Ankylosing spondylitis

What is the disease which improve pain & stiffness
with exercise & worsen with rest… ???
Dr. P. Ratan Khuman (PT)
M.P.T., (Orthopedic & Sports)
ANKYLOSING SPONDYLITIS

What are synonyms?
 Ankylosing Spondylitis
 Ankylosing Polyarthritis
 Atrophic Ligamentous Spondylitis
 Atrophic Spondylitis
 Bamboo Spine
 Fibrosis Ankylopoietica Dorsi
 Infectious Spondylitis
 Juvenile-adolescent Spondylitis
 Ossifying Ligamentous Spondylitis
 Pelvospondylitis Ossificans
 Rheumatismal Ossifying
Pelvospondylitis
 Poker Back
 Rheumatoid Spondylitis
 Rhizomelic Spondylosis
 Spondylitis Adolescens
 Spondylitis Ankyloarthritica
 Spondylitis Ankylopoëtica
 Spondylitis Ankylosans
 Spondylitis Atrophica Ligamentosa
 Spondylitis Deformans
 Spondylitis Ossificans
Ligamentosa12 December 2020
2
Ratankhuman (M.P.T., Ortho & Sports)

Contents
 Definition
 Serostatus
 Introduction
 Aetiology
 Pathology
 Clinical feature
 Radiological features
 Diagnosis & special test
 Lab test
 Differential diagnosis
 Prognosis
 Management
 Pharmacological
 Physical therapy
 Well known people
 References
12 December 2020
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Definition
 It is a seronegative, progressive inflammatory
disease presenting with pain & stiffness of
spine leading to bony ankylosis of the
sacroiliac & spinal joints. (Tidy’s, 12th ed, 1991)
 It is an inflammatory systemic disease
predominantly affecting the axial skeleton in
genetically predisposed individuals. (Carol
David, 1999)
12 December 2020Ratankhuman (M.P.T., Ortho & Sports)
4

Serostatus
 It is a term used to refer to presence or absence of
specific substances in blood serum.
 Test is looking for specific antibodies in an effort to
diagnose a particular disease.
 A person's test results can be –
 Sero-positive
 Sero-negative
 Indeterminate.
5

Seronegative spondylarthropathy
 It is a group of diseases involving the axial skeleton &
having a negative serostatus.
 "Seronegative" refers to the fact that these diseases are
negative for rheumatoid factor, indicating a different
pathophysiological mechanism of disease than what is
commonly seen in RA.
6

Conditions typically included within of
Seronegative Spondylarthropathies
Condition
% of people with
condition who are HLA-
B27 positive
Ankylosing Spondylitis
o Caucasians: 92%
o African-Americans:50%
Reactive arthritis (Reiter's syndrome) 60-80%
Enteropathic spondylitis or spondylitis
associated with inflammatory bowel &
ulcerative colitis (including Crohn’s disease)
60%
Psoriatic arthritis 60%
Isolated acute anterior uveitis 50%
Undifferentiated spondyloarthropathy 20-25%
12 December 2020Ratankhuman (M.P.T., Ortho & Sports)7

Common Characteristics
 They are in relation to HLA-B27
 Inflammatory arthritis, generally sacroiliitis & spondylitis
 Oligoarthritis, generally with asymmetrical presentation
 Enthesitis (inflammation of the sites where tendons or lig insert
into the bone.)
 Familial aggregation occurs
 Rheumatoid factor is not present
 Extra-articular features, such as involvement of eyes, skin &
genitourinary tract
 Overlap is likely between several of causative conditions12 December 2020Ratankhuman (M.P.T., Ortho & Sports)
8

Introduction
 Ankylosis spondylitis (AS) - Greek word
 Ankylos = Bent = Stiffening = fusion.
 When the joint loses its mobility & becomes stiff/fuse it is
said to be Ankylosed.
 Spondylitis = inflammation of the spinal vertebrae
Spondylos = Vertebra
Itis = Inflammation
Describes as inflammation of the spine
which can lead to fusion of the bone.
9

