About Axial Spondyloarthritis (Radiographic and Non-radiographic)
What is axial spondyloarthritis?
Axial spondyloarthritis is a chronic inflammatory disease that encompasses radiographic/ankylosing spondylitis (AS) and non-radiographic forms (nr-axSpA). Axial simply means the part of the skeleton that includes the spine and sacroiliac joints – joints that link the pelvis and lower spine. Non-radiographic indicates no visible damage on x-rays.
Ankylosing spondylitis is one of the most common types of inflammatory arthritis. Over time, it can cause some of the bones in the spine (vertebrae) to fuse. This fusing makes the spine less flexible and can result in a hunched posture or difficulty breathing when the rib cage is affected13. Please note that while some patients may have progressive fusion (aka bamboo spine), this does not occur in all patients. Risk factors for fusion include male sex, smoking, HLA-B27 positivity, elevation in CRP, and high degrees of persistent inflammation as seen on MRI.
In the case of non-radiographic axial spondyloarthritis, damage is not visible on x-rays, but the condition is characterized by a range of clinical manifestations12. Disease burden among individuals with AS and nr-axSpA is similar12.
Who can develop axial spondyloarthritis?
Ankylosing spondyloarthritis affects approximately 1% of the population and has been predominantly seen as a condition that affects men1. However, more recent data has demonstrated a more even distribution among men and women2,3. While it can strike at any age, it is most common in people between ages 15 and 40. Almost all patients develop symptoms of back pain before age 451.
Many people with ankylosing spondyloarthritis have family members who also have the disease, so a family history of AS and nr-axSpA should be considered a risk factor. If a person is showing signs of the disease, it is important that their family physician and rheumatologist be made aware of any family history. Epidemiological data is scarce, but one study found that AS is 2.7 times more common in Indigenous people living in Alberta, Canada. This difference was further exaggerated between rural and urban settings, suggesting both environmental and socioeconomic influences4. More studies are needed to better understand the presentation of AS and nr-axSpA among ethnically and culturally diverse groups.
The main symptoms of axial spondyloarthritis
Ankylosing spondylarthritis primarily affects the spine, but can also involve the hips, knees, shoulders, and rib cage. The most common symptom is long-term back pain, along with spinal stiffness in the morning or after a long period of rest for both radiographic and non-radiographic.
Ankylosing spondylarthritis often presents differently in male and female patients. For instance, males have greater radiographic progression (as seen on x-ray) of the lumbar spine. Whereas female patients often present with associated conditions such as psoriasis or inflammatory bowel disease4. It is also important to note that female patients tend to have a high disease burden, in part because they have a longer delay in diagnosis, higher disease activity, and are significantly less responsiveness to treatment2.
Ankylosing spondylitis is often mis-diagnosed as ordinary "low back pain" due to the common presentation1. On the other hand, nr-axSpA is often misdiagnosed as fibromyalgia due to poor awareness and no visible change on x-ray11.
Getting a diagnosis of axial spondyloarthritis
If ankylosing spondylarthritis is suspected, the physician may order blood tests to determine the presence of inflammation in the body, and test for specific markers (such as HLA-B27) which can indicate a genetic risk. An x-ray may also be taken, but often signs are not visible until the disease has progressed to a point where joint damage has already occurred. Therefore, the site of the stiffness, characteristics of onset of pain, and the time of day when pain is worse, may be the most important factors to support diagnosis. Keeping a journal of symptoms may help recall key information that, when shared with health care providers, may also support the diagnosis.
If a doctor suspects a diagnosis of axSpA, a referral to a rheumatologist will likely follow. A rheumatologist is a specialist in the treatment of arthritis. Rheumatologists have many years of extra training on top of their regular medical schooling and are experts at diagnosing and treating all forms of arthritis.
As is the case with most forms of inflammatory arthritis, early diagnosis, and treatment of axSpA can be key factors in maintaining joint health and preventing disability and deformity. If the inflammation is left unchecked, changes to the spinal column may result, causing spinal immobility and limited range of movement. If axSpA reaches other body parts, such as the hips, surgery may be needed.
