Use of Hydrotherapy for the Management of Ankylosing Spondylitis (AS)

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Original Editors - Harrison Chipchase, Lucy Thomas, Wilson Gay, Nico Pennant

Top Contributors - Wilson Gay, Angeliki Chorti, Harrison Chipchase, Lucy Olivia Thomas, Nico Pennant, Khloud Shreif, Kim Jackson and Cindy John-Chu  

Introduction to Ankylosing Spondylitis (AS) - Wilson

Ankylosing Spondylitis is a chronic inflammatory, sero-negative arthritic condition that typically affects the spine and the sacroilliac (SI) joints. Common clinical presentations of this disease can include:

·       Inflammatory nature of chronic back pain which improves with exercise

·       SI joint and spinal fusions

·       Formation of bony spurs and syndesmophytes along the intervertebral and SI joint

·       Arthritis and enthesitis (typically asymmetrical distribution within the lower limb)

·       Dactylitis (swelling of toes and fingers)

·       Extra-articular manifestations (anterior uveitis, psoriasis, IBS etc.)

·       Increased risk of osteoporosis and spinal fractures

·       Reduced Quality-of-Life

(Cite NICE)

Common features that differentiate between mechanical back pain and inflammatory back pain are listed below.

Inflammatory Back Pain (AS)	Mechanical Back Pain
Age of onset typically below 40 years	Age of onset at any age
Insidious onset; less likely to be acute	Variable onset; may be acute
Pain does not improve with rest	Pain often improves with rest (particularly in acute stage)
Pain improves with exercise
Morning stiffness for more than 30 minutes
Pain at night which may cause patient to wake up (particularly in the latter half of the night)

CITE NASS

Clinical Relevance & Relevant Anatomy

Pathophysiology of AS and how it cause various signs and symptoms

Pathogenesis

There appears to be a strong genetic pre-disposition in the development of AS. The most commonly associated genetic factor is the HLA-B27 allele.

The human leukocyte antigen (HLA) complex, also known as human major histocompatibility (MHC)complex, belongs to cell-surface proteins that helps in the process of acquired immunity. The MHC gene family is divided into subgroups: class I, II, and III.

HLA-A, HLA-B, and HLA-C are encoded by the MHC class I complex and is found on all nucleated human cells and platelets. MHC class I complex is polymorphic in nature and links 8–10 amino acids (peptide) to initiate and propagate a series of immune responses. The HLA-B27 belonging to the MHC class I surface protein complex and encoded by the MHC B gene on chromosome 6. Having HLA-B27 typically predisposes an individual to AS. HLA-B27 presents peptide antigens to T-cells within the human body as a defense mechanism and is widely considered to be significantly linked to inflammatory diseases such as AS with about 90 to 95% of people suffering with AS displaying a positive HLA-B27 allele.

The pathogenic role of HLA-B27 currently remains disputed and unclear. Three theories accounting for the role of HLA-B27 in AS have been put forth.

1)     The arthritogenic peptide: HLA-B27 is critical in the pathogenesis of joint specific joint-specific peptides to CD8⁺ cytotoxic T cells. However, there has been lack of identification of any specific arthritogenic peptide thus far.

2)   Misfolding of HLA-B27: It is hypothesised that misfolding of the HLA-B27 causes a stress to the Endoplasmic Reticulum and activates an unfolded protein response (UPR). This causes an increased expression of the IL-23 in dendritic cells. The role of the UPR in instigating the inflammation is yet to be proven.

3)     Cell-surface homodimers: It is thought that the HLA-B27 aberrantly folds to form homodimers on the surface of the cell. These different forms of HLA-B27 are identified in vitro by immunoglobulin-like receptors. These receptors can be express by Natural Killer (NK) cells or circulating CD4⁺ T cells. This induces the transcription of the Th17 transcription factorfor the expression of the Th17 immune pathway.

Hydrotherapy - Joe

include more variations of aquatic/hydrotherapy

Benefits and Evidence for effectiveness of Hydrotherapy for AS symptoms - Nico

Hydrotherapy can be beneficial for controlling symptoms of ankylosing spondylitis as:

• The warmth and the buoyancy of the water makes stretches more effective
• It’s less painful
• It’s easier to stay upright because the effect of gravity is less
• It requires less physical effort
• Afterwards you usually have a really good night’s sleep

• Water can act as resistance to help strengthen muscles  
• Can provide shock absorption  

Evidence for the effectiveness of hydrotherapy has been demonstrated through patient experience studies:  

(Martin et al., 2018) 250 members of the national axial spondylitis association (NASS) completed an online survey on the patients’ experience of hydrotherapy. From thematic analysis of the questionnaires, five themes emerged.

1. Emotional well being : Patients described greater control over their condition when exercising in water
2. Exercise behaviour : patients often performed a wider variety of exercises including challenging exercises that they would not usually attempt on land
3. Group effect : patients described a sense of motivational support when exercising with others in a group  
4. Professional support : Patients cited the benefit of hydrotherapy sessions led by a physiotherapist who shared their expertise and discussed problems.
5. Pool Environment: Patients described gains from non-impact exercise and weightlessness in the water. The warmer pool temperature was stated as a reason for the benefits obtained.

