Ankylosing spondylitis, a seronegative spondyloarthritic disease, is discussed from the point of view of pathology, clinical features (articular and extra-articular), and diagnosis (with differential diagnosis) along with an approach to the treatment by homeopathic medicines and essential non-medicinal management.
Among arthritis affecting adults, rheumatoid arthritis, osteoarthritis and gout are certainly the most important; but ankylosing spondylitis is also extremely important. Homeopathy is claimed as particularly effective in chronic joint disorders. To make this statement applicable also for ankylosing spondylitis, it is necessary to have a clear idea of this disease including its clinical features, diagnosis and scope of using non-medicinal measures.
Ankylosing spondylitis is a seronegative spondyloarthritic disease. Spondyloarthritic group also includes reactive arthritis, psoriatic arthritis, spondylitis, enteropathic arthritis, spondylitis and juvenile onset spondyloarthritis. (1) It is an inflammatory disorder of unknown cause that primarily affects the axial skeleton. The word originates from Greek word ‘ankylos’ which means stiff and ‘spondylos’ which means vertebrae. The name itself suggests characteristic stiffness of back in ankylosing spondylitis.
Sacroiliitis is the earliest manifestation of the disease followed by the formation of syndesmophyte along the edge of intervertebral cartilages. Ultimately, syndesmophytes of the vertebra above join with the syndesmophytes of the vertebra below making the spine stiff. (1) The disease is characterized by :( 3)
· Insidious onset before the age of 40 (usually 20–40 years) with distinct male preponderance
· Duration longer than 3 months
· Association with morning stiffness and night pains
· Improvement with the physical activity or exercise
Sacroiliitis manifests as stiffness and pain in the buttocks, sometimes radiating to the thighs. Alternating buttock pain is a characteristic. (2) Patient presents with an insidious onset of dull pain in the lower lumbar region and morning stiffness, which improves with the activity. After few months, the pain usually becomes persistent and bilateral. There may be nocturnal exacerbation of pain
The disease eventually involves lumbar, thoracic and cervical vertebrae causing pain and stiffness in the spine. This stiffer and flexed vertebral column is known as ‘Poker Back’ and ‘Rocker Back’ respectively. (3) Patient also experiences chest pain, which is due to enthesitis of the costovertebral, sternocostal, costochondral and sternal joints.(4) Peripheral joint involvement also occurs. Hip is involved in 50% cases; shoulder is involved less often. In advanced cases, patients suffer from severe peripheral arthritis; usually asymmetrical and predominantly affecting lower limbs. Heel pain is not uncommon.
On examination, there is a loss of normal lumbosacral curvature. Spinal movement is decreased with the limitation of anterior and lateral flexion and extension of the lumbar spine. Limitation of movement is usually out of proportion to the degree of bony ankylosis due to muscle spasm, pain and inflammation.
Flexion of lumbar spine is measured by the Schober test. Two points are taken in an erect posture; one is 5 cm below and other is 10 cm above the lumbosacral junction. The patient bends forward maximally, and the distance between the two marks is measured. The distance between the two marks increases to 5 cm or more in case of normal mobility and less than 4 cm in case of decreased mobility.(1) Springing the pelvis (pressing iliac crests towards each other) causes sacroiliac pain.
Extra articular Manifestations (1, 4)
Eye: Acute anterior uveitis (unilateral pain, photophobia, lacrimation; tends to recur in the opposite eye)
Cardiac: Aortic insufficiency (regurgitation), conduction abnormalities, which may include even Third Degree Heart Block
Pulmonary: Apical fibrosis, cavitation, restrictive lung disease (Respiratory failure may result from fixed rib cage with kyphoscoliosis and from fibrosing alveolitis)
Neurological: Cauda equina syndrome
Others include cataract, glaucoma, nephropathy and cervical myelopathy
Patients with advanced ankylosing spondylitis have a typical posture, characterized by obliterated lumbar lordosis, buttock atrophy and accentuated thoracic kyphosis. There may be a forward stoop of the neck or flexion contractures at hips compensated by flexion at knees (hang-dog appearance).(1) Disease progression in ankylosing spondylitis is assessed by loss of height of the patient, limitation of chest expansion and spinal flexion.
Laboratory Investigations (1, 4)
1. HLA B-27; about 90% of patients have a positive test.
2. Blood test for ESR, CRP, alkaline phosphatase (all increased), but RA Factor, Anti-CCP and antinuclear antibodies are negative.
Radiological Investigations (1, 2)
Sacroiliac joint: Blurring of the joint outline with para-articular ilial sclerosis, erosions and apparent widening followed by obliteration of the sacroiliac joint.
