Ankylosing Spondylosis

1. MANAGEMENTOFANKYLOSING
SPONDYLITIS
MANSI DEWAN
M.P.T –MUSCULOSKELTAL
ASSISTANT PROFESSOR
I.T.S-IHAS

2. INTRODUCTION
• Ankylosing spondylitis (AS) is a chronic, systemic,
inflammatory, rheumatic disorder of uncertain etiology
primarily affecting the axial skeleton.
• It usually starts in the late teens and early twenties and can
lead to progressive bony fusion of the sacroiliac joints and
the vertebral column; some patients may also show extra-
articular manifestations.
• Included among these accompanying features are
inflammatory bowel disease, acute anterior uveitis (iritis),
and psoriasis. In addition, there is a strong association with
the HLA-B27 antigen and a familial aggregation.
• Ankylosing spondylitis (AS) is generally easy to diagnose
when the characteristic findings of the “bamboo” spine and
fused sacroiliac joints are present on radiographs.

3. Epidemiology
• AS typically affects young adults, most commonly males (M:F = 3:1) in
their second through fourth decades.
• The incidence of AS in North America is reported to be 1 to 2 per 1,000.
Worldwide prevalence is up to 0.9%. Fifteen percent to 20% of patients with
AS have a positive family history of the disease. AS is linked to HLA-B27;
80% to 95% of patients with AS are HLAB27– positive.
• Carriers of this gene have a 16% to 50% increased risk of developing AS,
but other genetic factors are likely involved as well.
• Although both HLAB27–negative and HLA-B27–positive AS patients have
similar articular manifestations, the former usually develop the disease at an
older age and lack a positive family history.
• AS tends to occur at a later age in females than in males, and diagnosis is
often delayed.

4. ETIOLOGY
• Not everyone who is HLA-B27–positive develops AS; it is likely that
other genetic and/or environmental factors play a role in the etiology.
• One recent theory is that AS is an autoimmune disorder that occurs
subsequent to a Klebsiella pneumoniae infection in HLA-B27–positive
individuals. Elevated levels of antibodies to K pneumoniae have been
noted in AS patients.
• Elevated IgA levels in AS patients may reflect mucosal immunity to a
persistent bacterial infection and may be the autoimmune trigger for AS,
idiopathic bowel disease, and other reactive arthritides.
• No causal relationship has been established between AS and other
autoimmune diseases, but the incidence of AS in patients with idiopathic
bowel disease is approximately 3.7%.

5. Pathophysiology
• The pathognomonic feature of AS is a combination of inflammation and
bony destruction at the site of tendon insertion (ie, enthesopathy).
• Pannus or fibroblastoid tissue and inflammatory cell infiltrates invade the
bone adjacent to entheseal attachments; new bone formation in response to
inflammation leads to ankylosis of affected joints.
• Preferential involvement of the zygapophyseal joints has been noted on
MRI.
• Ankylosis and subsequent loss of motion of the zygapophyseal joints leads
to syndesmophyte formation, resulting in the characteristic “bamboo spine”
of individuals with AS.
• Enthesopathy also can occur in peripheral joints, leading to synovitis- like
symptoms and joint degeneration.
• Other manifestations of AS include inflammatory bowel disease, psoriasis,
uveitis/iritis (25%), pulmonary fibrosis, aortitis, and genitourinary
problems, with prevalence up to 40%.

6. Clinical History
• Patients usually present with symptoms and physical findings consistent
with the nonmechanical and inflammatory nature of AS.
• Onset is often insidious; patients typically cannot give the precise time of
onset or even pinpoint the initially affected site.
• These individuals frequently present in the second through fourth decades
of life with low back pain and stiffness, particularly in the morning, at
night, or after prolonged periods of sitting and/or recumbency.
• Chest wall pain is a frequent complaint, particularly with deep inhalation.
• Back pain not relieved by recumbency and the persistent discomfort may
compel the individual to leave the bed at night.
• Patients also may have buttock pain that radiates down the posterior thigh.
Enthesopathy involving the Achilles and plantar tendon insertions with
associated symptoms also is common.
• Some patients experience no pain but present with increasing stiffness in
the hips and spine.
• As with other inflammatory diseases, symptoms often improve with
exercise.

