Axial Spondyloarthritis
1. Introduction
Axial Spondylarthritis (AxSpA) is a general term for forms of inflammatory arthritis. You may also see this called Ankylosing Spondylitis.
It’s a progressive form of inflammatory arthritis and mainly affects the lower back which tends to present with certain signs and symptoms as detailed below (3). You should seek medical advice if you also have a current or history of inflammatory bowel disease (Crohn’s disease or ulcerative colitis), psoriasis or uveitis (red/painful eye) (4).
Frequently Asked Questions
Axial Spondyloarthritis (AxSpa) is an umbrella term for inflammatory arthritis affecting the spine and sacroiliac joints. It is a long-term condition, diagnosis of which is supported a history of stiffness, functional impairment and fatigue. Radiographic evidence and certain blood tests can aid diagnosis.
- 1 in every 200 of the adult population will be found to have AxSpa.
- Less than 0.5% of the adult population in the UK (1).
- Moderately.
- The condition is not curable and it is important that if you believe you have the symptoms that you see your GP who may refer you to see a specialist.
- With the right rehabilitation and medical approach this condition can be managed well.
- It most commonly begins between 20 and 30 years of age. 90–95% of people are aged less than 45 years when diagnosed (6).
- Current figures show that the same number of males and females are affected.
- People with an immediate family history of inflammatory conditions are more likely to have this (2).
- Constant, persistent lower back pain and/or stiffness for longer than 3 months.
- Pain typically improves with exercises and anti-inflammatories.
- Waking second half of the night due to symptoms.
- In addition, you may have other symptoms including a current or history of inflammatory bowel disease (Crohn’s disease or ulcerative colitis), psoriasis or uveitis (red/painful eyes).
- Fatigue.
- Dactylitis (swelling of a finger or toe) (2, 3, 4, 5).
There are many things you can do to help recover:
- Seek advice from your GP/Physiotherapist.
- Exercises prescribed by your physio can maintain mobility.
- Depending on the severity of your symptoms your doctor may need to give you a combination of medications to help you with the pain, stiffness and inflammation (3).
- Unfortunately, this is a long-term condition and is non-curable, however there are many things you can do to help manage the symptoms.
- Good management can reduce the effect of the condition on your ability to perform normal daily activities.
- Continue reading for more information and links to useful resources.
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk. Book online with us today to get a programme tailored to your specific needs.
2. Signs and Symptoms
- Tends to present in younger adults (aged under 45).
- Slow or gradual onset of low back pain and stiffness which is constant and persists for more than 3 months.
- Waking during the second half of the night because of your symptoms.
- Current or past psoriasis.
- Current or past enthesitis (inflamed joints/tendons).
- Improvement within 48 hours of taking anti – inflammatory’s
- Improvement with movement.
- Buttock pain (2).
3. Causes
Axial spondyloarthritis happens when the body’s immune system starts to cause inflammation in the joints and the area around them. Why this happens is not fully understood, but research shows that it can run in families (3).
4. Risk Factors
An immediate family history or first degree relative with ankylosing spondylitis, psoriatic arthritis or rheumatoid arthritis raises the suspicion of having this condition. If you are unsure, your musculoskeletal Physiotherapist or GP may get an understanding by asking questions about both your symptoms and other family members.
5. Prevalence
Each year, a GP may only see one person presenting with a new onset of AxSpa making it a challenge to diagnose (3). Cases of ankylosing spondylitis is believed to range from 0.05% to 0.23% in the general population (1).
6. Assessment & Diagnosis
Before further investigations, your musculoskeletal physiotherapist will assess for the signs/symptoms associated with AxSpa.
A Rheumatologist is a specialist in conditions affecting muscles and joints, they may be required to carry out further tests that may include X-ray, MRI and blood tests.
The tests can help to differentiate between forms of AxSpa which include:
- Ankylosing Spondyloarthritis (AS) – Where there are visible changes to your spinal x-ray mainly inflammation to your sacroiliac joint (one or both). Sometimes the presence of a specific gene in your blood called HLA-B27.
- Non-Radiographic Axial Spondyloarthritis – Where there are no changes in x-ray but visible inflammation following an MRI scan (5).
7. Self-Management
There is no cure for this condition however treatment is available to relieve symptoms and help prevent its progression. Your musculoskeletal physiotherapist will answer your queries regarding your condition, assess your posture and range of movement. They will also suggest useful strategies for managing your activity levels so that you are able to control your symptoms. Regular re-assessment will ensure you are maintaining health, fitness and function and will allow for changes to be made to your treatment programme.
8. Rehabilitation
Research is clear that remaining active within limitations will help manage your AxSpa symptoms. Aerobic exercises such as walking, swimming, and cycling will help improve your posture, chest expansion and overall fitness (3). It is equally important to stay strong and flexible. Any exercise you decide to undertake needs to be regular, consistent, and kept up with over the long-term so it is important to choose something you enjoy.
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at helping patient diagnosed with AxSpa. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point.
