PHYSIOTHERAPY

1. ANKYLOSING SPONDYLITIS
(Marie-Strümpell disease/ Bechterew's
disease )
ARAVINTH MATHIYALAGAN
GROUP # 6

2. Inflammatory disorder of unknown cause
that primarily affects the axial skeleton;
peripheral joints and extra-articular
structures may also be involved
Idiopathic
Rheumatoid factor absent
HLA-B27 present in > 90% cases
Disease usually begins in the second or
third decade.
M:F= 3:1

3. Etiology
Etiology is unknown, but probable
etiologic factors are:
• Genetic predisposition - % of people
with AS share the genetic marker
HLA-B27
Bacterias - Klebsiella pneumoniae
and
some other Enterobacterias.

4. PATHOGENESIS
Immune mediated. In some cases, the
disease occurs in these predisposed
people after exposure to bowel or
urinary tract infections.
? Autoimmunity to the cartilage
proteoglycan aggrecan.

5. PATHOLOGY
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.
Sacroiliitis is usually one of the earliest
manifestations.

6. The early lesions consist of subchondral
granulation tissue, infiltrates of lymphocytes
and macrophages in ligamentous and periosteal
zones, and subchondral bone marrow edema.
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.

7. 7
The outer annular fibers are eroded and eventually replaced by
bone → bony syndesmophytes, which then grows by continued
enchondral ossification, ultimately bridging the adjacent vertebra
bodies = “bamboo spine”.
•Axial Arthritis (Eg, Sacroiliitis And Spondylitis)
•Arthritis Of ‘Girdle Joints’ (Hips And
Shoulders)
•Peripheral Arthritis Uncommon
•Others:
Enthesitis
Osteoporosis
Vertebral Fractures
Spondylodiscitis
Costochondritis

8. Pathomorphology

9. Symptoms (early AS)
1. Pain in sacroiliac and lower back
regions:
permanent; dull
worsens in rest; in the morning;
nocturnal
reliefs in motion; in the afternoon
2. Buttock pain:
irradiates into posterior surface of hip
migrates from left to right gluteus

10. Symptoms (early AS)
3. Lower back stiffness:
in the morning, for ≥ 30 minutes
reliefs after activity, warm shower
4. Chest pain:
mimicries intercostal neuralgia and
intercostal muscles myositis
worsens in coughing, sneezing, deep
breathing

11. Symptoms (early AS)
5. Stiffness and tenderness of
back muscles.
6. Flattening of lumbar lordosis
7. Bilateral sacroilitis.

12. Symptoms (early AS)
8. Enthesopathies – pain in the site of ligamentous
attachment to bone:
lliac crests
trochanters
spinous processes of vertebrae
costovertebral joints
9. Extra-articular manifestations – usually eyes
affection (anterior uveitis); bilateral, acute onset,
lasts for 2-3 months, registered in 30% of patients.

13. Symptoms (advanced AS)
1. Pain in different segments of spine.
2. Question mark posture
3. Atrophy of back muscles.
4. Decreased thorax excursion.
5. Decreased articulations in spine.
6. Ankylosis of sacroiliac and intervertebral
joints.
7. Cutaneous lesions – that are identical to
pustular psoriasis

14. Symptoms (advanced AS)
8. Cardiovascular system involvement:
 aortitis
 aortic insufficiency
 pericarditis, myocarditis
9. Bronchopulmonary system involvement – fibrosis of apical
lung segments.
10. Urinary system involvement
 amyloidosis
 IgA-nephropathy
11. Gastrointestinal system involvement
 ulcerative colitis
 Crohn’s disease

15. Question mark posture
Question mark posture, or suppliant posture -
loss of lumbar lordosis, fixed kyphosis,
compensated extension cervical spine, protruberant
abdomen.

16. Cervical mobility
 Occiput-to-wall
distance
 Tragus-to-wall
distance
 Cervical rotation
 Chest expansion
Thoracic
mobility
Lumber mobility
Modified schober
index
Finger-to-floor
distance
Lumber lateral flexion
TEST and MEASUREMENT for AS

17. TESTS FOR SACROILITIS
Pelvic compression test
Faber test
Gaenslen Test
Pump Handle test
17

18. PELVIC COMPRESSION TEST
 Test irritability by compressing the pelvis with the patient prone. Sacroiliac
pain will be lateralised to the inflamed joint.

19. Patrick's test or FABER test
 The test is performed by
having the tested leg flexed,
abducted and externally
rotated. If pain results, this is
considered a positive
Patrick's test.

20. GAENSLEN TEST
Gaenslen test stresses
the sacroiliac joints,
Increased pain during
this test could be
indicative of joint
disease.

21. LAB TESTS:
HLA B27: present in ≈ 90% of
patients.
ESR and CRP – often elevated.
Mild anemia.
Elevated serum IgA levels.
ALP & CPK raised.

22. TREATMENT
1. Regular physical therapy
2. NSAIDS Indomethacin (up to maximum of 50 mg PO tid)
COX-2 inhibitors
3. Sulfasalazine, in doses of 2 to 3 g/d- Effective for axial and peripheral arthritis
4. Methotrexate, in doses of 10 to 25 mg/wk- primarily for peripheral arthritis
5. Local Corticosteroids injection- for persistent synovitis and enthesopathy 6.
Medications to avoid- Long term Systemic Corticosteroids, gold and
Penicillamine
7. Anti-TNF-α therapy - heralded a revolution in the management of AS.
Infliximab (chimeric human/mouse anti-TNF-α monoclonal antibody)
Etanercept (soluble p75 TNF-α receptor–IgG fusion protein)
have shown rapid, profound, and sustained reductions in all clinical and
laboratory measures of disease activity.
8. Pamidronate, thalidomide, α-emitting isotope 224Ra
9. Most common indication for surgery - severe hip joint arthritis, total hip
arthroplasty.

