ANKYLOSING SPONDYLITIS AND PHYSIOTHERAPY EXERCISES

ANKYLOSING SPONDYLITIS AND PHYSIOTHERAPY EXERCISES

DEFINITION:

  • Ankylosing spondylitis is a form of arthritis that is long-lasting (chronic) and most often affects the spine .
  • It can cause pain, stiffness, swelling, and limited motion in the low back, middle back, and neck, and sometimes areas such as the jaw, shoulders, hips, knees, and heels.
  • Ankylosing spondylitis is more common in men than women.

CLINICAL MANIFESTATIONS:

  • Inflammation primarily of the joints of the spine, but it can also involve inflammation of the eye, other joints (especially the hips)
  • on occasion, the heart, lungs, and chest wall. If the inflammation continues over time, it will lead to scarring and permanent damage.
  • In some people, the disease is mild and progresses slowly, and symptoms never become severe. Other people may have a more aggressive disease process.

PATHOPHYSIOLOGY:

  • Ankylosing spondylitis (AS) is a systemic rheumatic disease,meaning it affects the entire body. Approximately 90% of people with AS express the HLA-B27 genotype, meaning there is a strong genetic association. 1-2% of individuals with the HLA-B27 genotype contract the disease.
  • Tumor necrosis factor-alpha (TNF a) and IL-1 are also implicated in ankylosing spondylitis. Autoantibodies specific for AS have not been identified. Anti-neutrophil cytoplasmic antibodies (ANCAs) are associated with AS, but do not correlate with disease severity.
  • The association of AS with HLA-B27 suggests the condition involves CD8 T cells, which interact with HLA-B.This interaction is not proven to involve a self-antigen, and at least in the related reactive arthritis, which follows infections, the antigens involved are likely to be derived from intracellular microorganisms.
  • There is, however, a possibility that CD4+ T lymphocytes are involved in an aberrant way, since HLA-B27 appears to have a number of unusual properties, including possibly an ability to interact with T cell receptors in association with CD4 (usually CD8+ cytotoxic T cell with HLAB antigen as it is a MHC class 1 antigen).
  • “Bamboo spine” develops when the outer fibers of the fibrous ring (annulus fibrosus disci intervertebralis) of the intervertebral discs ossify, which results in the formation of marginal syndesmophytes between adjoining vertebrae.

SIGNS AND SYMPTOMS:

  • Pain and stiffnes: Constant pain and stiffness in the low back, buttocks, and hips that continue for more than three months. Spondylitis often starts around the sacroiliac joints, where the sacrum (the lowest major part of the spine) joins the ilium bone of the pelvis in the lower back region.
  • Bony fusion: Ankylosing spondylitis can cause an overgrowth of the bones, which may lead to abnormal joining of bones, called “bony fusion.” Fusion affecting bones of the neck, back, or hips may impair a person’s ability to perform routine activities. Fusion of the ribs to the spine or breastbone may limit a person’s ability to expand his or her chest when taking a deep breath.
  • Pain in ligaments and tendons: Spondylitis also may affect some of the ligaments and tendons that attach to bones. Tendonitis (inflammation of the tendon) may cause pain and stiffness in the area behind or beneath the heel, such as the Achilles tendon at the back of the ankle.
  • Ankylosing spondylitis is a systemic disease, which means symptoms may not be limited to the joints. People with the condition also may have fever, fatigue, and loss of appetite.
  • Eyeinflammation (redness and pain) occurs in some people with spondylitis. In rare cases, lung and heart problems also may develop.
  • Tenderness at the heel.
  • Pain and swelling in a finger or toe.
  • Tendernsess at the base of your pelvis.
  • Chest pain.
  • Inflammation of the eyes.
  • Inflammation of the bowel.
  • Tirdness(Fatigue).

MILD OR EARLY ANKYLOSING SPONDYLITIS:

  • Usually starts with dull pain in the low back and back stiffness. Some people have “flares” of increased pain and stiffness that may last for several weeks before decreasing again.
  • Affected bones of the low back, middle back, hips, or neck may become painful, stiff, and limited in motion. Pain tends to increase slowly over a period of weeks or months, and it is often hard to point to exactly where the pain is. Stiffness is usually worse in the morning. Physical activity often helps decrease pain and stiffness.
  • A feeling of tiredness is common as the disease progresses. This tiredness comes from the body fighting the inflammatory process that is part of ankylosing spondylitis, and from ongoing stiffness and pain.
  • The colored part of the eye (iris) may become inflamed. This inflammation, called iritis, occurs in about 25% to 30% of people with ankylosing spondylitis.Symptoms of iritis include redness and pain in the eye and sensitivity to light.

