Spine Health & Spinal Hygiene

Ankylosing spondylitis, or AS, is a type of inflammatory arthritis that usually impacts the spine, causing back stiffness and pain, pain in the hips, and decreased range of motion. Brain fog can also be a symptom of AS and other chronic inflammatory conditions. Brain fog can affect memory, concentration, decision-making, learning, and problem-solving. Injury Medical Chiropractic and Functional Medicine Clinic can educate on the causes of ankylosing spondylitis brain fog and how to reduce its effects.

Brain Fog

Experts do not fully understand how conditions like AS cause brain fog and how it affects the brain and central nervous system. However, they believe brain fog is linked to chronic inflammation and pain associated with the condition, along with certain factors.

Chronic Inflammation

• Inflammation occurs when the body's immune system attacks healthy cells.
• This triggers the release of inflammation-causing cytokines.
• Cytokines can interfere with normal brain function.

Ankylosing Spondylitis Chronic Pain 

• Chronic pain can cause fatigue and unhealthy sleep quality.
• Fatigue and poor sleep can worsen chronic pain, leading to intense fatigue and extreme sleep issues, becoming a vicious cycle.

Corticosteroids

• Doctors typically treat ankylosing spondylitis with corticosteroids.
• Individuals with cardiovascular risk factors have an increased risk of brain fog from the medications.

Depression

• Individuals with AS can present symptoms of depression, which has been linked to cognitive impairment.
• Depression can contribute to the development of brain fog.

Other Medical Conditions

• Thyroid Imbalances
• Fibromyalgia
• Lupus
• Sjogren's
• Chronic Fatigue Syndrome
• Anemia
• Encephalitis
• Multiple sclerosis

Other Possible Causes

• Stress
• Sleep problems
• Little to no physical activity or exercise.
• Pregnancy
• Menopause
• Antidepressants
• Chemotherapy

Effects

The effects of brain fog.

• Thoughts are blurry and difficult to recall.
• There are major lapses in concentration.
• Thinking is harder.
• There is constant confusion.
• More effort is required to maintain thoughts in short-term memory.
• Constantly forgetting what to do.

Chiropractic Care

Doctors recommend a multidisciplinary approach to manage AS brain fog. This includes:

• An anti-inflammatory nutrition plan.
• Ergonomic adjustments
• Regular physical activity and exercise.
• Mental exercises
• Concurrent treatment with a rheumatologist in combination with chiropractic care.
• Chiropractic care focuses on improving joint mobility and the function of the musculoskeletal system.
• Manual and instrument-assisted adjustments are paired with the following:
• Soft-tissue therapies
• Non-surgical spinal decompression
• Health Coaching
• Fitness Coaching
• Nutritional recommendations

Brain Cognition

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and directly or indirectly support our clinical scope of practice.* Our office has reasonably attempted to provide supportive citations and identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

Chiropractic. (2019). nccih.nih.gov/health/chiropractic

Cornelson, Stacey M et al. “Chiropractic Care in the Management of Inactive Ankylosing Spondylitis: A Case Series.” Journal of chiropractic medicine vol. 16,4 (2017): 300-307. doi:10.1016/j.jcm.2017.10.002

Creaky Joints. (September 17, 2018) “You can ease inflammatory arthritis brain fog with these 12 tips for a sharper mind.” https://creakyjoints.org/living-with-arthritis/arthritis-brain-fog/

Vitturi, Bruno Kusznir, et al. “Cognitive Impairment in Patients with Ankylosing Spondylitis.” The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques vol. 47,2 (2020): 219-225. doi:10.1017/cjn.2020.14

Zhang, Jun-Ming, and Jianxiong An. “Cytokines, inflammation, and pain.” International anesthesiology clinics vol. 45,2 (2007): 27-37. doi:10.1097/AIA.0b013e318034194e

Rheumatoid arthritis is said to affect around 1.5 million individuals. Recognized as an autoimmune condition that presents with chronic pain in the body’s joints. It commonly affects regularly used joints like the shoulders, hands, and feet. The condition can begin to present in individuals in their 30s. Concerns that come with a rheumatoid arthritis diagnosis are the condition's effect on the spinal facet joints. These joints are susceptible to attack from a dysfunctional immune system, leaving them prone to weakness, inflammation, and nerve compression. Chiropractors understand the manifestation of rheumatoid arthritis. They can pinpoint at-risk facet joints and provide corrective relief before more dangerous symptoms begin to present.

