Ankylosing Spondylitis

• The onset is typically between the ages of 20 and 30, with a male preponderance of about 3 : 1.
• In Europe, more than 90% of those affected are HLA B27 positive.
• The overall prevalence is less than 0.5% in most populations.
• Over 75% of patients are able to remain in employment and enjoy a good quality of life.
• Even if severe ankylosis develops, functional limitation may not be marked as long as the spine is fused in an erect posture. [1]
• This fusing makes the spine less flexible and can result in a hunched-forward posture.
• If ribs are affected, it can be difficult to breathe deeply. [2]

Several things make AS more likely:

Age:

• It tends to start between your teens and 30s.

Gender:

• Men are two to three times more likely to get the disease than women.

Genetics:

• You can inherit it from your parents.
• One gene, called HLA-B27, is common in people with AS.

Ethnicity:

• AS appears more often among native tribes in the U.S. and Canada, especially Alaskan Eskimos. [4]

Risk Factors

Family history and HLA-B27 gene

Age.

About 80 percent Trusted Source of people first develop ankylosing spondylitis symptoms under age 30.

Sex.

Ankylosing spondylitis tends to develop about twice as often in men than in women.

Ethnicity.

The prevalence of the HLA-B27 gene seems to vary between ethnic groups. According to one studyTrusted Source, its incidence rate was 7.5 percent in non-Hispanic whites, 4.6 percent among Mexican-Americans, and 1.1 percent among non-Hispanic blacks.

Gut inflammation.

Up to 70 percent Trusted Source of people with ankylosing spondylitis have gut inflammation, suggesting a potential origin in the gut. It’s thought disruption to the microbiome in your gut may play a role in its development.

Smoking.

Some research Trusted Source has found an association between the development of ankylosing spondylitis and smoking, but the association still is not clear.

Childhood infections.

A 2016 study Trusted Source found an association between childhood respiratory infections and the later development of ankylosing spondylitis. Childhood appendicitis was linked to a decreased risk.[10]

Pathophysiology

• Ankylosing spondylitis is thought to arise from an as yet ill defined interaction between environmental pathogens and the host immune system in genetically susceptible individuals.
• Increased faecal carriage of Klebsiella aerogenes occurs in patients with established AS and may relate to exacerbation of both joint and eye disease.
• Wider alterations in the human gut microbial environment are increasingly implicated, which could lead to increased levels of circulating cytokines such as IL 23 that can activate entheseal or synovial T cells.
• The HLA B27 molecule itself is implicated through its antigen presenting function (it is a class I MHC molecule) or because of its propensity to form homodimers that activate leukocytes.
• HLA B27 molecules may also misfold, causing increased endoplasmic reticulum stress.
• This could lead to inflammatory cytokine release by macrophages and dendritic cells, thus triggering inflammatory disease. [1]

Types

1. Nonradiographic axial spondyloarthritis (nr-axSpA). This is the less severe form of spondyloarthritis. “Nonradiographic” means that something is not easily visible on an X-ray. .
2. Radiographic axial spondyloarthritis. This is the first phase of ankylosing spondylitis. It happens when nr-axSpA gradually gets worse and affects the sacroiliac joints and the bones of the spine.[7]

Clinical Examination of Ankylosing spondylitis

Appearance of the Patient

• Patients with ankylosing spondylitis usually appear normal.

Vital Signs

• Vital signs are within normal limits in patients with AS.

Cervical spine 

• Forward stooping of the thoracic and cervical spine.
• The degree of flexion deformity is measured by asking the patient to stand erect with heels and buttocks against a wall and to extend the neck while keeping the mandible in the horizontal position and ask the patient to touch the wall.
• The degree of flexion deformity is measured by the distance between the occiput and the wall.

Thoracic spine

• The degree of chest expansion is measured by the range of motion of the costovertebral joints and is measured at the level of the xiphoid process.
• The physician must ask the patient to raise their arms beyond their heads and then ask the patient to maximal forced expiration how much they can and that is followed by a maximal inspiration.
• In normal individuals the expansion is usually >2 cm.
• In normal individuals it is greater than 10 cm.

