Axial spondyloarthritis (axSpA) mostly affects the spine. It can cause damage visible on X-ray (ankylosing spondylitis) or damage that doesn’t show up on X-rays (nonradiographic axSpA).
Axial spondyloarthritis (axSpA) is a type of arthritis. It mostly causes pain and swelling in the spine and the joints that connect the bottom of the spine to the pelvis (sacroiliac joint). Other joints can be affected as well. It is a systemic disease, which means it may affect other body parts and organs. The disease tends to run in families.
There are two types of axSpA:
- Radiographic axSpA (also called ankylosing spondylitis or AS) includes damage to the sacroiliac joints and spine that can be seen on X-rays.
- Nonradiographic axSpA (nr-axSpA) does not include damage you can see on X-rays but it may show up on magnetic resonance images (MRIs).
The disease can occur at any age, but typically begins between ages 20 and 40. AS is more common in men than in women. However, nr-axSpA may be just as common in women as in men. It is less common among African Americans than people of other racial backgrounds.
More About Ankylosing Spondylitis
It can also affect shoulders, knees, toes and fingers, as well as the eyes and gastrointestinal tract, and symptoms often begin in the teen and young adult years.
There are two types of axSpA:
- Radiographic — where bone damage shows on X-rays, known as ankylosing spondylitis — affects men more than women.
- Non-radiographic, or nr-axSpA — where X-rays don’t show damage despite symptoms — is more common in women but is often misdiagnosed. Nr-axSpA can lead to ankylosing spondylitis, especially in men.
Other signs of axSpA might include:
- Symptoms that come on gradually.
- Pain that lasts at least three months.
- Nighttime pain and morning stiffness.
- Less pain with movement.
- Blood tests that indicate bodywide inflammation.
- A positive HLA-B27 gene test and X-rays or MRIs showing changes in the pelvic joints may also point to axSpA but don’t confirm it.
- Ease back pain and help maintain your posture
- Prevent joint damage
- Help you maintain mobility and quality of life
Treatment may include activities and medications:
- Exercise, which is essential for pain relief and range of motion in your neck and back.
- Posture training.
- Nonsteroidal anti-inflammatory drugs (or NSAIDS), commonly used for axSpA, include over-the-counter or prescription medications.
- Corticosteroid (steroid) shots may ease joint pain and swelling but are not used in the spine.
- Biologics tamp down inflammation that drives the disease. Biologics used for axSpA include tumor necrosis factor (or TNF) blockers and interleukin-17 (or IL-17) blockers, but not everyone with axSpA needs these powerful drugs.
- Regular, low-impact physical activity, such as walking
- Quitting smoking, which can worsen disease and make some medications less effective
- Hot and cold therapy
- Relaxation, such as deep breathing and mindful meditation.
In shared decision-making, you can ask informed questions and tell your doctor your feelings about treatment options, and your doctor will listen to you and respect your values when recommending care.
Shared decision-making uses patient decision aids, which describe the pros and cons of treatments fairly, clearly and without promoting one approach over others.
Decision aids can be especially helpful for people who are used to their doctors making the decisions.
In shared decision-making, your doctor explains options clearly and provides guidance, but you take ownership of your own health care decisions. This approach has been shown to lead to greater patient satisfaction, better health outcomes and less need for health care overall.
Time is limited in doctor appointments, so write your questions in advance, and listed in priority so you can get the most important ones answered first.
When you have axSpA, some questions you might want to ask include:
- What other problems might I have as a result of axSpA?
- What should I expect in the future?
- How long will it take for my current treatment to start working?
- Will my insurance cover this treatment?
- What other health care providers should I see to help me live well with this disease?
- What can I do on my own to manage it?
Nutrition and Exercise
Aim for at least 150 minutes per week of moderate-intensity exercise, and ask your doctor for a referral to a physical therapist, who can show you appropriate exercises and how to do them properly. The therapist can design a workout that protects your back, strengthens the muscles around your spine and helps your posture.
