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Ankylosing spondylitis (AS).
Axial spondyloarthritis is a seronegative spondyloarthritis of the spine and pelvis. The term axial spondyloarthritis
has only been used since 2009 when the Assessment of Spondyloarthritis International Society Axial
Spondyloarthritis (ASAS) classification criteria was developed.
● The enthesis, the site of ligamentous attachment to bone, is thought to be the primary site
of pathology.
● Enthesitis is associated with prominent edema of the adjacent bone marrow and is often
characterized by erosive lesions that eventually undergo ossification.
● Synovitis follows and may progress to pannus formation with islands of new bone
formation.
● The eroded joint margins are gradually replaced by fibrocartilage regeneration and then
by ossification. Ultimately, the joint may be totally obliterated.
Patho
Relevant Anatomy
Pain in AS can be caused by sacroiliitis and spondylitis. Initially, the sacroiliac joints, situated in the lumbar part of
the back, which connect the spine and the pelvis, are damaged. Subsequently, the inflammation moves to entheses,
where ligaments and tendons integrate into the bone. Eventually, the spine is affected by this inflammation. The
vertebral column normally exists of 24 vertebrae, joined together by ligaments and separated by intervertebral
discs.
Patients diagnosed with AS form calcium deposits in the ligaments between and around the intervertebral discs.
An accumulation of the deposits leads to ossification starting from the vertebral rim towards the annulus fibrosis
and characterised by syndesmophytes.
Syndesmophytes are one of the main features of spinal structural damage in ankylosing spondylitis.
Epidemiology/Etiology
AS Affects 0.1 to 1.4% of the population.
Male to female ratio of 2:1
Onset of symptoms generally occurs between 20-40 years.
Strong link has been established of complex interactions between genetic background and environmental factors.
Genetic background gene called ( HLA-B27), microbial infection, endocrinal abnormalities and immune reaction related to
the occurrence of AS.
Initially, there is an infiltration of the subchondral bone by granulation tissue which causes small lesions, ultimately leading
to joint erosion.
Lesions in the annulus eventually undergo ossification, leading to a fusion effect of the spinal segments and the similarity in
appearance to bamboo.
Clinical Presentation
● Insidious onset of back pain in the sacroiliac (SI) joints and gluteal regions (presenting as alternating
buttock pain), which progress to involve the entire spine.
● Age of onset less than 45 years
● Duration of more than 3 months
● Morning stiffness lasting greater than 30 minutes
● Waking up in the second half of the night due to pain, but eases with arising
● Pain and stiffness increase with inactivity and improve with exercise.
● The patient is a young adult 15-30 years old male, presenting with a gradual onset of pain and stiffness of
the lower back.
● Initially, the stiffness may be noticed only after a period of rest, and improves with movement.
● Pain tends to be worst at night or early morning, awakening the patient from sleep.
D/D
● Degenerative Disc Disease
● Herniated Intervertebral Disc
● Fractures and/or dislocation
● Osteoarthritis
● Spinal Stenosis
● Spondylolisthesis, Spondylolysis, and Spondylosis
● Reactive arthritis
Assessment and diagnosis
A family history of AS or related disorders.
Positive HLA-B27 test: HLA B27 is positive in 80-90% of AS patients.
High ESR.
In 2009, the Assessment of SpondyloArthritis International Society (ASAS) developed
classification criteria for axial spondyloarthritis that are supported on these imaging, clinical, and
laboratory criteria. Implementing these criteria, the diagnosis is established in persons who have had
back pain for 3 or more sequential months prior reaching
45 years of age, with the
Presence of sacroiliitis confirmed on MRI or plain radiography, and have
A minimum of one clinical or laboratory finding that is characteristic of spondyloarthritis.
Alternatively, individuals with this history who have a positive test result for HLA-B27 and two symptoms
of spondyloarthritis, as identified on clinical examination or laboratory analysis will also meet the criteria
for a diagnosis of axial spondyloarthritis.
Bamboo spine
● Arthritis in the hips and shoulders (“root” joints) : in 25 to 35% of patients.
● Arthritis of other peripheral joints: usually asymmetric.
● Pain tends to be persistent early in the disease and then becomes intermittent, with
alternating exacerbations and quiescent periods.
● In a typical severe untreated case- the patient's posture undergoes characteristic changes,
with obliterated lumbar lordosis, buttock atrophy, and thoracic kyphosis. There may be a
forward stoop of the neck or flexion contractures at the hips, compensated by flexion at the
knees.