7. CRITERIAFORAS
 Modified New York Criteria,1984
• Low back pain atleast 3 months duration improved by exercise & not relieved
by rest
• Limitation of lumbar spine movement in sagittal & frontal planes
• Chest expansion decreased relative to normal values for age & sex
• Bilateral sacroiliitis grade 2-4
• Unilateral sacroiliitis grade 3-4
 Definite AS if unilateral grade 3 or 4, or bilateral grade 2-4 sacroiliitis & any
clinical criterion
 Rome Clinical Criteria,1961
• LBP & stiffness for more than 3 months, not relieved by rest
• Pain & stiffness in the thoracic region
• Limited motion in the lumbar spine
• Limited chest expansion
• History or evidence of iritis
 Radiological Criterion
• Roentgenogram showing B/L sacroiliac changes characteristic of AS

8.  Definite AS if:-
 Grade 3-4 B/L sacroiliitis with atleast one clinical criterion
 Atleast 4 clinical criteria
 Grading of Radiographs
 Sacro-iliac joints;
Grade 0 Normal
Grade 1 Suspicious changes
Grade 2 Minimal abnormality—small localized areas
with erosion or sclerosis without alterations in joint width
Grade 3 Unequivocal abnormality—moderate or
advanced sacro-iliitis with one or more of the following:
erosions, sclerosis, widening, narrowing or partial ankylosis
Grade 4 Severe abnormality—total ankylosis

9. Clinical Prediction Rule For SI Involvement
• Sacroiliac provocation tests :
• Approximation test (compression test)
• Gapping test (distraction test)
• Sacral thrust test
• Thigh thrust test
• Gaenslen’s test
• Pain on palpation of sacral sulcus medial to PSIS
Note : if 2 of the first 4 tests or
≥3 of the 6 tests are positive, SIJ pathology is present.
{Sn: 94% , Sp: 78%}

10. Approximation test
[sn:69% ; sp: 69%]
Gapping test[sn:60% ; sp: 81%]
Gaenslen’s test[sn:50% ; sp: 77%]
Patrick’ test

11. [sn:88% ; sp: 69%]

12. Physical Examination
• A systematic examination of the entire patient is imperative.
• Ocular pain, scleral redness, and photophobia are often indicative of acute
anterior uveitis and may be clinically apparent before other symptoms or
signs of AS appear.
• Chest expansion measured at the fourth intercostal space typically is limited
to <2.5 cm after fusion of the costovertebral joints; the patient then becomes
an obligate diaphragmatic breather. Total lung volume and vital capacity
usually are preserved; the diaphragm excursion is affected only in the patient
with severe thoracic kyphosis.
• Aortic and mitral regurgitation murmurs can occur as a consequence of
aortitis in patients with long-standing disease.
• Early in the disease, examination of the sacroiliac joints may reveal
tenderness to palpation, which can be exacerbated by hyperextension of the
hips.
• Patients with hip involvement develop hip flexion contractures.

13. • Some patients exhibit loss of lordotic curvature of the lumbar
spine and loss of spine movement in all planes.
• Patients with decreased mobility of the thoracolumbar spine have
an abnormal Schober sign—that is, lack of at least a 5-cm
increase in distance, measured in both the erect standing position
and full forward flexion.
• Late in the disease, the cervical spine can become rigid, with loss
of flexion and extension.
• Chinbrow angle, occiput-to-wall distance, and gaze angle are
used to evaluate functional deformity involving the cervical
spine .
• A slow, progressive cauda equina syndrome may appear late in
the course of the disease.

14.  COMPLICATIONS
• Neurological involvement/cauda equina syndrome
• Spinal fracture
• Spinal cord compression
• Amyloidosis
• Painful heel or achilles tendinitis
• Romanus lesions
• Reduced chest expansion and vital capacity
• Possibility of chest infection

15. Assessment of Deformity
• Correction of deformity most often is performed to improve the
patient’s visual field, respiratory function, balance, sitting
position, swallowing function, or ambulation.
• Determining the site of deformity is critical before surgically
treating the deformity.
• Deformity must be assessed both clinically and radiographically
as part of preoperative planning.
• The chin-brow angle is the angle formed by the vertical line
drawn from the chin to the brow with the patient’s hips and
knees fully extended.
• Occiput-to-wall distance is measured to grossly determine the
patient’s sagittal balance. The horizontal distance from the
occiput to the wall is measured with the patient’s buttocks and
heels against the wall, with hips and knees extended. Clinically,
occiput-to-wall distance should be 0 to 2 cm.

