A Comprehensive Review Integrative Approaches to the Management of Ankylosing Spondylitis

At times, it can be hard for any of us to wake up and get out of bed. But what if what stopped you was stiffness and discomfort in your spine instead of just wanting to stay under the covers? This experience is a common one for those living with ankylosing spondylitis (AS), a disease characterized by inflammation of the spine. 

This inflammation can lead to a slew of other troubling symptoms, including joint and back pain, which are often worse in the morning. At least 3 out of every 1,000 Americans suffer from this incurable disease. In this article, we will discuss what AS is, its impacts, and the potential benefits and considerations of functional medicine remedies and practices for managing the disease.

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What is Ankylosing Spondylitis?

AS is a chronic form of arthritis that primarily causes inflammation in the spine, specifically in the sacroiliac joints, which are located between the base of the spine and the pelvis. This condition, known as sacroiliitis, is often one of the first signs of AS. In certain instances, inflammation can spread to the joints between the vertebrae and the bones that constitute the spinal column, resulting in spondylitis.

This lifelong condition typically originates in the lower back but can escalate to the neck or affect joints in other parts of the body. Individuals' experiences with AS can vary widely; some may endure severe, consistent back and hip pain and stiffness, while others might face milder, intermittent symptoms. 

Over time, new bone formations may lead to the fusion of sections of the vertebrae, making the spine rigid, a state referred to as ankylosis. In severe instances, AS can lead to a hunched spine. Despite there currently being no cure for AS, interventions such as medication and exercise can help alleviate pain and strengthen the back, providing significant symptom relief and helping manage the condition effectively (32,2).

Symptoms of Ankylosing Spondylitis

AS typically manifests between the ages of 17 and 45, though it can affect individuals outside of this age range as well. The symptoms can fluctuate over time, with periods of worsening followed by remission. Primary indicators of AS include persistent lower back and hip pain, joint discomfort, and stiffness, particularly noticeable in the morning or after extended periods of sitting. Individuals may also experience fatigue, a loss of appetite, and unexplained weight loss.

In many cases, AS starts in the sacroiliac joints where the spine connects to the pelvis and may even result in the fusion of vertebrae. The disease can also affect where tendons and ligaments attach to bones, leading to a rigid, forward-curving spine. In some instances, individuals may struggle with taking deep breaths and may encounter swelling in their joints. Other complications can include abdominal pain, skin rashes, and vision problems. It's worth noting that the progression and the intensity of these symptoms can vary greatly among individuals suffering from AS, making it a highly individualized condition (32,2).

What Causes Ankylosing Spondylitis?

The cause of AS is largely linked to genetic factors. About 95% of individuals with AS possess a variation of the human leukocyte antigen-B gene (HLA-B), producing a protein known as HLA-B27 that significantly elevates disease risk. However, it's important to note that most people with the mutated HLA-B gene don't develop AS. Certain other conditions, such as Crohn's disease, ulcerative colitis, and psoriasis, may also raise the risk of developing AS.

Furthermore, demographic factors can play a role in the disease's manifestation. Men, for example, are more likely to have AS than women, and they usually experience an earlier and more severe onset. In contrast, women often have a milder form of AS known as non-radiographic axial spondyloarthritis. Age is another factor, as AS often commences during one's teens or young adulthood, with about 80% of cases beginning before the age of 30 and 95% by age 45 (32,2).

Ruling Out Differential Diagnosis

Differential diagnosis for AS is vital, as a number of conditions can mimic its symptoms. Mechanical low back pain, lumbar spinal stenosis, rheumatoid arthritis, and diffuse idiopathic skeletal hyperostosis (DISH) are among those conditions. An early indication of AS, such as significantly reduced mobility and spine stiffness, may assist in detection even when spinal pain isn't pronounced, leading to improvements in management strategies, particularly when intervention is implemented earlier in the disease process. 

Low back pain is often the primary symptom of AS later in the disease process, but it's important to distinguish it from non-specific low back pain for optimal treatment strategies. A key factor in early diagnosis could be distinct episodes of axial pain separated by more than 6 months, which might be more predictive than other characteristics, according to recent research.

Functional Medicine Labs That Can Help Individualize Treatment for Ankylosing Spondylitis Patients

Functional medicine labs offer a variety of tests that can help tailor treatment to patients, allowing providers to optimize management strategies.

Stool Testing

The GI-MAP Test is a comprehensive evaluation of gut microbiome health, which can be especially important for those with AS. The evolving body of research indicates a prominent role of the gut microbiome in AS, with imbalances linked to the disease process. This test can detect variations in gut bacteria, aiding in the development of therapies targeting these microbial changes. 

