Ankylosing Spondylitis: Causes, Symptoms, Treatment

Brief overview

  • Definition: Bekhterev’s disease is a form of inflammatory rheumatic disease that particularly affects bones and joints.
  • Causes: not yet clear, genetic reasons and a malfunction of the immune system are suspected.
  • Symptoms: mainly deep-seated back pain, nocturnal pain, morning stiffness.
  • Diagnosis: doctor-patient discussion (anamnesis), clinical tests to check mobility, blood test and imaging procedures if necessary.
  • Treatment: Exercise, medication, physiotherapy, possibly surgical intervention.
  • Prognosis: Bekhterev’s disease is not curable, but can be treated well; in this way, its course can be positively influenced.

What is ankylosing spondylitis?

In addition, the inflammations can cause bone appendages to form in the form of fibrocartilage, which replaces the joint edges. This can, but does not always have to, cause the many small joints and ligaments of the spine and pelvis to ossify. Pain and limited mobility are thus common signs of ankylosing spondylitis. In the final stage, the spine can stiffen completely into bones.

In Central Europe, ankylosing spondylitis occurs in about 0.5 percent of the adult population, mostly between the ages of 20 and 40. In Germany, about 350,000 people are affected to a greater or lesser degree by the disease, including three times as many men as women.

Bekhterev’s disease during pregnancy

Differentiation from Forrestier’s disease

Bechterew’s disease should not be confused with the less dramatic Forrestier’s disease (spondylitis hyperostotica). The symptoms of this disease include increasing stiffness and pain. However, this is certainly only a pure ossification of the spine, which occurs without inflammatory reactions. The consequences are usually much more harmless.

Bechterew’s disease: symptoms

Bekhterev’s disease is a chronic disease and often occurs in relapses. This means that patients experience periods of severe discomfort (relapses) and periods when they feel better. Over time, ankylosing spondylitis can progress from relapse to relapse, causing the spine to become stiffer and deformed.

The type and severity of the symptoms of Bekhterev’s disease depend on the stage of the disease in each individual case. On the other hand, there are also individual differences from patient to patient.

Common early signs also include:

  • occasional hip, knee and shoulder pain
  • pain at the heel
  • tennis elbow (tendon irritation at the elbow joint) or other tendon disorders
  • Fatigue
  • Weight loss
  • pain when coughing or sneezing

After months to years, ankylosing spondylitis can change posture and movement in typical ways: While the lower spine (lumbar spine) usually flattens, the thoracic spine increasingly curves. This often results in the formation of a hump. To compensate, the neck stretches and the hip and knee joints bend. The formation of a hump in the spine can restrict the field of vision when looking straight ahead. In addition, large joints (hip, knee, shoulder, elbow) can sometimes only be moved to a limited extent.

More rarely, ankylosing spondylitis leads to cardiovascular disease or inflammation of the large arteries (aortitis). Joint inflammation (arthritis) of entire fingers or toes or inflammation of the tendon insertion (enthesitis) are also possible. The latter develops particularly often at the base of the Achilles tendon.

Many patients also show reduced bone density (osteopenia) and even bone loss (osteoporosis).

Some patients also develop symptoms in the intestines with ankylosing spondylitis. A connection with chronic inflammatory bowel diseases (including Crohn’s disease or ulcerative colitis) is suspected. Painful intestinal cramps and diarrhea can then join the symptoms of Bekhterev’s disease.

It is also suspected that ankylosing spondylitis may be related to urinary tract disorders.

Ankylosing spondylitis: Causes

In Bekhterev’s disease patients, however, this protein seems to be less successful against some pathogens. Therefore, the immune system has to react more strongly in order to effectively fight against these invaders. This probably leads to chronic inflammation of the vertebrae and pelvic bones.

However, the hereditary predisposition alone is not sufficient for an outbreak of the disease: According to current scientific knowledge, an infection must also occur to trigger ankylosing spondylitis.