Facet joint risks

There are two facet joints that connect each vertebra to the one above and below. Their objective is to stabilize the spine, whether in a neutral position or engaged in flexion/extension movement. When targeted by the body’s immune system, the joints begin to weaken. The body attacks the synovial fluid that lubricates the joints. This creates friction that generates inflammation. Over time the joints break down leading to everything from loss of mobility to bone spurs. When left untreated the facet joints begin to deteriorate, causing nerve compression that can lead to permanent nerve damage. When the joints are not working properly the spine has to work around them.

• Subluxations
• Disc herniation
• Ruptured discs
• Sciatica all are possible with facet joint dysfunction.

Treatment

Currently, rheumatoid arthritis cannot be cured but symptoms can go into remission when treatment begins early. Chiropractic is an effective treatment at disrupting the symptoms of joint deterioration that stops the progression.

• It has the ability to increase and maintain an individual's range of motion, from a condition that causes loss of mobility.
• It helps to bring rapid pain relief and helps with postural improvements.
• It maintains positive spinal health and homeostasis.
• Prevents problems with compression and subluxations.
• Stretching and strengthening exercises are incorporated to preserve an individual's spinal integrity.
• Diet and nutrition are also adjusted to mitigate the effects, helping with inflammation prevention.

The spinal focus

As rheumatoid arthritis affects the body's joints, it is vital to protect the facet joints. These joints can experience degenerative damage that can cause long-term problems. Injury Medical Chiropractic and Functional Medicine Clinic provide individuals with the tools necessary to combat rheumatoid arthritis that medications by themselves might not be able to.

Body Composition

Muscle Mass Fitness for Long-Term Health

Muscle building is not just for bodybuilders and athletes. Everyone benefits from building muscle for long-term health. Monitoring the changes in Lean Body Mass can be accomplished by having body composition measured. Body composition analysis can divide an individual's weight into various components. These include:

• Fat Mass
• Lean Body Mass
• Basal Metabolic Rate will give a clearer picture of overall fitness and health.

Building Lean Body Mass is an investment for maintaining health long-term. The more Lean Body Mass that is built the more is in storage/reserve when the body really needs it. Before adding protein shakes and resistance workouts to the daily regimen, a plan needs to be developed. The first step to building a healthy level of lean body mass is to measure how much there is with a body composition analysis.

Disclaimer

The information herein is not intended to replace a one-on-one relationship with a qualified health care professional, licensed physician, and is not medical advice. We encourage you to make your own health care decisions based on your research and partnership with a qualified health care professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the musculoskeletal system’s injuries or disorders. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and support, directly or indirectly, our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request. We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP, CIFM, CTG*
email: coach@elpasofunctionalmedicine.com
phone: 915-850-0900
Licensed in Texas & New Mexico

References

Pope JE, Cheng J. Facet (Zygapophyseal) Intraarticular Joint Injections: Cervical, Lumbar, and Thoracic. Injections for Back Pain. 129-135. ClinicalKey.com. Accessed July 16, 2019.

Brummett CM, Cohen SP. Pathogenesis, Diagnosis, and Treatment of Zygapophyseal (Facet) Joint Pain. 816-844. ClinicalKey.com. Accessed July 16, 2019.

