Ankylosing Spondylitis: Causes & Treatments
A form of inflammatory arthritis, ankylosing spondylitis mainly affects the lower back – though other parts of the body and other joints can also be affected. It can affect anyone of any age, but it’s most common in young men (three times more men are thought to have ankylosing spondylitis than women). It also tends to first develop in teenagers and young adults, most commonly when you’re in your 20s or 30s (i). Only a minority of cases start in adults aged 45 or older (ii).
The symptoms of ankylosing spondylitis vary from one person to the next. Some may have very mild symptoms, but for others the symptoms can be debilitating and have a significant impact on their quality of life. Despite that, around 70 - 90 per cent of people with ankylosing spondylitis stay fully independent or minimally disabled in the long term, though some may eventually become more, sometimes severely, disabled (ii).
What are the symptoms?
As ankylosing spondylitis mainly affects the back, the main symptom is back pain and stiffness. There may also be pain and swelling caused by joint inflammation elsewhere in the body, as well as inflammation where a tendon joins a bone, a condition called enthesitis. Some people with ankylosing spondylitis also experience fatigue, which can make them feel overwhelmingly exhausted from time to time.
These symptoms tend to develop gradually, often over months or years, which usually come and go. For some, the symptoms can improve over time, while for others they may gradually worsen.
Other symptoms can include chest pain – where the spin is affected at chest level – and tenderness at the base of the pelvis or at the back of the heel. The condition can also cause pain and swelling in a finger or toe (dactylitis).
What causes ankylosing spondylitis?
If you have ankylosing spondylitis, the vertebrae and spinal joints of your spine become inflamed (this may be caused by the immune system producing autoantibodies (iii)). The inflammation triggers a process where calcium is laid down where the ligaments attach to the vertebrae, causing new bone to grow. Over time this can cause the vertebrae and spinal joints to fuse together, which reduces your spine’s flexibility. It usually starts in the lower back, but can spread up your spine to your neck – as well as affecting other parts of your body.
Nobody knows what triggers the inflammation that starts the damage, but it may have something to do with a gene called human leukocyte antigen B27 (HLA-B27). Research suggests more than nine out of 10 people with ankylosing spondylitis carry this gene, compared with eight out of every 100 people in the general population, most of whom do not have ankylosing spondylitis (iv).
However, if you have HLA-B27, it doesn’t mean you’ll develop the condition, as only one to two per cent of people with the gene have ankylosing spondylitis (v). If you pass it on to your children they’ll also have a lower than 20 percent chance of developing it (people who carry the HLA-B27 gene have a one in two chances of passing in to their children) (iv). However, if you have a close family member – such as a parent or sibling – who has ankylosing spondylitis, your risk of developing the condition is 15 - 20 per cent higher than others who don’t have it in their family (v).
Why some people with HLA-B27 develop ankylosing spondylitis while others don’t isn’t clear, but environmental factors are thought to be involved.
Diagnosing ankylosing spondylitis, therefore, can be difficult – not just because the presence of HLA-B27 isn’t a certain indicator, but because the condition usually develops slowly. Scans and x-rays can sometimes show spinal inflammation and fusing of the vertebrae, but this isn’t always visible in the early stages. Many people therefore find that getting a positive diagnosis for ankylosing spondylitis can take several years.
Ankylosing spondylitis: related conditions
As one of a group of conditions known as spondyloarthritis, ankylosing spondylitis shares many of the same symptoms with the following:
Non-radiographic ankylosing spondylitis/undifferentiated spondyloarthritis, which shares similar symptoms but cannot be picked up by x-rays.
Psoriatic spondyloarthritis, which affects some people who have the skin condition psoriasis.
Enteropathic arthritis, a condition related to inflammatory bowel disease. People with ankylosing spondylitis are also more likely to develop related conditions such as colitis or Crohn’s disease.
Reactive arthritis – or Reiter’s syndrome – a form of arthritis triggered by an infection.
Enthesitis-related arthritis, which affects children and teenagers (the entheses are where tendons and ligaments attach to bone).
Meanwhile, some people with ankylosing spondylitis also develop inflammation of the eye – a condition called uveitis or iritis – which can cause permanent damage to your vision if left untreated (get medical help within 24 - 48 hours). Those with ankylosing spondylitis may also have an increased risk of medical conditions such as osteoporosis, psoriasis, lung fibrosis, cardiovascular disease, heart valve problems, chest infections, spinal fractures and kidney problems.
Treatments for ankylosing spondylitis
Ankylosing spondylitis cannot be cured, but medical treatments can help ease the pain and stiffness, and even stop or delay the condition’s progression.