Cervical mobility
● Occiput-to-wall
distance
● Tragus-to-wall
distance
● Cervical rotation
● Chest expansion
Thoracic
mobility
Lumber mobility
Modified schober index
https://youtu.be/B9RaFB5BwrQ
Finger-to-floor distance
Lumber lateral flexion
TEST and MEASUREMENT for AS
Test
Occiput To Wall Distance / Flesche Test
● The occiput to wall distance should
be zero
Tragus-to-wall distance
20
● Maintain starting position i.e. ensure head
in neutral position (anatomical alignment),
chin drawn in as far as possible. Measure
distance between tragus of the ear and wall
on both sides, using a rigid ruler. Ensure no
cervical extension, rotation, flexion or side
flexion occurs.
Cervical rotation
● Patient supine, head in neutral position,
forehead horizontal (if necessary head on
pillow or foam block to allow this, must be
documented for future reassessments).
● Gravity goniometer / bubble inclinometer
placed centrally on the forehead. Patient
rotates head as far as possible, keeping
shoulders still, ensure no neck flexion or
side flexion occurs.
Normal ROM: 70-900
Chest expansion
● Measured as the difference between maximal inspiration and maximal forced
expiration in the fourth intercostal space in males or just below the breasts in
females. Normal chest expansion is ≥5 cm.
Lumbar flexion (modified Schober)
23
● With the patient standing upright, place a
mark at the lumbosacral junction (at the
level of the dimples of Venus on both
sides). Further marks are placed 5 cm
below and 10 cm above. Measure the
distraction of these two marks when the
patient bends forward as far as possible,
keeping the knees straight
• The distance less than 5 cm is abnormal
Finger to floor distance
● Expression of spinal column mobility when
bending over forward; the dimension that is
measured is the distance between the tips of the
fingers and the floor when the patient is bent over
forward with knees and arms fully extended.
Lateral spinal flexion
25
Patient standing with heels and buttocks touching the wall, knees straight, outer edges of
feet 30 cm apart, feet parallel. Measure minimal fingertip-to-floor distance in full lateral
flexion and without flexion, extension or rotation of the trunk or bending the knees.
Greater than 10cm is normal.
>>>> >>>>
Range of motion
TESTS FOR SACROILITIS
27
● Pelvic compression test
● Faber test
● Gaenslen Test
● Pump Handle test
GAENSLEN TEST
• Gaenslen test stresses the sacroiliac joints,
Increased pain during this test could be indicative of joint disease.
PELVIC COMPRESSION TEST
● Test irritability by compressing the pelvis with the patient prone.
Sacroiliac pain will be lateralised to the inflamed joint.
Disease Specific Instruments For The Measurement In Ankylosing
Spondylitis
Instrument Measures
Bath ankylosing spondylitis disease activity index
(BASDAI)
Disease activity
Bath ankylosing spondylitis functional index
(BASFI)
Function
Dougados functional index (DFI) Function
Bath ankylosing spondylitis metrology index
(BASMI)
Function
Modified stoke ankylosing spondylitis spinal score
(m-sasss)
Structural damage
Physiotherapy Management
AIM
It aims to reduce pain,
increase spinal mobility and functional capacity,
reduce morning stiffness,
correct postural deformities,
increase mobility and
improve the psychosocial status of the patients
Exercises
● Help to maintain spine mobility, maintain optimal posture, and to decrease stiffness
by putting sections of the spine through their full available movement
● Recommended as a warm up activity before other exercises
● Generally do 5-10 repetitions of each exercise, daily
● Move smoothly through your range.
Cervical Spine (Neck)
● To find neutral head position: Place your fist in the
notch between collar bones and rest chin on the fist.
Imagine holding a peach under your chin
● To set shoulder blades for optimal shoulder/neck
posture: Open collar bones wide and gently slide
shoulder blades down the back towards opposite hips.
● Bending Forward
● Sit up tall on the edge of a seat, feet shoulder width
apart on the floor
● Turn on inner core muscles, place head in neutral
position
● Set shoulder blades (hold onto sides of the seat to
help)
● Bend head down to look at belly button • Keep eyes
on belly button and lengthen back of the head away
from tailbone to return head to neutral position.
● Bending Backward • Sit up tall on the edge of a seat, feet
shoulder width apart on the floor • Turn on inner core
muscles, place head in neutral position • Set shoulder
blades (hold onto the sides of the seat to help) • Lift head
up to look backwards on the ceiling • Keep inner core
muscles and shoulder blades set to bring head back to
neutral position.