Hydrotherapy was shown to be most beneficial for improving pain relief, mood, quality of life stiffness and flare management, but less beneficial for improving sleep quality and fatigue.  

The effectiveness of hydrotherapy in comparison to land based therapy has been investigated in a randomised control trial: (Dundar et al., 2014)

A total of 69 patients (58 male and 11 female) completed the study. Patients were randomly allocated to a land exercise or aquatic exercise group. Following a course of 4 weeks completing either land based exercises or aquatic exercises, the study found that both groups showed significant improvements in their symptoms. Improvement in VAS score, bodily pain, general health and social functioning were greater in the aquatic exercise group. However, improvements in lumbar range of motion and chest expansion were greater in the land based exercise group.

Indications for Hydrotherapy

Hydrotherapy can be beneficial for those who are suffering with the following:

• Muscle Spasm
• Muscle Tightness/Weakness
• Joint Stiffness
• Inflammation

Given the inflammatory nature of AS and the stiffness around the spine that occurs, a person suffering with AS and displaying these symptoms would be a good candidate for hydrotherapy.

Barriers and Contraindications to the use of Hydrotherapy for the Management of AS - Harrison (barriers)

Barriers

Barriers for the use of hydrotherapy are factorised by patient internal factors, clinician specific factors and environmental factors. As a physiotherapist when using Hydrotherapy as a treatment method these barriers must be accounted for to ensure effective management for the patient. Below is a non-exhaustive evidence supported list which shows barriers that may impact upon the use of hydrotherapy in conventional management of AS.

Patient barriers	Physiotherapist barriers	Environmental factors
Pain	Training opportunities	Covid-19
Lack of interest	Staffing levels	Availability
Insufficient Knowledge		Expenses on NHS
Expenses		Transport
Waiting times

Essential communication skills as detailed by the NICE guidelines for 'Improving the experience of care for people using adult NHS services' with patients ensures that these barriers are somewhat accounted for. Although barriers cannot be eliminated fully physiotherapists can use their interpersonal communication skills to limit the patient barriers. The importance of ensuring these barriers are accounted for are highlighted in the 'Benefits of Hydrotherapy' Above. Current evidence of patient perspectives when limiting these barriers elicits improvements to: pain relief, improvement in mood and quality of life, stiffness and flare management after NHS hydrotherapy services.

Contraindications

Absolute Contraindications	Relative Contraindications	Precautions	Considerations
Acute Systemic Illness	Irradiated Skin during course of radiotherapy	Incontinence of urine/faeces	Shortness of breath with exertion (unfit or if any other causes)
Pyrexia	Known aneurysm	Gross obesity	Vertigo/nausea/blackouts
Acute vomiting or diarrhoea	Open wounds	Epilepsy	Multiple Sclerosis (especially those with high sensitivity to high temperatures)
Medical Instability following an acute episode	Unstable diabetes	Haemophilia	Communication problems
Proven chlorine or bromine allergy	Thyroid Deficiency	Widespread MRSA	Dermal sensitivity due to sanitising agents/Psoriasis
Resting Angina	Neutropaenia	Hypotension	Verruca/Tinea Pedia
Shortness of Breath at rest	Oxygen Dependency	Renal Failure	Boisterous, unpredictable or aggressive behaviour
Uncontrolled cardiac failure/paroxysmal nocturnal dyspnoea	Weight in excess of the evacuation equipment’s limit	Poor Skin integrity or open/surgical wounds	Contact lenses and conjunctivitis
Open, infected wounds		Pregnancy if water temperature exceeds 35°C	Hearing aids/grommets
Known HIV positive and Hepatitis C patients – not to enter pool during menstruation		Invasive tubes in situ	Impaired sensation/vision/hearing

Hydrotherapy Exercise and Prescription

Exercise

According to the NICE guidelines, individualised structured exercise programme could include:

·       Stretching, strengthening and postural exercises

·       Deep breathing exercises

·       Spinal extension exercises

·       Range-of-motion exercises from cervical down to lumbar spine

·       Aerobic exercises

·       Elements of hydrotherapy as an adjunct therapy for improving pain and functional outcomes

Prescription

In terms of Exercise Prescription several key things of note:

·       Consider the most appropriate time for activity as symptoms may vary across the day (particularly in the morning)

·       Place emphasis on warm-ups due to stiffness being a major concern for people with AS

·       Range-of motion exercises should work along all the spinal segments towards its end-range, however ensure that it is tolerable and comfortable

·       Emphasis can be placed on spinal extension due to the nature of the condition

·       Important to remind participants about their posture throughout the session

·       Avoid doing flexibility exercises right before strengthening or cardiovascular exercises due to the inhibition of muscular activities (cite)

