- Arthritis, Ankylosing Spondylitis, and Autoimmune Diseases: Your Questions, Answered
- Overview – Ankylosing spondylitis
- Complications of ankylosing spondylitis
- Living with AS
- What’s the deal with autoimmune disease?
- Some examples of autoimmune disease
- Why do autoimmune diseases develop?
- What can be done about autoimmune disease?
- The Bottom Line
Arthritis, Ankylosing Spondylitis, and Autoimmune Diseases: Your Questions, Answered
Do you know for sure what is behind your back pain? Masterfile
Everyday Health’s senior editor Denise Maher sat down with Suleman Bhana, MD, on April 3, 2019, to discuss ankylosing spondylitis, an inflammatory autoimmune disease that can be difficult to diagnose. In this conversation, Dr. Bhana, a practicing rheumatologist in the New York City area and the chair of the American College of Rheumatology’s communications and marketing committee, explains this form of arthritis and its symptoms. Read on to learn about why ankylosing spondylitis (AS) is hard to diagnose, and how AS is related to other autoimmune conditions such as rheumatoid arthritis and ulcerative colitis.
Everyday Health: What is ankylosing spondylitis (AS)?
Dr. Suleman Bhana: AS, or ankylosing spondylitis, is an inflammatory autoimmune disease. Autoimmune means a condition where the immune system is overactive, hyperactive, and instead of doing what we want, which is to help fight infections, the immune system is attacking its own body. In this case it could attack the joints, causing back pain and stiffness, but it may in fact even attack other body systems besides the back, such as the eyes, the skin, or the intestines, and may be part of a spectrum of disorders that are inflammatory.
What Is Ankylosing Spondylitis?
Everyday Health: How is AS different from rheumatoid arthritis, lupus, and ulcerative colitis?
Bhana: Ankylosing spondylitis tends to affect the joints more heavily, including the back or spine. Some autoimmune diseases, in contrast, like rheumatoid arthritis and lupus, don’t really have much spine involvement, but in ankylosing spondylitis the spine could become heavily involved, leading to back pain, stiffness, and loss of function. It may affect people quite early in their lives, not just in their fifties or sixties, but even in their twenties and thirties.
One of the reasons we’re here today for the Monster Pain in the AS campaign is to raise awareness about this disease, and to encourage people to go on our website and take a three-minute quiz to see if they have symptoms that may be suspicious for inflammation joint disease. And if so, to get checked out by a rheumatologist sooner rather than later.
RELATED: What Does Arthritis Pain Feel Like?
Everyday Health: We’ve heard that with AS and other rheumatic diseases it can take a really long time to get a diagnosis. Why is that?
Bhana: It’s complicated why that may happen, but unfortunately diagnosing ankylosing spondylitis is not as easy as diagnosing appendicitis, for example, where you do an imaging test and know within a few minutes whether somebody has a particular illness. This diagnosis depends on many factors: a thorough history, a physical exam, laboratory testing, imaging testing. All this takes time for the evaluation to come back. And even then, early disease states may not be readily evident. There are issues to do with the diagnostic testing alone, and people may not know if they have the symptoms until the disease has progressed well on its way. The diagnosis may come 10 years into the onset of symptoms. And then, finally, access to care may be another concern for patients; they may have a problem finding a rheumatologist in their local area.
Diagnosis of Ankylosing Spondylitis
Everyday Health: And what’s your typical patient complaining of? Joint pain?
Bhana: The way we distinguish inflammatory joint pain, which is what happens in ankylosing spondylitis, from mechanical joint pain or mechanical back pain, is, number one, chronicity. Is it going on more than three months continuously, as opposed to mechanical pain, which may last for a few weeks and go? And is there stiffness? Stiffness means you feel like the Tin Man from The Wizard of Oz, where you feel like you’re made of rusted metal; and is that predominantly after you’ve been sedentary? For example, when you wake up after sleeping or if you’re in a long car ride or plane ride, if the stiffness lasts 45 minutes, an hour, two hours, that could be a red flag that the pain is inflammatory and may prompt further evaluation.
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Everyday Health: You mentioned the importance of early diagnosis. Can you talk a little bit about that? Is AS a progressive disease?
Bhana: Most autoimmune inflammatory conditions are, or can be, progressive. That is, they may further affect the joints if nothing is really done over time. They can also be multisystemic; so besides joints, other body systems can be affected, such as the eyes, skin, intestines. And then lastly there may be comorbidities, meaning that if the chronic inflammation goes unchecked, it may lead to other problems such as increased risk of heart attacks, cancer, and stroke.
