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Ankylosing spondylitis: causes, symptoms, treatment

by Josephine Andrews
Published: Last Updated on 436 views

Morbus Bechterew is a special form of inflammatory rheumatism. It manifests itself mainly in back pain in the area of ​​the lumbar spine. As the disease progresses, ossifications can form, hence the medical name ankylosing spondylitis: It means “stiffening spinal disease”. Bechterew’s disease cannot be cured and can limit the mobility of those affected. Read everything you need to know about Bechterew’s disease here!

ICD codes for this disease:

ICD codes are internationally valid codes for medical diagnoses. They can be found, for example, in doctor’s letters or on certificates of incapacity for work.

M45 M46 M54

quick overview
  • Definition: Ankylosing spondylitis is a form of inflammatory rheumatic disease that particularly affects bones and joints.
  • Causes: not yet clarified, genetic reasons and a malfunction of the immune system are suspected.
  • Symptoms: mainly deep-seated back pain , nocturnal pain, morning stiffness.
  • Diagnostics: Doctor-patient discussion (anamnesis), clinical tests to check mobility, blood tests and imaging procedures if necessary.
  • Treatment: exercise, medication, physiotherapy , possibly surgery.
  • Prognosis: Bechterew’s disease cannot be cured, but is easily treatable; this can have a positive influence on the process.

Bechterew’s disease (M. Bechterew, ankylosing spondylitis) belongs to the group of so-called spondyloarthritides . These are diseases of the axial skeleton ( skull , spine and thorax). Ankylosing spondylitis particularly affects the spine and its connection to the pelvis, where inflammation develops. These can destroy bone tissue.

In addition, the inflammation can cause bony appendages to form in the form of fibrocartilage that replace the joint edges. This can, but does not always have to, lead to the many small joints and ligaments in the spine and pelvis ossifying. Pain and restricted mobility are therefore frequent signs of Bechterew’s disease. In the final stage, the spine can become completely bony.

Bechterew’s disease occurs in around 0.5 percent of the adult population in Central Europe, mostly between the ages of 20 and 40. In Germany, around 350,000 people are more or less severely affected by the disease, including three times as many men as women.

Bechterew’s disease in pregnancy

Ankylosing spondylitis in women does not normally pose any particular danger: it does not affect fertility, nor does it increase the risk of miscarriage or premature birth in the event of pregnancy . For the mother-to-be herself, there is usually no particular risk from Bechterew’s disease. However, pregnant women should generally take as few medications as possible. The attending doctor will advise each woman individually.

Distinction from Forrestier’s disease

Bechterew’s disease should not be confused with the less dramatic Forrestier’s disease (hyperostotic spondylitis). The symptoms of this disease also include increasing stiffness and pain. However, this is certainly just pure ossification of the spine, which occurs without any inflammatory reactions. The consequences are usually much more harmless.

Ankylosing spondylitis: symptoms

Ankylosing spondylitis is a chronic disease and often occurs in episodes . This means that the patients experience phases with severe symptoms (relapses) and phases in which they feel better. Over time, ankylosing spondylitis can progress from one episode to the next, causing the spine to become stiffer and deformed.

The type and severity of Bechterew’s disease symptoms depend on the individual case on the one hand on the stage of the disease. On the other hand, there are also individual differences from patient to patient.

The main symptoms of ankylosing spondylitis include deep- seated back pain , morning stiffness and nocturnal pain that lasts for at least three months. Many patients report pain in the second half of the night, which becomes more tolerable when they walk around or do gymnastics. Starting from the sacroiliac joints of the pelvis (sacroiliac joints), the pain in Bechterew’s disease radiates into both legs (thighs) and into the buttocks. Buttock pain alternates between left and right.

Also common early signs are:

  • occasional hip, knee and shoulder pain
  • pain in the heel
  • Tennis elbow (tendon irritation at the elbow joint) or other tendon disorders
  • fatigue
  • weight loss
  • Pain when coughing or sneezing

After months or years, the posture and movement of the body can change as a result of Morbus Bechterew , in a typical way: while the lower spine ( lumbar spine ) usually flattens out, the thoracic spine curves increasingly. This is how a hump often forms . To compensate, the neck stretches and the hip and knee joints flex. Due to the hump formation of the spine, the field of vision when looking straight ahead can be limited. In addition, large joints (hips, knees, shoulders, elbows) can sometimes only be moved to a limited extent.

