Back problems are one of the most common complaints that are seen in the clinic and are mostly due to "back strain", "slipped disc" or wear and tear problems associated with aging.

Useful symptoms which help to separate AS from other causes of back pain are:

• slow onset over weeks and months lasting for more than 3 months
• onset before the age of 40 years
• stiffness and pain in the early morning
• improvement with exercise, worsening with rest

The inflammation in AS can also affect the joints between the ribs and the back bone or breast bone causing chest pain. The shoulders, knees, ankles and heels can also be affected.

Patients with active disease can feel tired, have fever and lose appetite and weight. Occasionally inflammation of the eye can occur. Rarely heart or lung involvement can develop. It is uncommon for all these problems to happen in the same person.

The Diagnosis of Ankylosing Spondylitis

There is no diagnostic test that your doctor can do at the onset of back pain. However the symptoms would alert him to the possibility of AS.

Testing for the HLA B27 blood group may help to make the diagnosis in early disease.

Non-specific tests which indicate the presence of inflammation of the spine include the erythrocyte sedimentation rate (ESR) and the haemoglobin (Hb) level.

The characteristic changes in the sacroiliac joints take months to years to develop but when they are present the diagnosis is confirmed.

What is the End Result?

AS behaves differently in different people. Usually the symptoms come and go over long periods of time but almost always settle down in the end.

The lumbar spine usually becomes stiff and the rest of the spine can also be affected in the same way. For this reason it is very important to maintain a good posture so that serious deformities can be prevented.

Treatment and Management

Treatment is designed to reduce pain and stiffness so that normal activities can be continued. Your doctor, physiotherapist, occupational therapist and others involved in your care will help you find the best way to manage your disease. Bear in mind that what works for others may not work for you. Be patient and actively take part in your own treatment.

Remember: It is the doctor's job to relieve pain and the patient's job to keep exercising and to maintain a good posture.

Not every patient will return to normal, even if the exercises are followed, but serious deformities can be prevented. Even though a cure is not available at present, you can do a lot to prevent major problems from developing.

Posture
Maintaining a good posture is important at all times, whether sleeping, sitting or standing, so that the joints do not fuse in undesirable positions.

Every effort must be made to keep the spine straight as AS tends to cause flexion of the spine, especially if not treated.

It is rare for the spine to stiffen completely, but if this should happen, the patient should do everything he can to stiffen in a straight rather than bent position.

Rest
A period of rest in hospital or at home may be needed if the AS is very active and you are experiencing a lot of pain and stiffness. However you must still continue to exercise your chest, back and limbs to keep them supple.

When lying in bed it is important to lie flat on your back. Some time should also be spent lying on your face (prone position). You could do this for 20 minutes before getting up in the mornings and for 20 minutes before going to bed at night.

If you do this regularly it will help prevent your back and hips from becoming bent.

Your Bed
Your mattress should be firm to prevent any tendency for spinal curvature from developing later. If you find that it is too yielding you can put a sheet of plywood or chipboard 70 x 150 x 1 cm between the mattress and the bed frame.

If you are travelling and find that the bed in the hotel is too soft you could pull the mattress off the bed onto the floor and sleep on that.

Chairs
High chairs with a firm seat and upright firm back are better for keeping the spine in a good posture. The seat of the chair should not be too long otherwise you will find difficulty positioning your lower back into the base of the chair back. Do not spend time sitting in low soft chairs as they will result in bad posture and increased pain.

At Work
Pay attention to the position of your back when at work. A job that allows you to change from sitting to standing and walking from time to time is the most suitable. When seated at a desk or bench, adjust your seat to the proper height and try to move your back from time to time. The most unsuitable job is one where you have to stoop or crouch over a bench for long periods.

If you have a heavy or tiring job try to have a break before doing other activities at home or elsewhere. Resting flat for 20 minutes at midday is also helpful. Try also to lie for part of this time in the prone position.

If you have a job that involves a lot of stooping or back strain talk this over with your doctor. He may be able to advise you or help you change to more suitable work. Some AS sufferers have found it useful to show this booklet to their doctors or employers in explaining their needs.

Exercise
Your doctor or physiotherapist will suggest a programme of exercise to be done every day. This will help you keep posture and activity as normal as possible. Exercise helps to reduce stiffness and to strengthen the muscles surrounding the joints.

If you sometimes feel too stiff and sore to exercise try taking a hot bath or shower to loosen up. Start the exercises slowly and plan them for times of the day when you are least tired and have the least pain. This way you will gain the most benefit from your exercises.

Medical Management
Although there is no cure for AS much can be done to help you to have a normal social and working life. The doctor aims to relieve pain and stiffness so that you can do exercises to help prevent deformities and disability. You, your doctor and your physiotherapist all play an active role in the management of your illness.

AS tends to settle down as you grow older but you should realise that treatment has to continue, although you may not have to visit your doctor so frequently.

Medication
Drugs help to relieve pain and stiffness although they cannot cure AS.

