Ankylosing Spondylitis (Axial Spondyloarthritis)
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Original Editor - Thomas Rodeghero
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Clinically Relevant Anatomy
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Ankylosing spondylitis (AS) is a chronic, multisystem inflammatory disorder of the sacroiliac (SI) joints and the axial skeleton. The disorder is often found in association with other spondyloarthropathies, including reactive arthritis, psoriasis, juvenile chronic arthritis, ulcerative colitis, and Crohn disease. To a lesser degree, the shoulder, hip, and tempomandibular joints may also be effected.
Mechanism of Injury / Pathological Process
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The etiology of AS is not fully understood at this time; however, a strong genetic link has been determined[1]. In addition, a direct relationship between AS and the major histocompatibility human leukocyte antigen (HLA)-B27 has also been determined[2]. The exact role of this antigen is unknown, but is believe to act as a receptor for an inciting antigen leading to AS.
The most information known about the pathological process of AS is that it effects the subchondral granulation tissue and creates small lesions, which ultimately lead to joint erosion[3]. In the spine this occurs at the junction of the vertebrae and the anulus fibers of the discs. These lesions in the anulus fibers eventually undergo ossification, which leads to a 'fusion' effect of the spinal segments appearing as a 'bamboo' spine.
Clinical Presentation[edit | edit source]
AS predominately is seen in males in a 3:1 ratio and the onset of symptoms generally occurs in late adolescent years to early adulthood. Onset of symptoms past the age of 45 are uncommon.
The clinical presentation is usually an insidious onset of back pain in the area of the sacroiliac (SI) joints and gluteal regions. Morning stiffness lasting greater than 30 minutes is a common subjective complaint, as well as waking up in the second half of the night. Pain is usually exacerbated with rest and relieve with physical activity/exercise. Complaints of difficulty breathing at times may also be a common complaint as AS may cause a decrease in chest expansion.
Common physical findings include:
- Forward flexed, or stooped, posture
- Decreased spinal segmental mobility
- Tenderness to palpate in the SI regions
- Bamboo spine
Diagnostic Procedures[edit | edit source]
The diagnosis of AS is commonly made through a combination of a thorough subjective and physical examination in combination with laboratory data and imaging studies. Common laboratory data include the presence of the HLA-B27 antigen; however, its presence is not required for a diagnosis of AS. In addition, high C-reactive proteins (CRP) are found in approximately 75% of people with AS[4].
The New York criteria for diagnosing AS combines physical findings with radiograph studies. Physical findings include limitations of lumbar spine motion in 3 planes, pain (or history of pain) at the thoraco-lumbar junction or lumbar spine, and a limitation of chest expansion to 1 inch or less measured at the 4th intercostal space. Radiographic findings are graded on a scale of 0 to 4 where 4 is considered ankylosing[5]. A definitive diagnosis is considered if there is a grade 3 to 4 at bilateral SI joints on radiograph with at least 1 physical finding, or grade 3 to 4 unilaterally (or grade 2 bilaterally) with 2 physical findings present.
Outcome Measures[edit | edit source]
Certain quality of life or global rating of change outcome measures may be most appropriate in the physical therapy setting as AS often effects the patient on a more general level. However, since AS is most associated with the spine, outcome measures such as the Oswestry Disability Index (ODI) and Neck Disability Index (NDI) may also be appropriate. Laboratory values, such as the CRP, are used to monitor the effectiveness of medication treatments.
Management / Interventions
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Currently, evidence supports the use of a daily exercise routine to help alleviate pain and symptoms associated with AS. Physical therapy consults are highly recommended for educational purposes and to commence such an exercise routine[6][7]. It is important to stress there is no specific cure for AS and that surgery does not 'fix' the condition. Surgery becomes indicated if the patient displays cauda equina symptoms or severe neurological defecits.
Differential Diagnosis
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Common other disorders to consider in differentially diagnosing with AS are:
- Degenerative Disc Disease
- Herniated Nucleus Pulposus
- Fractures and/or dislocation
- Osteoarthritis
- Spinal Stenosis
- Spondylolisthesis, Spondylolysis, and Spondylosis
Key Evidence[edit | edit source]
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Resources
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Case Studies[edit | edit source]
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Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
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- ↑ van der Linden S, van der Heijde D. Clinical aspects, outcome assessment, and management of ankylosing spondylitis and postenteric reactive arthritis. Curr Opin Rheumatol. Jul 2000;12(4):263-8.
- ↑ Alvarez I, López de Castro JA. HLA-B27 and immunogenetics of spondyloarthropathies. Curr Opin Rheumatol. Jul 2000;12(4):248-53
- ↑ McGonagle D, Emery P. Enthesitis, osteitis, microbes, biomechanics, and immune reactivity in ankylosing spondylitis. J Rheumatol. Oct 2000;27(10):2302-4.
- ↑ Dougados M, Gueguen A, Nakache JP, et al. Clinical relevance of C-reactive protein in axial involvement of ankylosing spondylitis. J Rheumatol. Apr 1999;26(4):971-4.
- ↑ van der Heijde D, Spoorenberg A. Plain radiographs as an outcome measure in ankylosing spondylitis. J Rheumatol. Apr 1999;26(4):985-7.
- ↑ Hidding A, van der Linden S, Gielen X, et al. Continuation of group physical therapy is necessary in ankylosing spondylitis: results of a randomized controlled trial. Arthritis Care Res. Jun 1994;7(2):90-6.
- ↑ Kraag G, Stokes B, Groh J, Helewa A, Goldsmith C. The effects of comprehensive home physiotherapy and supervision on patients with ankylosing spondylitis--a randomized controlled trial. J Rheumatol. Feb 1990;17(2):228-33.