Lateral spinal flexion

• Physician must ask the patient with AS to standing erect with heel and back against a wall and knees and hands extended and measure the distance between the tip of the middle finger and the floor.
• Then ask the patient to bend sideways without bending the knees.

Schober test

• In patients with AS Schober test is used to measure forward flexion of the lumbar spine.
• Physician must ask the patient to stands erect then a point is placed at the middle of a line joining the posterior superior iliac spines, another mark is made above 10 cm in the midline then ask the patient to bends forward how much they can without bending the knees and measure the distance.
• In normal individuals  should exceed 2 cm.

Sacroiliac joint tenderness

• In AS patients to bring out sacroiliac pain apply direct pressure over the sacroiliac joint.
• Sacroiliac joint tenderness is also elicit by the following
  • Ask the patient to be supine position, then apply direct pressure on the anterior superior iliac spine and, at the same time physician must apply force on iliac spine laterally.
  • Ask the patient to be on the side, then physician must apply pressure to compress the pelvis.
  • Ask the patient to be supine position, physician must ask the patient to flex one of the knees and then to abduct as well as externally rotate the corresponding hip, then apply pressure on the knee which is flexed and this elicit pain on the sacroiliac joint.

Hip joint

• When a patient with AS is exhibiting abnormal gait hip involvement should be suspected.
• In AS patients hip involvement lead to flexion deformities and can be assessed by internal and external rotation of the hip.

Dactylitis

• Dactylitis also called as sausage digits. In AS patients the fingers looks like in appearance.

Lungs

• Restrictive lung disease
• Upper lobe fibrosis

Cardiovascular

• Patients with AS present with following cardiovascular features
  • Valvular heart disease
  • Aortitis
  • Conduction disturbance[8]

Investigation of Ankylosing spondylitis

Diagnosis of Ankylosing spondylitis

• In established AS, radiographs of the sacroiliac joint show irregularity and loss of cortical margins, widening of the joint space and subsequently sclerosis, joint space narrowing and fusion.
• Lateral thoracolumbar spine X ­rays may show anterior ‘squaring’ of vertebrae due to erosion and sclerosis of the anterior corners and periostitis of the waist.
• Bridging syndesmophytes may also be seen.
• Basically, these are areas of calcification that follow the outermost fibres of the annulus.
• In advanced disease, ossification of the anterior longitudinal ligament and facet joint fusion may also be visible.
• The combination of these features may result in the typical ‘bamboo’ spine.
• Erosive changes may be seen in the symphysis pubis, the ischial tuberosities and peripheral joints.
• Osteoporosis and atlanto­axial dislocation can occur as late features.
• Patients with early disease can have normal X Rays, but if clinical suspicion is high, MRI should be performed.
• This is much more sensitive for detection of early sacroiliitis than X­ ray and can also detect inflammatory changes in the lumbar spine.

Diagnosis criteria for Ankylosing Spondylitis:

[1]

The features include i.e.:

• Pain that does not improve with rest.
• Pain that causes sleep disturbance.
• Back pain that starts gradually, before the age of 40 years, and is not caused by injury.
• Symptoms that persist for over 3 months.
• Spinal stiffness in the mornings, which improves with exercise and motion. [3]

Differential Diagnosis of Ankylosing spondylitis

Prevention of Ankylosing Spondylitis

Homeopathic Treatment of Ankylosing Spondylitis

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

Which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improve with homeopathic medicines.

Homeopathic Medicines for Ankylosing Spondylitis:

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

1. Aesculus Hippocastanum – top medicine for ankylosing spondylitis:

• Generally, Aesculus Hippocastanum is a top listed medicine for ankylosing spondylitis.
• This medicine is prepared from a plant commonly called ‘horse chestnut.’
• The natural order of this plant is Sapindaceae.
• The prominent symptom indicating the use of Aesculus Hippocastanum is a pain in the sacrum and the hips.
• Along with this, there is marked stiffness in the lower back.
• The symptoms get worse from rising from the seat, also the person has to make repeated efforts.
• At the same time, there is a sensation as if the back would break.
• Aching pains in the lumbar, sacral also the pelvic region are treated well with homeopathic medicine Aesculus Hippocastanum.

