Musculoskeletal Lecture 5 PDF

# Ankylosing Spondylitis ## د. علي حسين الحافظ Ankylosing spondylitis (AS) is a chronic inflammatory seronegative arthritis with a predilection for sacroiliac joint & spine. It is characterized by progressive stiffness & fusion of the axial skeleton. Axial spondyloarthritis is another term for the...

# Ankylosing Spondylitis ## د. علي حسين الحافظ Ankylosing spondylitis (AS) is a chronic inflammatory seronegative arthritis with a predilection for sacroiliac joint & spine. It is characterized by progressive stiffness & fusion of the axial skeleton. Axial spondyloarthritis is another term for the disease. ## Epidemiology - The overall prevalence varies from 0.5-1% in most communities but is much greater in Haida Indians (6%). - AS is more common in men with a male: female ratio of 2:1. - The peak onset of the disease in the second & third decades of life but spinal features seldom appear before the age of 16-18 yr. ## Etiology - In spite of dramatic advances in recent years, the etiology of AS remains unclear. - **Genetic**: a strong association between HLA-27& AS. - There is a genetic predisposition, but mode of inheritance is unknown. - **Infection**: subclinical mucosal inflammation of small & large bowel. Klebsiella aernginosa has been implicated on the basis of molecular mimicry with HLA-27. ## Clinical Presentation - The onset is usually insidious with recurring episodes of low back pain sometimes radiating to the buttock or thighs & stiffness and a loss of motion in the back. - It causes characteristic inflammatory back pain, resulting in structural and functional impairments and a reduction in quality of life. - It causes a decreased range of motion of spine and, in its advanced stages, can give the spine an appearance similar to bamboo, hence the alternative name "bamboo spine". - Age of onset less than 45 years. - Duration of more than 3 months. - Morning stiffness lasting greater than 30 minutes. - The pain and stiffness are worse in the early morning & after rest & improved by exercises. - Night pain is frequent symptom and waking up in the second half of the night due to pain, but eases with arising. - Occasionally the onset may be acute resembling a lumbar disc protrusion. - Neck and upper thoracic pain occurs later in life. - A minority of patients present with oligoarthritis that may precede accompany or follow the spinal symptoms. Hips, knees, ankles & MTP joints are commonly affected. - **Constitutional features**: fatigue, sleep disturbance, fever, weight loss, depression & reduced capacity work. - **Enthesitis**: discovertebral, costovertebral, costotransverse joint, bony attachment of interspinous, paravertebral ligaments, plantar fascia, Achilles tendon, tibial tubercles causing pain & stiffness at these sites. - **Osteoporosis** is common in ankylosing spondylitis, related to both systemic inflammation and decreased mobility. Vertebral fracture risk is increased; acute back pain in these patients is not always a flare-up of the disease, as it can be related to bone complications. - **Extra-articular features**: iritis (25%), overt inflammatory bowel disease (10-15%), aortitis, aortic regurgitation, upper lobe fibrosis of lungs, atlanto-axial subluxations causing myelopathy, cauda equine syndrome, secondary amyloidosis. - **Deformities**: cervical kyphosis, dorsal kyphosis, lumbar flattening, hip flexion. ## Investigations - ESR-elevated and CRP. - Rheumatoid factor-negative. - Radiographs & MRI. - HLA typing. ## Medical Management - NSAIDS - Biological therapy - Sometimes DMARDs. ## Physical Therapy Management ### Aims of physiotherapy - Maintain & increase mobility (general& spinal). - Prevention & correction of deformity. - Maintain & improve physical endurance. - Attention to posture. - Increase chest expansion & vital capacity. - Relief of pain. - Decrease morning stiffness. - Improve overall function and quality of life. - Advice to patient. ### Assessment - **BASMI (Bath Ankylosing Spondylitis Metrology Index):** - Lateral lumbar flexion: Patient stands with heels and buttocks touching the wall, knees straight, shoulders back, and hands by the side. The patient is then asked to bend to the right side as far as possible without lifting the left foot/heel or flexing the right knee, and maintaining a straight posture with heels, buttocks, and shoulders against the wall. The distance from the third fingertip to the floor when patient bends to the side, is subtracted from the distance when patient stands upright. The manoeuvre is repeated on the left side. (≥20 cm). - Tragus-to-wall distance: Maintain same starting position as above. Ensure head in as neutral position (anatomical alignment) as possible, chin drawn in as far as possible. Measure distance between tragus of the ear and wall on both sides, using a rigid ruler. Ensure no cervical extension, rotation, flexion or side flexion occurs. (≤10 cm). - Lumbar flexion (modified Schober): With the patient standing upright, place a mark at the lumbosacral junction (at the level of the dimples of Venus on both sides). Further marks are placed 5 cm below and 10 cm above. Measure the distraction of these two marks when the patient bends forward as far as possible, keeping the knees straight. (≥7 cm). - Maximal intermalleolar distance: Patient supine on the floor or a wide plinth, with the legs along the resting surface as far as possible. Patient is asked to separate legs along the resting surface as far as possible. Distance between medial malleoli is