Ankylosing Spondylitis (Axial Spondyloarthritis)

Definition/Description[edit | edit source]

Ankylosing spondylitis (also called Bechterew's disease) is a spondyloarthritis of the spine and pelvis. It is a common chronic inflammatory rheumatic disease with unknown etiology. AS is associated with the HLA-B27 antigen and also with other chronic inflammatory diseases. AS affects the axial skeleton and sacroiliac joints, causing characteristic inflammatory back pain, which can lead to structural and functional impairments and a decrease in quality of life.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Affected joints progressively become stiff and sensitive due to a bone formation at the level of the joint capsule and cartilage. It causes a decreased range of motion and gives the spine an appearance similar to bamboo, hence the alternative name "bamboo spine".
Although not often recognized, ankylosing spondylitis can also cause peripheral joint pain, particularly in the hips, knees, ankles, and shoulders and neck.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title It involves synovial and cartilaginous joints, as well as sites of tendon and ligamentous attachment.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleEarly diagnosis and treatment helps to control the pain and stiffness and may reduce or prevent significant deformity.

Clinically Relevant Anatomy[edit | edit source]

Pain in AS can be caused by sacroiliitis, enthesitis and spondylitis.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Initially the sacroiliac joints, situated in the lumbar part of the back, which connect the spine and the pelvis, are damaged. Subsequently the inflammation moves to entheses, which are places where ligaments and tendons integrate into bone.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Eventually the spine is affected by this inflammation. The vertebral column normally exists of 24 vertebrae, joined together by ligaments and separated by intervertebral discs. These discs exists of an inner nucleus pulposus and an outer annulus fibrosis, consisting of fibrocartilage rings.
Patients diagnosed with AS form calcium deposits in the ligaments between and around the intervertebral discs. An accumulation of the deposits leads to ossification Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, starting from the vertebral rim towards the annulus fibrosis and characterized by syndesmophytes.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title In far advanced situations the spine can even fuse together as a result of the produced bone formation.


Sacroiliac Joint


Epidemiology /Etiology[edit | edit source]

AS Affects 0.1 to 0.2% of the population and Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title is predominantly seen in males in a 3:1 ratio. The onset of symptoms generally occurs in late adolescent years to early adulthood. The peak age in which AS is manifested varies from the teens to the fourth decade of life.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Its prevalence is highest among white people (0.1-0.2%), less common in American blacks and rare among Japanese. Thus there is both a familial and a racial predisposition to this disease.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The etiology of AS is not fully understood at this time, although a strong genetic link has been determined.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title In addition, a direct relationship between AS and the major histocompatibility human leukocyte antigen (HLA)-B27 has also been determined.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The exact role of this antigen is unknown but is believed to act as a receptor for an inciting antigen leading to AS. HLA-B27 occurs in 90-95% of patients with ankylosing spondylitis, compared to a 6 to 9% incidence in the normal population. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The majority of patients are HLA-B27 positive and the risk passing the same antigen onto a child is 1 in 2 Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title , so ankylosing spondylitis is a common, highly heritable inflammatory arthritis. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title It is also known that environmental or bacterial factors can be a trigger. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title 
At first there is an infiltration of the subchondral bone by granulation tissue which causes small lesions, ultimately leading to joint erosion (the adjacent cartilage is distorted which produces a very irregular surface).Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleThese lesions in the annulus eventually undergo ossification, leading to a 'fusion' effect of the spinal segments and the similarity in appearance to bamboo. In the spine this occurs at the junction of the vertebrae and the annular fibres of the intervertebral disc.
When synovium is the affected tissue, there is an infiltration by macrophages and lymphocytes. This is followed by replacement of the cartilage or fibrous tissue by a scar like fibroblast invasion which rapidly ossifies. The inflammatory response in the bone adjacent to the involved fibrocartilage, ligament or periosteum is frequently quite severe. As of the spine can resemble an infectious discitis when the spine is initially involved and, thus, can be an additional source of confusion for the treating physician. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Ankylosing Process
"Bamboo Spine" on X-ray

Characteristics/Clinical Presentation[edit | edit source]

The clinical presentation is usually an insidious onset of back pain in the sacroiliac (SI) joints and gluteal regions and progresses to involve the entire spine. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title 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 and stiffness increase with inactivity and improve with exercise.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title It may also variably involve peripheral joints, eyes, skin, and the cardiac and intestinal systems. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Eye disease occurs in about 25% of the patients as either iridocyclitis or conjunctivitis. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Joints other than those of the axial skeleton can be involved with an inflammatory arthritis and synovitis which is seldom as destructive as that of rheumatoid arthritis. The hips, shoulder and knees are the most commonly and most severely affected of the extremity joints. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Complaints of intermittent breathing difficulties may also be a common complaint because AS may cause a decrease in chest expansion.

