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Ankylosing spondylitis


Expert reviewer, Dr Sundeept Bhalara, Consultant Rheumatologist and General Physician
Next review due March 2022

Ankylosing spondylitis (pronounced an-kih-loh-sing spon-dih-lye-tis) is a type of arthritis that 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 late teens or early twenties. Men are almost three times more likely to have it than women.

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About ankylosing spondylitis

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

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. In some people, if the disease progresses, this can eventually cause the bones of the spine to join together. Usually, it’s your lower back and pelvis that are affected. But ankylosing spondylitis can affect other joints too, including your hips and shoulders, and the wall of your chest.

Ankylosing spondylitis belongs to a group of conditions called spondyloarthritis. You may sometimes hear ankylosing spondylitis referred to as ‘axial spondyloarthritis’, which means it affects your spine and central skeleton. Other types of spondyloarthritis affect your peripheral joints such as your knees and wrists.

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.
  • The pain usually gets better when you move around.
  • You might feel pain in your buttocks and base of your thighs too.

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

  • Pain in other joints such as your neck, shoulders, chest and hips. This can be worse when you’ve been inactive.
  • Pain in areas of the body where tendons attach to a bone. This is called enthesitis and includes your elbows, knees and heels.
  • 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 back pain that’s severe, getting worse or isn’t improving over time, see your GP.

Diagnosis of ankylosing spondylitis

Your GP will ask about your symptoms and medical history. They will also want to do a physical examination. This may involve asking you to do certain movements to check your range of movement, and feeling your back for any tenderness in the joints. If your GP thinks your back pain could be due to ankylosing spondylitis, they will refer you to a rheumatologist to confirm the diagnosis. A rheumatologist is 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 the following.

  • Blood tests for proteins that can be a sign of inflammation in your body.
  • Another blood test for the gene HLA-B27, which many people with ankylosing spondylitis have.
  • 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 – it isn’t something that can be cured. But there’s a lot you can do to help manage your condition, and treatments are available to ease any symptoms you have. This should reduce the impact the disease has on your everyday life.

Physiotherapy and exercise

Physiotherapy is a really important part of treatment for ankylosing spondylitis. When you’re diagnosed with ankylosing spondylitis, your doctor is likely to suggest you see a physiotherapist, who can put together an exercise programme tailored to you. The programme of exercises will be designed to help you to stay as flexible and mobile as possible. It may include some of the following.

  • 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 – doing special 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

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

If you take NSAIDs regularly, 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 any reason or they’re not helping enough, your doctor may suggest a different painkiller such as paracetamol or codeine.

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

Disease-modifying anti-rheumatic drugs

Your doctor may sometimes recommend treatment with a type of drug called a disease-modifying anti-rheumatic drug (DMARD). There are different types of DMARD. Newer DMARDs include a group of medicines known as tumour necrosis factor (TNF) blockers, or biological DMARDs. They include the medicines etanercept, adalimumab and golimumab, certolizumab pegol and secukinumab. These drugs target your immune system to reduce inflammation. Your doctor may recommend them if your symptoms are severe and haven’t been controlled by other treatments. These drugs are given as injections under your skin, which you can learn to do yourself. Your doctor will monitor your response to these drugs closely and only continue with treatment if it’s having a clear benefit.

Older, standard DMARDs include methotrexate and sulfasalazine. Your doctor may suggest trying these medicines 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 having it replaced. A small number of people with a fused and bent spine that’s severely affecting their quality of life may have an operation to correct it.

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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.

The condition often runs in families. Having a gene called HLA-B27 makes you more likely to develop the condition, especially if you also have a close relative with ankylosing spondylitis. Not everyone who has this gene develops ankylosing spondylitis though. There are other genes involved, and environmental factors too, which seem to trigger the disease in certain people.

Complications of ankylosing spondylitis

If you’ve had severe disease for a long time, you may be at greater risk of developing complications. These may include the following.

  • Spinal fractures – you’re at greater risk of this 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 three in 10 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.

Most people with ankylosing spondylitis don’t develop severe disability or any other complications.

Living with ankylosing spondylitis

Ankylosing spondylitis affects people in different ways. Most people will have very mild symptoms that cause few problems, whereas some people may 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). Dealing with flare-ups also includes stretches and exercises you can do, and information on how to manage your pain and fatigue.

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

It’s important to keep as active as possible to maintain your function and mobility. A physiotherapist can put together a programme of activities suitable for you (see our Treatment section for more information). You can also read our FAQ about what type of exercise you can do.

Frequently asked questions

  • 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, while improving your strength, flexibility and range of movement.

    A physiotherapist with specific experience of ankylosing spondylitis can help you to develop a daily routine of exercises, suitable for you. Your doctor should be able to refer you to a physiotherapist or, in some areas, you may be able to refer yourself. See our Treatment section for more information.

    It's also important to find activities that you enjoy and can keep doing over the long term. Some people with ankylosing spondylitis find T’ai-chi, yoga and Pilates useful because these regimes help with posture, flexibility and core strength. Swimming is a great exercise for ankylosing spondylitis, as it works all your joints and muscles, without putting pressure on them. Water or aqua aerobics can also be beneficial.

    It's best not to take part in contact sports such as rugby, basketball and hockey. This is because you’re more likely to be injured doing this type of activity.

    If you need advice about what types of exercise to do, talk to your doctor or physiotherapist.

  • Most people with ankylosing spondylitis don’t have any problems driving. But if you’re finding driving is becoming difficult, these tips may help.

    • During long journeys, stop regularly and get out of the car to stretch and move around.
    • If you have problems turning your head when you reverse your car, wide rear-view mirrors and parking sensors may help. If you have any adaptations to your car, you’ll need to tell the Driver & Vehicle Licensing Agency (DVLA).
    • Adjust your seat and neck rest so that they are comfortable and supportive.

    You’ll only need to inform the DVLA about your condition if it’s starting to affect your ability to drive safely. Ask your doctor if you’re not sure.


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Related information


    • Ankylosing spondylitis. BMJ Best Practice. bestpractice.bmj.com, last reviewed January 2019
    • Ankylosing spondylitis (AS). Versus Arthritis. www.versusarthritis.org, accessed 12 February 2019
    • Ankylosing spondylitis. PatientPlus. patient.info/patientplus, last edited 12 February 2015
    • What is axial SpA (AS)? National Ankylosing Spondylitis Society. nass.co.uk, accessed 12 February 2019
    • Ankylosing spondylitis and undifferentiated spondyloarthropathy. Medscape. emedicine.medscape.com, updated 17 July 2018
    • Spondyloarthritis. NICE British National Formulary. bnf.nice.org.uk, last updated 18 December 2018
    • Spondyloarthritis in over 16s: diagnosis and management. National Institute for Health and Care Excellence (NICE), February 2017. www.nice.org.uk
    • Back pain. Versus Arthritis. www.versusarthritis.org, accessed 12 February 2019
    • Musculoskeletal problems. Oxford handbook of general practice. Oxford Medicine Online. oxfordmedicine.com, published April 2014
    • Ankylosing spondylitis and driving. Driver and Vehicle Licensing Agency (DVLA). www.gov.uk, accessed 13 February 2019
    • Exercise. National Ankylosing Spondylitis Society. nass.co.uk, accessed 13 February 2019

  • Reviewed by Pippa Coulter, Freelance Health Editor, March 2019
    Expert reviewer, Dr Sundeept Bhalara, Consultant Rheumatologist and General Physician
    Next review due March 2022



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