the drug useful for ankylosing spondylitis. anti-interleukin-6 inhibitors such as tocilizumab, currently approved for the treatment of rheumatoid arthritis, and rituximab, a monoclonal antibody against cd20, are also undergoing trials. interleukin-17a inhibitors secukinumab and ixekizumab are options for the treatment of active ankylosing spondylitis in patients that have responded inadequately to (tnfα) blockers. janus kinase inhibitor tofacitinib is approved for the treatment of active ankylosing spondylitis in adult patients that show an inadequate response to prior dmard therapy. surgery in severe cases of as, surgery can be an option in the form of joint replacements, particularly in the knees and hips. surgical correction is also possible for those with severe flexion deformities (severe downward curvature) of the spine, particularly in the neck, although this procedure is considered very risky. in addition, as can have some manifestations which make anesthesia more complex. changes in the upper airway can lead to difficulties in intubating the airway, spinal and epidural anesthesia may be difficult owing to calcification of ligaments, and a small number of people have aortic insufficiency. the stiffness of the thoracic ribs results in ventilation being mainly diaphragm-driven, so there may also be a decrease in pulmonary function. physical therapy though physical therapy remedies have been scarcely documented, some therapeutic exercises are used to help manage lower back, neck, knee, and shoulder pain. there is moderate quality evidence that therapeutic exercise programmes help reduce pain and improve function. some therapeutic exercises include: exercise programs, either at home or supervised low intensity aerobic exercise, e.g. pilates spa-exercise therapy aquatic physical therapy proprioceptive neuromuscular facilitation (pnf) heat therapy cryotherapy in conjunction with exercise moderate-to-high impact exercises like jogging are generally not recommended or recommended with restrictions due to the jarring of affected vertebrae that can worsen pain and stiffness in some with as. diet research by alan ebringer at king's college in london, beginning in the 1980s, has implicated overgrowth of the bacterium klebsiella pneumoniae in the symptoms of ankylosing spondylitis. the body produces antibodies that attack klebsiella pneumoniae. enzymes made by the bacterium resemble human proteins, including three types of collagen (i, iii, iv) and the hla-b27 complex of glycoproteins. the antibodies therefore attack these human proteins, producing the symptoms of ankylosing spondylitis. ebringer and others recommend low-starch or no-starch diets. the site kickas.org, referencing the work of ebringer and others, created a "no starch diet" guide. prognosis fracture of the t5 and c7 vertebra due to trauma in a person with ankylosing spondylitis as seen on a ct scan prognosis is related to disease severity. as can range from mild to progressively debilitating and from medically controlled to refractory. some cases may have times of active inflammation followed by times of remission resulting in minimal disability while others never have times of remission and have acute inflammation and pain, leading to significant disability. as the disease progresses, it can cause the vertebrae and the lumbosacral joint to ossify, resulting in the fusion of the spine. this places the spine in a vulnerable state because it becomes one bone, which causes it to lose its range of motion as well as putting it at risk for spinal fractures. this not only limits mobility but reduces the affected person's quality of life. complete fusion of the spine can lead to a reduced range of motion and increased pain, as well as total joint destruction which could lead to a joint replacement. osteoporosis is common in ankylosing spondylitis, both from chronic systemic inflammation and decreased mobility resulting from as. over a long-term period, osteopenia or osteoporosis of the ap spine may occur, causing eventual compression fractures and a back "hump". hyperkyphosis from ankylosing spondylitis can also lead to impairment in mobility and balance, as well as impaired peripheral vision, which increases the risk of falls which can cause fracture of already-fragile vertebrae. typical signs of progressed as are the visible formation of syndesmophytes on x-rays and abnormal bone outgrowths similar to osteophytes affecting the spine. in compression fractures of the vertebrae, paresthesia is a complication due to the inflammation of the tissue surrounding nerves. organs commonly affected by as, other than the axial spine and other joints, are the heart, lungs, eyes, colon, and kidneys. other complications are aortic regurgitation, achilles tendinitis, av node block, and amyloidosis. owing to lung fibrosis, chest x-rays may show apical fibrosis, while pulmonary function testing may reveal a restrictive lung defect. very rare complications involve neurologic conditions such as the cauda equina syndrome. mortality mortality is increased in people with as and circulatory disease is the most frequent cause of death. people with as have an increased risk of 60% for cerebrovascular mortality, and an overall increased risk of 50% for vascular mortality. about one third of those with ankylosing spondylitis have severe disease, which reduces life expectancy. as increased mortality in ankylosing spondylitis is related to disease severity, factors negatively affecting outcomes include: male sex plus three of the following in the first two years of disease: erythrocyte sedimentation rate (esr) >30 mm/h unresponsive to nsaids limitation of lumbar spine range of motion sausage-like fingers or toes oligoarthritis onset <16 years old gait the hunched position that often results from complete spinal fusion can have an effect on a person's gait. increased spinal kyphosis will lead to a forward and downward shift in center of mass (com). this shift in com has been shown to be compensated by increased knee flexion and ankle dorsiflexion. the gait of someone with ankylosing spondylitis often has a cautious pattern because they have decreased ability to absorb shock, and they cannot see the horizon. epidemiology between 0.1% and 0.8% of people are affected. the disease is most common in northern european countries, and seen least in people of afro-caribbean descent. although the ratio of male to female disease is reportedly 3:1, many rheumatologists believe the number of women with as is underdiagnosed, as most women tend to experience milder cases of the disease. the majority of people with as, including 95 percent of people of european descent with the disease, express the hla-b27 antigen and high levels of immunoglobulin a (iga) in the blood. in 2007, a team of researchers discovered two genes that may contribute to the cause of as: arts-1 and il23r. together with hla-b27, these two genes account for roughly 70 percent of the overall number of cases of the disease. history