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Ankylosing Spondylitis; Ankylosing Spondylitis Symptoms & Ankylosing Spondylitis Treatment

In this episode we discuss the aetiology of ankylosing spondylitis and the common symptoms that are experienced by those suffering from this condition. We highlight the common investigations involved in diagnosing AS as well as the long-term prognosis of the disease. In addition, we discuss a pro-active approach to managing AS which includes the use of exercise as well as diet in the management of disease progression. Whilst there is limited scientific support for the dietary management of AS, improving gut health, and nutrition are proving increasingly important in the management of chronic inflammatory conditions.

Ankylosing Spondylitis; Ankylosing Spondylitis Symptoms & Ankylosing Spondylitis Treatment

Welcome to the Back Pain Solutions Podcast – Ankylosing Spondylitis; Anklyosing Spondylitis Symptoms & Ankylosing Spondylitis Treatment

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Episode Introduction

Alongside mechanical lower back pain there are several conditions that result in pain, and stiffness, in the back which need to be considered during diagnosis. One condition which targets the lower back specifically is ankylosing spondylitis. Ankylosing spondylitis is a progressive form of inflammatory arthritis which mainly affects the spine but can also affect other joints, tendons and ligaments. It’s a condition that affects young people with symptoms starting in the late teens to early twenties, and with the average age of onset being 24.The current average delay to diagnosis from when symptoms start is 8.5 years, by which time irreversible damage to the spine may have occurred! As a result, early conservative management of people with suspected AS is important.

In this episode we discuss the aetiology of ankylosing spondylitis and the common symptoms that are experienced by those suffering from this condition. We highlight the common investigations involved in diagnosing AS as well as the long-term prognosis of the disease. In addition, we discuss a pro-active approach to managing AS which includes the use of exercise as well as diet in the management of disease progression. Whilst there is limited scientific support for the dietary management of AS, improving gut health, and nutrition are proving increasingly important in the management of chronic inflammatory conditions. Given the average time to diagnosis, and the irreversible changes that will have occurred at that timepoint, we discuss the potential role that diet could play in the proactive management of this condition. Finally, we introduce a case study highlighting successful disease management by a lady who made specific dietary choices, as well as other lifestyle decisions, in support of her condition. 

Some of the things you’ll discover…

  • What is ankylosing spondylitis and what are the symptoms to be aware of?
  • How is ankylosing spondylitis diagnosed, and what is the time to diagnosis?
  • Radiographic versus non radiographic AS. What is the difference between the two?
  • What is the average age of onset of ankylosing spondylitis and is it influenced by gender?
  • Who is likely to manage the condition and what is the approach to disease management? 
  • Can exercise play a role and what considerations should be made with regards exercise prescription?
  • Could diet play a role in the prevention, as well as management of ankylosing spondylitis?

Episode Highlights

The average time to diagnosis of ankylosing spondylitis is 8.5 years and it is a progressive condition. Given this timeline there must be a big focus on the conservative management of this condition, as early as possible. Whilst nutritional research around the management of ankylosing spondylitis is limited, there is anecdotal evidence that it can play a role in the management of this condition. There are several success stories that have been shared online that support the impact nutrition can have on limiting disease progress. Whilst the recommendation is to follow the advice of your doctor it would certainly make sense to consider all options, especially given the duration of time it takes for a diagnosis to be made! Don’t waste time waiting for the diagnosis, take action!

Episode Transcription

Unknown Speaker 0:00
When we’re young, we move with freedom and confidence with a great resilience to injury. But somewhere along the line we develop poor habits and become more vulnerable to back pain. Back Pain solutions features evidence based and practical advice to help you take back control of your health and get back to the activities you love. This is your guide to better back health through movement. So join us as we demystify some of the commonly held beliefs about back pain and build your confidence to a stronger back the smartway.

Ben James 0:28
Okay, welcome back to the back pain solutions podcast everybody with me, Ben James. And as always my co host, Jacob Steyn. Good morning, Jacob.

Jacob Steyn 0:35
Good morning, man.