 AS is 1st reported in medical literature by
“Bernard O’Connor”, an Irish Physician in
1666 – 1698
10

Etiology
 Age – adolescence & young adulthood, common between 15 to
40 years
 Gender – Male > Female [3:1]
 Incidence – 0.6% of adult male are affected
 Heredity – occurs 30 time more in relative of patients than
general population
 Tissue types – 95% of patient with AS are Human Leucocyte
Antigen (HLA-B27) positive
 Associated conditions – sacroilitis associated with Ulcerative
colitis, Crohn’s disease or Reiter’s syndrome
11

12

Who is At Risk?
 Risk factors that predispose a person to AS include:
 Positive HLA-B27 marker
 A family history of AS
 Frequent GIT infections
13

Pathology
 Synovitis of sacroiliac joints
 Cellular infiltration of periosteum to ligament or muscle
junction (Entheses & Enthesiopathy).
 Chronic inflammation leads to fibrosis which gradually
become calcified & ossified in spinal synovial & fibro-
cartilaginous joints.
 Bony ridge form at periphery of IV joints leading to
ossification of annulus fibrosis & surrounding tissue (seen
in radiography & term as Syndesmophytes).
14

Syndesmophytes
15

 The disease can progress to bony ankylosis of –
 SI joints
 Symphysis pubis
 Joints of lumbar, thoracic & cervical spines
 Costovertebral joints
 Menubriosternal junction
 Sometime the shoulder & knee also affected
 The changes undergo exacerbation & remissions
16

Enthesitis
 It is an inflammation at the insertion of
tendons, ligaments or capsules into bone
which is a frequent manifestation in AS
 Occurred in 50% with long-standing AS &
39.4% with shorter disease duration.
 Most frequently affected at insertion of
Achilles’ tendon &/or the plantar fascia at
the calcaneus.
18

Enthesitis in peripheral joints
 The sites affected can be both the synovium & the
insertion of tendons/ligaments at bone.
 This implies that a peripheral joint might not be swollen,
only painful (especially pain on local pressure and, if
accessible, on movement).
 Hip involvement was reported in 27%
 Shoulder involvement was reported in 25%
19

Clinical features
 Articular features
 Extra-articular features
22

Articular features
 Onsets – often insidious with mild pain & stiffness in
lower lumbar spine & SI joints
 Morning stiffness – common in early stage
 Fatigue – very common
23

Articular features cont…
 Deformities –
 'Question Mark' Deformity
 Fixed spinal flexion deformities
 Hyper extended cervical spine
24

 Lumbar Spinal features –
 Pain & stiffness
 Pain radiating down the back of leg
(Sciatica)
 Peraspinal muscle spasm
 Flattening of lumbar spine
 All movt are affected
 SLR is affected bilaterally
 As disease progress, the same
feature are seen in thoracic &
cervical
25

 Thoracic spine features –
 Diminished costovertebral & manubriosternal movt resulting
loss of thoracic expansion
 Dependent on diaphragm for respiration
 Reduction in vital capacity
 Peripheral joints –
 Pain & stiffness at shoulder, hip & knee
26

Extra-articular features
 Iritis –
 Painful inflammation around iris occurs in 10% – 30% of
patients
 Cardiac features –
 Aortic incompetence
 Constitutional –
 Weakness
 General wasting
 Lassitude
28

Extra-articular feature
 Skin –
 Associated psoriasis
 Neurological disease –
 Spine at risk when combine with
fracture
31

Extra-articular feature
 Colon –
 Ulcerative colitis
32

Radiographic features
 Sacroiliac joint –
 Erosion & sclerosis of bone near the articular
surface
 Ankylos later
 Spine –
 Apophyseal joint erosion
 Squaring of the vertebral bodies with ossification of
disc margins
 Syndesmophytes
 “Bamboo Spine” due to calcification of longitudinal12 December 2020Ratankhuman (M.P.T., Ortho & Sports)
35

