Unlocking the Secrets of Diffuse Idiopathic Skeletal Hyperostosis (DISH): Everything You Need to Know!

Diffuse Idiopathic Skeletal Hyperostosis (DISH), sometimes called Forestier disease, is a type of non-inflammatory skeletal condition that primarily affects the tendons and ligaments around the spine, leading to the excessive formation of bone in abnormal places. While DISH most commonly affects the mid-back (thoracic spine), it can also impact the neck (cervical spine), lower back (lumbar spine), hips, heels, and other areas of the body. This article aims to provide a comprehensive overview of DISH, including its causes, symptoms, diagnosis, treatment, and management strategies.

What is DISH?

DISH is characterized by the calcification and ossification of ligaments and tendons, resulting in the formation of bony outgrowths called osteophytes or bone spurs. These bone spurs can fuse adjacent vertebrae, leading to stiffness and a reduced range of motion in the spine. DISH is also known as Forestier's disease, spondylitis ossificans ligamentosa, spondylosis hyperostotica, and ankylosing hyperostosis of the spine.

How Common is DISH?

DISH is more widespread than many realize, particularly among older adults. Studies estimate that up to a quarter of North Americans over 50 show evidence of DISH. The likelihood of developing DISH increases with age, and men are diagnosed twice as often as women. After osteoarthritis, DISH ranks as one of the most frequent skeletal disorders in this demographic.

Causes and Risk Factors of DISH

The exact cause of DISH remains unknown. As with most diseases, it’s probably a combination of genetic, environmental, metabolic, and possibly mechanical factors. Doctors believe aging, genetics, and metabolic abnormalities contribute to DISH.

Risk Factors

Several factors may increase the risk of developing DISH, including:

Advancing age: DISH primarily affects individuals over 50 years old.
Male gender: Men are more commonly affected than women.
Metabolic syndrome: Conditions like obesity, diabetes, high insulin levels, high uric acid levels, and high cholesterol are associated with DISH. DISH is more common in obese people and those with diabetes, as well as up to 20% of people with acromegaly (a rare condition caused by abnormal levels of growth hormone).
Certain medications: The acne medication isotretinoin (Amnesteem, Claravis, and others), a synthetic derivative of vitamin A, has been linked to DISH.

Symptoms of DISH

Many people with DISH don't experience any noticeable symptoms, especially in the early stages. The asymptomatic nature of DISH complicates diagnosis. When symptoms do occur, they are typically mild and develop gradually over time. Common symptoms include:

Stiffness and decreased range of motion: This is most common in the mid-back but can also affect the neck and other joints.
Chronic pain: Pain is particularly common in the back, neck, and shoulders, and may be more noticeable in the morning or during cold weather.
Joint pain or tendonitis: DISH can affect the peripheral skeleton, leading to pain in the shoulders, elbows, knees, or heels.
Difficulty swallowing or breathing: In severe cases, bone spurs in the neck can put pressure on the esophagus or airway, leading to difficulty swallowing, a hoarse voice, or sleep apnea.
Nerve compression symptoms: Bony outgrowths can compress spinal nerves, causing weakness, numbness, or tingling in the arms or legs.

Call your doctor if you have DISH and develop difficulty swallowing or changes in sensation (such as numbness or tingling) in your arms or legs. Signs and symptoms of the rare complication of compression of the spinal cord are difficulty walking, loss of bowel or bladder control, and loss of sensation in the groin.

Diagnosis of DISH

Doctors generally diagnose DISH based on a thorough physical exam, a review of medical history, and imaging tests.

Imaging Tests

X-rays: X-rays are the most commonly used imaging modality and can reveal characteristic findings of DISH, including flowing ossification along the anterior aspect of multiple contiguous vertebral bodies. X-ray findings are most prominent in the thoracic spine of the mid back. Therefore, X-rays of the thoracic spine are often necessary for diagnosis. X-rays may also show abnormal bone formation where ligaments attach to bones.
CT scans or MRIs: Additional imaging tests, such as CT or MRI scans, allow doctors to assess the extent of spinal involvement and rule out other potential causes of symptoms.

Blood Tests

Blood tests are generally not helpful in diagnosing DISH directly. While blood tests can rule out other possible causes of your symptoms or to look for signs of related metabolic disorders, they do not provide a direct diagnosis of DISH.

Treatment of DISH

There is currently no cure for DISH. Treatment aims to manage symptoms, improve mobility, and prevent complications. The treatment of DISH involves treating each bothersome symptom and should be individualized for the patient and their specific signs and symptoms.