For example, the disease can result from what is known as reactive arthritis. This is an inflammation of the joints that occurs as a reaction to an infection in another region of the body (respiratory tract, urinary tract, etc.). Whether factors such as physical stress, cold and wet weather or psychological influences promote the outbreak or only aggravate the symptoms subsequently has not been conclusively clarified. One thing is certain, however: ankylosing spondylitis is not contagious.

The most important source of information for the doctor when clarifying a possible ankylosing spondylitis is you yourself as the patient. The doctor will talk to you in detail to obtain your medical history (anamnesis). Above all, he will ask you to describe your symptoms in detail.

The doctor may also ask you to fill out special questionnaires (Bath indices). They are used as a subjective measure to assess the severity of the disease and physical functioning.

Typical questions that are important for the diagnosis of ankylosing spondylitis include:

  • Has the low back pain lasted for a long time (more than three months)?
  • Did the symptoms first appear before the age of 45?
  • Does the morning stiffness last longer than 30 minutes?
  • Does low back pain improve with exercise but not with rest?
  • Do you often wake up in the second half of the night because of your low back pain?
  • Did the complaints start insidiously?
  • Do you have vision problems, heart and/or kidney problems?

Next, if ankylosing spondylitis is suspected, the doctor can use some clinical tests to determine how mobile you are in your spine and if there is pain in the sacroiliac joints. Examples:

  • In the Mennel test, you lie down in a prone position. The doctor fixes your sacrum with one hand and lifts one of your outstretched legs backward with the other. If there is no inflammation in the sacroiliac joints, this movement is painless. Otherwise, you will feel a sharp pain in the sacroiliac joint.
  • The Schober and Ott signs can be used to assess the mobility of the lumbar and thoracic spine and joints. For these tests, you bend forward while standing and try to bring your fingertips as close to your toes as possible. The doctor measures how far the bending is possible by means of previously applied skin tags.

The imaging methods X-ray and magnetic resonance imaging (MRI, also known as magnetic resonance imaging) can be used to detect the destruction and formation of new bone tissue and the condition of the joints. MRI is the gold standard for detecting ankylosing spondylitis. Diagnosis is possible using magnetic resonance imaging even at an early stage of the disease – MRI images can also reveal inflammatory changes in the sacroiliac joints that are not yet visible on X-ray images.

Ankylosing spondylitis: Treatment

Ankylosing spondylitis therapy consists of alleviating the symptoms and slowing down the progression of the disease – the disease cannot yet be cured. In principle, there are various treatment options for ankylosing spondylitis, which are also combined with each other:

  • drug therapy
  • Surgical therapy
  • Healthy lifestyle
  • other therapy measures (physiotherapy, etc.)

Drug therapy

It is based on the patient’s symptoms and is primarily aimed at reducing inflammation, pain and stiffness in ankylosing spondylitis, as well as maintaining the patient’s mobility. For this purpose, anti-inflammatory and pain-relieving drugs from the group of non-steroidal anti-inflammatory drugs (NSAIDs) are usually used, for example ibuprofen.

Since these drugs attack the stomach lining, a stomach-protecting drug (e.g., omeprazole, pantoprazole) should also be taken.

In the event of an acute episode of Bekhterev’s disease or particularly severe joint pain, the doctor may inject a glucocorticoid (cortisone) into the corresponding region. The anti-inflammatory agent usually works quickly. However, it is not yet known whether and to what extent such cortisone injections influence the course of the disease.

In addition to these anti-inflammatory drugs, so-called TNF alpha blockers are sometimes used. These suppress the immune system. They are used in patients whose ankylosing spondylitis is severe and whose symptoms cannot be controlled in any other way.

By dampening the immune system, such drugs can make patients more susceptible to infections: Pathogens can spread through the body more easily and quickly.

Surgical therapy

Surgery may be necessary for ankylosing spondylitis, for example, if the chronic inflammation has severely damaged or destroyed a joint (such as the hip joint). Then it may be possible to replace it with a prosthesis.

If your patient’s cervical spine is very unstable as a result of the disease, the vertebrae may be surgically stiffened (cervical fusion). In addition, a surgeon can remove bone wedges to straighten a spine that is becoming increasingly curved (wedge osteotomy).