If your symptoms are mild between flare-ups, all you may need are simple, over-the-counter painkillers such as paracetamol or the over-the-counter anti-inflammatory painkiller ibuprofen. Prescription anti-inflammatory drugs (non-steroidal anti-inflammatory drugs or NSAIDs) are also used to treat flare-ups of ankylosing spondylitis pain, including naproxen, diclofenac and etoricoxib. Stronger painkillers containing codeine may also be recommended, including co-codamol (a combination of paracetamol and codeine).
If you have ankylosing spondylitis it’s likely you’ll be referred to a physiotherapist who can advise you about exercises that may help. You may practise your exercises with a group of people or by yourself. Physiotherapy may also include massage to improve your mobility and relieve pain, as well as hydrotherapy to help relax your muscles.
Also known as anti-TNF drugs, these are newer treatments that block the effects of a chemical produced by cells when tissue is inflamed called tumour necrosis factor. According to Versus Arthritis, these can be very effective for ankylosing spondylitis (vi). Given as an injection under the skin, these drugs aren’t suitable for everyone, however, and are only usually used where symptoms aren’t being controlled with painkillers and physiotherapy.
Injecting steroid medication into an affected joint or muscle can sometimes help treat flare-ups of ankylosing spondylitis symptoms. According to the NHS, specialists are advised to give a steroid injection up to three times in one year, with at least three months between injections in the same joint. Some people may also need to take a course of steroid tablets, or use steroid eye drops in the case of inflammation of the eye.
Disease-modifying anti-rheumatic drugs such as methotrexate and sulfasalazine are more commonly used to treat some other types of arthritis, but are sometimes also used to treat ankylosing spondylitis where there is pain and inflammation in parts of the body such as the arms or legs, rather than the spine.
If you have severe ankylosing spondylitis you may be advised to have surgery, such as a joint replacement operation or – in rare cases – corrective surgery to straighten the spine.
Lifestyle help for ankylosing spondylitis
Most people with ankylosing spondylitis find their symptoms are controlled with medication and physiotherapy. There are also other things you can do on a daily basis that may help:
Exercise doesn’t just keep you fit, it can also help you maintain flexibility in your joints and muscles – which can help with even the simplest everyday activities. Indeed, most people with ankylosing spondylitis are advised to do some exercise every day – though they should take it easy if they’re having a flare-up.
As well as the exercises recommended by your physiotherapist, you may benefit from other activities such as Pilates, yoga and t’ai chi. You can even take part in sports – though high-impact contact sports such as rugby and basketball aren’t a good idea if you have advanced ankylosing spondylitis. Swimming is considered an ideal exercise for people with ankylosing spondylitis, as it uses all the major muscles and doesn’t put pressure on the joints. Depending on what parts of your body are affected, however, you may need advice on which swimming strokes would be best for you (breaststroke, for instance, may be difficult if you have problems in your neck).
There’s lots more information about exercising for ankylosing spondylitis at the National Ankylosing Spondylitis Society website.
If you’re a smoker who has ankylosing spondylitis, you may have a higher risk of smoking-related lung damage because the condition can limit the movement of your rib cage when you breathe. Smoking also increases your risk of developing heart disease, which is also something people with ankylosing spondylitis have a higher risk for. If you need help to stop smoking, there are is a range of advice and products available to help you get started.
Keep your weight healthy
If you need to lose weight, it can reduce the strain on your back and other joints. Click here for more advice and tips for weight loss.
Make yourself comfortable for sleep
Having ankylosing spondylitis can cause poor sleep in some people. Try to find a mattress that offers good support while moulding to the shape of your spine, and keep your neck in a natural position by using as few pillows as possible.
Use mobility aids
If you have limited movement in your spine and struggle with everyday things like putting on your shoes, there are lots of aids available that can help make things easier. The best person to ask about mobility aids is an occupational therapist – ask your GP for a referral.
Support your feet
If you have ankylosing spondylitis, you’re also more likely to develop a condition that affects the arch and heel of your foot, called plantar fasciitis. In such cases, custom-made insoles – or orthotics – can help to relieve foot pain as well as pain in the hips, pelvis or lower back the condition may cause. You may also benefit from gel insoles or gel heel cushions, both of which are available over the counter in pharmacies and at sports shops.
Boost your work posture
If you work in an office, try to make sure your desk, computer keyboard and computer monitor are set up correctly to keep your posture healthy. It’s also a good idea to avoid lifting or anything else that may cause back strain whenever possible. Standing up and walking around or stretching for a few minutes every hour can help too, and don’t forget to build in short rest periods throughout the day.