9. Axial Spondyloarthritis
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme focuses on improving/maintaining range of movement within the hips and spine. It is important not to further irritate your symptoms and to pace yourself. We suggest you carry these exercises out daily prior to progressing onto the next stage of rehabilitation when your pain and function allows.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This is the next progression. More focus is given to progressive loading of the lower back and hips. It remains important not to further irritate your symptoms and pace yourself as you progress into doing these exercises so always progress as able.
- 0
- 1
- 2
- 3
- 4
- 5
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- 8
- 910
This programme is a further progression with challenging progressive loading of the lower back and hips. It remains important not to further irritate your symptoms and pace yourself as you progress into doing these exercises.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
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- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from further assessment to ensure you are making progress and establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage.
11. Other Treatment Options
Medications – Often you will be started with lowest effective dosage of medication to manage the inflammation along with protective medication for your stomach. If your Rheumatologist thinks that you have a form of Axial Spondyloarthritis then they may start you on medications known as Disease Modifying Anti-Rheumatic Drugs (DMARDS) to slow down the disease progression. However, please note that DMARDS is an umbrella term for several medications which comes under this category (3).
Surgery – This is not recommended unless your symptoms are significantly affecting the quality of your life and worsening/progressing despite optimal conservative treatment as outlined above (3).
12. Links for Further Reading
- National Axial Spondylitis Society – https://nass.co.uk/
https://nass.co.uk/wp-content/uploads/resources/81955-NASS-Guidebook-for-Patients.pdf - https://www.nhs.uk/conditions/ankylosing-spondylitis/
- https://www.versusarthritis.org/media/1247/ankylosing-spondylitis-information-booklet.pdf
- https://www.nice.org.uk/guidance/ng65/ifp/chapter/Spondyloarthritis-the-care-you-should-expect
25 locations and counting across the UK
References
- NICE (2016) TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis. Technology appraisal guidance [TA383]. National Institute for Health and Care Excellence.
- BMJ (2017) Guidance for primary care: Identifying and referring Spondyloarthritis
- NICE Guidelines (2017) Spondyloarthritis in over 16s: diagnosis and management
https://www.nice.org.uk/guidance/ng65/chapter/Recommendations - Murphy, S. N., Nguyen, B. A., Singh, R., Brown, N. J., Shahrestani, S., Neal, M. T., Patel, N. P., & Kalani, M. A. (2022). A brief human history of ankylosing spondylitis: A scoping review of pathogenesis, diagnosis, and treatment. Surgical Neurology International, 52(5), 749-756.
- NICE Guidelines (2019) Ankylosing spondylitis. https://cks.nice.org.uk/topics/ankylosing-spondylitis/#!diagnosisSub
- Sieper, J. and Poddubnyy, D. (2017) Axial spondyloarthritis. Lancet 390 (10089), 73-84
- Crossfield, S. S. R., Marzo-Ortega, H., Kingsbury, S. R., Pujades-Rodriguez, M., & Conaghan, P. G. (2021). Changes in ankylosing spondylitis incidence, prevalence and time to diagnosis over two decades. BMJ. 53(4), 650-657.
Other Conditions in
Long Term Conditions
Thumb Osteoarthritis
Thumb osteoarthritis (OA) is degeneration of the cartilage that covers the ends of the bones that form the joint, which creates pain and stiffness.
Spondylolisthesis
A term to describe a slight change in position (usually further forward) of one vertebra relative to the vertebrae below.
Shoulder Osteoarthritis (OA)
Age and activity related changes to the joints of the shoulder which can lead to pain and stiffness.
Scoliosis
Scoliosis is a sideways curvature of the spine that occurs most often during the growth spurt just before puberty.
Posterior Tibial Tendon Dysfunction
The main arch of the foot loses its height giving the appearance that the foot sits flat on the floor.
Polymyalgia Rheumatica (PMR)
A rare inflammatory condition affecting joints and surrounding muscles, usually affecting hips and shoulders.
Pelvic Girdle Pain
Typically seen in pregnancy causing pain, instability and limitation of mobility and functioning of the pelvic joints.
Pelvic Floor Dysfunction
The inability to effectively control the muscles of your pelvic floor, leading to issues with continence and pain.
Osteoarthritis
Osteoarthritis is the broad term given to pain, stiffness and loss of a function of a joint due to changes associated with the ageing process.
Lumbar Spine Osteoarthritis (OA)
Lumbar Spinal Stenosis
Narrowing of the spaces though which lower back spinal nerves travel which can result in weakness, pain and reduced function.
Long Covid
A term to describe the effects of Covid-19 that continue for weeks or months beyond the initial illness.
Knee Replacement Surgery
Replacement of the knee hinge joint, typically as a result of severe osteoarthritis or trauma.
Knee Osteoarthritis
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Hip Replacement Surgery
Replacement of the hip ball and socket joint, typically as a result of severe osteoarthritis or trauma.
Hip Osteoarthritis
Common age-related changes to the structure of the hip joint may be associated with pain, stiffness and loss of function.
Fibromyalgia
A persistent pain disorder that is characterised by pain affecting multiple areas of the body.
Degenerative Rotator Cuff Tear
A common cause of shoulder issues as we age, one of the tendons that insert into the shoulder joint can be damaged.
Complex Regional Pain Syndrome
A rare condition where a person experiences persistent, severe and debilitating pain, often with a complex cause.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.