– Lori A. Burkhart
ACCORDING TO THE SPONDYLITIS ASSOCIATION OF AMERICA, ankylosing spondylitis (AS) is a form of arthritis that primarily affects the spine, although other joints can become involved. It causes inflammation of the vertebrae, which can lead to severe, chronic pain and discomfort. In the most advanced cases (but not in all), this inflammation can result in new bone formation on the spine, causing it to fuse in a fixed, immobile position, sometimes creating a forward-stooped posture. This forward curvature is called kyphosis.
AS can also cause inflammation, pain and stiffness in other areas of the body, such as the shoulders, hips, ribs, heels and small joints of the hands and feet. Sometimes the eyes can become involved (known as iritis or uveitis), and rarely, the lungs and heart can be affected. The hallmark feature of AS is the involvement of the sacroiliac (SI) joints during disease progression. It is more common in men than women. There is no known cause or cure of AS, but the symptoms can be treated.
Diagnosis
The problem with diagnosing AS is that patients usually complain of lower back pain and stiffness, which are fairly common complaints in a doctor of chiropractic’s office. According to Dana Lawrence, DC, MmedEd, MA, senior director of the Center for Teaching and Learning at Palmer College of Chiropractic, diagnosis is usually made from radiographs, partly because of the generic pain and stiffness.
But the age range in which AS typically occurs, late adolescence into early adulthood, also contributes to diagnosis difficulties for this chronic lifelong condition, says Dr. Lawrence. And generic symptoms especially may be overlooked in younger patients. Norman W. Kettner, DC, DACBR, FICC, chair, Department of Radiology at Logan University, says the result is an average delay in AS diagnosis of seven years.
Leo Bronston, DC, MAppSc, vice president of ACA’s Council of Delegates and owner of six chiropractic clinics in Wisconsin, says MRI is the best way to determine the condition especially early on, but the cost is a deterrent and contributes to AS not being diagnosed promptly.
“There is a genetic component to AS, and the HLA-B27 is an antigen that is positive in 90 percent of the cases,” says Dr. Kettner, adding that “if you don’t have that genetic marker and you have AS, then your AS is more aggressive.” Dr. Bronston runs the blood test for the HLA-B27 genetic marker, but cautions that most people with the gene don’t have AS.
“You need to test for reactants that include ESR [erythrocyte sedimentation rate] and CRP [C-reactive protein], which measure damaged cells from inflammation that cause an increase in the ESR and CRP,” says Dr. Kettner. He explains that these are broken cells or fragments of proteins that elevate the sedimentation rate, which in a patient with AS will be high (i.e., 80 or 90).
On physical examination these patients present with limited mobility in the lumbar spine, sacrum and eventually the cervical spine, according to Dr. Bronston. “I reproduce the pain by pressing on the pelvis or by moving the legs in particular ways and notice the patient will have postural anomalies that provide an opportunity to differentiate the condition,” Dr. Bronston says. That includes stiffness in the lower back and pelvis in the morning, and throughout the day, the patient improves or improvement is irregular. “It is usually the L5-S1 vertebrae that I see in practice – the lumbosacral joint is involved.”
Management
All three chiropractic physicians agree that the symptoms can be managed and that chiropractic manipulation provides some relief. Dr. Kettner cautions that manipulation should be limited to the non-acute inflammatory stage. “Manipulation should not be performed in an acute joint disease,” he says, “as that will cause injury in the connective tissue.”
Dr. Kettner points out that AS can be treated pharmacologically and nonpharmacologically. ”In nonpharmacological management, exercise is the cornerstone, especially with emphasis on extension, as patients eventually will fall into a flexion posture; the head goes forward, they bend at the waist and are frozen in that posture,” he says.
“What I do to help relieve the symptoms is exercise and adjustments, but not the traditional posterior to anterior of pushing straight down; I use knee-to-chest movement to incorporate ligaments — a flexion distraction,” says Dr. Bronston. “My patients do a lot of range of movement and stretching exercises to maintain flexibility in the joints and preserve good posture,” he says. “Working with abdominal and back exercise can help maintain their upright posture.”
The doctors advise AS patients against smoking because tobacco use damages connective tissue and contributes to inflammation. “Ankylosing spondylitis can start to affect the rib cage as it becomes more advanced, where the ribs articulate, so there is loss of mobility, and it compromises the ability to breathe,” says Dr. Bronston.