In about 20 percent of patients, other inflammatory reactions occur in the body. Bechterew’s disease often affects the eyes (iris), heart and kidneys. This can lead to visual disturbances, cardiac arrhythmia or kidney failure, among other things. Such inflammatory reactions must be clarified: the function of the eyes, heart and kidneys can be endangered.

Less commonly, M. Bechterew suffers from cardiovascular disease or inflammation of the large artery (aortitis). Inflammation of the joints (arthritis) of entire fingers or toes or inflammation of the tendons (enthesitis) are also possible. The latter often develops at the insertion of the Achilles tendon.

Many patients also show reduced bone density (osteopenia) through to bone loss ( osteoporosis ).

Some sufferers also develop symptoms in the intestines with Bechterew’s disease . A connection with chronic inflammatory bowel diseases (including Crohn’s disease or ulcerative colitis) is suspected. Then painful intestinal cramps and diarrhea can accompany the Bechterew’s disease symptoms.

There is also a suspicion that ankylosing spondylitis could be related to urinary tract diseases.

Ankylosing spondylitis: causes

The exact cause of Bechterew’s disease is not known. But it is probably a malfunction of the immune system . Since several members of a family sometimes contract it, experts suspect a genetic predisposition for Bechterew’s disease – and thus possible inheritance : around 90 percent of all patients have a special protein called HLA-B27 . It sits on the surface of certain cells of the immune system and is supposed to recognize and fight off pathogens or foreign substances.

In Bechterew’s disease patients, however, this protein seems to be less successful with some pathogens. Therefore, the immune system needs to be more responsive in order to be effective against these invaders. This leads to chronic inflammation of the vertebrae and pelvic bones.

However, the hereditary predisposition alone is not enough for an outbreak of the disease: According to the current state of science, an infection must also occur in order to trigger Bechterew’s disease.

The disease can result from what is known as reactive arthritis . This is an inflammation of the joints that occurs as a reaction to an infection in another part of the body (airways, urinary tract, etc.). It has not been finally clarified whether factors such as physical stress, cold and wet conditions or psychological influences promote the outbreak or only worsen the symptoms afterwards. However, one thing is certain: Morbus Bechterew is not contagious .

Ankylosing spondylitis: diagnosis and investigations

The most important source of information for the doctor in the clarification of a possible Bechterew’s disease is you as the patient. The doctor will talk to you at length to take your medical history (anamnesis). Above all, he can describe the occurring complaints exactly.

The doctor may also ask you to fill out special questionnaires (bath indexes). They are used as a subjective measure to assess the severity of the disease and physical functioning.

Typical questions that are important for the diagnosis of Morbus Bechterew are, for example:

  • Has the back pain lasted longer (more than three months)?
  • Did the symptoms first appear before the age of 45?
  • Does morning stiffness last longer than 30 minutes?
  • Does low back pain improve with exercise but not with rest?
  • Do you often wake up in the second half of the night because of your lower back pain?
  • Did the symptoms start insidiously?
  • Do you feel mutual buttock pain?
  • Do you have visual disturbances, heart and/or kidney problems?

After that, if you suspect Bechterew’s disease, the doctor can use a few clinical tests to determine how flexible your spine is and whether there is pain in the sacroiliac joints. Examples:

  • For the Mennel test , you lie down on your stomach. The doctor fixes the sacrum with one hand and lifts one of your outstretched legs backwards with the other hand. If there is no inflammation in the sacroiliac joints, this movement is possible without pain. Otherwise you will feel a stabbing pain in the sacroiliac joint.
  • The mobility of the lumbar and thoracic spine and the joints can be assessed with the Schober and Ott signs . In these tests, you lean forward while standing and try to bring your fingertips as close to your toes as possible. The doctor uses previously applied skin marks to measure how far the flexion is possible.

There are no specific blood tests for Bechterew’s disease. Moderately elevated inflammatory values ​​(such as CRP or blood sedimentation rate ) can often be found in the patient’s blood. However, these blood values ​​can also be increased by many other diseases.

