What are axial spondyloarthritis (AxSpA) and ankylosing spondylitis (AS)?
These are related conditions where there is inflammation at the places where ligaments (fibrous bands which connect joints) and tendons (the ends of muscles) join onto bone. This process is called enthesitis. At the places where there is inflammation, new bone can form. In a few people this can cause fusion of the spine leading to very severe stiffness which is called ankylosis. Some people with AxSpA and AS can also develop inflammatory arthritis with inflammation, pain and swelling in other joints for example the hips, knees, wrists and ankles.
Who gets AxSpA and ankylosing spondylitis?
It used to be thought that these conditions were much more common in men, however both men and women are equally affected. The first symptom is usually back pain and stiffness that starts in young adults in their 20s and 30s. Many people with AxSpA and AS wait years for a diagnosis because back pain is very common and is usually put down to normal aches and pains. The delay in making a diagnosis is even longer in women. Some people with AxSpA and AS have a family member with the same condition or a related condition including psoriasis, uveitis (inflammation of the iris), inflammatory bowel disease such as Crohn’s disease or ulcerative colitis, or a condition called reactive arthritis which can happen after an infection. All of these conditions are connected with a gene called the HLA B27 gene, which is why they tend to run in families.
What are the symptoms of AxSpA and ankylosing spondylitis?
Most people with AxSpA and AS have “inflammatory back pain”. This is back pain and stiffness that is much worse in the morning or middle of the night, and improves with stretching, exercise or non-steroidal anti-inflammatory drugs such as ibuprofen (NSAIDs).
Many people find that they wake up at the same very early time of the morning and have to get up and walk around to help the pain. Inflammation in the sacroiliac joints at the bottom of the back is called sacroiliitis and this causes buttock pain and limping.
The back pain and stiffness of AxSpA and AS are completely different to the back pain that most of us get from time to time in our lives. This is called “mechanical back pain “ which is usually worse with activity such as gardening and better with rest. The pain of AxSpA and AS is worse with rest and better with stretching and exercise.
AxSpA and AS can also cause inflammation and swelling in other joints such as the ankles, knees and hips. Enthesopathy can cause tendon problems including heel pain due to Achilles’ tendonitis, tennis elbow and a painful condition of the soles of the feet called plantar fasciitis. Some people with AxSpA and AS also develop a condition called iritis or uveitis which is due to inflammation of the iris, causing severe eye pain, blurred vision and redness.
How are AxSpA and AS diagnosed?
Both these conditions are diagnosed with a combination of a history of inflammatory back pain and sometimes joint problems, blood tests to look for raised “inflammatory markers” and the HLA B27 gene. X-rays of the spine and sacroiliac joints can also show changes where ligaments and tendons attach to bone. If there are signs on x-ray that there is fusion of the sacroiliac joints, then the condition is called ankylosing spondylitis. If X-rays look normal, then an MRI scan of the spine and sacroiliac joints can show signs of inflammation, and the condition is then called axial spondyloarthritis (or non-radiographic spondyloarthritis).
What are the treatments for AxSpA and AS?
There are many different types of treatment and these can be divided into several groups.
- Medical– including pain-killers, non-steroidal anti-inflammatory medicines (NSAIDs), joint injections, disease-modifying drugs (DMARDs) such as methotrexate and “biologic” therapies such as etanercept and adalimumab.
- Physical therapies– including stretching exercises, physiotherapy, osteopathy, chiropractic, massage and acupuncture
- Occupational therapy – including splints and devices to help with the activities of daily living
- Self-management– including pain management, exercise and exercises, weight management, dietary modification, relaxation and emotional support, stretching and improving sleep
The treatment of AxSpA and AS depends on which parts of the body are affected and how severely. If there is spinal pain and stiffness, stretching is extremely important and it is vital to try to find a way of fitting stretching exercises into your everyday routine. Stretching alone can signifciantly improve back pain and stiffness.
NSAIDs are used for many people with AxSpA and AS as they can help a lot with morning stiffness. Joint injections can be helpful for the sacroiliac or other joints. If several joints are affected, disease modifying drugs such as methotrexate or sulfasalazine which are also used for people with rheumatoid and psoriatic arthritis can be useful. Biologic drugs such as anti-TNF drugs including etanercept or adalimumab are also used if AxSpA and AS are severe – this usually means pain of more than about 4/10 in severity. If symptoms improve, drug treatments can usually be reduced and occasionally even stopped.
What can I do to help myself?
There are lots of ways that you can help yourself deal with the pain of AxSpA and AS including stretching, trying to be more active and eating a healthy diet. Read more about self-management.
FAQ about ankylosing spondylitis
- I am HLA B27 positive. Does this mean I have AxSpA or AS?
- No. Although about 97% of people with AS have the B27 gene, so do about 1 in 10 of the UK population, most of whom do not have AS.
- Do AxSpA and ankylosing spondylitis run in families and will I pass it on to my children?
- These conditions do run in families but the severity between generations can vary a lot. If one of your parents has ankylosing spondylitis, you have a 50% chance of inheriting the B27 gene, but this does not mean that you will develop AxSpA and AS yourself or that it will be as serious.
- Are AxSpA and ankylosing spondylitis connected with any other conditions?
- Yes, these conditions are connected with several other medical conditions including psoriasis, inflammatory bowel disease such as Crohn’s disease and ulcerative colitis and reactive arthritis which is arthritis after a type of infection.