Key indications for using aesculus hippocastanum i.e.:

• Pain in sacrum and hips due to inflammation.
• Besides this, Marked stiffness in the lower back.
• Back pain worse rising from a seat and on stooping.

2. Kalmia Latifolia – for ankylosing spondylitis with constant pain in spine:

• Kalmia Latifolia is specifically a highly beneficial medicine for ankylosing spondylitis.
• This medicine is prepared from the fresh leaves of a plant i.e. ‘Mountain Laurel.’
• The natural order of this plant is Ericaceae.
• It is indicated when there is a constant pain in the spine.
• Pain in the lumbar area and a burning/heat sensation in the lumbar spine is present.
• A feeling of lameness in the back is present.
• Sometimes there is a sensation as if the back would break.
• There is also an intense pain in the neck (cervical spine) along with stiffness.
• The neck feels tender to the touch.
• Kalmia Latifolia is an effective homeopathic remedy for the pain in the neck (cervical spine) which then radiates to the shoulders.
• Early morning worsening of neck pain and stiffness is also present.

Key indications for using kalmia latifolia i.e.:

• Constant pain in the spine.
• Pain in lumbar back attended with heat / burning in the spine.
• Neck pain and stiffness.

3. Rhus Toxicodendron – for morning stiffness in back:

• Rhus Tox is especially a well indicated medicine for ankylosing spondylitis.
• It helps in reducing the stiffness of the back.
• The stiffness is most intense in the morning.
• Sitting also aggravates the stiffness.
• Rhus Tox also works wonders in reducing back stiffness that gets worse from taking rest.
• Here lying or sitting still worsens the stiffness.
• The person requiring Rhus Tox gets relief by walking.
• Pain in the lower back is also severe along with stiffness.
• Rhus Tox is also a natural medicine for managing back pain which gets relieved by the application of hard pressure.

Key indications for using Rhus Tox:

• Intense stiffness in the back.
• Back stiffness that is worse in the morning or due to inactivity.
• Back pain and stiffness that is reduced by walking.

4. Colocynthis – For Hip Pain in Ankylosing Spondylitis:

• Colocynthis is a medicine especially, for ankylosing spondylitis with marked hip pain. Additionally, It is prepared from a plant named ‘bitter cucumber.’
• Moreover, This plant belongs to the family Cucurbitaceae.
• For using Colocynthis hip pain may be cramping, drawing or tearing in nature.
• The pain from hip may also extend down to the knee, leg or even to the feet in a few cases.
• Sensitivity to touch the affected hip is also seen in many cases.
• Colocynthis is also a useful remedy for hip pain that gets better by lying on the affected side.
• In some cases, pressure on the affected hip offers comfort.
• Hip pain that gets better by warmth also indicates the use of homeopathic medicine Colocynthis.
• The person needing Colocynthis also experiences an aggravation of hip pain by sitting, standing, being in motion, and gets relief from rest.

5. Bryonia Alba – When Backache is Worse from Motion:

• Bryonia Alba is another well-indicated medicine for treating ankylosing spondylitis.
• This medicine is prepared from a plant commonly named ‘Wild Hops.’
• The natural order of this plant is Cucurbitaceae.
• A backache that is worse from motion or walking is the guiding feature to use Bryonia Alba.
• In a few cases, stooping, standing and sitting also worsen the backache.
• The relief in back pain is afforded only with absolute complete rest.
• Stiffness is also present along with a backache.
• The stiffness is so intense that a person has to sit and walk in a stooped posture.
• Maintaining an upright posture while sitting/walking is difficult.

6. Agaricus Muscarius – when back is sensitive to touch with pain:

• Agaricus Muscarius is majorly used in ankylosing spondylitis when the spine is sensitive to touch, along with pain.
• The sensitivity of the spine is severe in the morning.
• Other symptoms pointing towards the use of Agaricus Muscarius are back pain getting worse from stooping, a burning sensation in the spine, and a feeling of tightness in the back muscles.
• A lumbosacral backache that is worse during daytime exertion is also treated well with Agaricus Muscarius.
• A marked stiffness in the back is present along with pain.
• There is a sensation as if the back would break.
• Another sensation that may appear is that of a cold or hot needle piercing the back.