The importance of having a campaign like Monster Pain in the AS and taking a three-minute quiz is that by getting an earlier diagnosis and an earlier evaluation and treatment, a lot of these systemic problems and comorbidities may be avoided.
RELATED: Celebrities With Rheumatic Diseases
Everyday Health: It sounds like there’s good treatment available today if the disease is caught early. What was treatment like 20 to 30 years ago? Has it changed?
Bhana: Treatment has changed over the last 20 to 30 years. Currently we try to approach treatment for ankylosing spondylitis in a holistic way; there is a very important role for lifestyle changes such as diet, exercise, and nutrition and there’s a role for medical treatments and medications as well. One alone is not enough; having this holistic approach is really important for people’s well-being.
The Importance of Catching Ankylosing Spondylitis Early
Everyday Health: When we talk to people living with rheumatoid arthritis and some of the other diseases you mentioned, we hear a lot about related mental health conditions like anxiety and depression. What is the connection between mental health issues and AS?
Bhana: There are several connections. In general, people with autoimmune diseases have a higher risk of depression, anxiety, and mental health problems. There are many reasons for that. One can imagine if you’re living life in chronic pain or you’re debilitated and can’t do the things you want to do to enjoy life, that can cause problems in your mood and your function.
Other impacts that this may have, is that pain itself is very complicated. Scientists are starting to realize this more and more. That pain is not so much that a joint is dysfunctional and that’s why it hurts, but pain can also come from the brain — that’s called central pain. The brain itself can go on autopilot and try to hyperstimulate pain or even hyperamplify pain, and that tends to happen more often in people that have a history of depression or anxiety disorder.
As we treat people’s physical health, when managing a disease like ankylosing spondylitis, mental health is just as important, and we can’t disconnect our top part of us, our head, from our bottom part of us. The two are intricately connected.
Everyday Health: We talked before about how long the wait is to get an appointment with you and many rheumatologists. Why is that?
Bhana: This is a very challenging situation, access to care for rheumatology. It’s a very complicated discussion beyond the level of what we can talk about right now. But in general, it’s several factors. One is that there is not enough funding for graduate medical education, not just for rheumatology, but for many specialties, to train enough doctors in the U.S. fast enough to meet the current need. There’s also a fairly large swath of older rheumatologists that may be retiring soon or are retiring now from the workforce. Lastly, there is a prevalence or rise in the incidence of rheumatic diseases within the U.S. as well as many other countries.
RELATED: Celebrities With Rheumatoid Arthritis
Everyday Health: Any theories as to why?
Bhana: I’m not exactly sure, to be honest; there may be several reasons. We suspect the cause of autoimmune diseases is a very complex interaction between genetic risks and environmental risks. And it’s possible things in the environment people are encountering now are stimulating the immune system more than previously. It could also be a matter of awareness or selection bias — these people may have been there all along, but were never properly diagnosed. And as more awareness comes around, such as this campaign for ankylosing spondylitis awareness, people are being checked out and evaluated earlier.
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Complications of ankylosing spondylitis
The outlook for AS is highly variable. For some people the condition improves after an initial period of inflammation, whereas for others it can get progressively worse over time.
Some people with AS are able to remain fully independent or minimally disabled in the long-term.
However, some people eventually become severely disabled as a result of the bones in their spine fusing in a fixed position and damage to other joints, such as the hips or knees.
With modern treatments, AS does not normally affect life expectancy significantly, although the condition is associated with an increased risk of other potentially life-threatening problems.
For example, AS can lead to:
- weakening of the bones (osteoporosis)
- spinal fractures
- cardiovascular disease – a group of conditions affecting the heart and blood vessels
- chest infections
- rarely, kidney disease
Read about the complications of ankylosing spondylitis.
Living with AS
The National Ankylosing Spondylitis Society (NASS) has information on living with ankylosing spondylitis, including advice on working, travelling and driving.
Media last reviewed: 28 November 2017
Media review due: 28 November 2020
What’s the deal with autoimmune disease?
Published: May, 2018
Have you ever heard of autoimmune diseases? Do you, like millions of others, actually have one of them?
The term Autoimmune Disease is used to describe conditions in which the body’s immune system – which is supposed to be defending the body against viruses, bacteria and other invaders – is thought to be involved in causing or perpetuating illness. It’s as if the body’s defense system has turned on its host.