Inflammatory spinal arthritis can cause significant joint pain and severely damage sleep quality. Any of the following conditions can cause individuals to experience sleep problems:

• Spondylosis (osteoarthritis)
• Rheumatoid arthritis
• Ankylosing spondylosis
• Juvenile idiopathic arthritis

Dr. Jimenez from Injury Medical Chiropractic and Functional Medicine Clinic gives insight into how inflammatory spinal arthritis can disrupt healthy sleep, along with some tips to help individuals with joint pain restore healthy sleep.

Inflammatory Spinal Arthritis and Sleep

First, it is not just the joint pain of arthritis that is causing sleep problems. Research is discovering that more factors could be at play. A study in the journal SLEEP examined how individuals with chronic pain, including osteoarthritis slept. What was revealed was a strong connection between chronic pain and insomnia.

Insomnia can lead to added joint pain because poor sleep can trigger inflammatory pathways that worsen arthritis pain. Plus a poor night of sleep can heighten an individual's perception of pain the next day. Arthritis pain does not just impact the sleep of adults, but young individuals with juvenile idiopathic arthritis can also struggle with getting healthy sleep. Sleep, pain levels, and mood are strongly related.

Sleep Tips

Achieving quality sleep and a well-rested body can be done. Things to consider to help secure a healthy sleep.

Medication interference/side effects

Corticosteroids could be part of the sleep problem, as corticosteroid treatment has been linked to insomnia. If struggling to fall asleep, talk with a doctor about altering any prescribed medication regimen before sleep like taking aspirin or a nonsteroidal anti-inflammatory NSAID medication in its place.

Adjust sleep position to joint pain

If the neck is sore/aching rest the head on a flat pillow so the cervical spine is in a neutral position. For low back joint pain, individuals might find relief by sleeping on their back or side with the knees and hips flexed at a 90-degree angle. For hip joint stiffness, sleeping on the side with a pillow between the legs is recommended.

A firm mattress and support pillow

A firm mattress will support the body and help reduce pain. The right pillow/s are also important for healthy sleep. A lumbar and cervical pillow can help cushion tender areas.

Readjust chores

Joint pain first thing in the morning needs time to adjust. For morning physical chores try to reschedule for later on in the day or if possible the night before. This could be fixing lunches, picking out clothes, preparing breakfast, or packing the work case, tools, etc. The extra time will reduce morning stress and allow the body to gently adjust.

Wake up and stretch

With joint pain in the morning, some gentle stretching can help. Doing some stretches before even getting out of bed will help minimize pain and allow the body to gradually prepare for movement. Follow the stretch session up with a hot shower to loosen stiff joints.

Increase Sleep Quality

Sleep problems can affect anyone even those that don't have inflammatory spinal arthritis/joint pain. There could be other issues causing sleep problems unrelated to joint pain. If still not getting quality sleep, talk to a rheumatologist about available options.

Body Composition

Osteoarthritis and Exercise

Obesity is a significant risk factor in the development of osteoarthritis. This is not only from the effects of extra weight on the body's joints but also as a result of the pro-inflammatory effects of adipose tissue. The hips and knees are the weight-bearing joints. Excessive adipose tissue on the midsection and legs have been shown to negatively impact these weight-bearing joints.

Promoting Lean Body Mass and encouraging weight loss can potentially lower the risk of osteoarthritis and improve the quality of life. Gentle exercise is regarded as safe for individuals with osteoarthritis and is a key component to improve body composition, reduce body fat mass, improve lean body mass and maintain a healthy weight. Improving body composition and utilizing exercise in weight management can have a direct and positive effect on joint health.

Dr. Alex Jimenez’s Blog Post Disclaimer

The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.*

Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas& New Mexico*

References

Myers W. 9 Ways to Rise and Shine With Osteoarthritis. Everyday Health. http://www.everydayhealth.com/osteoarthritis/ways-to-rise-and-shine-with-osteoarthritis.aspx. Last updated September 25, 2014. Accessed April 18, 2017.

