Ankylosing Spondylitis is believed to be autoimmune or auto inflammatory type of arthritis in which there is a long-term inflammation of the joints of the spine, typically where spine joins the pelvis .
Occasionally other joints such as the shoulders or hips are involved.
Eye and bowel involvement may also occur.
Ankylosing spondylitis affects men more often than women
Signs and Symptoms
Early signs and symptoms /Acute Phase
Pain and Stiffness in the lower back, hips, and buttocks along with pain in the neck.
Tiredness or Fatigue.
Night sweats.
Mild fever
Appetite loss
General discomfort
Symptoms may develop gradually over several weeks or months
Signs and symptoms in Chronic Phase
Pain, Tenderness and stiffness may spread to the other parts of body including shoulders.
AS can eventually lead to changes in posture, Kyphosis of thoracic spine may develop.
Tiredness and Fatigue may persist to the body’s reaction to the inflammation.
Complications
Anemia of inflammation and chronic disease.
Inflammatory bowel disorders (IBD), such as Crohn’s disease or ulcerative colitis.
Eye inflammation. Around 33 percent of people who have AS will experience at least one case of eye inflammation. Pain, blurred vision, sensitivity to light, and watering are symptoms of this complication.
Inflammation of the aorta can occur in those with AS.
Reduced lung capacity. Fusion of the bones may lead to a stiffening of the rib cage, which might cause breathing difficulties.
Spinal compression fracture. Weakened bones can eventually collapse in those with AS causing a fracture.
Pathophysiology
The pathology mainly affects the Entheses, a typical histological finding is called Enthesitis.
Enthesis is the insertion of a tendon, ligament, capsule, or fascia into bone. Typically in anklylosing spondylitis this enthesis is inflamed at the vertebrae.
Studies show that the entheseal fibrocartilage is the major target of the immune system and inflammation in ankylosing spondylitis.
In addition, there is seen to be mild and destructive synovitis or inflammation of the synovium in the joints.
The myxoid subchondral bone marrow is also affected.
The major causative factors of AS are genetic, with the gene encoding HLA-B27 being the most important genetic factor .
Several other susceptibility genes have also been identified.
The HLA-B27 gene (Human Leukocyte Antigen)
Persons who suffer from ankylosing spondylitis seem to carry a particular gene known as human leukocyte antigen B27 (HLA-B27).
Nearly 90% of individuals with the condition test positive for this gene. However, having the gene along may not predict with 100% certainty that a person with get the disease.
Around 8% individuals in the general population have the HLA-B27 gene but do not have ankylosing spondylitis.
Family history of ankylosing spondylitis, such as a parent or a sibling, the risk of developing ankylosing spondylitis is increased.
There are no single agents that have been associated with the causation of ankylosing spondylitis.
There seems to be a complex interaction between raised serum levels of IgA (Immunoglobulin A) and acute phase reactants of inflammation, the body’s immune system and the HLA-B27 gene.
In Chronic Phases of the disease the original and new cartilages are replaced by bone through fusion.
This causes fusion or joining up of the joint bones and stiffness and immobility. This is the main symptom in the spine in ankylosing spondylitis.
Diagnosis
Magnetic Resonance Imaging or X ray.
Radiographic features in AS
The earliest changes in the sacroiliac joints demonstrable by plain x–ray show erosions and sclerosis.
Progression of the erosions leads to pseudo-widening of the joint space and bony ankylosis.
X-ray spine can reveal squaring of vertebrae with spine ossification with fibrous band run longitudinally called syndesmophyte while producing bamboo spine appearance.
Lateral and AP view X ray of lower lumbar region showing fusion of vertebrae.
Blood parameters
During acute inflammatory periods an increase in the blood concentration of CRP and an increase in the ESR in some cases .
While in some cases people with AS have normal levels of CRP and ESR, despite experiencing a significant amount of inflammation.
Genetic testing
Variations of the HLA-B gene increase the risk of developing ankylosing spondylitis, although it is not a diagnostic test.
Those with the HLA-B27 variant are at a higher risk than the general population of developing the disorder.
BASDAI
The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), developed in Bath (UK), is an index designed to detect the inflammatory burden of active disease.
Schober's Test
The Schober's test is a useful clinical measure of flexion of the lumbar spine performed during the physical examination.
Treatment
Medical management
The major types of medications used to treat ankylosing spondylitis are pain-relievers and drugs which include NSAIDs such as ibuprofen, phenylbutazone, diclofenac, indomethacin, naproxen and COX-2 inhibitors, which reduce inflammation and pain.
Surgery
Joint replacement surgery: If the disease has progressed to the point that daily activities are severely impaired.
Osteotomy with fusion: It may be used to fuse curved vertebrae together and straighten the spine .
Laminectomy: A laminectomy is performed to relieve pressure on the nerve roots .
Physiotherapy Management
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.
Respiratory exercises or Breathing exercises
It helps to increase or maintain rib cage excursion, as well as instruction in abdominothoracic breathing, should be taught such as twice the normal rate of inspiration through the nose and expiration through the mouth.
Encourage normal expiration through the nose and normal expiration through the mouth
Deep breathing and then expiration through the mouth slowly.
Resistance exercises for inspiratory pulmonary muscles.
Maintaining posture
A rigorous exercise routine with postural correction can be applied to delay, and possibly stop, the progression of the disease.
Spinal extension exercises are the key component and should be done twice daily.
Education in self-management is essential to discourage therapist dependence.
Proper sleeping posture on a solid, flat bed without pillow. Frequent sleeping or lying in a prone position.
Posture exercises with upper back hyperextension (performed with avoidance of lumbar hyperextension).
Range of motion exercises for hips and knees to prevent flexion limitation and contractures.
Periodic rest periods with avoidance of fatigue.
Bracing or corseting (combined with exercises)
Mobility Exercises
Manual mobilization improves chest expansion, posture and spinal mobility.
Passive mobility exercises consist of general, angular movements and specific translatory movements.
In addition to conventional exercises, flexibility exercises for cervical, thoracic and lumbar spine and major muscle groups.
Aerobic Exercises
Aerobic exercises such as swimming and walking are recommended. Research has shown a significant increase in chest expansion following swimming programs and a significant increase in PvO2 and Six Minute Walk Test distances in patients practicing swimming and/or walking aerobic exercises.
Aerobic exercises lead to a bigger chest expansion and therefore a better functional capacity and also decrease the chances of respiratory failure.
Hydrotherapy
The rationale for the use of hydrotherapy in patients with Ankylosing Spondylitis looks at addressing common symptoms such as stiffness and associated back pain, stooped posture and fatigue.
Warm water provides a relaxation effect the tight musculature around the back.
Buoyancy of water allows stretching to feel easier than on land.
Reduced pain while stretching/exercising as water provides shock absorption.
Easier to stay upright as effect of gravity reduced in water.
References
10]https://pubmed.ncbi.nlm.nih.gov/18254008/?from_term=ankylosing+spondylitis+physiotherapy&from_pos=4
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