Ben James 0:36
So today we’re talking ankylosing spondylitis. We had a question from one of our listeners regarding the potential, or of them suffering from ankylosing spondylitis. We’ve talked a lot about stiffness, particularly in a morning when you wake and when those discs are hyper hydrated. And that causes stretch and causes some stiffness and why you should be careful during that first 30 minutes of the day. But stiffness, particularly in the low back is often a symptom of ankylosing spondylitis. So a listener got in touch, and asked that question, could I be suffering from ankylosing spondylitis. So that is the topic for discussion in today’s show. But as always, before we start, head on over to the website, www.smartstrand.co.uk. Take advantage of our free book, start taking back control of your back health within the next seven days and great video content, and links there to help you on your journey to recovery. So ankylosing spondylitis so Jacob, it’s a progressive inflammatory arthritis mainly affects the spine affects other joints, tendons, ligaments, but it’s it’s a condition which takes some time to diagnose. I read up when I was looking at a bit of research that it takes on average 8.5 years to actually get a diagnosis.

Jacob Steyn 2:01
That’s a long time.

Ben James 2:03
Exactly. It is a long time. Have you have you yourself seen any patients that have been referred on for further imaging; testing and things in your time in practice?

Jacob Steyn 2:14
One, actually, okay. And that’s a long, long time ago, it’s it’s roughly 10 years ago, and I remember quite well, but only one person.

Ben James 2:23
Okay, no interesting. And I’ve never seen anyone specifically. But, you know, that’s not to say that potentially someone hasn’t come through the clinic door, you know, and had these kind of very early stage symptoms. And it’s because of this length of time to diagnosis. It’s it’s just not it’s not being the initial working diagnosis, should we say of that condition? And I guess, why is that? I guess is the is the question. And that is largely a result of the way that the condition works.

Jacob Steyn 2:54
Yeah. I think we can assume, as we’ve discussed earlier, that if it takes, on average, eight and a half years before somebody is diagnosed with AS, that it would probably be quite progressive at that point.

Ben James 3:08
Well, this is good. Yeah, great point. And I think this is certainly a focus for us to discuss during the show in terms of the kind of conservative management of this condition and what we can be doing proactively. If even there is a suspicion of this condition, given that it can take so long to actually have a definitive diagnosis, like you say, by that point, we’re likely to have got some significant progressive changes in the structure as a result of this condition in the back. And the reason for that is the way that this condition works is, as we say, is it is an inflammatory condition. And it very much targets the sites where ligaments or tendons attach to bone. And this is known as and thesis where there’s inflammation in those ligaments and tendons. Now, the inflammation is followed by some wearing of the bone at the site of attachment. And that’s known as anti soft. And as that inflammation then reduces, a healing process takes place in new bone develops. So therefore, as you can imagine, if you’re replacing some of those ligaments, tendons, by bone or bones within those ligaments, tendons, then you’re going to start to get stiffness. And that’s going to start to affect movement and can start to cause some discomfort. So the repetition of this inflammatory process leads to further bone formation. The individual bones that make up your backbone can start to fuse together. And this is why as part of the diagnosis of this condition, often you’ll look for radiographic changes. So you’ll have an X ray and you’ll start to see some of these changes as a result of that bone being laid down. And one of the classic kind of radiographic images is that kind of Bamboo spine, where you’ll see those ligaments tendons, starting to calcify, you’ll see on X ray that they’re more bone like, and that, as you can imagine, will lead to stiffness reduced motion. And because of the chronic inflammatory process behind this discomfort and pain, so it’s not always the case, though, that you will see these radiographic changes. So there’s a radiographic as well, whether changes to sacroiliac joints in the spine can be seen on X ray, but non radiographic is where you’ll you won’t see those X ray changes. But inflammation is visible on MRI. So it’s a, it’s an interesting condition. And around seven in 10, people have non radiographic, axial spawn the spondyloarthritis, and around three and 10, will have inflammation visible on MRI. And as we say, the average time to diagnosis is 8.5 years and the average age of onset depending on where you read and what literature you read is around 24 years of age. So it is a condition that you’re more likely to experience those symptoms, late teens, early 20s. So if you are listening, and you’re starting to feel stiffness and discomfort, and you’re later on 30s 40s, then much less likely is that going to be as but as we say, because of the progressive nature of this condition, you start with some maybe minor symptoms of stiffness and, and pain. But what we find is rest tend to help with as exercise often helps to reduce discomfort. So if you’re somebody that finds that the pain and the discomfort reduces with exercise, then that can be a sign that leads us down this route of diagnosis. But it is very much a diagnosis of elimination more than anything else. And I think one of the key things from a stiffness point of view is you’re not just going to experience that stiffness first thing in the morning. For a lot of back pain sufferers. We talked about that first 30 minutes of the day, as I said in the introduction, but with as that stiffness, it may alleviate a little bit having got it because you’re moving around. So it’s back to that kind of exercise. But you will notice and experience that stiffness, generally more regularly throughout the day, I think is a key differentiator. But so what is the what is the management I guess is the question. You know, what, what we don’t want to do is when we consider a patient that’s going through this process, let’s say does is suffering from AS, but hasn’t had that diagnosis, if it’s going to take 8.5 years, for an actual definitive diagnosis that’s a significant time frame where this calcification and this process of ligaments becoming more bone like is, is going to be happening. So we want to be conservatively looking at this and trying to reduce those symptoms and try and keep and restore that that motion as much as possible. So what are the things that we consider Because ultimately, once you, once you have a diagnosis, you’re likely to see a rheumatologist, they specialize in conditions of this type. And you’re likely to be given some form of medication. Now, sometimes that’s going to be for pain management. Sometimes that’s going to be disease modifying anti rheumatic drugs demands, different medications that will help to manage that con edition, outside the scope of this podcast, we’re not focused on their medications specifically. But you’re going to be a fair way down the track before you get some of these medications, and they certainly won’t reverse the condition, they certainly won’t prevent potential progression. So it is very much a management of the condition at that point. So really, we want to be looking at the things that we can do to help manage that condition conservatively in the early stages. And exercise if it’s going to help reduce those symptoms, which it does is an obvious place, an obvious place Jacob to start, and we wouldn’t advise doing anything really that much different to what we do already in terms of low back pain management, and developing the core and that focused, functional approach.