Micronutrient Testing

The SpectraCell Micronutrient Test can identify nutritional deficiencies that are often present in those with AS. It's worth noting that vitamin D deficiency is commonly observed in AS patients, so it’s a wise decision to test its level in your patients. Moreover, it can reveal any other potential nutrient deficiencies that may arise due to dietary restrictions or gut absorption issues.

Inflammation Testing

The Access Medical Labs C-Reactive Protein (CRP) Inflammation Test can detect inflammation, a key factor in AS. Given the significant role inflammation plays in AS, regular monitoring of CRP levels can help tailor treatments to manage inflammation better and possibly slow disease progression (2). 

Food Sensitivity Testing

The Alletess 96 IgG Food Sensitivity Panel can uncover specific food sensitivities that may be exacerbating AS symptoms. Given that 78% of AS patients believe their symptoms are diet-related, identifying and eliminating trigger foods can possibly contribute to managing AS symptoms and overall health.

Other Lab Tests to Check 

The HLA-B27 Antigen test is a blood test conducted to identify the presence of a protein located on the surface of white blood cells called human leukocyte antigen B27 (HLA-B27). This protein plays a role in the immune system's ability to distinguish the body's own cells from foreign, harmful entities. Being HLA-B27 positive is often associated with certain auto-immune diseases, including ankylosing spondylitis. However, being HLA-B27 positive does not necessarily mean an individual will develop ankylosing spondylitis; it merely increases their susceptibility. 

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Conventional Treatment for Ankylosing Spondylitis

Conventional treatment includes pharmacological treatments such as Nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying anti-rheumatic drugs (DMARDs), and corticosteroids, which can be effective in easing pain and reducing inflammation. Furthermore, lifestyle modifications like regular exercise, maintaining a nutritious diet and healthy weight, reducing alcohol consumption, and abstaining from smoking play crucial roles in alleviating the inflammatory processes and managing pain associated with AS. In severe instances, surgical interventions such as joint replacement or kyphoplasty may be considered (32,2).

Functional Medicine Treatment Protocol for Ankylosing Spondylitis

Functional medicine has the potential to significantly help patients with AS due to the fact that research has shown how diet and the microbiome significantly influence its disease process. Other factors play into managing the disease as well, including using supplements judiciously, incorporating physical exercise, and using complementary treatment modalities. 

The Importance of Gut Health Optimization For Ankylosing Spondylitis

The evolving body of research increasingly indicates a prominent role of the gut microbiome in the initiation and progression of AS. Changes in the gut microbiota, marked by an increase in pro-inflammatory species like Escherichia coli and a decrease in anti-inflammatory strains such as Clostridium leptum, Bifidobacterium, Lactobacillus, and Faecalibacterium prausnitzii, have been intimately linked with the onset and development of AS. Such alterations within the gut environment are believed to interact with genetic factors, especially the presence of the HLA-B27 marker, in precipitating the disease.

Evidence from studies suggests that therapies targeting these microbial changes, such as the use of adalimumab, can restore the balance of the gut microbiome and potentially ameliorate the symptoms of AS. This has substantial implications for developing predictive tools and establishing precise medical interventions in clinical practice, potentially providing new therapeutic avenues in the management of AS. 

Such microbiome modifications might include the incorporation of probiotic strains into the diet, although, at this time, further research is needed before recommending specific strains. Therefore, it’s a good idea to improve your microbiome diversity generally, eating various prebiotic and probiotic foods which can help to grow good bacteria species in the body. A healthy and balanced diet is integral in maintaining a balanced gut microbiome and mitigating inflammation, potentially reducing the risk and severity of diseases like AS.

Therapeutic Diet and Nutrition Considerations for Ankylosing Spondylitis

Evidence indicates that the human leukocyte antigen, HLA-B27, can predispose people to AS by modifying the intestinal microbiome, leading to a distinct gut flora composition in comparison to healthy individuals. Certain studies propose a potential link between high-starch diets and increased colonization of the gut with Klebsiella, a type of bacteria associated with heightened disease activity in AS. Interestingly, a low-starch diet is associated with a decrease in Klebsiella in the gut. 

A low-starch diet involves limiting foods high in carbohydrates, such as bread, pasta, and potatoes while increasing the intake of meat, fish, and fruits and vegetables. Conversely, there is some conflicting but compelling research indicating that an anti-inflammatory diet, which typically includes foods rich in omega-3 fatty acids, antioxidants, and fiber such as fatty fish, nuts, fruits, vegetables, and whole grains, may help to mitigate inflammatory processes and delay disease flare-ups. 

