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Ankylosing Spondylitis
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Ankylosing spondylitis - (AS)

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Ankylosing spondylitis (AS) is a rheumatic disease that causes arthritis of the spine and sacroiliac joints and can cause inflammation of the eyes, lungs, and heart valves. It varies from intermittent episodes of back pain that occur throughout life to a severe chronic disease that attacks the spine, peripheral joints and other body organs, resulting in severe joint and back stiffness, loss of motion and deformity as life progresses. Ankylosing spondylitis is one of many forms of inflammatory arthritis, the most common of which is rheumatoid arthritis. The condition primarily causes inflammation of the joints between the vertebrae of your spine and the joints between your spine and pelvis (sacroiliac joints). However, ankylosing spondylitis may also affect joints in your arms and legs, tendons and ligaments where they attach to your bones, and the joints in your ribs where they attach to your spine.

As the condition worsens, and the inflammation persists, new bone forms in the healing process. Your vertebrae begin to grow together, forming vertical bony outgrowths (syndesmophytes) and becoming stiff and inflexible. Fusion can also stiffen your rib cage, restricting lung capacity and function.

Ankylosing spondylitis is a chronic condition. However, treatments can decrease your pain and lessen your symptoms. Effective treatment may also help prevent complications and physical deformities. Also called spondylitis or rheumatoid spondylitis previously, ankylosing spondylitis.

Signs and symptoms

Your condition may change over time, with symptoms getting worse, improving or completely stopping at any point. Early signs and symptoms may include:

  • Low back pain

  • Pain and stiffness in any part of your spine, or your entire spine, and perhaps other joints; often worse in the morning and after periods of inactivity

In advanced stages, the following signs and symptoms may develop:

  • Restricted expansion of your chest

  • Chronic stooping

  • Stiff, inflexible spine

  • Fatigue

  • Loss of appetite

  • Weight loss

  • Eye inflammation (iritis)

Ankylosing spondylitis can lead to a stiff, inflexible spine....

Causes

Ankylosing spondylitis has no known specific cause, though genetic factors seem to be involved. The majority of people with ankylosing spondylitis have a gene called HLA-B27. This gene may make people more susceptible to developing ankylosing spondylitis.

Risk factors

Genetics may play a role in the development of ankylosing spondylitis. In fact, 90 percent of people with this condition have the HLA-B27 gene. Having this gene doesn't mean that you'll acquire ankylosing spondylitis — only about 2 percent of people with this gene develop the condition — but it may make you more susceptible to the disease.

If you test positive for the HLA-B27 gene, are younger than 40 and have a family member with ankylosing spondylitis, you have about a 20-percent chance of developing the condition. However, if you're older than 40, your chances of acquiring ankylosing spondylitis are low. If you have ankylosing spondylitis, you have about a 50-percent chance of passing the HLA-B27 gene on to your children if you have the gene.

Ankylosing spondylitis affects males more often than females.

When to seek medical advice

See your doctor if you have symptoms of ankylosing spondylitis. Also contact your doctor if you're being treated for the disease and new signs and symptoms develop.

Screening and diagnosis

In most cases, ankylosing spondylitis is mild, so it may go undiagnosed for decades. In addition, some people may mistakenly attribute many of the symptoms of ankylosing spondylitis for more common back problems.

To determine the cause of your discomfort, your doctor will conduct a medical history and complete a physical examination. Then, your doctor may use the following diagnostic procedures:

  • Imaging. X-rays allow your doctor to check for changes in your joints and bones, though the characteristic effects of ankylosing spondylitis may not be evident early in the disease. Your doctor may also use other imaging tests, such as computerized tomography (CT) or magnetic resonance imaging (MRI) scans, to detect inflammation and other changes in your joints.

  • Blood tests. For instance, your doctor may check to see if you have an elevated sedimentation rate — a measurement of the speed at which your red blood cells settle to the bottom of a tube in 1 hour — which is an indication of inflammation. Another blood test can determine if you have anemia, a condition in which there aren't enough healthy red blood cells to carry adequate oxygen to your tissues. Anemia is a complication that can result from the chronic inflammation of ankylosing spondylitis. Finally, you may need a blood test to see if you have the HLA-B27 gene. The presence of this gene doesn't determine whether you have ankylosing spondylitis. But its absence makes it less likely that you do.

Complications

Ankylosing spondylitis doesn't follow a set course. The severity of symptoms and development of complications vary widely among individuals. Complications may include:

  • Difficulty walking or standing. Typically, ankylosing spondylitis begins with soreness in your spine. As the disease progresses, the affected bones may fuse together, rendering your joints immobile and causing a stiff, inflexible spine (bamboo spine). This can make walking or standing difficult. Your joints may fuse even if you undergo proper treatment — and once joints fuse, additional treatment won't help restore mobility. However, if fusion occurs with your spine in an upright position, you can remain more able to perform activities of daily living.

