Ankylosing Spondylitis (ढाडको बाथ): Symptoms, HLA-B27 and Treatment
By Dr. Krishna Adhikari, Consultant Rheumatologist
MBBS, MD (Internal Medicine), Fellowship in Clinical Rheumatology
Awaiting medical review: this new article has not yet been checked by Dr. Krishna Adhikari. It will be updated after his review.
Ankylosing spondylitis (AS), known in Nepali as ढाडको बाथ, is a long-term inflammatory arthritis of the spine and a type of axial spondyloarthritis. Its back pain and stiffness usually start before the age of 45 and get better with movement, not with rest. There is no cure at present, but exercise, physiotherapy and medicines can relieve the symptoms and help slow the disease.
What is ankylosing spondylitis (ढाडको बाथ)?
AS mainly affects the spine and the sacroiliac joints, where the spine meets the pelvis (Arthritis Foundation). Over time, in some people, parts of the spine join together (fuse) and stiffen; this is what "ankylosis" means. When the spine changes do not show on an X-ray, the NHS calls it non-radiographic axial spondyloarthritis, with similar symptoms and treatment.
The name ढाडको बाथ is also in the title of Dr. Krishna Adhikari's video on this page. It is one kind of बाथ रोग (bath rog), but not every back pain is ढाडको बाथ: a pulled muscle is a common cause.
What are the three main symptoms of ankylosing spondylitis?
The NHS says the symptoms usually involve:
Back pain and stiffness. You may also have pain around the buttocks, and it may be worse in the morning and at night.
Pain and swelling elsewhere: in joints such as the hips and knees, or where a tendon joins a bone (enthesitis), such as the heel.
Extreme tiredness (fatigue).
Symptoms build up over months or years and may come and go. People with AS may also have a red, painful eye (iritis, also called uveitis), psoriasis or inflammatory bowel disease.
Who gets ankylosing spondylitis?
AS usually starts between the ages of 18 and 40, according to the NHS. It is more common in men (Arthritis Foundation), but axial spondyloarthritis as a whole affects a similar number of women as men (NICE, the UK guideline body). The risk is higher if a family member has the disease, and people with psoriasis, Crohn's disease or ulcerative colitis may be more likely to develop it (NIAMS).
Inflammatory or mechanical back pain: what is the difference?
NICE warns that axial spondyloarthritis is often misdiagnosed as mechanical low back pain, which delays treatment. Typical patterns (Spondylitis Association of America, NICE, NHS):
Inflammatory back pain (the pattern in AS)
Starts gradually, usually before the age of 45, and lasts longer than three months.
Is worse after keeping still, at night and early morning; it may wake you in the second half of the night.
Can bring morning stiffness that lasts 30 minutes or longer.
Eases with movement and exercise, not with rest.
Mechanical back pain (the everyday kind)
Is usually caused by a strained muscle, a sprained ligament or a slipped disc.
Often follows lifting, twisting badly or an injury, and tends to get better with rest.
Usually improves within a few weeks, though it can last longer or come back.
No single feature decides it; a doctor weighs the whole picture.
HLA-B27: what does a positive test mean?
HLA-B27 is an inherited gene variant; a blood test shows whether you carry it. It is linked with AS but does not diagnose it.
Positive does not by itself mean you have AS. The UK's NHS estimates that 8 in every 100 people carry it, and most of them do not have AS. More than 8 in 10 people with AS carry it (NHS), but the Arthritis Foundation notes that this share is lower in some ethnic groups.
Negative does not rule AS out. NICE tells doctors not to rule out spondyloarthritis on a negative HLA-B27 result alone.
Without symptoms it means little. A positive result in someone with no symptoms and no family history of related disease is not clinically significant (Testing.com).
It runs in families. A parent with AS who carries it has a 1 in 2 chance of passing it to a child; an estimated 5 to 10 in 100 children who inherit it develop AS (NHS).
If you have inflammatory back pain, see a rheumatologist whatever your HLA-B27 result. Your doctor will tell you which tests you need; ask the laboratory for its current price and any preparation.
How is ankylosing spondylitis diagnosed?
No single test diagnoses AS. According to NIAMS, the doctor puts together:
Your history: where and how long it hurts, what helps, and family history.
An examination of your spine, pelvis, heels and chest, including how you bend and breathe.
Blood tests: HLA-B27 and markers of inflammation such as ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein). A normal ESR and CRP do not rule AS out (NICE); see our guide to ESR and CRP blood tests.
Imaging: X-rays, which may stay normal for years, and MRI, which can help diagnose AS early.
Are there stages of ankylosing spondylitis?
Some websites describe "4 stages", but the NHS, NIAMS, American College of Rheumatology and NICE pages listed below do not divide AS into numbered stages. At regular check-ups, doctors follow how active the disease is and may repeat X-rays or MRI to see changes (NHS, NIAMS). In some people AS gets better with time; in others it slowly gets worse (NHS).
How is ankylosing spondylitis treated?
This describes treatments a doctor may use; it is not advice to take any medicine.
Exercise and physiotherapy
The NHS calls physiotherapy a key part of treatment. NICE recommends a personal exercise programme that includes stretching, strengthening, posture, deep-breathing and aerobic exercise. Is walking good for ankylosing spondylitis? Yes: the Arthritis Foundation lists walking, swimming, yoga and tai chi as helpful for flexibility and posture.
Medicines
NSAIDs (non-steroidal anti-inflammatory drugs) are usually the first medicine, at the lowest dose that controls symptoms. Rare but serious side effects include stomach ulcers or bleeding and kidney problems (NHS), so take them only as a doctor advises.
