Ankylosing Spondylitis
Ankylosing spondylitis (AS) is a medical condition that involves the inflammation (spondylitis) and fusion/stiffening (ankylosis) of the vertebrae or small bones in the spine.
Ankylosing spondylitis (AS) is a chronic inflammatory condition mainly affecting the spine that causes progressive stiffness and pain.
Also known as Bechterew disease, ankylosing spondylitis is described as a rare type of arthritis. The disease is found to be more common in men than in women, and is usually found in adult patients more than younger people.
Causes and Risk Factors of Ankylosing Spondylitis
Ankylosing spondylitis has no known etiology, but some experts believe that the gene HLA-B27 increases the risk for developing this disease.
- Heredity: People who are positive for HLA-B27 gene are more prone to develop ankylosing spondylitis.
- Sex: When compared to women, men are more likely to develop ankylosing spondylitis.
- Age: Most commonly seen in adolescence.
- Race: Ankylosing spondylitis is more common in Native American tribes.
Pathophysiology
Ankylosing spondylitis (AS) is a potentially disabling form of seronegative spondyloarthritis. The main symptom of AS is inflammatory spinal pain; with time, some patients develop ankylosis and spinal immobility. The pathology mainly affects the entheses, where ligaments, tendons and capsules are attached to the bone.
Three processes are observed at the entheses: inflammation, bone erosion and syndesmophyte (spur) formation. Tumor necrosis factor is an important mediator of the inflammatory processes, but this proinflammatory cytokine is not closely involved in bone erosion or syndesmophyte formation. The major causative factors of AS are genetic, with the gene encoding HLA-B27 being the most important genetic factor.
Several other susceptibility genes have also been identified.
Signs and Symptoms
- Lower back and/or hip pain – early sign of ankylosing spondylitis; usually worse in the morning and when the person is inactive (e.g. after watching TV, sitting, or taking a nap); may be accompanied with stiffness
- Inflammation in other body parts – over time, the disease may aso affect other areas of the body such as shoulder joints, ribs, breastbone, back of the heel, and the eyes
- Hunched-forward posture, Stooped posture in response to back pain (bending forward tends to relieve the pain)
- Difficulty of breathing
- Swelling of joints
- Tiredness or fatigue
- Straight and stiff spine
- Inability to take a deep breath, if the joints between the ribs and spine are affected
- Appetite loss
- Weight loss
- Fatigue
- Fever
- Anemia
- Joint pain
- Mild eye inflammation
- Organ damage, such as to the heart, lungs, and eyes
- Skin rashes
Diagnosis / Investigations.
- Physical exam – involves checking for the spine’s range of motion by asking the patient to bend in various directions as well as palpation of the spinal and pelvic areas
- X-ray. This test uses a small amount of radiation to create images of internal tissues, bones, and organs onto film.
- MRI may show more detailed pictures of the soft tissues and bones; AS might not be detected easily during its early stages despite performing imaging tests
- Erythrocyte sedimentation rate (ESR ). This test looks at how quickly red blood cells fall to the bottom of a test tube. When swelling and inflammation are present, the blood’s proteins clump together and become heavier than normal. They fall and settle faster at the bottom of the test tube. The faster the blood cells fall, the more severe the inflammation. Up to 7 in 10 people with AS have a high ESR.
- Genetic testing. Genetic testing is done to find if a person carries a copy of an altered gene for a disease. The gene HLA-B27 is found in more than 19 in 20 people with AS.
Management.
Aims
- There is no cure for AS yet and the goals of treatment for this disease is the relief of stiffness and pain,
- delaying of its progression, and
- prevention of complications.
Nursing management;
- Physical Therapy. Staying active is the number one management for ankylosing spondylitis. Sitting, lying, and staying in one position for long periods of time increase the pain and stiffness of joints. An AS patient will benefit from an urgent referral to a physical therapist (PT) who will create an exercise and activity plan for him or her. Stretching and range-of-motion (ROM) exercises, as well as proper posture, walking, and sleeping positions will be discussed by the PT to the patient.
- Use warm compress to increase blood circulation to the affected part and relieve pain.
- Proper positioning of the patient while sleeping and walking.
- Exercise.
- Stretching.
- Massaging the affected part.
- Diet; patient should take balanced diet and food rich in calcium.
- Send patient to a physiotherapist who will design suitable exercises.
Pharmacological management;
- Nonsteroidal anti-inflammatory drugs (NSAIDs) – commonly utilized to relieve pain, inflammation, and stiffness of joints.
- Give prescribed analgesics like paracetamol and ibuprofen for pain.
- Biological medication like tumor necrosis factor.
- Steroids – to slow down the damage of the joints, reducing inflammation and pain; they can be in oral form or injectables directly to the inflamed joint, like dexamethasone.
- An interleukin 17 inhibitor (which targets the protein cells that cause inflammation in the body) helps to reduce pain, tenderness, and swelling of the joints. This is administered by IV or injecting under the skin. E.g. adalimumad (humira) and certolizumab-pegel (cimzia).
- Tumor necrosis factor (TNF) blockers – alternative to NSAIDs if the latter are not effective; usually administered via subcutaneous injection or intravenous infusion; involves the use of monoclonal antibodies (MABs)
Surgical treatment.
- Most people with this condition don’t require surgery but though the doctor may suggest surgery if there’s severe pain/ joint damage where there’s need for replacement.
- Home remedy.
- Stay active. Exercise can help to ease pain, increase flexibility and
improve posture. - Apply hot or cold compress.
- Avoid smoking to prevent other related problems coming in e.g. further hampering breathing.
- Practice good posture while moving, standing or sitting.
Complications.
- Ineffective breathing.
- Uveitis (inflammation of the eye).one of the most complication resulting into blurred vision and photo phobia.
- Compressed fractures in early stages.
- Weakening in the vertebra.
- Heart problems majorly on the aorta.( if its inflamed the valves are involved too hence affecting the function).
Nursing Diagnosis
- Acute pain related to vertebral and joint inflammation secondary to ankylosing spondylitis, as evidenced by pain score of 10 out of 10, guarding sign on the affected area (commonly lower back, hip, shoulders), joint swelling, hunched-forward posture, restlessness, and irritability
- Activity intolerance related to vertebral and joint inflammation and pain secondary to ankylosing spondylitis, as evidenced by pain score of 8 to 10 out of 10, fatigue, disinterest in ADLs due to pain, verbalization of tiredness and generalized weakness.
- Impaired Physical Mobility related to vertebral and joint inflammation as evidenced by severe pain rated 10/10, failure to perform ADLs, and verbalization of fatigue.
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