In a ground-breaking report released in July 2021, the Arthritis Consumer Experts (ACE) alongside the Axial Spondyloarthritis International Federation (ASIF) looked at key diagnosis challenges across different healthcare systems to better understand how the delays affect individuals and to identify opportunities for addressing these. ASIF’s Delay to Diagnosis Report is based on a full literature review, and two global forum events, involving more than 90 patients and patient group representatives, researchers, rheumatologists, and other health care professionals from 23 countries. The report identified that an average 7-year delay to diagnosis of axial spondyloarthritis can leave young patients with irreversible damage to their spine and devastating effects on their mental health. Self-reported questionnaires from another study – the IMAS study – also showed high rates of disability, absenteeism, impact on promotions at work, and again, about a 7 years delay in diagnosis14.
JointHealth™ express - Key research highlights from EULAR 2021
https://jointhealth.org/programs-jhexpress-view.cfm?id=2473&locale=en-CA
About ankylosing spondylitis page
https://jointhealth.org/aboutarthritis-diseasespotlight.cfm?id=2&locale=en-CA
ASIF Delay to Diagnosis Report
https://jointhealth.org/pdfs/ASIF-Delay-to-Diagnosis-Report.pdf
Treatment of axial spondyloarthritis
Once a rheumatologist has diagnosed axial spondyloarthritis, there are effective treatments available to help manage symptoms and minimize joint damage. While there is no known cure, treatments are available.
Quitting smoking6,7
Smoking negatively impacts a person’s health in several ways, and in addition to increasing your risk for lung cancer and heart disease, smoking worsens symptoms. Research has found that people with AS who smoke have more spinal damage than non-smokers. In one study, smokers had damage that was 5.5 times greater than non-smokers with the same level of disease activity. Smoking can also worsen the pain of AS and impact how well medications like biologics work. Stopping smoking significantly improves disease activity in people with AS, and quitting smoking is also associated with improvements in physical mobility and quality of life.
Physical therapy8
A physiotherapist can develop an individualized program designed to help you increase your strength, flexibility, range-of-motion, and general mobility and exercise tolerance through a wide variety of therapeutic treatments and strategies. These include exercise prescription, physical interventions, and relaxation, in addition to advising you on other techniques for reducing pain and increasing your overall quality of life.
Physiotherapists can also refer you to other health professionals and community services for further measures that will help you adapt to your changing circumstances.
Physical activity9
Regular physical activity is critical to managing the pain and stiffness, which are often worse in the morning after a night’s sleep or after periods of inactivity. Symptoms tend to improve with movement and activity or a warm shower. Although exercise and physical therapy have not been demonstrated to prevent the progression of axSpA, getting regular movement in the joints can help manage the symptoms of the disease and help people living with AS maintain their flexibility and mobility. Each individual should work with their doctor and physical therapist to determine which exercises are appropriate and safe for their unique situation.
Diet10
Living with a chronic condition like axSpA increases the importance of healthy habits, including diet. While there is not a specific diet that has been proven to impact axSpA, it is important to try and maintain a weight that is healthy for you. Being overweight can place stress on joints, which may worsen symptoms of axSpA. Additionally, in some people with food sensitivities, certain foods may increase their symptoms. The anti-inflammatory diet may reduce symptoms in some people. Some foods have been shown to increase inflammation in the body while other foods may reduce inflammation.
Stress management5
Stress can worsen symptoms like inflammation and chronic pain. Finding ways to manage stress can help people with axSpA take an active role in managing their overall health. Stress management may include meditation, support groups, counseling, breathing techniques, massage, and being in nature.
Key take-aways
References
| ACE is committed to using inclusive language that is free from words, phrases and tone that reflect discriminatory or stereotyped views of underrepresented people or groups. In our attempt to avoid bias or using language that appropriates other cultures as it relates to Indigenous Peoples health and wellness, ACE consults with Indigenous advisors to ensure its website and other written materials use terms and expressions that align with Indigenous identities and are culturally appropriate. |
Axial spondyloarthritis is a chronic inflammatory disease that encompasses radiographic/ankylosing spondylitis (AS) and non-radiographic forms (nr-axSpA). Axial simply means the part of the skeleton that includes the spine and sacroiliac joints – joints that link the pelvis and lower spine. Non-radiographic indicates no visible damage on x-rays.
