Ankylosing spondylosis and physiotherapy- Dr Gurjant Singh (PT)

Ankylosing Spondylitis
(Marie-Strumpell disease)
Presented by:-
Dr Gurjant Singh (PT)
Assistant Professor, MMIPR

“Ankylos” – Bend or Fusion
“Spondylos” – Vertebral Disc
“Itis” – Inflammation
 Inflammatory disease of the spine that causes
stiffening of the back.
Dr Gurjant Singh, Assistant
Professor, MMIPR

What is Ankylosing Spondylitis ?
 It is a chronic painful rheumatic disease that involves
the back i.e. spine and the sacroiliac joints.
 It typically begins at the age of adolescence and
rarely seen after the age of 45 yrs.
 It is seronegative HLA-B27 spondyloartropathy
Professor, MMIPR

Prevalence & Incidence
 Prevalence : from 67.7/100000 to 197/100000
 Incidence : 7.3 per 100,000 persons
 More common in males
 Familial predominance
Professor, MMIPR

Etiology
 Age: - Onset is commonest between 15 to 45 years of
age, rarely seen after 45 years
 Sex: - Male : Female is 3:1
 Incidence: - 0.6% of adult males are affected
 Heredity: - The disease occurs 30 times more
commonly in relatives of patients than general
population
 Tissue type: - 95% of patients with AS are HLA-B27
positive.
Professor, MMIPR

Pathology
Sacroiliac joint synovitis
↓
Enthesitis
↓
Further calcification and ossification
↓
Formation of bony ridges
↓
Syndesmophytes
↓
Bamboo Spine

Enthesitis
Calcaneal Spur (plantar fascia)
Erosion (Achilles
tendon)
Professor, MMIPR

Clinical Features
 Onset – Insidious
 Morning stiffness – Common in early stages
 Fatigue – This is a common feature in AS
 Spinal features –
 Pain and stiffness in the lumbar spine
 Pain radiating down the back of leg
 Lumbar paravertebral muscles spasm
 Flattening of lumbar spine
 loss of movement and limited SLR

 Thoracic features –
 Diminished costovertebral and manubriosternal
movements result in the loss of thoracic
expansion.
 Patient becomes dependent on diaphragm for
respiration and there is reduction of vital
capacity
Professor, MMIPR

 Deformity – The common deformities are as
follows: -
 Hyperextension of upper cervical spine
 Flexion of lower cervical spine
 Increased thoracic kyphosis
 Flattened lumbar lordosis
 Hip flexion deformity
 Knee flexion deformity
 Peripheral joints – At later stages pain may
develop in: -
 Shoulders
 Hips
 Knees Dr Gurjant Singh, Assistant
Professor, MMIPR

Criteria of Ankylosing Spondylitis
 Low back pain of at least 3 months,duration improved by
exercise, not relieved by rest
 Morning stiffness
 Limitation of lumbar spine in sagittal and frontal planes
 Reduced chest expansion
 Unilateral or Bilateral sacroiliitis
Professor, MMIPR

Physical Examination
 Evidence of sacroiliitis – Faber’s test
 Expansion of the lumbar spine –Schober test
 Chest expansion < below 5 cm
 Enthesitis
 Posture –forward sloop of the neck, stiffness of the spine,
loss of lumbar lordosis, thoracic kyphosis
Professor, MMIPR

Anthropometric Measurement
 According to Bath Ankylosing Spondylitis Metrology Index
(BASMI) commonly used five measurement are as follows: -
 Tragus to wall
 Modified Schober’s test
 Cervical rotation
 Lumbar side-flexion
 Intermalleolar distance (hip abduction)
Professor, MMIPR

Tragus to wall: -
 Starting position: -
The patient stands with bare
feet together and shoulders,
hip and heels as close to the
wall as possible. The chin is
tucked in as far as possible.
 Method: -
The distance is measured both
sides with a rigid rule. The
average of the two
measurements is recorded.
Normal= below 10cm

Schober’s test (modified)
This measures the amount of
lumbar spine flexion.The
patient stands bare feet.
 Method : -
Draw a line at L4-L5 junction.
Mark 10 cms above and 5
cms below the line. The
patient bends forward. Take
the measurement between
two points. Any increase
beyond 15 cms is the lumbar
flexion.
Professor, MMIPR

Cervical rotation
The patient lies supine with head at the end of
the plinth and chin tucked in. Ensure shoulders
do not move and the head is not tilted back.
 Method: -
Place the goniometer lightly on the head. The
patient rotates his/her head.
Repeat on other side.
Professor, MMIPR

Lumbar side-flexion: -
The patient stands as straight as possible with bare feet
and back against the wall. The feet are a standardized
distance apart. Keep knees straight and heels on the
floor.
 Method: -
Place a long ruler at the outer edge of left foot. The
patient reaches down the ruler to left with fingers
straight keeping shoulders against the wall. Measure the
middle finger tip to floor.
Above 18cm is normal
Repeat on other side.
Professor, MMIPR

Intermalleolar distance: -
The patient lies supine on the floor with legs
apart, knees in extension and feet turned out.
 Method : -
Measure between the medial malleoli.
Professor, MMIPR

Extra skeletal manifestations
 Acute anterior uveitis
 Cardiovascular disease
 Pulmonary disease
 Neurological involvement
 Renal involvement
Professor, MMIPR