16. • The degree of hip flexion contracture is determined by
placing the patient supine with the lumbar spine pressed flat
to the examining table, then measuring the angle that each
femur makes with the horizontal. Normal sagittal balance
places the center of mass just in front of the S1 vertebral
body.
• Radiographically, a plumb line drawn from the center of the
C7 vertebral body should just touch the anterior edge of the
body of S1 on the lateral radiograph. Normal individuals are
able to compensate for small changes in sagittal balance
through changes in sacral inclination; hip, knee, and ankle
flexion; or extension. In patients with AS, these normal
compensatory changes are ameliorated by loss of motion in
these areas.

19. LABORATORY EVALUATION
The following lab investigations are done:
• Basic metabolic panel,
• Complete blood count,
• Erythrocyte sedimentation rate (ESR),
• C-reactive protein (CRP) level,
• Rheumatoid factor,
• HLA-B27, helpful in the differential diagnosis.

20. The clinician should be suspicious of a diagnosis of AS in
patients who are HLA-B27–negative.
• Active phase:
• Mildly elevated ESR,
• CRP level ( C-reactive test),
• White blood cell count,
• In most cases, rheumatoid factor is negative
• HLA-B27 is positive.
• Chronic AS: Normocytic, Normochromic anemia.

21. IMAGING STUDIES
• The sacroiliac joints usually are the first joints affected in patients with AS.
• Sacroiliitis initially presents as a widening of the sacroiliac joints with
progressive sclerosis of the joint margins, leading to eventual bony fusion
across the joints with subsequent loss of sclerosis.
• Hip involvement presents as ossification of the ligamentous origins and
insertions about the trochanters, iliac crests, and ischial tuberosities.
• Late findings include loss of joint space, sclerosis, and fusion with loss of
sclerosis at the hips.

22. • The ascending osseous changes of the cervical, thoracic, and lumbar spine
lead to the characteristic bamboo spine in advanced stages of the disease.
• Spine lesions in AS are the result of wedging of vertebral bodies and
ossification of disk spaces leading to a rigid kyphotic spine. Enthesopathy of
the zygapophyseal joints leads to fusion of the posterior elements.
• The bone loss and reabsorption that lead to these deformities occur early in
young persons with active disease.
• Erosions at the discovertebral junctions are called Romanus lesions
sclerosis in this region gives rise to so called “shining corners.”
• In AS, the syndesmophytes are bilateral and have their insertions at the
upper and lower margins of adjacent vertebrae.

25. PT MANAGEMENT

26. AIMS OFPT MANAGEMENT
 The overall aims are to minimise deformity and disability and to
improve well-being, thereby maintaining normal function and improving
the person's quality of life. These aims can be achieved by :
1. Advising on postural awareness and ergonomics
2. Reducing pain
3. Maintaining and improving posture and function by (a) increasing
mobility of spinal, costovertebral and peripheral joints, (b)
strengthening the antigravity muscles, and (c) stretching specific
muscle groups
4. Improving and maintaining cardiovascular fitness
5. Monitoring posture, mobility and function through regular
assessment
6. Devising and monitoring a home programme of specific exercises
that are suitable and consistent with long-term compliance
7. Imparting knowledge about the disease and its management
8. Improving the person's psychological state, coping strategies and
exercise compliance
(6)

27. ERGONOMIC CONSIDERATIONS & POSTURAL
CORRECTION
• Ergonomic advice on how to maintain good posture at work, home and
during leisure activities will improve the long-term outcome of the disease.
• If the patient has a job that requires a stooped posture, the advice would be
get up & move around at regular intervals & check the posture regularly.
• Maintain a good posture by walking tall & tucking the chin in.
• For people who spend a lot of time at computer, simple alterations such as
altering the height of the computer screen & chair can make a significant
difference.
• Invest in chairs & car seats that are comfortable & supportive. Ideally any
chair should provide support for the whole spine including the neck. The
hips & knees should be at right angles & the feet should be supported if they
do not touch the floor. Forearms supported on arm rests can relieve tension
in the neck.
(6)

