Ankylosing spondylitis is an inflammatory arthritic disease or spondyloarthropathy, classified with reactive arthritis, bowel disease arthritis and psoriatic arthritis. The underlying relationships between these diseases are complex but they are connected by enthesitis (inflammation of the ligament/bone junctions) and by possession of the HLA B27 gene on white blood cells. The enthesitis process at the joint edges can cause fibrosis and then ossification of the area (bone formation).
The frequency of the HLA B27 gene in the population determines the number of people with Ankylosing spondylitis, the most common disease in the spondyloarthropathy group. AS occurs in about 0.1 to 1.0% of people, being much more common in northern Europe and much less common in equatorial regions and with white people more frequently affected. 100 people may possess the HLA B27 gene but only one or two of them will develop AS unless they have a closely related person with it, in which case their risk rises to 15 or 20%.
Only one female is diagnosed with AS for every three males, and female patients' symptoms are often much milder and some may be missed as a diagnosis of AS. The most typical presenting group is young men under 40 years old, with under sixteen year olds making up to twenty percent of this group. The symptoms appear on average at twenty-five years of age and the diagnosis is rarely made above fifty years old. AS can look like mechanical back pain if sufficient attention to detail is not made. Strong and persistent stiffness is often an answer to the question of how they are in the morning.
Ankylosing spondylitis has similarities but distinct differences from the much more common low back pain:
Morning stiffness in the lumbar spine, lasting at least 30 minutes or longer Exercise improves the back pain and stiffness Rest worsens the pain and stiffness Pain is usually worse in the second half of the night, after a time of rest Peripheral joints are affected in 30 to 50% of patients Tiredness is common AS has systemic affects from its inflammatory nature which can include feeling unwell, fever and loss of weight.
Physiotherapy examination of the spine in an AS patient usually uncovers significantly reduced ranges of spinal movement from normal, with perhaps a reduced lumbar lordosis and an increased thoracic curve. Neck movements may also be limited in later stages and a reduction in chest expansion noted due to rib joint involvement. Peripheral symptoms occur in around a third of patients and the physio will palpate the tender areas, searching for evidence of enthesitis in the insertions of the Achilles tendon and plantar ligament of the foot. These are areas of high mechanical stress and commonly affected.
Postural analysis of the AS patient is the first thing a physiotherapist notes after the subjective examination, recording spinal abnormalities, flexed knees, rounded shoulders or poking head posture. The ranges of movement of the cervical, thoracic and lumbar spine are measured and a battery of standard measures taken which allows assessment of the disease progression. The hips or other peripheral joints may be affected and these need to be measured also, with the physio likely testing out sites where the enthesis is likely to be painful and inflamed. If the disease is active then the patient may also have joint effusions and may appear unwell, be sweating and not have slept well.
Initially a physiotherapist might treat an active, inflamed site such as the tendo Achilles insertion using ultrasound, ice and gentle stretching, with foot problems responding to insole use. Whole spine exercises are taught with encouragement to get to the end of the movements, concentrating on antigravity movements including extension of the lumbar and thoracic spine, rotation of the thorax and neck retraction and rotations. To counter the typical spinal deformities, patients are taught to rest in good positions such as flat on a firm surface with only one pillow and lying prone. Pool therapy is very popular and effective and patient education is vital to maintain therapy over time.
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