X- ray and magnetic resonance imaging (MRT, also known as magnetic resonance imaging) imaging methods can be used to identify the destruction and regeneration of bone tissue and the condition of the joints. MRI is the gold standard for detecting ankylosing spondylitis. The diagnosis can be made using magnetic resonance imaging at an early stage of the disease – MRI images can also show inflammatory changes in the sacroiliac joints that are not yet visible on X-rays.

Ankylosing spondylitis: treatment

Bechterew’s disease therapy consists of relieving the symptoms and slowing down the progression of the disease – the disease is not yet curable. Basically, there are different treatment options for M. Bechterew, which can also be combined with each other:

  • medical therapy
  • operative therapy
  • healthy lifestyle
  • other therapeutic measures (physiotherapy, etc.)

Morbus Bechterew therapy is individually adapted to the needs of a patient.

Medical therapy

It is based on the patient’s symptoms and aims primarily to reduce inflammation, pain and stiffness in Bechterew’s disease and to maintain the patient’s mobility. For this purpose, anti-inflammatory and pain-relieving agents from the group of non-steroidal anti-inflammatory drugs ( NSAIDs ), such as ibuprofen , are usually used .

Since these drugs attack the gastric mucosa, a stomach-protecting drug (e.g. omeprazole , pantoprazole ) should also be taken.

In the case of an acute attack of Bechterew’s disease or particularly severe joint pain, the doctor can inject a glucocorticoid (cortisone) into the relevant region. The anti-inflammatory agent usually works quickly. So far, however, it is not known whether and to what extent such cortisone injections influence the course of the disease.

If the arms and legs are also affected by Bechterew’s disease and other anti-inflammatory drugs are not sufficient, the doctor can prescribe an immunomodulator : sulfasalazine or upadacitinib. These active ingredients intervene in the metabolism of inflammatory messengers.

In addition to these anti-inflammatory drugs, so-called TNF-alpha blockers are sometimes used. They suppress the immune system. They are used in patients whose ankylosing spondylitis is difficult and whose symptoms cannot be controlled in any other way.

Due to the dampening effect on the immune system, such drugs can make people more susceptible to infections: pathogens can spread more easily and quickly in the body.

Surgical therapy

For example, an operation may be necessary for ankylosing spondylitis if the chronic inflammation has severely damaged or destroyed a joint (such as the hip joint). Then you can possibly replace it with a prosthesis .

If a patient’s cervical spine is very unstable as a result of the disease, the vertebral bodies can be surgically stiffened ( cervical fusion ). In addition, a surgeon may remove wedges of bone to straighten an increasingly curved spine ( wedge osteotomy ).

Healthy lifestyle

Movement

Exercise can positively influence the course of the disease. It is perhaps even the most important building block in Bechterew’s disease treatment. Physical activities in everyday life such as going for walks, regular gymnastics, cycling, swimming , Nordic walking and other sports maintain your mobility. In addition, exercises that strengthen the muscles are important in Bechterew’s disease – such as the trunk muscles, which supports the straightening of the spine.

nutrition

Diet also plays an important role in Bechterew’s disease. It is known that the omega-6 fatty acid arachidonic acid promotes inflammation in the joints. This fatty acid is mainly found in (pork) meat. In contrast, high-fat cold-water fish, linseed and rapeseed oil contain plenty of omega-3 fatty acids . They can reduce inflammation. A low- meat diet with lots of fruit, vegetables, fish, vegetable fats and low-fat dairy products is therefore recommended for you as a Bechterew’s disease patient .

Eating the right diet, along with regular exercise, is also important for maintaining a healthy weight . Bechterew’s disease is not particularly advisable if you are overweight: if you have too many fat deposits, it is more difficult to maintain an upright posture and to exercise enough.

Talk to your doctor about structured educational programs that include advice and support on exercise, healthy eating, and more.

Renunciation of nicotine

Smoking is generally bad for your health, but even more so with M. Bechterew: nicotine consumption can cause the bony changes to progress more quickly. Therefore, you should never smoke if you have Morbus Bechterew!

Other therapeutic measures

Heat treatments, massages and targeted gymnastic exercises for Morbus Bechterew are very useful to support your therapy: They help you to maintain your posture and mobility, to stretch shortened muscles and to strengthen weak ones. Regular physical therapy can also delay stiffening of your spine and reduce pain.

