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Ankylosing Spondylitis

Rheumatologists divide inflammatory arthritis into two main categories:

  1. Rheumatoid arthritis where people with symptoms of inflammatory arthritis (often involving the hands and feet) have antibodies called rheumatoid factor in their blood. This is often referred to as being rheumatoid factor or sero-positive.
  2. Spondyloarthritis where people with symptoms of inflammatory arthritis (often involving the spine as well as other joints) do not have rheumatoid factor antibodies in their blood. This is also sometimes called sero-negative spondyloarthritis [SpA].  Four different conditions make up the SpA group:
    1. Ankylosing spondylitis
    2. Enteropathic arthritis
    3. Psoriatic arthritis
    4. Reactive arthritis [Reiter's syndrome]

The above SpAs have their own differentiating characteristics, but in each case the body's immune system is wrongly triggered to attack itself, leading to pain, stiffness, damage to joints and, if left untreated, possibly disability.

Ankylosing Spondylitis
Ankylosing spondylitis [AS] is the major sub-type of SpA.  It is a painful and progressive condition which mainly affects the spine but can also affect other joints, tendons and ligaments.  'Ankylosing' is the Greek for fusing together and 'spondylitis' means inflammation of the vertebrae.

Disease Process
In AS inflammation occurs at the entheses, where certain ligaments and/or tendons attach to the bone.  The inflammation is followed by some erosion ('enthesopathy') of the bone at the site of the attachment.  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/or tendons.  Repetition of this inflammatory process leads to further bone formation and the axial skeleton (sacroiliac joints and spinal column) are at risk of eventually fusing together.  Complete fusion of the spine is unusual however and many people will only have partial fusion, sometimes limited to the pelvic bones.

People Affected By AS
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.  In men the most commonly affected areas are the pelvis and spine. Other joints which may be involved are the chest wall, hips, shoulders and feet.  Men are affected approximately twice as often as women.  In women the involvement of the spine tends to be less severe and instead the pelvis, hips, knees, wrists and ankles are most frequently affected.  It is unusual for children under the age of eleven to develop AS symptoms, but in such instances the knees, ankles, feet and hips are the joints most typically affected. Children are less likely to suffer from back pain.

Genetics
Genetic research has indicated a strong association between AS and a gene called HLA B27.  Ninety to 95% per cent of AS patients test positive for HLA B27, but AS only develops in 5% of HLA-B27-positive individuals.  This finding suggests that the gene alone is not responsible for people developing AS and that other, as yet unidentified, genetic and environmental factors also play a significant role in the pathogenesis of AS.  For AS patients carrying the HLA B27 gene there is a 50% chance that their children will inherit the gene and an 8% chance of developing the condition.  If the child has inherited the HLA B27 gene this risk doubles to about 15%. 

People with AS are also genetically predisposed to a range of other medical conditions, including inflammatory bowel disease (Crohn's disease or ulcerative colitis), uveitis / iritis (inflammation of the iris and its attachment to the outer wall of the eye) and the skin condition psoriasis.

Case History Reports
The usual pattern for AS is one of slow and steady progression, with disease complications such as spinal fractures rarely manifesting themselves until much later in life.  People with AS might report a combination of the following when presenting to a clinician:

  1. Back pain for more than 3-months
  2. Age at onset < 30 years
  3. Insidious onset of pain (non-traumatic, gradual)
  4. Improvement with exercise
  5. No improvement with rest
  6. Pain at night (with improvement on getting up).

Diagnosis
The clinical diagnosis of AS is effectively threefold, initially involving a thorough physical examination by a primary healthcare manual therapist (Chiropractor, Osteopath or Physiotherapist) and a rheumatologist to assess a person's flexibility and joint tenderness.  Secondly, blood tests including erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP], which measure the body's levels of inflammation, and a genetic test to identify the presence of the HLA-B27 gene, are carried out.  Thirdly, x-rays and/or magnetic resonance imaging [MRI] are used to highlight any inflammation or damage to the joints.

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

Medications prescribed vary depending on the severity of the condition.  Non-steroidal anti-inflammatories [NSAIDs] help to reduce the symptoms of inflammation and corticosteroids in the form of local injections into joints or in tablet form can be used in cases where only a small number of joints are affected.  If however AS symptoms are not controlled with NSAIDs or corticosteroids, a disease modifying anti rheumatic drug [DMARD] might be prescribed – typically in presentations involving the hips, knees, ankles or wrists (peripheral disease) rather than in the spine (axial disease). 

In more severe cases (people with refractory AS), rheumatologists might consider anti TNF therapy – a new class of drugs for AS.  In people with AS, along with some other forms of inflammatory arthritis, a protein called tumour necrosis factor (TNF) is over-produced in the body. This causes inflammation and damage to bones, cartilage and tissue. Anti-TNF therapy blocks the action of TNF thus reducing the inflammation. NASS reports that four anti-TNF drugs have now received a Europe-wide license:

Adalimumab Etanercept Golimumab Infliximab

In 2008 Adalimumab and Etanercept were approved by the National Institute for Clinical Excellence [NICE] for use on people with AS and in 2011 Golimumab was added to the list.  Infliximab was turned down for cost purposes, rather than effectiveness or side effects.  Each of the above drugs have shown clear efficacy against placebo in AS (Davis et al, 2003; Inman et al, 2008), with marked improvements in pain, functional ability and inflammatory markers such as CRP.  To date, there have been no randomized controlled trials to investigate the use of switching between anti-TNF therapies. It is recognized that a proportion of patients will have to stop their first anti-TNF therapy due to inefficacy or side effects. However there have been no interventional studies to determine the optimal treatment following this first anti-TNF failure.