Side turning & Side bending
Thoracic Spine (Upper – Mid Back)
● Ribcage Movement
● a. Towel Resistance • Sit tall on edge of seat, legs
shoulder width apart • Wrap a towel around base of
ribcage, cross arms for a snug hold on opposing ends
of towel • Turn on inner core muscles and set
shoulder blades • Inhale gently into the towel. Feel
ribcage expand and lift sideways • Keep inner core
muscles on and exhale through the nose. Feel ribcage
relax and drop down.
● Anchor Shoulder Blades on your Ribcage • Hands
hold on to sides of chair to keep shoulders blades
down • Turn on inner core muscles and set shoulder
blades • Breath in slowly and feel ribcage expand
sideways • Keep inner core muscles on and exhale
through the nose. Feel ribcage relax and drop down.
● Rotation
● a. Side Lying
● • Lie on the side with knees bent • Press lower
hand on opposite thigh • Turn on inner core
muscles • Breath in slowly as you turn upper
body, reaching upper arm across to the floor.
Keep eyes on moving hand • Exhale slow and
long through the nose as you use stomach
muscles to bring body and upper arm back to
starting position
Education
According to a study conducted by Sweeney and colleagues, education into long term home self-care has
proven to be effective.
Studies have highlighted how limited education and information can result in poor adherence to
rehabilitation.
A study by Viitanen et al; provides a very important data for our investigation.
The results showed that the duration of the disease does not affect the results: the effects of physical exercise on
these patients are independent of the progression of the disease or of the stage of the pathology in which the patient
is found.So that age would not be an inconvenience for the inclusion of these Patients in a physical exercise
program.
Aquatic physiotherapy
The buoyancy, resistance and support offered by water, combined with the warm
temperature, allow patients to exercise in a controlled yet effective way.
Aquatic physiotherapy (also known as hydrotherapy) can offer patients a number of
benefits including.
Improved ease of movement.
• Increased muscle strength.
• Balance re-education.
• Enhanced psychological well-being, due to the social interaction
Strengthening and stretching
Different muscles will need to be strengthened or stretched to help resist or correct
potential postural deformities in patients with AS. In addition to regular chest expansion
exercises.
Note-
http://mpap.vch.ca/wp-content/uploads/sites/16/2016/05/Spondylitis-Exercise-Program.pdf
For further exercises for AS
Other Considerations
ankylosing spondylitis physiotherapy management

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ankylosing spondylitis physiotherapy management

  • 2. Axial spondyloarthritis is a seronegative spondyloarthritis of the spine and pelvis. The term axial spondyloarthritis has only been used since 2009 when the Assessment of Spondyloarthritis International Society Axial Spondyloarthritis (ASAS) classification criteria was developed.
  • 3. ● The enthesis, the site of ligamentous attachment to bone, is thought to be the primary site of pathology. ● Enthesitis is associated with prominent edema of the adjacent bone marrow and is often characterized by erosive lesions that eventually undergo ossification. ● Synovitis follows and may progress to pannus formation with islands of new bone formation. ● The eroded joint margins are gradually replaced by fibrocartilage regeneration and then by ossification. Ultimately, the joint may be totally obliterated.
  • 5. Relevant Anatomy Pain in AS can be caused by sacroiliitis and spondylitis. Initially, the sacroiliac joints, situated in the lumbar part of the back, which connect the spine and the pelvis, are damaged. Subsequently, the inflammation moves to entheses, where ligaments and tendons integrate into the bone. Eventually, the spine is affected by this inflammation. The vertebral column normally exists of 24 vertebrae, joined together by ligaments and separated by intervertebral discs. Patients diagnosed with AS form calcium deposits in the ligaments between and around the intervertebral discs. An accumulation of the deposits leads to ossification starting from the vertebral rim towards the annulus fibrosis and characterised by syndesmophytes. Syndesmophytes are one of the main features of spinal structural damage in ankylosing spondylitis.
  • 6.
  • 7.
  • 8.
  • 9.
  • 10.
  • 11. Epidemiology/Etiology AS Affects 0.1 to 1.4% of the population. Male to female ratio of 2:1 Onset of symptoms generally occurs between 20-40 years. Strong link has been established of complex interactions between genetic background and environmental factors. Genetic background gene called ( HLA-B27), microbial infection, endocrinal abnormalities and immune reaction related to the occurrence of AS. Initially, there is an infiltration of the subchondral bone by granulation tissue which causes small lesions, ultimately leading to joint erosion. Lesions in the annulus eventually undergo ossification, leading to a fusion effect of the spinal segments and the similarity in appearance to bamboo.