  • Difficulty breathing. Inflammation can also spread up your spine and cause the bones in your rib cage to fuse. This results in breathing problems. When your ribs can't move when you breathe, it's difficult to fully inflate your lungs. However, if you don't have an unrelated lung condition, you may be able to continue your everyday activities without experiencing shortness of breath.

  • Heart problems. If the inflammation reaches your heart, you can develop valve problems, such as inflammation of the body's largest artery (aorta), also known as aortitis. Another possible complication is aortic valve regurgitation, which occurs when the aortic valve — which connects the heart's lower-left chamber (ventricle) to the aorta — widens.

  • Lung infections. In some people with ankylosing spondylitis, cavitary lesions develop in the upper portion of the lungs. These cavities can slowly enlarge over many years and develop infections, most commonly fungal infections. It's uncommon for this complication to occur in nonsmokers.

Typically, many of the complications involving the lungs and heart don't develop until after ankylosing spondylitis is no longer active in your spine. This can take up to 20 years.

Inflammation can also involve other parts of your body, resulting in conditions such as:

Treatment

Treatment for ankylosing spondylitis exists, but the fusion of joints is irreversible. Instead, the goal of treatment is to relieve pain and stiffness, and prevent or delay complications and spinal deformity. Treatment of ankylosing spondylitis is most successful early, before it causes irreversible damage to your joints, such as fusion, especially in positions that limit your function.

Medications
Your doctor may recommend that you take one or more of the following medications:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs — such as ibuprofen (Advil, Motrin, others), naproxen (Aleve, Anaprox, others) and indomethacin (Indocin) — are the medications doctors most commonly use to treat ankylosing spondylitis. They can relieve your inflammation, pain and stiffness.

  • Disease-modifying antirheumatic drugs (DMARDs). Your doctor may prescribe a DMARD, such as sulfasalazine (Azulfidine) or methotrexate (Rheumatrex), to treat inflamed joints and other tissues.

  • Corticosteroids. These medications, such as prednisone, may suppress inflammation and slow joint damage in severe cases of ankylosing spondylitis. You usually take them orally, ideally for a limited period of time because of their side effects. Occasionally, corticosteroids are injected directly into a painful joint.

  • Tumor necrosis factor (TNF) blockers. Doctors originally used TNF blockers to treat rheumatoid arthritis. TNF is a cytokine, or cell protein, that acts as an inflammatory agent in rheumatoid arthritis. TNF blockers target or block this protein and can help reduce pain, stiffness, and tender or swollen joints. These medications, such as etanercept (Enbrel) and infliximab (Remicade), may decrease inflammation and improve pain and stiffness for people with ankylosing spondylitis.

Physical therapy
Physical therapy can provide a number of benefits, from pain relief to improved physical strength and flexibility. Your doctor may recommend that you meet with a physical therapist, who will provide you with specific exercises designed for your needs.

Range-of-motion and stretching exercises can help maintain flexibility in your joints and preserve good posture. In addition, specific breathing exercises can help to sustain and enhance your lung capacity.

As your condition progresses, your upper body may begin to stoop forward. Proper sleep and walking positions and abdominal and back exercises can help maintain your upright posture. Though you may develop spine stiffness despite your treatment, proper posture can help to ensure that your spine is fused in a fixed upright position.

Surgery
Most people with ankylosing spondylitis don't need surgery. Surgery may help if you have severe pain or joint damage. You may need surgery if a nonspinal joint needs to be replaced. However, doctors don't usually recommend back surgery.

Prevention

Because genetic factors appear to play a part in ankylosing spondylitis, it's not possible to prevent the disease. However, being aware of any personal risk factors for the disease can help in early detection and treatment. Proper and early treatment can relieve joint pain and help to prevent or delay the onset of physical deformities.

Self-care

If you smoke, try to quit. Smoking is bad for your health, but creates additional problems for people with ankylosing spondylitis. It's also a risk factor for the development of cavitary lesions in your lungs, a complication of ankylosing spondylitis. And depending on the severity of your condition, ankylosing spondylitis can affect the mobility of your rib cage. Damaging your lungs by smoking can compromise your ability to breathe.

Coping skills

The course of your condition may change over time, and you may experience relapses and remissions throughout your life. But despite the potential complications, most people are able to live productive lives despite a diagnosis of ankylosing spondylitis.

You may want to join a support group of other people with this condition, in order to share experiences and support. Contact your local office of the Arthritis Foundation to see if there are any groups in your area or if you can start your own.

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