Watson S. Why Osteoarthritis Could Disrupt Your Sleep—and Your Partner’s. Arthritis Foundation. http://www.arthritis.org/living-with-arthritis/comorbidities/sleep-insomnia/osteoarthritis-and-sleep.php. Accessed April 18, 2017.

Degenerative Arthritis

• Spinal Arthritis:
• Spondylosis aka Degenerative disease of the spine represents an evolution of changes affecting most mobile spinal segments beginning with:
• Intervertebral disc (IVD) dehydration (desiccation) and degeneration aka Degenerative Disc Disease (DDD) with an abnormal increase in mechanical stress and degeneration of posterior elements affecting 4-mobile synovial articulations ( true osteoarthritis)
• 2-Facets in the L/S & 2-Facets & 2-Uncovertebral joints in the C/S
• Imaging plays a significant role in the diagnosis, grading, and evaluation of neurological complications (e.g., spondylotic myelopathy/radiculopathy)
• X-radiography with AP, Lateral & Oblique spinal views provides Dx and classification of Spondylosis
• MR imaging may help to evaluate the degree of neurological changes associated with degenerative spinal canal and neural foraminal stenosis

• Spinal motion segment:
• 2-adjacent vertebrae
• IVD (fibrocartilage)
• 2-facets (synovial)
• Pathology: loss of disc height increases mechanical stress on mobile elements
• Ligamentous laxity/local instability
• Spinal osteophytes aka spondylophytes & bony facet/uncinate proliferation
• Disc herniation and often disc-osteophyte complex
• Ligamentum flavum "hypertrophy" or thickening due to buckling
• Loss of normal lordosis with or w/o reversal or kyphosis
• Vertebral canal & neural foraminal stenosis

Neutral lateral cervical radiograph: note mild to moderate disc narrowing and spondylophyte formation at C5-6 & C6-C7 (most common levels affected by cervical spondylosis). Straightening or flattening with mild reversal of cervical lordosis. Some mild facet proliferation is noted at the above levels

• On radiographs: evaluate for disc height (mild, moderate or severe) loss
• End-plate sclerosis & spondylophytes; mild, moderate or severe
• Facet and uncinate irregularity, hypertrophy/degeneration; mild, moderate or severe
• Note degenerative instability aka degenerative spondylolisthesis/retrolisthesis
• Normal or lost lordosis vs. degenerative kyphosis
• Key Dx: correlate with a clinical presentation: neck/back pain with or w/o neurological disturbance ( myelopathy vs. radiculopathy or both)

• Uncinate processes undergo degeneration/proliferation resulting in uncovertebral arthrosis
• Early findings present with mild bone proliferation along the cortical margin (white and black arrows) if compared to normal uncinate (orange arrow)
• Later, more extensive bone proliferation extending into and narrowing vertebral canal and neural osseous foramina (IVF's) may be noted. The latter may contribute to spinal/IVF stenosis and potential neurological changes
• Posterior oblique views may help further

• AP lower cervical (a) and posterior oblique (b) views
• Note mild uncinated process proliferation with neural foraminal narrowing (arrows)
• Typically if less than a third of IVF becomes narrowed, patients may present w/o significant neurological signs

• Lumbar spondylosis is evaluated with AP and lateral views with additional AP L5-S1 spot view to examine lumbosacral junction
• Typical features include disc height loss/degeneration
• Intra-discal gas (vacuum) phenomenon (blue arrow) along with spondylophytes
• Degenerative spondylolisthesis and/or retrolisthesis (green arrow) may follow disc and facet degeneration and can be graded by the Meyerding classification
• In most cases, degenerative spondylolisthesis rarely progresses beyond Grade 2
• Lumbar facet degeneration seen as bone proliferation/sclerosis and IVF narrowing

