Ankylosing spondylitis (AS) is a systemic disorder that refers to inflammation of the joints in the spine. AS is the primary disease in an entire group of conditions known as seronegative spondylarthropathies. It is also known as rheumatoid spondylitis or Marie–Strümpell disease (among other names). AS is an autoimmune disease, as are most forms of arthritis. By definition, other joints, in addition to the spine, can also be affected, including the shoulders, hips, knees, and feet. Tissues in the eye can also be affected.
A form of arthritis, AS is characterized by chronic inflammation, causing pain and stiffness of the back, progressing to the chest and neck. Eventually, the whole back may become curved and inflexible if the bones fuse, which is known as "bamboo spine." Other conditions associated with AS include reactive arthritis, psoriatic arthritis, spondylitis of inflammatory bowel disease, and undifferentiated spondyarthropathy. AS may involve multiple organs, such as the:
- eye (causing an inflammation of the iris, or iritis)
- heart (causing aortic valve disease)
- skin (causing a scaly skin condition, or psoriasis)
- gastrointestinal tract (causing inflammation within the small intestine, called ileitis, or inflammation of the large intestine, called colitis).
Less than 1% of the population has AS; however, 20% of AS sufferers have a relative with the disorder.
Causes & symptoms
Genetics, in the form of a gene named HLA–B27, can play an important role in the disease, but the precise cause of AS remains unknown. According to information from the Spondylitis Association of America, HLA–B27 is a perfectly normal gene found in 8% of the general population. Generally speaking, no more than 2% of people born with this gene will eventually get spondylitis. The gene itself does not cause spondylitis, but people with HLA–B27 are more susceptible to getting spondylitis. To date, 15 subtypes of HLA–B27 have been identified. The most common subtypes in the United States being B27.05, and then after that B27.02. The way in which HLA–B27 interacts with some other proteins seems to be very important to the cause of AS, but further research must be conducted to find out exactly how. According to information published in 1997 from The Arthritis Cure, by Dr. Jason Theodosakis, M.D., M.S., M. P. H., and others, research was being conducted regarding the possibility that a certain type of infection could be the trigger for the onset of AS.
Symptoms of AS include:
- low back and hip pain and stiffness
- duration of symptoms longer than three months
- difficulty expanding the chest
- early morning stiffness improved by a warm shower or light exercise
- pain in the neck, shoulders, knees, and ankles
- low-grade fever
- weight loss
AS occurs most often in males between 16 and 35 years of age. Initial symptoms are uncommon after the age of 30, although the diagnosis may not be established until after that age. The incidence of AS in African Americans is about 25% of incidence among Caucasians, but is rarely seen in that population.
Some naturopathic healers link the cause of AS to its autoimmune origins in food allergies and abnormal bowel function, sometimes referred to as "leaky gut" syndrome. According to this theory, food allergies combine with the leaky gut and, according to the Healing-With Nutrition website, from a 1986 article in the Britain Journal of Rheumatology, "..result in the increased circulation of gut-derived antigens into other areas of the body. The body produces antibody-antigen complexes (immune complexes) characteristic of RA (rheumatoid arthritis) to battle these gut-derived foreign antigens; but these antibody-antigens are thought to also cross-react with antigens in the joint tissues. In other words, the antibodies formed to attack the (leaky gut) microbes also cross-react and attack joint collagen."
Doctors usually diagnose the disease simply by the patient's report of pain and stiffness. Doctors also review spinal and pelvic x rays since involvement of the hip and pelvic joints is common and may be the first abnormality seen on the x ray. The doctor might also order a blood test to determine the presence of HLA–B27 antigen if the x rays have not clearly determined the diagnosis. If the gene is present, it could facilitate the accuracy of the possible AS diagnosis. When a diagnosis is made, patients may be referred to a rheumatologist, a doctor who specializes in treating arthritis. Patients may also be referred to an orthopedic surgeon, a doctor who can surgically correct joint or bone disorders.
To reduce inflammation, various herbal remedies, including white willow (Salix alba), yarrow (Achillea millefolium), and lobelia (Lobelia inflata), may be helpful. Acupuncture, performed by a trained professional, has helped some patients manage their pain. Homeopathic practitioners may prescribe such remedies as Bryonia and Rhus toxicodendron for pain relief.
A key alternative treatment for AS is massage therapy. Reported benefits include a decrease in pain, increase in circulation, lymph flow improvement, and increase in range of motion. The major benefit of this therapy could be that it provides further motivation for a regular excerise program, considered the most beneficial of all treatments for AS.
Diets of various regimens have been offered that include supplements of fatty acids and antioxidants, as with other arthritis diets. Naturopaths and some medical doctors have theorized that certain foods should be eliminated from the diet in order to alleviate symptoms. Possible problem foods include wheat, corn, milk and other dairy products, beef, tomatoes, potatoes, and peppers. Tobacco has also been thought to aggravate the condition. Various reports have surfaced in many books and articles that indicate a diet high in fiber and fresh fruits and vegetables—minus those listed above—and low in sugar, meat, refined carbohydrates, and animal fats might help in the treatment of the symptoms, particularly with pain or swelling.
Nonsteroidal anti-inflammatory drugs (NSAIDs), like naproxen (Naprosyn) or indomethacin (Indocin) are used to relieve pain and stiffness. In severe cases, sulfasalazine (Azulfidine), another drug to reduce inflammation, or methotrexate (Rheumatrex), an immune-suppressing drug, are recommended. In cases where chronic therapy is needed, potential drug side effects must be taken into consideration. Corticosteroid drugs are effective in relieving symptoms, but are usually reserved for severe cases that do not improve when NSAIDs are used. To avoid potential side effects, treatment with corticosteroids is usually limited to a short amount of time with a gradual weaning from the drug.
In April 2002, a study published revealed that a drug already approved for patients with rheumatoid arthritis was successful in helping most AS patients as well. Infliximab helped alleviate pain and improved functioning in more than 80 % of patients in a clinical trial. The drug worked rapidly and reduced disease activity by more than half in about 50% of patients. Some serious side effects did occur, so researchers continued to test the drug and seek Food and Drug Administration (FDA) approval for Infliximab for AS patients. In the same year, scientists were testing another drug called Etanercept that also showed promising results in preliminary trials.
Physical therapists prescribe exercises to prevent a stooped posture and breathing problems when the spine starts to fuse and ribs are affected. Back braces may be used to prevent continued deformity of the spine and ribs. Only in severe cases of deformity is surgery performed to straighten and realign the spine, or to replace knee, shoulder, or hip joints. Because it is a major and complicated procedure, with a potential for complications, this surgery is recommended cautiously even in severe cases.
There is no cure for AS, and the course of the disease is unpredictable. Generally, AS progresses for about 10 years, then levels off. Most patients can lead normal lives with treatment to control symptoms. Claims that homeopathic remedies have cured them have not been verified.
There is no known way to prevent AS. With twenty-first century advances in gene therapy, the possibility exists for further determination of the factor that HLA–B27 gene plays in its manifestation, and what role it could play in preventing it for future generations.
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Teresa G. Odle