Ankylosing spondylitis is one of the most common types of inflammatory arthritis. Over time, it can cause some of the bones in the spine (vertebrae) to fuse. This fusing makes the spine less flexible and can result in a hunched posture or difficulty breathing when the rib cage is affected13. Please note that while some patients may have progressive fusion (aka bamboo spine), this does not occur in all patients. Risk factors for fusion include male sex, smoking, HLA-B27 positivity, elevation in CRP, and high degrees of persistent inflammation as seen on MRI.
In the case of non-radiographic axial spondyloarthritis, damage is not visible on x-rays, but the condition is characterized by a range of clinical manifestations12. Disease burden among individuals with AS and nr-axSpA is similar12.
Who can develop axial spondyloarthritis?
Ankylosing spondyloarthritis affects approximately 1% of the population and has been predominantly seen as a condition that affects men1. However, more recent data has demonstrated a more even distribution among men and women2,3. While it can strike at any age, it is most common in people between ages 15 and 40. Almost all patients develop symptoms of back pain before age 451.
Many people with ankylosing spondyloarthritis have family members who also have the disease, so a family history of AS and nr-axSpA should be considered a risk factor. If a person is showing signs of the disease, it is important that their family physician and rheumatologist be made aware of any family history. Epidemiological data is scarce, but one study found that AS is 2.7 times more common in Indigenous people living in Alberta, Canada. This difference was further exaggerated between rural and urban settings, suggesting both environmental and socioeconomic influences4. More studies are needed to better understand the presentation of AS and nr-axSpA among ethnically and culturally diverse groups.
The main symptoms of axial spondyloarthritis
Ankylosing spondylarthritis primarily affects the spine, but can also involve the hips, knees, shoulders, and rib cage. The most common symptom is long-term back pain, along with spinal stiffness in the morning or after a long period of rest for both radiographic and non-radiographic.
Ankylosing spondylarthritis often presents differently in male and female patients. For instance, males have greater radiographic progression (as seen on x-ray) of the lumbar spine. Whereas female patients often present with associated conditions such as psoriasis or inflammatory bowel disease4. It is also important to note that female patients tend to have a high disease burden, in part because they have a longer delay in diagnosis, higher disease activity, and are significantly less responsiveness to treatment2.
Ankylosing spondylitis is often mis-diagnosed as ordinary "low back pain" due to the common presentation1. On the other hand, nr-axSpA is often misdiagnosed as fibromyalgia due to poor awareness and no visible change on x-ray11.
Getting a diagnosis of axial spondyloarthritis
If ankylosing spondylarthritis is suspected, the physician may order blood tests to determine the presence of inflammation in the body, and test for specific markers (such as HLA-B27) which can indicate a genetic risk. An x-ray may also be taken, but often signs are not visible until the disease has progressed to a point where joint damage has already occurred. Therefore, the site of the stiffness, characteristics of onset of pain, and the time of day when pain is worse, may be the most important factors to support diagnosis. Keeping a journal of symptoms may help recall key information that, when shared with health care providers, may also support the diagnosis.
If a doctor suspects a diagnosis of axSpA, a referral to a rheumatologist will likely follow. A rheumatologist is a specialist in the treatment of arthritis. Rheumatologists have many years of extra training on top of their regular medical schooling and are experts at diagnosing and treating all forms of arthritis.
As is the case with most forms of inflammatory arthritis, early diagnosis, and treatment of axSpA can be key factors in maintaining joint health and preventing disability and deformity. If the inflammation is left unchecked, changes to the spinal column may result, causing spinal immobility and limited range of movement. If axSpA reaches other body parts, such as the hips, surgery may be needed.
