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Ankylosing spondylitis - causes, symptoms and treatment
Bechterew's disease is an incurable and difficult to diagnose inflammatory rheumatic disease. The technical term ankylosing spondylitis describes the predominant form of the disease in which the joints of the spine are affected by the inflammation and tend to stiffen. But other joints or organs can also be affected by the highly individualized and progressive inflammatory processes. Various therapy methods enable many sufferers to significantly alleviate the symptoms and have a positive long-term influence on the course of the disease.
A brief overview
In the following, a short summary summarizes the most important facts about the ankylosing spondylitis and offers a quick overview. The further article provides comprehensive information for those affected and interested.
- definition: Ankylosing spondylitis (ankylosing spondylitis) is a chronic inflammatory rheumatic disease that mainly affects the spine and can lead to bony stiffening of the spine in the course of the disease. Inflammation occurs most frequently in the joints of the lumbar and thoracic spine as well as in the area of the sacrum and colon (sacroiliac joints).
- Symptoms: The most common are joint pain in the lower back and mutual buttock pain that radiates up to the thigh. Typical signs include morning stiffness, restricted movement and poor posture, which in the worst case can lead to severe and stiffened curvature of the spine (kyphosis).
- causes: The exact causes have not yet been clarified. It is believed that several factors determine the development of the disease. Malfunctioning of the immune system ultimately seems to be responsible for the inflammatory processes (autoimmune disease). In addition, a certain predisposition to this disease is considered to be inheritable.
- diagnosis: Diagnosis is particularly difficult in the early stage of the disease and with rather mild symptoms. Considering specific criteria, blood tests, X-rays and results of magnetic resonance imaging, many, but not all, cases of illness can be diagnosed today.
- treatment: The basis of a successful treatment is a consistent and regular exercise therapy, in which special exercises are integrated into everyday life. In addition, therapies with heat or cold as well as drug treatment are used. This also includes some controversial treatment methods. Operations are rarely performed. Experience shows that natural healing methods can offer a good alternative to combating pain and inflammation compared to conventional pain relievers.
There are many names for Bechterew's disease. The medical term ankylosing spondylitis (also known as ankylosing spondylitis) is generally described as ankylosing spondylitis. Morbus in Latin means disease, Bechterew refers to the Russian neurologist Vladimir Bechterew, who brought the disease to the attention of the scientific community in the late 19th century.
Ankylosing spondylitis can be translated as "stiffening vertebral inflammation". This describes the chronic inflammatory rheumatic disease, which mainly affects the spine and can lead to bony stiffening of the spine in the course of the disease. Inflammatory processes occur most frequently in the joints of the lumbar and thoracic spine as well as in the area of the connection between the sacrum (Os sacrum) and ilium (Os ilium), the so-called sacroiliac joints (sacroiliitis). However, the disease can also affect other joints, tendons and organs (e.g. the eyes) or occur in association with other diseases.
Bechterew's disease is not a disease of the spine, as is often wrongly assumed, but a malfunction of the immune system (autoimmune disease). It is estimated that almost two percent of the adult population suffer from this disease. Contrary to previous opinions, according to the German Association of Morbus-Bechterew e.V. (DVMB), women and men suffer equally frequently. However, despite the very individual course of the disease, the disease usually has a milder effect on women. The disease usually begins between the ages of 15 and 30, although younger or older people can also become ill.
The first signs of the disease are often unspecific and are therefore often not associated with Bechterew's disease. Very individual characteristics and symptoms as well as the intermittent course of the disease also make it difficult to recognize the special inflammation of the spine.
Back pain, lower back pain and joint pain are most commonly reported. Specialists refer above all to mutual buttocks pain radiating to the thighs, together with a restricted movement in the lumbar spine, as a possible first sign. Contrary to many other back ailments, the symptoms typically worsen at rest.
Other criteria primarily relate to the temporal occurrence and duration of the pain. This is particularly noticeable at night and especially in the morning after waking up there is a joint stiffness (morning stiffness) that can last for over 30 minutes. In contrast to osteoarthritis, the symptoms improve with movement. The buttocks pain comes from the sacroiliac joints, which are often the first to be affected.
In addition to the typical complaints that originate from the spine, pain can also occur in other parts of the body. This often leads to complaints (pain, swelling, restricted movement) in the area of the sternum or in the hip, knee and ankle joints. Most of the time, this pain only occurs on one side, since it is usually an asymmetrical inflammatory process of individual joints. Heel pain or inflammation of the tendon (enthesitis), which makes standing on a hard surface uncomfortable, often also indicate ankylosing spondylitis.
About 40 percent of all sufferers have one or more inflammations of the iris (iritis) in the eye. Eye pain, reddening of the eyes and sensitivity to pressure occur in the eye. In addition, other eye infections (for example uveitis and iridocyclitis) can occur.
