Ankylosing Spondylitis

Learn about Ankylosing Spondylitis (AS), current treatments available and get helpful tips to help co-management Ankylosing Spondylitis

painHEALTH - Ankylosing Spondylitis

Ankylosing Spondylitis (AS) is a painful inflammatory rheumatic condition that is characterised by inflammation of structures in the spine. It is part of a group of disorders called Spondyloarthritis. Pain is one of the main issues you have to deal with when managing AS.

AS only affects a small proportion of the population, estimated at up to 0.5%. The condition is symptomatically more common in men with the disease usually starting at an early age, in the 3rd decade of life. Women can also be affected by this condition.

There is a familial predisposition to AS. This means the risk of developing AS is increased if a relative is affected, especially if a gene called HLA B27 is present. HLA B27 can be detected in a blood test. Ask your doctor about this test.

If uncontrolled, the result of ongoing inflammation within the spine and in other musculoskeletal soft tissues and joints is an increase in bone formation. Joints become progressive stiffer and ultimately may fuse. This joint stiffening impacts upon the ability to keep your head up, to look forward, to move normally and do the things you want to do.

What symptoms and signs suggest Ankylosing Spondylitis?

Inflammation in AS particularly affects the sites at which tendons and/or ligaments join onto bone. The most commonly affected region are the sacroiliac joints: this is where the spine joins onto the pelvis. Symptoms and signs of AS include:

  • pain and stiffness at the lower back, buttocks, mid-back or neck
  • pain and stiffness typically worse at night or after prolonged rest
  • pain and stiffness which improves with activity
  • joint pain and swelling, usually in the larger joints
  • recurrent or recalcitrant enthesopathy (tendon pain), for example achilles tendinopathy; tennis elbow (lateral epicondylalgia or extensor tendinopathy); patella tendinopathy; plantar fasciitis
  • decreased ability to do daily activities including work, home and recreational interests
  • fatigue or tiredness
  • other organs can also be involved, with inflammation of the eyes, the skin, the lungs and the gastrointestinal tract

What about symptom 'flare ups'?

There may be times where some of your symptoms are particularly bad: these are called ‘flare ups’. Your spine may feel more painful and stiff. Movement may be difficult and uncomfortable. Sleep may be disrupted. You may develop joint swelling or pain and fatigue. There are a number of things you can do to help manage pain and other symptoms through these pain flares. See our pain management modules including:

It is important that you see your specialist or your doctor as early as possible. Your doctor or specialist may need to investigate the problem or to change your management or to on-refer you to other members of the health team if that is appropriate for you.

Being diagnosed with Ankylosing Spondylitis

AS is commonly under-recognised in some people suffering with chronic back pain. The delay to diagnosis can be quite long, up to 10 years. The ability to diagnose this condition early is a significant challenge due to poor awareness of this disease and limitations with medical investigations.

If you have concerns about your back pain and think these signs and symptoms are like yours, see your doctor. Your doctor should suspect AS if you list these signs and symptoms. This is what we call ‘a high index of suspicion’ and your doctor can assist with differentiating if your spinal pain is of an inflammatory-type.

For a simple self-check back pain screen, visit the Don’t Turn Your Back On It (Note: this screening self check is not diagnostic, so it is important to use it as a guide only and to discuss the results with your doctor).

We recommend that you consult your doctor and discuss the potential for further investigations to diagnose AS and to guide your management. Being educated about AS is considered one of the most important current treatment recommendations1. Diagnosing AS early and starting the right treatments at the right time, mean you will have a better outcome and will be better able to manage pain and stay active. Your doctor may refer you to a specialist called a rheumatologist (this is a doctor who specialises in diagnosing and treating arthritis and systemic autoimmune diseases).

Rheumatologists will perform a thorough examination, and work closely with you to educate you about AS. In partnership, you and your specialist will make a decision about your management based on current best evidence recommendations1,2, what you can do (self management), and the role of active non-pharmacological management and the use of appropriate medications for your condition and your pain. Individual or group treatment may be of benefit to you1. They may also recommend visits to relevant health professionals (such as a physiotherapist). Physiotherapists play a large role in helping people with AS to manage pain and to maintain participation in daily work, home and recreational activities1,2. Other health professionals may also be part of your team including occupational therapists and dieticians. Occasionally, if pain is hard to manage you may also be referred to a pain medicine doctor. For pain management, you may also be advised to use some medicines2. Visit our medicines and procedures pain management module for further information about pain medicines.

Why having the right management is so important

If you do have AS, you will need a good management plan that is tailored for you and includes both medicines and other forms of management2. Specific medications may be required because control of the excessive inflammation is a very important goal3. Specific medications can help reduce the pain and stiffness and importantly, will allow you to continue to perform your everyday activities with less limitation. Reduction of inflammation can slow down AS disease progression and prevent excessive damage to your tissues and persistent pain3.

Medications such as non-steroidal anti-inflammatory medications (NSAIDs), Cox-2 inhibitors or biologic disease-modifying anti-rheumatic drugs (bDMARDs) are usually required to control AS when the disease is active2,3. For more information on analgesics see medicines and procedures.

Regular exercise is also very important1,2. Exercise helps to keep you moving and doing the things that are important to you. Exercise reduces pain and stiffness, strengthens muscles and joints, helps your brain, heart and lungs, helps to boost your immune system and manage fatigue and sleep. Specific prescribed exercise that is tailored to your needs can help you to maintain spinal flexibility, whole body flexibility and to reduce pain. Even when you have pain, exercising in a sensible way has these important benefits. Check out the movement with pain management module. The combination of the right medication and the right exercise programme may allow you to set new goals once you are able to perform everyday activities with more ease and less pain.

You may also experience low mood with AS or sleep disturbances1. There are simple things that can help you to manage your mood and to assist sleep hygiene1. Practical tips and skills to help manage mood can be found in our pain management modules:

Want further information?

For further information about Ankylosing Spondylitis visit Arthritis Australia and Cochrane Summaries. For more information about medicine and Ankylosing Spondylitis, visit the Australian Rheumatology Association website.

If you’re experiencing Ankylosing spondylitis or are concerned about Ankylosing spondylitis, we recommend our Medical Self-Check through our pain self-checks page to help you screen for conditions that may suggest you should consult a Health Professional.

Movement with pain

Pacing and goal settings

Mindfulness and pain

Chronic and Non-Cancer pain management plan

Michael Slater Ankylosing Spondylitis exercise video

Ankylosing Spondylitis symptom screener

Just diagnosed with Ankylosing Spondylitis

Empowered - Arthritis Australia

  1. Zangi HA, Ndosi M, Adams J, et al. EULAR recommendations for patient education for people with inflammatory arthritis. Annals of the rheumatic diseases 2015; 74(6): 954-62. [PubMed]
  2. Ward MM, Deodhar A, Akl EA, et al. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol 2015. [PubMed]
  3. Miedany YE. Treat to target in spondyloarthritis: the time has come. Curr Rheumatol Rev 2015; 10(2): 87-93. [PubMed]

This module has been developed by Irwin Lim MBBS, FRACP, Rheumatologist & Director, and Errol Lim, B. App Sc – Physio, GAICD, Physiotherapist & Director. Both practice at BJC Health, Sydney, Australia. The information in this module is based on current best evidence research and clinical practice.