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Diffuse Idiopathic Skeletal Hyperostosis (DISH)

What is diffuse idiopathic skeletal hyperostosis (DISH)?  

Diffuse idiopathic skeletal hyperostosis (DISH) is a disease of the back or spine. Unlike other types of arthritis, it does not involve inflammation. It involves hardening (calcification) of ligaments and connective tissues, most often in the spine, resulting in “bony bridges” between the small bones of the back (called vertebrae). This hardening can also be seen in the tissues around other joints of the body (such as elbows, knees and Achilles tendons) causing bony growths (spurs) where the tendons and ligaments attach to the bone.

DISH is not a new disease; it has been identified throughout the archeological record had has even been found in ancient Egyptian remains. But the variability in symptoms from person to person and our lack of understanding of the disease mean that many physicians are still unfamiliar with DISH.

How common is DISH? 

DISH is thought to be the second most common form of arthritis after osteoarthritis. The exact prevalence and incidence of DISH is unknown since it often goes undetected at the early stages of disease. Approximately 15-25% of North Americans over the age of 50 years have DISH. The prevalence of DISH increases with every decade of life beyond 50 years and is diagnosed twice as often in males than females.  

What are the warning signs of DISH?  

Initial symptoms of DISH vary from person to person and many people in the very early stages of the disease have only mild symptoms or even no symptoms at all.  The mild symptoms in people with early DISH are often blamed on “normal aging”.  

Overall, patients with DISH tend to have higher levels of back pain and stiffness than the general population. Symptoms of DISH include ongoing or repeated back pain and decreased range of motion, particularly in the morning or after long periods of inactivity. Back pain and stiffness associated with DISH are often relieved through mild activity.  

More severe symptoms of DISH may (but do not always) occur as the disease progresses, when the size and location of bony growths begins to affect the surrounding tissues. For example, the bony growths can narrow the wind pipe, resulting in difficulty or inability to swallow. People with DISH may also have an increased risk of fractures or breaks in the vertebrae. People with DISH may also have repeated bouts of pain around joints in the arms and legs (which feels like tendonitis) due to the bony growths affecting those tendons and ligaments. Abnormal sensations in arms or legs, or loss of muscle strength can occur due to pressing of the bony growths on the spinal nerves. These symptoms are rare, but should prompt urgent assessment by a physician.  

How is DISH diagnosed? 

DISH is usually diagnosed by X-ray of the upper spine or chest.  Doctors look for the following:  

  • the presence of bony bridges, usually along the front of the spine, on four or more vertebrae 
  • at sites affected by bony bridges, the intervertebral discs do not show signs of damage (which would mean that any back pain was caused by some other disease) 
  • the joints running along the back of the spine are not completely fused (which again would mean that any back pain was caused by some other disease)  

These characteristics help doctors to distinguish DISH from other spine diseases; however, these characteristics are not seen in the early stages of the disease. 

Blood tests for inflammation, electrolyte abnormalities or growth hormones are typically normal.  

What are the risk factors for DISH? 

The exact cause of DISH is unknown. It is more common in males than females and the chance of developing DISH increases with age. It is more common in some ethnic groups but less common in others. People who are overweight or have metabolic disorders (including metabolic syndrome and diabetes) may develop DISH more often. Some medications have also been associated with DISH-like changes in the spine. 

Medication 

Unfortunately, no proven medications have been developed yet that can prevent or reduce the hardening (calcification) of the tendons and ligaments that occurs in DISH, although important research is being conducted. Medical treatment is therefore limited to managing symptoms, which are on and off, and to optimizing physical function. 

Fluctuating pain and stiffness are the main symptoms experienced by patients with DISH. For most people, these can be managed with gentle exercise and other non-medical therapies. When pain and stiffness are not relieved by non-medical therapy, ask your physician which medications are likely to be effective in your specific case, and which would be safe for you to use. Pharmacists can also advise on medication safety and options available, in collaboration with your doctor. As with any medical treatment plan, a team approach is best to find a personalized solution for you.  

Your doctor may consider a number of medication options to help you manage your DISH. Some of these may include: 

  • Acetaminophen for pain 
  • Non-steroidal anti-inflammatory drugs (NSAIDs) can be effective, but should not be taken unless your doctor confirms you are not at high risk of complications 
  • Local steroid injections for severely affected areas  

It is important not to take any medication without the advice of a doctor. Your doctor will give you advice on how safe it is for you to use these or any medications.  

To explore this area of treatment, The Arthritis Society has developed a comprehensive expert guide that delivers detailed information on medications used to treat DISH and other conditions

EXPLORE: Arthritis Medications – A Reference Guide

The optimal treatment is what is best in each individual case, so speak with your doctor and/or pharmacist about what kind of medications are most appropriate for you. 

Surgery  

Surgical intervention is a last resort treatment only when DISH has progressed to a point where it is causing complications such as large bony growths affecting important surrounding tissues such as the wind pipe, spinal cord, nerves or blood vessels. In these cases, a surgeon may remove the bony growths. Surgery is not a cure for DISH, but can be an important and useful step to improve your symptoms and quality of life if symptoms are being caused by bony growths.  A decision to proceed with surgery should always be considered with risks and benefits in mind. Your surgeon will help determine if DISH is causing your symptoms and, if so, discuss the risks and benefits of surgery with you to determine the best way to proceed. In most cases, surgery is not indicated for DISH management. 

Physiotherapy 

A physiotherapist (PT) can develop an individualized program that is designed to help you increase your strength, flexibility, range-of-motion and general mobility and exercise tolerance through a wide variety of therapeutic treatments and strategies. These include exercise prescription, physical interventions and relaxation to reduce pain and increase your overall quality of life. PTs can also refer you to other health professionals and community services for further measures that will help you adapt to your changing circumstances.  

Occupational therapy 

An occupational therapist (OT) trained in musculoskeletal diseases can analyze your daily activities and develop a program to help you protect your back and limbs. If necessary, they can help you redesign your home or workplace to make it easier for you to work or simply get around. They can also make or recommend aids that can help reduce your pain and increase your mobility and daily function. An OT’s goal is to prepare you, using assistive devices and adaptive strategies, to allow you to live as full and comfortable a life as possible. 

Each person with DISH will find certain strategies to be more effective than others. You should share your experiences with your health-care provider to help guide treatment and develop a plan that combines multiple therapies: 
  • Gentle exercise (such as walking, swimming and other water-based therapy) 
  • Range of motion exercises to reduce stiffness 
  • Core strengthening exercises to improve mobility and reduce pain 
  • Heat therapy (10 minutes on-off-on method) 
  • Orthotics, especially when foot and ankle tendons are affected 

Living well with arthritis

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Contributors

This information was last updated 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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