Ankylosing Spondylitis Dibyendunarayan Bid Senior LecturerThe Sarvajanik College of Physiotherapy, Rampura, Surat – 395009. firstname.lastname@example.org
Ankylosing Spondylitis is derived from the greek words- words- Ankylos meaning stiffening of a joint Spondylos meaning vertebraSpondylitis refers to inflammation of one or more vertebrae, often resulting in spinal fusion between the vertebrae.A fused spine is often called a “bamboo spine” because of it’s appearance on radiologic examination.
AS occurs in primarily the axial skeleton,although it can manifest in peripheral sitesas well, including the eyes, chest andcardiac areas.Focus usually begins in the hips and lowerback.
EtiologyThe etiology of Ankylosing Spondylitis (AS) isunknown.There is an association with the HumanLeukocyte Antigen-B27(HLA-B27) Antigen-B27(HLA-90-95% of patients with AS also have HLA-B2790- HLA-Within the general population, 7% carry theHLA-HLA-B27 antigenOnly 1% of those carrying HLA-B27 develop AS. HLA-
PrevalenceAS occurs in approximately 0.1 to 0.2% ofthe general populationGenerally Under-recognized, and Under-therefore underreportedMore prevalent than Multiple Sclerosis,Cystic fibrosis, and amyotrophic lateralsclerosis combined
PrevalenceRace: Predominant in Caucasians worldwide High prevalence in some American Indian tribes Appears to be lowest in African Americans
PrevalenceGender: Affects men three times as more often than womenCan present differently in women tends to affect the peripheral joints rather than the axial skeleton Progress less rapidly Cause less dramatic spinal changes
AgeTends to develops in adolescence or youngadulthoodPeak incidence of onset is 15-35 years of age 15-Mean age is 26 years of ageIn 15-20% of pts, disease begins in second 15-decade of lifeIn 10%, onset occurs in pts older than 39 yearsWhen the onset is juvenile, hip and peripheraljoint involvement is more frequent and severethan in adult onset
Mortality/MorbidityLife expectancy remains unchanged forthose who do not develop severecomplicationsMany mild cases are undetectedPatients should be encouraged maintain afull and normal lifestyle
PathophysiologyIt is suspected that cartilage antigens maybe the target for the immune responseIn the early phases of AS, T cells andmacrophages cause erosion of cartilage atdifferent sitesAreas of focus for attack in AS includeentheses, periosteum,entheses, periosteum, fibrous tissues ofthe joint capsule, and cartilage thatsurrounds intervertebral disks.The Hallmark of Ankylosing Spondylitis isbilateral sacroiliitis. sacroiliitis.
PathophysiologyThe basic lesion of AS occurs at theentheses. This is the location in whichbone attaches to ligaments, joint capsulesand tendons.Inflammation develops at these sites,resulting in ossification and calcificationInfiltration by plasma cells and leukocytes,leads to erosion of the bone
This bone erosion most often begins at thesacroiliac joints. It can be noted in the vertebralcolumn on x ray as the vertebra appear to haverounded corners during this breakdown process.These are referred to as Romanus Lesions.
The lesion will then develop as new bonewithin the paravertebral soft tissues.On radiographic examination, thevertebrae appear squared off. Disc fiberseventually become replaced by new bone.
This causes the joint to fuse and flexibility is lost.The bony outgrowth within the vertebral disc isreferred to an a syndesmophyte.Syndesmophytes develop on top on the oldentheses.This results the appearance of the classic“bamboo spine”.
AnatomyInitial site of involvement for classic presentationis the sacroilliac jointThis is often followed by the thoracolumbar andlumbosacral junctionsProgression continues through mid lumbar,upper thoracic, and cervical vertebraeThis is the classic presentation. But the patternof ascent is not always found with AS, especiallyin women.
