I had to learn to always have a “high level of suspicion” for Ankylosing Spondylitis (AS) while a rheumatologist-in-training. This meant, I needed to “unlearn” most of what I was taught about back pain as an internal medicine resident. As an internist or primary care provider, you see a lot of patients with back pain. It is very common. In order to keep costs down and not overly worry patients, doctors are trained to treat back pain with common anti-inflammatory medications before jumping to x-rays and MRIs. And this isn’t JUST to keep costs down. The overwhelming majority of those with back pain will have resolution of that pain within 2 months. Hence, doing an MRI on every patient just doesn’t make sense. But as a rheumatologist, we are trained to look at back pain differently.
The fact that most back pain will self-resolve is still true, but we are trained to have a more precise “nose” for inflammation. We ask the questions that get to the heart of inflammation and know what signs to look for aside from the back. Ankylosing Spondylitis is an autoimmune inflammatory arthritis that affects the back and it can take patients years to reach a diagnosis. Not wanting to be another doctor who missed the clues, I became obsessed with finding the sacroiliac inflammation typical of AS and prided myself on my physical exam and pointed questions during my appointments.
What is ANKYLOSING SPONDYLITIS?
Once a diagnosis is made, however, I would often get scared but blank stares, “WHAT do I have??? (and “HOW do you pronounce it?”) It is not a condition many people are familiar with and this fact alone can lead to a lot of fear. AS is often thought of as “Rheumatoid Arthritis (RA) of the back,” but it is really not that at all. Like RA, it is an inflammatory arthritis, but as opposed to the inflamed small joints of the hands, wrists and feet we typically see in RA, AS affects the back, the knees, shoulders and hips. It belongs to a larger group of conditions, even more confusingly called, seronegative spondyloarthropathies.
negative – uh….negative
pathies – disease
*conditions with negative blood tests (no Rheumatoid Factor or ANA) and associated with disease of the back/joints.
The conditions that fall under this category are AS, psoriatic arthritis, uveitis (inflammation of the eye) and arthritis with inflammatory bowel disease, to name a few. You can see how this gets confusing. And it’s not just patients. Teaching this to medical students and residents is met with many confused looks. But it’s important to understand the concept, especially if you have any of these conditions. They reside along a spectrum and are not discrete entities under an umbrella. Someone can be diagnosed with AS, and months to years later develop eye inflammation or inflammatory bowel disease. Knowing this, will keep your eyes out for any warning symptoms that you can then bring to your doctor’s attention.
Are Ankylosing Spondylitis and Rheumatoid Arthritis treated the same?
Yes….but really no. The strategies are very similar. We always want to identify the condition as early as possible. Both RA and AS, if left untreated, can result in irreversible joint damage. We are fortunate these days to have therapies that can slow down and even stop the progression of this damage. However, the medications that are effected in RA, many times aren’t in AS. This led the scientists and researchers to go back to the lab. With more information about the cellular differences between AS and RA they have now come out with a group of new meds, specifically for this group of conditions.
As doctors, we still have a ways to go to diagnose patients in a timely manner with AS. Back pain is so common that being able to effectively identify who needs more testing and who needs time and rest is still an art many haven’t mastered. Bringing your concerns to your doctor can do alot to get their mind thinking in that direction and even if you don’t have AS, will help remind them to always keep it in mind with any back pain patient.
In good health,
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