Jacob Steyn 9:46
And I would like to mention, and we didn’t mention that it’s more often occurs more often in men and women.

Ben James 9:53
Good point yeah,

Jacob Steyn 9:54
A Fair. A fair bit more even though my patient 10 years ago was was a lady, young lady But and then I also would like to add the medications are there to generally slow down the disease process. So it doesn’t generally halt it or reverse it, like you mentioned, but it actually just slows down the progression. y

Ben James 10:21
Yeah.

Jacob Steyn 10:21
I think, you know, very interesting this, this patient I had was quite, it was interesting to have her as a patient because her story story was quite remarkable. She was diagnosed after a few years of having it obviously, took some time, I remember that. And then she changed the life, she went into, you know, training regularly doing weight training, change her diet, change her diet completely. As I remember, I remember she wrote me a report, I asked her to write me a whole report, a little bit of a timeline of what she went through, because it was a very interesting case for me. And she literally worth the checkups after that. I don’t know how often she went back to have a look at the progression of the disease, but I completely stopped. So she, she halted the disease process. And that was significant. That was very interesting for me at that point. And, as you know, 10 years ago, it was it was the belief that we many of the diseases and problems that we know these days, that we can turn back or halt the disease process, were believed not to be possible.

Ben James 11:38
Yeah, there’s a lot more now, a lot more focus on the kind of chronic inflammatory conditions, not just as, but others that that are influenced by diet and a more conservative, non traditional, shall we say, medical approach or not medical approach at all, when we’re looking at specifically nutrition? So I think that’s an interesting point that we, we want to discuss here, because definitely, there’s some anecdotal evidence and stories online of others that have done exactly that. So like you this condition, you know, otherwise is, is progressive, but we’re just trying to hold the disease process with a medical approach. So we’re not preventing it, we’re not stopping it, we’re not reversing it. It’s just how can we control the symptoms? How can we control the disease process to avoid it being as rapidly progressive as it could be? And that’s not to say it will be because in some patients, they they don’t experience that progressive change? or certainly, it’s only mild, whereas others it is, it is more rapid. So again, it’s not absolute, how this disease process is going to progress in different individuals. So that’s interesting about the story of your patient, Jacob with regards to the changes, because I think there’s that’s another point here with as with any condition, there’s a psychological element, is there a positive optimistic attitude to trying to look at the most beneficial ways that you can help yourself with something like this? Or is there a negative kind of, this is something I’ve got now, I’m just going to accept it. And, you know, I’ll do what I’m told in terms of medication, but I won’t really look at any other any other ways that I could potentially manage this myself and know that, as with any condition or any illness, that psychological component is always there, and is always something to consider, both as a clinician, but certainly, as an individual. So it’s a it’s an interesting story of, of success, I guess, from somebody that presumably, with your patient had the definitive diagnosis of, of as they went down that route, and were given that definitive diagnosis we can issue.

