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Ankylosing Spondylitis

6th November, 2012

Ankylosing spondylitis [AS] is an inflammatory arthritic condition, often compared with other examples such as enteropathic arthritis, psoriatic arthritis and reactive arthritis. In each case the body's immune system is wrongly triggered to attack itself, leading to pain, stiffness, joint damage and, if left untreated, possibly disability.  AS alone is a painful and progressive condition mainly affecting the spine but with the ability to affect other joints, tendons and ligaments.

Disease Process
With AS inflammation occurs at the sites where ligaments and tendons attach to bone.  Some erosion of the bone at the site of the attachment follows and as the inflammation subsides, a healing process takes place and new bone develops.  Range of movement becomes restricted where bone replaces the elastic tissue of ligaments and tendons.  Repetition of this inflammatory process leads to further bone formation and the joints are at risk of eventually fusing together. 

Background
The age of onset for AS is < 30 years in 80% of patients.  Some people with AS have virtually no symptoms whereas others suffer more severely.  It is a variable condition, often affecting men, women and children in different ways. 

Symptoms
People with AS might report a combination of the following when presenting to a clinician:

  • Back pain for more than 3-months
  • Age at onset < 30 years
  • Insidious onset of pain (non-traumatic, gradual)
  • Improvement with exercise
  • No improvement with rest
  • Pain at night (with improvement on getting up)
  • Intermittent Flare Ups

Diagnosis
The clinical diagnosis of AS involves a thorough physical examination (with a chiropractor, osteopath or physiotherapist and a rheumatologist to assess a person's flexibility and joint tenderness), blood tests to measure the body's levels of inflammation, and a genetic test to identify the presence of a gene called HLA-B27.  X-rays and/or MRI are used to highlight any inflammation or damage to the joints.

AS Management
There is currently no cure for AS (NASS, 2012).  Management might include manual therapy, medications, invasive and/or surgical interventions which are adapted to suit each individual's AS presentation, current symptoms and clinical findings (Inman et al, 2008). 

Manual Therapy & Exercise
The aim of manual therapy treatment is to maintain physical function, reduce pain and promote an active and independent life at home and at work.  A range of treatments exist for AS patients, including (van der Linden et al, 2002):

  • Supervised exercises for individuals / groups of patients
  • Unsupervised, prescribed exercises
  • Fitness training
  • Manual therapy (soft tissue and joint mobilisation techniques)
  • Hydrotherapy and spa therapy
  • Electrotherapy / ultrasound
  • Acupuncture
  • Patient education

Treatment goals for practitioners might include (van der Linden et al, 2002):

  • Avoidance of pain-provoking postures / activities
  • Independent pain management (e.g. postural awareness, use of canes or a rolling walker, pacing of activities and use of heat, ice, massage and relaxation techniques)
  • Improved function including safe and proper movement with or without walking canes or a rolling walker
  • Improved muscle strength
  • Improved flexibility
  • Improved fitness
  • Prevention of postural deformities
  • Pain relief
  • Therapeutic exercises/stretches to target tight muscles
  • Stabilisation exercises
  • Breathing exercises and postural exercises
  • Gait analysis
  • Massage and joint mobilisation

Education
Educating AS patients about their condition is vital.  It allows them to better manage their disease and to recognise when it is necessary to ask for help.  Education improves motivation and reduces patient and/or family anxiety.

By Nikki Harris, MOst. MA APNT Dip. Cert Acup.

References
Inman, R.D., Davis, J.C., Heijde, D., Diekman, L., Sieper, J., Kim, S.I., Mack, M., Han, J., Visvanathan, S., Xu, Z., Hsu, B., Beutler, A. & Braun, J. (2008); Efficacy and safety of golimumab in patients with ankylosing spondylitis: results of a randomized, double-blind, placebo-controlled, phase III trial; Ann Rheum Dis: September 62(9), pp.817-24

Van der Linden, S., van Tubergen, A. & Hidding, A (2002); Physiotherapy in ankylosing spondylitis: what is the evidence? Clin Exp Rheumatol (28), pp.60-64

www.nass.co.uk