What Is Axial Spondyloarthritis?
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Medically reviewed by David Ozeri, MD
Axial spondyloarthritis (axSpA) is a type of inflammatory arthritis that primarily affects the spine and joints that connect the lower spine to the pelvis (known as the sacroiliac joints). An estimated 3 million Americans live with axSpA, which causes symptoms like low back pain, stiffness, and fatigue that often develop in early adulthood. This condition is a systemic disease, which means it can affect other joints and body parts, especially as the condition progresses.
Researchers don’t know exactly what causes axSpA, but evidence suggests certain genetic and environmental factors play a role. Fortunately, treatment options for axSpA can help reduce symptoms, improve physical function, slow disease progression, and prevent complications like joint damage.
Types of Axial Spondyloarthritis
There are two types of axial spondyloarthritis: ankylosing spondylitis and nonradiographic axial spondyloarthritis. While the core symptoms of both types are similar, there are some key differences between the two types:
Ankylosing spondylitis: This condition causes inflammation and structural changes in the sacroiliac joints which are visible on X-rays. Over time, the inflammation can cause the bones in the spine to fuse into a fixed and immobile position, which often reduces flexibility and mobility.
Non-radiographic axial spondyloarthritis: Shares some symptoms with ankylosing spondylitis, but this type does not show visible joint damage on X-rays. The lack of radiographic evidence can make diagnosing this condition a challenge, so diagnosis often relies on magnetic resonance imaging (MRI), which can show evidence of inflammation that X-ray images do not detect.
Symptoms of Axial Spondyloarthritis
The symptoms of axSpA typically develop gradually before the age of 45 and can persist for three months or longer. With this condition, it's common to experience:
Buttocks pain
Hip pain
Joint pain, such as discomfort in the neck, knees, and shoulders
Stiffness that worsens in the morning or after inactivity
Fatigue and low energy that can disrupt daily activities
Enthesitis, or inflammation of the entheses, where tendons and ligaments attach to your bones
Uveitis, or inflammation of the eye which causes symptoms like redness, blurry vision, and sensitivity to light
As axSpA progresses, it's also possible to experience gastrointestinal problems. In the later stages of this condition, you may develop abdominal pain, diarrhea, bloody stools (poops), and rectal bleeding. Many with this type of arthritis also develop inflammatory bowel disease (IBD).
Causes
Axial spondyloarthritis is an autoimmune disease, meaning your body’s immune system mistakenly attacks healthy tissues. When this happens, inflammation occurs in the sacroiliac joints and spine and produces pain and stiffness, among other symptoms. Like most autoimmune disorders, the exact cause of axSpA is unknown. But research suggests a combination of genetic and environmental factors play a role in its development.
Genetics
There is a strong link between the HLA-B27 gene and axial spondyloarthritis. In fact, up to 90% of people with ankylosing spondylitis and 70% of those with nonradiographic axial spondyloarthritis carry the HLA-B27 gene. The HLA-B27 gene provides instructions for producing an important immune protein, and variants on this gene may prompt the immune system to misidentify healthy body tissues as threats, leading to inflammation.
Although the HLA-B27 gene is associated with an increased risk of axSpA, most people with the HLA-B27 gene do not develop axSpA, and some people with axSpA do not carry the gene at all. This suggests other factors play a role in the development of the disease, such as the environment.
Environmental Factors
Experts theorize that specific environmental factors may trigger an overactive immune response in people with the HLA-B27 gene and contribute to the development of axSpA. Possible triggers for axSpA include bacterial infections, viral infections, and dysbiosis (an imbalanced gut microbiome).
Risk Factors
Certain factors can also increase your risk of developing axial spondyloarthritis, such as:
Having a family history of axial spondyloarthritis or people who carry the HLA-B27 gene
Being between the ages of 20 and 45, which is when symptoms are most likely to occur
Experiencing frequent gastrointestinal infections
Smoking tobacco, which can worsen inflammation
Diagnosis
If you experience frequent back or joint pain, it's important to see your healthcare provider for proper testing. It's worth noting that axial spondyloarthritis can be challenging to diagnose. If you have symptoms of axSpA, your primary healthcare provider may refer you to a rheumatologist, or a doctor who specializes in diagnosing and treating arthritis and other conditions that affect the joints, bones, and connective tissues.