Spine: Syndesmophytes formation. When syndesmophytes from above and below fuse, the shadow at the level of disc becomes wider than that of vertebral bodies. This looks like nodes and internodes of bamboo — hence called “bamboo spine”.
While reactive arthritis, rheumatoid arthritis, psoriatic arthritis and juvenile onset spondyloarthritis are considered, the most important differential diagnosis is from Caries Spine (Tuberculosis of Spine).
In ankylosing spondylitis, the modern medicinal treatment is not satisfactory and much stress is given on the non-medicinal approach (exercise). Analgesics are the main drugs used but they do not modify the basic course of disease. Surgical measures like osteotomy of the spine or hip replacement are advocated in advanced cases with an aim of restoring the mobility. (2)
Acupuncture claims success in treating ankylosing spondylitis using simple acupuncture therapy. Acupuncture combined with massage, cupping and Chinese medicine treatment, moxibustion therapy, moxibustion and acupoint injection, embedding method, etc. are other approaches of the treatment. (5)
Homeopathic treatment is expected to be effective. Individualistic approach of homeopathic treatment in each particular case helps to allay the pain and hinder the progression of the disease. Following are few rubrics taken from some repertories.
Rubrics from Kent’s repertory (6)
· BACK, Pain, aching, lumbosacral region: AESC., ONOS., CIMIC., PHOS.
· BACK, Pain, aching, night: AESC.
· BACK, Stiffness, morning: phyt., zinc.
· BACK, Stiffness, painful: amm., calc., CAUST., helon., manc., nit-ac., puls., RHUS-T.
· BACK, Curvature, cervical: calc., PHOS., SYMPH.
· BACK, Curvature, dorsal: calc., calc-s., con., lyc., puls., rhus-t., sil., sulph., syph., bar-c., bufo, plb., thuj.
· EXTREMITIES, Stiffness, hip, morning: arg-m., ars., chin-s., staph.
Rubrics from BTPB (7)
· SENSATION, Rigidity: CHEL., DROS., KALM., LED., RHUS., Bell., Cic., Cimic., Colch., Hyos., Kre., Lith., Mos., Nux v., Phyt., Plat., Puls., Sec.c., Stram.
· SENSATION, Pain, Dull: AGAR., HYOS., NUX V., Ant-c., Camph., Chin., Dulc., Guai., Hell., Hep., Ign., Kre., Laur., Mang., Mar., Meny., MERC., Mez., Mos., Puls., Sul., Zinc
Rubric Ankylosis” can be found in:
Complete Repertory chapter Extremities; Joint
Phatak’s Repertory — Joints
Apart from the medicinal treatment, some non-medicinal methods are necessary to combat the stiffness of ankylosing spondylitis and reduce progression. It includes regular spinal extension exercises in prone position, breathing exercises, swimming and bathing in warm water. (2)
An exercise program based on strengthening and aerobic fitness should be an integral part of the management even with the homeopathic approach. A daily stretching program focusing on cervical rotation and thoracic extension should be included. Swimming with different stroke especially backstroke is very effective. Power type walking with increased spinal rotation and arm swing is recommended. Heavy lifting, jarring activities and running should be avoided. (2)
Bed rest is contraindicated as it increases the stiffness. Activity is needed in both affected and unaffected joints. Careful posture with spinal muscle exercise is essential to prevent chronic deformity. Sleeping on a firm bed without pillows help prevent fixed spinal flexion. (2)
It is in this context that correct and early differentiation from caries spine is essential. In ankylosing spondylitis, exercise/activity is needed and if not done, there would be more stiffness and loss of movement. In caries spine, rest is needed and if not taken there would be more damage to spine with possibility of paraplegia.
Ankylosing spondylitis is a seronegative arthropathy whose successful management by homeopathy is dependent on the early diagnosis, correct differential diagnosis and proper advice on exercise apart with appropriate medicine.
1. Kasper D. L. et al (Ed). Harrison’s Principles of Internal Medicine. Vol 1. 16th Ed. New Delhi: McGraw Hill, 2005: 2109 – 2112.
2. Rheumatology. Therapeutic Guidelines Limited, Melbourne. Version 2, 2010: 98-102
3. Robert B S. Textbook of Disorders and Injuries of the Musculoskeletal System. Baltimore: The Williams and Wilkins, 1970:185
4. Sainani G S. API Text book of Medicine. 6th Ed. Mumbai: Association of Physicians of India, 1999
5. Internet sources
6. Kent J. T. Repertory of Homoeopathic Materia Medica. New Delhi: B. Jain Publishers, 1984: 914, 918,946, 887, 1194
7. Allen T F. Therapeutic Pocket Book…. 5th Ed. New Delhi: B. Jain Publishers, 1972: 177,164.