Peripheral Joint InvolvementOccurs more frequently in chronic diseaseGlenohumeral and knee joints may be affected30% of the timeDiffuse articular disease can occur involvinghands, feet and wrists.Pubic symphysis can have radiographicchangesOther cartilaginous sites affected- affected-manubriosternal,acromioclavicular,andstrenoclavicular
Diagrams for Anatomy review
Peripheral Joint continued….Enthesopathic changes are often seen atsites of ligament and tendon attachment.These include: Ischial tuberosity Iliac crest Trochanters of the femur Inferior calcaneum
Clinical ManifestationsCharacteristic posture of a patient suffering from AS.
Clinical ManifestationsLow back pain, persisting even at rest, andmay improve with activity.Stiffness, especially in the morningForward flexion, rotation, and lateralflexion are painfulEarly Pain is due to inflammation ratherthan bony fusion.
Clinical Manifestations Con’t……….With disease progression, lumbar lordosisis diminished Kyphosis increasesPatient becomes “stooped”Thoracic spine become roundedHead and neck become held forward onthe shouldersHips are flexed
Chest pain and limited chest expansioncan develop due to inflammation of thetendon insertions at the costosternal andCostovertebral anglesThe patient must practice diaphragmaticbreathingPressure placed on the anterior chest wallmay cause tendernessImportant to discourage smoking due tolimited chest expansion and lung capacity.
Tenderness also may develop over ischialtuberosities and in the heelsThis can make sitting in hard seats orgoing for walks unbearablePatient may develop a limpUveitis(inflammation of the middle layer ofthe eye) affects approximately 20% ofpatients
Other Complications to watch out for:Cardiovascular-Cardiovascular- Including aortic incompetencesecondary to aortitis,conduction defects,cardiomyopathy and pericarditisRespiratory-Respiratory- restrictive ventilatory pattern as aresult of limited chest expansionNeurologic-Neurologic- Rare. Can include radiculitis fromnerves running over the sacroiliac joints, andspinal cord damage in late disease due totramautic fractures of the ankylosed spine.
Complications, Con’t…Amyloidosis - the deposition of amyloids (aglycoprotein) in various areas of the body,impairing function of specific organs, suchas the kidneys.Achilles TendonitisInflammatory bowel disorders
LabsESR-ESR- erythrocyte sedimentation rate will beindicative of inflammation. It will be elevated inthe acute phase of the disease.CBC-CBC- Mild leukocytosis can occur, and at timesa normocytic, normochromic anemia candevelop.Rheumatoid factors- will be negative factors-HLA-B27-HLA-B27- This test may be positive but cannotbe used to diagnose AS since a smallpercentage of patients with positive HLA-B27 HLA-actually develop Ankylosing Spondylitis
Diagnosis of ASFor an individual to be diagnosed ashaving AS, s/h e must have the following: Sacroiliitis on X-ray or MRI X- Limited movement of the lower back in frontal and sagittal planes Inflammatory back pain for more than 3 months, improved by exercise and unrelieved by rest Morning stiffness in the back lasting in excess of one hour Restricted chest expansion
Diagnostic CriteriaSpecific criteria have been developed atrheumatic disease conferences in Romeand New YorkBoth sets of criteria list Sacroillitis as thehallmark of Ankylosing Spondylitis.
Rome Criteria(1963)AS is present if bilateral sacroiliitis is associated with any single following criterion: Low Back pain and Stiffness for more than 3 months Pain and stiffness in the thoracic region Limited motion in the lumbar region Limited chest expansion History of evidence of iritis and it’s sequelae
New York Criteria(1968)Definite AS is present if grade 3-4 bilateral 3- sacroillitis is associated with one criterion, or if grade 3-4 unilateral or grade 2 3- bilateral sacroillitis is associated with clinical criterion 1 or with both clinical criteria 2 and 3.Probable AS is present if grade 3-4 bilateral 3- sacroillitis is associated with none of the criteria.
New York Criteria con’t….1. Limitation of motion of the lumbar spine in anterior flexion, lateral flexion, and extension.2. History of pain or the presence of pain at the thoracolumbar junction or in the lumbar spine.3. Limitation of chest expansion to 1 inch or less.