Once you know what you should and shouldn’t do to protect your joints, you can work out on your own or in a group class.
The best activity is the one you’ll stick with, but it’s best to include stretching and balance exercises, like yoga, strength training with machines, free weights or resistance bands and cardiovascular activities like walking or swimming.
Deep breathing is also important to expand your chest and prevent stiffness in your rib cage and upper back.
Mind-body exercises like yoga, tai chi or Pilates provide mental as well as physical benefits. Work with an instructor familiar with axSpA who can help you modify moves to protect your joints.
Although there’s no axSpA diet, some people find that certain foods affect their symptoms.
A Mediterranean diet is a healthy, anti-inflammatory choice. Focus on eating more fruits, vegetables and healthy fats like olive oil and fish rich in omega-3 fatty acids, and minimize red meat, added sugars and processed foods.
This type of diet also can help you reach or maintain a healthy weight. Being overweight can increase joint pain and inflammation and may make certain medications less effective.
Continue taking your medications as prescribed and be sure to eat well and stay active to help your axSpA symptoms. Talk to your doctor before making any exercise or diet changes, and keep a journal to monitor your symptoms and what affects them.
With axSpA, you might not be able to do all the things you used to. It may alter your plans for the future, and how you live, work and think about yourself. The inflammation that drive this disease may also play a role in depression.
But you can take control of the disease and how it affects you, both mentally and physically. Healthy lifestyle habits, like eating well, staying physically active and maintaining good posture can help you feel better and live well. And it you smoke, get help quitting if you need it; smoking worsens the disease and makes medications less effective.
Many people report that mindfulness-based stress reduction, meditation or mental health counseling helps them.
Try to get plenty of sleep. Have a regular bedtime routine to wind down. Keep your bedroom cool and dark while you sleep and keep a regular sleeping schedule.
Stay engaged socially, but don’t let fear of missing out or guilt keep you from backing out when pain or fatigue are too much. And don’t hesitate to ask for help when you need assistance physically or emotionally.
Having the opportunity to share experiences and information with other people who know what you’re going through can be a game-changer, especially when your friends and family don’t get it. Consider attending a support group, like the Arthritis Foundation’s Live Yes! Connect Groups.
If you’re feeling depressed or can’t sleep, tell your doctor. And keep a journal to see how your activities, diet, mood and other factors affect your symptoms.
The exact cause of axSpA is not clear. Researchers believe that people with certain genes develop axSpA when they are exposed to a virus, bacteria or another trigger. Many people with axSpA have a gene called HLA-B27. But most people that have the gene never develop axSpA.
Low back, buttocks and hip pain are usually the first symptoms. Children, however, may have pain in the hips, knees or heels before the back.
Symptoms of axSpA include:
- Pain in the low back, buttocks and hips that develops slowly over weeks or months.
- Pain, swelling, redness and warmth in the toes, heels, ankles, knees, rib cage, upper spine, shoulders and neck.
- Stiffness when first waking up or after long periods of rest.
- Back pain during the night or early morning.
- Appetite loss.
Joints. Over time, the joints and bones of the spine may grow together (fuse). This usually happens at the base of the spine first. This causes the back to become stiff and hard to move. The rib cage may also fuse, making chest expansion difficult.
Eyes. Chronic eye inflammation (uveitis) causes dryness, pain, redness, sensitivity to light and vision problems. The white part of the eye may also get inflamed and red (called scleritis).
Digestive Tract. Inflammation may cause abdominal pain and diarrhea.
Heart. Though uncommon, inflammation may affect the largest artery that leads to the heart (aorta). People with axSpA also have an increased risk for heart attack and stroke.
Lungs. Complications affecting the lungs are rare. Inflammation may cause shortness of breath and impaired lung function
It’s important to see a doctor early to get an accurate diagnosis. A primary care doctor may be the first person to assess your joint pain. A doctor that specializes in arthritis (a rheumatologist) should be seen if axSpA is suspected.