In a ground-breaking report released in July 2021, the Arthritis Consumer Experts (ACE) alongside the Axial Spondyloarthritis International Federation (ASIF) looked at key diagnosis challenges across different healthcare systems to better understand how the delays affect individuals and to identify opportunities for addressing these. ASIF’s Delay to Diagnosis Report is based on a full literature review, and two global forum events, involving more than 90 patients and patient group representatives, researchers, rheumatologists, and other health care professionals from 23 countries. The report identified that an average 7-year delay to diagnosis of axial spondyloarthritis can leave young patients with irreversible damage to their spine and devastating effects on their mental health. Self-reported questionnaires from another study – the IMAS study – also showed high rates of disability, absenteeism, impact on promotions at work, and again, about a 7 years delay in diagnosis14.
JointHealth™ express - Key research highlights from EULAR 2021
https://jointhealth.org/programs-jhexpress-view.cfm?id=2473&locale=en-CA
About ankylosing spondylitis page
https://jointhealth.org/aboutarthritis-diseasespotlight.cfm?id=2&locale=en-CA
ASIF Delay to Diagnosis Report
https://jointhealth.org/pdfs/ASIF-Delay-to-Diagnosis-Report.pdf
Treatment of axial spondyloarthritis
Once a rheumatologist has diagnosed axial spondyloarthritis, there are effective treatments available to help manage symptoms and minimize joint damage. While there is no known cure, treatments are available.
- Treatment guidelines were established for the management of AS – these include several groups of medications such as5:
- Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil® or Motrin IB®), naproxen (Naprosyn®), diclofenac (Voltaren®)
- COX-2 inhibitors, such as celecoxib (Celebrex®)
- Glucocorticoid (sometimes called 'cortisone') injections directly to the site of inflammation. Unlike other forms of arthritis, there is little evidence to support the use of glucocorticoid tablets such as prednisone or other "systemic corticosteroids" for disease involvement in the spine.
- There is little evidence to support the use of traditional disease-modifying anti-rheumatic drugs (DMARDs) used in treating rheumatoid arthritis such as methotrexate, sulfasalazine, hydroxychloroquine, leflunomide and azathioprine for the treatment of spinal disease involvement. However, sulfasalazine may be used in patients with ankylosing spondylitis with peripheral (large joints such as elbows, wrists, knees, and ankles) disease involvement.
- Biologic DMARDS (or "biologics"), specifically adalimumab (Humira®, Abrilada®, Amgevita®, Hadlima®, Hulio®, Hyrimoz®, Idacio®, Simlandi®, Yuflyma®), certolizumab pegol (Cimzia®), etanercept (Enbrel®, Brenzys®, Erelzi®), golimumab (Simponi®), infliximab (Remicade®, Avsola®, Inflectra®, Renflexis®), ixekizumab (Taltz®), and secukinumab (Cosentyx®) have all been approved in Canada for use in treating ankylosing spondylitis - both the spinal inflammation and the peripheral inflammation.
- Targeted synthetic molecule (tsDMARD), specifically upadacitinib (Rinvoq®).
Quitting smoking6,7
Smoking negatively impacts a person’s health in several ways, and in addition to increasing your risk for lung cancer and heart disease, smoking worsens symptoms. Research has found that people with AS who smoke have more spinal damage than non-smokers. In one study, smokers had damage that was 5.5 times greater than non-smokers with the same level of disease activity. Smoking can also worsen the pain of AS and impact how well medications like biologics work. Stopping smoking significantly improves disease activity in people with AS, and quitting smoking is also associated with improvements in physical mobility and quality of life.
Physical therapy8
A physiotherapist can develop an individualized program designed to help you increase your strength, flexibility, range-of-motion, and general mobility and exercise tolerance through a wide variety of therapeutic treatments and strategies. These include exercise prescription, physical interventions, and relaxation, in addition to advising you on other techniques for reducing pain and increasing your overall quality of life.
Physiotherapists can also refer you to other health professionals and community services for further measures that will help you adapt to your changing circumstances.