Jacob Steyn 14:06
Yeah, and I think that’s a very good point, you’re always then in front of those two paths, you know, you you can choose whether you just obey and follow the typical advice and medical regime prescribed, or whether you just look a little bit further, I’m not saying you shouldn’t take the medication, but we know now that there are so many other possibilities to to, for example, bring down the inflammation, inflammatory process to make sure that the body regulates the inflammatory process better. And these, these these are, you know, these are, it’s a very big factor in any inflammatory arthropathy or inflammatory diseases that anybody can have. So, even if you look, if you look outside the scope of ankylosing spondylitis any inflammatory process these days, even if you look at diabetes, how much has been achieved in the understanding of what we can do with? With diet? It’s just phenomenal in the last 10 years.

Ben James 15:12
Yeah, no, it’s it is certainly a fascinating subject in terms of that proactive, I guess there’s an element of A, looking at things differently when the when that disease process is already there. And looking at the management of that difficulty with things like diet and lifestyle advice and things. But there’s also for me, now, that real focus and drive to help educate people and support people and hopefully inspire people to prevent these things, because we just know, now, increasingly, how successfully we can be preventing conditions in the first place, if we just change a few things. And we’re not, we’re not always having to change things drastically. But certainly, taking a bit more of a proactive approach just makes sense, because the incidence of things like type two diabetes and obesity are just so significantly high now. And the impact of that not just from the quality of life of individuals, but economically is is just staggering. So I think it’s definitely needs to be more of a focus. And, you know, back to the as subjects, you know, why shouldn’t we be looking at those opportunities, particularly, again, back to the drive home, the point, this kind of average time to diagnosis is, in the years, we’re talking nearly a decade, 8.5 years, based on some of the research is the average. So we don’t want to just simply wait if we can look at opportunities to, to conservatively manage this condition and exercise. Now, as we said earlier, is is one of those one of those treatment options. And we know that exercise helps to reduce those feelings of discomfort. This is where there’s an element of, I guess, complexity, but based on the information that we’ve often shared before, one of the recommendations from an AI point of view is, is restoring mobility or flexibility or retaining that flexibility, at least in the low back. And that’s an area for us, Jacob, but we would always say, well, we don’t really want to be looking at flexibility in the low back. Because we want to neutral spine, we don’t want to be bending through the back. So there’s a little bit of a disconnect here. Because we don’t want to be doing those things that lead to other spinal problems with someone where they ask, but at the same time, there’s got to be an element of consideration of trying to retain that flexibility, what are your thoughts?

Jacob Steyn 17:48
Absolutely, my thought is that, you know, when we have an unstable lower back spine, we want to stabilize it through creating stiffness and stability using exercises. And that’s the general low back patient that we will see. But I think when we go further down the line, and losing mobility of stiffening tendons, and ligaments and joint capsules, at the lower back spine, and you know, then we’re moving towards the other end of the spectrum. And so we we start really losing mobility. And that’s something we want to try and avoid. So in this case, I think we have to be smart about how we try to maintain mobility in the low back, you know, I don’t think we need to use techniques, that’s, that’s going to cause a problem, like you say, but they are really wonderful light mobilization techniques that we can do on a daily basis, and maybe more than once a day, to preserve that mobility. And, and together with that, I think if you if you do a sort of weight training, you have a weight training program, generally doing free, free body or body weight weight training programs, there, there’s still movement coming through the low back, not extreme, but you’ll be working with your low back in certain positions, and that will also ensure that you get the the movement that’s required to keep a good move to keep the mobility going.

