Clinical Description with emphasis on Physiotherapy management and case scenario

1. ANKYLOSIS SPONDYLITIS
BY: Dr Krishna Bhatt,
ARIP

3.  Chronic inflammatory disorder of the axial
skeleton affecting the sacroiliac joint and the
spine.
 Other name is Marie-Strumpell Disease
 The hallmark is bilateral sacroilitis
 Seronegative spondyloarthropathies

4. Onset → late adolescent and early adulthood
Males >> Females
Genetic marker → (+) HLA-B27~ 90%
The usual age at onset is between 15 and
25 years.

5. CAUSES :
 A genetically determined immuno-pathological
disorder.
 Various theories are proposed similar to RA and
they are : Antigen – Antibody reactions.

6. PATHOLOGY:

7. PATHOLOGICAL CHANGES
PROCEED IN
THREE STAGES:
 an inflammatory reaction with cell infiltration,
granulation tissue formation and erosion of
adjacent bone
 replacement of the granulation tissue by fibrous
tissue
 ossification of the fibrous tissue, leading to
ankylosis of the joint.

10. CLINICAL MANIFESTATIONS
 Skeletal Involvement
 Insidious onset, back pain or tenderness in the bilateral SI joint.
 Persistent symptoms of at least three months
 Lumbar morning stiffness that improves with exercise
 Lumbar lordosis—decreased and thoracic kyphosis—increased

11.  Enthesitis (An inflammatory process occurring at the site
of insertion of muscle.)
 Tenderness over the ischial tuberosity, greater trochanter,
ASIS, iliac crests.
 Respiratory restriction with limited chest expansion
 Once restrictive lung disease pattern ensues: – Chest
expansion decreases – Patient develops diaphragmatic
breathing – Thoracic spine involvement—costovertebral,
costosternal, manubriosternal, sternoclavicular joints.

12.  Extra skeletal Involvement:
Other complaints include—fatigue, weight
loss, low-grade fever
Acute iritis/iridocyclitis → most common
extra skeletal manifestation of AS
Cardiac – Aortitis leading to fibrosis –
Conduction defects

13. Apical pulmonary fibrosis – May experience
dyspnoea and cough
Amyloidosis
Neurologic
Cauda equina syndrome
C1 to C2 subluxation

14.  Laboratory Findings
(+) HLA-B27
↑ ESR and C-Reactive Protein
Anemia

15.  Radiographic Findings:
SI Joint narrowing—Symmetric, may lead
to fusion
Pseudo-widening of the joint space –
Subchondral bone resorption—blurring –
Erosion sclerosis – Calcification leading to
ankylosis
Bamboo spine
Syndesmophyte formation
Squaring of lumbar vertebrae’s anterior
concavity
 Other Tests • Schober Test

22. TREATMENT
 Education
 Good posture
 Firm mattress, sleep straight—Supine or prone
 Prevent flexion contractures
 Physical Therapy – Spine mobility—Extension
exercises –
 Swimming is ideal
 Pulmonary—Maintain chest expansion – Deep
breathing exercises

23.  Medications
NSAIDs—Indocin :Control pain and
inflammation
Corticosteroids
Modify disease process – Methotrexate
Topical corticosteroid drops—Uveitis

24. PHYSIOTHERAPY TREATMENT
 General exercise programme to maintain the mobility
of the spine as well as other joints.
 Breathing exercises to maintain chest expansion. Deep
breathing exercises can improve or maintain lung
capacity.
 Correction posture
 Pain :- Superficial heating – acute. Deep heating –
chronic.
 Chest mobility exercises

25. SWIMMING:
 Swimming as part of your exercise program helps
to maintain chest expansion and movement of
the spine without jarring the spine. Breast stroke
is especially good for chest expansion.

26. INTERVENTIONS/TEACHING
 Maintaining proper posture and chest
expansion. Good posture is important because
it can help prevent abnormal bending of the
spine.
 Maintaining chest expansion will help prevent
problems such as lung infection (pneumonia).
 It's a good idea to lie on your stomach a few
times each day to keep your spine and hips
extended.
 For sleeping, choose a firm mattress and a
small pillow that supports your neck.

31. SURGERY
 Total joint replacements
 Spinal osteotomy
 Post-operative Physiotherapy
 During immobilisation – ankle toe movements, deep
breathing exercises, upper limb and lower limb movements.
 After removal of immobilisation – graduated mobilisation
from turning to sitting up and standing. Postural guidance
is given.

32. PICTURES

33. CASE SCENARIO
 A 30-year-old male presents to his family doctor with a
six-month history of back pain. Currently, the pain is in
the midline lower back and radiates into the buttock
region bilaterally. He reports it is aggravated by his daily
activities and also awakens him frequently at night.

34.  On direct questioning, he admits to being very stiff
and sore first thing in the morning and somewhat
less after doing his exercises and taking a hot
shower. The patient’s background history is notable
for a similar pain of several months’ duration in his
late teens, which he attributed to his summer job of
landscaping.

35.  He also reports that as a teenager he had plantar
fasciitis for six months, which eventually settled
after the introduction of orthotics. He recalls
stopping some of his sports activities in high school
due to persistent hip pain that subsequently
resolved