ankylosing spondylitis

Quick Overview

• Definition: M. Bechterew is a form of inflammatory rheumatism that affects especially bones and joints.

• Causes: not yet clarified, genetic causes and a malfunction of the immune system are suspected.

• symptoms: mainly deep-seated back pain, nocturnal pain, morning stiffness.

• Diagnosis: Doctor-patient interview (history), clinical tests to check the mobility, if necessary blood test and imaging.

• Treatment: Exercise, medications, physiotherapy, possibly surgery.

• Forecast: Ankylosing spondylitis is not curable, but treatable; this way the course can be positively influenced.

Ankylosing Spondylitis: description and causes

Ankylosing spondylitis (M. Bechterew) belongs to the group of so-called spondyloarthritides, These are diseases of the axial skeleton (skull, spine and thorax). Ankylosing spondylitis particularly affects the spine and its connection to the pelvis, where inflammation forms. These can destroy bone tissue. In addition, the inflammations can cause bone appendages to form in the form of fibrocartilages replacing the articular margins. This may, but not always, lead to ossification of the many small joints and ligaments of the spine and pelvis. This is painful for those affected and drastically restricts their mobility.

Bechterew’s disease occurs in Central Europe in about 0.5 percent of the adult population, usually between the ages of 20 and 40 years. In Germany, about 350,000 people are more or less affected by the disease, including three times as many men as women.

The exact cause of Bekhterev’s disease is unknown. Presumably, it is a malfunction of the immune system. Since sometimes several members of a family get it, experts assume that there is a genetic predisposition to ankylosing spondylitis: About 90 percent of all patients have a special protein called HLA-B27, It sits on the surface of certain cells of the immune system and is supposed to recognize and repel pathogens or foreign substances.

In the case of ankylosing spondylitis patients, this protein seems to be less successful in some pathogens. Therefore, the immune system has to react more strongly in order to be effective against these invaders. It then comes to a chronic inflammation of the vertebrae and pelvic bones.

According to the current state of science, one must Infection coincide with a hereditary predispositionto cause Bekhterev’s disease.

The disease can be from a so-called reactive arthritis emerge. This is a joint inflammation that develops in response to an infection in another body region (respiratory tract, urinary tract, etc.). Whether factors such as physical stress, cold and wet or emotional influences favor the outbreak or only aggravate the symptoms subsequently, is not conclusively clarified. However, one thing is certain: Bechteres disease is not contagious.

Ankylosing Spondylitis: Symptoms

Ankylosing spondylitis is a chronic disease and often occurs in spurts. This means that patients experience phases (relapses) with severe discomfort and those in which they feel better. Over time, the disease can progress, causing the spine to stiffen and become deformed.

The type and severity of ankylosing spondylitis symptoms depend on the individual case on the stage of the disease. On the other hand, there are also individual differences from patient to patient.

Among the main symptoms of M. Bechterew count deep-seated backache, morning stiffness and nocturnal painthat last for at least three months. Many patients report pain in the second half of the night, which becomes more bearable when they walk around or do gymnastics. Starting from the sacral iliac joints of the pelvis (sacroiliac joints), the pain radiates into the buttocks and into both thighs. The buttocks pain changes between left and right.

Common early signs are also:

• occasional hip, knee and shoulder pain
• Pain on the heel
• Tennis elbow (tendon irritation at the elbow joint) or other tendon diseases
• fatigue
• weight loss
• Pain when coughing or sneezing

After months to years, the Bechterew’s disease can turn into Change posture and movementTypically, while the lower spine (lumbar spine) usually flattens, the thoracic spine increasingly curves. This is how one often forms humpback, To balance, the neck stretches, and the hip and knee joints bend. Due to the humpback of the spine, the field of vision when looking straight ahead can be limited. In addition, large joints (hips, knees, shoulders, elbows) can sometimes be restricted.