There is no single test to diagnose axSpA. The doctor will talk with you, perform a physical exam and order a few tests to rule out other causes of back and hip pain.
- Medical history. The doctor will ask about symptoms, when they started, if they come and go, current medical conditions, medication use and whether family members have arthritis.
- Physical examination. The doctor will look for signs of tenderness, swelling and pain in your spine, pelvis and hips. They will watch how your joints move and may check your eyes.
- Blood tests. The doctor may order a test for the HLA-B27 gene. Having this gene doesn’t mean you have axSpA, but it can help with diagnosis. Other tests will check for body-wide inflammation.
- Imaging tests. The doctor may order X-rays, ultrasound, MRI or CT scans of the pelvis and spine to look for damage.
There is no cure for axSpA, but treatment aims to:
- Relieve pain and stiffness in the back and affected areas.
- Keep your spine straight.
- Prevent joint and organ damage.
- Preserve joint function and mobility.
- Improve quality of life.
Early, aggressive treatment is the key to preventing long-term complications and joint damage. A well-rounded treatment plan includes medication, nondrug therapies, healthy lifestyle habits and rarely, surgery.
- Nonsteroidal anti-inflammatory drugs. NSAIDs are the most commonly used drugs to treat axSpA and help relieve pain. They include over-the-counter drugs, such as ibuprofen (Advil) and naproxen (Aleve), as well as the prescription drugs indomethacin, diclofenac or celecoxib.
- Analgesics. In addition to NSAIDs, the doctor may recommend acetaminophen (Tylenol) for pain relief.
- Disease-modifying antirheumatic drugs (DMARDs). Conventional DMARDs are not usually used in people with axSpA that effects just the back. Sulfasalazine, however, may be used for joints other than those in the back and pelvis.
- Biologics. A type of DMARD, biologics target certain proteins and processes in the body to control disease. Biologics are self-injected or given by infusion at a doctor’s office. The ones that work best for axSpA are tumor necrosis factor (TNF) inhibitors and interleukin (IL-17) inhibitors.
- Corticosteroids. These powerful drugs are not often used for spinal disease in axSpA. However, injecting steroids into a knee or shoulder can provide quick relief.
Regular physical activity is a critical part of managing axSpA. It helps prevent stiffness and preserves range of motion in the neck and back. Walking, swimming, yoga and tai chi can help with flexibility and posture. It’s also important to strengthen your core and legs. Talk to a physical therapist to put together a total exercise plan.
Physical Therapy and Assistive Devices
A physical therapist will teach you to strengthen and stretch your muscles to help keep you mobile and reduce your pain. Occupational therapists can prescribe assistive devices and give tips for protecting joints and making daily tasks easier.
Most people with axSpA will never need surgery. But joint replacement can help people with severe pain or joint damage. Surgery may also help straighten a severely bent forward spine.
Eat a healthy diet. There’s no special diet for axSpA. But, eating anti-inflammatory foods, like the ones found in the Mediterranean diet may help. Eat plenty of fatty fish, fruits, vegetables, whole grains and extra virgin olive oil. Limit red meat, sugar, and processed foods.
Avoid smoking. Smoking worsens overall health, and it can speed up disease activity and joint damage. It can also make it harder to breathe. Talk to your doctor about ways to help you quit.
Practice good posture. Good posture can help ease pain and stiffness. Adjust the height of the computer monitor or desk so the screen is at eye level. Plant your feet firmly on the ground. Avoid staying in cramped or bent positions. Alternate between standing and sitting, and use a cushion to support your back. Be careful of “texting neck” when cellphone use is constant.
Stretch. Stretching exercises, especially after a warm bath or shower, can help ease pain and relieve stiffness.
Pace yourself. On tough days, pace your activities and take short breaks throughout the day to manage fatigue.
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