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Diseases » Ankylosing Spondylitis » Wikipedia
 

Ankylosing Spondylitis in Wikipedia

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This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Ankylosing spondylitis". (Source - Retrieved 2006-09-07 14:01:49 from https://en.wikipedia.org/wiki/Ankylosing_spondylitis)

Introduction

Ankylosing spondylitis (AS; also known as Bechterew's disease; Bechterew syndrome; Marie Strümpell disease / Marie Struempell disease) is a chronic, painful, progressive inflammatory arthritis primarily affecting spine and sacroiliac joints, causing eventual fusion of the spine; it is a member of the group of the autoimmune spondyloarthropathies with a probable genetic predisposition. Complete fusion results in a complete rigidity of the spine, a condition known as bamboo spine.

Signs and symptoms

The typical patient is a young man of 15-30 years old with chronic pain and stiffness in the lower part of the spine. Males are affected by ankylosing spondylitis three times more than women. Younger patients may experience knee pain even at very young ages (3 years old), commonly misinterpreted as simple rheumatisms. Recurring mouth ulcers (aphthae) may also be experienced and are part of typical AS symptoms. Fatigue is also a widely spread symptom.

In 40% of cases, ankylosing spondylitis it is associated with iridocyclitis (anterior uveitis) causing eye pain and photophobia (increased sensitivity to light). AS is also associated with ulcerative colitis, psoriasis and Reiter's disease.

Osteopenia or osteoporosis of AP spine, causing eventual compression fractures and a back "hump" if untreated.

Organs affected by AS, other than the axial spine, are the hips, heart, lungs, heels, and other areas (peripheral).

Diagnosis

The diagnosis of AS is done by X-ray studies of the spine, which show characteristic spinal changes and sacroiliitis. A draw back of x-ray diagnosis is that signs and symptoms of AS have usually been established as long as 8-10 years prior to x-ray evident changes occuring on a plain film x-ray, which means a delay of as long as 10 years before adequate therapies can be introduced. An option for more accurate (and much earlier) diagnosis are tomography and magnetic resonance of the sacroiliac joints.

During acute inflammation periods, AS patients will usually show an increased values of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).

Variations of the HLA-B gene increase the risk of developing ankylosing spondylitis. Those with the HLA-B27 variant are at highest risk of developing the disorder. HLA-B27, demonstrated in a blood test, is occasionally used as a diagnostic, but does not distinguish AS from other diseases and is therefore not of real diagnostic value. Over 95% of people with AS are HLA-B27 positive, although this ratio varies from population to population (only 50% of African American patients with AS possess HLA-B27, and it is close to 80% among AS patients from Mediterranean countries).

The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), developed in Bath (UK), is an index designed to detect inflammatory burden of active disease and which can help to establish a diagnosis of AS in the presence of other factors such as HLA-B27 positivity, persistent buttock pain which resolves with exercise, and x-ray or MRI evident involvement of the sacroiliac joints.$[1]$ It can be easily calculated by hand or online tools, and accurately assess a patient's need for additional therapy; a score of 4 out of a possible 10 points while on adequate NSAID therapy is usually considered a good candidate for biologic therapy.

The Bath Ankylosing Spondylitis Functional Index (BASFI) is a functional index which can accurately assess a patient's functional impairment due to disease, as well as improvements following therapy.$[2]$ The BASFI is not usually used as a diagnostic tool, but as a tool to establish a patient's current baseline and subsequent response to therapy.

Unattended cases of AS normally lead to knee pain, and may be accompanied by dactylitis or enthesitis, resulting in a fair assumption of normal rheumatism.

Pathophysiology

AS is a systemic rheumatic disease, and about 90% of the patients are HLA-B27 positive. HLA-DR and IL1ra are also implicated in ankylosing spondylitis. Although specific autoantibodies cannot be detected, its response to immunosuppresive medication has prompted its classification as an autoimmune disease.

