Spondylitis actually means "spine rheumatism" in medical language. Ankylosing Spondylitis is popularly known as "spine inflammation" or "inflammatory lumbar rheumatism". Ankylosing Spondylitis (AS) is an inflammatory disease of the spine and usually begins in the lower back, in the pelvis, in the joint known as the sacroiliac joint, which connects the coccyx and pelvis. Later, as the disease progresses, ankylosis (fusion in the spine) begins, the structure of the lumbar, back and neck vertebrae deteriorates, which may lead to restriction and hunchback in waist and neck movements. However, AS is not just a form of lumbar rheumatism; it can also cause foot and heel or rib/sternum pain for years. Since AS is a disease with an insidious and slow course, it is often confused with arthritis or a herniated disc. Unfortunately, if the disease is not diagnosed early, the structure of the spine may deteriorate. Most of the patients diagnosed with AS in our country have been diagnosed with a herniated disc for years, and some of them have undergone a herniated disc surgery but did not benefit from it. AS disease usually starts in young men (especially in the 17-25 age group), but AS is not only a men's disease and can be more insidious in women.
What are the Symptoms of Ankylosing Spondylitis?
AS usually causes insidious onset of low back or hip pain. AS is considered a disease in cases of back pain that lasts more than 3 months and is under the age of 40. AS patients' lower back pain does not improve with rest, and they often have night pain. There is improvement in back pain with exercise and movement. When they wake up in the morning, there is stiffness in the waist and hip areas, and this stiffness lasts longer than 30 minutes. This pattern of low back pain is generally called inflammatory low back pain.
In addition, a recurring eye inflammation called uveitis may occur. That's why Uveitis is sometimes known as "Eye Rheumatism" among the public. Recurrent Tendonitis/Tendinitis and Enthesitis may occur. These most commonly appear as inflammation at the point where the Achilles tendon attaches to the bone on the heels or at the point where the plantar fascia attaches to the bone on the sole of the foot. In this case, patients suffer from severe heel and sole pain when they take their first steps in the morning, and these pains subside during the day. it gets worse. In addition, there may be a sausage-like swelling of the fingers or toes, known as Dactylitis, accompanied by pain, redness and limitation of movement.
What Does “Inflammatory Low Back Pain” Mean in Ankylosing Spondylitis?
Low back pain is a very common problem all over the world and can have dozens of causes.
The majority of low back pain occurs due to "mechanical" reasons such as structural disorders, slipped disc and herniated disc. Most of this type of mechanical pain is triggered by factors such as straining the waist area, such as lifting something heavy or moving excessively. In general, most mechanical pain decreases with rest.
However, inflammatory back pain occurs insidiously, without any strain or trauma. The most distinctive feature of inflammatory low back pain is; It worsens with rest and decreases with movement. It is almost the opposite of mechanical back pain. Inflammatory back pain is also known as inflammatory back pain in medical terms, but it is inflammation that is not due to infection. Most of the inflammatory lower back pains are defined under the Spondyloarthropathy group, popularly known as "inflammatory lower back rheumatism" diseases. The most severe of this Spondyloarthropathy group of diseases is Ankylosing Spondylitis (AS).
Inflammatory back pain is a condition that should definitely be taken into consideration. Especially in patients younger than 40 years of age, if morning stiffness (at least 45 minutes) and low back pain are experienced for more than 3 months, and if the low back pain worsens with rest and decreases with movement, these symptoms are most likely caused by inflammatory low back pain. Many patients say that just opening their eyes when they wake up in the morning is not enough to be ready for the morning. When the patient wakes up in the morning, he/she has difficulty in personal care and wearing clothes. These patients experience severe pain or lumbar stiffness in the second half of the night, especially between 03:00 and 05:00 in the morning. The characteristic of inflammatory back pain is that it decreases during the day and disappears completely in many people. It is relieved by movement or exercises and many patients feel as if they are walking. He gives similar descriptions such as "I am a different person in the morning, my pain or stiffness disappears completely, but when I wake up in the morning, I still feel stiff."
If inflammatory low back pain is not controlled, it can later become a progressive disease because it can progress in an insidious manner. That's why it's a condition we try to diagnose accurately and definitively as soon as possible. If inflammatory back pain is not treated in time, it can lead to fusion in the spine. Heel, back, neck, hip or rib pain may also accompany inflammatory lower back pain for years. Patients who are thought to have low back pain for a long time should be reviewed by a Rheumatologist if their back pain still persists. A patient who has had "mechanical" pain for years may actually develop Spondyloarthropathy, known as inflammatory low back pain. Unfortunately, most of the patients diagnosed with Ankylosing Spondylitis in our country have been diagnosed with "mechanical" disc herniation for years, and some of them have undergone back surgery but did not benefit from it. That's why we should take into account and care about low back pain, especially in young people, and diagnose whether it is inflammatory as soon as possible.
Why Does Ankylosing Spondylitis Develop?
There is no specific cause of Ankylosing Spondylitis, but there is a genetic predisposition. In particular, a gene known as HLA-B27 greatly increases the risk of developing ankylosing spondylitis. However, this gene is not found in every Turkish Ankylosing Spondylitis patient, and the presence of the HLA-B27 gene alone does not mean that AS disease will be seen in 100% of cases.
How is Ankylosing Spondylitis Diagnosed?
Most of the time, Ankylosing Spondylitis is diagnosed by an Orthopedic or Physician. It begins with the suspicion of the treating specialist. Especially when there is no response to "lumbar herniation treatment", AS disease is considered in the differential diagnosis and is referred to a Rheumatism specialist physician. The definitive diagnosis is made by this specialist Rheumatologist. The most important issue for the rheumatologist is the history of the disease, especially if there is waist/lower back pain lasting more than 3 months and the above-mentioned “Inflammation” If it is compatible with “Lower Back Pain”, the diagnosis is confirmed. During the physical examination, movement limitation tests and special sacroiliac joint maneuvers are performed. Then, the definitive diagnosis is often supported by radiological imaging (X-ray and MRI) and laboratory tests.
How is Ankylosing Spondylitis Treated?
In very mild cases, only the sacroiliac joints and Spine are involved. Patients with Ankylosing Spondylitis are started with NSAIDs (anti-inflammatory painkillers that do not contain cortisone) and in cases where there is no response, anti-rheumatic drugs that change the course of the disease are given. If there is no sufficient treatment response to the above-mentioned drugs after 3 months or if there is no response to 3 different NSAID drugs, biological treatments are given. Biological treatments include medications such as TNF blockers or interleukin 17 inhibitor. These types of Biological agents help reduce pain and swelling in the joints and morning stiffness.
Does Physical Therapy Play a Role in Ankylosing Spondylitis?
Physical therapy is a very important part of the treatment and is often consulted by a Rheumatologist. A Physical Therapy program is coordinated together with the medications. The aim of physical therapy in Ankylosing Spondylitis is very useful in relieving pain and increasing endurance and flexibility. The physical therapist usually designs a patient-specific exercise program. Most of the time, the exercise program designed by the Physical Therapist should then be done regularly and long term. However, FTR program and exercise should not be done during an acute attack. Additionally, if the disease is not under control and active "inflammation" is visible in blood tests, hot water/Thermal/spa/Turkish bath etc. treatments and sudden and harsh movements should be avoided.
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