As 78% of patients with AS believe that their symptoms are related to diet, it might be worth trying out an elimination diet to see if specific foods contribute to your symptoms. An elimination diet involves two main stages. First, there's the elimination phase, lasting about three to four weeks, where potential trigger foods and inflammatory substances like processed foods, alcohol, and excess sugar are excluded from one's diet. This time period aligns with the life cycle of certain antibodies related to food sensitivities and the gut lining's regeneration, aiding in overall gut health and reducing inflammation. Following this, each food is gradually reintroduced individually during a period known as the reintroduction phase. Throughout this phase, any changes or return of symptoms are carefully monitored to identify possible food triggers.

Supplements Protocol for Ankylosing Spondylitis

For patients interested in supplements and herbs, there are various evidence-based solutions that may help reduce symptomatology.

Omega-3 for Ankylosing Spondylitis

Research has shed light on the potential beneficial effects of omega-3 fatty acids on AS. In a small randomized controlled trial, patients supplemented with a higher dose of omega-3 fatty acids displayed a significant decrease in disease activity. This points to the capacity of omega-3 fatty acids, in sufficient doses, to potentially reduce the severity of AS, a benefit that extends to other rheumatic conditions as well. 

Dose: 4.55 g omega-3/day

Duration: 3 weeks

Vitamin D for Ankylosing Spondylitis

An association has been found between lower Vitamin D levels, decreased Bone Mineral Density (BMD) values, and AS. Studies have revealed that patients with AS tend to have lower Vitamin D levels and BMD values, specifically in the femur region, compared to healthy controls. Given that Vitamin D has important roles in the immune system, this suggests that it may play a crucial part in the pathogenesis and treatment of AS, a finding that resonates with its role in other rheumatic diseases as well. Therefore, monitoring and managing Vitamin D levels could form an integral part of AS treatment. 

Dose: Current recommendations suggest a daily intake of Vitamin D between 400-800 IU. However, this may be insufficient for some adults. A moderate supplement dosage of 1,000-2,000 IU of vitamin D3 typically suffices for the majority. For greater requirements, daily doses can range from 20-80 IU per kilogram of body weight.

Duration: Ongoing

Curcumin for Ankylosing Spondylitis

Curcumin, the active component of the spice turmeric (Curcuma longa), shows promise as a natural supplement in the management of AS. Randomized controlled trials indicate that supplementation with Curcumin or Curcuma longa extract can improve symptoms and reduce inflammation levels in people with AS. These benefits extend to other forms of arthritis as well, suggesting a wider application for curcumin in the management of various rheumatic conditions. Thus, adding curcumin to the regimen of those with AS could be beneficial in improving their symptoms and reducing inflammation. 

Dose: 120-1500mg

Duration: 4 weeks

Physical Activity and Exercise For Ankylosing Spondylitis

Recent meta-analyses of clinical trials indicate that physical activities, especially aerobic ones such as walking, running, and swimming, along with high-intensity interval training, can effectively enhance disease activity and lower inflammation in individuals with AS. In a similar vein, home-based physical activity interventions have been demonstrated to improve quality of life and functional ability significantly and to reduce disease activity and pain in patients diagnosed with a variety of autoimmune rheumatic diseases, including AS. Another recent study further supports these findings, with physical activity providing improvements in symptoms, physical condition, and quality of life for those with AS. 

Acupuncture for Ankylosing Spondylitis

Acupuncture, a traditional therapeutic technique, has shown potential in managing pain and reducing inflammation in patients with various rheumatological conditions, including AS.

Clinical studies have examined the efficacy of acupuncture in AS treatment, particularly focusing on moxibustion - a method that involves burning dried mugwort on specific points on the body. One study found that combining moxibustion with standard Western medicine could enhance the treatment's efficacy, reduce inflammation, and improve the patient's symptoms and immune indexes. Additionally, simple-needling, another variant of acupuncture, has shown promise in AS treatment. Furthermore, as acupuncture has been found to aid pain relief for other types of rheumatology patients, this suggests that it could potentially offer similar benefits to AS patients.

Chiropractic for  For Ankylosing Spondylitis

The use of chiropractic interventions is typically not advised for the management of AS. Given the fusion of the bones in individuals with this condition, spinal manipulations performed by a chiropractor could inadvertently lead to dislocation or fracture, especially in the spine or neck. 

When to Retest Labs

Testing is advised to be repeated at least every six months. However, this is judiciously based depending on patient symptoms and presentation. It is also important to note that physicians should be aware of medication-specific testing requirements, such as those for patients using conventional treatment with drugs such as DMARDs, as these recommendations can vary by drug.

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Summary

In summary, AS is a condition characterized by an inflammatory process of the spine. This inflammation can lead to a slew of other symptoms, most often related to stiffness and pain. Although this disease is incurable, many factors play into its severity. Functional medicine works to address these factors, helping to reduce symptom burden through changes in diet and lifestyle, using supplements, and treating with modalities such as acupuncture. Thankfully, with diligent attention to managing your AS, there is hope that each day will be better than the last.