Ankylosing Spondylitis

February 3, 2017

Ankylosing spondylitis is a type of arthritis of the spine. It causes inflammation between your vertebrae, which are the bones that make up your spine, and in the joints between your spine and pelvis. In some people, it can affect other joints. Its name comes from the Greek words “ankylos,” meaning stiffening of a joint, and “spondylo,” meaning vertebra. Spondylitis refers to inflammation of the spine or one or more of the adjacent structures of the vertebrae.

The condition is grouped into a set of overlapping arthritis disorders that doctors call the spondyloarthritides or spondylarthritis. In addition to ankylosing spondylitis, this classification includes other types of spondylitis caused by syndromes such as inflammatory bowel disease and psoriasis. Although these disorders have similarities, they also have features that distinguish them from one another. The hallmark of ankylosing spondylitis is “sacroiliitis,” or inflammation of the sacroiliac (SI) joints, where the spine joins the pelvis. AS affect joints outside of the spine, like the shoulders, ribs, hips, knees, and feet. It can also affect entheses, which are sites where the tendons and ligaments attach to the bones. It is possible that it can affect other organs, such as the eyes, bowel, and—more rarely—the heart and lungs. In the most severe cases, long-term inflammation leads to calcification that causes two or more bones of the spine to fuse. Fusion can also stiffen the rib cage, resulting in restricted lung capacity and function.

In the most severe cases, long-term inflammation leads to calcification that causes two or more bones of the spine to fuse. Fusion can also stiffen the rib cage, resulting in restricted lung capacity and function. Around 1% of the adult population is affected by spondylarthritis, with an estimated 1.7 million Americans aged 20-69 years thought to have the condtion.


The cause of AS is multifactorial, as in many autoimmune diseases, and based on genetic factors, such as the very strong genetic influences of HLA-B27 and environmental factors, such as bacterial infections.

Genetic Factors – Research has shown that more than 9 out of 10 people with AS carry a particular gene known as human leukocyte antigen B27 (HLA-B27).

Having this gene does not necessarily mean you will develop AS. It is estimated that 8 in every 100 people in the general population have the HLA-B27 gene, but most do not have AS.

It is thought that having this gene may make you more vulnerable to developing AS, and the condition is triggered by one or more environmental factors – although it is not known what these are.

Testing for this gene may be carried out if AS is suspected. However, this test is not a very reliable method of diagnosing the condition because some people can have the HLA-B27 gene but not have ankylosing spondylitis. AS can run in families, and the HLA-B27 gene can be inherited from another family member.

Environmental Factors – Apart from genetic factors, environmental factors also seem to play a role in the multifactorial causes of AS. The innate immunity could be disturbed, like in some polymorphisms of the TLR4 and CD14 genes, and make individuals prone to abnormal reactions after bacterial infections. The pathogenetic role of bacteria can be illustrated by the onset of another subtype of SpA, reactive arthritis. In this disease the symptoms manifest after bacterial infections, especially gastrointestinal (with Salmonella, Shigella, Yersinia or Campylobacter) or urogenital (with Chlamydia trachomatis).


Three main symptoms characterize ankylosing spondylitis:2

  • Pain
  • Stiffness
  • Loss of mobility.

Pain is the main symptom of ankylosing spondylitis, especially in the lower back and buttock areas in the early stages of the disease.2 Read on to the next section about diagnosis to find out the typical onset and character of pain in ankylosing spondylitis, and how it differs from other causes of back pain.

Although lower back pain is a key symptom of ankylosing spondylitis, the inflammation is not confined to the lumbar spine – it is systemic – meaning that pain can also arise in other parts of the body.

  • In other joints (arthritis and synovitis symptoms)
  • In the neck (upper – cervical – spine)
  • At the top of the shin bone in the lower leg
  • Behind the heel of the foot (inflammation – enthesitis – in the Achilles tendon)
  • Under the heel of the foot
  • In the chest (which can restrict breathing).

People with ankylosing spondylitis may also experience fatigue – a feeling of being tired and having low energy most of the time.

Tendons and ligaments in various parts of the body (in addition to those attached to the bones (vertebrae) of the lower spine) may become inflamed and painful where they attach to bones. Common examples are the Achilles tendon where it attaches to the heel, and where chest muscles attach to the ribs.

Uveitis affects about 1 in 3 people with AS from time to time. Tell a doctor urgently if you have AS and develop a painful or red eye. If you develop uveitis, treatment with eye drops should be started as soon as possible after eye symptoms begin. Treatment of uveitis is usually successful. However, if not treated quickly there can be permanent loss of vision in the eye (partial or complete).