Read also: Explore Diet and Disease

Non-Surgical Treatments

Exercise and physical therapy: These are essential for getting back pain under control and improving stiffness and range of motion. Physical activity and physical therapy are usually beneficial for patients suffering from spinal stiffness. Because DISH can cause loss of range of motion of the spine, exercises that involve stretching the spinal range of motion can often be beneficial. Physical therapists are specifically trained to provide instructions in this area. Stretching and gentle exercise generally help with stiffness. Formal physical therapy can include assistance with the appropriate stretching and exercises, as well as modalities such as ultrasound. A very effective self-care treatment is physical activity. This may include stretching, walking, or swimming. Introduction of a new exercise regimen should always be done gradually and gently.
Weight and blood sugar control: Because DISH is often associated with obesity and diabetes, keeping your weight and blood sugar in a healthy range is key. Maintaining a healthy weight and a healthy diet high in vegetables, whole grains, lean meats and fruits, and low in added sweeteners, logically should decrease the risk of DISH, as well as a variety of other medical conditions.
Pain relievers: Acetaminophen and nonsteroidal anti-inflammatories (NSAIDs) like ibuprofen can be used when needed. For those patients with pain that does not respond to exercise and physical therapy, acetaminophen (Tylenol) and NSAIDs (nonsteroidal anti-inflammatory drugs) are frequently very beneficial. These medications may be taken over the counter, unless they are contraindicated due to another medical condition, or prescribed by a health care professional if necessary.
Corticosteroid injections: If exercise and physical therapy don’t relieve severe pain, corticosteroid injections may be an option.
Heat therapy: Heat can be very effective for spinal stiffness. Applying a heating pad or warm compress for short intervals (generally using a “10 minutes on, 10 minutes off, then back on” method) promotes blood flow and reduces tightness, making movement less painful and morning stiffness less noticeable. Always use caution to avoid burns, and discuss the best approach with your healthcare provider.
Orthotics: By distributing pressure more evenly and supporting proper alignment, custom shoe inserts or braces can help relieve foot and lower limb pain. This improvement in stability can make walking and standing safer and more comfortable-particularly valuable if mobility is already a challenge.

Surgical Treatments

In cases where conservative measures fail to provide relief or severe complications arise, doctors will recommend surgery. Surgical options may include decompression procedures to alleviate nerve compression or spinal fusion to stabilize the spine and prevent further progression of the disease.

Lifestyle Modifications and Home Remedies

Along with following doctor’s instructions, getting the proper amount of physical activity, and strengthening the muscles that support the spine, you can manage your condition in additional ways. Practicing healthy lifestyle habits will also help to improve your overall health and help you to manage your pain.

Nutritious diet: Eat a nutritious and balanced diet that avoids sugary, fatty, and processed foods. Following a diet with adequate amounts of calcium and vitamin D will help reduce the risk of osteoporosis. As for nutritional measures, it is known that oils of fish contain omega-3 fatty acids, which can provide additional antiinflammatory effects that might reduce some of the symptoms of DISH. Omega-3 fatty acids can also be purchased in pharmacies and health-food stores as food supplements.
Quit smoking: If you currently smoke, ask your doctor to help you quit.
Manage emotional and mental health: Manage your emotional and mental health so you can cope with the challenges of your condition.
Stay informed: Get involved with the arthritis community. Stay in the Know. Live in the Yes.
Safe lifting techniques: Individuals with DISH are particularly susceptible to back and spinal injuries that can exacerbate their condition. Practice safe lifting techniques.
Fall prevention: Ensure your living and working environments are free from tripping hazards.
Avoid tobacco use and excessive alcohol consumption: These habits may exacerbate inflammation and contribute to bone health issues. Consuming more than two alcoholic drinks per day increases a person's chances of developing weakened bones. In addition, alcohol mixed with certain medications can cause serious side effects to the gastrointestinal tract and major organs such as the liver and the kidneys. Since the liver detoxifies (or metabolizes) alcohol, continued and excessive use of alcohol may damage the liver in various ways, including the eventual development of a potentially fatal condition of the liver called cirrhosis. To further complicate things, the presence of alcohol impairs the absorption of essential nutrients because it can damage the lining of the small intestine and the stomach, where most nutrients are digested.