Ben James 19:25
Yeah, no, absolutely. I think I agree on that point. And, and, I mean, there’s other elements of exercise as well, that are beneficial. Just as a side note, you know, we generally find that people on average, sleep better as a result of doing exercise and this is something that can be affected pain can be a symptom during the night of of a so if exercise can lead to a better quality of sleep and that’s another benefit of, of doing exercising consider an exercise program as is kind of lung capacity because the joints that are affected in the spine can also affect your the movement in in the ribs, and therefore, your your lung capacity can be affected. So exercise as well, he’s going to, he’s going to work those lungs, which is going to lead to mobility within those ribs and those joints. So again, another benefit in terms of the exercise based approach, but I certainly think like you say, Jacob, there’s nothing stopping people with this condition, building strength building core, that’s going to support the back generally, but support them from a health point of view, overall. And there’s going to be nothing that we recommend in terms of exercises, really, in terms of the choice of exercises that are going to be any different to anybody else suffering from low back pain, we’re going to want to look at that neutral spine, we’re going to look on a look at the the abdominals, the core, to really look at that overall health and, and wellness of the spine in general, which is going to be beneficial in managing this condition as well as anybody else’s back pain over the long term. So definitely exercises, it should be a consideration. And as always, you know, the exercise choices that, that we recommend and alluded to in the intro in the ebook, you know, take advantage of those and head on over to YouTube and have a look because there’s nothing stopping you doing the same thing as, as anyone else when it comes to exercise. focused on back pain. I think that’s fair to say, Jacob.

Jacob Steyn 21:25
Yeah, I totally agree there. I think the danger is not moving enough, you know, sitting in front of a computer, having an office job. And that’s typically where someone who doesn’t have as also becomes the from the low back and lose range of motion and develop osteophytes or, or calcification of ligaments and tendons in the low back, not having the disease process of as. So, I think just moving, doing weight training, ensuring that your course a strong, you’re already gonna have a lot of benefit from doing that.

Ben James 22:04
Yeah, no, I completely agree. So I think that is clear. You know, exercise is important exercise is beneficial. So make sure that if you are experiencing these symptoms, if there has been a consideration or suggestion of, of as, particularly if you’re in the early stages, and just make sure that you you do keep moving you do consider those exercises can be beneficial for building core strength and support and your low back, you know, and that’s a lifestyle choice and a long term decision that you should be making anyway. But certainly, if there’s a suspicion of this condition, then that’s going to help conservatively managed this problem. So that, you know, if it does come to the point where you are diagnosed with this further down the line, you’d be managing it and proactively considering it as early as possible. And I think the same goes with with diet.

Jacob Steyn 22:58
Yes, yes. Let’s get onto the diet topic. So I read a little bit to see what are the recommended supplements for somebody who’s got as, and there’s not a lot on it. And it’s very conservative, and a lot of research actually showing that something specifically helps cholesterol spondylitis. But what they realized from studying small groups of patients compared to control groups is that there’s always almost always a lowered vitamin D level in ankylosing spondylitis patients. And so that’s, you know, for numerous reasons, not only for keeping your bones strong, but it’s very important that you make sure as someone who’s got as that your vitamin D levels are good, you know, not not only for those people, but for everybody. It’s actually very important as we know. But and that’s, that’s an interesting thing, because that Monday also helps with the inflammatory response. So my assumption is that it’s going to affect the disease process in that way. And it regulates the inflammatory response, so it needs to be on par. And then another thing.

Yeah, and I think, you know, yeah.

You broke up there a little bit. Um, and another thing is for the Medicaid for them and K two, and I couldn’t find anything on vitamin K to four as I could only find something on k two for rheumatoid arthritis. And there was it was a very positive study for supplementing with K two specifically menaquinones seven, as you have many quantum four as well, which are also called vitamin K two, but it reduced all the inflammatory markers in People with rheumatoid arthritis. So I hope that in the future, there’ll be more studies on especially vitamin K to maybe in combination with vitamin D. and another supplement that I found they show could have benefit is omega three, so EPA fish oil,