Radiographic features
36

9 most significant physical problems rated by
patients with AS (Dziedzic 1998)
 Difficulty sleeping on the stomach
 Stiffness on waking
 Difficulty in standing for longer periods
 Difficulty in prolonged sitting
 Difficulty in bending
 Being a spectator rather than participating in activities
 Pain increasing with higher levels of stress
 Tiredness on waking
 Limitation of leisure activities
37

Diagnosis & Special Tests
 Diagnosis criteria were first proposed by Kellgren et al. Rome,
1961 – 1963
 Later in New York by Bennett & Burch, 1968
 New York criteria have been modified by Cats et al., 1987
 Secondary AS is Dx if it is coexists with psoriatic arthritis,
Reiter’s Syndrome & inflammatory bowel disease. (Calin,
1993)
41

Diagnosis Criteria for AS
HISTORY EXAMINATION RADIOLOGY
SCREENING
TEST
Back pain:
1. Commences <40 years
2. Insidious onset
3. Persists 3>3 months
4. Associated morning stiffness
5. Improves with exercise
ROME
CRITERIA
1. LBP >3 months Not relieved
by rest
1. Limited motion of lumbar spine
Bilateral sacro-iliitis
2 limited chest expansion
2. Thoracic pain and stiffness
3. Iritis (past or present evidence)
3. Iritis (history)
NEW YORK
CRITERIA
1. Pain in lumbar spine
or at dorsolumbar junction
1. Limited movement of lumbar spine in 3 planes
1. Bilateral sacro-iliitis: grade 3-
4
2. unilateral sacro-iliitis: grade
3-4
Or bilateral sacro-iliitis: grade 2
2. Chest expansion <2.5 cm
MODIFIED
NEW YORK
CRITERIA
I. LBP 3>3 months, Improved
by exercise and not Relieved
by rest
1. Limitation of lumbar spine in Sagittal and
frontal planes
1. Bilateral sacro-iliitis: grade 2-
4 or
2. Limitation of Chest expansion relative to
normal values corrected for age & sex
2. Unilateral sacro-iliitis: grade
3-4
Rome criteria: AS if bilateral sacro-iliitis and any clinical criterion are present or four of five clinical criteria.
New York criteria: Definite AS if grade 3 or 4 bilateral sacro-iliitis with any clinical criterion or grade 2 bilateral or 3
or4 unilateral sacroiliitis with either clinical criterion 1 or both clinical criteria 2 and 3.

Modified New York criteria for AS
 Diagnosis –
1. Clinical criteria –
LBP & stiffness > 3 months which improves with ex, but not
relieved by rest.
Limitation of motion of the lumbar spine in both the sagittal &
frontal planes.
Limitation of chest expansion relative to normal values
corrected for age & gender.
2. Radiological criterion –
 Sacroiliitis grade 2 bilaterally
 Sacroiliitis grade 3–4 unilaterally.
43

Modified New York criteria for AS
Grading –
 Definite Ankylosing Spondylitis –
 If the radiological criterion is associated with at least 1 clinical criterion.
 Probably Ankylosing Spondylitis if –
 Three clinical criteria are present.
 The radiological criterion is present without any signs or symptoms
satisfying the clinical criteria (other causes of sacroiliitis should be
considered).
44

Enthesitis
 Maastricht Ankylosing Spondylitis Enthesitis Score
(MASES)
 Mander enthesitis index
45

