ANKYLOSING SPONDYLITIS

(Marie-Strümpell
disease/ Bechterew's
disease )

ARAVINTH MATHIYALAGAN
GROUP # 6
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
 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.
 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.
 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.
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.
 •Axial Arthritis (Eg, Sacroiliitis And
Spondylitis)
7
•Arthritis Of ‘Girdle Joints’ (Hips And
Shoulders)
•Peripheral Arthritis Uncommon
•Others:
Enthesitis
Osteoporosis
Vertebral Fractures
Spondylodiscitis
Costochondritis
The outer annular fibers are eroded and eventually
replaced by bone → bony syndesmophytes, which then
grows by continued enchondral ossification, ultimately
bridging the adjacent vertebral bodies = “bamboo spine”.
Pathomorphology
 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
 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
 Symptoms (early AS)

5. Stiffness and tenderness of

back muscles.

6. Flattening of lumbar lordosis

7. Bilateral sacroilitis.
 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.
 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
 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
 Question mark posture
Question mark posture, or suppliant posture -
loss of lumbar lordosis, fixed kyphosis,
compensated extension cervical spine,
protruberant abdomen.
 TEST and MEASUREMENT for AS
Cervical mobility Thoracic Lumber mobility
mobility
 Occiput-to-wall  Chest expansion Modified schober
distance index
 Tragus-to-wall
distance Finger-to-floor
distance
 Cervical rotation
Lumber lateral flexion
17 TESTS FOR SACROILITIS

Pelvic compression test

Faber test
Gaenslen Test
Pump Handle test
 PELVIC COMPRESSION TEST
 Test irritability by compressing the pelvis with the patient prone.
Sacroiliac pain will be lateralised to the inflamed joint.
 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.
 GAENSLEN TEST

Gaenslen test
stresses the
sacroiliac joints,
Increased pain
during this test
could be indicative
of joint disease.
LAB TESTS:

HLA B27: present in ≈ 90% of

patients.
ESR and CRP – often elevated.
Mild anemia.
Elevated serum IgA levels.
ALP & CPK raised.
 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.
 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.
 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.
The relevant physiotherapy modalities in
the management of AS include :
Supervised & unsupervised exercises
Training
Manual therapy
Massage
Hydrotherapy
Electrotherapy
Acupuncture
Patient information & educational
programs
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
 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.
 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.
 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
their tolerances to exercise.
 The importance of circulation.
 The encouragement of functional activities.
 The maintenance and improvement of balance, co-
ordination and posture.
 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
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
 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
 Chiropractic Treatment

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