  • 12. Clinical Presentation ● Insidious onset of back pain in the sacroiliac (SI) joints and gluteal regions (presenting as alternating buttock pain), which progress to involve the entire spine. ● Age of onset less than 45 years ● Duration of more than 3 months ● Morning stiffness lasting greater than 30 minutes ● Waking up in the second half of the night due to pain, but eases with arising ● Pain and stiffness increase with inactivity and improve with exercise. ● The patient is a young adult 15-30 years old male, presenting with a gradual onset of pain and stiffness of the lower back. ● Initially, the stiffness may be noticed only after a period of rest, and improves with movement. ● Pain tends to be worst at night or early morning, awakening the patient from sleep.
  • 13. D/D ● Degenerative Disc Disease ● Herniated Intervertebral Disc ● Fractures and/or dislocation ● Osteoarthritis ● Spinal Stenosis ● Spondylolisthesis, Spondylolysis, and Spondylosis ● Reactive arthritis
  • 14. Assessment and diagnosis A family history of AS or related disorders. Positive HLA-B27 test: HLA B27 is positive in 80-90% of AS patients. High ESR. In 2009, the Assessment of SpondyloArthritis International Society (ASAS) developed classification criteria for axial spondyloarthritis that are supported on these imaging, clinical, and laboratory criteria. Implementing these criteria, the diagnosis is established in persons who have had back pain for 3 or more sequential months prior reaching 45 years of age, with the Presence of sacroiliitis confirmed on MRI or plain radiography, and have A minimum of one clinical or laboratory finding that is characteristic of spondyloarthritis. Alternatively, individuals with this history who have a positive test result for HLA-B27 and two symptoms of spondyloarthritis, as identified on clinical examination or laboratory analysis will also meet the criteria for a diagnosis of axial spondyloarthritis.
  • 16. ● Arthritis in the hips and shoulders (“root” joints) : in 25 to 35% of patients. ● Arthritis of other peripheral joints: usually asymmetric. ● Pain tends to be persistent early in the disease and then becomes intermittent, with alternating exacerbations and quiescent periods. ● In a typical severe untreated case- the patient's posture undergoes characteristic changes, with obliterated lumbar lordosis, buttock atrophy, and thoracic kyphosis. There may be a forward stoop of the neck or flexion contractures at the hips, compensated by flexion at the knees.
  • 17. Cervical mobility ● Occiput-to-wall distance ● Tragus-to-wall distance ● Cervical rotation ● Chest expansion Thoracic mobility Lumber mobility Modified schober index https://youtu.be/B9RaFB5BwrQ Finger-to-floor distance Lumber lateral flexion TEST and MEASUREMENT for AS Test
  • 18. Occiput To Wall Distance / Flesche Test ● The occiput to wall distance should be zero
  • 19. Tragus-to-wall distance 20 ● Maintain starting position i.e. ensure head in neutral position (anatomical alignment), chin drawn in as far as possible. Measure distance between tragus of the ear and wall on both sides, using a rigid ruler. Ensure no cervical extension, rotation, flexion or side flexion occurs.
  • 20. Cervical rotation ● Patient supine, head in neutral position, forehead horizontal (if necessary head on pillow or foam block to allow this, must be documented for future reassessments). ● Gravity goniometer / bubble inclinometer placed centrally on the forehead. Patient rotates head as far as possible, keeping shoulders still, ensure no neck flexion or side flexion occurs. Normal ROM: 70-900
  • 21. Chest expansion ● Measured as the difference between maximal inspiration and maximal forced expiration in the fourth intercostal space in males or just below the breasts in females. Normal chest expansion is ≥5 cm.
  • 22. Lumbar flexion (modified Schober) 23 ● With the patient standing upright, place a mark at the lumbosacral junction (at the level of the dimples of Venus on both sides). Further marks are placed 5 cm below and 10 cm above. Measure the distraction of these two marks when the patient bends forward as far as possible, keeping the knees straight • The distance less than 5 cm is abnormal
  • 23. Finger to floor distance ● Expression of spinal column mobility when bending over forward; the dimension that is measured is the distance between the tips of the fingers and the floor when the patient is bent over forward with knees and arms fully extended.