In about 20 percent of patients occur further inflammatory reactions in the body. Often affected are eyes (iris), heart and kidneys. Among other things, this can lead to visual disturbances, cardiac arrhythmias or kidney weakness. Such inflammatory reactions must be clarified: The function of the eyes, heart and kidneys may be at risk.

It is less common in M. Bechterew to cardiovascular disease or inflammation of the large body artery (aortitis). Joint inflammation (arthritis) of the whole fingers or toes or tendinitis (enthesitis) are possible. The latter develops particularly often on the approach of the Achilles tendon.

Many patients also show one reduced bone density (Osteopenia) to the bone loss (Osteoporosis). There is also a suspicion that Bechterew’s disease may be related to gastrointestinal or urinary tract disorders.

Differentiation from Forrestier disease

Ankylosing spondylitis may not be less dramatic Forrestier’s disease (Hyperostotic spondylitis). Although the symptoms of this disease include increasing stiffening and pain. However, this is certainly only a pure ossification of the spine, which develops without inflammatory reactions. The consequences are usually much more harmless.

Ankylosing spondylitis in pregnancy

Ankylosing spondylitis does not cause infertility or increase the risk of miscarriage or premature birth. Fertility is usually unimpaired by the disease.

During pregnancy, Bekhterev’s disease usually poses no risk to either the expectant mother or the unborn child. Pregnant women should take as few medicines as possible. The attending physician will advise each woman individually.

Ankylosing spondylitis: diagnosis and examinations

The most important source of information for the doctor in clarifying a possible ankylosing spondyland disease is the patient himself. The doctor talks extensively to the patient to whom medical history to raise (anamnesis). Above all, he can describe the symptoms occurring exactly. Sometimes he also asks the patient to fill in special questionnaires (Bath indices). They are used as a subjective measure to estimate the severity of the illness and physical functioning. Typical questions that are important for the diagnosis of ankylosing spondylitis, for example:

• Does the backache last longer (more than three months)?
• Did the symptoms occur before the age of 45?
• Does the morning stiffness last longer than 30 minutes?
• Does the back pain improve with movement, but not with rest?
• Do you often wake up in the second half of the night because of your back pain?
• Did the symptoms begin slowly?
• Do you feel reciprocal buttock pain?
• Do you have blurred vision, heart and / or kidney problems?

After that, the doctor with some clinical tests Determine how mobile the patient is in his spine. In addition, he can determine exactly where the pain is.

When so-called Mennel test He puts the patient in prone position and raises his leg backwards. Sitting in the joints no inflammation, this movement is possible joke-free. Otherwise, the patient feels a stabbing pain in the cross-leg joint.

With the Schober and Ott characters The mobility of the lumbar and thoracic spine as well as the joints can be assessed. In these tests, the patient leans forward while standing and tries to bring his fingertips as close to the toes as possible. The doctor uses previously applied skin marks to measure how far the flexion is possible.

There is no specific blood tests for Bechterew’s disease. Often, although in the blood of patients moderately elevated levels of inflammation (such as CRP or erythrocyte sedimentation) can be found. These blood levels can also be increased by many other diseases.

With the imaging method roentgen and MRI (Magnetic Resonance Imaging or Magnetic Resonance Imaging) can also detect the destruction and new formation of bone tissue and the condition of the joints.

Ankylosing spondylitis: treatment

Ankylosing spondylitis is not curable. Today, however, the typical symptoms of Bechterew’s disease are easily treatable – with physiotherapy and medication. If such therapeutic measures are implemented consistently, the quality of life of patients can be maintained relatively well and the course of the disease can be positively influenced.

Basically, there are various treatment options in the case of ankylosing spondylitis, which partly also interlock:

• medical therapy
• operative therapy
• healthy lifestyle
• other therapeutic measures (physiotherapy, etc.)

Medical therapy

It depends on the complaints of the patients. In particular, inflammation, pain and stiffness should be reduced and mobility should be maintained with suitable medications. These are usually anti-inflammatory and analgesic agents from the group of non-steroidal anti-inflammatory drugs (NSAIDs), for example ibuprofen.

