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.
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.
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.
A significant reduction in the ranges of spinal motion is usually recorded by the physiotherapy examination of an AS patient, with a flattened lumbar curve and an accentuated thoracic kyphosis. Later involvement can include reduced neck ranges of motion and reduced chest excursion from involvement of the rib joints. Peripheral inflammation at insertion sites occurs in about one third of patients, the commonest sites being the insertion of the tendo Achilles on to the calcaneum and the insertion of the plantar ligament in the foot. These areas cope with large mechanical loads which may be why they more commonly occur.
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.
Physiotherapy starts with treating active enthesis sites with ice, ultrasound and gentle stretches, with insoles useful in the foot. Routine range of movement exercises for the whole spine and affected joints are taught with concentration on getting to end range at each time. This targets the antigravity movements such as lumbar and thoracic extension, thoracic rotations and neck rotation and retraction. Patients are also taught to rest in good positions to avoid encouraging the typical deformities, such as on a firm mattress with just one pillow, or lying on the front regularly. Hydrotherapy is a very helpful and popular way of maintain joint ranges and patients need to keep up self treatment over the long term. - 16004
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.
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.
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.
A significant reduction in the ranges of spinal motion is usually recorded by the physiotherapy examination of an AS patient, with a flattened lumbar curve and an accentuated thoracic kyphosis. Later involvement can include reduced neck ranges of motion and reduced chest excursion from involvement of the rib joints. Peripheral inflammation at insertion sites occurs in about one third of patients, the commonest sites being the insertion of the tendo Achilles on to the calcaneum and the insertion of the plantar ligament in the foot. These areas cope with large mechanical loads which may be why they more commonly occur.
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.
Physiotherapy starts with treating active enthesis sites with ice, ultrasound and gentle stretches, with insoles useful in the foot. Routine range of movement exercises for the whole spine and affected joints are taught with concentration on getting to end range at each time. This targets the antigravity movements such as lumbar and thoracic extension, thoracic rotations and neck rotation and retraction. Patients are also taught to rest in good positions to avoid encouraging the typical deformities, such as on a firm mattress with just one pillow, or lying on the front regularly. Hydrotherapy is a very helpful and popular way of maintain joint ranges and patients need to keep up self treatment over the long term. - 16004
About the Author:
Jonathan Blood Smyth is a Superintendent of Physiotherapy at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in London.
