There is an auto-immune disease that causes back pain, and unfortunately many doctors
miss this diagnosis.
The name is ankylosing spondylitis, and there are specific treatments for this condition.
So, today I will explain: - What is ankylosing spondylitis?
- Why is it so easy to miss this diagnosis?
- What are the symptoms?
- How do we make the diagnosis?
- What is the treatment for ankylosing spondylitis?
- What are the exercises for people with ankylosing spondylitis.
So, let’s talk about ankylosing spondylitis today.
The word ankylosing means stiff or rigid Spondylo means spine
And itis means an inflammation.
Ankylosing spondylitis, or AS, is an auto-immune disease, which means, that the person produces
antibodies that attack the collagen.
It is estimated that 1 per cent of Canadian adult population lives with AS, that is about
300,000 people in Canada.
Predominantly it attacks the collagen in the spine and the sacroiliac joint.
Here is the spine, the intervertebral discs are formed by collagen, the facet joints also
have collagen.
The SI joint also have these ligaments and they are formed by collagen.
If the SI joint is affected the person will feel pain in the buttock area.
So, these antibodies attack and destroy the discs, the joints, the ligaments.
But they do this slowly, so it takes years for the spine to become rigid and stiff.
The collagen starts to be replaced by bone and the vertebrae fuse with each other, that
is why the person loses the mobility and become rigid and stiff.
We will talk about exercises at the end of this video, and these stiffness and rigidity
can be reduced a lot with proper exercises.
Unfortunately, in ankylosing spondylitis the antibodies cannot be detected by a blood test.
So, this type of arthritis is called a seronegative, as opposed to rheumatoid arthritis, where
you can do a blood test and measure the rheumatoid factor, which is how many antibodies are in
the blood, or lupus, that you measure anti-nuclear antibodies or ANA.
This inflammatory process starts at a younger age, it can start in childhood, but it is
more common to start in their 20s or 30s.
The person may have episodes of back pain during their lifetime, but they may also have
periods that they don’t have pain.
So, it is hard to diagnose the disease unless the doctor suspects of ankylosing spondylitis.
The antibodies also attack other parts of the body, so it is not just the spine.
In the eyes it causes uveitis In the heart, it causes a problem in the aortic
valve.
In the tendons, it causes inflammation like Achilles tendinitis or enthesitis
Because it is a systemic inflammatory disease, it causes other symptoms like fatigue, weight
loss and poor appetite.
The diagnosis is made by a combination of: Symptoms
Physical examination Blood tests
And image tests, like x-rays, ct-scans and MRI
These are the list of symptoms that we look for:
Back pain that gets better with movement.
Back pain that does not get better with rest.
Back pain that is worse in the night and in the morning.
They have morning stiffness in their joints.
Back pain that gets better with anti-inflammatory drugs, like ibuprofen.
Check my other video about NSAIDs.
They also have enthesitis, which is pain in the area where the tendons attach to the bones.
The most common is Achilles tendon enthesitis, plantar fasciitis, but any tendon can be affected.
The ribs can be affected, so they may have enthesitis of the ribcage.
Ankylosing spondylitis is also linked to inflammatory bowel diseases, such as Crohn’s disease
and Ulcerative Colitis.
Up to 3% of people with IBD also have ankylosing spondylitis.
In the physical examination we look for positive signs and negative signs:
If you are enjoying this video so far, subscribe to this channel and turn on the notifications
button, so you can be alerted when I post new videos here.
Positive signs are signs that when they are positive they suggest ankylosing spondylitis.
These are: decreased mobility of the spine, it could be the cervical spine, thoracic spine
or lumbar spine.
That is why we need to examine the patient and we measure the mobility of the spine in
all directions, bending forward, bending backwards, sideways and rotation.
We also examine the eyes, looking for uveitis, we examine the heart for an abnormal heart
sound, and the tendons, for enthesitis.
Negative signs are signs that if we find them, it points to other rheumatological diseases
or neurological diseases, so excluding the diagnosis of ankylosing spondylitis.
So, for example, if we find inflammation in the joints of both hands, like this, we suspect
it is rheumatoid arthritis, a different type of auto-immune inflammatory arthritis.
Of if we find an abnormal reflex this suggests a nerve compression in the spine.
The blood tests are rarely useful, because as I said before, we can’t measure the antibodies
in the blood.
However, we still do these tests to get clues if there are other inflammatory arthritis,
or if the person has a type of genetic profile that predispose them to have more ankylosing
spondylitis.