7. Kali Carbonicum – for weakness in back:

• Kali Carb is a medicine is especially used to treat ankylosing spondylitis where weakness in the lower back accompanies back pain.
• The pain is present in the lower back, hips, also thighs.
• Besides this, The person feels better by lying down.
• It is also helpful when there is difficulty in turning in bed from a backache.
• Another chief indication to use kali carb is a sharp pain in back extending up and down.

8. Natrum Muriaticum – when lying on the back brings relief:

• Natrum Mur is specifically, another valuable medicine used to treat ankylosing spondylitis.
• The characteristic feature to use natrum mur is relief from back pain upon lying down, especially on a hard surface.
• Other symptoms include difficulty in stooping, a pulsating sensation in the back and pain in the sacrum.
• The person needing homeopathic medicine Natrum Mur may also need firm support on the back.

9. Cimicifuga Racemosa – for ankylosing spondylitis with neck (cervical back) pain and stiffness:

• It is prepared from a plant i.e. black cohosh of natural order Ranunculaceae.
• Cimicifuga Racemosa is used to treat neck (cervical back) pain and stiffness in cases of ankylosing spondylitis.
• A contracted sensation in the neck is present, because the neck is sensitive to touch.
• Pressure seems to worsen the pain in the neck.
• Any motion of the head and hands also aggravates the neck pain.
• Worsening of neck pain from exposure to cold air is also treated well with homeopathic medicine Cimicifuga Racemosa.

10. Calcarea Fluorica – to dissolve osteophytes:

• Calcarea Fluor is a especially indicated medicine for dissolving osteophytes (bony outgrowths appearing in the spine) in cases of ankylosing spondylitis.
• Another symptom that suggests the use of Calcarea Fluor is a back pain that is worse from rest conversely, better from motion.
• Application of warmth may also relieve back pain in a few cases.
• Restlessness along with back pain is also present.

11. Tellurium Met – for sacral pain radiating down the thigh:

• Tellurium Met is a medicine for ankylosing spondylitis with marked sacral pain radiating down the thigh.
• The back is sensitive, so that the pain gets worse from touch.
• A feeling of weakness in the back, and cervical back pain spreading to the shoulder and between the scapulae are other symptoms that indicate the need for this medicine.
• The cervical spine is also sensitive to pressure and touch.

12. Conium Maculatum – for sacral pain from walking a short distance:

• Conium Maculatum is especially indicated when there is a severe aching in the sacral region from walking a short distance.
• Stitching pain in the sacrum when standing, weakness also lameness in the small of the back, tightness in the nape of the neck with pain and stiffness and soreness in the lower cervical spine are also present.
• Pain in the dorsal back between both the shoulders and the lumbar region also indicates the need for this medicine.

13. Guaiacum – for ankylosing spondylitis with stiff neck:

• Guaiacum is a significant medicine for ankylosing spondylitis with a stiff neck.
• It is a plant-based medicine especially, prepared from the plant ‘Guaiacum Officinale.’ Additionally, The natural order of this family is Zygophyllaceae.
• Marked stiffness in the neck is the key feature to use this medicine.
• Pain in the neck and the back (between scapulae) is also treated well with this medicine.
• It is also indicated in some cases where neck pain radiates down the sacrum. [5]

Frequently Asked Questions

What is Ankylosing Spondylitis?

Ankylosing spondylitis (in other words, AS) is characterised by a chronic inflammatory arthritis predominantly affecting the sacroiliac joints and spine, which can progress to bony fusion of the spine.

Homeopathic Medicines used by Homeopathic Doctors in treatment of Ankylosing Spondylitis?

• Aesculus Hippocastanum
• Kalmia Latifolia
• Rhus Toxicodendron
• Colocynthis
• Bryonia Alba
• Agaricus Muscarius
• Kali Carbonicum

What are the symptoms of Ankylosing Spondylitis?

• Pain and stiffness
• Bony fusion
• Pain in ligaments and tendons
• Bent posture
• Breathing problems
• Heart trouble

Give name of the exercise for Ankylosing Spondylitis?

• Back Against a Wall
• Prone Lying
• Seated Thoracic Extension
• Quadricep Stretch
• Seated Figure Four Stretch
• Plank