Ankylosing spondylitis is a chronic inflammatory disease primarily affecting the spine and sacroiliac joints, leading to pain, stiffness, and eventual fusion of the spine. Diagnosis often includes clinical tests and imaging, while treatment focuses on alleviating symptoms using medications and physiotherapy to enhance mobility. Surgical options may be necessary for severe cases, and the application of specific exercises and ergonomic practices is crucial for management.

1. ANKYLOSING SPONDYLITIS
BY
SATISH CHAUDHARY
BPT

2. OUTLINE
• INTRODUCTION
• AETIOLOGY
• PATHOLOGY
• CLINICAL FEATURES
• DIAGNOSIS
• INVESTIGATIONS
• DIFFERENTIAL DIAGNOSIS
• TREATMENT
• PHYSIOTHERAPY TREATMENT
• REFRENCES

3. INTRODUCTION
IT IS THE CHRONIC DISEASE CHARACTERIZSD
BY A PROGRESSIVE INFLAMMATORY
STIFFENING OF THE JOINT ,WITH A
PREDILECTING FOR THE JOINTS OF AXIAL
SKELETON.SPECIALLY THE SPINE AND
SACROILIAC JOINTS PRIMARILY AND THEN
OTHER JOINTS LIKE HIP JOINT KNEE JOINT
SHOULDER JOINT AND SO ON.

4. AETIOLOGY
• THE AGE OF ONSET BEING 15-20 YEARS.
• THE EXACT CAUSE OF THIS DISEASE IS UNKNOWN.
• THE STRONG ASSOCIATION HAS BEEN FOUND BETWEEN A GENETIC
MARKER –HLA B27 AND THIS DISEASE.(PRESENT IN MORE THAN 85%
OF PATIENT WITH ANKYLOSING SPONDYLITIS.
• SOMETIME ASSOCIATED WITH URETHRITIS, ULCERATIVE COLITIS AND
CONJUNCTIVITIS.
• RATIO MALE :FEMALE-10:1

5. PATHOLOGY
• -SACROILIAC JOINTS ARE USUALLY THE FIRST TO GET INVOLVED
FOLLOWED BY THE SPINE FROM THE LUMBAR REGION UPWARD.
• THE HIP JOINT, KNEE JOINT, MANUBRIO-STERNAL JOINTS ARE ALSO
INVOLVED.
• INITIALLY SYNOVITIS OCCURS ,FOLLOWED BY CARTILAGE DISTINCTION
AND BONY EROSION
• RESULTANT FIBROSIS ULTIMATELY LEADS TO FIBROSIS,FOLLOWED BY
BONY ANKYLOSIS.

6. • OSSIFICATION ALSO OCCURS IN THE ANTERIOR
LONGITUDINAL LIGAMENT AND OTHER LIGAMENTS OF THE
SPINE
• AFTER BONY FUSION OCCURS, THE PAIN MAY SUBSIDE
,LEAVING THE SPINE PERMANENTLY STIFF.

7. CLINICAL FEATURES
• GRADUALLY ONSET OF PAIN AND STIFFNESS IN LOWER
BACK
• STIFFNESS OF BACK THAT IS WORSE IN THE MORNIN
INITIALLY AMD PROGRESS TO THE WHOLE DAY.
• OCCASIONLY THE PAIN RADIATES TO LOWER LIMB

8. • THE STIFFNESS OF BACK INCREASES
PROGRESSIVELY,AFFECTING THE WHOLE SPINEAND OTHER
PERIPHERAL JOINTS BECOME STIFF GRADUALLY
• IN LATE STAGE, KYPHOTIC DEFORMITY OF SPINE AND
DEFORMITY OF HIP MAY BE PROMINENT FEATURES.

9. ON EXAMINATION
• INITIALLY THERE IS TENDERNESS OVER THE LUMBOSACRAL
SPINE AND SACROILIAC JOINTT.
• THE CHEST EXPANSION DECREASE
• THE GAIT IN THESE PATIENTS IS VERY CHARACTERISTICS-THE
PATIENT WALKS WITH A STIFF SPINE SWINGING THEIR
ARMS IN AN ARC.