Amor’s Classification Criteria for Spondyloarthritis (SpA)
1
Clinical symptoms or past history of Lumbar or dorsal pain at night or morning stiffness of lumbar
or dorsal pain
1
2 Asymmetrical oligoarthritis 2
3 Buttock pain 1
4 If alternate buttock pain 2
5 Sausage-like toe or digit 2
6 Heel pain or other well-defined enthesopathy 2
7 Iritis 1
8 Non-gonococcal urethritis or cervicitis within one month before the onset of arthritis 1
9 Acute diarrhea within one month before the onset of arthritis 1
10 Psoriasis, balanitis, or inflammatory bowel disease (ulcerative colitis or Crohn’s disease) 2
11 Radiological findings Sacroiliitis (bilateral grade 2 or unilateral grade 3) 3
12
Genetic background: Presence of HLA-B27 and/or family history of ankylosing spondylitis,
reactive arthritis, uveitis, psoriasis or inflammatory bowel disease
2
13
Response to treatment: Clear-cut improvement within 48 hr after NSAIDS intake or rapid relapse
of the pain after their discontinuation
2
Note: A patient is considered as suffering from SpA if the sums core is >612 December 2020Ratankhuman (M.P.T., Ortho & Sports)46

Domains and Instruments for All Three ASAS Core Sets
Domain Recommended instrument
Physical function
BASFI a patient oriented questionnaire of 10 questions that are averaged to
yield a score between 0 and 10. As an alternative the Dougados functional
index including 20 questions on a 5-point Likert scale (range 0–40) is
acceptable.
Pain
Two separate questions: (1) total pain in the spine due to AS, (2) pain at night
in the spine due to AS.
Patient global of
disease activity
Patient global-visual analogue scale ith 0 being no disease activity and 100
being severe disease activity
Spinal mobility
Four instruments: 1.Occiput to wall distance, 2. Chest expansion,
3. Modified schober index, 4. Lateral lumbar flexion or BASMIa
Inflammation (spinal
stiffness)
Average of morning stiffness duration and intensity (e.g., BASDAI questions 5
and 6) or duration of morning stiffness only
Fatigue Fatigue question from the BASDAI
Peripheral joints &
Entheses
Number of swollen joints (44 joint count) Validated entheses index (no
preferred instrument)
Acute phase reactants ESR
Radiographs of spine
and hips
X-pelvis (SI joints and hips) Lateral lumbar spine and lateral cervical spine
(mSASSS)

Diagnostic Procedures of As
 Symptoms
 Positive family history of AS
 Inflammatory back pain
 Thoracic pain
 Fractures of spine after minor trauma
 Oligoarthritis
 Anterior uveitis
 Diarrhea
 Shortness of breath
48

 Physical examination
 BP & Pulse rate
 Skin: psoriatic lesions?
 Eyes: redness, irregular
pupil?
 Heart: murmur?
 Lungs
 Costovertebral,
costotransverse &
manubriosternal joints
 Cervical spine: flexion,
extension, rotation, occiput to
wall distance
 Thoracic spine: chest
expansion
 Lumbar spine; Schober’s
test, fingers–floor distance,
lateral flexion
 Peripheral joints: arthritis?
 Enthesitis lesions?
12 December 2020
49

 Laboratory tests
 ESR or CRP
 Blood count
 HLA-B27 antigen (in case of doubtful diagnosis)
 Urine: erythrocytes, protein?
 Radiology
 Pelvis: sacroiliitis, hip involvement?
 Cervical, thoracic, lumbar spine
50

Laboratory Tests
 Elevated ESR or CRP
 Platelet Count may be slightly elevated & mild normochromic,
normocytic anemia, due to a chronic disease
 Positive RA factor & antinuclear antibodies (ANA) do not occur
 HLA-B27 antigen present in majority of AS patients
 Adolescent patients, radiographic confirmation of sacroiliitis can be
difficult, HLA-B27 testing could be helpful in Rx.
 Raised levels of Alkaline Phosphatase, primarily derived from bone,
& serum immunoglobulin A (IgA)
 Urine might show protein or erythrocytes in renal involvement.
51

Radiology
 The radiograph of pelvis show signs of sacroiliitis
 Severity of sacroiliitis can be graded from 0 to IV of the SI
joints.
 At early stages, sacroiliitis can be detected with CT &
MRI before the abnormalities at plain radiograph of pelvis
.
52

