Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier’s Disease, is a complex and often under-recognized form of arthritis characterized by the progressive stiffening and calcification of soft tissues within the body, primarily affecting ligaments, tendons, and joints. This condition is particularly notable for its impact on the spinal column, where it can lead to significant rigidity and discomfort. DISH is distinct in its presentation and progression, often manifesting without the typical inflammatory symptoms associated with other forms of arthritis, such as rheumatoid arthritis or ankylosing spondylitis.
The calcification process in DISH can lead to the formation of bone spurs, which are bony projections that develop along the edges of bones. These bone spurs can impinge on surrounding tissues, nerves, and other structures, resulting in a variety of symptoms, including localized pain, difficulty swallowing, sleep apnea, stiffness, and reduced mobility. Patients with DISH may experience a gradual onset of symptoms, which can sometimes be mistaken for normal aging or other musculoskeletal disorders.
ETIOLOGY
The etiology of DISH remains largely idiopathic, meaning that the exact cause is not well understood; however, various factors such as gout, hyperlipidemia, obesity, diabetes, and metabolic syndrome have been associated with an increased risk of developing this condition.
RISK FACTORS
DISH is a condition that is frequently observed in older adults. The onset of DISH is quite rare in individuals under the age of 40, making it predominantly a condition associated with aging. Research indicates that it affects a significant portion of the older population, with estimates suggesting that up to 40% of individuals over the age of 50 may be impacted by this condition.
The prevalence of DISH is notably higher in males compared to females, with studies indicating that men are affected at a rate that is approximately twice as high as that of women. This disparity may be attributed to various factors, including hormonal differences, lifestyle choices, and perhaps genetic predispositions that influence the development of skeletal conditions as individuals age.
SYMPTOMS
As DISH progresses, it can lead to a range of symptoms and complications, including stiffness and pain in the spine, which can significantly affect mobility and quality of life.
- Stiffness, typically in the morning or evening
- Pain in the neck, upper back, shoulders, elbows, knees, or heels
- Pain when pressure is applied to the affected area(s)
- Difficulty moving the neck or back
- Decreased range of motion in the affected area (s), especially in the morning or after prolonged periods of inactivity
- Hoarseness or difficulty swallowing when nerves in the neck are compressed
- Tingling or numbness in the legs from compressed nerves in the lower back
- Possible paralysis from a compressed spinal cord
- Joint pain or tendonitis in the hips, shoulders, knees, ankles, or heels
- Increased risk of fractures in the vertebrae
DIAGNOSIS
Diagnosis typically involves a combination of clinical evaluation, imaging studies such as X-rays or CT scans, and a thorough assessment of the patient’s medical history. The condition is characterized by calcification of the anterior longitudinal ligament, which can lead to a characteristic radiological appearance on imaging studies.
MANAGEMENT
Management of DISH is primarily centered on alleviating the various symptoms associated with this condition while simultaneously enhancing the overall quality of life for those affected individuals. This multifaceted approach to treatment is crucial, as DISH can lead to a range of challenges that significantly impact daily living. Treatment options may encompass a variety of strategies, starting with physical therapy, which aims to improve the range of motion. Through targeted exercises and techniques, physical therapy can help individuals maintain or regain mobility, thereby reducing stiffness and discomfort that often accompanies the condition. Additionally, physical therapists may provide valuable pain management strategies, including modalities such as dry needling, heat, cupping, and instrument assisted soft tissue manipulation (IASTM) which can help alleviate pain and promote relaxation in the affected areas.
Moreover, in certain cases where the symptoms are particularly severe or complications arise, surgical intervention may become necessary. This surgical approach is typically considered when there are significant issues such as the presence of bone spurs that can impinge on nerves or cause debilitating pain, or when there is considerable spinal stiffness that limits movement and quality of life. Surgical options might include procedures to remove bone spurs, decompress nerves, or even spinal fusion in more severe instances to stabilize the spine and improve function. Each treatment plan is highly individualized, taking into account the specific symptoms, overall health of the patient, and their personal circumstances. Overall, the goal of managing DISH is not only to address the physical manifestations of the condition but also to support emotional and psychological well-being, ensuring that individuals can lead fulfilling lives despite the challenges posed by this disorder.
FUTURE
Ongoing research continues to explore the underlying mechanisms of DISH and potential therapeutic approaches to manage this challenging condition more effectively.