Currently, no definitive test can diagnose axial spondyloarthritis, so healthcare providers use a combination of exams to make an accurate diagnosis. These tests may include a physical exam, blood tests, and imaging scans.
Physical Exam
Your healthcare provider will review your medical history and ask about your symptoms and risk factors (e.g., family history of arthritis). During the physical exam, your healthcare provider will look for signs of inflammation (e.g., pain and tenderness) along your spine, neck, chest, pelvic bones, and heels. They may also ask you to move your body in certain ways to check the range of motion in your joints and examine your eyes for signs of inflammation.
Blood Tests
Blood tests can check for markers of inflammation and other factors that may suggest that you have axSpA. Your provider may order one or more of the following blood tests:
C-reactive protein (CRP): Measures CRP levels in the blood, which is a protein the liver produces. People with axSpA often have high levels of CRP.
Erythrocyte sedimentation rate (ESR): Checks inflammation in the body by showing how quickly red blood cells (erythrocytes) separate from other blood cells and collect at the bottom of a test tube.
Plasma viscosity (PV): Assesses the thickness and stickiness of the blood. Positive PV blood tests may signal axSpA.
HLA-B27 test: Looks for the presence of human leukocyte antigens on the surface of white blood cells to determine whether you carry the HLA-B27 gene.
Imaging Scans
Imaging tests create images of your body to visualize the bones, joints, and connective tissues so healthcare providers can look for signs of inflammation and damage. Your provider may recommend one of the following imaging scans:
X-ray: Reveals damage to the sacroiliac joints, spine, and pelvis. It's worth noting that relying only on X-rays may delay diagnosis, as it can take up to 10 years of disease progression for visual damage to show up on X-ray images.
Magnetic resonance imaging (MRI): Provides detailed images of the sacroiliac joints and spine. MRI can detect inflammation before structural changes (e.g., damage) show on X-rays.
Ultrasound: Uses sound waves to produce detailed images of internal body structures, which may help detect inflammation in the entheses (where ligaments and tendons connect to bone).
Axial Spondyloarthritis Treatment
At this time, there is no cure for axial spondyloarthritis. But there are treatment options to help reduce pain and discomfort, maintain physical function and flexibility, slow disease progression, and prevent complications like joint and organ damage. Your exact treatment plan will depend on your symptoms and overall health, but may include medications, therapy, and surgery.
Medications
Medications are an essential part of axSpA management. Healthcare providers prescribe medicines for symptom relief and slowing disease progression. Common medications include:
Non-steroidal anti-inflammatory drugs (NSAIDs): These are first-line treatments for axSpA. Aleve (naproxen) is one example of an NSAID that can effectively reduce pain and inflammation.
Disease-modifying antirheumatic drugs (DMARDs): When axSpA causes pain in the shoulders, neck, and other joints besides the spine and sacroiliac joints, DMARDs such as Azulfidine (sulfasalazine) may help control symptoms.
Biologics: When NSAIDs are ineffective, healthcare providers may prescribe biologic drugs called tumor necrosis factor (TNF) inhibitors. These drugs block certain cytokines (immune system proteins) to reduce inflammation. FDA-approved biologics for axSpA include Humira (adalimumab), Cimzia (certolizumab pegol), Enbrel (etanercept), Simponi (golimumab), Remicade (infliximab), Taltz (ixekizumab), and Cosentyx (secukinumab).
Corticosteroids: If axSpA affects your shoulders or knees, your healthcare provider may inject corticosteroids (a form of powerful anti-inflammatory drugs) directly into the affected joint for rapid pain relief.