measured. (≥120 cm). - Cervical rotation: Patient supine, head in neutral position, forehead horizontal (if necessary head on pillow or foam block to allow this, must be documented for future reassessments). Gravity goniometer placed centrally on the forehead. Patient rotates head as far as possible, keeping shoulders still, ensure no neck flexion or side flexion occurs. (≥85°) - **Others**: - Range of movement of other joints. - Occiput to Wall Distance (Flesche test). - Oswestry Disability Index. - Neck Disability Index (NDI). - Visual Analogue Scale. - Patient Specific Functional Scale. - Chest expansion at 4th intercostal space (<2cm of expansion IN AS). - Vital capacity measured by spirometer (greatest amount of air that can be expired after a maximal inspiration). ### Outlines of physiotherapy: - Patient education. - Extended periods of immobility should be minimized &interrupted with breaks to permit frequent stretching. - Prone positioning for at least one hour daily during active phase for patients with hip joint involvement to prevent deformity. - The patient should be used a firm mattress & a minimal pillow. - Encourage a non-contact sport such as swimming, badminton & squash. - A contact sport should be considered with caution. - Smoking cessation. - Hydrotherapy is useful for general management of AS, both for individual treatment & group therapy. - Splints are contraindicated for prevention of deformity & is best achieved by exercises. - Always be conscious of posture. - Group therapy with following advantages-The support given by members to each other: - Shared problems. - Competitive & motivational aspects. - Improvement in physical endurance. - (Group exercises in hospitals are more effective than a home-based program). ### Exercises - An aggressive approach is essential in AS unlike other rheumatological diseases. - The exercises program is designed to improve or maintains mobility, posture and physical endurance rather than muscle strength as muscle weakness is not a significant feature. - The exercises should be simple, limited in number & such that the patient is encouraged to perform them daily. - Home exercises should be done twice daily. - Home exercises started by warm-up exercises. ### Respiratory functions - Deep breathing exercises. - Discontinue smoking. ### Stretching exercises - Forward and backward head stretch. - Sideway head stretch. - Chest and shoulder stretch. - Deltoid muscle stretch. - Triceps muscle stretch. - Overhead stretch. - Lateral trunk muscle stretch. - Arched back stretch. - Leg extensor and pelvic flexor stretch. - Spinal twist stretch. - Paravertebral muscle stretch. - Loosen-up stretch. - Upper back prayer. - Double knee-to-chest stretch. ### List of group exercises - Supine lying: relaxation, static quadriceps contractions, static gluteal contraction, straight leg raising. - Crook lying: pelvic tilting, diaphragmatic breathing exercises, arm elevation maintaining thoracic spine, neck rotation. - Prone lying: alternate hip & leg extension, bilateral leg extension, arms at side-shoulder retraction, head & shoulders extension, bilateral leg abduction, trunk side flexion, arms extended, head, neck & trunk extension,a medicine ball may be lifted to offer resistance. - Sitting: breathing exercises, posture correction, neck rotation& side flexion, trunk rotation, trunk curl & stretch. - Standing: posture correction, alternate knee & hip flexion to 90° at increasing frequency breathing exercises. ### List of home exercises - Early morning warm-up exercises to facilitate daily activities. The patient assume all-fours position ( kneeling position on the hands & knees in bed with hands directly under shoulders & knees directly under hips), rock back onto heels, rock forward onto shoulders, to increase stretch put hands one side & then draw body & repeat on opposite side, alternating stretch one arm & opposite leg, neck & back extension. It can be repeated 3-5 times. - Gentle ROM of cervical spine: flexion-extension, rotation& lateral flexion (3-5 times). - Back arch by prone position with raising top half of the body by propping up elbows& sink spine, chest & shoulder blades toward floor with straight neck not overextension. - Rotation of thoracic spine is best performed with the patient straddling a chair & twisting to one side & then to another. - Back: side flexion, rotation, extension (standing). - Hips & shoulders exercises. ### Spa-exercises - Spa-exercise and balneotherapy programs have short-term benefits in quality of life outcomes; spa-exercise is superior in pain relief, while balneotherapy further improves disease activity. The balneotherapy interventions consist of mineral baths plus mud packs, radon-carbon dioxine baths, carbon dioxine baths, Dead Sea baths and tap water of 36°C. ### Aerobic exercises - Aerobic exercise to conventional stretching and mobility home exercise programs results in superior functional fitness. Walking and swimming are examples of such aerobic exercise. - **Swimming**: three times a week for six weeks: - 10 min warm-up + 5 min stretching. - 30 min of swimming at a moderate intensity (60-70% heart rate [HR] reserve – 12 beats/minute). - 10 min cooling down + 5 min stretching - **Walking**: 30 minutes, three times a week for six weeks - Walking exercise should be performed at 60-70% heart rate reserve. ### Maximum Heart Rate Formula =206.9 - (0.67 x age) - Moderate exercise intensity: 50% - 69 % of maximum heart rate. - Vigorous exercise intensity: 70% - 85% of maximum heart rate.