Axial spondyloarthritis

What is axial spondyloarthritis?

Spondyloarthritis

Spondyloarthritis is a type of inflammatory arthritis. This happens when the body's immune system, which is meant to keep us well by fighting infection, starts to cause inflammation in the joints and the areas around them, causing damage.

There are two main types of spondyloarthritis:

• Axial spondyloarthritis, which mainly causes pain and stiffness in the spine and sacroiliac joints.

• Peripheral spondyloarthritis, which mainly causes pain, stiffness and swelling in the hands, feet, arms and legs.

Some people with axial spondyloarthritis also have peripheral symptoms and some people with peripheral spondyloarthritis have back symptoms.

Axial spondyloarthritis

If arthritis of the sacroiliac joints (pelvis) or spine and sacroiliac joints can be seen on X-ray, the term used is radiographic axial spondyloarthritis (r-axSpA). This condition is also called ankylosing spondylitis. See also the separate leaflet called Ankylosing Spondylitis for more information.

If there are no signs of sacroiliitis on X-ray but there is evidence of inflammation in the joints on magnetic resonance imaging (MRI) scan, the term used is non-radiographic axial spondyloarthritis (nr-axSpA).

Some people with nr-axSpA go on to develop r-axSpA. It is estimated that this occurs in about 1 in 20 within 5 years, and 1 in 5 within 10 years.

How common is axial spondyloarthritis?

Axial spondylitis most often begins between 20 and 30 years of age. Nearly all people affected by axial spondyloarthritis are aged less than 45 years when the disease first appears.

About twice as many men as women have ankylosing spondylitis. However, non-radiographic axial spondyloarthritis affects a similar number of women and men.

What causes axial spondyloarthritis?

The exact cause of axial spondyloarthritis is not clear. Researchers believe that people with certain genes develop axial spondyloarthritis when they are exposed to a certain virus, bacteria or other environmental trigger.

More than 9 out of 10 people with axial spondyloarthritis have a gene called HLA-B27. But most people who have this gene never develop axial spondyloarthritis.

What are the symptoms of axial spondyloarthritis?

Low back, buttocks and hip pain are usually the first symptoms. The symptoms of axial spondyloarthritis include:

• Pain in the low back, buttocks and hips that develops slowly over weeks or months.

• Pain, swelling, redness and warmth in the toes, heels, ankles, knees, ribcage, upper spine, shoulders and neck.

• Stiffness when first waking up or after long periods of rest.

• Back pain during the night or early morning.

• Pain that gets better with exercise but doesn't improve with rest.

• Non-steroidal anti-inflammatory drugs (NSAIDs) usually work well to relieve the pain.

• Fatigue.

• Appetite loss.

Some people with axial spondyloarthritis also develop symptoms of peripheral spondyloarthritis.

What other conditions are associated with axial spondyloarthritis?

People with spondyloarthritis also have an increased risk of developing other conditions, including:

• Cardiovascular disease, including heart disease (eg, angina and heart attack), cerebrovascular disease (transient ischaemic attacks and stroke) and peripheral arterial disease.

• Thinning of bones (osteoporosis).

• Psoriasis.

• Inflammatory bowel disease (Crohn's disease and ulcerative colitis).

• Certain infections, such as some stomach bugs or sexually transmitted infections (STIs)

• A painful eye condition called uveitis.

How is axial spondyloarthritis diagnosed?

Axial spondyloarthritis can be difficult to diagnose and there is no one single test that confirms or rules out the diagnosis. Investigations include:

• Blood tests, which may include an HLA-B27 test.

• X-rays: radiographic axial spondyloarthritis (ankylosing spondylitis) is suggested by X-ray changes of the sacroiliac joints and spine.

• MRI scanning: in some people with symptoms of axial spondyloarthritis, inflammation of the sacroiliac joints can be detected on MRI despite X-rays having appeared normal. The diagnosis is then non-radiographic axial spondyloarthritis.

How is axial spondyloarthritis treated?

There is no cure for axial spondyloarthritis, but treatment aims to:

• Relieve pain and stiffness in the back and any other affected areas.

• Keep your spine straight.

• Prevent joint and organ damage.

• Preserve joint function and mobility.

• Improve your quality of life.

Early, treatment is very important to prevent long-term complications and joint damage. Treatments include medication, non-drug therapies, healthy lifestyle habits and, rarely, surgery.

Self-care

Because of the increased risk of cardiovascular disease, it is even more important to reduce your risk of cardiovascular disease:

• Eat a healthy diet. Eating anti-inflammatory foods, like the ones found in a Mediterranean diet may help.

• Avoid smoking. Smoking worsens overall health, and it can speed up disease activity and joint damage. It can also make it harder to breathe. Consult your doctor about ways to help you quit.

Regular physical activity helps prevent stiffness and preserves the range of movement in your neck and back. Activities such as walking, swimming, yoga and t'ai chi can help with flexibility and posture.

Good posture can help ease pain and stiffness. Simple changes such as adjusting the height of your computer monitor or desk can help. Avoid staying in cramped or bent positions, and try to alternate between standing and sitting positions.

Stretching exercises can help to relieve pain and stiffness.

Pace your activities depending on how you feel. Take short breaks throughout the day if you're feeling tired.

Physiotherapy and occupational therapy

Physiotherapy will help you to develop an exercise plan, and teach you to strengthen and stretch your muscles to help you stay mobile and reduce pain.

Occupational therapists can assess whether any assistive devices will help you, and give you advice on how to protect your joints and make daily tasks easier.

Medications

Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs are the most commonly used drugs to treat axial spondyloarthritis and help relieve pain. Examples of NSAIDs are ibuprofen, naproxen, indometacin, diclofenac and celecoxib.

Other painkillers
Other painkillers such as paracetamol may also be used to help reduce pain.

Biological medicines
Biologics can be used to control the disease process. The main ones used for axial spondyloarthritis are called tumour necrosis factor (TNF) inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab or infliximab).

If you are unable to take a TNF inhibitor or they are not effective then other medicines, such as secukinumab or ixekizumab, may be used.

Steroid injections
Injecting steroids into a knee or shoulder can provide relief of pain and stiffness.

Surgery

Most people with axial spondyloarthritis will not need surgery. But joint replacement can help people with severe pain or joint damage. Surgery may also help straighten a severely bent forward spine.

What are the complications of axial spondyloarthritis?

In addition to the increased risk of associated conditions as outlined above, there is:

• Increased risk of fractures of the spine.

• For a small number of people with chronic progressive disease, development of significant disability due to new bone forming that causes the bones of the spine to fuse together (spinal fusion).

• The complication of experiencing side-effects from the medicines used for treatment.

People with persistent and severe symptoms of axial spondyloarthritis may have a reduced quality of life due to pain, stiffness, fatigue and sleep problems.

What is the outlook for axial spondyloarthritis?

There is no cure for axial spondyloarthritis and the outlook (prognosis) tends to be variable. The pattern of symptoms within the first 10 years of disease often suggests the likely long-term severity of symptoms and disability.