Hypotheses on its pathogenesis include a cross-reaction with antigens of the Klebsiella bacterial strain (Tiwana et al. 2001).$[3]$ Particular authorities argue that elimination of the prime nutrients of Klebsiella (starches) would decrease antigenemia and improve the musculoskeletal symptoms. On the other hand, Khan (2002) argues that the evidence for a correlation between Klebsiella and AS is circumstantial so far, and that the efficacy of low-starch diets has not yet been scientifically evaluated.$[4]$ Similarly, Toivanen (1999) found no support for the role of klebsiella in the etiology of primary AS.$[5]$

The Radical Induction Theory of Ulcerative Colitis proposes that ulcerative colitis is initiated by a metabolic aberration that results in accumulation of hydrogen peroxide and related free radicals between the cells of intestinal wall and the epithilial membrane that protects the cells from bacteria in the gut. The immune system then attacks the bacteria in the gut, producing the inflammatory symptoms of that disease. It is plausible that AS could also be initiated by loss of the epithelial membrane and activation of the immune system against bacteria in the gut, but without obvious inflammation in the colon. This could explain why sulfasalazine is effective against AS even though it is poorly absorbed and is believed to mainly act within the intestine.

Epidemiology

The sex ratio is 3:1 for men:women. In the USA, the prevalence is 0.25%, but as it is a chronic condition, the number of new cases (incidence) is fairly low.

History

AS was first recognized as a disease which was different from Rheumatoid Arthritis by Hippocrates as early as the second century AD, however skeletal evidence of the disease (ossification of joints and entheses primarily of the axial skeleton, known as "bamboo spine") were first discovered in an archaeological dig that unearthed the skeletal remains of a 5000 year–old Egyptian mummy with evidence of "bamboo spine".$[6]$

The anatomist and surgeon Realdo Colombo described what could have been the disease in 1559,$[7]$ and the first account of pathologic changes to the skeleton possibly associated with AS was published in 1691 by Bernard Connor.$[8]$ In 1818, Benjamin Brodie became the first physician to document that iritis accompanied what is believed to have been a patient with active AS.$[9]$ In 1858, David Tucker published a small booklet which clearly described a patient by the name of Leonard Trask who suffered from severe spinal deformity subsequent to AS.$[10]$ In 1833 Trask fell from horse exacerbating the condition and resulting in severe deformity. Tucker reported that "it was not until he [Trask] had exercised for some time that he could perform any labor" and that "his neck and back have continued to curve drawing his head downward on his breast", evidence of inflammatory disease characteristics of AS, and the hallmark of deforming injury in AS. This account became the first documented case of AS in the United States.

It was not until the late nineteenth century (1893-1898), however, when physicians Vladimir Bechterew of Russia in 1893,$[11]$ Adolph Strümpel of Germany in 1897,$[12]$ and Pierre Marie of France in 1898,$[13]$ were the first to give adequate descriptions which permitted an accurate diagnosis of AS prior to severe spinal deformity. For this reason, AS is also known as Bechterew Disease or Marie–Strumpell Disease.

Therapy

No cure is known for AS, although treatments and medications are available to reduce symptoms and pain.

Physical therapy and exercise, along with medication, are at the heart of therapy for ankylosing spondylitis. Physiotherapy and physical exercises are clearly preceded by medical treatment in order to reduce the inflammation and pain, and commonly followed by a physician. This way the movements will help in diminish pain and stiffness, while exercises in an active inflammatory state will just make the pain worse.

Medication

There are three major types of medications used to treat ankylosing spondylitis.

TNFα blockers have been shown to be the best promising treatment, slowing the progress of AS in the majority of clinical cases. They have also been shown to be highly effective in treating not only the arthritis of the joints but the spinal arthritis associated with AS. A drawback is the fact that these drugs increase the risk of infections. For this reason, the protocol for any of the TNF-α blockers include a test for tubercolosis (like Mantoux or Heaf) before starting taking any drug. In case of recurrent infections, like even recurrent sore throats, the therapy may be suspended due to the involved immunosuppression.

Surgery

In severe cases of AS, surgery can be an option in the form of joint replacements, particularly in the knees and hips. Surgical correction is also possible for those with severe flexion deformities (severe downward curvature) of the spine, particularly in the neck, although this procedure is considered risky.