28. MOBILITY EXERCISES (6)

30. STRENGTHENING EXERCISES

32. STRETCHING EXERCISES

34. Diaphragmatic breathing. This move helps you learn what a deep breath
should feel like, Stelmach says. Lie on your back on a flat, firm surface, with
your hands on your stomach. As you breathe in deeply, feel your stomach
expand and push into your hands. Then notice how it deflates as you breathe
out. “This takes some concentration and practice,” she says. “If you can learn to
do this, you’ll have more effective breathing.”
Rib cage expansion. Lie on a flat surface and place your hands at the base of
your rib cage with your fingers on your ribs and thumbs toward the back.
Breathe in deeply and hold for a few seconds, feeling your ribs push into your
hands. Exhale and feel them lower back down. “You can even add some
resistance by pushing down with your fingers and trying to breathe against that
pressure,” Stelmach says.
Standing arm rotation. For this exercise, the National Ankylosing Spondylitis
Society explains that you should stand up straight, with elbows bent and palms
facing up — like you're balancing a tray in front of you. Breathe in and rotate
your arms out to your sides, making sure to keep your elbows close to your
body. Try to imagine that your shoulder blades are coming closer together.
Exhale and rotate your arms back inward.
Pulmonary Exercises (8)

35.  Hydrotherapy (By NASS)
• The buoyancy, resistance and support offered by water, combined with the
warm temperature, allow patients to exercise in a controlled yet effective
way, with a number of benefits:-
• Improved ease of movement, Balance re-education, Increased muscle
strength, Enhanced psychological well-being, Allows exercise during a
flare.
 Effect of aquatic exercise on ankylosing spondylitis: a randomized
controlled trial:-
• This study compared the effectiveness of hydrotherapy with land-based
exercises in the treatment of AS. The land-based exercise programme was
demonstrated by a physiotherapist on one occasion and then, an exercise
manual booklet was given to all patients in this group.
• The hydrotherapy programme consisted of 20 sessions (five times per week
for 4 weeks) in a swimming pool at 32-33 °C.
• Hydrotherapy exercise showed better improvements in: Pain, General
health, Vitality, Social functioning, General mental health

36. Stretching exercises
• forward and backward head stretch
• sideways head stretch,
• chest and shoulders 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, and
• double knee-to-chest stretch.
Done during Warm up and Cool down period.

37. Stretching Exercises (9)
(left) backward head stretch, (right) forward head
stretch.
sideways head stretch
chest and shoulders stretch

38. Deltoid muscle stretch Triceps muscle stretch Overhead stretch
Lateral
trunk
muscle
stretch
Arched back
stretch

39. Leg extensor stretch Spinal twist stretch Double knee-to-chest stretch
Loosen-up stretch: (left) downward, (right) upward. Upper back prayer

40. Aerobic exercises
The prescribed intensity of aerobic exercise training was
calculated for the main period using the Karvonen formula :
220 - patient age = estimated maximum heart rate
(HRMx)
HRMx - mean resting heart rate (MRHR) = (C)

41. The subjects in the exercise group measured their heart rate
(HR) (HR per minute = HR within 15 seconds * 4) during the
exercise programe.
The exercises selected were applied easily to both the warm-up
and main periods of the exercise program by the subjects in the
exercise group:
1. March
2. Tap up-tap down
3. V step
4. Step touch
5. Turn step
6. Grapevine
7. Grapevine with knee up
8. Grapevine with leg curl

42. Balance
 Static balance tests
• Weight bearing squat test: This test revealed percentage of
body weight borne by each foot while standing (knees
extended, 0° flexed) and squatting with 30°, 60°, and 90°
flexed knees. The differences between percentages of body
weight on the right and left foot depicted static balance
impairment.
• Modified clinical tests of sensory interaction on balance:
The subject stood on a firm base with eyes opened and closed.
Then, the test was repeated on a foam base. This was
performed three times. The mean values of sway velocity
(degree/second) and COG alignment (degree) were assessed.
This test indicates whether visual system or proprioception
helped to maintain balance .

43.  Dynamic balance tests
• Walk across test: The subjects walked on a firm base of support as
usual and got off the base of support. This test was repeated three
times. The step length (cm), step width (cm), speed (cm/second),
and step length symmetry (%) were measured.
• Tandem walk test: The subjects performed a tandem walk and
waited at the end of the base of support. This test was repeated
three times. The step width (cm), speed (cm/second), and the end
sway (degree/ second) were assessed.
• Step and quick turn test: The subjects took their left steps first
and then their right steps forward. Then, they turned 180° back
without taking their feet off the base of support. This test was
performed three times for each side; the mean values of turning
time to left and right (second) and turning sway (degree) were
assessed.