Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a condition affecting the spine and sometimes other joints. Distinct from inflammatory arthritis, DISH is characterized by the hardening or calcification of ligaments and tendons. This process leads to the formation of “bony bridges” between vertebrae in the spine. Calcification can also occur around other joints such as elbows, knees, and the Achilles tendon, resulting in bone spurs at tendon and ligament attachment points.
While DISH is not a newly discovered disease – evidence exists in archeological records, including ancient Egyptian remains – its varied symptoms and incomplete understanding mean it is often underdiagnosed. Many healthcare professionals may still be unfamiliar with DISH and its diagnostic criteria.
How Common is DISH? Prevalence and Incidence
DISH is considered the second most prevalent form of arthritis after osteoarthritis. However, the exact numbers regarding its prevalence and incidence are not fully known due to frequent underdiagnosis, especially in the early stages. It is estimated that DISH affects between 15% and 25% of North Americans over the age of 50. The likelihood of diagnosis increases with each decade after 50, and men are diagnosed approximately twice as often as women.
Recognizing DISH: Early Warning Signs and Symptoms
The initial symptoms of DISH can be highly variable. Many individuals in the early stages experience only mild symptoms or none at all. These subtle symptoms are often mistakenly attributed to normal aging processes.
Generally, individuals with DISH report higher levels of back pain and stiffness compared to the general population. Common symptoms include persistent or recurring back pain and reduced range of motion, particularly in the morning or after periods of inactivity. Interestingly, mild physical activity often provides relief from the pain and stiffness associated with DISH.
As DISH progresses, more pronounced symptoms may develop, although this is not always the case. The severity of symptoms depends on the size and location of the bony growths and their impact on surrounding tissues. Complications can include:
- Dysphagia (Difficulty Swallowing): Bony growths can compress the esophagus, making swallowing difficult.
- Upper Airway Compression: Compression of the pharynx and larynx can lead to hoarseness, stridor (noisy breathing), sleep apnea (airway obstruction during sleep), and aspiration (inhalation of saliva into the lungs).
- Increased Fracture Risk: DISH may increase the susceptibility to vertebral fractures.
- Tendonitis-like Pain in Limbs: Recurrent pain around joints in the arms and legs, mimicking tendonitis, can occur due to bony growths affecting tendons and ligaments.
- Neurological Symptoms: In rare cases, bony growths pressing on spinal nerves can cause abnormal sensations or muscle weakness in the arms or legs. These symptoms require prompt medical evaluation.
DISH Diagnosis: Methods and What to Expect
DISH diagnosis typically relies on X-ray imaging of the upper spine or chest. Doctors look for specific radiographic features:
- Bony Bridges: The presence of continuous bony bridges along the anterior (front) aspect of the spine, spanning four or more vertebrae.
- Preserved Intervertebral Disc Height: At the sites of bony bridging, the intervertebral discs should show no signs of degeneration or damage. This helps differentiate DISH from other causes of back pain related to disc disease.
- Absence of Facet Joint Fusion: The facet joints (small joints at the back of the spine) should not be completely fused. Fusion of these joints would suggest a different underlying condition.
These radiographic criteria are crucial for distinguishing DISH from other spinal conditions. However, it’s important to note that these characteristic features may not be evident in the very early stages of the disease, which can complicate early Dish Disease Diagnosis.
Blood tests are generally not helpful in diagnosing DISH. Inflammatory markers, electrolyte levels, and growth hormone levels are typically within the normal range in individuals with DISH. Therefore, imaging is paramount for accurate dish disease diagnosis.
Risk Factors Associated with DISH Development
The precise cause of DISH remains unknown. However, several risk factors have been identified:
- Age: The risk of developing DISH increases significantly with age, particularly after 50.
- Sex: Men are more likely to develop DISH than women.
- Ethnicity: Certain ethnic groups show a higher prevalence of DISH, while others have a lower prevalence, suggesting a possible genetic component.
- Obesity and Metabolic Disorders: Individuals who are overweight or obese and those with metabolic disorders like metabolic syndrome and diabetes have a higher risk of DISH.
- Medications: Some medications have been linked to DISH-like changes in the spine, although the causal relationship is not fully established.
DISH Treatment and Management Strategies
Currently, there are no medications proven to prevent or reverse the calcification process in DISH. Research is ongoing in this area. Therefore, medical management focuses on symptom relief and optimizing physical function. Treatment approaches are often tailored to the individual’s specific symptoms and needs.