• MR imaging w/o gad C is an effective modality to evaluate clinical signs of spondylosis & associated neurological complications with pre-surgical evaluation
• Case: 50-y.o Fe with neck pain. Case b-45-y.o.M (top a b images). MRI reveals: loss of disc hydration or desiccation, spondylophytes and disc herniation w/o neurological changes
• (Bottom images) Left: preoperative and right postoperative MRI slices of the patient presented with clinical signs of cervical spondylotic myelopathy. Note disc herniation, ligam flavum hypertrophy and canal stenosis (left)

• Sagittal MRI slice of lumbar DDD manifested with disc desiccation and posterior herniation effacing thecal sac
• Correlating sagittal and axial slices will be more informative to evaluate canal stenosis and potential degree of neurological involvement (above-bottom images)

• Use the following resources to learn more on MRI evaluation and diagnosis of Degenerative Disc Disease:
• https://radiopaedia.org/articles/intervertebral-disc-disease-nomenclature
• https://ac.els-cdn.com/S1529943014004094/1-s2.0-S1529943014004094-main.pdf?_tid=bab686bc-cf70-4479-a243-b6d2b342461c&acdnat=1535573367_98364d2d06b7c967d3e859e785eb6f13

Diffuse Idiopathic Skeletal Hyperostosis (DISH) aka Forestier disease

• Flowing degenerative ossification of ALL
• M/c Thoracic spine. 2nd m/c-cervical spine
• Dx by imaging only. X-radiography is sufficient
• CT w/o contrast helps with Dx of Fx
• Men>women. Pts>60-y.o. Extensive DISH shows 49% association with type 2DM
• Complications: Chalk (carrot) stick Fx. Unstable 3-column Fx requiring surgical fusion

• Sagittal reconstructed CT scan slice in bone window
• Chalk stick Fx at C5-C6 in the patient with DISH and OPLL

Spinal Arthritis

A pinched nerve in the hip can cause numbness, tingliness, weakness, and pain. A pinched/compressed nerve creates pressure that can result from a bone structural issue like hip misalignment or the nerve getting overly stretched, stuck, twisted, or kinked. The pressure obstructs the neural pathways and decreases neural activity. This causes pain. If discomfort or pain is present, chiropractic, physical rehabilitation, rest, exercise, and ice and heat can release and reset the nerve and help prevent re-injury.

Pinched Nerve In The Hip

A pinched or compressed nerve results from pressure being applied to the nerve. A pinched nerve in the hip often causes pain in the groin region, radiating down the inner thigh to the knee. The pain can feel like a dull ache or a sharp, burning pain. Individuals also report tightness, numbness, or a tingling sensation in the buttocks. The most common causes include:

• Unhealthy posture.
• Sitting for too long without moving around.
• Misaligned bone or cartilage.
• Muscle strain.
• Pregnancy.
• Obesity.
• Inflamed tissue.
• Herniated disc.
• Arthritis.
• Bone spurs.

Chiropractic

Different causes require different treatment approaches. For example, an obese individual could require chiropractic adjustments, specific exercises/stretches, and diet adjustments to address the whole body. The recommended treatment plans can vary but usually include:

• Physical therapeutic massage.
• Manipulative therapies of the joints and muscles.
• Mobilization of the joints. 
• Soft tissue treatments.
• Spinal decompression.
• Exercise.

Walking and activity can worsen the pain when the hip presents with pain. This can cause the rest of the body to compensate by shifting the weight to the healthy side, which can cause even more pain in the back or legs or cause another injury. Regular chiropractic hip adjustments will improve posture, maintaining muscle and skeleton alignment that will prevent pinching nerves in the hip.

Chiropractic Hip Treatment

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified health care professional or licensed physician and is not medical advice. We encourage you to make your own healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and directly or indirectly support our clinical scope of practice.* Our office has reasonably attempted to provide supportive citations and identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

Ahuja, Vanita, et al. “Chronic hip pain in adults: Current knowledge and future prospective.” Journal of anaesthesiology, clinical pharmacology vol. 36,4 (2020): 450-457. doi:10.4103/joacp.JOACP_170_19

Christmas, Colleen, et al. “How common is hip pain among older adults? Results from the Third National Health and Nutrition Examination Survey.” The Journal of family practice vol. 51,4 (2002): 345-8.