10. DIAGNOSIS
• GANSLEN’S TEST
THE HIP AND THE KNEE JOINTS OF THE
OPPOSITE SIDE ARE FLEXED TO FIX THE
PELVIS,AND THE HIP JOINT OF THE SIDE
UNDER TEST IS HYPEREXTEND OVER THE
EDGE OF THE TABLE .THIS WILL EXERT A
ROTATIONAL STRAIN OVER THE
SACROILIAC JOINT AND GIVE RISE TO
PAIN.

11. •PUMP-HANDLE TEST
PATIENT IN SUPINE ,THE
EXAMINER FLEXES HIS HIP
AND KNEE ACROSS THE
CHEST ,SO AS TO BRING IT
CLOSE TO THE OPPOSITE
SHOULDER.THIS WILL CAUSE
PAIN IN THE OPPOSITE SIDE.

12. • FLE’CHE TEST
TI MAY DETECT AN EARLY INVOLVEMENT OF THE
CERVICAL SPINE.
THE PATIENT STANDS WITH HIS HEEL AND
BACK AGAINST THE WALL AND TRIES TO
TOUCH THE WALL WITH THE BACK OF
HIS HEAD WITHOUT RAISING THE
CHIN.INABILITYBTO TOUCH THE HEAD TO
THE WALL SUGGEST CERVICAL SPINE
INVOLVEMENT.

13. • OTHER TESTES
• STRAIGHT LEG RISING TEST
THE PATIENT IS ASKED TO LIFT THE LEG UP WITH THE KNEE
EXTENDED.THIS WILL CAUSE PAIN AT AFFECTED
SACROILLIAC JOINT.
• SACROILIAC COMPRESSION
DIRECT SIDE TO SIDE COMPRESSION OF THE PELVIS MAY
CAUSE PAIN AT SACROILIAC JOINTS.

14. EXTRA ARTICULAR MANIFESTATION
• OCCULAR:ABOUT 25%PATIENT WITH ANKYLOSING SPONDYLITIS DEVELOP AT LEAST ONE
ATTACK OF ACUTE IRITIS
• CARDIOVASCULAR: SPECIALLY WITH A LONG STANDING ILLNESS ,DEVELOP CARDIOVASCULAR
MANISESTATION IN FORM OF AORTIC INCOMPETENCE,CARDIOMEGALY,CONDUCTION
DEAFNESS, PERICARDITIS ETC
• NEUROLOGICAL:PATIENT MAY DEVELOP SPONTANEOUS DISLOCATION AND SUBLUXATION OF
ATLANTO-AXIAL JOINT OR FRACTURE OF CERVICAL SPINE AND MAY PRESENT WITH SIGN AND
SYMPTOMS OF SPINAL CORD COMPRESSION.
• PULMONARY:THERA MAY OCCUR BILATERAL APICAL LOBE FIBROSIS WITH CAVITATION.

15. INVESTIGATIONS
• RADIOLOGICAL EXAMINATION:
X-RAY OF THE PELVIS(AP) AND DORSO-LUMBAR SPINE
(AP AND LATERAL)
RADIOGRAPHS OF SACROILIAC JOINTS SHOWS
INVOLVEMENT,GRADUALLY LEADING TO
FUSION.SIMILARLY THE WHOLE SPINE MAY GET FUAED
EVENTUALLY ;IT IS THEN CALLED THE 'BAMBOO SPINE’
• OTHER INVESTIGATIONS;
ESR-ELEVAED
HB-MILD ANAEMIA
HLA-B27-POSITIVE(TO BE TESTED IN DOUGHTFUL CASES)

16. DIFFERENTIAL DIAGNOSIS
• TB SPINE
• FLUOROSIS
• LUMBOSACRAL STRAIN
• DISC PROLAPSE
• OSTEOARTHRITIS
• OSTEITIS CONDENSANS ILIAC

17. TREATMENT
• NO SPECIFIC TRATTMENT AVAILABLE
• SYMPTOMATIC AND SUPPORTIVE TREATMENT
ANALGESIC AND ANTI-INFLAMMATORY DRUGS FOR PAIN AND INFLAMMATION.
CORTICOSTEROID INJECTIONS MAY BE PRESCRIBED OR DISEASE MODIFYING ANTI-RHEUMATIC
DRUGS (DMARDS), INCLUDING METHOTREXATE AND SULFASALAZINE.
• OPERATIVE METHODS
ROLE OF OPERATIVE TREATMENT IS IN CORRECTION OF KYPHOTIC DEFORMITIES OF THE
SPINE BY SPINAL OSTEOTOMY ,AND JOINT REPLACEMENT FOR CASE WITH HIP OR KNEE
JOINT ANKYLOSING.