Medication Options for Symptom Management
Pain and stiffness are the primary symptoms in DISH. For many, these can be effectively managed with gentle exercise and non-pharmacological therapies. When these measures are insufficient, medications may be considered. It is crucial to consult with a physician to determine the most appropriate and safe medication options. Pharmacists can also provide valuable advice on medication safety and potential interactions. A collaborative team approach involving doctors and pharmacists is essential for personalized treatment plans.
Medication options your doctor might consider include:
- Acetaminophen: For mild to moderate pain relief.
- Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs can be effective in reducing pain and stiffness, but their use should be carefully considered due to potential side effects. A doctor should assess individual risk factors before recommending NSAIDs.
- Local Steroid Injections: Injections of corticosteroids directly into severely affected areas can provide localized pain relief.
Important Note: Never take any medication without consulting a healthcare professional. Your doctor will assess your individual health status and advise on the safety and suitability of any medication.
For further information on medications used to manage DISH and related conditions, resources like the Arthritis Society’s medication guide can be helpful.
Surgical Intervention for Severe Cases
Surgery is rarely necessary and is considered only as a last resort when DISH complications become severe. This may include cases where large bony growths compress critical surrounding tissues such as the trachea, spinal cord, nerves, or blood vessels. In such situations, a surgeon may surgically remove the bony growths to alleviate pressure and improve symptoms.
Surgery is not a cure for DISH but can be an important step to improve quality of life when symptoms are directly caused by bony growths. The decision to proceed with surgery involves careful consideration of the potential risks and benefits, which should be discussed thoroughly with a surgeon. In most cases, surgery is not indicated for DISH management.
Physiotherapy and Rehabilitation
Physiotherapy (PT) plays a crucial role in managing DISH. A physiotherapist can develop a personalized program to improve strength, flexibility, range of motion, and overall mobility and exercise tolerance. Therapeutic techniques may include exercise prescription, manual therapy, and relaxation techniques to reduce pain and enhance quality of life. Physiotherapists can also connect patients with other healthcare professionals and community resources as needed.
Occupational Therapy for Daily Living Adaptations
Occupational therapy (OT) focuses on adapting daily activities to minimize strain and improve function. An OT specializing in musculoskeletal conditions can analyze daily routines and develop strategies to protect the back and limbs. This may involve modifying the home or workplace environment and recommending assistive devices to reduce pain, improve mobility, and enhance daily function. The goal of occupational therapy is to enable individuals with DISH to live as independently and comfortably as possible.
Self-Management Strategies for Living with DISH
Effective self-management is essential for individuals with DISH. Individual experiences vary, and it’s important to communicate with healthcare providers to develop a comprehensive and personalized management plan combining various therapies. Helpful self-management strategies include:
- Gentle Exercise: Activities like walking, swimming, and water-based therapy are beneficial.
- Range of Motion Exercises: Regular exercises to maintain and improve joint mobility and reduce stiffness.
- Core Strengthening Exercises: Strengthening core muscles to improve spinal support, mobility, and pain reduction.
- Heat Therapy: Applying heat (e.g., using a 10-minutes on, 10-minutes off approach) to relieve pain and stiffness.
- Orthotics: Especially helpful when tendons in the feet and ankles are affected.
Resources for Living Well with Arthritis
Actively managing arthritis, including DISH, is key to improving quality of life. Numerous resources are available to provide support and information:
- Flourish: Offers health and wellness advice, self-management tips, and inspirational stories.
Explore Flourish - Online Learning Courses: Provides online courses covering specific issues and symptoms related to arthritis.
Discover Arthritis Courses - Workshops and Webinars: Offers educational events and webinars on arthritis management.
Find Workshops and Webinars - Navigating Through Arthritis: Provides information about available services and support.
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Contributors
This information was updated in September 2017, with expert advice from:
Tom Appleton, MD, PhD, FRCPC Assistant Professor, Department of Physiology and Pharmacology, Western University
Jeff Dixon DDS, PhD Professor, Department of Physiology and Pharmacology, and School of Dentistry, Western University
Dale Fournier, MSc. Candidate in Anatomy and Cell Biology, Western University
Cheryle Séguin, MSc, PhD Associate Professor, Department of Physiology and Pharmacology, Western University
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