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Ankylosing spondylitis

Expert reviewer, Dr Sundeept Bhalara, Consultant Rheumatologist and Physician
Next review due June 2024

Ankylosing spondylitis is a type of arthritis. It mainly affects the joints in your spine (backbone). It causes pain and stiffness in your lower back. You can develop ankylosing spondylitis at any age, but it usually starts in your twenties. Men are almost three times more likely to have ankylosing spondylitis than women.

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About ankylosing spondylitis

Ankylosing spondylitis belongs to a group of conditions called spondyloarthritis. Axial spondyloarthritis means it affects your spine and central skeleton.

In ankylosing spondylitis, the joints in your spine become inflamed and worn down. As your body tries to repair the damage, it starts to produce new bone. If the disease progresses, this can eventually cause the bones of your spine to join together. Usually, ankylosing spondylitis affects your lower back and pelvis. But it can affect other joints too. These include your hips and shoulders, and the wall of your chest.

Ankylosing spondylitis is a chronic (long-term) disease – it can affect you over many years. The symptoms can come and go, and you may have periods of feeling well. For a lot of people, the symptoms stay mild and don’t cause any significant problems.

Causes of ankylosing spondylitis

It’s not clear exactly what causes some people to develop ankylosing spondylitis. But it’s known that there is a strong genetic link.

Ankylosing spondylitis often runs in families. If you have a gene called HLA-B27, you’re more likely to develop the condition. This is especially so if you also have a close relative with ankylosing spondylitis. Not everyone who has this gene develops ankylosing spondylitis though. There are other genes and environmental factors that may be involved.

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Symptoms of ankylosing spondylitis

The symptoms of ankylosing spondylitis tend to develop slowly over several years. Your symptoms may be very mild at first, but they might slowly get more noticeable over time. You may also have times when your symptoms temporarily get worse (flare-ups), followed by periods when you feel better again (remission).

The main symptoms of ankylosing spondylitis are pain and stiffness in your lower back.

  • The pain is usually worse in the second half of the night or first thing in the morning. It can sometimes be bad enough to wake you up. And the pain usually gets better when you start to move around.
  • You might feel pain in your bottom and back of your thighs too.

 

Ankylosing spondylitis can also cause symptoms in other parts of your body, which may include the following.

  • Pain in other joints such as your neck, shoulders, chest and hips. This can be worse if you haven’t been active.
  • Pain in areas of the body where tendons attach to a bone – for example, your elbows, knees and heels. This is called enthesitis.
  • Inflammation of your eye. Your eye may be red and painful, and you might become sensitive to bright lights. If you develop this, seek medical help straight away to prevent permanent damage.
  • Feeling weak and exhausted (fatigued).

 

If you have bad back pain that gets worse or doesn’t get any better over time (over three months), see your GP.

Diagnosis of ankylosing spondylitis

Your GP will ask about your symptoms and medical history and will examine you. They may ask you to do certain movements to check your range of movement. And they may feel your back for any tenderness in the joints. Your GP may refer you to a rheumatologist (a doctor who specialises in diagnosing and treating conditions that affect your joints and surrounding tissues).

You may have several tests to help diagnose ankylosing spondylitis, including:

  • blood tests for proteins that can be a sign of inflammation in your body
  • a blood test for the gene HLA-B27
  • an X-ray of the bones and joints in your back
  • an MRI scan of your back – this may show up changes at an earlier stage in the disease than an X-ray

Treatment of ankylosing spondylitis

Ankylosing spondylitis is a long-term condition for which there isn’t a cure. But there’s a lot you can do to help manage your condition. And ankylosing spondylitis treatments are available to ease any symptoms you have. This should reduce the impact the disease has on your everyday life. One thing you can do to help yourself is to stop smoking (if you smoke). This may help to prevent your condition getting worse.

Physiotherapy and exercise

Physiotherapy is an important part of treatment for ankylosing spondylitis. Your doctor will refer you to a physiotherapist or you may be able to refer yourself.

A physiotherapist will put together an exercise programme for you. This will be designed to help you to stay as flexible and mobile as possible. It may include:

  • exercises to help stretch and strengthen your back
  • exercises to help maintain a good posture
  • deep breathing exercises, to help expand your chest muscles
  • exercises that extend your spine
  • exercises that work the different sections of your spine and help to improve your range of movement in each area
  • aerobic exercise (exercises that increase your heart rate and get you out of breath)
  • hydrotherapy – exercises in a heated pool – this may help to manage your pain and improve how much you can move

 

Medicines

Painkillers and anti-inflammatory medicines

Your doctor will usually offer you treatment with non-steroidal anti-inflammatory drugs (NSAIDs) first. These are to help reduce pain and stiffness in your joints. If you take them regularly, these medicines may help to slow down any worsening of your condition. If your medicine doesn’t help within a few weeks, your doctor may adjust your dose or try a different medicine.

If you take NSAIDs, your doctor may suggest you take a medicine called a proton pump inhibitor as well. This will protect your stomach and reduce the risk of side-effects from NSAIDs. If you can’t take NSAIDs for some reason or they’re not helping, your doctor may suggest a different painkiller. This might be paracetamol or codeine.

