Why is breathing difficult & at times, painful in Ankylosing spondylitis?

June 26, 2016

The mechanical apparatus for breathing consists of the ribs, intercostals muscles, costochondral junctions & the diaphragm. Diaphragm is a muscle located at the base of the chest wall cavity. The ribs move at the joint formed by them with the vertebrae (costovetebral joint). The intercostals muscles are attached to the ribs & are responsible for the movements of the ribs during respiration.

costovetebral joint

During inspiration, the diaphragm moves downwards & expands the chest cavity. At the same time, the ribs move up & out to expand the thoracic cavity. This movement is akin to a bucket handle (moving up). The movement of the ribs is brought about by the contraction of the intercostal muscles.

 

 

In Ankylosing spondylitis, there is inflammation of the costovertebral joint. Later, as AS progresses, the joint may also get fused. This inflammation/ fusion then restricts the movement at the joint & consequently the chest expansion. Physically, this manifests as restricted chest expansion.

Ankylosing spondylitis also leads to inflammation at insertion of intercostal muscles to the ribs (enthesitis). This leads to pain in the rib cage area & also further difficulty in taking a deep breath.

Sneezing involves a rapid & high intensity contraction of the intercostal muscles. It is very painful due to the enthesitis & is almost felt like a ‘catch’

Tight control of AS with NSAIDs/ DMARDs/ biologics/ diet & deep breathing exercises are helpful in reducing this chest pain.

 


What causes foot pain in Ankylosing spondylitis?

June 5, 2016

Foot pain is a common component of Ankylosing Spondylitis (AS) & other seronegative spondyloarthropathies (SpA- psoriatic arthritis, reactive arthritis). In AS/ SpA, the inflammation is predominantly at two locations- within the joints- synovitis & at the attachment of ligaments/ tendons to a bone (enthesitis)

Let us have a look at the various causes of foot pain—

Heel pain– also known as plantar fasciitis. The foot has a bone called calcaneum located at the heel region. A muscular structure ‘plantar fascia’ is attached at the lower end of this bone.

plantar fascia

There is inflammation at the attachment of this fascia to the bone (enthesitis) & causes pain that is generally maximal in the morning & after periods of rest.

plantar fascitis NSAIDs & at times local steroid injection is used to take care of the fasciitis. Persistent inflammation does indicate ongoing inflammation & would require better control of AS/ SpA.

Use of soft footwear & heel cushion/ cup in footwear helps reduce the pain. A simple exercise involving rolling of the foot on top of a bottle in the morning before walking does a lot good in many.

silicon heel cup

Pain at the backside of the foot– this is commonly due to Achilles enthesitis.

Achilles tendon is the thick band like structure at the backside of the foot. This is attached to the calcaneum bone below.

6Inflammation of the attachment (enthesitis) causes pain & localised swelling.

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Achilles enthesitis is a telltale sign of active AS/ SpA & mandates better control with DMARDs/ biologics.

Toe pain—At times, the entire toe may be swollen & painful. This is known as dactylitis & is a feature of AS.

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This is suggestive of ongoing active inflammation.

Pain & swelling at the base of the toe can be due to inflammation of the joint & DMARDs/ steroid injection in the joint/ biologics are used to control it.

Mid foot pain– is generally due to inflammation of the underlying joints especially if associated with swelling. This would require better control of AS.

Ankle & midfoot pain can also be due to a flat foot.

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This would require foot analysis & an insole to correct the flat foot.

foot analysis

All in all, understand your foot pain & discuss with your rheumatologist.

Understanding the reason can help you take better decisions to take control of your AS.

oot pain in AS


How does ankylosing spondylitis cause osteoarthritis of the hip? — the Pacman game

May 15, 2016

I’m sure all of you know that Ankylosing spondylitis (AS) is an autoimmune disease, which means that the body’s immune system considers its own joints as foreign & attacks them. We have not been able to pinpoint the exact reason for this.
If this immune attack is not controlled in time, it ends up destroying the joints; especially the hips. This is known as osteoarthritis of the hips. Ankylosing spondylitis is a unique disease as it causes destruction of the bones in the hip & at the same time it leads to excessive bone formation in the spine (syndesmophytes). So what starts as backache can well end up as deformities & disability.