Most people with AS won't need surgery.  Improved exercise regimens and medications for people with AS have collectively reduced the need for surgery.  For those who do need it, surgery can make a huge difference to your quality of life by reducing pain and improving mobility.  The two types of surgical treatment that are sometimes needed by people with AS are joint replacement surgery and/or spinal correction surgery.

Flare Ups
People with AS have times when their symptoms seem to worsen or flare up, but inadequate research been carried out to date on the pattern of such flare ups and they remain poorly understood.  NASS reports that no clear definition of a flare up in AS has been reached.  Considerations include an increase in disease activity and/or symptoms (leading people to seek additional medication or changes in medication), the presence of additional symptoms such as uveitis / iritis and/or inflammatory bowel disease, or an increase in inflammatory markers in the blood.

Many people with AS eventually come to terms with their symptoms and build up an increased tolerance of symptoms.  For some people their AS might truly be inactive but for others it means only that things have reached a relatively calm steady state.

Manual Therapy & Exercise
The aim of manual therapy treatment is to maintain physical function, reduce physical pain and promote an active and independent life at home and at work in people with AS.  A range of therapeutic modalities exist for AS patients from which practitioners may collate  a bespoke treatment plan based upon an individual's physical function, levels of pain, spinal mobility, stiffness and patient global evaluation.  These modalities include (van der Linden et al, 2002):

  1. Supervised exercises for individuals / groups of patients
  2. Unsupervised, prescribed exercises
  3. Fitness training
  4. Manual therapy (soft tissue and joint mobilisation techniques)
  5. Hydrotherapy and spa therapy
  6. Electrotherapy / ultrasound
  7. Acupuncture
  8. Patient education

Treatment goals for practitioners (with bespoke measurable parameters and timelines) might include (van der Linden et al, 2002):

  1. Avoidance of pain-provoking postures and activities
  2. Independent pain management with proper use of joint protection methods (e.g. postural awareness, use of support devices, pacing of activities, modification of activities, body mechanics and use of comfort measures when required (heat, ice, massage, relaxation techniques)
  3. Improved function including safe and proper ambulation with or without ambulatory devices (canes or a rolling walker), frequency and/or distance of walking
  4. Improved muscle performance/strength and quality of performance based upon repetitions and nature of prescribed exercises
  5. Improved flexibility of identified tight soft tissue structures
  6. Improved level of fitness allowing patients to complete conditioning and/or recreational activities
  7. Maintenance of a patient's maximal potential movement
  8. Prevention of postural deformities
  9. Pain relief
  10. Therapeutic exercises/stretches with extension bias to target identified tight muscles
  11. Thoracic lumbar spine and lower extremity stabilization exercises
  12. Breathing exercises and postural exercises
  13. Gait analysis to ensure balance, safety, pacing of cadence and planning for distance tolerated
  14. Soft tissue and joint mobilisation techniques to improve level of symptoms, mobility and posture

According to (Dagfinrud et al, 2006) AS patients undertaking supervised group physical therapy programmes benefit more than those completing individualized home exercise programmes due to non-physical factors such as mutual encouragement, increased motivation and the exchange of experiences with fellow AS patients.  Additionally, when group exercise is combined with three-week hydrotherapy or spa treatments the intervention is better than weekly group physical therapy alone (Dagfinrud et al, 2006).

Precautionary measures must be employed during all manual therapy sessions to ensure that the most appropriate levels of manual therapy care are administered for each individual AS patient.

Education
Educating and advising AS patients about their condition is crucial as it enables them to better manage their disease and to recognise when it is necessary to seek assistance.  Additionally education improves motivation and reduces patient and/or family anxiety.  The patient needs to fully understand their diagnosis and related basic anatomy for AS, as well as joint protection techniques including postural awareness, activity modifications, body mechanics, stretching techniques, use of ambulatory devices and heat/cold, relaxation techniques or massage. 

Contributing Author:
Nikki Harris MOst. MA APNT Dip. Cert Acup. 

References
Bradley Jacobs, W. & Fehlings, M.D. (2008); Ankylosing spondylitis and spinal cord injury: origin, incidence, management, and avoidance; Neurosurgical Focus: 24(1), pp.12

Davis, J., Braun, J.,  Dougados, M., Sieper, J., van der Linden, S. & van der Heijde, D. (2003); First update of the international ASAS consensus statement for the use of anti-TNF agents in patients with ankylosing spondylitis; Ann Rheum Dis: March 65(3),       pp. 316-320

Dagfinrud, H., Hagen, K.B. & Kvien, T.K (2006); Physiotherapy interventions for ankylosing spondylitis (Cochrane  Review). The Cochrane Library (Issue 1), Oxford.

http://www.nass.co.uk/ [Accessed 29 September 2012]

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

Passalent, L.A. (2011); Physiotherapy for ankylosing spondylitis: evidence and application; Curr Opin Rheumatol: (23)

Ton Nghiem, F. & Donohue, J.P. (2008); Rehabilitation in ankylosing spondylitis; Curr Opin Rheumatol: 20(2), pp.203-207

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