Radiology cont...
 Vertebral column often shows –
 Bony sclerosis with squaring of vertebral bodies
 Ossification of annulus fibrosis with syndesmophytes.
 This might lead to fusion of vertebral column with a classical
“Bamboo Spine”.
 Involvement of hip & shoulder joints –
 Joint space narrowing can be detected by conventional X-rays.
53

Differential Diagnosis
 Other types of spondyloarthropathies
 Psoriatic arthritis
 Inflammatory bowel disease:
 Ulcerative colitis or Crohn’s disease
 Reactive arthritis
 Juvenile spondyloarthropathy
 Other types of arthritis
 Rheumatoid arthritis
62

 Other causes of back pain
 Non-inflammatory back pain
 Fibromyalgia
 Spine diseases: prolapsed intervertebral disc, spinal tumors,
bone tumors
 Infections: tuberculosis, and others
 Metabolic diseases
 Diffuse idiopathic skeletal hyperosthosis (DISH or
Forestier’disease
63

 Other causes of sacroiliitis
 Osteitis condensans ilii, septic sacroiliitis, paraplegia, paget’s
disease, dialysis associated
 Spondylarthropathy, hyperparathyroidism, etc.
64

Prognosis
 Can range from mild to progressively debilitating & from
medically controlled to refractive.
 Some have active inflammation followed by remission,
while others never have remission & have acute
inflammation & pain.
 Unattended cases of AS accompanied by enthesitis,
especially when spine inflammation is not yet active, may
result in misdiagnosis of normal rheumatism.
65

Prognosis …
 In long-term undiagnosed –
 Osteopenia or osteoporosis of spine may occur, causing
eventual compression fractures & back "hump".
 Typical signs of progressed AS are –
 Syndesmophytes formation on X-rays & abnormal bone
outgrowths similar to osteophytes affecting the spine.
 In fusion of the vertebrae –
 Paresthesia is a complication due to the inflammation of the
tissue surrounding nerves.
66

Disease-specific Instruments
1) Bath AS disease activity index [BASDAI]
2) Bath AS functional index [BASFI]
3) Bath AS metrology index [BASMI]
4) Bath AS radiology index [BASRI]
5) Modified stroke AS spinal score [mSASSS]
67

69 12December2020Ratankhuman(M.P.T.,Ortho&Sports)

Bath AS Metrology Index (BASMI)
 5 clinical measurements that reflect axial mobility:
 Tragus to wall
 Lumbar flexion
 Cervical rotation
 Lumbar side flexion
 Inter-malleolar distance
 Grading 0–2 or grading 0–10 or linear function.
 Total score 0–10.
71

Management of as
75
Education, Exercise,
Physical therapy,
Rehabilitation,
Patient Associations,
Self help group
NSAIDs
Axial Disease Peripheral Disease
TNF Blockers
Local Corticosteroid
DMARD (Sulfasalazine)
A
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S
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Management
 Pharmacology –
 NSAIDS
 Analgesic & Cortico-gluco-corticoid injections
 Disease-modifying Anti-rheumatic Drugs (DMAD)
 Biological AgentsTumour Necrosis Factor blockers (TNF)
 Physiotherapy & Exercise
 Surgical Rx
 Hip surgery
 Spinal surgery
 Atlanto axial dislocation
 Vertebral fractures 12 December 2020Ratankhuman (M.P.T., Ortho & Sports)
76

Pharmacology Rx
 The NSAIDs for AS –
 Recommended as 1st Line Drug Rx for AS with pain & stiffness
 Good anti-inflammatory capacity
 Reducing pain & stiffness rapidly after 48–72 hours
 With Gastrointestinal (GI) Risk, non-selective NSAIDs plus a gastro
protective agent, or a selective COX-2 inhibitor could be used.
 Analgesics for AS –
 Might be considered for pain control in whom NSAIDs are insufficient, C/I
& poorly tolerated.
 E.g. Paracetamol & Opioids
77

