The treatment of ankylosing spondylitis has improved considerably in recent years, especially for severe cases. In particular, drug treatment has improved greatly since the introduction of so-called biologics, which work by inhibiting “TNF-alpha”. Previously, drug treatment was mainly limited to non-steroidal anti-inflammatory drugs (diclofenac, piroxicam, ibuprofen, Celebrex, Arcoxia).
Cortisone is effective, but is used only to a very limited extent and only for a short, limited period, mainly because it further increases the risk of osteoporosis, which is already higher in ankylosing spondylitis. Centrally acting analgesics (medicines that act via the central nervous system) have no anti-inflammatory effect and are therefore only useful for symptomatic pain relief. Intolerance reactions are not uncommon. In the long term, there is a risk of drug dependence if these medicines are not used according to specific, precisely defined rules.
Other medicines, the so-called basic therapies used for example in rheumatoid arthritis, are only useful if peripheral joints are affected. A therapeutic effect on the spine has not been reliably demonstrated so far. If peripheral joints are affected, sulfasalazine (AZULFIDINE RA or PLEON RA) and methotrexate in particular have proven effective in HLA-B27-associated diseases, including ankylosing spondylitis. A combination of both medicines is also possible. Because treatment with the biologics infliximab (REMICADE), etanercept (ENBREL), adalimumab (HUMIRA) and golimumab (SIMPONI) is very expensive (20,000 to 25,000 euros per year), statutory health insurers only cover the costs for very severe cases.
The severity of confirmed ankylosing spondylitis is determined with a questionnaire in which defined parameters are scored and assessed. In Europe, the BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) is mainly used. If a certain score is reached or exceeded (usually > 4) and at least 2 non-steroidal anti-inflammatory drugs have been used without success for a sufficiently long time, biologics can be prescribed. Besides reducing pain as successfully as possible, the aim of treatment is to prevent the spine from becoming increasingly stiff.
This is why, besides medication, the basis of every treatment concept is regular and consistent physiotherapy. Certain exercises have been developed specifically for ankylosing spondylitis. Klapp’s crawling exercise, done “crawling” on hands and feet, mobilises for example the sacroiliac joints. Other exercises counteract the tendency of the thoracic spine to curve forward more (kyphosis): over time, a “hunchback” develops in the thoracic spine, the bony chest becomes less flexible and the chest can expand less when breathing, which is then often compensated by increased abdominal breathing. Or stiffening of the cervical spine narrows the upper field of vision, i.e. looking above the horizon is only possible by bending the knees. This can shorten the muscles at the back of the legs and cause a permanent inability to straighten the knees fully, with corresponding consequences.
Factors of the disease must also be considered when choosing sports. In general, gentle sports without impact are preferable (walking is better than jogging, volleyball is better than squash). Sports that stretch the front of the chest are favourable (volleyball, backstroke). Prolonged hunching of the front of the chest is unfavourable (road cycling). A bicycle with upright handlebars is better because it keeps the upper body upright. Everyday habits are also important.
Sleeping with the upper body bent forward, e.g. by using several pillows, is unfavourable because it promotes stiffening in increased thoracic kyphosis (hunchback). If possible, lying on your stomach every day for about 30 minutes is useful, as this stretches the front of the chest.