For young people, less heard ailment Ankylosing Spondylitis (AS) is an emerging disturbance, but that is a stark reality: initially, victims develop symptoms such as low back pain and stiffness that lasts for more than 30 minutes and worsens in the morning or after prolonged inactivity.

Panacea lies in regular exercise before AS grips individual like a wasp with stiffened ligaments and muscles. Dr. Uma Kumar, states that such cases were burgeoning, and timely treatment can only stave off complications.

Patients with AS must exercise regularly because it helps to limit spinal deformity and maintain their spinal movement and flexibility, while also relieving the back pain. Swimming and deep breathing are the best exercises. In addition, a hot shower in the morning can help to ease the pain and stiffness. Patients should avoid smoking, eat a healthy diet and maintain a healthy weight.

AS is not curable, but it is completely treatable if detected early. Only 10% of patients have a severely disabling disease. With the help of the correct medication and lifestyle modification, approximately 80% people with AS remain completely independent or just minimally disabled in the long-term.

In an exclusive interview to InnoHEALTH magazine, Dr. Kumar traces the original meaning of the disease, and says the word Ankylosing Spondylitis (AS) is derived from the Greek words ankylosis meaning ‘stiffening’, spondylosis meaning ‘vertebra’, and – it means ‘inflammation’.

She answered several questions on the ailment.

Question: Can you please explain in detail AS?

AS is a chronic inflammatory type of spondyloarthritis (a broad term for all types of arthritis that affects the spine) that is further classified as an ‘axial spondyloarthritis’ because it affects the joints of the spine and pelvis (where the sacral bone attaches to the iliac bone on either side of the body). When spinal ligaments get inflamed at the point where they attach to the vertebrae, the ‘bone-making cells’ of the body get stimulated and start to grow bone within the ligaments, which results in the formation of bony bridges between adjoining vertebrae – this is what leads to a stiff back.

Question: Does it affect other parts of the body as well?

Sometimes, other joints of the body such as the ankle, knee, and hip may also be affected. AS is more common in young men between 20 and 30 years of age than women. It can occur in children as well. The prevalence of AS ranges from 0.8% to 1.8% in the general population.

Question: Are genetic and environmental factors linked to AS?

The exact cause of AS is unknown. However, there is a strong genetic predisposition and most patients with AS have the HLA B27 gene. About 6% to 8% of the Indian population has the HLA B27 gene and amongst them, those with a family history of AS in a first-degree relative have a 30% chance of developing the disease. However, only 2% of individuals with this gene actually develop the disease. It is hypothesized that some stimuli (e.g. environmental factors, gut microbiome) trigger AS development in genetically predisposed individuals. Moreover, AS can also develop in individuals without HLA B27. It is likely that there are some undiscovered genetic factors that could also be involved in its etiology.

Question: Whether Initial symptoms itself are alarming or not?

Initial symptoms may not appear alarming, but they can be serious. Patients with AS initially develop symptoms such as low back pain and stiffness that lasts for more than 30 minutes and worsens in the morning or after prolonged inactivity. They often find it difficult to turn on the bed during the latter part of the night and the pain sometimes wakes them up from sleep. Typically, the back pain improves with activity. Some of the tendons and ligaments of the body may also get inflamed (e.g. costochondritis & Achilles tendinitis).

Question: What are the other symptoms?

Other symptoms of AS are chest stiffness; pain in the neck, hip, shoulder, glutes (buttock) and heel; as well as arthritis of the knee, ankle, toes or fingers. About 30% of the patients may develop uveitis (painful red eye) and a similar number of patient’s long-standing disease may develop osteoporosis (thin weak bones). The lungs, heart (valves) and kidneys may also get affected.

Question: How can it be diagnosed accurately?

We do clinical diagnosis with imaging and genetic tests. AS is diagnosed based on a patient’s clinical profile and radiological (X-ray) investigations. Blood tests include genetic tests to detect the HLA B27 gene; and tests that detect raised erythrocyte sedimentation rates (ESR) and increased C-reactive protein (CRP) levels to help support the diagnosis. X-ray imaging cannot detect bone changes during the initial stages of the disease making early diagnosis difficult. However, MRI scans of the sacroiliac joints can be used to diagnose AS in the early stages, when the X-ray of this region still appears ‘normal’.

Question: Can treatment help to slow down or stop the progression of AS?