In everyday life, you should avoid activities that require you to bend far forward. It is ideal if you (have to) get up regularly. A wedge-shaped seat cushion can be helpful when working at a desk or driving a car: it prevents the pelvis from tipping backwards. So you automatically sit upright.

Make sure your bed mattress is firm and not sagging. The pillow should be as flat as possible and keep your head straight. A hollow pillow can prevent the head from tipping back.

Ankylosing spondylitis: course and prognosis

Bechterew’s disease is a long-term ( chronic ) disease that occurs in phases. This means that the symptoms (pain and stiffness) suddenly become worse within a few weeks. After that, there is usually a slight recovery up to an almost symptom-free interval. This can last for varying lengths of time before the next flare-up occurs.

Bechterew’s disease can not be cured . All therapeutic approaches can only slow down the progression of the disease and alleviate the symptoms. However, mortality is not affected by Bechterew’s disease: the life expectancy of the patients is the same as the average population.

As a M. Bechterew patient, you should go to regular check – ups. The doctor checks the mobility of the spine, the pelvis and the large joints in the arms and legs. In Bechterew’s disease, the eyes (vision) and heart function should also be checked regularly.

Ankylosing spondylitis: tips

severely handicapped pass

Depending on how severely you are affected by Bechterew’s disease and restricted in your everyday life, your illness can be classified as a disability or even a severe disability. The basis for the classification is the Supply Medicine Ordinance (to be found at https://www.gesetze-im-internet.de/versmedv/BJNR241200008.html).

If the degree of disability (degree of disability, GdB) is at least 50 in the case of an impairing illness such as Morbus Bechterew , a severe disability is present. The person concerned then receives a severely handicapped pass.

The pension office is responsible for the classification and issuance of the severely disabled person’s pass, in some federal states also the office for care and rehabilitation of the district office or the urban district. You can find out which authority is responsible in your case on the Internet at: https://www.integrationsaemter.de/kontakt/89c7/index.html.

Workplace

As a chronically ill patient with Bechterew’s disease, your risk of being unable to work is increased. However, there is sometimes the possibility of adapting one’s own working environment to individual needs together with the employer. This includes, for example, adjustments in terms of seating furniture and working height and possibly the purchase of a sit-stand desk .

You may also be able to arrange a later start to work with your employer if you suffer greatly from morning stiffness. In addition, you should not lift heavy loads and avoid working in a hunched-over posture .

The Social Security Code requires needs-based support from the employer.

In addition to heavy physical work and an unfavorable sitting posture, too much stress can also trigger a flare-up. So make sure you take the necessary breaks and manage your strength well. Laying flat on your back for 10-20 minutes at lunchtime straightens your spine.

If such workplace adjustments are not possible or if your work is unsuitable for your illness, you can contact the company doctor or the integration office.

Bechterew’s disease & COVID-19

The Robert Koch Institute has generally classified patients with ankylosing spondylitis and other forms of inflammatory rheumatism (such as rheumatoid arthritis ) as patients at risk for COVID-19. Because some drugs used to treat inflammatory rheumatism suppress the immune system. However, it is actually still unclear whether this also increases the risk of becoming more seriously ill with the new infectious disease COVID-19. Researchers are therefore currently in the process of collating international cases of rheumatism patients with COVID-19 in registers and observing and comparing the courses. Such a register is also kept in Germany (first data at: https://www.covid19-rheuma.de ).

Results so far are reassuring – most patients recover from COVID-19 even when receiving rheumatism medication. In the “EULAR and Global Rheumatology Alliance COVID-19” register, 600 COVID-19 diseases in patients with rheumatic diseases from 40 countries have already been analyzed from March 24, 2020 to April 20, 2020: The intake of basic medication such as sulfasalazine, biologics, nonsteroidal anti-inflammatory drugs and TNF-alpha inhibitors did not increase the likelihood of needing hospital treatment for COVID-19. Only treatment with a moderate to high dose of cortisone (greater than 10 mg prednisone per day) was associated with a higher likelihood of hospitalization.

The above findings are only preliminary. More research and studies are needed to better assess the risk.

Danger! The German Society for Rheumatology expressly warns against the unauthorized discontinuation of rheumatism therapy!

You can support the researchers: Sign up if you are a rheumatic patient suffering from COVID-19 or if you would like to take part in a patient survey on the situation of rheumatic patients independently of COVID-19

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