The inflammatory, painful flare-ups and progressive stiffening of the spine often lead to postural problems. If there are strong ossifications on the spine, one speaks of a “bamboo rod spine” and there is typically a pronounced rounded back with a stiff forward stance (kyphosis). This in turn is associated with severe movement restrictions as well as back and lower back pain. A stiffened spine is also prone to bone porosity (osteoporosis) and thus to vertebral fractures. According to the DVMB, seven percent of those affected have broken bones.
Especially in the late stage of the disease, internal organs can also be affected by the disease, such as the lungs, heart, kidneys and nervous system.
The entire course of the disease and the prognoses are very different. So the disease can be very aggressive and go hand in hand with severe symptoms or show a rather mild course. Which primary symptoms are expressed in which body regions is very individual. The personal medical history decides whether and to what extent those affected are subject to physical restrictions.
Bechterew's disease can occur in combination with psoriasis or chronic inflammation of the bowel (Crohn's disease or ulcerative colitis). Experts then speak of psoriatic spondylitis or enteropathic spondylitis.
There are also other related diseases from the group of spondyloarthritis. Certain inflammatory rheumatic diseases are summarized here. An example of this is reactive spondyloarthritis (reactive arthritis), an inflammation of the joints that occurs after a bacterial infection. If inflammation of the urethra (urethritis) and conjunctiva (conjunctivitis) occurs in combination, this is referred to as the so-called Reiter syndrome.
If the spine is primarily affected by a disease from the group of spondyloarthritis, this is referred to as axial spondyloarthritis (axial refers to the axis skeleton). It is possible that these manifestations, with the addition of changes to the iliac joints, develop into ankylosing spondylitis. Radiological axial spondyloarthritis is also used as a synonym for Bechterew's disease. Non-radiological axial spondyloarthritis refers to the early stages and mild forms of ankylosing spondylitis, which are usually not shown on the radiograph.
The exact cause of the ankylosing spine inflammation is not yet known. It is believed that this is a malfunction of the immune system, in which the immune system is not directed against invading pathogens as is usually the case, but fights its own body cells (autoimmune disease). Thus Bechterew's disease, like rheumatism, falls under the systemic diseases.
According to all previous knowledge, there appears to be a connection between the disease and the presence of a specific antigen on the white blood cells (leukocytes), the so-called "human leucocyte antigen (HLA-B27)". It is striking that this antigen is detectable in 90 percent of those affected. Even if the characteristic is not pathogenic in itself, one speaks in this context of a certain susceptibility (predisposition) to Bechterew's disease. It is believed that this vulnerability, in combination with other factors (such as certain bacterial infections), is a trigger for the disease. The predisposition to the disease is therefore likely to be inheritable.
Ankylosing spondylitis is particularly difficult to detect in the early stages. It is not uncommon for the first symptoms to exist several years before a reliable diagnosis can be made. If it is a very mild form, the disease can even go undetected permanently. The technical term for these difficult to diagnose forms is non-radiological axial spondyloarthritis. X-rays do not reveal these phenomena. So far, no other methods have been available that sufficiently improve the possibilities of diagnosis.
Experienced experts and rheumatologists are particularly in demand in the early phase of the disease, who can make a reliable diagnosis based on a number of criteria. The basis of the diagnosis is usually the assessment of existing complaints - mostly in the area of the spine and the surrounding body regions. The curvature of the spine and its mobility are also determined. In addition, there is an exact pain diagnosis.
X-rays are taken as the standard examination procedure and magnetic resonance imaging is also being carried out with increasing frequency. The latter depicts certain soft tissue changes due to inflammation. In this way, ankylosing spondylitis can be made visible earlier than with X-rays, which only reveal bony changes that occur later.
A blood test can provide additional evidence of ankylosing spondylitis. As a rule, specific values are determined that provide information about existing inflammations in the body. If the special protein (antigen) HLA-B27 is also detected in the blood on the surface of the leukocytes, this can provide additional evidence of the disease. However, other examination results must also be taken into account, since HLA-B27 may also be present in completely healthy people.
Bechterew's disease is not curable and requires lifelong therapy that ensures that the sufferer has a high quality of life for as long as possible. Various treatment methods as well as good and comprehensive specialist care enable those affected to influence their course of the disease favorably.
The best places to go after diagnosis are rheumatologists or even a specialized rheumatism clinic. A limited time inpatient intensive care can be helpful for some sufferers in order to learn how to deal with the lifelong illness individually and to create an individual therapy concept. Furthermore, regular outpatient medical care and consistent therapeutic measures form the basis for successful treatment.
The most important part of the treatment is physiotherapy. In individual therapy sessions, those affected learn targeted movement exercises to counteract stiffening and the associated pain. The exercises must be carried out consistently (preferably in the morning and in the evening) in order to delay imminent restrictions on movement as long as possible. Offers of special therapy groups can complement individual treatment, such as (water) gymnastics groups geared towards Bechterew's disease.
