ANKYLOSING SPONDYLITIS: Clinical Features

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The association between ankylosing spondylitis and human leukocyte antigen (HLA) B27 was reported for the first time in 1973.34 This finding has stimulated quite a lot of research in many aspects of ankylosing spondylitis. However, the cause of the disease is still largely unknown. It has been postulated that an infectious agent ( possibly Klebsiella), in some way interacting with HLA-B27, may trigger the disease.17 This theory is analogous to the situation in reactive arthritis or Reiter's syndrome where bowel infection owing to certain Shigella, Salmonella, Yersinia, or Campylobacter strains may cause disease. Also, the association between ankylosing spondylitis and chronic inflammatory bowel diseases (Crohn's disease and ulcerative colitis) has stimulated the idea that the causative agent in ankylosing spondylitis might belong to the (ubiquitous) bowel flora.

This article briefly reviews the state of the art one quarter of a century later. It focuses on those topics that are most relevant from the clinical point of view.

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

References (42)

  • A. Ebringer

    The relationship between Klebsiella infection and ankylosing spondylitis

    Baillieres Clin Rheumatol

    (1989)

  • Spondylitis: Time for a new name and a new approach to diagnosis

    Lancet

    (1985)
  • F. Arnett

    Seronegative spondyloarthropathies

    Bull Rheum Dis

    (1987)
  • C. Bakker et al.

    Measures to assess ankylosing spondylitis: Taxonomy, review and recommendations

    J Rheumatol

    (1993)
  • C. Bakker et al.

    Cost effectiveness of group physical therapy compared to individualized therapy in ankylosing spondylitis. A randomized controlled trial

    J Rheumatol

    (1994)
  • J. Braun et al.

    Use of dynamic magnetic resonance imaging with fast imaging in the detection of early and advanced sacroiliitis in spondyloarthropathy patients

    Arthritis Rheum

    (1994)
  • J. Braun et al.

    Prevalence of spondyloarthropathies in HLA-B27 positive and negative blood donors

    Arthritis Rheum

    (1998)
  • M.A. Brown et al.

    Ankylosing spondylitis in West Africans— Evidence for a non-HLA-B27 protective effect

    Ann Rheum Dis

    (1997)
  • M.A. Brown et al.

    Susceptibility to ankylosing spondylitis in twins: The role of genes, HLA, and the environment

    Arthritis Rheum

    (1997)
  • M. Brown et al.

    Predisposing factors to spondyloarthropathies

    Curr Opin Rheumatol

    (1997)
  • A. Calin

    Ankylosing spondylitis: Defining disease status and the relationship between radiology, metrology, disease activity, function, and outcome (Dunlop-Dottridge lecture)

    J Rheumatol

    (1995)
  • A. Calin et al.

    A new approach to defining functional ability in ankylosing spondylitis: The development of the Bath Ankylosing Spondylitis Functional Index (BASFI)

    J Rheumatol

    (1994)
  • A. Calin et al.

    Clinical history as a screening test for ankylosing spondylitis

    JAMA

    (1977)
  • D.O. Clegg et al.

    Comparison of sulfasalazine and placebo in the treatment of ankylosing spondylitis: A department of veterans affairs cooperative study

    Arthritis Rheum

    (1996)
  • M.C.W. Creemers et al.

    Methotrexate in severe ankylosing spondylitis: An open study

    J Rheumatol

    (1995)
  • M. D'Amato et al.

    Relevance of residue 116 of HLA-B27 in determining susceptibility to ankylosing spondylitis

    Eur J Immunol

    (1995)
  • M. Dougados et al.

    Evaluation of a functional index and an articular index in ankylosing spondylitis

    J Rheumatol

    (1988)
  • DougadosM. et al.

    European Spondyloarthropathy Study Group (ESSG): Preliminary criteria for the classification of spondyloarthropathy

    Arthritis Rheum

    (1991)
  • DougadosM. et al.

    Sulphasalazine in the treatment of spondylarthropathy: A randomized, multicenter double-blind, placebo-controlled study

    Arthritis Rheum

    (1995)
  • M.B. Ferraz et al.

    Metanalysis of sulphasalazine in ankylosing spondylitis

    J Rheumatol

    (1990)
  • S. Garrett et al.

    A new approach to defining disease status in AS: The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)

    J Rheumatol

    (1994)

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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

    *

    Department of Medicine, Division of Rheumatology, University of Maastricht, Maastricht, the Netherlands

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    Copyright © 1998 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.