Exercise

Exercise can have a positive influence on the course of the disease. It is perhaps even the most important building block in ankylosing spondylitis treatment. Physical activities in everyday life such as walking, regular gymnastics, cycling, swimming, Nordic walking and other sports maintain your mobility. In addition, exercises that strengthen the muscles are important for Bekhterev’s disease – for example, the trunk muscles, which helps straighten the spine.

Nutrition

The right diet – together with regular exercise – is also important for a healthy body weight. Being overweight is particularly inadvisable in ankylosing spondylitis: with too many fat deposits, it is more difficult to maintain an upright posture and get enough exercise.

Talk to your doctor about structured training programs, where you can receive advice and support on exercise and healthy eating, among other things.

Avoid nicotine

Smoking is generally bad for your health, but even more so in ankylosing spondylitis: nicotine consumption can accelerate bone changes. For this reason, you should never smoke if you have Bekhterev’s disease!

Other therapeutic measures

In everyday life, you should avoid activities that require you to bend far forward. It is ideal if you (have to) stand up regularly. When working at a desk or driving a car, a wedge-shaped seat cushion can be helpful: it prevents the pelvis from tilting backwards. This way, you automatically sit up straighter.

Make sure your bed mattress is firm and does not sag. The pillow should be as flat as possible and keep your head straight. A trough pillow can prevent the head from tipping into the neck.

Bechterew’s disease: course and prognosis

Ankylosing spondylitis is a disease that progresses over a long period of time (chronically) and occurs in episodes. This means that the symptoms (pain and stiffness) suddenly become more severe within a few weeks. After that, there is usually a slight recovery to an almost symptom-free interval. This can last for varying lengths of time before the next disease flare-up occurs.

As an ankylosing spondylitis patient, you should go for regular check-ups. The doctor checks the mobility of the spine, the pelvis and the large joints in the arms and legs. In ankylosing spondylitis, the eyes (vision) and heart function should also be checked regularly.

Bekhterev’s disease: Tips

Severe disability certificate

Depending on how severely you are affected by ankylosing spondylitis and how restricted you are in your daily life, your disease can be classified as a disability or even severe disability. The basis for the classification is the Versorgungsmedizinverordnung (Versorgungsmedizinverordnung, which can be found at https://www.gesetze-im-internet.de/versmedv/BJNR241200008.html).

If, in the case of a debilitating disease such as Bekhterev’s disease, the degree of disability (GdB) is at least 50, you have a severe disability. The person concerned then receives a severely disabled person’s card.

Workplace

As a chronically ill patient with ankylosing spondylitis, your risk of becoming unable to work is increased. However, it is sometimes possible to adapt your own work environment to your individual needs together with your employer. This includes, for example, adjustments regarding seating furniture and working height, and possibly the purchase of a sit-stand work table.

You may also be able to arrange with your employer to start work later if you suffer a lot from morning stiffness. In addition, you should not lift heavy loads and avoid working in a forward-bending posture.

The Social Code requires support from the employer in line with your needs.

If such workplace adaptations are not possible or if your work is unsuitable for your condition, you can contact the company doctor or the Integration Office.

Bekhterev’s disease & COVID-19

The Robert Koch Institute has generally classified patients with ankylosing spondylitis and other forms of inflammatory rheumatism (such as rheumatoid arthritis) as being at risk for COVID-19. This is because some drugs used to treat inflammatory rheumatism suppress the immune system. However, it is actually still unclear whether this also increases the risk of contracting the new infectious disease COVID-19 more severely. For this reason, researchers are currently compiling international registers of cases of rheumatism patients with COVID-19 and observing and comparing the courses of the disease. Such a registry is also being maintained in Germany (initial data at: https://www.covid19-rheuma.de).

The above findings are only of a preliminary nature. Further research and studies are needed to better assess the risk.

Caution. The German Society for Rheumatology expressly warns against the unauthorized discontinuation of rheumatism therapy!