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

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Original Editors - Harrison Chipchase, Lucy Thomas, Wilson Gay

Top Contributors - Wilson Gay, Angeliki Chorti, Harrison Chipchase, Lucy Olivia Thomas, Khloud Shreif, Nico Pennant, 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.

Clinical Relevance & Relevant Anatomy

Pathophysiology of AS and how it cause various signs and symptoms

Hydrotherapy - Joe

include more variations of aquatic/hydrotherapy

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

Benefits of hydrotherapy:

stiffness, pain, risk of developing a stooped posture and fatigue are all issues associated with AS.  

Hydrotherapy can be beneficial as:

• The warmth and the buoyancy make 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  

(National axial spondylitis association)  

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.  

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. The study found that both groups showed significant improvements in their symptoms. However, improvement in VAS score, bodily pain, general health and social functioning were greater in the aquatic exercise group.  

explain how hydrotherapy help as compared to land-based

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 (Harry)

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 (5-10 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

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

Conclusion

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References

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