Ankylosing Spondylitis and Physiotherapy

Ankylosing spondylitis is an inflammatory arthritic disease or spondyloarthropathy, classified with reactive arthritis, bowel disease arthritis and psoriatic arthritis. The underlying relationships between these diseases are complex but they are connected by enthesitis (inflammation of the ligament/bone junctions) and by possession of the HLA B27 gene on white blood cells. The enthesitis process at the joint edges can cause fibrosis and then ossification of the area (bone formation).

AS is the commonest of the spondyloarthropathies and its occurrence varies with the occurrence of the HLA B27 gene in the population, AS being less common in the tropics and more common in northern European countries. 0.1 to 1.0% of people are affected but this varies with latitude and is more common in white people. About 1-2% of people with the HLA B27 gene actually develop AS but this becomes 15-20% likelihood if they have a first degree relative with the disease.

Three males to every one female is the ratio of patients with Ankylosing spondylitis, as female patients may have much less obvious symptoms and so be missed from the diagnosis. Young men are the commonest presenting group with most consulting a doctor before they are 40 and up to 20% before they are sixteen years old. 25 years is the average age that someone goes down with the symptoms and is uncommon to find a diagnosis of AS in a person over fifty. It is easily overlooked as it can look like mechanical back pain if care is not taken. On questioning how they are in the morning, a typical answer is very stiff.

Ankylosing spondylitis has similarities but distinct differences from the much more common low back pain:

Morning stiffness in the lumbar spine, lasting at least 30 minutes or longer  Exercise improves the back pain and stiffness  Rest worsens the pain and stiffness  Pain is usually worse in the second half of the night, after a time of rest  Peripheral joints are affected in 30 to 50% of patients  Tiredness is common  AS has systemic affects from its inflammatory nature which can include feeling unwell, fever and loss of weight.

Physiotherapy examination of the spine in an AS patient usually uncovers significantly reduced ranges of spinal movement from normal, with perhaps a reduced lumbar lordosis and an increased thoracic curve. Neck movements may also be limited in later stages and a reduction in chest expansion noted due to rib joint involvement. Peripheral symptoms occur in around a third of patients and the physio will palpate the tender areas, searching for evidence of enthesitis in the insertions of the Achilles tendon and plantar ligament of the foot. These are areas of high mechanical stress and commonly affected.

Postural analysis of the AS patient is the first thing a physiotherapist notes after the subjective examination, recording spinal abnormalities, flexed knees, rounded shoulders or poking head posture. The ranges of movement of the cervical, thoracic and lumbar spine are measured and a battery of standard measures taken which allows assessment of the disease progression. The hips or other peripheral joints may be affected and these need to be measured also, with the physio likely testing out sites where the enthesis is likely to be painful and inflamed. If the disease is active then the patient may also have joint effusions and may appear unwell, be sweating and not have slept well.

Physiotherapists will concentrate on treating the inflamed areas first such as the areas where the ligaments insert into the bone, using insoles, cold, ultrasound and stretching techniques. Routine spinal range of motion exercises are taught to patients with an emphasis on getting to end ranges, concentrating initially on the anti-gravity muscles such as thoracic and lumbar extensors. Neck rotation and retractions and thoracic rotations are also important functional movements not to lose. Patients should rest themselves in good postures such as prone or supine with only one pillow, to avoid accentuating the typical spinal deformities. Treatment for AS in a hydrotherapy pool is beneficial and soothing and patient education important so they keep up their programme.

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