Pharmacology Rx
78

Pharmacology rx Cont…
 Cortico-gluco-corticoid injections –
 Directed to the local site of musculoskeletal inflammation may
be considered.
 Disease-Modifying Anti-Rheumatic Drugs (DMARD)
 The use of DMARDs for the Rx of axial disease in
spondyloarthritides (SpA) has been disappointing.
 Sulfasalazine improves peripheral arthritis associated with SpA, but not
spinal pain.
 Methotrexate is generally used in patients with RA to improve symptoms
& slow progression of erosive disease.
 Bisphosphonates could be useful for spinal symptoms withAS12 December 2020Ratankhuman (M.P.T., Ortho & Sports)
79

 Use of Biological Agents in AS –
 Success of anti Tumour Necrosis Factor blockers (TNF) Rx in
SpA is probably class “A” effect.
 Recommended drugs: e.g. Infliximab, Etanercept, Adalimumab
80

 The following criteria should be fulfilled before initiating
biological agents:
 A definitive diagnosis of AS
 Presence of active disease for at least 4 weeks as defined by
both a sustained BASDAI of at least 4 (on a scale of 0-10) & an
expert opinion based on clinical features, acute phase
reactants & imaging modalities.
 Presence of refractory disease defined by failure of at least two
NSAIDS during a 3-month period , failure of intra-articular
glucocorticoids if indicated & failure of sulfasalazine in patients
with peripheral arthritis. 12 December 2020Ratankhuman (M.P.T., Ortho & Sports)
81

Physiotherapy Management
82

Physiotherapy Management
 There are ample of evidence that Physiotherapy in the
form of exercises is effective (level A evidence) in
management of AS - SpA.
 However, scientific evidence of long-term effectiveness is
not yet available.
 But some suggested, ex should be continue life time.
 Most AS feel too stiff to ex in morning, so taking a warm
bath before ex tends to ease this discomfort.
 Choose a time of day that works best for patient.12 December 2020Ratankhuman (M.P.T., Ortho & Sports)
83

Aims of Physio Rx
 To educate the patient
 To relieve pain & spasm
 To maintain & improve mobility of the spine & peripheral
joints.
 To strengthen the muscles of the trunk, the legs, the back
& the abdomen
 To minimize deformities
 To regain fitness
 To relax the body 12 December 2020Ratankhuman (M.P.T., Ortho & Sports)
84

Patient Education
 Before starting an exercise program
 Patient education plays a central role in successful
management of AS.
 Soon after Dx of AS, patients should be explained about
possible progression of symptoms & other C/F, prognosis &
treatment.
 Informing the patient about the possible occurrence of spinal
ankylosis will enhance compliance with proposed treatments.
85

To Relieve Pain & Spasm
 Heat therapy as a hot
pack can be applied
locally to the specific joint
& muscle affected.
 Hold-relax technique are
best in relieving muscle
spasm after acute
inflammatory changes.
 Hydrotherapy helps in
minimizing pain & spasm &
also restored mobility.
 Recreational exercise –
 Improves pain and stiffness &
improves function.
 Exercise at least 30 min/day
 Exercises at least 5
days/week
12 December 2020
86

Application of Heat
 Warm shower or application of local heat promote
relaxation & help in stretching of tight muscles.
 Should not apply local heat to an area >15min at a time
 Avoid areas overlying artificial joints.
 Keep the temperature of the heating pad at low or
medium level, never on high setting.
 Do not lie on back with the heating, it increase the risk of
burn due to decreased blood circulation in the area by
pressure of body weight. 12 December 2020Ratankhuman (M.P.T., Ortho & Sports)
87

Swimming
 Swimming is an ideal exercise because it gently uses all
the muscles & is very relaxing.
 It provides aerobic exercise to enhance general fitness &
enhance lung capacity.
 Warm or even hot pool is generally most comfortable.
 Heated swimming pool or spa helps to decrease pain and
stiffness.
 Low-impact exercises in the water (swimming & water
aerobics) & stationary bicycling can help improve ex
capability, muscle strength & ROM.
88

