Ankylosing Spondylitis Treatment by Physiotherapy

Author: Jonathan Blood Smyth

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 commonest spondyloarthropathy is Ankylosing spondylitis, which occurs as a reflection of the occurrence of the HLA B27 gene in the population. The gene occurs much less commonly near the equator and much more commonly in northern latitudes, and this is also the pattern with the development of AS. White race people are more commonly affected with around 0.1 to 1.0 percent overall, varying with latitude. Only 1 or 2 people of a hundred with the HLA B27 gene actually develop AS, but if they have a close relative who has the condition the likelihood rises to 15 to 20%.

AS occurs more often in males, with a 3:1 ratio, but females may suffer much milder disease or have minor symptoms which are not diagnosed. AS is a disease of young men, with most presenting before they are 40 years old, and 10-20% presenting with the disease before they are 16. On average people get the symptoms of the disease around 25 years old and are rarely diagnosed when over 50 years of age. The condition is often missed initially as it presents as low back pain so it is important to take a proper history. A useful question is \"how does your back feel when you wake up\" and AS patients will all say \"very stiff\".

Low back pain is the major diagnostic alternative but AS patients are generally younger and the inflammatory process leads to different symptoms:

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.

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.

Jonathan Blood Smyth is Superintendent of a large team of Physiotherapists at an NHS hospital in Devon. 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 Glasgow or elsewhere in the UK.