There's no cure for ankylosing spondylitis (AS), but treatment is available to help relieve the symptoms.
Treatment can also help delay or prevent the process of the spine joining up (fusing) and stiffening.
In most cases treatment involves a combination of:
Physiotherapy and exercise
Keeping active can improve your posture and range of spinal movement, along with preventing your spine becoming stiff and painful.
As well as keeping active, physiotherapy is a key part of treating AS. A physiotherapist can advise about the most effective exercises and draw up an exercise programme that suits you.
Types of physiotherapy recommended for AS include:
- a group exercise programme – where you exercise with others
- an individual exercise programme – you are given exercises to do by yourself
- massage – your muscles and other soft tissues are manipulated to relieve pain and improve movement; the bones of the spine should never be manipulated as this can cause injury in people with AS
- hydrotherapy – exercise in water, usually a warm, shallow swimming pool or a special hydrotherapy bath; the buoyancy of the water helps make movement easier by supporting you, and the warmth can relax your muscles
Some people prefer to swim or play sport to keep flexible. This is usually fine, although some daily stretching and exercise is also important.
If you're ever in doubt, speak to your physiotherapist or rheumatologist before taking up a new form of sport or exercise.
The National Ankylosing Spondylitis Society (NASS) provides detailed information about different types of exercise to help you manage your condition.
You may need painkillers to manage your condition while you're being referred to a rheumatologist. The rheumatologist may continue prescribing painkillers, although not everyone needs them all the time.
Non-steroidal anti-inflammatory drugs (NSAIDs)
The first type of painkiller usually prescribed is a non-steroidal anti-inflammatory drug (NSAID). As well as helping ease pain, NSAIDs can help relieve swelling (inflammation) in your joints.
Examples of NSAIDs include:
When prescribing NSAIDs, your GP or rheumatologist will try to find the one that suits you and the lowest possible dose that relieves your symptoms. Your dose will be monitored and reviewed as necessary.
If NSAIDs are unsuitable for you, an alternative painkiller, such as paracetamol, may be recommended.
Paracetamol rarely causes side effects and can be used in women who are pregnant or breastfeeding. However, paracetamol may not be suitable for people with liver problems or those dependent on alcohol.
If necessary, you may also be prescribed a stronger type of painkiller called codeine as well as paracetamol.
Codeine can cause side effects, including:
- feeling sick
If your symptoms can't be controlled using painkillers or exercising and stretching, anti-tumour necrosis factor (TNF) medication may be recommended. TNF is a chemical produced by cells when tissue is inflamed.
Anti-TNF medications are given by injection and work by preventing the effects of TNF, as well as reducing the inflammation in your joints caused by ankylosing spondylitis.
Examples of anti-TNF medication include:
These are relatively new treatments for AS and their long-term effects are unknown. However, they have been used for longer in people with rheumatoid arthritis and this is providing clearer information about their long-term safety.
If your rheumatologist recommends using anti-TNF medication, the decision about whether they're right for you must be discussed carefully, and your progress will be closely monitored.
In rare cases anti-TNF medication can interfere with the immune system, increasing your risk of developing potentially serious infections.
The National Institute for Health and Care Excellence (NICE) has produced guidance about the use of anti-TNF medication for AS.
NICE states adalimumab, etanercept and golimumab may only be used if:
- your diagnosis of ankylosing spondylitis has been confirmed
- your level of pain is assessed twice (using a simple scale that you fill in) 12 weeks apart and confirms your condition has not improved
- your Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is tested twice, 12 weeks apart, and confirms your condition has not improved – BASDAI is a set of measures devised by experts to evaluate your condition by asking a number of questions about your symptoms
- treatment with two or more NSAIDs for four weeks at the highest possible dose has not controlled your symptoms
After 12 weeks of treatment with anti-TNF medication, your pain score and BASDAI will be tested again to see whether they've improved enough to make continuing treatment worthwhile.
If they have, treatment will continue and you'll be tested every 12 weeks. If there's not enough improvement after 12 weeks, you'll be tested again at a later date or the treatment will be stopped.
Corticosteroids have a powerful anti-inflammatory effect and can be taken as tablets or injections by people with AS.
If a particular joint is inflamed, corticosteroids can be injected directly into the joint. You'll need to rest the joint for up to 48 hours after the injection.
It's usually considered wise to have a corticosteroid injection up to three times in one year, with at least three months between injections in the same joint.
This is because corticosteroids injections can cause a number of side effects, such as:
- infection in response to the injection
- the skin around the injection may change colour (depigmentation)
- the surrounding tissue may waste away
- a tendon near the joint may burst (rupture)
Corticosteroids may also calm down painful swollen joints when taken as tablets.
Disease-modifying anti-rheumatic drugs (DMARDs)
Disease-modifying anti-rheumatic drugs (DMARDs) are an alternative type of medication often used to treat other types of arthritis.
DMARDs may be prescribed for AS, although they're only beneficial in treating pain and inflammation in joints in areas of the body other than the spine.
Sulfasalazine is the main DMARD sometimes used to treat inflammation of joints other than the spine.
Most people with AS won't need surgery. However, joint replacement surgery may be recommended to improve pain and movement in the affected joint if the joint has become severely damaged.
For example, if the hip joints are affected, a hip replacement may be carried out.
In rare cases corrective surgery may be needed if the spine becomes badly bent.
As the symptoms of AS develop slowly and tend to come and go, you'll need to see your rheumatologist or GP for regular check-ups.
They'll make sure your treatment is working properly and may carry out physical assessments to assess how your condition is progressing. This may involve further sets of the same blood tests or X-rays you had at the time of your diagnosis.
Any complications of ankylosing spondylitis that arise will be treated as they develop.