“Free Communications: Case Reports: Hip.” Journal of Athletic Training vol. 38,2 Suppl (2003): S.73–S.74.

Individuals with ankylosing spondylitis have a new treatment option that was previously used for rheumatoid arthritis. It is a medication that belongs to a class known as JAK inhibitors. Ankylosing spondylitis combines joint pain with reduced mobility. Ankylosing spondylitis is different because in severe cases, the bones in the spine can fuse together, literally reducing mobility.

The disease typically begins with pain and stiffness in the back. This is usually after some time of inactivity. Symptoms start before the age of 45 and develop gradually. There is no cure for ankylosing spondylitis but there are treatments that can improve symptoms and put the condition into remission. Ankylosing spondylitis treatment is the most successful when addressed early before irreversible damage to the joints begins.

Janus Kinase Inhibitors

Janus kinase inhibitors have traditionally been used to treat:

• Rheumatoid arthritis
• Psoriatic arthritis
• Ulcerative colitis

The medication works by decreasing the immune system’s activity. Janus kinase inhibitor drugs affect several cellular compounds that are important in the development and progression of ankylosing spondylitis. Currently, there are only three Janus kinase inhibitor medications available in the United States and FDA-approved to treat rheumatoid arthritis:

• Xeljanz
• Rinvoq
• Olumiant
• Each of the approved inhibitors targets specific enzymes

Current Ankylosing Spondylitis Treatments

Janus kinase inhibitors are not given to individuals right away. However, it could be an option if first and second-line treatments are not working. Treatments usually consist of:

First-Line Treatments

NSAIDs

Nonsteroidal anti-inflammatory medications are the most commonly used to treat ankylosing inflammation, pain, and stiffness.

Chiropractic

Chiropractic physical therapy is a major part of ankylosing spondylitis treatment keeping the spine flexible and as healthy as possible. A chiropractic/physical therapy team design and develop specific exercises to fit individual needs, which include:

• Stretching and Range-of-motion exercises help maintain flexibility in the joints
• Sleeping and walking posture adjustment exercises
• Abdominal and spinal exercises to maintain a healthy posture
• Strength training

Second-Line Therapies

If nonsteroidal anti-inflammatory medications do not relieve symptoms, then biological medications could be prescribed. This class of medications includes:

• Tumor necrosis factor blockers
• Interleukin-17 inhibitors

Tumor Necrosis Factor

Tumor necrosis factor blockers work by targeting cell protein that is part of the immune system, known as tumor necrosis alpha. This protein causes inflammation in the body, and the blockers suppress it.

Interleukin 17 Inhibitors

Interleukin 17 in the body's immune system defends against infection. It uses an inflammatory response to fight infections. The IL-17 inhibitors suppress the inflammatory response and help reduce symptoms.

Other Treatment Options

Lifestyle Adjustments

Following a medical treatment plan is often combined with diet and lifestyle adjustments that are recommended to help with the condition, these include:

• Being as physically active as possible will help:

1. Improve/maintain a healthy posture
2. Maintain flexibility
3. Ease pain

• Applying heat and ice will help alleviate:

1. Pain
2. Stiffness
3. Swelling

• Practicing posture exercises

Surgery

Most individuals with ankylosing spondylitis do not require surgery. However, a doctor could recommend surgery if there is joint damage, the hip-joint needs to be replaced, or if the pain is severe.

