Ankylosing Spondylitis (SpA)

Ankylosing spondylitis (AS) is a type of arthritis that mainly affects the back. It causes inflammation in the joints of the spine, leading to pain and stiffness. Ankylosing spondylitis affects people in different ways – some people can almost forget they have the condition, while for others it can have a big impact on their quality of life. Sometimes joints other than those in the spine can be affected too. Occasionally, other parts of the body may also be affected. Ankylosing spondylitis is a type of spondyloarthritis (pronounced as spond– ee–lo–arth–ritis), a group of conditions that share many of the same symptoms.

Ankylosing spondylitis typically starts in the joints between your spine and pelvis (the sacroiliac joints), but it may spread up your spine to your neck (see Figure 1). It can sometimes affect other parts of your body, including your joints, tendons or eyes.

In the early stages, ankylosing spondylitis is likely to cause:

• stiffness and pain in your lower back in the early morning which eases through the day or with activity

• pain in your sacroiliac joints (the joints where the base of your spine meets your pelvis), your buttocks or the backs of your thighs.

Some people first notice problems after a muscle strain, so the condition can sometimes be mistaken for common backache. However, stiffness that lasts at least 30 minutes in the morning helps to distinguish ankylosing spondylitis from simple back pain. It may also occur after rest, or it may wake you in the night. The stiffness can be eased by exercise or movement.

You may also have neck, shoulder, hip or thigh pain, which is often worse when you’ve been inactive for a time, for example if you work at a computer. Some people have pain, stiffness and swelling in their knees or ankles. In psoriatic spondyloarthritis, the smaller joints of the hands and feet (fingers, toes) may be affected. For some people, especially children and teenagers, the first signs may be in their hip or knee rather than in their back. Inflammation can occur at any point in the body where tendons attach to bone (enthesitis), for example at the elbow and heel.

Other possible symptoms include:

• Tenderness or discomfort around your heels: This makes it uncomfortable to stand on a hard floor. Inflammation can occur at the back of your heel where your Achilles tendon meets your heel bone, or in the tendon in the arch of the foot, which causes pain known as plantar fasciitis.

• Swollen fingers or toes: When the whole digit is swollen it’s known as dactylitis.

• Tenderness at the base of your pelvis (ischium): This makes sitting uncomfortable.

• Chest pain or tightness: If your spine is affected at chest level (the thoracic spine), it can affect movement at the joints between your ribs and breastbone. This makes it difficult to take a deep breath. Your ribs may be very tender, and you may feel short of breath after even gentle activity. Coughing or sneezing may cause discomfort or pain.

• Eye inflammation (painful, bloodshot eyes); uveitis or iritis: The first signs of this are usually a red (bloodshot), watery and painful eye, and it may become uncomfortable to look at bright lights.

• Inflammation of the bowel: People with ankylosing spondylitis can develop bowel problems known as inflammatory bowel disease (IBD) or colitis. It’s a good idea to tell your doctor if you develop diarrhoea for more than two weeks or begin to pass bloody or slimy stools.

• Tired (fatigue): People with ankylosing spondylitis may experience tiredness caused by the activity of the condition, anaemia or sometimes depression and frustration associated with the condition.

Ankylosing spondylitis can affect anyone, although it’s more common in young men and most likely to start in your late teens and 20s. It’s linked to the genes we inherit, but having ankylosing spondylitis doesn’t mean you’ll definitely pass it on to your children.

Most back pain isn’t caused by ankylosing spondylitis. However, the symptoms, especially in the early stages, can be very similar to more common back problems.

Because of this, many people put up with the pain for some time before seeking help. When you first see your doctor, there may be little to show whether the problem is ankylosing spondylitis or some other, more common, back problem. Unfortunately, ankylosing spondylitis may even be misdiagnosed at first. Usually, ankylosing spondylitis is diagnosed by a rheumatologist rather than a GP.

No specific test will confirm you have ankylosing spondylitis, so diagnosis involves piecing together information from different sources, including:

• The history of your condition (including whether pain and discomfort is waking you up during the second half of the night)

• A physical examination

• Blood tests, which may show inflammation

• X-rays or an MRI scan.

X-rays can show changes in the spine as the condition develops but aren’t always helpful in the early stages so magnetic resonance imaging (MRI) scans are often used instead

A number of treatments are available that can ease pain and stiffness, but exercise and close attention to your posture are just as important to keep your spine mobile and help you to live a normal life.

The healthcare professionals in your rheumatology department can help you find treatments that are best for you. These will often include:

• drug treatments – These are given as tablets or injections to relieve pain, reduce inflammation or, if other treatments haven’t helped, to modify the condition itself.

• physiotherapy and exercise – These are very important to keep your spine strong and flexible.

Surgery is very rarely needed but may be very helpful if your hip joints are badly affected. Back surgery is even more uncommon and only used if your spine has become very bent.

Guidance for primary care (GP): identifying and referring spondyloarthritis

https://www.bmj.com/content/bmj/suppl/2017/02/28/bmj.j839.DC1/mcak020217.wi.pdf

Referral for Spondyloarthritis

http://www.bad.org.uk/shared/get-file.ashx?id=1655&itemtype=document

Tools

http://oml.eular.org/sysModules/obxOml/docs/ID_39/ASM%20MIX.pdf

Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)

http://oml.eular.org/sysModules/obxOml/docs/ID_33/BASDAI_English.pdf

https://www.asas-group.org/education/asas-app/

2. Bath Ankylosing Spondylitis Functional Index (BASFI)

http://oml.eular.org/sysModules/obxOml/docs/ID_34/BASFI_English.pdf

https://www.asas-group.org/education/asas-app/

3. ASDAS

http://oml.eular.org/sysModules/obxOml/docs/ID_31/ASDAS-CRP_Calculation_Form_updated.pdf

3. Ankylosing Spondylitis Quality of Life (ASQoL) scale

https://www.asas-group.org/education/asas-app/

4. Health Assessment Questionnaires for the Spondyloarthropathies (HAQS)

http://oml.eular.org/sysModules/obxOml/docs/ID_32/ASQoL%20Questionnaire%20English.pdf

5. Work productivity and activity impairment questionnaire WPAI-SpA

http://oml.eular.org/oml_search_results.cfm?action=showResults

6. Bath Ankylosing Spondylitis Metrology Index (BASMI)

http://asif.info/wp-content/uploads/2018/04/basmi-10-e-2.pdf

https://www.youtube.com/watch?v=ko8E1lNDzeQ