Physical Therapy
People with axSpa often benefit from regular exercise. Physical therapy can help maintain your flexibility, range of motion, and strength. A physical therapist will work with you to develop a personalized exercise program with tailored exercises to help:
Build abdominal and back strength to reduce pain
Improve flexibility to maintain joint range of motion and physical function
Emphasize proper posture to relieve pain and lower the risk of injury
Maintain the ability to perform everyday activities
Surgery
When other treatments are ineffective, joint surgery may be necessary to improve function and reduce pain. Generally, providers only recommend surgery for people who have a severe form of this condition. Surgical procedures that people with axSpA may need include:
Hip arthroplasty: Hip replacement surgery involves removing the damaged part of the hip and replacing it with new, artificial parts that act as normal hip joints.
Osteotomy: A spinal surgery that involves cutting and reshaping bones to realign and straighten the spine in people with advanced ankylosing spondylitis who have difficulty with mobility due to spinal vertebrae fusing.
How to Prevent Axial Spondyloarthritis
There is no known way to prevent the development of axial spondyloarthritis. However, self-management strategies and adherence to your treatment plan may help prevent the disease from progressing too quickly and improve your quality of life. Consider the following strategies:
Getting regular physical activity (such as yoga, swimming, or strength training) to reduce stiffness, improve flexibility, and strengthen muscles
Quitting smoking to prevent joint inflammation from worsening
Eating a balanced diet filled with fruits, vegetables, whole grains, and lean proteins
Protecting your posture by sleeping on a firm mattress or using a thin (or no) pillow
Prioritizing sleep by limiting screen time before sleep and avoiding caffeine in the evenings
Considering complementary therapies like meditation, breathing exercises, and acupuncture for stress management and symptom relief
Keeping in contact with your healthcare provider for regular check-ups and to adjust your treatment plan as needed
Related Conditions
Approximately 83% of people with axial spondyloarthritis have co-occurring conditions, such as:
Psoriatic arthritis (PsA): A chronic, inflammatory form of arthritis that affects the skin (psoriasis) and causes joint pain, swelling, and stiffness. Up to 70% of people with PsA may also have axSpA.
Inflammatory bowel disease (IBD): Chronic gut inflammation is common in people with axSpA and between 4% and 12% of people with axSpA have Crohn’s disease or ulcerative colitis (the two most common types of IBD).
Hypertension: Studies show that roughly 52% of people with axSpA have hypertension (high blood pressure), which may be due to long-term NSAID use.
Depression: The psychological burden of chronic pain and managing a chronic condition can contribute to depression.
Chronic pulmonary disease (CPD): About 23% of people with axSpA have chronic pulmonary (lung) disease. People with CPD tend to have more severe axSpA symptoms, though researchers are not sure of the specific reason why.
Living With Axial Spondyloarthritis
Living with axial spondyloarthritis and dealing with chronic pain requires proactive management. There are times you may feel overwhelmed by your symptoms—and that's OK. It takes time to adjust to a diagnosis and it's important to be patient with yourself as navigate your condition.
Following your treatment plan and adopting healthy lifestyle habits makes it possible to live a fulfilling and active life with axSpA. It's also important to remember that you are not alone. Talking to your healthcare provider and opening up to your loved ones about your condition can help. Online communities and in-person support groups for people living with axSpA can also foster a space for support and understanding.
Frequently Asked Questions
What foods should you avoid if you have spondyloarthritis?
While there is no specific diet to follow if you have spondyloarthritis, limiting your intake of processed and fried foods, red meats, and foods high in preservatives and artificial ingredients is important. Aim to eat a diet rich in fruits, vegetables, lean proteins, healthy fats, and whole grains.
What is the life expectancy of someone with spondyloarthritis?
Thanks to recent advancements in treatment options, most people with spondyloarthritis can expect to live an average lifespan. Maintaining healthy lifestyle habits, including regular exercise and eating a nutritious diet, can help improve joint and heart health and lower the risk of complications that may reduce lifespan.
What is the best sleeping position for axial spondyloarthritis?
Sleeping flat on your back with no pillow—at least for part of the night—may help reduce morning pain and stiffness. If you can’t sleep well on your back, try putting a pillow under your knees to improve blood flow and prevent joint pain.
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