Ankylosing Spondylitis

Ankylosing spondylitis (AS) is an autoimmune rheumatic disease that involves chronic inflammation of the spine and the sacroiliac joints. It is more common in men than in women, with age predominance in the third decade of life. Chronic inflammation may lead to fusion of vertebral bodies and ankylosis of the spine, producing pain and decreased mobility. Inflammation also may affect other joints and organs, with possible involvement of the eyes, heart valves, lungs, and kidneys. Ankylosing Spondylitis may cause lower back pain that can spread and be felt in the buttocks and thighs, lower back stiffness. Other symptoms include tiredness, weight loss and a mild fever. The pain and stiffness are usually worse early in the morning and after resting, but improve with exercise as the day progresses. Because the spine loses its normal shape, people may find their back becomes bent forwards. This can make walking and moving around painful and difficult.

Most commonly our patients come in with symptoms that begin as decreased flexibility in the spine and stiffness associated with pain in the sacroiliac joints or joints on both sides of the lower back. Your medical doctor usually prescribes NSAIDs or pain killers to give relief and if that does not work they will give you anti-rheumatic medications including steroids, methotrexate, and sulfasalazine. As a Chiropractor, my advice for the best form of Ankylosing Spondylitis relief you can do on your own is for you to include some form of exercise that includes movement such as Tai Chi, Pilates, Yoga, swimming; anything to get your body moving to give you an improved functional quality of life. In older patients with Ankylosing Spondylitis, fractures are common, and surgical treatment of thoracic or cervical injuries may be necessary. These fractures in older patients with Ankylosing Spondylitis must be considered highly unstable and should be treated with caution.

No one knows the cause of Ankylosing Spondylitis, but that does not mean we give up and stop looking. If you have Ankylosing Spondylitis, accepting it emotionally is important as it can be demoralizing. Since Ankylosing Spondylitis is a form of inflammatory disease, what most practitioners will do is to prescribe anti-inflammatories whether drug or natural like tumeric. One of my patients is currently on Enbrel (Etanercept) 50mg, Indomethacin 25mg, and since Indomethacin, an anti-inflammatory drug, can cause gastric ulcers, he was also prescribed Famotidine 20mg to counter any gastric problems. Famotidine helps prevent gastric ulcers by inhibiting stomach acid. Hopefully, his digestion will not be greatly affected because our body needs stomach acid for digestion. Complications arise when you don’t have stomach acid. Based on the following research, I suggest looking at gluten sensitivity or Celiac disease that may result in inflammation in turn resulting in Ankylosing Spondylitis either directly or indirectly. If you love wheat products like breads, pasta, biscuits, and have AS this may be an area to explore. Check for gluten sensitivity using the Gliadin Ab Test. Gliadins are polypeptides found in wheat, rye, oat, barley, and other grain glutens, and are toxic to the intestinal mucosa in susceptible individuals. Healthy adults and children may have a positive antigliadin test because of subclinical gliadin intolerance. Some of their symptoms include mild enteritis, occasional loose stools, fat intolerance, marginal vitamin and mineral status, fatigue, or accelerated osteoporosis. Scan. J. Gastroenterol. 29:248(1994).

Ankylosing Spondylitis Abstract

“The presence of anti-gliadin antibodies (AGA) and their relationship with intestinal permeability and prevalence of undiagnosed celiac disease (CD) in Ankylosing Spondylitis (AS) were investigated. Blood samples from 30 AS patients and 19 age- and sex-matched controls were analysed for human leucocyte antigen (HLA)-B27, AGA and endomysial antibodies (EMA). Immunoglobulin (Ig) A-type AGA and IgG-type EMA were determined by enzyme-linked immunosorbent assay. AGA-positive patients were examined by gastroduodenoscope and proximal small bowel mucosa biopsies were performed. Eleven (36.7%) AS patients were AGA positive (compared with none of the control subjects) and three (10.0%) of these AS patients were also EMA-positive. The presence of AGA was not associated with more severe AS. Mild-to-severe villous atrophy and hyperplasia of crypts with increased chronic inflammatory cells in the lamina propria, which is typical of CD, was only observed in one AGA/EMA positive AS patient; CD was subsequently diagnosed by histology. Although AGA positivity might contribute to the pathogenesis of AS by increasing intestinal permeability to micro-organisms or by modifying intestinal immune mechanisms, further work is required to clarify its role in AS.”

Question 1:

Hi, Dr Lim, i’m turning 35 this year and I’ve just been diagnosed with suspected Ankylosing Spondylitis, by doctors at Singapore General Hospital (SGH) and Changi General Hospital (CGH).
A very recent X-ray taken shows that 2 of my lower back spine has bone growth over the cartilage. This causes my back to be very stiff and I can’t bend forward.
Currently I’m on Declofenac prescribed by my Rheumatalogist. I was told that the blood test was negative but all other symptoms, X-rays and MRIs indicate Ankylosing Spondylitis. So can Chiropractic indeed help to reduce my stiffness?


Have you had any recent infection(s) especial viral or allergies to any foods? Not all AS patients have pain. Do you experience any pain?
The results depend on how serious your condition is. Some of our patients have to use drugs prescribed by a Rheumatalogist to help and slow down the disease progression. Often increase in dosages or change in medication is necessary later on.

Diagnostic testing demonstrates an elevated erythrocyte sedimentation rate during active phases of the Ankylosing Spondylitis disease, a negative antinuclear antibody, and rheumatoid factor. HLA-B27 haplotype is present in 60%-90% of Ankylosing spondylitis (AS) patients compared to only 4%-8% of normal controls.*
Standard chiropractic spine mobilization can help some to help relief the stiffness but does not fix the problem. No one is addressing the root cause here, which in my opinion, is an inflammatory process triggered by an event or a process. [The above labs mentioned including hs-CRP, ESR are helpful.]

We help our patients who have AS via spine mobilization and design a nutritional protocol to slow down the inflammatory process. In addition, we recommend our patients to follow an aggressive strengthening program to maintain posture (prevent kyphosis) and build muscle strength in areas of affected joints.

One of my patients said swimming really helps him and when he doesn’t move it can feel quite bad. Hope the advice helps you [and I wish I have a happier answer for you]!

* Wright D. Juvenile rheumatoid arthritis. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter’s Pediatric Orthopaedics. 5th ed. Philadelphia, Pa: Lippincott-Raven; 2003:427-435. 

Question 2:
Can MRI and CT scan be used as an alternative form of diagnosis apart from X-ray? If yes, what are the differences?

X-rays are usually sufficient together with [labs a mentioned] to diagnose Ankylosing Spondylitis. MRI and CT scan may be used for further investigation.
I know sometimes not all the puzzle pieces seems to fit your condition. I had one patient who does not have stiffness but has X-rays to show they have AS, but the patient’s main complaint is feeling hot or heat all over his body. This disease does not follow the text book’s description.