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Ankylosing Spondylitis

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Kate O'Sullivan

on 27 March 2014

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Transcript of Ankylosing Spondylitis

Ankylosing Spondylitis

Rheumatology is a multidisciplinary branch of medicine that deals with the investigation, diagnosis and management of patients with arthritis and other musculoskeletal conditions.

The chief problem is delayed diagnosis: many people go undiagnosed for 8 – 11 years (Feldtkeller
et al,
Multi-Disciplinary Team Managemement
“We have a place and it’s important we are here, but our place is part of something bigger”

Break Time!
Objectives of Short Course
What is AS?
Ankylosing spondylitis (AS) is a chronic inflammatory disease of unknown aetiology, characterised by inflammation of spinal joints and adjacent structures that may lead to progressive and ascending bony fusion of the spine (Davis 2005).

The exact pathology of AS remains largely unknown.
Limited evidence

Disease Process
Wide geographical and ethnic variation in reported estimates of the prevalence of AS

Worldwide prevalence of up to 0.9% (Sieper et. al 2002)

Male: Female 5:1

Arthritis Ireland (2013) reports that there are currently over 44,000 people diagnosed with AS

Age of onset
Inflammatory Process
Human Leucocyte Antigen (HLA) B27

Tumor necrosis factor-alpha (TNF)and interleukin 1(IL-1)

T-Cell Response
Environmental Factors
Learning Needs from Case Study

To present information on the background of AS

To be able to identify clinical features of AS in order to refer appropriately
To gain an in-depth understanding of the role of physiotherapy in AS, by giving the necessary tools to formulate an appropriate treatment plan.

To have an awareness of the psychosocial issues and their impact on daily life in people with AS and other chronic conditions

To be able to transfer the above skills to other areas of practice
Why Pick Ankylosing Spondylitis?
Other Rheumatic Diseases
Class Survey
Poor awareness of AS among physiotherapists in Ireland
Inflammation occurs at the site where ligament attaches to bone (entheses)
Cytokines are released as part of the healing and repair process post inflammation

Tissue scarring, which eventually leads to extra bony formation (syndesmophytes) forms as a result.
Chronic cycles of inflammation leads to bony fusion of ligaments in the spine
et al
, 2014
NASS, 2013
Peripheral Joint Involvement



Temperomandibular Joint

(Zochling et al, 2006).
et al
, 2013)
(Dougados et al, 2010)
(Li et al, 2012).
Extra-Articular Symptoms




Inflammatory Bowel Disease

Enthesitis is inflammation at insertion sites of tendon, ligament, fascia or joint capsule to bone (Rudawaleit et al 2009)

Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) (Heuft-Dorenbosch
et al
, 2003).
Psoriasis presents as raised, red, scaly patches on the skin and is present in 10-25% of those with AS.
Uveitis is inflammation of the middle layer of the eye. 20-30% develop (Agache et al 2008)
An overwhelming sense of tiredness, lack of energy, and feeling of exhaustion. Disease related fatigue is often chronic, more severe and unrelieved by rest or sleep (Brophy
et al
, 2012).

Collective term for Ulcerative Collitis and Crohn’s Disease. Mucosal iflammation of GI tract with abdominal pain, diarrhoea, urgency and weight loss.

NASS, 2013
It is the most widely used method of diagnosing AS currently.
Occupational Therapist
Self management advice
Home assessment/ environmental modification
Joint protection/orthoses
Fatigue management
Sleep hygiene
ADL training

Clinical Nurse Specialist
Education regarding disease management and drugs
Joint assessments
Administering drugs
Giving injections
Psychological support
Refer to other health professionals
Monitor patients on DMARDS
Managing depression and anxiety (common in AS)
Address barriers to healthcare utilisation
Coping with diagnosis/chronic condition
Scarcity of literature regarding psychology in AS
Alternative Therapies
Objectives of Physiotherapy
Maintaining and/or increasing:
Recommended by ASAS/EULAR guidelines
Can help with postural management when combined with stretching and ROM exercises
Counteract deconditioning
Maintain and improve bone health

An increased risk of cardiovascular (CV) mortality and morbidity has been associated with patients who present with AS.

Lower physical activity levels because of intermittent and fluctuating disease activity, pain, and fatigue can also contribute to AS-related CV disease.

Flexibility exercise has rarely been investigated in isolation.