23. PHYSIOTHERAPY TREATMENT:
Regular physiotherapy is very
essential in the management of a
patient of AS and only
physiotherapist is the person who
can help the patient to fight with
the disease.

24. AIMS OF PHYSIOTHERAPY MANAGEMENT IN
ANKYLOSING SPONDYLITIS TREATMENT:
 Relieve pain.
 Maintain the mobility of joints affected like spine, hip,
thorax, shoulder etc.
 Prevent and correct deformity.
 Increase chest expansion and vital capacity.
 Attention to posture.
 To maintain and improve physical endurance.
 Advice to patient.

25. The relevant physiotherapy modalities in the
management of AS include :
Supervised & unsupervised exercises
Training
Manual therapy
Massage
Hydrotherapy
Electrotherapy
Acupuncture
Patient information & educational programs

26. The Super-vised group physical therapy is
offered mainly to stimulate and motivate the
patients to continue exercising, and to
provide social contacts with and control by
fellow-patients
The unsupervised individualized exercises
may consist of exercises based on a pre d e
fined program , but may also include
recreational exercises. Th e s e exercises
should become part of daily routine in a
patient’s life

27.  General instruction to patients:-
 Make the exercise part of your daily routine.
 Try to do a complete set of exercises at least twice daily at a
time convenient to you.
 Heat and cold application amy precede exercises to enhance
relaxation and decrease pain.
 Perform only those exercises given to you by your
physiotherapist.
 Perform exercises on a firm surface.
 Exercise slowly with a smooth motion, do not rush.
 Avoid holding your breath while exercising.
 Modify the exercise regime during an acute attack and contact
your physical therapist if you have any complaints or problems
with the exercises.

29. MASSAGE:
reduce stress
provide short-term pain relief
lessen stiffness
increase flexibility
Remember: A massage is supposed to make you
and your body feel better. Some people with AS
find that massages only increase their pain and
discomfort. To avoid this, make sure your
massage therapist knows you have AS.

30. Hydrotherapy
 Hydrotherapy, in real sense refers to the therapeutic use of
water. The therapeutic effects of water in relation to
Ankylosing Spondylitis Treatment-
 The relief of pain and muscle spasm.
 The maintenance or increase in range of motion of joints.
 The strengthening of weak muscles and an increase in
tolerances to exercise.
 The importance of circulation.
 The encouragement of functional activities.
 The maintenance and improvement of balance, co-
ordination and posture.

31. Electrotherapy
There are many forms of electrotherapy
available for home use, also known as Electrical
Stimulation Devices.
 The most commonly self administered ESDs is
(TENS) Transcutaneous Electrical Nerve
Stimulation. TENS uses electrical current
applied at a high frequency to stimulate the
nerves

32. The second ESDs that we’ll discuss in this
article is (MENS) Microcurrent Electrical
Nerve Stimulation. MENS uses microcurrents
that are so small, typically less than 600
microamps, that there is no discomfort
or discernible sensation during application

33. Acupuncture
Acupuncture is an ancient Chinese
practice. It involves the use of thin
needles to puncture the skin at
particular points.
Studies show that acupuncture can
reduce pain. It’s likely because the brain
releases opium-like molecules during
the practice

34. ChiropracticTreatment
Many AS patients find that chiropractic
treatment helps relieve pain. However, it’s
important to find a chiropractor who has
experience treating those with AS.

35. EDUCATION
 A big part of your physiotherapist's role is to help
educate you about your AS, how it can affect you and
what you can do yourself to help you minimize the
effect AS has on you and your family. Make sure you
ask any questions you might have about work, sleep
or anything else that may be worrying you.
 Physiotherapists can give advice on posture at work,
how to sit correctly at a desk, how a computer screen
can be positioned and what height it needs to be.
 If you do a lot of driving the physiotherapist can talk
you through correct seat position, head rests and
advise you on taking regular breaks.

36. Pain and muscle spasm are treated
by the following modalities and the
relaxation is advised-
Infra red.
Hot packs.
Cryotherapy.
Steam bath.
Hydrotherapy.

37. Exercises for mobilization of joints:-
Maintaining the mobility of joints, by giving
mobility exercises to particular joints, which are
affected like, spine, hip, shoulder, thoracic cage
are essential in Ankylosing Spondylitis
Treatment. Maintenance of the mobility is very
important and the basic aim is that all the joints
are moved to their maximum limit and by this,
we can delay the process of ankylosis.

38. Increase chest expansion and vital capacity:-
 To increase the chest expansion and vital capacity, the
breathing exercises are required. Breathing
exercises that are used in Ankylosing Spondylitis
Treatment:
 Apical breathing exercises.
 Diaphragmatic breathing exercises.
 Lateral costal breathing exercises.
 Deep breathing exercises are encouraged. Ballooning
exercise is also very useful in Ankylosing Spondylitis
Treatment. They increase the vital capacity of the lung.
Thoracic mobility exercises.