Spondyloarthropathies

Spondyloarthropathies are a family of long-term (chronic) diseases of joints. These diseases may occur in children (juvenile spondyloarthropathies) or/and in adults. Spondyloarthritis is a type of arthritis that attacks the spine and, in some people, the joints of the arms and legs. It can also involve various organs, most frequently the skin, intestines and eyes. The main symptom in majority of patients is low back pain. This occurs most often in axial spondyloarthritis.

Spondyloarthropathies are sometimes called spondyloarthritis, they include:

• Ankylosing spondylitis – this is the most common form of spondyloarthritis. It attacks joints between the bones that make up your spine (vertebrae).
• Reactive arthritis – often develops after an infection in the urinary tract or digestive system. It tends to attack joints in the lower limbs. Reiter’s syndrome is a type of reactive arthritis that happens as a reaction to an infection in another part of your body. It can include redness, joint swelling and pain, often in knees, ankles, and feet.
• Psoriatic arthritis – affects major joints of the body, as well as the fingers and toes, along with the back and pelvis. It typically happens to people who have a skin condition called psoriasis or who have family members with psoriasis.
• Enteropathic arthritis – joint problems linked to inflammatory bowel disease eg. Crohn Disease. About 1 in 5 people who suffer from Crohn’s or ulcerative colitis will get this form of spondyloarthopathy.
• Undifferentiated spondyloarthropathy – produces symptoms that aren’t as specific as other illnesses in this family. It sometimes develops into a more identifiable form of the disease.

In some cases, in the initial stage of disease particularly, it is difficult to establish diagnosis, however clinical features argument for spondyloarthropaty. "Unclassified" spondyloarthropaty is diagnosed is such case until it is clarified. The various organs, besides joints, are frequently affected in all spondyloarthropaties, e.g. choroid inflammation (choroid is vascular layer of the eye).

Reactive Arthritis

Reactive arthritis (ReA), formerly termed Reiter syndrome, is an autoimmune condition that develops in response to an infection. It has been associated with gastrointestinal (GI) infections with Shigella, Salmonella, Campylobacter, and other organisms, as well as with genitourinary (GU) infections (especially with Chlamydia trachomatis).

Ankylosing Spondylitis Juvenile

Juvenile ankylosing spondylitis is a type of arthritis. It affects children in the spine and the places where the muscles, tendons, and ligaments are attached to bone. Ankylosing means stiff or rigid. Spondyl means spine. Itis refers to inflammation. JAS affects boys and men more than girls and women. It usually happens between the ages of 17 and 35. JAS is a long-term (chronic) condition. Some people will have periods of time in which the disease is not active or mild (remission). Others will have more symptoms ongoing.

Psoriatic Arthritis

Psoriatic arthritis is a form of arthritis that affects approx. 20 - 30 % people who have psoriasis – a condition that features red patches of skin topped with silvery scales. Most people develop psoriasis first and are later diagnosed with psoriatic arthritis, but the joint problems can sometimes begin before skin lesions appear. The illness usually starts between 30 and 50 year of age, however kids may be also affacted.

Joint pain, stiffness and swelling are the main symptoms of psoriatic arthritis. They can affect any part of your body, including your fingertips and spine, and can range from relatively mild to severe. In both psoriasis and psoriatic arthritis, disease flares may alternate with periods of remission.

No cure for psoriatic arthritis exists, so the focus is on controlling symptoms and preventing damage to your joints. Without treatment, psoriatic arthritis may be disabling.

Useful links for the UK patients

	NHS UK → ankylosing spondylitis
	National Ankylosing Spondylitis Society UK → NASS
	Arthrits Research UK → ankylosing spodylitis

Here you may find some more links to read about ankylosing spondylitis:

• F1000 Prime: Daikh ID and Chen PP.: Advances in managing ankylosing spondylits (pdf file 8 pages).
• Physiopedia: Ankylosing spodylitis
• Cochrane: Dagfinrud H, Hagen KB, Kvien TK Physiotherapy for Ankylosing Spondylitis.
• J Can Chiropr Assoc: Ankylosing spondylitis: recent breakthroughs in diagnosis and treatment

Please notice! Ankylosing spondylitis is very important medical issue and hereinafter we have presented some general information about this subject. We have given also several web links where the readers may get more profound information.

Ankylosing Spondylitis

Ankylosing Spondylitis (AS) – synonims: Bechterew disease, Marie-Strümpll disease, lat. spondylitis ankylopoetica, spondyloarthritis ankylopoetica – is a chronic form of arthritis that primarily affects the spine, although other joints may become involved. Ankylosing spondylitis has autoimmune background and belongs to the seronegative spondyloarthropaties. It causes inflammation of the spinal joints (vertebrae) that may produce severe, chronic pain and discomfort, and can lead to disability.

AS is chronic and progressive connective tissue disease of autoimmune background. It affects small intervertebral joints, intervertebral ligaments and sacroiliac joints leading to their hardening (ankylosing). Inflammatory process of AS, however chronic and progressive, has periods of exacerbation (aggregation) and longtime remissions.