Physical activity9
Regular physical activity is critical to managing the pain and stiffness, which are often worse in the morning after a night’s sleep or after periods of inactivity. Symptoms tend to improve with movement and activity or a warm shower. Although exercise and physical therapy have not been demonstrated to prevent the progression of axSpA, getting regular movement in the joints can help manage the symptoms of the disease and help people living with AS maintain their flexibility and mobility. Each individual should work with their doctor and physical therapist to determine which exercises are appropriate and safe for their unique situation.
Diet10
Living with a chronic condition like axSpA increases the importance of healthy habits, including diet. While there is not a specific diet that has been proven to impact axSpA, it is important to try and maintain a weight that is healthy for you. Being overweight can place stress on joints, which may worsen symptoms of axSpA. Additionally, in some people with food sensitivities, certain foods may increase their symptoms. The anti-inflammatory diet may reduce symptoms in some people. Some foods have been shown to increase inflammation in the body while other foods may reduce inflammation.
Stress management5
Stress can worsen symptoms like inflammation and chronic pain. Finding ways to manage stress can help people with axSpA take an active role in managing their overall health. Stress management may include meditation, support groups, counseling, breathing techniques, massage, and being in nature.
Key take-aways
- Speak to a doctor if inflammatory back pain lasts more than three months and improves with exercise, but not with rest
- 74% of patients living with axial spondyloarthritis reported difficulties finding a job due to their condition
- An average 7-year delay to diagnosis of axial spondyloarthritis can leave young patients with irreversible damage to their spine and have a devastating effect on their mental health
References
| 1 | Stolwijk et al. (2016). Global prevalence of spondyloarthritis: a systematic review and meta‐regression analysis. https://doi.org/10.1002/acr.22831 |
| 2 | Rusman et al. (2018). Gender Differences in Axial Spondyloarthritis: Women Are Not So Lucky. https://doi.org/10.1007/s11926-018-0744-2 |
| 3 | Rusman et al. (2020). Sex and gender differences in axial spondyloarthritis: myths and truths. https://doi.org/10.1093/rheumatology/keaa543 |
| 4 | Barnabe (2017). Inflammatory Arthritis Prevalence and Health Services Use in the First Nations and Non-First Nations Populations of Alberta, Canada. https://doi.org/10.1002/acr.22959 |
| 5 | Spondylitis Association of America website (Treatment) |
| 6 | NASS website |
| 7 | Dülger S, et al. How does smoking cessation affect disease activity, function loss, and quality of life in smokers with ankylosing spondylitis? https://doi.org/10.1097/RHU.0000000000000851 |
| 8 | Ozgocmen et al. (2020). Expert opinion and key recommendations for the physical therapy and rehabilitation of patients with ankylosing spondylitis. https://doi.org/10.1111/j.1756-185X.2011.01700.x |
| 9 | Pécourneau et al. (2018). Effectiveness of exercise programs in ankylosing spondylitis: a meta-analysis of randomized controlled trials. https://doi.org/10.1016/j.apmr.2017.07.015 |
| 10 | Spondylitis Association of America website (Diet) |
| 11 | Robinson, P. C., Sengupta, R., & Siebert, S. (2019). Non-radiographic axial spondyloarthritis (nr-axSpA): advances in classification, imaging and therapy. Rheumatology and therapy, 6(2), 165-177. |
| 12 | Burgos-Varga et al. (2016). The prevalence and clinical characteristics of nonradiographic axial spondyloarthritis among patients with inflammatory back pain in rheumatology practices: a multinational, multicenter study. https://doi.org/10.1186/s13075-016-1027-9 |
| 13 | Wang & Ward (2018). Epidemiology of axial spondyloarthritis: an update. https://doi.org/10.1097/BOR.0000000000000475 |
| 14 | Garrido-Cumbrera et al. (2019) The European Map of Axial Spondyloarthritis: Capturing the Patient Perspective—an Analysis of 2846 Patients Across 13 Countries. https://doi.org/10.1007/s11926-019-0819-8 |
Arthritis Consumer Experts
ACE thanks Arthritis Research Canada (ARC) for its scientific review of ACE and JointHealth™ information and education programs.