The Role of Occupational Therapy

Occupational therapy offers valuable support for individuals living with Diffuse Idiopathic Skeletal Hyperostosis (DISH). An occupational therapist (OT) works closely with you to address the practical challenges that DISH presents in daily life. The OT begins by assessing your daily routines and identifying tasks or activities that may cause pain or increased strain on your spine and joints. Through this evaluation, they recommend practical changes-such as modifying your home setup, rearranging your workspace, or adapting the way you perform certain activities-to minimize discomfort and help preserve your independence. Additionally, occupational therapists can introduce assistive devices, like grabbers or supportive cushions, that make it easier to move about or complete daily activities with less pain. They’ll also coach you on safer body mechanics and strategies to manage fatigue, so you can continue engaging in your favorite hobbies, work, and social activities. The overall goal is to empower you to stay active and comfortable while protecting your back and joints from further stress or injury. By focusing on adaptive skills and ergonomic solutions, occupational therapy enables you to enjoy a fuller, more independent life-even while managing the effects of DISH.

Potential Complications of DISH

Complications of DISH may include:

Spinal stenosis: This results from the compression of spinal nerves or the spinal cord by bony outgrowths.
Spinal fractures and instability: DISH disease stiffens your spine, which makes it more vulnerable to breaks. Even minor trauma (a low-energy impact) might be enough to fracture or displace one of your vertebrae. This makes your spine unstable and more prone to injury.
Difficulty swallowing or breathing: This occurs in cases of cervical spine involvement, which may require surgery to alleviate compression of the esophagus or airway.
Spinal cord compression: Bone thickening or large bone spurs along your spinal column can compress your spinal cord in severe cases. This can lead to nerve pain syndromes like sciatica and other nerve symptoms, called myelopathy.

Prevention

While the exact cause of DISH is unknown, several preventive measures may help reduce the risk of developing the condition or alleviate symptoms:

Maintaining a healthy weight and adopting a balanced diet: Weight loss plays a crucial role in preventing Diffuse Idiopathic Skeletal Hyperostosis (DISH). Shedding excess pounds can mitigate the occurrence of conditions that are often linked with DISH. By maintaining a healthy weight, you not only reduce the strain on your skeletal system but also improve your overall metabolic health. This preventive approach helps you manage or even avert the development of DISH and its associated complications.
Engaging in regular physical activity: This promotes flexibility, strength, and overall musculoskeletal health.
Practicing good posture and body mechanics: This reduces strain on the spine and joints.

Diet and DISH

In recent years, many specialized diets have gained popularity among some people with arthritis. To date, few of these claims have been substantiated by rigorously controlled studies. That said, some people find that certain foods trigger changes in symptoms - either for the better or the worse.

It is important to find out from your doctor whether any medications that you take affect how your body uses what you eat. For instance, some medications cause a person to retain sodium, while others cause potassium loss. Avoid alcohol or foods that can interact with your medication.

Besides the well-known medical problems individuals can develop as a result of weight gain (high blood pressure, diabetes, cancer, stroke, and heart disease), extra weight puts additional stress on joints and bones. For example, the corticosteroid prednisone causes weight gain to some degree in nearly all patients who take the medication and can lead to redistribution of body fat to places like the face, back of the neck, and abdomen. On the other hand, underweight people can suffer from medical problems, ranging from chronic fatigue and anemia to lowered resistance to infection and clinical depression. Inflammation, certain medications, and depression associated with a chronic illness may lessen your appetite or upset your stomach, making it difficult for some people with spondylitis to maintain a healthy weight. This is especially true for those who have spondylitis with inflammatory bowel disease or Crohn’s disease who experience gastrointestinal problems on top of arthritis symptoms.

Researchers have found that patients who take folic acid or folinic acid supplements along with the arthritis drug methotrexate are less likely to have a malfunctioning liver than those taking just methotrexate. As a result, patients taking folate supplements are able to continue their drug therapy for longer periods.

Popular arthritis drugs called nonsteroidal anti-inflammatory drugs (NSAIDs) can damage the lining of the gut. Adding a cup of active-culture yogurt and a banana each day to the diet can help protect the digestive tract. Yogurt's bacteria helps maintain a healthy mix of microorganisms, while bananas have a type of starch that is digested by organisms in the gut to form a substance that helps protect the lining of the gut wall. Easily reap the benefits by combining the banana, yogurt, and a cup of orange juice for a quick and delicious smoothie!

If you are taking any medication, including over-the-counter medications, check with your pharmacist before drinking alcohol. Alcohol can intensify the effects of many medications, and can interact with others, making them ineffective. Such interactions also can lead to an increased risk of illness, injury, or death.

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