ANKYLOSING SPONDYLITIS (Marie-Strümpell disease/ Bechterew's disease ) 

ARAVINTH MATHIYALAGANGROUP # 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.

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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”.

•Axial Arthritis (Eg, Sacroiliitis And Spondylitis)•Arthritis Of ‘Girdle Joints’ (Hips And Shoulders)•Peripheral Arthritis Uncommon•Others: EnthesitisOsteoporosisVertebral FracturesSpondylodiscitisCostochondritis

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 joints9. 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 posture3. 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, myocarditis9. Bronchopulmonary system involvement – fibrosis of apical lung segments.10. Urinary system involvement amyloidosis IgA-nephropathy11. Gastrointestinal system involvement ulcerative colitis Crohn’s disease

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

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

Test

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.

TREATMENT1. Regular physical therapy 2. NSAIDS Indomethacin (up to maximum of 50 mg PO tid)

COX-2 inhibitors3. Sulfasalazine, in doses of 2 to 3 g/d- Effective for axial and peripheral

arthritis4. 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 224Ra9. 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.