Rheumatology

Axial Spondyloarthritis

Axial spondyloarthritis (SpA) is a chronic rheumatologic inflammatory disease, usually affecting areas such as the joint between the spine and the pelvis, the vertebrae of the lower back, the junction where tendons and ligaments connect attach to bones primarily in the spine, and sometimes the back of the heel, the cartilage between the sternum and the ribs, and finally the hips and shoulders.

Overview

The term axial spondyloarthritis includes:

SpA usually develops in the thirties, and affects more men than women. The ratio is estimated at around 2 men to 1 woman in the case of the radiographic form, and 1:1 for the non-radiographic form.

Signs and symptoms

Complications

In the most severe cases of the disease, there is fusion of vertebrae. The spine therefore becomes rigid and inflexible. Fusion can also occur in the rib cage, which limits lung capacity and function.

Other complications can also arise. Among these, inflammation of the eye, called uveitis, is a common complication of ankylosing spondylitis. It is characterized by inflammation of the middle layer of the eye, called the uvea. Uveitis can cause sudden eye pain, increased sensitivity to light (photophobia), eye redness, and blurred vision. It is important to seek immediate medical attention if these symptoms occur in order to assess and treat uveitis appropriately. Early medical intervention can help reduce inflammation, relieve symptoms, and prevent potential serious eye complications.

There are also compression fractures. These occur when the bones weaken during the early stages of the disease. The weakened vertebrae can compress, thus aggravating the severity of the hunched posture. Spinal fractures can put pressure on the spinal cord and possibly damage the nerves that pass through the spine.

Ankylosing spondylitis can also cause heart problems, specifically of the aorta, the largest artery in the body. The inflamed aorta can enlarge to the point of deforming the aortic valve of the heart, affecting its function. The inflammation associated with ankylosing spondylitis increases the risk of heart disease in general.

Causes

Axial spondylitis is a complex and multifactorial disease. Research has demonstrated a variety of complex interactions of genetic, environmental and psychosocial factors.
The element that comes up most often in scientific research is family predisposition. The genetic component is important to consider in the case of ankylosing spondylitis, in particular the presence of the HLA-B27 antigen. This antigen is present in more than 90% of the white population with SpA, but the risk of developing the disease if one is a carrier of this allele is 20%.

Prognosis

Axial spondylitis, or SpA, is a chronic and progressive disease that can lead to a reduced quality of life. It is possible to slow the progression of the disease and avoid serious complications.

The prognosis of SpA depends on several factors such as the severity of the disease, the response to treatment and whether there are associated comorbidities. Pain, stiffness and fatigue are symptoms that can vary in intensity and frequency from person to person. Patients with SpA may also have complications such as joint deformities, visceral involvement, or cardiovascular involvement. In its most severe forms, the disease can cause postural deformities that can be disabling.

The quality of life of patients with SpA is significantly impaired compared to the general population due to chronic pain, joint stiffness, fatigue, psychological impact and loss of function.

Mortality in patients with SpA is generally comparable to that of the general population. However, patients with SpA may be at increased risk for cardiovascular complications, including atherosclerosis and high blood pressure, which may affect their prognosis.

Disease management 

SpA treatments aim to reduce pain, stiffness, inflammation and improve patients’ quality of life. There are several treatments for SpA, which can be divided into two main categories: drug and non-drug treatments. 

Drug treatments: 

  1. Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs are often used as the first line of treatment to relieve pain and inflammation in SpA. Several studies have demonstrated the effectiveness of NSAIDs in the treatment of SpA. 
  2. Anti-TNF drugs: These drugs are inhibitors of TNF, an inflammatory protein produced by the body. They are used to treat moderate to severe forms of SpA that do not respond to NSAIDs. Studies have shown that anti-TNFs are effective in reducing SpA symptoms, including pain, inflammation, and stiffness. 
  3. JAK inhibitors: JAK inhibitors are a new class of drugs used to treat SpA. They work by blocking an enzyme that plays a key role in inflammation. JAK inhibitors are used to treat moderate to severe forms of SpA that do not respond to NSAIDs or anti-TNFs. 

Other treatments: 

Management of spondyloarthritis may include physiotherapy rehabilitation interventions to relieve symptoms, mobilize, increase range of motion, and strengthen. 

Adapted physical activities can also help. Indeed, several studies have shown that physical activity is effective in reducing pain, improving posture, increasing mobility, muscle strength and quality of life in people with spondyloarthritis. It is important to  emphasize that exercises and physical activities must be adapted to the abilities and limitations of each individual, and that regular monitoring by a health and physical activity professional is essential. 

Occupational therapy can help adapt the environment to the joint deformities present, improve activities of daily living and prevent complications. For example, using assistive devices to facilitate daily activities can reduce pain and fatigue. 

Other complementary therapies may be added. For example, massage can provide some relief for people with spondyloarthritis, particularly by reducing pain and muscle stiffness. 

Surgical treatment: 

The majority of individuals with ankylosing spondylitis or non-radiographic axial spondylitis usually do not need to undergo surgery. However, in some cases, surgery may be recommended if the pain is severe or if the hip joint has deteriorated so badly that it requires a joint replacement. The decision to opt for surgery is made on a case-by-case basis, carefully weighing the potential benefits and risks, as well as the specific needs of the patient. It is important to consult a specialized healthcare professional to determine the best therapeutic approach in each situation. 

Support 

Living with a chronic illness can be frustrating and it is normal to feel angry, depressed or discouraged. The pain and deformities that result from the disease can become increasingly disabling over time. 

People with SpA may be more prone to depression. Talk to your doctor if you experience intense or persistent feelings of sadness or hopelessness. 

While friends and family can be your best allies, support from people who know what you’re going through can be especially helpful. To learn more about support groups in your community, talk to your doctor, social worker, or local chronic rheumatoid disease association. 

You and your loved ones can also benefit from talking to a mental health professional, such as a psychologist or social worker trained in working with people with chronic conditions. 

References

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National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2016, August). Ankylosing Spondylitis. https://www.niams.nih.gov/health-topics/ankylosing-spondylitis

National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2022, January). Diagnosis, Treatment, and Steps to Take. https://www.niams.nih.gov/health-topics/ankylosing-spondylitis/diagnosis-treatment-and-steps-to-take 

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