Symptoms

It is important to note that the course of ankylosing spondylitis (AS) varies greatly from person to person. So too can the onset of symptoms. Although symptoms usually start to appear in late adolescence or early adulthood (ages 17 to 45). However, symptoms can occur in children or much later in life. Men are more often affected (2 - 3 times). Estimates of the prevalence of AS vary but it is likely that the prevalence in the UK adult population is approximately 0.2% (according to Mouyis M, Keat A, ankylosing spondylitis GM, 42, December, 2012). Men predominate, but with a sex ratio of 3:1, it is not the much higher ratio that was once thought to apply. Thus a Trust serving 500,000 adults should expect that 1000 people with AS live within the area. To this must be added others with related forms of spondyloarthritis and an unknown number of undiagnosed cases. The beginning of illness is not or hardly noticed usually. Following symptoms may be observed in the early phase of ankylosing spondylitis:

• Dull pain in the sacro-lumbal area radiating to buttocks
• Pain intensification during night and early morning
• Symmetric pain (both sides), increasing after rest
• Morning spine stiffness
• General weakness and fatigue
• Low grade fever (subfebrile state)
• Loss of appetite
• Body mass loss

As the illness progress another symptoms may appear. The most common joint symptoms are: pain in lower back and/or buttocks region, symmetric usually, aggravating during night time, diminishing after physical exercise (activity) and increasing after immobilisation.

Pain in the chest while deep breathing (pain is radiating from the spine along the ribs, mobility reduction and afterwards immobilisation of neck segment of the spinal column, gradually progressive pain symptoms in another segments of spinal column (involving the whole spine).

Proximal joints are affected (in approx. 25% of cases), typically large joints and more rarely small ones. Pain in heels (approx. 40 % of cases), pain and swollenness in sternoclavicular joints, pain and stiffness in ribs’ regions.

Markers of Akylosing Spondylitis

Serum and plasma biomarkers have been examined extensively in assessing disease activity, treatment response, and as predictors or radiographic severity. We have presented ptential biomarkers for AS in the table below. Some markers, like e.g. CRP, ESR are very well known and used for years to monitor activity of inflammatory process. Some other biomarkers are new and still under evaluation.

AS – ankylosing spondylitis, AxSpaA – axial spodyloarthritis, TNF – tumor necrosis factor, YKL-40 - is secreted glycoprotein – chitinase-3-like protein 1 (CHI3L1). YKL-40 is novel biomarker, it is expressed and secreted by various cell-types including macrophages, chondrocytes, fibroblast-like synovial cells, vascular smooth muscle cells, and hepatic stellate cells. The biological function of YKL-40 is unclear. Its pattern of expression is associated with pathogenic processes related to inflammation, extracellular tissue remodeling, fibrosis and solid carcinomas, diabetes and asthma.

To read more see a papper by John D. Reveille: Biomarkers for diagnosis, monitoring of progression, and treatment responses in ankylosing spondylitis and axial spondyloarthritis Clin Rheumatol. 2015 Jun; 34(6): 1009–1018.

Diagnosis

Diagnosis is based on medical examination (reported symptoms, history (anamnesis) and physical examination), x-ray imaging and lab tests.

HLA-B27 testing plays a role in the diagnosis of spondyloarthropaties. HLA – Human Leukocyte Antigen B27 is a protein located on the surface of your white blood cells. An HLA-B27 test is a blood test that identifies HLA-B27 proteins. Test is sensitive, however not highly specific. The presence of HLA-B27 is associated with certain autoimmune and immune-mediated diseases, including: (1) ankylosing spondylitis, (2) reactive arthritis, (3) juvenile rheumatoid arthritis, (4) anterior uveitis.

Treatment

Ankylosing spondylitis has significant impact on all aspects of patient's life. Active disease has been correlated with reduced quality of life and work disability, and progressive syndesmophyte formation can result in greatly reduced functional status. The goal of both non-pharmacologic and pharmacologic therapy is to halt disease progression as determined by clinical symptoms, radiographic disease, and serologic inflammatory markers. Treatment of ankylosing spondylitis is a complex and interdisciplinary issue and has to be managed by experienced rheumatologist.

Physical therapy is an essential part in the treatment of AS. It aims to alleviate pain, increase spinal mobility and functional capacity, reduce morning stiffness, correct postural deformities, increase mobility and improve the psychosocial status of the patients. Treatment of ankylosing spondylitis is a complex and interdisciplinary issue and has to be managed by experienced rheumatologist.

The Global Postural Reeducation method has shown promising short- and long-term results and includes specific strengthening and flexibility exercises. A global and functional approach is more efficient than localised exercises in AS patients. Multiple systematic reviews and studies have shown that exercise can improve pain, physical function, spinal mobility, and patient global assessment. In addition, supervised physical therapy with individual or group exercise is better than home exercise in improving functional status.

Patient education and counseling about abstinence and smoking cessation are also key non-pharmacologic interventions for AS because cigarette smoking has been shown to be an independent risk factor for radiographic progression.