Ankylosing Spondylitis

by Dr. Vinaya Kunjir

Recently, I visited Aurangabad with a group of friends. During all sight seeing tours, we noticed that our guide walked with a stooped posture. He was a man of about 40 years of age, thin built, whose spine was bent forward at the trunk and he was walking with short steps. On inquiry we learned that he used to be a farmer by occupation & was suffering from low back pain of 12 years duration. Initially the pain was mild & was associated with stiffness, more in the mornings. The pain used to get worse with rest and was relieved with hot fomentation & exercise. He was treated by several doctors as a case of Spondylitis which was caused due to hard, strenuous labour. Gradually, the stiffness spread to the knees, hips, shoulders, heels and cervical spine. The farmer also tried many alternative therapies like Ayurveda, Homeopathy and tribal medicines, but there was no relief. As the disease progressed, he noticed restriction in the movements of the spine. Since the last 4-5 years, he was unable to pick up objects from the ground & was disturbed due to severe stiffness & pain all over the back and the needed to change his position constantly in sleep. There was a progressive deformity of the spine. Consequently, his farm work and financial status were affected. He became depressed & frustrated as he could not work in the fields anymore. Finally, he gave up farming and became a tourist guide to earn his livelihood

Based on his classical history, there was no doubt that he suffered from Ankylosing Spondylitis. We referred him to a Rheumatologist. After clinical evaluation, laboratory investigations and x-rays, he was diagnosed with Ankylosing Spondylitis (A. S.) He was begun on oral anti-inflammatory analgesics to relieve his symptoms & sulphasalazine to reduce the inflammatory disease. The importance of diet, fluid intake and exercises was explained to him. Presently he is better with oral medication under the supervision of a Rheumatologist and regular exercises

Ankylosing Spondylitis is an inflammatory disorder affecting the spine, hips and large joints of the body, where the initial inflammatory changes in the joints are followed by fibrosis & ultimately bony fusion. This leads to gross restriction in the movements of the joints. The etiology of A. S. is unknown although it is strongly associated with a gene - HLA-B 27. The patients with this gene are at a greater risk of developing A.S. when it is triggered by environmental micro-organisms, especially the organisms in inflammatory bowel disease

The typical presentation is a young man between 14 - 50 years of age, with intermittent or persistent low back pain associated with stiffness which is worse in the morning and after rest and relieved by activity. The pain is usually present in the lower back & sometimes may be in the hips, buttocks & may radiate to thighs

Sometimes there is involvement of thoracic spine and cervical spine. Consequently there is restriction in chest expansion during respiration. With the progression of the disease, the normal curvature of the spine is lost & the patient develops a stooped posture with flexion deformities in hips & knees

Heel pains and inflammatory conditions in the eyes may occur sometimes during the course of the disease

Laboratory investigation show elevated ESR & Creative proteins, Rheumatoid factor is negative & the rest of the investigations are normal. HLA-B 27 is positive in 80% - 90% cases of A. S.

Radiographs show inflammatory changes in spine, hips, sacroiliac joints, characterized by erosions which are followed by new bone formation & fibrosis, finally leading to fusion of the joints. Fusion of the vertebrae of the spine makes it look like a bamboo on x-rays. It is aptly named as "Bamboo Spine"

Management

The aims of management in A. S. are to control pain, maintain maximum mobility of joints and to prevent deformities

The role of anti-inflammatory analgesics is to relieve pain & inflammation. The immunomodulatory drugs are used to control the inflammatory process in the joints. Such drugs should be used under the supervision of the Rheumatologists only

All patients of A. S. must be told about the importance of posture control and exercises

Maintenance of erect posture is very important in all activities like sitting, standing & walking. The patient should sleep in a prone position or supine position with no pillow

Walking & swimming are excellent ways to maintain joint mobility

Surgery is indicated only in patients with far advanced disease causing painful deformities or loss of function. Total hip replacement is the most commonly performed procedure

The course of A. S. varies. In some patients the disease never progresses beyond mild Arthritis, while in others it runs a very relentless course in spite of treatment. Most patients who exercise regularly, maintain erect posture and take medicines judiciously are able to lead relatively normal & active lives with minor adjustments in lifestyle

Psoriatic Arthritis

by Dr. Harbeer Ahedi

What is Psoriatic Arthritis ?

It is an inflammatory kind of Arthritis that affects the skin and joints. Arthritis means pain and swelling in the joints, while psoriasis is one of the skin diseases. A combination of both is called Psoriatic Arthritis In many ways, it may be similar to other types of Arthritis, but the Rheumatoid Factor in this disease is often negative. In a few patients it may be limited to joints with less skin lesions, but in others it may show pains in many joints with silvery scaly or greyish skin lesions Both men and women at any age can suffer from Psoriatic Arthritis

Why does one get this disease ?

The cause for Psoriatic Arthritis is not known. A person is likely to develop Psoriatic Arthritis if he has a family history of Arthritis or Psoriasis or has long standing Psoriasis. It is an auto-immune disorder

What happens in this disease ?

Both joints and skin are involved in this disease. Pain, swelling and stiffness is seen in the affected joints. The disease is different in every person. In one, it might affect only small joints of the fingers, while in others many large and small joints might be affected. Mostly it affects the DIP (Distal Inter Phalangeal) joints or the hands and feet, knees, elbows, ankles, etc. DIP joints are generally not affected by Rheumatoid Arthritis. Psoriatic can affect low back involving lumber spine and sacroilic joints and present with Ankylosing Spondylitis like picture. It can also affect tendons and ligaments The skin disease also goes hand in hand with the joint pains. Skin shows lesions that are red, large and small, silvery or grey in color, usually seen on the scalp. In an active disease grouped patches of these lesions might be seen on the back and legs. In the patients where the disease is less active, the patches are smaller, whitish and less itchy

Are any other parts of the body that are affected ?

Yes. Pitting, separation of nails from nail bed, changes and cracking of nails are noted Also, sometimes, there is diffuse swelling in one or two fingers of the hands, involving joints and tendons called Dactylitis

Does it cause any deformities ?

Yes, psoriatic arthritis can cause deformities like rheumatoid arthritis. They are mostly seen in the fingers

Is there any specific test for this disease ?

There is no diagnostic laboratory test for Psoriatic Arthritis. The ESR is high in many patients and RF, if negative, is the most important laboratory feature. Sometimes, in patients with multiple joints Arthritis, Rheumatoid Factor is positive X-rays can help the doctors as they show loss of bone density in small joints of the hands with or without erosions and deformity

How to treat this disease ?

The disease should be treated keeping in mind both skin and joints. Non-steroidal anti-inflammatory drugs (NSAIDs), eg. Diclofenac, Naproxen, etc. help in the patients with moderate pain and swelling, but where there is less pain and more skin involvement, first attention is given to the skin. If the disease is active the doctor needs to use Disease Modifying Anti Rheumatic Drugs (DMARDs) that affect both the skin and the joints. Methotrexate is a drug of choice that works on skin and joints.The skin is treated with topical creams like tar preparations or corticonsteroids and UV radiation can also help Talking with the patients and explaining to them the importance of medicines and proper care solves many of the patients doubts and problems Skin care includes application of cold creams and avoidance of soaps and detergents which contain harmful chemicals. Stress plays an important role in aggravating Psoriasis skin and joint problems. Patients will benefit form Yoga and meditation as it may help to relieve mental tensions to a certain extent