18. PHYSIOTHERAPY MANAGEMENT
• PHYSIOTHERAPY IS AN ESSENTIAL PART OF THE TREATMENT OF
ANKYLOSING SPONDYLOSIS. IT AIMS TO ALLEVIATE PAIN, INCREASE
SPINAL MOBILITY AND FUNCTIONAL CAPACITY, REDUCE MORNING
STIFFNESS, CORRECT POSTURAL DEFORMITIES, INCREASE MOBILITY
AND IMPROVE THE PSYCHOSOCIAL STATUS OF THE PATIENTS.

19. • PAIN CONTROL:
1. PAIN AND MUSCULAR SPASM IN ACUTE STAGE ARE
CONTROLLED BY SUPERFICIAL MODALITIES SUCH AS
HYDROCOLLATOR PACKS OR CRYPTOTHERAPY.
2. DEEP HEATING IS EFFECTIVE IN CHRONIC CASES.
3. POOL THERAPY IS BEST FOR PAIN RELIEF AND
IMPROVES MOBILITY AND GIVES A FEELING OF FULL
BODY FITNESS AS THE WHOLE BODY IS EXERCISED.

20. • MOBILITY:
ACTIVE EXERCISE
MOBILIZATION OF SPINE AND OTHER JOINTS
STRETCHING FOR TIGHT MUSCLES AND STRENGTHENING
FOR WEAK SPINE MUSCLE.

21. • RESPIRATION:
DEEP BREATHING EXERCISE(INCREASE CHEST EXPANSION
AND VITAL CAPACITY)
APICAL BREATHING EXERCISES
DIAPHRAGMATIC BREATHING EXERCISES
LATERAL COSTAL BREATHING EXERCISES

22. • BODY ERGONOMIC:
• BODY ATTITUDES PROMOTING DEFORMITIES SHOULD BE DISCOURAGED. MAXIMUM EMPHASIS
NEEDS TO BE GIVEN TO STATIC AS WELL AS DYNAMIC POSTURAL ATTITUDES, E.G. KEEPING THE
CHIN TUCKED IN, REPEATED PRONE POSITION WITH HYPEREXTENSION AT THE DORSAL SPINE
ON FOREARM SUPPORTS, HIP HYPEREXTENSION IN PRONE POSITION AND TRUNK LATERAL
BENDING WITH DEEP BREATHING.
•
• THE USUAL TENDENCY TO STOOP SHOULD BE STRICTLY DISCOUR AGED. INSTEAD, THE CHEST
SHOULD BE HELD UP AND FOR WARD WITH THE SHOULDERS RETRACTED REPETITIONS OF
ISOMETRIC SHOULDER BRACING ARE VALUABLE AND SHOULD BE MADE A PART OF DAILY
ROUTINE..

23. • SURGERY:
• SURGERY MAY BE NECESSARY WHEN THERE IS ANKYLOSIS OF THE JOINTS WITH SEVERE FIXED
DEFORMITY. HIP ANKYLOSIS MAY NEED EX CISIONAL OR REPLACEMENT ARTHROPLASTY. SEVERE
FLEXION DEFORMITY OF THE SPINE MAY NEED WEDGE OSTEOTOMY. APPROPRIATE
PHYSIOTHERA PEUTIC MEASURES WILL BE NECESSARY AS PER THE TYPE OF SURGERY.
• DUE TO RIGIDITY, THE WHOLE SPINE DEVELOPS AN ATTITUDE TOWARDS FLEXION. FLEXED AND
RIGID SPINE DISCOURAGES ATTITUDE TOWARDS PRONE POSITIONING, WHICH, IN TURN,
RESULTS IN FFD AT THE HIPS AND OCCASIONALLY, HIP JOINTS GET ANKYLOSED, WITH
INABILITY EVEN TO STAND; THEY MAY NEED THR.

26. • REFERENCES
• JOSHI AND KOTWAL’S ESSENTIALS OF ORTHOPAEDICS
AND APPLIED PHYSIOTHERAPY
• ESSENTIAL ORTHOPAEDICS (INCLUDING CLINICAL
METHODS)-MAHESHWARI & MHASKAR