Your doctor will probably first prescribe a drug from the class of drugs known as non-steroidal anti-inflammatory drugs (NSAIDs). Indomethacin is one of the most effective of these drugs. However it can cause "gastric" symptoms such as indigestion and heartburn especially if taken on an empty stomach. Some other side effects include dizziness, headache and a "light-headed" feeling.

There are many other NSAIDs available which may work for you. Talk with your doctor about how you should take your medications, what side effects they can cause and what to do should these side effects occur.

Sulphasalazine (Salazopyrin) is a drug which acts to control disease activity. It is sometimes prescribed, especially when arthritis of the limb joints is troublesome. It does not relieve pain immediately and you should continue to take it as prescribed for a period of time to allow it to work. The side effects include rashes and anaemia. It cannot be used in men who are planning to have children as it affects the sperm count, although this returns to normal once the drug is stopped.

Surgery
Surgery has only a small part in management. It is used to restore movement to joints which have been damaged by arthritis. Artificial joint replacement surgery of the hips (hip arthroplasty) and spinal surgery are sometimes done.

Other Treatment
People with AS should stop smoking because AS itself causes reduced chest expansion and can be complicated by lung involvement.

If you have any problems with your eyes such as a painful or red eye or reduced vision you should not delay seeing an ophthalmologist (eye doctor) for iritis. Iritis is a painful condition resulting from inflammation of the coloured part of the eye called the iris.

Ankylosing Spondylitis and the Family

Almost all sufferers of AS have the white blood cell group HLA B27 but the reverse is not true. There are far more people with this blood group who never get AS than those who get it.

If I Have Ankylosing Spondylitis, Will My Children Get It Too?

From the present evidence about 20 percent of people with HLA B27 will get ankylosing spondylitis, although most will not be diagnosed because the disease is very mild. The chances of your children getting AS is quite low, being not more than 15 percent.

Of these 15 percent only one will have disease severe enough to interfere with a normal life. Parents sometimes ask if they should have their children tested for HLA B27. At present the answer is no since there is no way of predicting which child with the blood group will get the disease.

Ankylosing spondylitis does not usually interfere with lovemaking unless the hips are affected. One of the most important aspects of a good sexual relationship is communication. If you and your partner can comfortably discuss both of your needs, difficulties can be overcome.

Pregnancy for the woman with AS is usually no different from a normal person. Sometimes a Caesarean operation is needed if the hip joints are very rigid.

People who develop a chronic (long-standing) disease such as AS often go through many emotional ups and downs. You may need to make changes in your life and this can leave you feeling depressed and angry. It often helps to talk about these feelings to family members, a close friend or someone else who has spondylitis. You might also want to talk to a counselor who can help you deal with these feelings.

Car Driving

Patients with stiffness of the neck or other parts of their spine often have difficulty backing theirs cars into a parking lot. Special mirrors could be fitted onto your car to help you. It is important to practise parking using these new attachments. Head rests are also advised to avoid sudden injuries to the neck as the stiff neck of an AS patient is more easily injured than a normal neck.

Life Insurance

Many life insurance companies do not fully understand AS and will automatically have a loading factor included in the policy. AS patients could shop around for an insurance company which is more sympathetic towards this disease.

Sporting Activities

The most suitable activity is swimming since the muscles and joints are used without being jarred. Contact sports are not recommended since the joints can be injured.

Jogging and distance running are enjoyed by many young patients. Badminton and tennis can be beneficial as can basketball, netball and volleyball since they all combine movements with stretching. Bicycling is also good as it helps to keep the joints active besides providing breathing exercise.

Folk Remedies

There is no evidence that acupuncture or other traditional remedies are useful in AS. Don't be swayed into trying expensive forms of treatment which are not proven. Manipulation of the neck can be dangerous when the neck is stiff.

The Future

People with ankylosing spondylitis can expect to lead fairly normal lives. Only a few will suffer severe disability. Ankylosing spondylitis is not curable but it can be controlled so that it will not interfere with an active and useful life.

The Singapore Ankylosing Spondylitis Club (SASC)

Founded in 1990 the Singapore Ankylosing Spondylitis Club is a self help group of the National Arthritis Foundation devoted to patients with ankylosing spondylitis.

The SASC's aims are:

• to motivate patients to preserve their mobility through regular exercise programmes
• to promote awareness of ankylosing spondylitis among patients and their families
• to improve patient morale so that they can cope better with their disease

Come to one of the following sessions to find out for yourself. Do not worry that you might be out of place or that your pain is too unbearable, or that you are too stiff to do any exercise. Come and give it a try – you will feel better, no longer alone and you have the unique chance to meet fellow sufferers – your friends!

Fridays 7.00 p.m.
Tan Tock Seng Hospital
Department of Rehabilitation Medicine
Entrance by Mandalay Road
Tel: 3595422 / 2560913

Tuesdays 7.00 p.m.
National University Hospital
Physiotherapy Department
Tel: 7725168

* A note of fitness to exercise from your doctor is needed.

Application forms to join the SASC are available from
The Singapore Ankylosing Spondylitis Club
National Arthritis Foundation