So, one of these genetic tests is called HLA-B27.
But having a positive HLA-B27 is not required for the diagnosis.
If it is positive, it will suggest a higher probability of AS.
Because of this disease has a genetic predisposition, sometimes we find other members of the family
with the same diagnosis.
But there are lots of cases where the person is the only one affected in their family.
The markers for inflammation, like C-reactive protein or erythrocyte sedimentation rate,
ESR, they are helpful to make the diagnosis if they are elevated, but they are not required.
So, a person may have normal CRP and Sed rate and still have ankylosing spondylitis.
The imaging tests that we order usually start with an x-ray of the spine, it could be the
cervical spine, thoracic and lumbar, and also x-ray of the sacroiliac joints.
If we see this, what we call, bamboo spine, then we know the bones are already fused,
and this is very likely 7 to 10 years after the ankylosing spondylitis has started.
If we suspect an early stage of ankylosing spondylitis, then we need to order a CT scan,
or an MRI.
And it is very important to look at the sacroiliac joint, as this is the hallmark of ankylosing
spondylitis.
So, how do we treat ankylosing spondylitis?
Please remember that this video is not intended to provide medical advice, if you have a condition
that is causing pain, please talk to your doctor to get an appropriate diagnosis.
This video is for educational purpose only.
If there is an emergency please go to the nearest emergency department or call an ambulance.
The treatment will be guided by the symptoms the patient is having and also if we find
that the disease is active or not.
Not everyone with AS has the inflammatory process active all the time.
In cases when the disease is not active, the person will need to engage in lifestyle changes,
and these include: - A healthy diet.
Basically you should include more vegetables, fruits, and foods that contain omega-3 essential
fats.
If you want to learn more watch my other video of omega-3 here.
You need to reduce the amount of unsaturated, saturated and trans fats.
Also limit the amount of processed foods.
And very important, reduce the amount of refined sugars, or empty calories that do not have
any nutritional value.
I explain all of this in another video.
Watch my other video about an anti-inflammatory diet here.
- Mind-body therapies, especially to reduce the influence of stress on their body.
We know that having a diagnosis like AS is frightening.
And fear is paralyzing, and it is a fuel to develop chronic pain and central sensitization.
So, participating in mind-body interventions is important to learn how to cope with this
new diagnosis, how to cope with pain, sleep problems, weight management, relationships
with other people, etc.
Watch my other video about mind-body interventions.
- Sleep efficiency is very important, especially because many people with ankylosing spondylitis
have pain at night.
Watch my other video here.
- Regular exercises, these are extremely important, specially to strengthen the muscles of the
back, flexibility to reduce the stiffness and improve mobility.
I have another video specific of exercises for Ankylosing spondylitis.
Watch it here.
- Don’t forget to add many tools in your toolbox, like heat and cold, TENS, and massage
with a foam roller.
Watch my other videos about these topics here.
I’ll put the links to these videos below, so you can watch them later.
You may also get my book, the 8 STEPS to Conquer Chronic pain, to learn about the pain system
and all of these lifestyle approaches are included in my book.
When the disease is active, the person continues doing everything that we mentioned before,
but then we should treat the inflammation to try to stop the damage that the cytokines
will do to the bones, tendons and collagen around the body.
In mild cases, NSAIDS, exercises and mind-body therapies to reduce stress and muscle tension
are all that is needed.
In moderate to severe cases, we can use disease modifying anti-rheumatic drugs, DMARDs like
sulfasalazine or methotrexate.
In cases that are not responding well to NSAIDs or DMARDS, we can use biologics, there are
many types.
In this case the person should see a specialist, and these are rheumatologists, who specialize
in arthritis.
We rarely indicate surgery to fix the problem of ankylosing spondylitis, as it is very risky.
The exercises are very important to avoid the deformities of stiffness and fusion of
the bones.
The main focus should be on flexibility, mobility and stretching exercises.
There is a systematic review published in 2015 that examined 13 studies that combined
an exercise program with medication anti-TNF.
They found that when doing both, exercises and taking this medication was more effective
than taking the medication alone, in terms of symptom severity, function and quality
of life, activities of daily living and other measures such as weight and blood pressure.
Watch my next video where I demonstrate exercises for ankylosing spondylitis.
I’ll show you a routine that you can do at home, everyday.
It is easy and does not require any special equipment.
Thank you for watching!
Good bye