Sona/ SPA
89

Swimming cont…
 Regular free-style swimming is
considered to be one of the best
exercises for people with AS.
 Using a snorkel may be helpful.
 Careful not to slip on wet surfaces in
the pool area & it is also wise to avoid
diving.
90

Spinal Extension & Deep Breathing Ex
 Spinal extension exercises in prone lying
 Hold time: 5 seconds and then relax
 Repeat the exercise about 20 times.
91

Spinal extension and deep
breathing exercises cont…
 Chest Expansion Exercise in supine –
 Clasping hands behind head & extending your elbows
outwards towards the bed while taking a deep breath.
 Hold the breath for a count of 10 before exhaling and
relaxing for about 10 seconds.
 Repeat the exercise about 20 times.
 Give up smoking, in order to prevent its adverse
effects on the lungs and heart.
92

Spinal extension and deep
breathing exercises cont…
 Combine spinal extension & chest expansion
exs –
 Performing corner push-ups
 Take in a deep breath during this manoeuvre.
 After a count of 10, exhale while returning.
 Repeat exercise about 20 times thrice daily if
possible.
93

Muscle-strengthening and
stretching exercises
 Strengthening of back extensor & hip muscles to
keep the spine mobile & erect.
 Try achieving functional ROM of hip & shoulder
joint
 Daily stretching of involved joints to improve
mobility of the back, hips, shoulders, or other
involved joints.
 Needs of Ex are –
 To prevent stiffness
 To regain muscle strength & prevent muscle wasting
& weakness. 12 December 2020Ratankhuman (M.P.T., Ortho & Sports)
94

Examples of exercises
B
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CAT & Camel
EXERCISE
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S
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E
B
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R
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R
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100

101

S
H
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S
H
O
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103

group exercise
 Use of large Swiss balls & group exercise sessions that
include hydrotherapy are enjoyable and very helpful.
 In some European countries, professionally supervised
special physiotherapy and hydrotherapy group sessions
for AS patients have been organized by AS patient
organizations.
 Group physical therapy is cost-effective compared to
individualized therapy.
104

Living with as: some hints
 If you have physical limitations due to
advanced AS, there are devices to help
perform daily tasks:
 Walking canes,
 Special chairs and desks,
 Special shoes, and
 Devices that assist in putting on socks or
stockings and shoes, or for scratching or applying
soap on back, etc.
105

Avoiding falls
 Always wear a good pair of skid-resistant
shoes.
 Use grab bars in the shower and toilets,
shower seats, raised toilet seats, and floor
lighting at night.
 Avoid slippery surfaces and loose carpets.
106

Posture
 Sleep on a firm bed to maintain a good resting
posture at night.
 Preferably make a habit of sleeping prone, to
prevent hip joints and the back flexion.
 Avoid a pillow under knees because it increase
the tendency to muscle and tendon shortening.
 Avoid a saggy mattress or a waterbed.
107

 Avoid using a pillow if possible, or use one just
thick enough to allow a horizontal position of
the face to prevent pain from overextension of
neck.
 Practice lying prone
 e.g. for 5 minutes or more before getting out of
the bed in the morning, and also before going to
bed at night.
 People with AS need to practice good posture
habits at all times, and should be taught about
dynamic, resting, and occupational postures.12 December 2020Ratankhuman (M.P.T., Ortho & Sports)
108

Dynamic posture
 Be aware of standing posture & try to maintain
an erect posture, with the spine as straight as
possible.
 Avoid any tendency to slump forward.
 Splints, braces and corsets are generally not
helpful and are not advised.
 Some form of bracing may be necessary on
rarely.
 e.g. after injury to the back or neck
110

Occupational posture
 Analyse habitual and work
postures and modify working
positions to maintain a good
posture.
 E.g, a drafting table with tilting
work surface may be better than
an ordinary office desk for writing
and reading & avoiding stress on
neck.
111