Differential Diagnosis
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Common disorders to consider as differential diagnoses with AS are:
• Degenerative Disc Disease
• Herniated Intervertebral Disc
• Fractures and/or dislocation
• Osteoarthritis
• Spinal Stenosis
• Spondylolisthesis, Spondylolysis, and Spondylosis
• Reactive arthritis
• Inflammatory bowel-related arthritis
• Diffuse idiopathic skeletal hyperostosis (DISH)
• Rheumatoid arthritis Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Psoriatic arthritis Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Reiter syndrome (milder with asymmetric sacroiliitis) Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Diagnostic Procedures[edit | edit source]

The diagnosis of AS is commonly made through a combination of thorough subjective and physical examinations, laboratory data and imaging studies.
Common laboratory data include blood tests to determine the presence of the HLA-B2 antigen or substances that indicate an inflammatory process: Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

  • Erythrocyte sedimentation rate (ESR): This is a blood test for inflammation, in approximately one third of the SA patients there is a raised ESR observable in exacerbations of the disease. But it is necessary to know that other conditions can also cause a high ESR.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • C-reactive proteins (CRP): This is also a marker of inflammation and is found in 50-70% Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title of people with AS.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleHowever, this test is discouraged because it is associated with a high rate of false positives due to the fact that high CRP occurs in 10% of the Caucasian population.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • HLA-B27 antigen: HLA B27 is positive in 80-90% of AS patients.] This is especially true in white people and less true in some other ethnic groups, especially African Americans. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleAlthough the presence of this hereditary factor is not required for a diagnosis of AS and does not absolutely confirm or exclude the presence of this disease. The HLA-B27 antigen also occurs in other inflammatory conditions of the joints or intestines. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title


Laboratory tests are specific and are often more helpful to exclude other diagnoses rather than confirming AS. In combination with other symptoms, the diagnosis can often be made more accurate. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The detection of SA by medical imaging: Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

  • X-rays are the most helpful imaging modality in established disease, although they may be normal in early disease. The X-ray will show areas where the bone has been worn away by the condition. The vertebrae of the spine may start to fuse together because the ligaments between them become calcified.
  • MRI scanning may be useful in identifying eary sacroiliitis. MRI of the sacroiliac joints is more sensitive than either plain X-ray or CT scan in demonstrating sacroiliitis. Sacroiliitis initially shows as blurring in the lower part of the joint, then bony erosions or sclerosis occur and widening or eventual fusion of the joint.


Radiographic findings are graded on a scale of 0 to 4 where 0 represents normal findings and 4 represents complete ankylosis.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title A definitive diagnosis is considered with the following combinations.

  • Grade 3 or 4 at bilateral SI joints on radiograph with at least one physical finding
  •  Grade 3 or 4 unilaterally (or Grade 2 bilaterally) with two physical findings


Standard questionnaires can also be used as part of the assessment to sketch the evolution of the disease.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Available questionnaires include:

  • AMOR criteria for Spondyloarthritis
  • BASDAI index ( Bath Ankylosing Spondylitis Disease Activity Index)
  • BASDMI (Bath Ankylosing spondylitis Metrology Index)
  • BASFI index ( Bath Ankylosing Spondylitis Functional Index)
  • BAS-G index ( Bath Ankylosing Spondylitis Global Index)


The modified New York criteria (1984) for diagnosing AS combines physical findings with radiograph studies:
1. Clinical criteria
a) Low back pain and stiffness for at least 3 months, which improves with exercise, but is not relieved by rest
b) Limited lumbar spinal motion in sagittal (sideways) and frontal (forward and backward) planes.
c) Chest expansion decreased relative to normal values corrected for age and sex