But then, how does AS cause destruction of the hips?
Hip joint is lined by a thin membrane called the synovial membrane from the inside. The immune attack is targeted towards the synovial membrane. The synovial membrane swells up due to the attack. This inflamed synovium is like the pacman. Remember the pacman game?… pacman eats away all the dots. In a similar fashion, the pannus eats the cartilage & the bones around it. When it eats the bones, the same is known as erosion. Apart from the hips, these erosions are also seen in the sacroiliac joints. Destruction of the cartilage & the bone ultimately leads to osteoarthritis.

 

Rheumatoid_Arthritis_Knee_Joint

 

pacman

The Pacman game.. Pacman keeps eating the dots…just like the inflamed synovium keeps eating the cartilage & the bones. Note how the AS Pacman has destroyed the hip bones (above) & the sacroiliac joint (SI joint) (below).

 

Ankylosing_Spondylitis_CT_Scan

Can the hip osteoarthritis be prevented?
Yes, very much so. Seeing a Rheumatologist at the earliest & starting definitive treatment at the earliest can definitely tame this pacman & prevent osteoarthritis.


An Individual Is Much Bigger Than His/ Her Disease

January 3, 2016

Yesterday, I met one of my regular known patients who had come with sweets to announce a new arrival in his family. Why known? …. Because he has taught me an important lesson. AN INDIVIDUAL IS MUCH BIGGER THAN HIS/ HER DISEASE. Now, what does that mean?

life goals blog

Samir, a young man in his early thirties consulted me almost 3 years back. He was suffering from Ankylosing spondylitis for 6-7 years. Apart from the disease details, I could make out that he had seen his life go tospy turvy in these years. Right from the first day, I realized that there was something different about him. Once the discussion about his Ankylosing spondylitis was over, he would make it a point to talk about his life, his goals & ambitions. In fact, I felt as if he was laying down a roadmap of what he wanted & asking me to help achieve that with the medications.

From his talks, I understood that he had a saree shop. He was unable to manage it due to his backache & his wife had to do the needful. His social & married life too was in bad shape due the persistent pain. Once as he was talking about his life, I asked him to take time out to put down his wishes & priorities on paper & bring it during his next visit.

This is what he had listed-
1) Conquer his pain & the disease
2) Get back to work. Manage the shop on his own
3) If possible, change the business into some other business that was more manageable. A saree business required one to travel to distant areas to buy sarees at a cheaper cost & for variety.
4) Once the financial situation improved, think of starting a family.

As I said, he had given me a roadmap to work on. We started the work together.
DMARDs were not helping him. We discussed about biologics. In India, biologics is never an easy thing as these are expenses out of pocket. He spoke to his wife, the seniors in the family, friends & mustered sufficient funds to start & sustain the treatment. I did my part & managed to provide the most from the company’s ‘Patient assistance Programme’.

As I think about it today, the rest is history. He did well with biologics. He achieved his first goal of conquering his pain & the disease in the subsequent months. He was managing his shop well. His profits improved. With these resources, he could manage the biologics on his own. After a year, he decided to shift over to a DTP business. He undertook a part time course to learn DTP. A DTP business does not require traveling or lifting weights. His plan was clear. Once the business was set, he would employ the staff & get the work done. This was clearly a good decision given his condition. His DTP business stabilized over a period of time.

Yesterday, he was at the clinic not for a consultation but to announce a new arrival. I was moved. He had indeed come a long way. Though this would sound like a fairy tale, but it isn’t. There were many obstacles particularly with the finances for the biologics. But, since he had mentioned his priorities & made me a partner not just in achieving remission but also in his life related goals, our path was clear.

Please understand that you are not the same as your disease. You are not ‘a case of Ankylosing spondylitis’. That is so not right. Your life is much bigger & you should not forget your professional, personal, social, marital life. Talk about your goals, aspirations with your Rheumatologist. Apart from ensuring that your disease goes in remission, we can plan & help you achieve these goals.


Low Starch Diet for Ankylosing Spondylitis: Part 2 – The Scientific Evidence

November 2, 2014

We have already seen (in the last blog) the theoretical possibility of a ‘Low starch diet’ being beneficial for Ankylosing Spondylitis. Let us now see whether it really works in real life & whether there is sound medical evidence to support it.