·       Strengthening of extensor muscles and flexibility in flexor muscles are preferred

·       For strengthening: focus on low weight, high repetition movements with 2-3 sets progress by increasing number of sets as strength improve

·       Cardiovascular exercise intensities are dependent on the level of fitness of the individual, a recommended 30 minutes session of moderate intensity for five times a week is recommended and progressed as appropriate (NICE…)

Recommendation from the ACSM includes:

Frequency	Intensity	Time	Type	Resistance	Flexibility
5 or more days a week of moderate exercise OR 3-5 days a week of moderate and vigorous exercises	Moderate or vigorous (measure	At least 30 minutes of continuous or accumulated exercises (10-minute bouts)	Aerobic exercises in body positions that are well tolerated	2-3 days per week 2-4 sets of 8-12 repetitions at 60 to 70% of 1RM intensity 10-15 repetitions with 40-50% 1RM for elderly	2-3 days per week Stretch to point of slight discomfort 2-4 repetitions, 10-30s for most adults 30-60s for elderly

Case Study

Mr Smith (sufferer of AS)

Mr Smith is a 32 - year old male who has been diagnosed with AS in the past 3 years.

He reports:

·       Flare ups of pain to 7/8 on VAS scale

·       Pain is a dull ache and is usually in the lower thoracic spine but can often spread into legs when not managed

·       Occasional sleep disturbance when moving in the night and suffers with continued fatigue affecting office work

Aggravating factors:

·       Sitting more 45 minutes at work

·       Thoracic rotation

·       Lifting and carrying any weight

·       Sudden movements

Easing factors:

·       lying

·       Intermittent walking / sitting

·       Pain medication

·       Heat

24 Hour Pattern

Wakes occasionally in the night with dull ache pain. Feels very stiff in the morning, walks with hunched back to protect back.  Pain is better during the day when more active, slowly stands into a more upright posture. Becomes more painful at late PM after a full day of work.

Social History

·       Sales assistant – works in office 9-5

·       Has enjoyed playing football in the past and socialising with friends.

·       Single, recently divorced, no children.

·       Lives alone in 2-bedroom house, Toilet upstairs and downstairs.

·       Driver

Drug History

·       Naproxen

·       Paracetamol (PRN)

Past Medical History

·       Nil

Physiotherapy Management of Case Study

Due to his symptoms fitting the aforementioned indications for hydrotherapy, Mr Smith would benefit from some sessions in adjunct to land-based exercises. A possible outline for hydrotherapy exercises are detailed below:

Warm Up (5 minutes)

• Walking the length of hydrotherapy pool

This is a good way to start the session to get used to the water and ease the muscles into exercise. The buoyancy nature of water means that a body can weigh 50-90% less than on land. This allows for less stress on the joints and so walking the length of the pool can help strengthen the joints with less impact.

Stretches (5-10 minutes)

As AS can reduce Range of Motion (ROM) in the spine, stretches are beneficial to help maintain ROM and relax sore muscles. As Mr Smith can get pain into his legs, examples of stretches to use include:

• Quadricep Stretch

Can be performed either with patient’s own hand or by placing ankle behind a pool noodle and bringing knee up into flexion

• Hamstring Stretch

Can be performed by having a patient’s back against pool wall and placing ankle over pool noodle, bringing up slowly in front of them.

The inflammation and possibly eventual bony fusion that occurs at the spine normally affects the lumbar region first but can spread and also cause stiffening at the ribcage as well, which could potentially be the case with Mr Smith due to his pain at the thoracic spine. This can affect chest expansion and breathing. Thoracic hydrotherapy stretches to help with this include:

• Wall Corner Stretch

Patient stands facing corners of pool and places hands against the two walls – helping to open up chest. A patient can practice deep, slow breathing in through their nose and out through their mouth during this stretch.

• Thoracic Rotation

Patient stands with their arms crossed over their chest and, keeping their feet pointing forwards, slowly rotate their thoracic spine to the left before returning back to centre. This is then repeated to the right side.

Strength Exercises (10 minutes)

Strength exercises are also important in AS Mx to support joint structures and assist with reducing pain (Nolte et al, 2021). Examples include:

Hip Extension in a Hydrotherapy Pool

• Hip Abduction

Patient stands facing wall and abducts hip outwards before bringing back to centre. This exercise can help strengthen the muscles surrounding the hip and lower back.

• Hip Extension

Patient stands facing wall and slowly extends hip behind them before bringing back again.

• Squats

 Patient faces wall and slowly squats in the water.

• Knee Extension

Patient stands in pool and brings knee up to a 45degree of flexion before extending outwards in front of them and then bringing back to flexion. The resistance from the water allows for greater strengthening of the quadricep muscles.

• Cycling

The patient has their back to the wall and supports their weight through their elbows/hands. Their legs then push through the water in a cycling motion. The resistance of the water helps to strengthen the gluteal, quadricep and hamstring muscles.

Examples of these exercises can be seen in the hydrotherapy video below:

Conclusion

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References

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