Ben James 25:25
Yeah, and it’s a such an interesting subject, because I suspect that, you know, increasingly, as there’s a more of a focus on these nutritional, proactive, preventative dietary, you know, approaches to management of these conditions that, you know, across the board, we’re just going to see an increasing, I would like to think prescription of these supplements to support these conditions, because, like you say, a lot of a lot of information previously was, was anecdotal, and then there started to be a bit more science and structure and focus on it. And now we are seeing, you know, some some strong evidence to support the use of these supplements, or certainly, you know, the patterns of these individuals suffering a low levels of these kind of vitamin D and others. So I suspect that we will just see an increasing focus on on diet as an approach to manage these conditions. And another element is, with regards to food intake, there is some, some evidence and it still is limited, it’s fair to say, but that there’s a bacteria that can be an initiator, a potential triggering factor involved in the development of Ace specifically. And that’s a bacteria called klebsiella pneumoniae, and that actually is, is in most of our guts, it’s, it’s there, it’s present. And it’s it’s not causing any problems when it’s in the gut. But outside of the gut, it can cause us issues and problems. And like with the vitamin D, like with the supplements and the things you mentioned, Jacob they there’s increasing focus on this kind of leaky gut syndrome and this issue that a lot of people are experiencing with their gut health, that is potentially a causative factor in chronic inflammatory conditions. So is there a risk, for example, that people are suffering from this leaky gut? And that very specific is leaking out? And is the cause and triggering factor in as potentially? And I think the the message here is, well, if it’s going to take 8.5 years for a definitive diagnosis, and there’s some potential evidence that reduction of things like starch, which, which has been associated with increasing klebsiella pneumoniae, if you can look at those things and dietary choices that could proactively help with this, then why would you not do that? And I think that’s the take home here. Yes, the evidence is limited. And I did a literature review and found maybe just one recent study, it was a systematic review, looking at all these different papers around diet choices, and as and they couldn’t find any definitive result results, that that it does influence or there is a link, but they acknowledge the researchers acknowledge that they’re, you know, this scarce literature on the topic, there’s very limited data to make informed decisions on diet and AS specifically, but we know, from some of these other studies regarding things like the klebsiella pneumoniae, there’s a potential initiating factor trigger, and therefore, why would you not proactively look at that, because back to the story that you shared Jacob with your patient, and certainly when you look online, other patients or other stories, there is some significant successes as a result of changing diet in the management of as specifically as well as other chronic inflammatory conditions.

Jacob Steyn 29:18
Yeah, I totally agree with you. And I think that’s something that needs to be explored a lot more. And I think it’s so individual with diet that we we’ve, you know, when we look at general health, some people do better on a slightly different diet to somebody else. So it’s something you need to some in some cases with the help of a specialist, someone who knows more about diet, get it right for yourself. So you can do some blood work and make sure that your, you know, your, your inflammatory markers are down, you don’t have any existing low grade inflammation. hormonally, you’re functioning well. And your energy is up you know, if you can make sure that your inflammatory responses working properly and all these other things are good, then you are just decreasing the chances of developing a problem. And if it’s present, you know, you’re just limiting the chance of it progressing at a fast rate.

Ben James 30:19
Yeah, no, I totally agree. And I think, you know, that’s quite potentially quite overwhelming for anybody listening that, that may be suffering symptoms and concerned that, you know, what they read online, they may have this this condition, specifically as in this case, but I think they’re increasingly are things you can be looking at to conservatively manage this condition, and diet is one of them. And, you know, go go and have a look at this, you know, because we say, starch is something that you could look to eliminate and see what the responses of that omega three oils good. choice of, of omega three is important. But look at the omega three, look at their vitamin D levels. Now increasingly, you can get very simple testing kits to establish your levels of, of these things within your diet. So within the the bloodstream, so, you know, it’s it’s worth exploring these options, as well as, you know, following the the advice of any medical doctor, but as always, keep moving, keep exercising, because there’s going to be not just physical benefits for this condition, specifically, but there’s going to be psychological benefits as well as always from partaking in an exercise program. So hopefully that clears things up a little bit regarding the question of as we’ve got from the listener, and if you’re only suffering from some stiffness early in the morning and not suffering it from later on in the day, then don’t be overly concerned. But as always, seek the advice you need to get the help and the reassurance you need regarding your back health. And as always, send us over any questions you have happy to answer them happy to jump on the phone if needs be to support you on your journey to back recovery. So thanks, as always, Jacob. Thanks everybody for listening, and we’ll catch you again on the next show.

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