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Ankylosing Spondylitis Treatment by Physiotherapy

 



The inflammatory arthritis diseases or spondyloarthropathies include various diseases such as Ankylosing spondylitis, the arthritis of bowel disease, reactive arthritis and the arthritis associated with psoriasis. The typical linking features of these diseases are enthesitis (an inflammation at the bone/ligament junction) and the presence of HLA B27, a gene on white blood cells. The inflammation at the entheses can develop into fibrosis and eventually to fusion of the joints from bone formation.

The frequency of the HLA B27 gene in the population determines the number of people with Ankylosing spondylitis, the most common disease in the spondyloarthropathy group. AS occurs in about 0.1 to 1.0% of people, being much more common in northern Europe and much less common in equatorial regions and with white people more frequently affected. 100 people may possess the HLA B27 gene but only one or two of them will develop AS unless they have a closely related person with it, in which case their risk rises to 15 or 20%.

Only one female is diagnosed with AS for every three males, and female patients' symptoms are often much milder and some may be missed as a diagnosis of AS. The most typical presenting group is young men under 40 years old, with under sixteen year olds making up to twenty percent of this group. The symptoms appear on average at twenty-five years of age and the diagnosis is rarely made above fifty years old. AS can look like mechanical back pain if sufficient attention to detail is not made. Strong and persistent stiffness is often an answer to the question of how they are in the morning.

The presentation of Ankylosing spondylitis is similar but different from that of mechanical low back pain due to the inflammatory nature of AS:

Back pain and stiffness in the morning, lasting at least half an hour or more   The back pain and stiffness are improved by exercising   Resting worsens the stiffness and pain   Pain is worse later in the night   Thirty to fifty percent of patients exhibit other joint symptoms   Fatigue is typical   Systemic inflammatory affects include fever, loss of weight and unwellness.

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.

Physiotherapy assessment of patients with Ankylosing spondylitis begins with postural assessment of spinal deformity and perhaps flexed knees. Increased cervico-thoracic kyphosis is common with a poking chin and rounded shoulders. General spinal mobility is obviously limited in normal movement and assessments are made of the lumbar, thoracic and neck ranges of motion. Other standardized measurements are taken to gage the progress of the disease or the affect of therapy. Areas of peripheral involvement are noted, e.g. the hips, and the appropriate measurements made, with palpation of any painful enthesis sites. Joint effusions, e.g. in the knees, are also possible if the disease is active, along with sleeping problems, sweating and feeling unwell.

Initially a physiotherapist might treat an active, inflamed site such as the tendo Achilles insertion using ultrasound, ice and gentle stretching, with foot problems responding to insole use. Whole spine exercises are taught with encouragement to get to the end of the movements, concentrating on antigravity movements including extension of the lumbar and thoracic spine, rotation of the thorax and neck retraction and rotations. To counter the typical spinal deformities, patients are taught to rest in good positions such as flat on a firm surface with only one pillow and lying prone. Pool therapy is very popular and effective and patient education is vital to maintain therapy over time.


 

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