ImagingRadiographs are a definitive method ofdiagnosis with AS. Calcification,ossifications, and bony changes can all beobserved through X ray.CT is useful in evaluating sacroillitis, but itis not ideal for imaging of large portions ofthe spine due to high doses of radiation.MRI is useful in observing early cartilagechanges as well as bone marrow edema.
Differential DiagnosesGout-Gout-presents with either elevated urate level ortophi in addition to arthritic sx.Psoriatic Arthritis- form of arthritis associated Arthritis-with psoriatic lesions of the skin and nails.Rheumatoid Arthritis- Can present similarly, but Arthritis-RA has both rheumatoid factor andpannus(granulation tissue)present when ASdoes not.Spondylodiskitis-Spondylodiskitis- Inflammation of the vertebraldiscs.
Pharmacological ManagementNSAIDS and COX-2 inhibitors - help COX-control pain and stiffness within 48 hours,first line treatmentDMARDs - Disease modifyingantirheumatic drugs (methotrexate andsulfasalazine) have been shown to havelittle or no effect on AS. Recommendedonly for those with peripheral arthritis.
Pharmacological ManagementAnti-Anti-TNF medication (Enbrel, Remicade)- Remicade)-traditionally used to treat lymphoma. Usedfor severe cases of AS, especially thosewith functional impairment. Given as IVinfusions by rheumatologist or as selfinjected medications. Most serious sideeffect is increased infections, especiallyTB.
Anti TNF con’t…In a study by Crussen(2007), it was found thatalthough Anti-TNF therapy is new for AS, it was Anti-utilized by over 40% of patients in a Belgianrheumatology practice.Although Anti-TNF has recently been approved Anti-by the FDA for treatment of AS, one factor thathas been observed is neutropenia. It is a wellknown side effect of Anti-TNF and must be Anti-monitored continually, prior to and aftertreatments.
Non- Non-Pharmacological TherapySurgery is not a course of treatment used veryoften with AS, and is only considered in extremecases.Exercise is the cornerstone of a goodankylosing spondylitis program.Exercise at a time of day that is convenient- the convenient-point in the day when stiffness and pain is theleast.Physical Therapy can guide and encourage thepatient to learn proper exercises and strengthenpostureEncourage the patient to split up the exerciseperiods if necessary.
PostureGood posture habits are essentialIf spinal fusion occurs, it is easier to function in afused upright position- but fusion does not occur position-with everyoneEncourage patients to “Think Tall”“Back against the wall” exercises can be helpfulProne lying for 20 minutes is the best exercise tomaintain postureCan enlist the help of a “posture buddy”.Someone who has permission to nag, remindspatient to sit up straight.
Diet and NutritionSome foods may trigger symptomsEncourage patients to keep a food diary ifthis is the caseEncourage high calcium intake tostrengthen bonesMaintain a healthy weight - extra weightcan put stress on joints
Alternative TreatmentsAcupuncture-Acupuncture-stimulation of specific pressurepoints can relieve pain in some peopleChiropractic treatment - Not recommended. TheSpondylitis Association of America(2007)statesthat chiropractic treatments have inadvertentlylead to spinal fractures and neurologcalcomplications
Alternative TherapiesMassage-Massage- can be beneficial for stressrelief and pain reduction. Providestemporary relief of pain and stiffness, whileimproving circulation.Yoga Therapy - Can be a great form ofexercise, assisting to strengthen andstretch muscles, while relieving pain andstiffness.
ImplicationsImplications for practice include- include- Working closely with a rheumatologist, especially if the treatment requires Anti- Anti- TNF therapy. Checking for TB prior to tx with anti-TNFs, anti- and monitoring for neutropenia over course of treatment.
ImplicationsNot only focusing on the pt’s symptoms, but howthis disease is affecting their life as a whole. Canthey perform ADLs? Are they depressed?A study by Cakar et al.(2007) found that ASaffected many patients’ sexual functioning. Notonly did male patients have sexual dysfunction,but females as well, due to the pain of AS. Theyfeared many things, including pain, being hurt,as well as sexual insufficiency.
