Rheumatic Diseases
Ankylosing Spondylitis
Ankylosing spondylitis (AS), also known popularly as "spinal rheumatism" or "back rheumatism," is a chronic inflammatory rheumatic disease that affects the spine and the sacroiliac joints where the spine meets the pelvis. It generally appears between the ages of 20 and 40. If it is not diagnosed early and followed up regularly, it can lead to permanent restriction of movement and stooping of the spine; with the right treatment and exercise program, the great majority of patients can lead an active, high-quality life.
What Is AS?
It is the most common type of a group of chronic inflammatory rheumatic diseases called “spondyloarthritis.” The inflammation begins in the sacroiliac joints, can progress over time along the spine, and can lead to new bone formation at the edges of the vertebrae and fusion of the vertebrae (ankylosis). AS should come to mind in cases of back pain that begins before the age of 40 and lasts longer than 3 months.
What Causes It?
Genetic predisposition (the HLA-B27 gene — positive in 70–80% of AS patients in Turkey, versus 7% in the general population; AS develops in only about 2% of carriers), immune system dysregulation (the IL-23/IL-17 inflammation pathway), environmental triggers (gut infection), smoking (increases the risk and the rate of spinal involvement), and family history.
Its Symptoms
Inflammatory back pain (onset before age 40, lasting longer than 3 months, worse at rest/at night, easing with movement, morning stiffness lasting more than 30 minutes, a good response to NSAIDs); back-mid-back-hip pain; heel/sole pain (enthesitis); chest pain and shortness of breath; restricted spinal movement/stooped posture; and extra-articular findings (uveitis, gut complaints, psoriasis-like rashes, and rarely heart involvement).
The Gut-Joint Axis
Current research draws attention to the relationship between AS and the gut microbiota; it is associated with dysbiosis, increased gut permeability (mediated by zonulin) and the triggering of the IL-23/IL-17 pathway. This area is still being researched; there is no definitive evidence that gut-directed interventions treat AS on their own, but a balanced diet and the protection of gut health may play a supportive role in addition to drug therapy and physical therapy. At our clinic, a holistic approach is followed that takes standard medical treatment as its basis while also incorporating gut health and nutrition.
How Is It Diagnosed?
Patient history, physical examination, laboratory tests (CRP, sedimentation — which can be normal in half of patients), imaging (X-ray, and MRI in the early stage), and HLA-B27 testing (supportive; it does not establish the diagnosis on its own).
How It Differs From Mechanical Back Pain
Mechanical back pain due to a herniated disc typically increases with movement and eases with rest, worsens toward the end of the day, and involves brief morning stiffness. Inflammatory back pain in AS, by contrast, increases at rest and at night, eases with movement, and is accompanied by morning stiffness lasting more than 30 minutes and a good response to NSAIDs.
Its Treatment
There is no definitive cure; the goal is to reduce pain/stiffness, slow progression and preserve mobility. NSAIDs (effective in 60–70% of patients), disease-modifying drugs, biologic drugs (anti-TNF, IL-17 inhibitors), cortisone (limited), regular exercise, and rarely surgery. A personalized, holistic approach combining medication, exercise and lifestyle gives the best results.
Recommendations for Patients
Regular exercise (swimming, walking, Pilates, yoga), avoiding contact sports, quitting smoking, paying attention to posture, a balanced/anti-inflammatory diet, calcium and vitamin D, avoiding hot thermal springs during an active flare, and regular medical check-ups.
Realistic Expectations and Long-Term Follow-Up
Most patients can carry on their daily lives normally with regular medication and exercise; the disease follows a course of flares and periods of well-being; involvement is generally milder in women. Rather than a “complete cure,” the goal is long-term control.
Frequently Asked Questions
What happens if ankylosing spondylitis is left untreated?
In untreated cases or those with irregular follow-up, fusion between the vertebrae can develop; this can lead to permanent restriction of movement in the spine and a forward curvature. Early diagnosis and regular treatment greatly reduce this risk.
Will ankylosing spondylitis be passed on to my child?
Because genetic predisposition plays a role in the development of the disease, the risk is somewhat higher (about 5–20%) in the children of people with a family history of AS. However, this does not mean the disease will definitely develop in the child. If there are no complaints, routine screening (the HLA-B27 test) is not necessary.
I have pain during exercise — can I skip it?
Continuing to exercise regularly, even during painful periods, is important for the course of the disease. When the pain is brought under control with an appropriately dosed NSAID treatment, the exercises can be performed more comfortably. It is recommended that the programme be tailored to the individual with the guidance of a physician and a physiotherapist.
What is the difference between ankylosing spondylitis and a herniated disc?
Whereas the mechanical pain due to a herniated disc increases with movement and eases with rest, the inflammatory pain in ankylosing spondylitis increases at rest and at night, eases with movement, and is accompanied by prolonged morning stiffness.
Does diet affect ankylosing spondylitis?
Diet alone does not cure the disease; however, a balanced, anti-inflammatory eating pattern can contribute to the overall success of treatment by supporting gut health.
Does going to a thermal spa help the disease?
Because heat applications can increase pain and stiffness during an active inflammatory period, thermal spas are not recommended, especially during a flare.
Does ankylosing spondylitis progress differently in women than in men?
Yes. AS is 2–3 times more common in men and usually progresses faster. In women, spinal involvement follows a milder course and hunching is less common; neck involvement, however, may be relatively more frequent in women.
My HLA-B27 test came back positive — will I definitely get ankylosing spondylitis?
No. A positive HLA-B27 increases the risk of the disease, but AS develops in only a small proportion of the people who carry this gene. The diagnosis is made together with the history, examination, and imaging findings.
Does ankylosing spondylitis last a lifetime?
Yes, AS is a chronic disease and currently has no definitive cure. However, with the right medication and regular exercise, the disease can be kept under control, and most patients can largely preserve their quality of life.
This article is for general information purposes and does not replace medical advice. For diagnosis and treatment, be sure to consult a specialist.
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