2. Radiologic criteria
a) Bilateral sacroiliitis grade 2 to 4
b) Unilateral sacroiliitis grade 3 or 4


3. Grading
a) A patient can be classified as having definite AS if at least 1 clinical criterion (inflammatory back pain, limitation of mobility of the lumbar spine, or limitation of chest expansion) plus the radiologic criterion (radiographic sacroiliitis of grade 2 bilaterally or grade 3–4 unilaterally) are fulfilled.
b) A probable diagnosis of AS is made if three clinical criteria are present or the radiologic criterion is present without any signs or symptoms satisfying the clinical criteria Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title,[39

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 because AS often affects the patient on a more general level. However, since AS affects 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.

Examination[edit | edit source]

A thorough physical examination, particularly of the musculoskeletal system, is needed. Clinical signs are sometimes minimal in the early stages of the disease. Examination of the sacroiliac joints and the spine (including the neck), measurement of chest expansion and range of motion of the hip and shoulder joints, and a search for signs of enthesitis are critical in making an early diagnosis of AS. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Video 1: The aim of the Schober test is to assess the mobility of the lumbar spine, which can be abnormal even when it's not obvious to the person.

[1]

Video 2: The lumbar spine side flexion test is another test to measure the lumbar spine mobility.

[2]

Video 3: When ankylosing spondylitis affects the mid-back region, normal chest expansion may be compromised. The aim of the chest expansion test is to assess the thoracic mobility.

[3]

Video 4: The tragus to wall test is a test to measure the cervical mobility.

Medical Management
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First line drug treatment : NSAIDs
Non-steroidal anti-inflammatory drugs (NSAIDs) are primarily used for ankylosing spondylitis (AS) patients to reduce the inflammatory symptoms such as pain and stiffness of the spine and other joints. It is important to remember that NSAIDs don’t alter the disease-cause and only affects the symptoms.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 1B) Commonly used NSAIDs for AS are tolmetin, sulindac, naproxen, diclofenac and indomethacin, Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 3A) being the most effective.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 1A)


Second line treatments: corticosteroids and DMARDs
When patients are refractory to NSAIDs, doctors may describe corticosteroid injections or disease modifying anti-rheumatic drugs (DMARDs)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title(Level of evidence 1B), including methotrexate and sulfasalazine. However, corticosteroids don’t have evidence-based outcomes and DMARDs are only proven to be effective for the treatment of peripheral joint diseases.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 1A)


Biological medications
1) Tumor necrosis factor inhibitors
Research has shown that patients with ankylosing spondylitis have an abundance of pro-inflammatory cytokine tumor necrosis factor (TNF) messenger RNA and proteins in the sacroiliac joints. The use of anti-tumor necrosis factor therapies is therefore proven positive.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 1B), Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 1B), Etanercept Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 2B) and InfliximabCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 1B) have both been used to treat AS patients with successful results.


2) Biphosphonates
Biphosphonates have good outcomes on bone turnover, which is positive because ankylosing spondylitis is characterized by bone resorption and formation. Neridronate and pamidronate are amino-biphosphonates with similar effects as the TNF inhibitor Infliximab. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title(Level of evidence 2A)
All drugs have side effects, thus patients with other health issues need to verify if they may use the recommended medicines.

Physical Therapy Management
[edit | edit source]

Physical therapy is an essential part in the treatment of AS.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 1A) It aims to alleviate pain, increase spinal mobility and functional capacity, reduce morning stiffness, correct postural deformities, increase mobility and improve the psychosocial status of the patients.
The Global Postural Reeducation method has shown promising short- and long-term results.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 5) It includes specific strengthening and flexibility exercises in which the shortened muscle chains are stretched. A global and functional approach is more efficient than analytic exercises in AS patients.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 1B) Muscle chains are constituted by gravitational muscles (erector spine muscles, piriformis muscle, scalene muscles, suboccipital muscles) which work synergistically with each other. The analytic stretching of any individual gravitational muscle would be inefficient if not associated with a stretching of the whole muscle chain.
The GPR method results in greater improvement with a group physical therapy program than with home exercises. This can be explained by the mutual encouragement, reciprocal motivation, and exchange of experience in group therapy.
Since a decrease in chest expansion is secondary to ankylosis in AS, there is also pulmonary involvement. This may even further decrease the low psychological status and quality of life in patients with AS.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 1B) By performing the following exercises, the chest expansion can increase, leading to better functional capacity.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 1B)