The aim of treatment is to relieve pain; slow down or stop disease progression, and maintain mobility of the spine. Medicines for AS include non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, disease modifying anti-rheumatic drugs (DMARDs) and biologics (targeted therapy). NSAIDs provide pain relief and also retard the progression of AS and patients prescribed these medicines must take them regularly and NOT ‘as and when required’. DMARDs like methotrexate, sulphasalazine, and leflunomide are prescribed for patients with peripheral arthritis. Patients who do not respond well to these drugs may be prescribed biologics such as anti-TNF alpha agents and anti-IL-17 inhibitors, as long as they have not had TB or a similar significant illness in the past.

These biologics and other tools that help us assess the disease have made it possible for patients to lead an almost normal life. Oral or parenteral glucocorticoids have no role in the management of AS though intraarticular steroid injections may sometimes be needed.

Question: Is surgical intervention a solution?

Surgery is rarely required for correcting spinal deformity, though a hip or knee replacement surgery may be needed if there is significant joint damage.

Question: What should be a frequency for consulting doctors?

Regular follow-up with the doctor is extremely important to adjust the dose and to detect any drug adverse effects or any complication or comorbidity at the earliest.

Availability of large neighbourhood parks encourages people to increase their physical activity, and those suffering from chronic conditions who regularly exercise in these parks are less prone to major depression, a new study has found. Besides increasing physical activity, regular exposure to outdoor green spaces improves cognitive functioning and lowers mortality risks. This is significant for those with chronic conditions like arthritis, diabetes, asthma and heart diseases as they are the most vulnerable to depression.

The study was done in Delhi, which has several public parks in residential areas. “Large parks in Delhi have diverse landscapes and are more likely to receive regular and frequent visitors, providing an opportunity for regular socialization,” say researchers.

People who used large-sized neighbourhood parks walked for more than 150 minutes per week, the study found. For overall health, fitness and cognitive maintenance, the World Health Organization recommends adults to engage in 150 minutes of physical activity per week.

Dr. Debarati Mukherjee, lead author of the study says,” High levels of exercise encourage birth of new neurons which aid memory functions and learning.”

Researchers measured the association between park availability and major depression in 1208 adult park-users in Delhi. Major depression was measured using a structured clinical interview. Compared to residents exposed to large parks, major depression was 3.1 times higher among those exposed to small parks. They also showed that large-sized parks reduced stress and increased satisfaction with the immediate living environment.

“There are several mechanisms by which mental health is enhanced by physical activity. This is largely by increasing levels of endorphins in the brain” said Dr Dorairaj Prabhakaran of Public Health Foundation of India and one of the researchers. Endorphins are a group of chemicals that are natural mood elevators.

Dr. Mukherjee says that high levels of exercise encourage birth of new neurons which aid memory functions and learning. Physical activity is also thought to reverse cell and tissue damage as seen in Parkinson’s and Alzheimer’s.

Researchers point out that negative impact of shrinking green spaces due to rapid socio-economic development in metropolitan cities has not been studied, stressing the need for more studies on the matter. In addition to health benefits, urban green spaces reduce air and noise pollution. They also function as an important habitat islands for urban wildlife.

Certain neighborhoods may enable behaviours that promote mental health, while other residents may find it more restrictive to follow a healthy and happy lifestyle.

Dr. Mukherjee says, “Our study provides the first empirical evidence of the benefits of availability of parks in the Indian context. It highlights the importance of having large parks near people’s living quarters”. The study could be a model for similar studies in other cities across the country.

The scientists also recommend inclusion of urban green spaces in city planning to increase overall health of people. Their findings come at an important time whena largescale development in major cities is being undertaken in the country. “This is an opportune moment given that development of sustainable cities is ongoing in 109 cities selected in the SMART Cities Mission. Allocating municipal land for large urban parks should have a high priority,” adds Dr. Prabhakaran.

Altogether, 11 scientists from India, America and United Kingdom contributed to this study. Participating institutions include Centre for Control of Chronic Conditions, Public Health Foundation of India, All India Institute of Medical Sciences, National Institute of Mental Health and Neurosciences, Rollins School of Public Health USA, London School of Hygiene and Tropical Medicine UK. The findings were recently published in journal Health and Place.

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InnoHEALTH Volume 1 Issue 1 (July to September 2016) – https://goo.gl/iWAwN2 
InnoHEALTH Volume 1 Issue 2 (October to December 2016) – https://goo.gl/4GGMJz 
InnoHEALTH Volume 2 Issue 1 (January to March 2017) – https://goo.gl/DEyKnw 
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InnoHEALTH Volume 2 Issue 4 (October to December 2017) – http://amzn.to/2B2UMLw
InnoHEALTH Volume 3 Issue 1 (January to March 2018) – https://goo.gl/fksdQx

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