JAK Inhibitor Potential

Studies are ongoing in the treatment of ankylosing spondylitis. The drug is currently in Phase 3 trials for the treatment of adults. The trial results have shown patients with active ankylosing spondylitis showed improvement in:

• Fatigue
• Inflammation
• Back pain

The study enrolled adults with active ankylosing spondylitis who took at least two NSAIDs that were ineffective at treating symptoms. Most of the participants were men, average age of 41, and no prior usage of biologic disease-modifying antirheumatic drugs.

Janus kinase could become a standard treatment

There is still not enough research to make a prediction, but the data is promising. The inhibitors seem to be a safe option when used in a properly screened, well-matched setting that includes regular monitoring. The inhibitors appear to be effective and have the advantages of being taken orally and working fast.

Body Composition

Osteoarthritis and weight loss

Being obese has shown to be a high-risk factor for the development of osteoarthritis. This is not only from the effects of extra weight on the body's joints but also as a result of the inflammatory effects of adipose tissue. The lower back, hips, and knees, bear the majority of the body's weight.

An excess amount of adipose tissue on the body's midsection and legs has been shown to negatively impact the weight-bearing joints. Promoting Lean Body Mass and encouraging weight loss lowers the risk of osteoarthritis and improves an individual's quality of life. Exercise is regarded safe for individuals with osteoarthritis and should be incorporated to improve body composition, reduce Body Fat Mass, improve Lean Body Mass and maintain a healthy weight.

Dr. Alex Jimenez’s Blog Post Disclaimer

The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.*

Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas& New Mexico*

References

Hammitzsch A, Lorenz G, Moog P. Impact of Janus Kinase Inhibition on the Treatment of Axial Spondyloarthropathies. Frontiers in Immunology 11:2488, Oct 2020; doi 10.3389/fimmu.2020.591176. https://www.frontiersin.org/article/10.3389/fimmu.2020.591176, accessed Jan 21, 2021.     

van der Heijde D, Baraliakos X, Gensler LS, et al. Efficacy and safety of filgotinib, a selective Janus kinase 1 inhibitor, in patients with active ankylosing spondylitis (TORTUGA): results from a randomized, placebo-controlled, phase 2 trial. Lancet. 2018 Dec 1;392(10162):2378-2387. doi: 10.1016/S0140-6736(18)32463-2. Epub 2018 Oct 22. PMID: 30360970. https://pubmed.ncbi.nlm.nih.gov/30360970/ accessed Jan 19, 2021.

• Spinal Arthritis
• Ossification of Posterior Longitudinal Ligament (OPLL). Less frequent than DISH.
• Greater clinical importance d/t spinal canal stenosis and cervical myelopathy
• Asian patients are at higher risk
• Both OPLL & DISH may co-exist and increase the risk of Fx
• Imaging: x-rad: linear radioopacity consistent with OPLL
• Imaging modality of choice: CT scanning w/o contrast
• MRI may help  to evaluate myelopathy
• Care: surgical with laminoplasty (above right image) that has been pioneered and advanced in the Far East

M/C Inflammatory Arthritis In Spine

• Rheumatoid spondylitis (Rheumatoid arthritis) d/t inflammatory synovial proliferation pannus rich in lymphocytes, macrophages, and plasma cells
• C/S RA may affect 70-90% of patients
• Variable severity from mild to destructive disabling arthropathy
• RA IN C/S m/c affects C1-C2 due to an abundance of rich synovial tissue
• Typically infrequent in the thoracic/lumbar region
• Sub-axial C/spine may be affected later due to facets, erosions, ligament laxity and instability showing "Stepladder" appearance
• Clinically: HA, neck pain, myelopathy, etc. inc. Risk of Fx/subluxation. Any spinal manipulation HVLT ARE STRICTLY CONTRAINDICATED.
• Rx: DMARD, anti-TNF-alfa, operative for subluxations, etc.