  • Twice the normal rate of inspiration through the nose and expiration through the mouth
  • Normal expiration through nose and normal expiration through mouth
  • Respiration through the chest and abdomen
  •  Deep breathing and then expiration through the mouth slowly
  • Resistance exercises for inspiratory pulmonary muscles

A rigorous exercise routine with postural correction can be applied to delay, and possibly stop, the progression of the disease. Spinal extension exercises are the key component and should be done twice daily. Education in self-management is essential, this to discourage ‘doctor dependence’. Young patients need a great deal of encouragement and support as self-worth understandably diminishes with the progression of postural deformity. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 5)

Treatment is essentially to minimize or prevent deformity. These deformities are excessive dorsal kyphosis with compensatory cervical lordosis and hip flexion contracture. Non-Surgical treatment involves:

  • Proper sleeping posture on a solid, flat bed without pillow. Frequent sleeping or lying in prone position.
  •  Posture exercises with upper back hyperextension (performed with avoidance of lumbar hyperextension).
  • Breathing exercises to increase or maintain rib cage excursion, as well as instruction in abdominothoracic breathing.
  • Range of motion exercises for hips and knees to prevent flexion limitation and contractures.
  • Periodic rest periods with avoidance of fatigue.
  • Bracing or corseting (combined with exercises). Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 5)

Manual mobilization improves chest expansion, posture and spinal mobility.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 3B) Both active angular and passive mobility exercises can be used in the physiological directions of the joints in the spinal column and the chest wall in flexion, extension, lateral flexion and rotation and in different starting positions (lying face down, sideways, on the back and in a sitting position). Passive mobility exercises consist of general, angular movements and specific translatory movements.
In addition to conventional exercises (flexibility exercises for cervical, thoracic and lumbar spine and major muscle groups) and respiratory exercises (pursed-lip breathing, expiratory abdomen augmentation, and synchronization of thoracic and abdominal movement), aerobic exercises such as swimming and walking are recommended. Research has shown a significant increase in chest expansion following swimming programs and a significant increase in PvO2 and Six Minute Walk Test distances in patients practicing swimming and/or walking aerobic exercises. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 1B) Aerobic exercises lead to a bigger chest expansion and therefore a better functional capacity. It also decreases the chance of respiratory failure.
Spa therapy has shown significant positive short- and long-term effects on pain, stiffness, well-being and functioning of patients with AS.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleHowever, this treatment is very expensive and since the optimal length of therapy is four weeks, this is unfeasible for many people, especially those who are in the workforce or have families at home.
Results of different studies shows us that an individual home-based or supervised exercise program is better than no intervention. Supervised group physiotherapy is better than home exercises and combined inpatient spa-exercise therapy followed by group physiotherapy is better than group physiotherapy alone. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 2A)