ImplicationsThe Physio must provide proper education,including education on meds, diet, and posture.Letting the patient know where they may go tofor support is another implication of practice. TheSpondylitis Association of America providesseveral patient resources, including books andsupport groups.
Aims of Physiotherapy ManagementReduction of painAdvice on postural awareness & ergonomicsImprovement & maintenance of posture andfunctionImprovement & maintenance ofCardiovascular fitnessMonitoring posture, mobility & functionthrough regular assessmentProviding information about the dz and itsmgt.
Bath IndicesThe Bath Ankylosing Spondylitis MetrologyIndex (BASMI)The Bath Ankylosing SpondylitisFunctional Index (BASFI)The Bath Ankylosing Spondylitis DiseaseActivity Index (BASDAI)
Clinical Features of ASSkeletal Axial arthritis (eg, sacroiliitis and spondylitis) Arthritis of ‘girdle joints’ (hips and shoulders) Peripheral arthritis uncommon Others: enthesitis, osteoporosis, vertebral, fractures, spondylodiscitis, pseudoarthrosisExtraskeletal Acute anterior uveitis Cardiovascular involvement Pulmonary involvement Cauda equina syndrome Enteric mucosal lesions Amyloidosis, miscellaneous
Modified New York Criteria for the Diagnosis of ASClinical Criteria • Radiologic Criteria Low back pain, > 3 – Sacroiliitis grade ≥ 2 bilaterally or grade 3 – 4 months, improved unilaterally by exercise, not • Grading relieved by rest – Definite AS if radiologic Limitation of criterion present plus at lumbar spine least one clinical criteria motion, sagittal – Probable AS if: and frontal planes • Three clinical criterion Limitation of chest • Radiologic criterion expansion relative present, but no signs or to normal values symptoms satisfy clinical criteria for age and sex
AssessmentThe five measures are: • cervical rotation • tragus to wall distance (Fig. 7.14) • lateral flexion • modified Schobers test of lumbar flexion • intermalleolar distance.
Disease Activity Assessment Index Metric BASFI Disability level BASDAI Disease activity level ASAS - Composite sum of disease IC activityBASFI = Bath Ankylosing Spondylitis Functional IndexBASDAI = Bath Ankylosing Spondylitis Disease Activity IndexASAS - IC = ASsessment in Ankylosing Spondylitis Improvement Criteria
Bath Ankylosing Spondylitis Functional Index (BASFI)Visual analog scale (VAS) – 10 cmMean score of 10 questionsQuestions level of functional disability,including: Ability to bend at the waist and perform tasks Looking over your shoulder without turning your body Standing unsupported for 10 minutes without discomfort Rising from a seated position without the use of an aid Exercising and performing strenuous activity Performing daily activities of living Climbing 12 to 15 steps without aid
Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)A self-administered instrument (using 10-cmhorizontal visual analog scales) that comprises6 questions:Over the last one week, how would youdescribe the overall level of: Fatigue/tiredness AS spinal (back, neck) or hip pain Pain/swelling in joints other than above Level of discomfort from tender areas Morning stiffness from the time you awake How long does morning stiffness last?
Assessment in Ankylosing Spondylitis (ASAS)ASAS 20: An improvement of > 20% and absoluteimprovement of > 10 units on a 0–100 scale in > 3 of thefollowing 4 domains: Patient global assessment (by VAS global assessment) Pain assessment (the average of VAS total and nocturnal pain scores) Function (represented by BASFI) Inflammation (the average of the BASDAI’s last two VAS concerning morning stiffness intensity and duration)Absence of deterioration in the potential remaining domain (deterioration is defined as > 20% worsening)
ManagementThe main approaches to management ofpatients with AS include: • • Patient education • • Family education • • Genetic counselling • • Pain relief • • Physiotherapy • • Occupational therapy • • Possible surgery