ANKYLOSING SPONDYLITIS: Clinical Features
Section snippets
CLINICAL SPECTRUM OF ANKYLOSING SPONDYLITIS
The well-known association between ankylosing spondylitis and the HLA class I antigen HLA-B27 has contributed considerably to a better understanding of the clinical spectrum of the disease. Although there is a tendency to develop fibrous or bony ankylosis, the term “ankylosing” (from the Greek root ankylos, now meaning fusion) is often misleading. It has been proposed to omit the term “ankylosing” from ankylosing spondylitis, whereas a better name might be spondylitis or spondylitic disease.1, 2
DIAGNOSIS OF ANKYLOSING SPONDYLITIS
In most cases, ankylosing spondylitis is largely diagnosed, or at least initially suspected, on clinical grounds. The best clues are offered by the patient's symptoms, the family history, and the articular and extra-articular physical findings. Clinical manifestations of ankylosing spondylitis usually begin in late adolescence or early adulthood (Fig. 1). The most common and characteristic early complaint is low back pain and back stiffness. However, back pain is an extremely common symptom in
ANKYLOSING SPONDYLITIS AMONG THE SPONDYLOARTHROPATHIES
Patients with ankylosing spondylitis may present with “classical” manifestations, but atypical cases or forme frustes do not occur infrequently. Ankylosing spondylitis is now generally considered to be the prototype of a group of diseases which are collectively referred to as spondyloarthropathies (SpA) (See list).
Diseases belonging to the spondyloarthropathies:
Ankylosing spondylitis
Reiter's syndrome/Reactive arthritis
Arthropathy of inflammatory bowel disease (Crohn's disease, ulcerative
CRITERIA FOR ANKYLOSING SPONDYLITIS AND SPONDYLOARTHROPATHIES
In practice there is often a lot of misunderstanding about the appropriate application of criteria. In our opinion, this is owing to the fact that the purpose of criteria might not be clear to many clinicians. Also, the literature itself is often confusing. Sometimes criteria are incorrectly called “diagnostic.” This mistake has been made in the past.39 In fact, the distinction between diagnostic and classification criteria is often not stated clearly in literature. Useful diagnostic criteria
GENETICS OF ANKYLOSING SPONDYLITIS AND RISK FOR HUMAN LEUKOCYTE ANTIGEN B27 POSITIVE PEOPLE
The prevalence of ankylosing spondylitis in most white populations is about 0.1% to 0.2%. Approximately 1% to 2% (certainly less than 10%) of HLA-B27-positive adults in the general population are likely to have ankylosing spondylitis.40 There seems to be a north to south gradient in the susceptibility to ankylosing spondylitis; HLA-B27 positive people in northern Norway might be at higher (6.7%) risk of developing ankylosing spondylitis than HLA-B27 positive persons in more southern European
ASSESSMENT OF ANKYLOSING SPONDYLITIS
Axial involvement usually is the predominant feature in classical ankylosing spondylitis. Signs and symptoms such as spinal pain and limitation of motion might be owing to disease activity or to damage as a result of prolonged periods of active disease. Assessment of the degree of inflammation (i.e., the activity of disease) may be more difficult in ankylosing spondylitis than in rheumatoid arthritis. In contrast to peripheral joints in the latter disease, spinal structures are not easily
FUNCTIONAL PROGNOSIS OF ANKYLOSING SPONDYLITIS
Functional limitations increase with duration of disease. Vocational counseling and job training for patients with ankylosing spondylitis reduce the probability of long-term disability (Fig. 2).22 This applies also to sedentary work. On the other hand, prolonged standing at work or exposure to cold conditions are risk factors for disability. Patients with peripheral joint involvement are more likely to experience sick leaves than ankylosing spondylitis patients with only axial manifestations.
TREATMENT OF ANKYLOSING SPONDYLITIS
The main objectives of ankylosing spondylitis management are to relieve pain and stiffness and to minimize and prevent spinal deformity and disability.36 Patient education is very important to increase compliance and obtain active participation in the therapeutic program. The exercise program is an essential part of therapy and may be individualized or done in a group setting.4, 23 Compared to ankylosing spondylitis patients who did only daily exercises at home, those who additionally had once
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2016, Revista Brasileira de ReumatologiaCitation Excerpt :It is more frequent in young adults aged between 20 and 40 years. There is a greater prevalence in males (3:1), Caucasians, and HLA-B27 positive individuals.2,3 The HLA-B27 antigen is strongly correlated with the appearance of the disease, and a positive test for this marker is found in 80–98% of cases.4
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Address reprint requests to Sjef van der Linden, MD, Department of Medicine, Division of Rheumatology, University of Maastricht, PO Box 5800, NL-6202-AZ MAASTRICHT, The Netherlands
Adapted from Arnett FC. American College of Rheumatology (ACR) Review Course.Washington, 1997; with permission.
SMARD = symptom modifying antirheumatic drugs
DCART = disease controlling antirheumatic therapy
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Department of Medicine, Division of Rheumatology, University of Maastricht, Maastricht, the Netherlands