Physical therapy

  • Physiotherapy has shown to be of great benefit to AS patients;
  • Swimming is one of the preferred exercises since it involves all muscles and joints in a low gravity environment;
  • Slow movements exercises like stretching, yoga, tai chi;
  • Any physical movement like, jogging, Pilates method, etc.

Alternative medicine

Although the effectiveness of alternative medicines has not been proved by any clinical trial, some patients find some relief in adding these alternative treatments to the medicaments and physical exercises:

Prognosis

AS can range from mild to progressively debilitating, and from medically controlled to refractive.

Famous patients

Well known sufferers of AS include:

  • Ramses II
  • Mötley Crüe guitarist Mick Mars
  • former England cricket captain Mike Atherton
  • former Australian cricketer Michael Slater
  • British comedian Lee Hurst
  • Canadian radio personality Mike Stafford
  • Norwegian Prime Minister Jens Stoltenberg
  • chess player Vladimir Kramnik
  • Former author and "Saturday Review" editor Norman Cousins
  • Scottish former snooker player Chris Small
  • former American Major League baseball player Rico Brogna.
  • Canadian Musician, writer and actor Chris Michaud

See also

  • NASC, the AS patients' federation
  • NIAMS, the National Institute of Arthritis and Musculoskeletal and Skin Diseases

Footnotes

  1. Garrett S, Jenkinson T, Kennedy L, Whitelock H, Gaisford P, Calin A (1994). "A new approach to defining disease status in ankylosing spondylitis: the Bath Ankylosing Spondylitis Disease Activity Index.". J Rheumatol 21 (12): 2286-91. PMID 7699630.
  2. Calin A, Garrett S, Whitelock H, Kennedy L, O'Hea J, Mallorie P, Jenkinson T (1994). "A new approach to defining functional ability in ankylosing spondylitis: the development of the Bath Ankylosing Spondylitis Functional Index.". J Rheumatol 21 (12): 2281-5. PMID 7699629.
  3. Tiwana H, Natt R, Benitez-Brito R, Shah S, Wilson C, Bridger S, Harbord M, Sarner M, Ebringer A (2001). "Correlation between the immune responses to collagens type I, III, IV and V and Klebsiella pneumoniae in patients with Crohn's disease and ankylosing spondylitis.". Rheumatology (Oxford) 40 (1): 15-23. PMID 11157137.
  4. Khan MA. (2002). Ankylosing spondylitis: The facts. Oxford University Press. ISBN 0-19-263282-5.
  5. Toivanen P, Hansen D, Mestre F, Lehtonen L, Vaahtovuo J, Vehma M, Möttönen T, Saario R, Luukkainen R, Nissilä M (1999). "Somatic serogroups, capsular types, and species of fecal Klebsiella in patients with ankylosing spondylitis.". J Clin Microbiol 37 (9): 2808-12. PMID 10449457.
  6. Calin A. (1985). "Ankylosing spondilitis.". Clinics in Rheumatic Diseases 11: 41–60.
  7. Pierre Marie (1995). "Benoist M. - Historical Perspective". Spine 20: 849–852.
  8. Blumberg BS (1958). "?". Arch Rheum 1: 553.
  9. Leden I (1994). "Did Bechterew describe the disease which is named after him? A question raised due to the centennial of his primary report.". Scand J Rheumatol 23 (1): 42-5. PMID 8108667.
  10. Life and sufferings of Leonard Trask (PDF for registered members)). Ankylosing Spondylitis Information Matrix.
  11. Bechterew W. (1893). "Steifigkeit der Wirbelsaule und ihre Verkrummung als besondere Erkrankungsform.". Neurol Centralbl 12: 426–434.
  12. Strumpell A. (1897). "Bemerkung uber die chronische ankylosirende Entzundung der Wirbelsaule und der Huftgelenke.". Dtsch Z Nervenheilkd 11: 338–342.
  13. Marie P. (1898). "Sur la spondylose rhizomelique.". Rev Med 18: 285–315.
  14. Ebringer A, Wilson C (Jan 15 1996). "The use of a low starch diet in the treatment of patients suffering from ankylosing spondylitis.". Clin Rheumatol 15 Suppl 1: 62-66. PMID 8835506.
 

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