Exercise Type Methods Recommended Dosage Effects on Pulmonary Function
General Exercises See Table 2 below for recommended exercises to include in the exercise program[4] 2 Times Per Week Minimum, For 6 Months Increased Functional Capacity, Improved Chest Expansion.
Pilates[5]  Consists of a supervised Pilates session which follows the accepted Pilates method of movement. The difficulty of the movements should be easy to moderate difficulty and not exceed 14 on the BORG scale. 1 Hour Sessions, 3 Times Per Week, For 12 Weeks Significant Improvements In Chest Expansion.
Incentive Spirometry[6] This is a session of breath holding and controlling breaths. Patients should carry out 3-5 second breath holds and carry out Forced Expiratory Techniques interspersed between breath holds. This treatment should be combine with General Exercises and should not be used as a sole treatment (see above for general exercises 30 Minute Sessions, Once Per Day, For 16 Weeks Improved Chest Expansion and Improved Forced Vital Capacity
Inspiratory Muscle Training[7] The supervised exercise program, delivered by a qualified physiotherapist, should include; motion and flexibility exercises of the cervical, thoracic, and lumbar spine; stretching of the hamstring muscles, erector spine muscle, and shoulder muscles; control abdominal and diaphragm breathing exercises and chest expansion exercises. In addition to these exercises, at home patients should perform six loaded inspirations with a 60 second rest period between each inspiration. This sequence of six exercises continued with 45, 30, 15, 10 and five second rest periods up to 36 loaded inspirations. A rating of more than 17 on the BORG requires the patient to stop exercising. 40 minute session (supervised), Once Per Week, 5 Unsupervised Home Exercise Sessions Per Week Increased Aerobic Capacity, Improved Resting Pulmonary Function and Ventilatory Efficiency.
Manual Mobilisation [8] Both active angular and passive mobility exercises can be used in the physiological directions of the joints in the spinal column and the chest wall in flexion, extension, lateral flexion and rotation and in different starting positions. Passive mobility exercises consist of general, angular movements and specific translatory movements. 1 Hour Sessions, 2 Times Per Week, for 8 Weeks Improved Chest Expansion, Posture and Spinal Mobility
Aerobic Exercise[9] Research shows that in the short term aerobic exercise has a major effect of all symptoms relating to ankylosing spondylitis. Although there is no bad form of aerobic exercise, studies show that swimming is the best for pulmonary rehabilitation. Studies also show that high impact contact sports should be avoided as this can have a negative impact on symptoms relating to AS 1 hour per day, 5 days per week. (more can be done however should not achieve more than 17 on the BORG Scale Improved Chest Expansion, Improved Functional Capacity and Decreases the Chance of Respiratory Failure.

Table of AS Exs.jpg

Hydrotherapy/Aquatic Physiotherapy

Hydrotherapy is used for many pathology’s relating to back pain.[10] The rationale for the use of hydrotherapy in patients with Ankylosing Spondylitis looks at addressing common symptoms such as stiffness and associated back pain, a stooped posture and fatigue.

These factors include:
- Warm water provides a relaxation effect the the tight musculature around the back.
- Buoyancy of water allows stretching to feel easier than on land.
- Reduced pain while stretching/exercising as water provides shock absorption.
- Easier to stay upright as effect of gravity reduced in water.
- Effort required is reduced due to upward thrust of the water. In waist high water, body weight is half of what it would be on land. [11]

Evidence for the use of Hydrotherapy/Aquatic Physiotherapy
A Randomised Control Trial (2014) has looked at the effect of hydrotherapy for patients with AS compared to home-based exercise programs. It concluded that an intensive hydrotherapy programme produced better outcomes in terms of pain and quality of life for AS patients compared to the home exercise group.[12]


A qualitative research study (2012) investigated AS patient’s views on treatment options. hydrotherapy proved popular amongst AS patients who partook in the study, however it was reported that access to a hydrotherapy pool proved problematic.[13]


Most recently, the American College of Rheumatology (2015) published evidence based recommendations for the treatment of AS. A small section of the report recommends land based exercises over hydrotherapy. However, this was mainly due to accessibility and cost implications because the study they looked at did show improvements for the use of hydrotherapy, but they were not significant when compared to land based exercise.[14]


Overall, hydrotherapy appears popular amongst AS patient's, but difficult to access.
Further research should investigate the initial use of hydrotherapy to educate patients on beneficial exercises in the pool, followed up by patients self-managing in local leisure centres as this could benefit patients finding it difficult to access formal hydrotherapy classes led by physiotherapists.

Spa therapy has shown significant positive short- and long-term effects on pain, stiffness, well-being and functioning of patients with AS.[15] However, this treatment is very expensive and since the optimal length of therapy is four weeks, this is unfeasible for many people, especially those who are in the workforce or have families at home.

Group Therapy

Group therapy has been reported to be superior to individualised therapy in improving thoracolumbar mobility and aerobic fitness, as well as having an important effect on patient reported global health[16].


Pilates has also been shown to have many positive effects on AS, most notably on improving physical capacity[17]. Other studies have noted a relationship between pilates and an improved quality of life particularly in patients who are in the early stages of AS even after a relatively short duration of treatment. While the method is easy to learn and adaptable to individual variations, it can be easily implemented in the rehabilitation treatment of ankylosing spondylitis[18].