Associated diseases

Some other conditions develop more commonly than normal in people who have AS. For example, people with AS have a greater than average chance of developing ulcerative colitis, Crohn’s disease, psoriasis, osteoporosis, lung fibrosis, cardiovascular disease (see later) and heart valve problems.


Conventional treatment – The following two main approaches are typically used in the management of ankylosing spondylitis.

  • Painkillers and other drugs to reduce pain and inflammation
  • Physical therapy and exercises to maintain movement and posture.

Surgery is used only rarely, in severe cases to correct great deformity – for example, when the spine is bent over too far – or to replace a joint, such as in hip replacement.

  • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) – These drugs relieve pain and inflammation, and are commonly used to treat ankylosing spondylitis. Aspirin, ibuprofen, and naproxen are examples of NSAIDs.1 All NSAIDs work similarly by blocking substances called prostaglandins that contribute to inflammation and pain. However, each NSAID is a different chemical, and each has a slightly different effect on the body. Side effects of NSAIDs include stomach problems; skin rashes; high blood pressure; fluid retention; and liver, kidney, and heart problems.


  • Corticosteroids – These strong inflammation-fighting drugs are similar to the cortisone made by our bodies. If NSAIDs alone do not control inflammation in people with ankylosing spondylitis, doctors may inject corticosteroids directly into the affected joints to bring quick, but temporary relief. Injections may be given to the sacroiliac joint, hip joint, or knee joint, but are not given in the spine.



  • Disease-Modifying Antirheumatic Drugs (DMARDs) – These drugs work in different ways to control the disease process of ankylosing spondylitis. The most commonly used DMARDs for ankylosing spondylitis are sulfasalazine and methotrexate.


  • Biologic Agents – These new class of medications are genetically engineered to block proteins involved in the body’s inflammatory response. Four biologics—adalimumab, etanercept, golimumab, and infliximab—are approved by the Food and Drug Administration (FDA) for treating ankylosing spondylitis. All four work by suppressing a protein called tumor necrosis factor-alpha (TNF-α), and are often effective for relieving symptoms when NSAIDs or other treatments are not. These drugs are taken by intravenous infusion or injection.


Physical Therapy – Physical therapy for ankylosing spondylitis can help to prevent symptoms and is tailored to individuals’ needs. In general, physical therapists will devise a program including exercises directed at the joints or that promote extension and mobility of the spine. Range-of-motion and stretching exercises can help maintain flexibility in the joints and preserve good posture. Proper sleep and walking positions and abdominal and back exercises can help maintain the upright posture.


Surgery – Most people with ankylosing spondylitis don’t need surgery. However, the doctor may recommend surgery if the patient has severe pain or joint damage, or if the hip joint is so damaged that it needs to be replaced.


Alternative Treatment


Cod Liver Oil – Cod liver oil is an important omega-3 fat supplement. This supplement helps relieve inflammation in the entire body and reduces the pain and progression of the condition.

Vitamin D – Vitamin D is an important vitamin that helps maintain good bone health. As such, a daily vitamin D supplement will help maintain the strength of the bones and prevent unusual growth.

Potassium – Potassium deficiency is one of the suspected causes of inflammatory conditions in the body. As such, a daily potassium supplement can help relieve general inflammation as well as treat ankylosis.

Probiotics – These should be a mainstay in any inflammatory condition. They can normalize the bowel flora and replace the bad bacteria with good intestinal microflora. Studies specific to their benefits in ankylosing spondylitis have been mixed, but they do have an effect on immune system modulation and are often included in any anti-inflammatory regimen.

Wobenzyme N – This is an enzyme supplement that is used in the treatment of inflammation and pain. Enzymes in this supplement include bromelain (from pineapple) and papain (from papaya).

Turmeric – It is a great anti-oxidant that can reduce inflammation and pain.

Tart Cherry Formula – Specifically Montmorency tart cherry extract is excellent for decreasing pain and inflammation.

Magnesium – Magnesium deficiency can promote inflammation and pain. For sore muscle and/or joints, the use of Magnesium gel or oil applied directly to the area can promote healing and reduce inflammation and increase joint and muscle mobility and flexibility.

Morinda citrifolia (Noni) – This is a tropical plant from East Asia that has been used for many years. It has anti-inflammatory properties and can help in the treatment of pain.

Complementary Treatent

Warm Soaks – A warm bath or shower is a natural way to relieve the pain and stiffness of ankylosing spondylitis.

Acupuncture – This ancient technique that involves inserting thin needles through the skin may stimulate your body’s natural pain relievers.

Message – Massage therapy, when performed by a therapist accustomed to working with ankylosing spondylitis.

Transcutaneous electrical nerve stimulation (TENS) – TENS involves passing an electric current through the skin. It may work on the same principle as acupuncture — by bringing about the release of the body’s natural pain relievers.