Topic: Ankylosing Spondylitis Ideal for: BPT, BOT Students Level: Beginner

1. ANKYLOSING SPONDYLITIS

2. AS is a chronic disease
characterised by a progressive
inflammatory stiffening of the
joints, with a predilection for
the joints of the axial skeleton,
especially the SI joint.

3. • Not known exactly.
• Co-relation has been found between a genetic marker- HLA-B27 and
the disease.

4. SI JOINTS
Spine from
the
lumbar
regions
upwards.
The hip
The knee
The
manubrio-
sternal
joints
JOINTS GETTING
INVOLVED…..

6. • M:F=10:1
• CLASSIC PRESENTATION
15-30 yr old male
Gradual onset of pain
Stiffness of lower back only after rest
Pain worst at night or in early morning
Pain and stiffness relieved after movement
Pain- pubic symphysis, manubrium sterni and costo-sternal joints
Deformity- kyphotic spine and hip deformity

7. • UNUSUAL PRESENTATION
Involvement of peripheral joints
Smaller joints are rarely involved
Chronic inflammatory bowel disease

8. • Patient walks with stiff and straight spine
• Diffuse kyphosis
• May be loss of lumbar lordosis
• Lumbar spine flexion may be limited

9. TESTS
Tenderness
• PSIS or deep gluteal region
SI
Compression
• Direct side to side compression of the pelvis may cause pain at SI joints
Gaenslen’s
Test-
• The hip and knee of the opposite side of the body are flexed to fix the pelvis, and the hip joint of
the side under test is hyperextended over the edge of the table. Pain will occur.
SLR test
• The patient is asked to lift the leg up with the knee extended. This will cause pain at the affected
SI joint
Pump-
Handle Test-
• With the patient lying supine, the examiner flexes his hip and knee completely, and forces the
affected knee across the chest so as to bring it close to the opposite shoulder. Pain at affected
side.

10. CERVICAL
SPINE
FLE’CHE TEST
The patient stands with his heel
and back against the wall and
tries to touch the wall with the
back of his head without raising
the chin. The inability to touch
the head to the wall suggests
cervical spine involvement.
THORACIC
SPINE
CHEST EXPANSION TEST
Maximum chest expansion, from
full expiration to full inspiration
is measured at the level of
nipples. A chest expansion less
than 5 cm indicates the
involvement of the costo-
vertebral joints.

11. Extra- articular
Ocular
Acute iritis,
scarring and
depigmentatio
n of iris
CVS
aortic
incompetence,
cardiomegaly,
conduction
defects,
pericarditis
Neurologica
l
Spontaneous
dislocation and
subluxation of
the atlanto-axial
joints, fractures
of cervical spine
with trivial
trauma, signs of
SC compression
Pulmonary
Painless
restriction of
the thoracic
cage, bilateral
apical lobe
fibrosis with
cavitation
Systemic
generalised
osteoporosis,
amyloidosis.

12. • RADIOLOGICAL
Oblique view of SI Joints:-
Haziness of the SI Joints
Irregular subchondral erosions in SI Joints
Sclerosis of the articulating surfaces of SI Joints
Widening of the SI joint space
Bony ankylosis of the SI joints
Calcification of the SI ligaments sacro-tuberous ligaments
Enthesopathy

13. Lumbar spine
Squaring of vertebrae
Loss of lumbar lordosis
Bridging ‘osteophytes’ ( syndesmophytes)
Bamboo-spine appearance
• ESR: elevated
• Hb : mild anaemia
• HLA B27 - positive

15. PHYSIOTHERAPY
OPEREATIVE
CONSERVATIVE

16. • CONSERVATIVE : NSAIDS are given for pain
relief and morning stiffness , radiotherapy and yoga
therapy is also given.
• OPERATIVE : It is done for correction of kyphotic
deformity by spinal osteotomy. For hip and knee,
joint replacements are done.

18. AIMS OF PHYSIOTHERAPY
• To minimise deformity
• To minimise disability
• To improve well-being
• To reduce pain and stiffness

19. • Advising on postural awareness and ergonomics
• Reducing pain
• Maintenance and improving posture by
• Increasing mobility of spinal, costovertebral and peripheral joints
• Strengthening of anti-gravity muscles
• Stretching specific muscle groups
• Improving and maintaining CVS fitness

20. • Monitoring posture, mobility and function through
regular assessment
• Devising and monitoring a home programme of
specific exercises that are suitable and consistent
with long-term compliance
• Imparting knowledge about the disease and its
management
• Improving the person’s psychological state, coping
strategies and exercise compliance

21. • Hyperextension of upper cervical spine
• Flexion of lower cervical spine
• Increased thoracic kyphosis
• Flattened lumbar lordosis
• Knee flexion and hip flexion deformity so that the person can shift the
line of gravity back within the base to become more stable.

22. • Maintenance of good posture at work, home and during leisure
activities will improve the long-term outcome of the disease.
• If a patient has a job that requires a stooped posture- advice him to
get up and move around at regular intervals
• Ask the patient to walk tall and tucking the chin in
• Posture can be checked in a mirror
• Chair should provide support for the whole spine including the neck.
Hip and knees should be at right angles and feet supported.

23. AIM INTERVENTION DOSIMETRY RATIONALE
To reduce pain 1.US therapy
2. TENS
4.Heat therapy via hot
pack or hot shower
1 MHz for 7 minutes
For acute condition-
pulsed
Chronic- continuous
Localised application
Conventional tens
15-20 minutes
Deep penetrating waves,
loosen stiff connective
tissue, increase
extensibility of the tissue
Pain Gate Mechanism
It increases superficial
circulation which drains
noxious substances
To increase ROM 1. Active assisted
exercise ( Flexion,
extension, lateral
flexion and rotation
of spine )
2. Stretching- SCM and
trapezius, shoulder
adductors, Hams and
gastro
3. Spinal mobilization
Contract relax
20 repetitions
3 times a day
Wand bar can be used
Regular muscle
contraction in available
range helps to maintain
ROM
Mobilization prevent
adhesion formation in
joint space.

24. AIM INTERVENTION DOSIMETRY RATIONALE
To improve muscle
strength
Strengthening
exercise of anti-
gravity muscles and
abdominals, lumbar
side flexors and
thoracic rotators
10 repetitions
3 times a day
Can be made
harder by extending
the lever arm using
gravity as resistance
Muscle weakness
owing to postural
deformity and
inactivity and
associated pain can
be overcome by
strengthening
To maintain posture Stretching exercise
Strengthening
exercise
To improve activity
tolerance
Rowing machine,
static bike,
swimming,
aerobics, cycling,
walking
30 minutes To improve
cardiovascular
activity and
increase endurance
To improve
respiratory system
CVS fitness
exercises

27. • Effective way of treating AS
• Warmth of water relieve pain and muscle spasm
• Provides relaxation
• Dry-land exercises are most effective after hydrotherapy
• Buoyancy also helps in movement
• Enjoyable and can improve morale
• Floatation can also be used
• To increase resistance, lever arm can be lengthened

28. • A forty minute hydrotherapy session may include:-
• A warming up with some cardiovascular content
• Mobilising exercises against the side of the pool
• Fun and games
• Strenghtening exercises in supine and prone
• Trunk and leg stretches
• A cooling down with neck exercises, breathing
exercises and relaxation.