  • 24. Lateral spinal flexion 25 Patient standing with heels and buttocks touching the wall, knees straight, outer edges of feet 30 cm apart, feet parallel. Measure minimal fingertip-to-floor distance in full lateral flexion and without flexion, extension or rotation of the trunk or bending the knees. Greater than 10cm is normal. >>>> >>>>
  • 26. TESTS FOR SACROILITIS 27 ● Pelvic compression test ● Faber test ● Gaenslen Test ● Pump Handle test
  • 27. GAENSLEN TEST • Gaenslen test stresses the sacroiliac joints, Increased pain during this test could be indicative of joint disease.
  • 28. PELVIC COMPRESSION TEST ● Test irritability by compressing the pelvis with the patient prone. Sacroiliac pain will be lateralised to the inflamed joint.
  • 29. Disease Specific Instruments For The Measurement In Ankylosing Spondylitis Instrument Measures Bath ankylosing spondylitis disease activity index (BASDAI) Disease activity Bath ankylosing spondylitis functional index (BASFI) Function Dougados functional index (DFI) Function Bath ankylosing spondylitis metrology index (BASMI) Function Modified stoke ankylosing spondylitis spinal score (m-sasss) Structural damage
  • 30. Physiotherapy Management AIM It aims to reduce pain, increase spinal mobility and functional capacity, reduce morning stiffness, correct postural deformities, increase mobility and improve the psychosocial status of the patients
  • 31. Exercises ● Help to maintain spine mobility, maintain optimal posture, and to decrease stiffness by putting sections of the spine through their full available movement ● Recommended as a warm up activity before other exercises ● Generally do 5-10 repetitions of each exercise, daily ● Move smoothly through your range.
  • 32. Cervical Spine (Neck) ● To find neutral head position: Place your fist in the notch between collar bones and rest chin on the fist. Imagine holding a peach under your chin ● To set shoulder blades for optimal shoulder/neck posture: Open collar bones wide and gently slide shoulder blades down the back towards opposite hips. ● Bending Forward ● Sit up tall on the edge of a seat, feet shoulder width apart on the floor ● Turn on inner core muscles, place head in neutral position ● Set shoulder blades (hold onto sides of the seat to help) ● Bend head down to look at belly button • Keep eyes on belly button and lengthen back of the head away from tailbone to return head to neutral position.
  • 33. ● Bending Backward • Sit up tall on the edge of a seat, feet shoulder width apart on the floor • Turn on inner core muscles, place head in neutral position • Set shoulder blades (hold onto the sides of the seat to help) • Lift head up to look backwards on the ceiling • Keep inner core muscles and shoulder blades set to bring head back to neutral position.
  • 34. Side turning & Side bending
  • 35. Thoracic Spine (Upper – Mid Back) ● Ribcage Movement ● a. Towel Resistance • Sit tall on edge of seat, legs shoulder width apart • Wrap a towel around base of ribcage, cross arms for a snug hold on opposing ends of towel • Turn on inner core muscles and set shoulder blades • Inhale gently into the towel. Feel ribcage expand and lift sideways • Keep inner core muscles on and exhale through the nose. Feel ribcage relax and drop down. ● Anchor Shoulder Blades on your Ribcage • Hands hold on to sides of chair to keep shoulders blades down • Turn on inner core muscles and set shoulder blades • Breath in slowly and feel ribcage expand sideways • Keep inner core muscles on and exhale through the nose. Feel ribcage relax and drop down.
  • 36. ● Rotation ● a. Side Lying ● • Lie on the side with knees bent • Press lower hand on opposite thigh • Turn on inner core muscles • Breath in slowly as you turn upper body, reaching upper arm across to the floor. Keep eyes on moving hand • Exhale slow and long through the nose as you use stomach muscles to bring body and upper arm back to starting position
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  • 38. Education According to a study conducted by Sweeney and colleagues, education into long term home self-care has proven to be effective. Studies have highlighted how limited education and information can result in poor adherence to rehabilitation. A study by Viitanen et al; provides a very important data for our investigation. The results showed that the duration of the disease does not affect the results: the effects of physical exercise on these patients are independent of the progression of the disease or of the stage of the pathology in which the patient is found.So that age would not be an inconvenience for the inclusion of these Patients in a physical exercise program.
  • 39. Aquatic physiotherapy The buoyancy, resistance and support offered by water, combined with the warm temperature, allow patients to exercise in a controlled yet effective way. Aquatic physiotherapy (also known as hydrotherapy) can offer patients a number of benefits including. Improved ease of movement. • Increased muscle strength. • Balance re-education. • Enhanced psychological well-being, due to the social interaction
  • 40. Strengthening and stretching Different muscles will need to be strengthened or stretched to help resist or correct potential postural deformities in patients with AS. In addition to regular chest expansion exercises. Note-
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