Dear Dr. Roach: My significant other and I are debating whether I should pursue followup testing with a rheumatologist for the possibility of ankylosing spondylitis. I say no, and she says yes, because things could be worse down the road if do have AS and don鈥檛 deal with it starting now.
I am in my mid-60s, 45 years with iritis (almost annually treated with prep forte) and in the past year was positive on an HLA-B27 test. My lumbar spine X-ray impression was 鈥渕ild lumbar spondylosis,鈥� but not fusion (as is often seen with AS). My lower-back and hip pain and stiffness generally are worse in the morning and get better with activity and as-needed Advil. My primary care physician gave me an option to refer out to a rheumatologist for followup.
My feeling is that it would be an unnecessary expense and time. I鈥檓 doubtful of an AS diagnosis, and even if diagnosed, it鈥檚 not really worth treating at this point. My significant other disagrees. What would you recommend?
B.B.
I agree with your significant other, without hesitation.
Ankylosing spondylitis is an inflammatory type of arthritis whose major symptom is lower-back pain, but one which can affect other joints and other parts of the body, including skin, gut and eye. The abnormalities usually show up on X-ray but sometimes do not.
Making the diagnosis of ankylosing spondylitis (physicians often abbreviate this verbally as the somewhat uncouth 鈥渁nk spon鈥�) isn鈥檛 always straightforward. Chronic back pain at an early age is suggestive. The genetic test you had, HLA-B27, is positive in 90 per cent or so of people with AS but only eight per cent of the general population. Still, even most people with back pain and who are HLA-B27 positive do not have AS.
A careful interpretation of the spine film results is necessary by an experienced radiologist who can grade the sacroiliac joint; this is critical in helping to support or reject a diagnosis of AS.
Iritis, inflammation of the iris, is more consistent with a different inflammatory joint disease called reactive arthritis. With AS, the eye disease is typically uveitis. Although it鈥檚 possible the eye doctor used the term imprecisely.
The reason I think a rheumatologist is essential in this disease (I feel the same way about rheumatoid arthritis and other inflammatory arthritides) is that the condition should be recognized as early as possible so that proper treatment may be begun. You may be right that no more than ibuprofen is necessary. However, AS can progress despite medication, and a more aggressive regimen may be necessary. You deserve an expert opinion.
Dear Dr. Roach: I have been unable to complete a yawn for a couple of years. You know, that final 鈥渁aah鈥� feeling. My doctor just smiled and offered no explanation; I鈥檓 sure she had never heard of this before. I am a 70-year-old woman who is retired. Any ideas, suggestions or recommendations to end this unsatisfied feeling?
M.G.
Nobody knows for sure why we yawn. It can be related to low oxygen, fatigue or boredom, but there is a 鈥測awn centre鈥� of the brain (in the hypothalamus) and even fetuses have been shown to yawn.
I have read two possible explanations why some people have incomplete or unsatisfying yawns: The first is that in some people, anxiety is the impetus to yawn, and that type of yawn just isn鈥檛 satisfying. The second is that stretching of the muscles of the face and jaw are necessary for the yawn to be complete. For some people, repeated stretching (from a 鈥渇orced鈥� yawn) and breathing in very deeply can lead to a satisfying yawn. I鈥檇 be happy to hear advice from readers.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected].