Don’t know effect on long term disease process.

Flexibility as part of a mixed intervention appears to improve flexibility and spinal mobility.

Medical Management
Surgical Management

Analgesics (Opioid and Non-Opioid)


Anti Tumour Necrosis Factor (TNF) alpha

Hip – THR, hip re-surfacing

Spinal surgery – corrective osteotomy and stabilisation.

Denis Finn, Nevin Kasantzi, Conor Mahony, Mark Melbourne , Katie O'Neill, Kate O'Sullivan
AS Overview
Differential Diagnosis
Management of AS
Life with AS
Ankylosing Spondylitis Overview
Case Studies!
Differential Diagnosis
“A greater emphasis on physiotherapist IBP education in professional university programmes, CPD courses and via physiotherapists’ preferred educational approaches may improve early detection and hence outcomes in AS”

"Being able to identify the onset of it, and refer appropriately is essential to getting diagnosis established and get appropriate treatment straight off"
Angela Reid, Senior Physiotherapist
7.8% could identify all 4 features of IBP, 40% did not believe peripheral joint symptoms were associated with AS and 80% were interested in furthering their education on this topic

(Flynn et al 2014)
(Flynn et al 2014)
Dr Alexander Fraser, Consultant Rheumatologist
Signs and Symptoms
Chronic low back pain

First symptoms before the age of 45

Morning stiffness that lasts longer than 30 minutes

Pain improves with exercise, not rest

Awakening in the second half of the night

Alternating buttock pain

(Sieper & Braun 2011)
Inflammatory vs Mechanical Back Pain
Does Ann need further investigation?
Niall Halliday, Senior Physiotherapist
The role of the rheumatologist is to diagnose, treat and medically manage patients with AS
American College of Rheumatology, 2013
Muscle strength
Endurance and overall fitness
Preventing postural changes and joint deformities
Evidence Based Practice
Research Evidence
Expert Opinion
Patient Preference
Treatment Plan
et al
, 2013).
Keep the weight setting low so that you can manage the full number of reps in each set without difficulty. Allow at least 1 day rest between each session
Glute Strengthening
Spinal Strengthening
Lat pull down
Seated row
Leg press
NASS, 2010
Evidence Based Practice
Research Evidence
Expert Opinion
Advises to use ACSM Guidelines - "Should aim for 30minutes in 5 days of the week, but this can be broken up into 10minute segments."
Patient Preference
Treatment Plan / Options
Paddy pics

back in action
Evidence Based Treatment
Evidence Base
Expert Opinion
Should be done after a warm-up
Should be held for at least 30 seconds
No breath holding
Should not be painful
Patient Preference
Treatment Plan
Due to the disease process resulting in stiffness and a reduction in spinal range of movement, flexibility exercises are required to maintain /restore joint and muscle length.
Hip flexors
Latissimus Dorsi
Breathing Exercises
NASS, 2010
Evidence Based Practice
Evidence Base
Cervical and thoracic spine ROM
Stretching of anterior muscle groups
Flexibility exercises for the lumbar spine
Postural Advice
Strengthening posterior muscle groups
Expert Opinion
"It is of critical importance that our patients have an excellent understanding of good posture and neutral spine position"
Patient Preference
(Gunay et al, 2012)
Hammond, 2010
(British Society for Rheumatology, 2012)
(Wolf, 2012)
(Rudwaleit et al, 2005)
“The rheumatologist will tell you, its all about the drugs and he would be dead right, drugs is where it’s  at."
Niall Halliday, Senior Physiotherapist
"With time you'll find that Musculoskeletal Triage will all be going through physio....so it will be very important that you guys are skilled up"

(Sieper et al, 2002)
(Khan, 2002)
(Sieper et al, 2002)
To address differential diagnosis in AS

Learning Outcomes:
Identify the common signs and symptoms of AS
Distinguish between the key features of inflammatory back pain due to AS and mechanical low back pain
Justify whether or not to refer a patient for further investigation

To give an overview of the evidence based management of AS

Learning Outcome
Explain the role of physiotherapist within the multidisciplinary team in the management of patients with AS
Prescribe an evidence based individualised exercise programme
Appreciate the components of the BASMI and have an awareness of how to apply it

"Stretching programs should be carried out daily"
Arthritis Australia, 2012
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