Since these drugs attack the gastric mucosa, a stomach-protective drug (eg omeprazole, pantoprazole) should also be taken.

In acute episodes or particularly severe joint pain, the doctor can inject an anti-inflammatory agent in the appropriate region (Glucocorticoid = cortisone), This usually helps fast. However, it is not yet known if and to what extent such cortisone injections influence the course of the disease.

If the arms and legs of ankylosing spondylitis syndrome are also affected and other anti-inflammatory agents are not enough, the doctor may also prescribe a drug that interferes with the metabolism of inflammatory messengers (sulfasalazine).

In addition to these anti-inflammatory drugs are sometimes called so TNF alpha blocker for use. They dampen the immune system. It is used in patients who have severe ankylosing spondylitis and the symptoms are not otherwise controllable.

With the addition of such drugs, pathogens can spread faster in the body, opening the door to potentially dangerous infections.

Operative therapy

For example, surgery may be necessary in ankylosing spondylitis if chronic inflammation has severely damaged or destroyed a joint (such as the hip) and needs to be replaced with a prosthesis. If the cervical spine of a patient is very unstable as a result of the disease, the vertebral bodies can be surgically stiffened (cervical fusion). In addition, a surgeon can remove bone wedges to re-erect an increasingly curving spine (wedge osteotomy).

Healthy lifestyle

Move and proper nutrition can positively affect the course of the disease. Movement may even be the most important component of Bekhterev’s disease. Exercise in everyday life such as walking, regular gymnastics, cycling, swimming, Nordic walking and other sports as well as targeted strengthening exercises maintain the mobility of patients. In addition, they support the erection of the spine.

nicotine consumption On the other hand, the bony changes can progress faster. Therefore, you should not smoke in ankylosing spondylitis.

Generally the plays nutrition a very big role for the health. So you know that the polyunsaturated fatty acid arachidonic acid Promotes inflammation in the joints. This fatty acid is mainly present in (pork) meat. In high-fat cold-water fish, linseed and rapeseed oil, however, is plentiful Omega-3 fatty acid, This also unsaturated fatty acid can inhibit inflammation. Bechterew’s disease is therefore recommended for a low-meat diet rich in fruits, vegetables, fish, vegetable fats and reduced-fat dairy products.

The right nutrition is – along with regular exercise – also important for a healthy body weight. Especially overweight is not advisable: With too many fat pads, it is harder to maintain an upright posture and to move sufficiently.

Talk to your doctor about how your diet should look best. The right diet can effectively support the ankylosing spondylitis treatment.

Other therapeutic measures

Warmth treatments, massages and specific gym exercises are very useful for ankylosing spondylitis: they help maintain posture and flexibility, stretch shortened muscles and strengthen weak ones. Regular physiotherapy can also delay spinal fusion and reduce pain.

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

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

Ankylosing spondylitis: history and prognosis

Bechterew’s disease is a long-term (chronic) disease that occurs in spurts. This means that the symptoms (pain and stiffness) suddenly become stronger within a few weeks. After that, it usually comes to a slight recovery, to an almost symptom-free interval. It can take a different amount of time before the next disease episode arrives.

People with M. Bechterew should go to regular check-ups. The doctor examines the mobility of the spine, the pelvis and the large joints on the arms and legs. Also, vision and heart function (ECG, ultrasound) should be checked regularly.

Ankylosing spondylitis is not curable. All therapeutic approaches can only slow down the progression of the disease and relieve the symptoms. Mortality is not affected by ankylosing spondylitis: The life expectancy of patients is the same as in the population average.

Additional information:

Books:

• Ankylosing spondylitis, inflammatory spinal rheumatism (Paul Schmied and Heinz Baumberger, Urban & Fischer Verlag, 1998)

guidelines:

• Guideline “Axial Spondyloarthritis including Ankylosing Spondylitis and Premature Disease” of the German Society of Rheumatology (2013)

Support Groups:

• German Association Morbus Bechterew e.V.