Mindfulness Based Therapies


Non exercise-based interventions have also been shown to have positive effects in the management of AS; in a 2012 RCT, a 10-week group-based mindfulness course was administered to 73 people with a diagnosis of AS in the form of a Vitality Training Program (VTP), following a 6-month follow up session statistically significant improvements were reported in psychological distress (measured by the General Health Questionnaire). In addition to this other improvements were reported in self-efficacy, pain and symptoms, emotional processing, fatigue, self-care ability and overall well-being[19].


Due to existing evidence suggesting the effectiveness of mindfulness interventions, scope has been established for its use in a group session in order to manage patient fatigue (which has been further sub-categorised into physical emotional, and psychological components). This is due to patients reporting that they often feel lost without any formal guidance or support, in addition to the fact that patients have expressed a preference for psychological therapies as opposed to pharmacological one for managing fatigue; information on Mindfulness-Based Stress Reduction (MBSR) was received with interest [20].

Resources [edit | edit source]

• CINAHL
• JOSPT
• Pubmed
• Medline with Full Text
• PEDro
• Spondylitis Association of America
• MedicineNet.com
• Mayo Clinic

Clinical Bottom Line[edit | edit source]

Ankylosing spondyitis is a common chronic inflammatory rheumatic disease with unknow aetiology. Affected joints progressively become stiff and sensitive due to a bone formation at the level of the joint capsule and cartilage. This can lead to structural and functional impairments and a decrease in quality of life. Regions most affected by the disease are the axial skeleton and sacroiliac joints.
A combination of medicines (such as non-steroidal anti-inflammatory drugs and biological medications) and physical therapy is recommended. Physiotherapists primarily use range of motion- and respiratory excercises as wel as postural corrections.

Presentations[edit | edit source]

https://http://www.youtube.com/watch?v=hci1ea2coy8Ankylosing spondylitis ppt.PNG
Ankylosing Spondylitis

This presentation, created by Kyle Martin, Robby Martin, Haley Metzner, and Stacey Potter; Texas State DPT Class.

View the presentation

Recent Related Research (from Pubmed)[edit | edit source]

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• Sieper J, Effect of Certolizumab Pegol over 96 Weeks in Patients with Axial Spondyloarthritis: Results from a Phase 3 Randomized Trial., Arthritis Rheumatol, 2014.
• Martindale J1,2, Kashefi E3, Goodacre L3., An Exploratory Study of the Experience of Ageing with Ankylosing Spondylitis: 'Same Backdrop but a Changing Scene'., 2015

Related physiopedia pages:
http://www.physio-pedia.com/Spondyloarthropathy--AS
http://www.physio-pedia.com/Spondyloarthritis#Resources

References[edit | edit source]

  1. bjchealthAU. Modified Schober's Test. Available from: http://www.youtube.com/watch?v=B9RaFB5BwrQ [last accessed 01/12/12]
  2. bjchealthAU. Lumbar Side Flexion Test. Available from: http://www.youtube.com/watch?v=c-IeFZkPEoE [last accessed 01/12/12]
  3. bjchealthAU. Chest Expansion Test. Available from: http://www.youtube.com/watch?v=SumtVr5c1Qg [last accessed 01/12/12]
  4. Ince G, Sarpel T, Durgun B, Erdogan S. Effects of a multimodal exercise program for people with ankylosing spondylitis. Physical therapy. 2006 Jul 1;86(7):924-35.
  5. Altan L, Korkmaz N, Dizdar M, Yurtkuran M. Effect of Pilates training on people with ankylosing spondylitis. Rheumatology international. 2012 Jul 1;32(7):2093-9.
  6. So MW, Heo HM, San Koo B, Kim YG, Lee CK, Yoo B. Efficacy of incentive spirometer exercise on pulmonary functions of patients with ankylosing spondylitis stabilized by tumor necrosis factor inhibitor therapy. The Journal of rheumatology. 2012 Sep 1;39(9):1854-8.
  7. Drăgoi RG, Amaricai E, Drăgoi M, Popoviciu H, Avram C. Inspiratory muscle training improves aerobic capacity and pulmonary function in patients with ankylosing spondylitis: A randomized controlled study. Clinical rehabilitation. 2015 Mar 25:0269215515578292.
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