People with ankylosing spondylitis shouldn’t find driving difficult. However, if you’re driving on a long journey, make an effort to stop regularly to get out of the car and stretch your legs. Also make sure your head rest is adjusted correctly to provide your neck with the support it needs.
Natural treatments for ankylosing spondylitis
Some people with ankylosing spondylitis find massage can soothe their aching back or joints, while others claim heat therapy is helpful. Try having a warm bath before bed or a shower in the morning to tackle stiffness, or use a hot water bottle or a microwaveable heat pad on the affected part of your back or joints whenever you need relief.
Meanwhile, there are some nutritional supplements that may be beneficial, including the following:
The omega-3 fatty acids found in oily fish such as mackerel, salmon, sardines and fresh tuna are widely thought to help reduce inflammation in the body, including joint inflammation. Indeed, there is some evidence that a high daily dose of fish oils (4.55g) may reduce the disease activity of ankylosing spondylitis (iii).
If you’re a vegetarian or vegan you can still benefit from an omega-3 supplement, thanks to the availability of products that contain the natural triglyceride (TG) form of omega-3, which is sourced from plant organisms called microalgae rather than fish.
Calcium and vitamin D
Since people with ankylosing spondylitis have a greater risk of developing osteoporosis than the general population, many experts – including the people at Versus Arthritis – recommend making sure you get enough calcium and vitamin D in your diet to help strengthen your bones (vi). One study claims people with ankylosing spondylitis have lower vitamin D levels (ix), while another suggests that having high levels of vitamin D may reduce the activity of the ankylosing spondylitis, as well as reduce the risk of developing the condition (x).
The recommended form of vitamin D is vitamin D3 or cholecalciferol, as it’s the natural form of vitamin D that the body makes when it’s exposed to sunlight. Vitamin D3 supplements are available in tablet form, and now you can get them in veggie-friendly drops too.
However, most vitamin D3 supplements are made from the fat of lamb’s wool, which means they’re unsuitable for vegans. The good news is that vegan vitamin D3 supplements sourced from lichen are now more widely available.
Like fish oils, turmeric – or rather the active ingredient in turmeric called curcumin – may help relieve ankylosing spondylitis symptoms as it is thought to have an anti-inflammatory effect. In fact there’s some evidence it may work by blocking several substances that play a role in inflammation, including tumor necrosis factor (TNF), prostaglandins, interleukin-12, cyclooxygenase 2, collagenase, elastase and thromboxane (xi).
Glucosamine and chondroitin
Found in and around the cells of cartilage, glucosamine and chondroitin are available as supplements sourced from shrimp or crab shell, and may help reduce wear and tear in the joints by building and repairing cartilage. Many studies have been carried out on both substances, but one suggests it may be more beneficial to take glucosamine and chondroitin together rather than either one or the other (xii).
High-strength multivitamin and mineral
Some experts think ankylosing spondylitis may be an autoimmune condition, which is when the immune system produces antibodies that attack healthy tissues (iii). As well as helping to support your overall health, a good-quality multivitamin and mineral supplement may also help to maintain normal function of your immune system.
To discover more advice on how to keep your body healthy, visit our health advice library.
Also known as palmitoylethanolamide, PEA is a type of fatty acid made naturally by the body and found in all cells, tissues and fluids including the brain (it’s also found in foods such as soya beans, peanuts, eggs, flaxseed and milk). Described as an endocannbinoid-like chemical that belongs to a family of fatty acid compounds called amides (xiii), PEA is an alternative to CBD, since both substances are thought to have similar properties including the ability to reduce pain and inflammation. However researchers suggest PEA is safer than CBD, since it has been studied more extensively and has a more robust safety profile (xiv) with no known side effects (xiii).
Your body naturally increases its production of PEA when your cells are damaged or threatened. But in certain situations – such as when your body is experiencing chronic inflammation – the level of PEA in your cells drops (xiv). When this happens, PEA supplements may be helpful. In fact one study suggests PEA supplements may help with chronic lower back pain management when used alongside a conventional type of painkiller, claiming that it may even allow those affected to reduce their painkiller dosage over time (xv).
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Disclaimer: The information presented by Nature's Best is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. Self-treatment is not recommended for life-threatening conditions that require medical treatment under a doctor's care. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or pharmacist for any health problem and before using any supplements or before making any changes in prescribed medications.
Christine Morgan has been a freelance health and wellbeing journalist for almost 20 years, having written for numerous publications including the Daily Mirror, S Magazine, Top Sante, Healthy, Woman & Home, Zest, Allergy, Healthy Times and Pregnancy & Birth; she has also edited several titles such as Women’ Health, Shine’s Real Health & Beauty and All About Health.