SEVERE OR ADVANCED ANKYLOSING SPONDYLITIS:

  • Scarring in the spine causes the joints of the spine to grow together (fuse, or “ankylose”). As the bones fuse , back pain will gradually go away, but the spine will remain very stiff and unable to bend. The fused spine is more likely to break.
  • The upper spine can curve forward until eventually the person has a hard time looking straight ahead. In addition, as the spine loses its natural curves it becomes hard to balance for standing and walking, especially if the hips are also affected.
  • Breathing can become difficult as the upper body curves forward and the chest wall stiffens. Severe ankylosing spondylitis can also cause scarring of the lungs (pulmonary fibrosis) and an increased risk of lung infection. This can cause even greater problems in smokers because their lungs are already more prone to lung infection and scarring.
  • Scarring in the eye can lead to permanent visual impairment and glaucoma.
  • In rare cases, the heart muscle can become scarred and the heart valves may become inflamed. The heart may be unable to pump properly (heart failure). The main artery leading from the heart (aorta) can also be affected by becoming inflamed and enlarged near where it leaves the heart.

DIAGNOSTIC TEST:

  • X-rays of the spine and pelvis to check for bone changes (bony erosions, fusion, or calcification of the spine and sacroiliac joints). Certain changes in the sacroiliac joint confirm the diagnosis of ankylosing spondylitis, but those changes can take several years to develop enough to show on X-ray.
  • MRI and ultrasound are both being studied as ways to diagnose ankylosing spondylitis earlier.
  • A genetic test (through a blood test), which may be done to determine the presence of a particular gene (HLA-B27) that is often associated with ankylosing spondylitis. This test will not confirm whether you have ankylosing spondylitis. However, if you have the HLA-B27 gene, you could pass it along to your children. This would increase the chances they could get ankylosing spondylitis or one of the other spondyloarthropathies.
    You will have a physical exam to see how stiff your back is and whether you can expand your chest normally. Your doctor will also look for tender areas, especially over the points of the spine, the pelvis, the areas where your ribs join your breastbone, and your heels.

INTERVENTION/ TEACHING:

  • Reducing pain by taking pain relievers such as nonsteroidal anti-inflammatory drugs, or using heat to decrease your pain and stiffness.
  • Warm showers or baths or sleeping under a warm electric blanket may reduce stiffness.
  • Exercising regularly. This reduces pain and stiffness and helps maintain fitness and mobility of the spine, chest, and joints.
  • Deep breathing exercises can improve or maintain lung capacity.
  • Swimming as part of your exercise program helps to maintain chest expansion and movement of the spine without jarring the spine. Breast stroke is especially good for chest expansion.
  • You should avoid contact sports, since joint fusion may make your spine more likely to fracture as the disease progresses, but your doctor may approve of other activities such as golf and tennis.
  • Maintaining proper posture and chest expansion. Good posture is important because it can help prevent abnormal bending of the spine . Maintaining chest expansion will help prevent problems such as lung infection (pneumonia). It’s a good idea to lie on your stomach a few times each day to keep your spine and hips extended.
  • For sleeping, choose a firm mattress and a small pillow that supports your neck.
  • Using assistive devices such as canes or walkers. Your local chapter of the Arthritis Foundation, your physical therapist, or a medical supply company may be able to help you find assistive devices in your area.
  • If your neck is becoming stiff, your doctor may recommend that you wear a soft neck brace when you ride in the car, to prevent injury in case of an accident .
  • Avoid smoking
  • See your ophthalmologist for regular eye exams.
  • Joining a support group.

MEDICAL TREATMENT:

  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Corticosteroids.
  • Muscle relaxants.
  • Opioids.

PHYSIOTHERAPY TREATMENTS:

  • 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.

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 any 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.

Pain Relief:-

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.

Prevent and correct deformity by giving attention to posture:-

  • The spondylitic patient should always be conscious of his posture while sitting, standing and walking patient should maintain the erect posture during these activities. This helps to prevent and correct deformity and thus help in Ankylosing Spondylitis Treatment.
  • Sleeping should occur in prone position or supine on a firm mattress with a thin or no pillow by this, the spine remain in extended position and not in flexion.
  • The design of chairs is important particularly for those who spend most of their working hours sitting at desk. Low arm chair should be avoided, an upright chair with some cushioning to support the lower lumber spine is better.
  • Adjust the height of the working table and ensure that the patient does not stoop on that.
  • Avoidance of prolonged immobilization or bed rest, because of this, the spinal extensors become weak and by this the extended position of the spine is not retained.

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.

Group Therapy Classes:-

  • The patient can give support to the other member of the class that is another patient.
  • Shared problems providing a good medium for patient’s education and latest information about the disease process.
  • Development of competitiveness and motivational aspects.
  • Improvement in physical fitness.

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