Occupational posture cont…
 Avoid physical activity that places prolonged
strain on back & neck muscles, and prolonged
stooping or bending.
 Alternate between sitting and standing
positions to perform jobs that take a long time
to finish.
 Maintain a good posture while sitting, and
avoid sitting for prolong periods, especially in
low soft sofas and chairs.
112

Occupational posture cont…
 During your mid-day break at work, lie flat for a
few minutes, and do some corner push-ups to
stretch the back.
 A daily routine of deep breathing and spinal
motion/stretching exercises may minimize the
fusion, and at least preserve better posture.
 Do deep breathing exercises at frequent
intervals during the day.
113

Sports and recreational
activities
 Sports and recreational activities that
encourage good posture & arching of the back
(extension) and rotation of the trunk are
recommended.
 E.g. walking, hiking, swimming, tennis,
badminton, cross-country skiing, and archery.
 Volleyball and basketball are excellent sports for
people however, not everyone can tolerate.
114

Sports and recreational
activities cont…
 Sports activities that require prolonged spinal
flexion may not be recommended.
 E.g. golf, bowling & long distance cycling
 Body contact sports (boxing, rugby, soccer,
American football & hockey) and downhill skiing,
are also not recommended due to greater
potential for injury.
 Stationary cycle are good, but the handlebars
must be properly adjusted not to lean forward
while exercising.
115

Sports & recreational activities
cont…
 Cycling is good for general cardiovascular
conditioning, strengthening the leg muscles, and
exercising the hip and knee joints.
 Aerobic exercises with machines that enhance
back, leg, and shoulder extension are helpful,
but should avoid undue stress on the neck.
116

Well-known people with AS
 Pope John Paul
 Mötley Crüe's guitarist
 Ed Sullivan , US
 World Chess Champion
Vladimir Kramnik
 England cricket captain
Mike Atherton
 Australian cricketer
Michael Slater
 Norwegian Prime Minister
Jens Stolenberg
 Scottish snooker player
Chris Small
 US Major League baseball
player Rico Brogna
 Taiwanese musician Jay
Chou
 Czech writer Karel Capek
 Ian Woosnam British golfer
 French tennis player
Tatiana Golovin
 Lee Hurst comedian
117

Pope John Paul
118

World Chess Champion
Vladimir Kramnik
119

England cricket captain Mike
Atherton
120

Australian cricketer - Michael
Slater
121

French tennis player Tatiana Golovin
122

Norwegian Prime Minister Jens Stolenberg
123

Scottish snooker player Chris Small
124

US baseball player
Rico Brogna
125

Comedian - Lee Hurst
126

Reference
 Joachim Sieper, ankylosing spondylitis in clinical
practice, 2011
 Barend J. Van Royen, ankylosing spondylitis
diagnosis and management, 2006
 Karen Atkinson, Physiotherapy in Orthopaedics: A
problem-solving approach, 2005
 Muhammad asim khan, Ankylosing Spondylitis: the
facts, 2002
 Stuart Porter, Tidy Physiotherapy, 13th ed, 2003
 Ann Thomson, Tidy Physiotherapy, 12th ed, 1995
127

Reference cont…
 Van Der Linden, Evaluation Of Diagnostic
Criteria for Ankylosing Spondylitis: A
Comparison of the Rome, New York & Modified
New York Criteria in Patients with a Positive
Clinical History Screening Test for Ankylosing
SpondylitiS, British Journal Of Rheumatology
1985;24:242-249
 Joachim Sieper Ankylosing Spondylitis,
Seminar, Medical Department I, Rheumatology,
April 21, 2007
128

Reference cont…
 J Sieper et al., The Assessment of
SpondyloArthritis international Society (ASAS)
handbook: a guide to assess SpA, Ann Rheum
Dis 2009;68;ii1-ii44
 AN Malaviya et al., Indian Rheumatology
Association consensus statement on the
diagnosis and treatment of axial SpA,
129

Ankylosing spondylitis

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