Heat and cold treatments
In addition to physiotherapy, various forms of cold and heat therapy that promote blood circulation can help to relieve stiffness and pain. In domestic use, this includes, for example, warm baths or heat wraps and hot water bottles. In outpatient or inpatient therapy, fango packs, infrared radiation or thermal and mud baths can have a supporting effect. Cold applications are also often helpful for inflammatory rheumatic complaints and can be useful, especially during severe painful episodes of illness, to enable subsequent active movement therapy.
In drug therapy, mainly cortisone-free non-steroidal anti-inflammatory drugs (NSAR) are used. These anti-inflammatory and pain-relieving medicines cause the symptoms to subside relatively quickly over the period of ingestion. Whether and at what intervals sufferers should take these drugs varies greatly from person to person. Any side effects here are also countered by an effective benefit for the sick.
In an advanced stage of the disease, where ossification, poor posture and possibly osteoporosis play a greater role than previous inflammation, simple pain relievers such as paracetamol are used. Only in an emergency are cortisone-like medications used, which can have many harmful side effects over a long period of use.
Controversial treatment approaches
Some of those affected are offered the much-discussed treatment with the radioactive noble gas radon (radon balneology, radon therapy). In any case, an assessment of the success of the treatment in relation to possible radiation-related side effects must be made together with those affected.
If other parts of the body such as the shoulder, hip or knee are affected (and not the spine), a so-called basic therapy with long-term disease-modifying drugs (sulfasalazine, methotrexate) can be used. But this is also a controversial concept, which is mainly used for rheumatoid arthritis (chronic polyarthritis).
Newer and very expensive treatment options include drugs that counteract inflammation by blocking a particular cytokine as a tumor necrosis factor (TNF-alpha). This signal substance is involved in systemic inflammation and plays an important role in the immune system. A TNF-alpha blockade not only alleviates symptoms, but also increases the risk of infectious diseases.
Last option: surgery
Improved diagnosis and treatment options have had a favorable impact on the course of the disease to the extent that operations are rarely necessary these days and only in particularly severe cases. The surgical interventions include various joint operations, such as the insertion of artificial joints (endoprostheses), and an erection operation in the presence of kyphosis. In some cases, these operations are the only way to restore mobility.
Naturopathy can also help those affected to alleviate the symptoms and deal with the disease well. According to patient experience, different approaches can help to the extent that the use of painkillers is (temporarily) unnecessary.
Alternative medical procedures that are often used in Bechterew's disease are, for example, methods of traditional Chinese medicine (acupuncture or Chinese herbal therapy). Homeopathy and special nutritional programs are also chosen by many affected people.
When it comes to nutrition, the main focus is on a low-meat diet. In addition, the intake of vitamin E and various enzyme preparations plays an important role. Vitamin E provides natural protection for the body against oxidizing oxygen radicals, which are involved in the development of inflammation. Hazelnuts are a perfect source of vitamin E and offer an effective protective function for the body.
Current state of research
In order to further optimize the diagnosis and treatment of ankylosing spondylitis and thus to improve the prognoses for this disease, various studies and research activities are ongoing. The difficult diagnoses at an early stage and with slight manifestations as well as controversial and newer treatment methods are important research topics.
For example, a recent clinical study on Bechterew's disease (2016-2020) is investigating a simple TNF-alpha blocker therapy with a combination therapy with the addition of NSAIDs.
The DVMB regularly announces a research award in the field of ankylosing spondylitis and related diseases. Crucial scientific knowledge in German can be found in the work of the award-winning research organizations.
Further current information can also be found in the Morbus-Bechterew-Journal, which is written regularly and in particular by those affected for those affected. (tf, cs)
For further reading:
Author and source information
This text corresponds to the specifications of the medical literature, medical guidelines and current studies and has been checked by medical doctors.
Dr. rer. nat. Corinna Schultheis
- German Association of Bechterew's Disease - Federal Association: clinical picture and symptoms (accessed: 03.07.2019), bechterew.de
- Deutsche Rheuma-Liga Bundesverband e.V .: leaflet Morbus Bechterew (accessed: 03.07.2019), rheuma-liga.de
- German Society for Rheumatology (DGRh: S3 guideline for axial spondyloarthritis including ankylosing spondylitis and early forms, as of November 2013, detailed view of guidelines
- German Society for Orthopedics and Orthopedic Surgery (DGOOC): S2K guideline for specific low back pain, as of December 2017, detailed view of guidelines
- Merck and Co., Inc .: Bechterew's disease (accessed: July 3, 2019), msdmanuals.com
- Swiss Association of ankylosing spondylitis: what is ankylosing spondylitis? (Call: 03.07.2019), bechterew.ch
- Spondylitis Association of America: Overview of Ankylosing Spondylitis (accessed: July 3, 2019), spondylitis.org
- Mayo Clinic: Ankylosing spondylitis (access: 03.07.2019), mayoclinic.org
ICD codes for this disease: M45ICD codes are internationally valid encodings for medical diagnoses. You can find e.g. in doctor's letters or on disability certificates.