, it may be time to start treatment with disease-modifying anti-rheumatic drugs.
It is a new type of immunosuppressive drug capable of decreasing inflammation and slowing the progression of the disease, generally used to prevent loss of mobility.
Substances frequently used in the treatment of ankylosing spondylitis are sulfasalazine and methotrexate.
This type of medication works by blocking proteins that participate in the inflammation process.
The main protein inhibited by these drugs is the tumor necrosis factor α , responsible for the death of tumor cells and very active in autoimmune diseases.
Some of these drugs released by ANVISA are:
- Adalimumab ;
- Certolizumab pegol ;
- Golimumab ;
- Infliximab ;
- Etanercept .
It is worth remembering that etanercept, infliximab and adalimumab are available through the Unified Health System (SUS) .
NEVER self-medicate or stop using a medication without first consulting a doctor. Only he will be able to tell which medication, dosage and duration of treatment is the most suitable for his specific case. The information contained in this website is only intended to inform, not in any way intended to replace the guidance of a specialist or serve as a recommendation for any type of treatment. Always follow the instructions on the package insert and, if symptoms persist, seek medical or pharmaceutical advice.
Complications: what can spondylitis cause?
Fusion of vertebrae and loss of mobility
As has been said many times, ankylosing spondylitis can lead to fusion of vertebrae in advanced stages. This leads to loss of mobility, as the spine loses its fibrous joints, which are calcified and become a piece of bone.
One of the consequences of fusing the vertebrae is thoracic stiffness, since the ribs are directly connected to the spine.
When she is no longer able to move normally, the ribs also undergo a process of stiffness that, in turn, impairs the lung’s ability to expand.
There may be shortness of breath and problems with oxygenating the blood due to this stiffness.
Spinal compression fractures
Vertebral compression fractures are characterized by cracks in a vertebra that decreases it by about 20% in height. When this happens, there may be compression of nerves in the spine.
Rarely, AS can cause problems in the aorta, the largest artery in the human body. An inflammation in that blood vessel can widen and distort the heart’s aortic valve, impairing its function.
Inflammation by the body
As in the joints, AS can cause inflammation in different parts of the body. As a result, it is common for patients with the disease to also suffer from uveitis (inflammation in the eyes) and colitis (inflammation in the intestine).
Living with ankylosing spondylitis
A diagnosis like ankylosing spondylitis can be a tragic event, especially for people who rely heavily on the body in their daily activities. Therefore, it is extremely important to do everything possible to help yourself.
Some tips are:
Practice exercises and maintain good posture
While exercise will help you preserve mobility as much as possible, maintaining good posture also preserves a healthy spine for longer.
To maintain good posture, here are some tips:
- When performing domestic activities, always try to keep your spine straight: do not lean over to sweep the floor or iron your clothes;
- You always sit down to put your shoes on, taking your feet up to the knee, not your head up to your feet;
- Try to sleep on suitable mattresses that distribute the weight well, such as semi-rigid or foam mattresses;
- When sitting, try to leave your feet on the floor, with your legs slightly apart, your thighs touching the largest possible area of the seat, as well as the upright column supported on the back of the chair and sofa;
- When you need to drive for a long time, always take breaks to stretch your legs and spine.
Seek psychological help
If you feel that the disease is affecting your emotional, be sure to seek a mental health professional. Psychologists and psychiatrists are there to help deal with these feelings and ensure quality of life even with difficulties.
Letting the bad feelings consume you is not worth it . Do not give up on your life or treatment without first seeking help to deal with these emotions.
Join support groups
Another way to help yourself, both psychologically and pragmatically, is to join support groups. In them, several people with AS and related diseases can talk about their frustrations, discuss tips and improvements for the day-to-day, as well as share experiences.
Ankylosing spondylitis entitles you to retirement?
When the disease is at a very advanced and irreversible level, the patient is entitled to disability retirement by Social Security. However, retirement will only be guaranteed after the evaluation and approval of the INSS expert doctor.
The rheumatologist can apply for indefinite leave of absence, or can directly request retirement, but only the INSS can release the grant of sickness or retirement benefits.
It is worth remembering that, when receiving sickness benefits for being away, the patient must be periodically evaluated by the INSS doctor, in order to guarantee the continuation of the program.
This right is only valid for patients who contribute to the INSS.
For this, it is necessary that he is employed with a portfolio record, unemployed within the grace period or individual taxpayer (self-employed person, individual microentrepreneur or company partner).
Does ankylosing spondylitis hinder your career?
Not exactly. People who need a healthy body to carry out their activities may encounter challenges, but people who do more intellectual work just need to be careful not to spend too much time sitting, without moving.
A job that has a varied amount of time sitting, standing and walking is ideal for someone diagnosed with AS.
And the sex life?
Unless the hip joints are affected, ankylosing spondylitis does not interfere with sexual activity.
Are there risks for pregnant women with spondylitis?
In general, pregnant women with AS need not worry, as the disease does not usually harm the fetus.
Depending on the progression of the disease, it may be difficult for the mother to maintain her center of gravity, especially when there is already stiffness in the spine.
The medications taken must also be adjusted so that they do not interfere with the generation of the fetus. In addition, pregnancy should occur without major complications.
It is worth remembering that, unlike rheumatoid arthritis, the symptoms of ankylosing spondylitis do not improve during pregnancy.
How to relieve pain?
When indicated by the doctor, medication is the best way to relieve pain. However, sometimes, alternative forms of relief are needed. In such cases, it is recommended to use heat, by means of hot compresses, heated baths or electric blankets.
Another tip is acupuncture, a therapy based on traditional Chinese medicine that uses pressure points to treat symptoms.
Although there is no evidence that it is capable of treating ankylosing spondylitis, there is evidence that it helps in relieving chronic pain.
Can using orthoses help with treatment?
Unfortunately, orthoses – such as vests and braces – are of no use in EA and sometimes even make the situation worse. Therefore, they should only be used when the doctor prescribes them.
It is best to follow the treatment recommended by the doctor and physiotherapist. Always remember to consult these professionals before starting any other form of treatment.
What sports can the patient play?
In general, contact sports such as football, basketball, among others, should be avoided. In addition, golf is not highly recommended, due to the curved stance required by the sport.
The best sport for patients with ankylosing spondylitis is swimming, as it works the joints and muscles. Cycling, with adequate protection, can also be beneficial.