Uveitis
 Anterior
 Acute and unilateral
 Red and painful eye
 Photophobia, lacrimation
 Attacks usually subside in 4-8 weeks
 More common in HLA-B27 positive
Professor, MMIPR

Cardiovascular
 May be clinically silent although clinically important
 Aortitis
 Aortic valve incompetence
 Conduction abnormalities
 Cardiomegaly
 Pericarditis
Professor, MMIPR

Aortic Insufficiency
Professor, MMIPR

Pulmonary disease
 Progressive fibrosis of the upper lobes
 Eventual secondary colonization with aspergillus
 Impaired pulmonary ventilation due to
involvement of thoracic joints
 Restrictive lung disease
Professor, MMIPR

Neurologic involvement
 Fracture, instability or compression of vertebrae
 Ossification of the posterior longitudinal
ligament resulting in compressive myelopathy
 Cauda equina syndrome: lumbosacral roots,
pain, sensory loss, urinary & bowel symptoms
Professor, MMIPR

Renal Involvement
 Immunoglobulin A (IgA) nephropathy
 Secondary amyloidosis
 High incidence of prostatitis
Professor, MMIPR

Aims of Physiotherapy for AS patients
 Pain relief
 Reducing stiffness
 Increase of spinal mobility
 Increase of chest expansion
 Maintaining good posture
 Maintain / improve physical function
 Maintain / improve well-being
Professor, MMIPR

Types of Physiotherapy
 Mainly two types of physiotherapy are
given:-
 Individual Therapy
 Group Therapy
Professor, MMIPR

Individual Physiotherapy
 Exercises
 Hydrotherapy
 Aerobics
 Education & instruction
Professor, MMIPR

Treatment
 Regular physiotherapy is very essential in the management of
an AS patient. This helps in moulding the fibrous tissue along
the line of stress, which is continuously formed due to
inflammation. It thus helps in preventing restriction of patient’s
movement.
 Relief of pain and muscle spasm may be obtained by local
application of hot packs
 Muscle spasm that persist after the acute inflammation has died
down is treated best by hold relax technique.
 Relief of pain and muscle spasm together with restoration of
mobility is readily obtained by hydrotherapy
Professor, MMIPR

Hydrotherapy
Float lying: -
 Relaxation practice.
 Arms and legs pushing down into the water and resting.
 Arms stretching sideways and upwards.
Prone lying grasping rail: -
 Breast stroke action of the leg
Lying on half-stretcher: -
 Leg pushing down
 Leg pushing down and out
 Deep breathing exercises
Sitting: -
 Turning trunk side to side, progress by holding arms forward and
grasping.
Swimming:-
 Gradual progression to underwater swimming.

Positional Exercises
Lying: -
 Physiological relaxation
 Practice feeling a position of a straight extended spine.
 Push arms and legs into the floor (static contractions for
quadriceps, glutei and back extensors)
Prone lying: -
 Alternate straight leg raising and lowering.
 Both legs raising and lowering.
 Hands clasped behind back, thrust hands towards feet with
head and shoulders raising and relaxing.
 Place hands on floor, raise head and shoulders, walk hands to
right and then left (side flexion in extension).
Professor, MMIPR

Lying with knees bent (crook lying): -
 Knees rolling from side to side.
 Raise right arm upwards and outwards, turn head to
watch hand. Repeat to left.
 Deep breathing exercises with hands over upper
abdomen, feel air fill under the hands and then sigh
out feeling the hands sink down to encourage full use
of the diaphragm.
 Pelvic tilting forwards and backwards (The ROM is
greater if the pelvis is on a small block).
Professor, MMIPR

Sitting: -
 Stretch hand and neck upwards, posture correction.
 Hands on shoulders, trunk turning from side to side.
 Hands clasp, bend and twist to touch the right foot stretch
upwards and backwards to the left watching hands. Repeat to
opposite side.
 Head and neck turning from side to side.
Standing: -
 Hands on shoulders – trunk turning from side to side.
 Deep breathing
 Trunk bending from side to side.
Professor, MMIPR

Mobility Exercises
 Lumbar flexion – extension
 Lumbar side – flexion
 Thoracic rotation
 Thoracic extension
Professor, MMIPR

Strengthening Exercises
 Thoracic spine extensors
 Lumbar spine extensors (glutei)
Dr Gurjant Singh, Assistant Professor, MMIPR

Strengthening exercises – thoracic spine extensors

Strengthening exercises – lumbar spine extensors/glutei

Stretching Exercises
 Neck rotators
 Neck side – flexors
 Hamstrings
 Hip adductors
 Hip flexors
 Calf muscles
Professor, MMIPR

Group Physiotherapy should
comprise of:
 Exercises given previously
 Overhead ball throwing to partner
 Prone lying (over gymnastic ball supported on
hands) stretch leg upwards and backwards.
 Stride standing, pass ball to partner with trunk
turning.
Professor, MMIPR

Sports to be encouraged
 Swimming
 Basketball
Professor, MMIPR

Advantages of Group Therapy
 Patients offer mutual support
 Competition provides enjoyment at the same
time promotes physical fitness.
 A forum is available for educational lectures on
research, diet and cardiovascular fitness.
Professor, MMIPR

Professor, MMIPR

Ankylosing spondylosis and physiotherapy- Dr Gurjant Singh (PT)

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