Rheumatoid Spondylitis C1-C2. Perform X-radiography initially with flexed-extended views. Note Dens erosion, C1-2 subluxation (2.5 mm) that changes on mobility 

• RA spondylitis: an erosion of the odontoid with the destruction of C1-C2 ligaments and instability
• Stepladder aka Step-step sub-axial deformity d/t facets erosions and ligamentous destruction/laxity
• MRI required to evaluate cord compression/myelopathy 

• Sagittal T2 WI MRI of pt with RA. Rheumatoid pannus formation is present at C1-2 (arrow) causing mild cord compression
• RA pannus may develop early before frank x-radiography changes noted
• Clinically: HA, neck pain, tingling in UE, positive Lhermitte phenomenon d/t cervical myelopathy

Operative Care of Rheumatoid Spondylitis and Its Complications

Seronegative Spondyloarthropathies

• Ankylosing Spondylitis (AS)
• Enteropathic Arthritis (EnA) (d/t IBD: Crohn's & UC) identical to AS on imaging
• Psoriatic Arthritis (PsA)
• Reactive Arthritis (ReA)
• All share the following features: m/c HLA-B27 marker, RF-, Sacroiliitis, Enthesitis, Ocular Involvement (i.e., conjunctivitis, uveitis, episcleritis, etc.)
• AS & EnA are radiographically virtually indistinguishable, but EnA typically presents with less severe spinal changes than AS
• Both PsA & ReA present with virtually identical spinal changes, but ReA typically affects the lower extremity compared to PsA affecting hands and feet

• AS: likely autoimmune systemic inflammatory disease that targets SIJ, spinal facet joints annuls of the disc, rib joints and all spinal ligaments.
• Key path feature: enthesitis.
• Extraspinal features: uveitis, aortitis, pulmonary fibrosis, amyloidosis, cardiovascular disease.
• M:F 4:1, age: 20-40 m/c. Clinic LBP/stiffness, reduced rib expansion <2 cm is > specific than HLA-B27, progressive kyphosis, risk of Fx's.
• Imaging steps: 1st step-x-rays to id. Sacroiliitis/spondylitis. MRI & CT may help if x-rays are unrewarding.
• Labs: HLA-B27, CRP/ESR, RF-
• Dx: clinical+labs+imaging.
• Rx: NSAID, DMARD, anti-TNF factor therapy
• Key Imaging Dx: always presents initially as b/l symmetrical sacroiliitis that will progress to complete ankylosis. Spondylitis presents with continuous ascending discovertebral osteitis (i.e., marginal syndesmophytes, Romanus lesion, Anderson lesion), facets and all spinal ligament inflammation and fusion with a late feature of "bamboo spine, trolley track, dagger sign," all indicating complete spinal ossification/fusion. Increasing risk of Fx's. 

Key Dx of Sacroiliitis

• Blurring, cortical indistinctness/irregularity with adjacent reactive subchondral sclerosis initially identified primarily on the iliac side of  SIJs.
• Normal SIJ should maintain a well defined white cortical line. Dimension 2-4 mm. May look incongruous d/t 3D anatomy masked by 2D x-rays. 

Key Imaging Dx In Spine

• Marginal syndesmophytes and inflammation at the annulus-disc (above arrows) at the earliest dx; by MRI as marrow signal changes on T1 and fluid sensitive imaging (above top images). 
• These represent enthesitis-inflammation that will ossify into bamboo spine.
• Lig ossification: trolley track/dagger sign

• AS in extraspinal joints: root joints, hips, and shoulders
• Symphysis pubis
• Less frequent in peripheral joints (hands/feet)
• All seronegatives may present with heel pain d/t enthesitis

• Complication: Above Carrot-stick/chaulk-stick Fx

• PsA & ReA (formerly Reiter's) present with b/l sacroiliitis that virtually identical to AS
• In the spine PsA & ReA DDx from AS by the formation of non-marginal syndesmophytes aka bulky paravertebral ossifications (indicate vertebral enthesitis)
• For a clinical discussion of Spondyloarthropathies refer to:
• https://www.aafp.org/afp/2004/0615/p2853.html

Spinal Arthritis