The DCs recognize that NSAIDs are commonly used to provide relief from AS. Dr. Bronston points out that many patients, especially the elderly, are trying to avoid NSAIDs. “They prefer more natural forms of anti-inflammatories, such as omega-3 fatty acids that are high in EPA [eicosapentaenoic acid], which are found to be just as effective as NSAIDs, especially when used in the longer term and with less side effects,” he says. He advises AS patients to increase omega 3s in their diets.
Patient Close-Up
Dr. Lawrence provides his father as an example of how AS avoids detection and to explain its effects. His father’s AS was an incidental finding when he fell offa ladder in his 50s, causing a burst fracture of the fourth lumbar vertebra. The AS was detected on an X-ray series prior to rods being placed to stabilize the low back. “I’m not sure he ever would have complained of low-back pain,” he says of his father.
The most important takeaway is that AS is not just a spinal condition: Dr. Lawrence says it is tempting to think of it as a spinal condition because of the radiographs, which produce a characteristic finding of ligaments fused to their attachments. “You see a nice bright fusion that begins in the lower back and runs up the spine, which is why the patient loses mobility, because all the ligaments that would normally allow movement are calcifying,” he says. “The spine begins to lock down.”
“My father walks with a typical gait associated with AS – he hunches forward with a little bit of a C-curve in his spine. He looks like an old man who has a dowager’s hump, but he doesn’t have a dowager’s hump; he has AS,” Dr. Lawrence says. “He has limited mobility in his hips so his steps are shorter than most people because of the calcification, and he has limited mobility in his spine.”
Dr. Lawrence points to visceral manifestations as well, including bowel inflammation. “This is what causes my father the greatest misery, that he constantly has gastrointestinal distress — cramping akin to ulcerative colitis. In later stages of AS, it is common to have persistent bowel inflammation and also uveitis,” he says.
Inflammatory or Mechanical?
It is important to differentiate between mechanical and inflammatory back pain when diagnosing patients. Dr. Bronston notes that when dealing with mechanical back pain, usually a patient will rest and then feel better; while often the pain will last only a month or two. “With inflammatory back pain, they feel stiff, and it worsens with rest or inactivity, and it occurs early morning and later at night,” he says. “If they exercise, it feels a little bit better, and it lasts more than three months.”
AS is one of a family of disorders known as spondyloarthritis. According to Dr. Kettner, AS is inflammatory and mechanical, which is a relatively new concept. He explains that patients show symptoms of pain and localized swelling when the ligament attachment to the spine joint called the entheses is inflamed, which is relatively common. “The term enthesitis speaks to an inflammatory focus when that ligament causes the pain,” he says. “Eventually the cartilage in the joint disappears, the ligaments are inflamed, joints don’t move and you lose mobility. Enthesitis is one of the principal causes of pain in any spondyloarthritis. These are relatively new ideas that enthesitis is the key pathological lesion in spondyloarthritis, and that includes AS.”
Dr. Kettner adds that AS is an axial disease but has peripheral components, so a patient can develop arthritis outside the spine. One of the sites is the Achilles tendon. “But that is a mechanical component, so an orthotic could provide some relief as the tendon is inflamed. But peripheral suspicions of arthritis always should initiate a search for axial that is spinal arthritis and that includes the SI joint,” he says.
Integrative Opportunities
AS disease is multisystem. “The patient care always should be coordinated with a rheumatologist; this has to be a multidisciplinary approach, both in diagnosis and in treatment,” says Dr. Kettner. “DCs need to have consultations through a rheumatologist because there can be involved heart disease, eye disease and many areas of the body.” He adds that the disorder has diminished life expectancy even with early diagnosis.
Nonradiographic Ankylosing Spondylitis
While radiographic diagnosis is the hallmark of ankylosing spondylitis, (AS) especially in the younger patient, according to Dr. Kettner, there are two forms of AS. There is the common form of AS, and there is one in which the patient has no X-ray changes yet has AS. “This is a new concept that the patient will have a form of AS that is radiographically negative,1” says Dr. Kettner. “There can be an MRI diagnosis, however, when the sacroiliac joints show subchondral edema.” The patient will be treated even though the radiographs are negative, and the ESR and CRP rates are another way to monitor the treatment results. Nonradiographic AS is more common in women.
1. Boonen A. et al. The burden of Non-radiographic Axial Spondyloarthritis. Published online Oct. 22, 2014. In press accepted manuscript. Seminars in Arthritis and Rheumatism Accessed Dec. 2, 2014. DOI: http://dx.doi.org/10.1016/j. semarthrit.2014.10.009.