Today’s medicine works on the basis of evidence. If a new medicine/ intervention is thought to be useful, it is tested in clinical trials. A group of patients is given the standard treatment & placebo (an inert substance that has no effect on disease activity) while another comparable group is given the standard treatment & the experimental therapy/ intervention. A ‘double blinded study’ that ensures that neither the investigator nor the patient knows whether he is taking the experimental drug or placebo is ideal to avoid any bias; both on the investigator or the patient front. This is not possible for studies with dietary modifications as blinding is not possible & bias tends to creep in.

As against medicines, it is very difficult to keep an exact track of the diet of any patient for obvious reasons. It is extremely difficult to ensure that a patient sticks to a particular diet in the long run throughout the study period.

These two factors make studies based on dietary interventions difficult to conduct as well as interpret.

For the reasons mentioned, there are hardly any studies about ‘low starch diet’ in Ankylosing spondylitis. In 1996, Dr. Ebringer discussed the disease activity trend of one of his patients following the diet for a long period (1983- 1995). His ESR showed a continuously decreasing trend. In another study (mentioned widely on the internet with no reliable data available on any of the medical literature sites) 36 patients received Dr. Ebringer’s diet & showed considerable improvement in symptoms. These two studies would be highly inadequate for any definite conclusions.

So, as we have seen, the utility of ‘low starch diet’ in Ankylosing spondylitis is not yet proven scientifically.

One way of looking at things would be to give it a try & see whether it works. However it has to be weighed against the risks involved in pursuing such a diet.

In the next blogpost, let us look at what a ‘low starch diet’ includes/ excludes & the possible health hazards of such a diet.


“Low starch diet’ for ankylosing Spondylitis

October 25, 2014

Many patients keep asking me about the role of ‘Low starch diet’ to control Ankylosing Spondylitis. This has been a hot topic of discussion on most Ankylosing spondylitis groups on social media & many confirming the good results of a low starch diet.

The original idea of a ‘low starch diet for Ankylosing Spondylitis’ comes from Dr. Alan Ebringer, Prof of Immunology at King’s College London. He found high levels of a gut pathogen called Klebsiella Pneumoniae in stool samples of patients with Ankylosing spondylitis. He also found high levels of antibodies to klebsiella in the blood of patients with Ankylosing spondylitis. These findings indicated the presence of the bacteria in the gut of patients with Ankylosing spondylitis & the body’s immune reaction to it.

These findings evoked further research & Dr. Alan’s further research showed that K. pneumoniae was isolated more frequently during the active phase of Ankylosing Spondylitis & clinical relapse was preceded by appearance of the bacteria in fecal samples. This meant that Klebsiella Pnemoniae was somehow related to inflammation of Ankylosing Spondylitis.

Dr. Alan’s research continued & he went on to show that there are similarities in structure of the HLA-B27 molecule & enzyme Pullulanase produced by the Klebsiella bacteria. There is also similarity between the enzyme & type I, III & IV collagens found in joints & other organs. This gave rise to the ‘Molecular mimicry theory’. The human immunity recognizes Klebsiella as foreign & attacks it. However, since HLA-B27 & collagens have similar structure, they get attacked to. This may be responsible for the inflammation in joints & other structures like the eyes in Ankylosing spondylitis.

One can infer from the proposed ‘molecular mimicry theory’ that by reducing the klebsiella bacteria in the gut, one can reduce the inflammation associated with Ankylosing spondylitis.

Various studies have shown that the gut bacteria including klebsiella grow on undigested starch in the gut. Hence a reduction in starch in the diet may help reduce the klebsiella bacteria in the gut. Klebsiella bacteria is well adapted to the human gut & produces the Pullulanase enzyme that can break down the starch, derive nutrition & thrive in the gut.

The rationale of the ‘low starch diet’ is to cut down on the starch, make life difficult for the klebsiella bacteria. This may indirectly help control the Ankylosing spondylitis.

This is the exact basis of the ‘low starch diet’ for Ankylosing Spondylitis.

Now that we know the basis of the theory, we also need to look at the following points—
1. What is a ‘low starch diet’?
2. Are there any studies conducted in patients with Ankylosing spondylitis to prove the benefits of ‘low starch diet’?
3. If the concept looks so convincing, why do Rheumatologists not recommend it on a regular basis?

I would be answering these questions in the subsequent blog posts. These posts are coming soon & follow my blog so that you don’t miss out on any of those useful posts.

References: Erbinger A, Wilson C. J Med Microbiol 2000; 49: 305-311 http://jmm.sgmjournals.org/content/49/4/305.abstract


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