Biologic medicines, such as TNF inhibitors and IL-17 inhibitors, are given by injection or drip and may be used when NSAIDs and exercise are not enough. In rare cases TNF inhibitors raise the risk of serious infection, so treatment is monitored closely.
Steroid injections can help one inflamed joint; steroid tablets are not recommended (American College of Rheumatology).
DMARDs, used in other types of arthritis such as rheumatoid arthritis, help in AS only with joints outside the spine.
Most people with AS will not need surgery.
What you can do at home
There is no special diet, but a healthy weight reduces stress on painful joints (NIAMS). Stretching after a warm bath or shower and good posture can help ease pain and stiffness (Arthritis Foundation). If you smoke, stop: AS is more severe in smokers, and smoking reduces the effect of treatment (NIAMS).
Can ankylosing spondylitis be cured?
No. The NHS states that there is no cure for AS and that damage already done cannot be reversed. Treatment relieves symptoms and can help delay the disease; NIAMS says that with treatment, most people with AS can have productive lives. Be careful with anything that promises a cure, and ask your doctor before stopping any medicine.
Is ankylosing spondylitis life-threatening?
Usually not. The American College of Rheumatology says that with newer treatment options, most people with axial spondyloarthritis lead normal, productive lives and have a normal lifespan. The NHS says AS does raise the risk of weak bones (osteoporosis) and spinal fractures, of heart and blood vessel disease, and of iritis, which can harm your sight if it is not treated promptly.
ढाडको बाथ (एन्काइलोजिङ स्पोन्डिलाइटिस): नेपालीमा संक्षेप
एन्काइलोजिङ स्पोन्डिलाइटिस (ढाडको बाथ) ढाड र कम्मरका जोर्नीहरूमा सुजन (इन्फ्लामेसन) हुने, लामो समयसम्म रहने बाथ रोग हो। यो प्रायः ४५ वर्षभन्दा कम उमेरमा सुरु हुन्छ। मुख्य लक्षणहरू यस्ता छन्: ढाड र कम्मर दुख्ने र कडा हुने, बिहान र राति बढी दुख्ने, आराम गर्दा नघट्ने तर हिँडडुल र व्यायाम गर्दा कम हुने, एडी वा अरू जोर्नी दुख्ने, र धेरै थकान लाग्ने। हरेक ढाड दुखाइ ढाडको बाथ होइन। मांसपेशी तन्किँदा हुने सामान्य ढाड दुखाइ आराम गर्दा कम हुन्छ र प्रायः केही हप्तामा ठीक हुन्छ। HLA-B27 पोजिटिभ आउँदैमा यो रोग लागेको हो भन्ने हुँदैन, किनकि यो रोग नभएका धेरै मानिसमा पनि यो जीन हुन्छ। रोग पत्ता लगाउन डाक्टरले लक्षण, शारीरिक जाँच, रगत परीक्षण (ESR, CRP, HLA-B27) र एक्स-रे वा MRI हेर्छन्। यो रोग हाल पूर्ण रूपमा निको हुँदैन, तर नियमित व्यायाम, फिजियोथेरापी र डाक्टरले दिएको औषधिले लक्षण कम गर्न र रोग बढ्न ढिलो गर्न मद्दत गर्छन्। धूमपान नगर्नुहोस्। आँखा रातो हुने, दुख्ने, उज्यालो सहन नसकिने वा धमिलो देखिने भएमा सोही दिन आँखाको डाक्टरलाई देखाउनुहोस्। ४५ वर्षभन्दा कम उमेरमा सुरु भएको ढाड दुखाइ तीन महिनाभन्दा लामो समयसम्म रहेमा बाथ रोग विशेषज्ञ (रुमाटोलोजिस्ट) लाई देखाउनुहोस्।
When to see a rheumatologist
See a rheumatologist if back pain started before 45, has lasted over three months and follows the inflammatory pattern above, especially with heel pain, swollen joints, psoriasis, or a parent, sibling or child with spondyloarthritis (NICE). An eye that becomes painful or red, sensitive to light or blurred needs an eye doctor the same day (NICE). Go to a hospital emergency department at once if back pain comes with weakness or numbness in both legs that is severe or getting worse, numbness around the genitals or anus, or new trouble controlling urine or stool (NHS). A rheumatologist can tell AS apart from back strain and from other rheumatic diseases such as lupus.
Rheumatology care in Kathmandu Valley
Rheumatology care at Tulsi Multi Speciality Clinic is provided by Dr. Krishna Adhikari, consultant rheumatologist and Lecturer in Internal Medicine at Patan Academy of Health Sciences (Patan Hospital), NMC No. 13049. He consults Sunday to Friday from 4:00 PM at AVM Chowk, Manbhawan, Lalitpur-5, Kathmandu Valley. See our rheumatology service and Dr. Krishna Adhikari's profile, book an appointment, or call +977-1-5914294. This article is general information, not a substitute for a consultation.
Sources
NIAMS — Ankylosing Spondylitis: Diagnosis, Treatment, and Steps to Take
NIAMS — Rheumatoid Arthritis: Diagnosis, Treatment, and Steps to Take
American College of Rheumatology — What is a Rheumatologist?
NICE — Spondyloarthritis in over 16s: diagnosis and management (NG65)
Arthritis Foundation — Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis
Spondylitis Association of America — Overview of Spondyloarthritis
Spondylitis Association of America — Inflammatory vs Mechanical Back Pain
Rheumatology care at Tulsi Multi Speciality Clinic · Dr. Krishna Adhikari, consultant rheumatologist
To see a doctor, book online, call +977-1-5914294 or message the clinic on WhatsApp.