Some examples of autoimmune disease
Unfortunately, there is no shortage of conditions considered to be autoimmune. Some typical or common examples include:
- Rheumatologic diseases, such as
- Rheumatoid arthritis – This condition causes multiple joints to become inflamed, stiff and painful; inflammation in other organs (such as the lungs or eye) may also develop
- Lupus – When people develop lupus, they usually have inflammation in multiple parts of the body, especially the joints, skin, lining of the lungs and kidney.
- Sjögren’s syndrome – This condition causes dryness of the eyes and mouth due to inflammation and scarring of the glands that make tears and saliva; arthritis, lung disease and inflammation in other organs are also common.
- Polymyalgia rheumatic (PMR) – Those with PMR are usually over age 60 and have the sudden onset of pain and stiffness in shoulders, neck and hips; it may be a “close cousin” of rheumatoid arthritis.
- Ankylosing spondylitis – This disease is marked by inflammation and stiffness in the lower spine, including sacroiliac joint; other joints are often inflamed as well.
- Vasculitis – This term means “inflammation of vessels” and refers to a family of conditions in which blood vessel inflammation leads to bothersome symptoms and, in some cases, organ damage. Examples include temporal arteritis, granulomatosis with polyangiitis, and hypersensitivity vasculitis.
- Multiple sclerosis – This is a condition in which the lining of axons (called myelin) is damaged by an immune attack; axons are projections of nerve cells that allow them to talk to each other. As a result, the brain and spinal cord do not function properly leading to impaired movement, balance, vision and other problems.
- Celiac disease – With celiac disease, gluten consumption leads to an immune reaction that damages the small intestine and impairs normal digestion. Other problems, such as rash, joint pain, and fatigue may also develop.
- Type 1 diabetes – When people talk about diabetes, they are usually referring to Type II diabetes (in which the body becomes resistant to insulin); this type accounts for about 95% of all cases of diabetes. With Type 1 diabetes, an immune attack damages the part of the pancreas that produces insulin leading to too little insulin to regulate blood sugar or the body’s use of energy. Organ damage (including the kidney and eyes), frequent urination and excess thirst are common problems.
- Alopecia areata – This is a skin disease in which an immune attack on the hair follicles leads to patchy hair loss, especially on the scalp.
And there are many more.
What all of these conditions have in common is evidence that the body’s immune system is in some way responsible. For example, a skin biopsy may show immune cells collecting near an area of a rash; or, there may be antibodies circulating in the blood that are targeting normal tissues. In addition, medications that suppress parts of the immune system may be effective treatment. Still, for most of these conditions, the idea that they are autoimmune in nature is suggested by the evidence but difficult to prove; in fact, certain autoimmune diseases may turn out be due to an infection or allergic reaction and the immune abnormalities are just a reaction.
Why do autoimmune diseases develop?
The immune system is exceedingly complex and decades of research have illuminated some of the ways it goes awry in autoimmune disease. But, for most autoimmune illness – including those mentioned above – the true cause is unknown. The most common (and quite general) theory is that a person with a particular genetic background that makes them prone to immune system ‘misfiring’ encounters an environmental trigger (such as an infection or a toxin) and that sets off autoimmune disease. For the most part, we don’t know the trigger or toxin and in a particular population (or family or even among identical twins) we don’t know why some people develop these conditions and others don’t. These gaps in our knowledge slow the development of effective treatments or preventive measures.
What can be done about autoimmune disease?
Treatment depends on the condition but most autoimmune conditions are treated with medications that suppress or otherwise alter the immune system hoping to dampen it down enough to quiet the disease but not so much that side effects (including infections) develop. In some cases, effective treatments are discovered by happenstance; for example, in the 1920s, gold salt injections were first used to treat rheumatoid arthritis because gold had been used as an antibiotic to treat tuberculosis and rheumatoid arthritis was thought to be caused by an infection. In more recent years, the identification of immune cells (such as B-cells that make antibodies) or chemical messages (also called cytokines, such as tumor necrosis factor, or TNF) involved in autoimmune disease have led to therapies targeting these components of the immune system (such as rituximab, an anti-B-cell treatment or infliximab, an anti-TNF drug).
The Bottom Line
The autoimmune diseases are a mysterious set of conditions that vary in severity from the merely annoying to life-threatening. Research is ongoing and has provided remarkable advances in recent years; while effective therapies are available for most of these conditions, cures are not.
It has long been predicted that we will soon be able to analyze a person’s genes, assess how their immune system is behaving, measure the number and function of immune cells or chemical messengers and put all of this information together to devise a specific, individual treatment regimen that’s likely to be safe and effective. We’re not there yet.
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