In this week’s installment of Ask the Expert, Dr. Susan Goodman, Rheumatologist, answers your questions, which were gathered by the Spondylitis Association of America, on spondylitis. This will be the first of a two part series.
Q1. Patients are often dismissed for years and simply live in pain as blood work and x-rays can often all come back normal in spondyloarthiris, and it can be an “invisible disease” for a long time. How should a good primary care physician go about screening for Spondyloarthritis in their patients with chronic back/joint pain? And what can the patient do to better advocate for themselves when living with an undiagnosed illness?
Dr. Goodman: Due to the scope of the problem, screening patients with low back pain (LBP) is a challenge for primary care physicians. About 25% of those between the ages of 30 and 50 report LBP, which is the most common cause of disability in those aged 45 or younger, yet 50% of those with LBP are better at one week, and 90% in 8 weeks. However, spondyloarthropathy, manifested by inflammatory back pain, may be as prevalent as rheumatoid arthritis, yet the average delay in diagnosis is 9 years, in part due to the lag in x-ray manifestations of sacroiliitis needed for diagnosis. Since the problem of back pain is so common, radiographic sacroiliitis may not be apparent on plain x-rays and MRI evaluations on all patients with LBP is impractical, primary care MDs should screen by identifying the features of inflammatory back pain. These include onset below age 40, insidious onset, improvement with exercise, no improvement with rest, and night pain. Improvement with NSAIDs is another useful feature. When these features of inflammatory back pain are present, the patient may be either referred to a rheumatologist for evaluation, or further screened by testing for the genetic marker for spondyloarthropathy, the HLA-B27, which is the key lab marker for spondyloarthropathy. Using the strategy of screening by history with referral of all patients with inflammatory back pain, with or without a positive HLA-B27, or with sacroiliitis on imaging, early diagnosis can be made.
Q2. Could you address the ways Ankylosing Spondylitis can present in women that is different from how it generally presents in men (i.e. tendency of more neck/peripheral involvement, especially in early stages)? How can this different presentation lead to more delays in diagnosis and inaccurate diagnosis commonly given to women such as fibromyalgia and depression? What are some solutions?
Dr. Goodman: Spondyloarthropathy was described as a form of arthritis, which is more prevalent in men, due to the differences in presentation between men and women. Women tend to have more cervical spine disease, and more peripheral arthritis, while men tend to have lumbar disease, which ascends the spine. In the 1950s-60s, fewer than 10% of patients diagnosed with Ankylosing Spondylitis, the prototypic spondyloarthropathy, were women. The male to female ratio currently is approaching 1. Multiple factors have contributed to the solution of this problem, including the wider availability of more sensitive imaging techniques such as the MRI, which can detect early changes of inflammation of the sacroiliac joints leading to early diagnosis, wider availability and decreased cost of the HLA-B27 test, as well as the increase in women in medicine.
Q3. How exactly and why are gut issues such as Crohn’s IBS and SpA so closely related? Also, what is your opinion on “leaky gut syndrome”/”intestinal permeability” and how or if it may perpetuate systemic inflammation or affect inflammatory/autoimmune conditions?
Dr. Goodman: The spondyloarthropathy group of diseases is characterized as an interrelated group of diseases with many shared features. Patients with inflammatory bowel disease such as Crohn’s or Ulcerative Colitis may have clinical features of disease shared with patients with inflammatory back pain and Ankylosing Spondylitis, such as uveitis, or inflammatory eye disease, psoriasis, or a shared family history. About 20% of patients with extra-articular disease manifestations have clinically apparent inflammatory bowel disease, and 50-60% of spondyloarthropathy patients have asymptomatic mucosal ulcerations without clinical bowel disease.
Another link to spondyloarthritis from the gut comes through reactive arthritis, which is a form of spondyloarthritis which may be precipitated by infections elsewhere, such as Shigella, Salmonella, or campylobacter, which are gut pathogens. These infections may set off an immunologic reaction leading to inflammatory disease elsewhere in the body, the joints in particular. Moreover, the bowel wall is not a complete barrier, but may be permeable to various substances, in particular in the setting of mucous membrane ulcerations are common in patients with AS or spondyloarthropathy. In this model, the molecules that are able to breach the leaky bowel wall lead to increased exposure to immunologic stimulation, which in susceptible individuals, can result in the immunologic reactions typical of reactive arthritis.
Q4. Are there anti-inflammatory foods? If so, how might they benefit those with spondyloarthritis? Are there foods that should be avoided that may cause inflammation? What is your opinion on gluten free and/or low starch diets for SpA patients? Cutting out meat or dairy? Is there anecdotal evidence from patients vs. lack of scientific validation?
Dr. Goodman: While there are foods that are known to have anti-inflammatory activity such as fish oils, these have not been shown to be of benefit in spondyloarthropathy. There are no specific foods that increase inflammation in spondyloarthropathy. In Celiac Disease, exposure to gluten, a specific wheat antigen, leads to an immunologic reaction in which bowel inflammation and inflammatory arthritis can occur. While this sounds similar to reactive arthritis, in fact, the genetic associations are quite different, and removing the gluten stimulus can resolve all the symptoms of celiac disease. For reactive arthritis, once the antigenic stimulus produces the disease manifestations, they do not resolve after the precipitating infection is cleared.
Q5. Are there other non-medicinal approaches to improving spondyloarthritis symptoms (i.e. exercise, alternative medicine, meditation) that may be helpful for SpA patients?
Dr. Goodman: All patients with spondyloarthritis should see a physical therapist. This is critically important as none of the medications, which are extremely helpful in treating the symptoms of spondyloarthritis, have been shown to reverse or prevent the stiffening of the spine, in those who are affected. Stretching and extension spine exercises are very important for patients to maintain optimal function.
Q6. Why do some women with SpA go into remission during pregnancy? Is it because of hormones or other reasons? Could it be something to investigate to find medicinal use for patients?
Dr. Goodman: While there are differences in the clinical features of SpA in women compared to men, no difference among women has been seen with use of oral contraceptive pills, which are a source of exogenous estrogen. The differences between men and women in clinical SpA features such as more neck and knee disease in women or more foot involvement in men, has not been clearly attributed to hormones. In regard to pregnancy, while one study described improved back pain in the first trimester of pregnancy, by the later stages, back pain had returned and worsened, although back pain returned to the pre-pregnancy level postpartum. Unlike patients with rheumatoid arthritis, who frequently report involvement in RA signs and symptoms during pregnancy, patients with AS and SpA typically report higher disease activity, possibly due to the mechanical stresses of pregnancy.
Dr. Susan Goodman is a Rheumatologist at Hospital for Special Surgery. She specializes in treatment of patients with inflammatory arthritis such as rheumatoid arthritis, psoriatic arthritis, and spondyloarthritis. Her other areas of specialization is in the perioperative care of patients with rheumatic diseases. Her research interests have focused on the perioperative outcomes of rheumatic disease patients undergoing arthroplasty.