Ankylosing spondylitis or Bechterew’s disease

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What is it about ?

Ankylosing spondylitis or Bechterew’s disease is axial spondylitis (SpA), that is, it is characterized by inflammation of the joints on the axis of the body. Mainly in the spine and in the joints between the sacrum and the pelvis (the sacroiliac joints). Other joints can also become inflamed, such as the knees, ankles and shoulders.

When these joints remain inflamed for a long time, the joints become increasingly stiff and may eventually come to a standstill.

What is its frequency?

In Germany, axial spondylitis (SpA) affects about 1 in 100 people, like rheumatoid arthritis (RA). We do not have reliable data for Belgium, but we do know that around 1% of the Belgian population suffers from RA1. According to the latest estimates, Bechterew’s disease affects 1 in 1,000 people in the Netherlands.

SpA usually starts around the age of 25, and almost always before the age of 45. Family predisposition also plays a role.

SpA has long been considered a disease specific to young adult males. The affection progresses less severely in women; this is the reason why it often goes unnoticed.

About 9 in 10 people with SpA carry the HLA B27 protein. In the general population, this is less than 1 in 10 people.

How to recognize it?

The disease can progress in very different ways: in aggressive outbreaks in some, slowly and gently in others, especially in women, to the point where it goes undiagnosed.

The first sign is usually pain in the lower back, which radiates to the buttock, groin, and thigh. The pain sometimes alternates between the right side and the left side of the body. This is a characteristic sign of spondyloarthritis (SpA).

Another characteristic feature is the worsening of pain following prolonged immobilization, followed by improvement in mobilization. Often the pain is felt during the second half of the night, waking you up and forcing you to get up. In the morning, the pain gives way to a significant stiffness of the back. Any sudden movement can trigger severe pain.

It is possible that the disease is not limited to the spine. In 1 in 2 people, inflammation affects one or more of the large joints (shoulders, ankles). Tendons and tendon sheaths can also become inflamed, especially the large tendon at the back of the ankle (Achilles tendon).

Other symptoms associated with SpA are inflammation of the eyes (uveitis) affecting about 1 in 5 people, and inflammation of the colon (colitis) such as Crohn’s disease and the ulcerative colitis. Inflammation of the heart muscle (myocardium) and aorta are extremely rare.

It takes an average of 7 years to make the correct diagnosis. This duration is explained by the many possible manifestations of the disease. SpA will be suspected in a person who has suffered from back pain for at least 3 months meeting 4 of the following 5 criteria:

  • the complaints started before the age of 40;
  • the pain gradually increases over the years;
  • pain manifests itself at night;
  • rest does not improve symptoms;
  • movement improves symptoms.

How is the diagnosis made?

The doctor will decide whether or not you have spondyloarthritis based on your description of your symptoms. If he suspects the disease, he will perform a physical examination. The abnormalities he can find are mainly in the spine. Stiffness can indeed reduce the mobility of the spine in all directions. This is, however, a late sign.

The stiffness of the thorax vertebrae is assessed by measuring the difference in chest circumference on inspiration and expiration; in most people with SpA, this difference is less than 2.5 cm (it is 6 to 9 cm in healthy people).

If he notices any abnormalities in the eyes or heart, the doctor will refer you to a specialist (rheumatologist).

Your doctor will then order a blood test, not only to detect the HLA B27 protein, but also to screen for other forms of rheumatism.

Finally, he will order an x-ray of the sacroiliac joints, lower back vertebrae and thorax vertebrae. Note that some anomalies are not visible for 2 to 8 years. At an advanced stage, the vertebrae have literally fused together and resemble a bamboo rod.

An MRI scan is more sensitive, but it is only done if you meet the criteria for SpA and the simple x-ray does not show any abnormalities.

What can you do ?

One of the mainstays of treatment is the prevention of stiffness and deformity of the joints. The ideal is to follow a daily exercise program. At the beginning, the exercises will be explained to you by a physiotherapist. Then you will need to continue them at home, including during periods without symptoms. The program concerns the back, other joints and tendons.

Breathing exercises are also essential. Ask your physiotherapist to review your exercise program from time to time. This will help you avoid the routine and be less tempted to stop exercising during periods without symptoms.

Avoid sitting or hunched over for too long. If this is not possible, for example due to the nature of your job, try to stand up and take a few steps at regular intervals. It is recommended to choose a suitable car seat with a good neck support.

What can your doctor do?

Anti-inflammatory drugs are effective in relieving symptoms associated with SpA. Unless the doctor advises otherwise, limit taken for flare-ups and for short periods of time, as they can have side effects on the stomach, blood pressure and kidneys. Sometimes, however, it is necessary to prolong their intake for a few months.

At the same time, the doctor will set up disease-modifying treatment for people with early-stage SpA who experience frequent flare-ups. This treatment can slow the progression of the disease and reduce the number of flare-ups.

In the event of inflammation of a single large joint and tendonitis, cortisone infiltrations may be beneficial.

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