If you have a very painful and swollen joint, your doctor may suggest a steroid injection into it.

Disease-modifying anti-rheumatic drugs

Your rheumatologist may recommend you take a type of medicine called a disease-modifying anti-rheumatic drug (DMARD).

There are different types of DMARD, including a group of medicines known as tumour necrosis factor (TNF) blockers, or biological DMARDs. Examples of these medicines are:

  • etanercept
  • adalimumab
  • golimumab
  • certolizumab pegol
  • secukinumab
  • ixekizumab
  • upadacitinib

 

These medicines target your immune system to reduce inflammation. Your rheumatologist may recommend you take them if your symptoms are severe and other treatments haven’t controlled them. You can have these medicines as an injection, which you can learn to do yourself. Your rheumatologist will monitor your response to these medicines closely and only continue your treatment if it’s clearly working.

Older types of DMARD include methotrexate and sulfasalazine. Your rheumatologist may suggest you try these if your symptoms have spread to your arms or your legs (peripheral disease). They don’t seem to help with pain and stiffness in your spine.

Surgery

Most people with ankylosing spondylitis don’t need surgery. But if one of your joints such as your hip or shoulder is severely affected, your doctor may suggest you have it replaced. If you have a fused and bent spine that really affects your quality of life, you may have an operation to correct it.

Complications of ankylosing spondylitis

If you’ve had severe disease for a long time, your risk of developing complications is higher. These may include the following.

  • Spinal fractures. You’re at greater risk if the bones in your spine have joined together (fused).
  • Osteoporosis. This is when your bones become weak and brittle, which can make them more likely to break. Up to a third of people with ankylosing spondylitis are thought to develop osteoporosis.
  • Heart problems. People with ankylosing spondylitis seem to be at greater risk of developing problems with their heart and circulation.
  • Breathing problems. People with ankylosing spondylitis seem to be at greater risk of developing problems with their breathing.

Living with ankylosing spondylitis

Ankylosing spondylitis affects people in different ways. Most people will have very mild symptoms that cause few problems. But some people go on to have significant disability.

When you’re first diagnosed, your doctor should talk you through how to deal with any flare-ups. This might include who you can contact if you need help (for example, a rheumatology nurse). They may also show you some stretches and exercises you can do. And they will also give you information on how to manage your pain and fatigue.

If you’re having difficulties with everyday activities, your doctor may refer you to an occupational therapist for advice. They can advise you on any changes you can make or devices you can use to make life easier. You might need to make changes at work, especially if you have a physically demanding job.

Most people with ankylosing spondylitis don’t have any problems driving. But if you’re finding it difficult, make sure you take regular breaks to stretch and move around. You may have problems turning your head when you reverse your car. If you do, wide rear-view mirrors and parking sensors may help. If you make any adaptations to your car, you’ll need to tell the Driver & Vehicle Licensing Agency (DVLA).

Keeping active is one of the most important things you can do if you have ankylosing spondylitis. Exercise can help to ease stiffness and pain. At the same time, it improves your strength, flexibility and range of movement. A physiotherapist can help you to develop a daily routine of exercises. For more information, see our section: Treatment of ankylosing spondylitis. You may also find exercises such as T’ai-chi, yoga and Pilates useful. These help with posture, flexibility and core strength. Swimming is a great exercise for ankylosing spondylitis. It works all your joints and muscles, without putting pressure on them. If you need advice about what types of exercise to do, talk to your doctor or physiotherapist.

Frequently asked questions



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Related information

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    Discover other helpful health information websites.

    • Ankylosing spondylitis. BMJ Best Practice. bestpractice.bmj.com, last reviewed 19 April 2021
    • Ankylosing spondylitis. NICE Clinical Knowledge Summaries. cks.nice.org.uk, last revised May 2019
    • Ankylosing spondylitis. MSD Manuals. msdmanuals.com, last full review/revision May 2020
    • Ankylosing spondylitis and undifferentiated spondyloarthropathy. Medscape. emedicine.medscape.com, updated 2 February 2021
    • Ankylosing spondylitis. Versus Arthritis. versusarthritis.org, accessed 19 May 2021
    • Spondyloarthritis. NICE British National Formulary. bnf.nice.org.uk, last updated 29 April 2021
    • Spondyloarthritis in over 16s: diagnosis and management. National Institute for Health and Care Excellence (NICE), updated 02 June 2017. www.nice.org.uk
    • Ixekizumab. NICE British National Formulary. bnf.nice.org.uk, last updated 29 April 2021
    • Upadacitinib. NICE British National Formulary. bnf.nice.org.uk, last updated 29 April 2021
    • Zhu W, He X, Cheng K, et al. Ankylosing spondylitis: etiology, pathogenesis, and treatments. Bone Res 2019; 7(22). doi: https://doi.org/10.1038/s41413-019-0057-8
  • Reviewed by Rachael Mayfield-Blake, Freelance Health Editor, June 2021
    Expert reviewer, Dr Sundeept Bhalara, Consultant Rheumatologist and Physician
    Next review due June 2024

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