Ankylosing Spondylitis

Question 1

What does ankylosis mean

Answer 1

severe or complete loss of movement at a joint

Question 2

What type of disease is ankylosing spondylitis

Answer 2

an inflammatory disease of unknown origin

Question 3

What joints does ankylosing spondylitis usually affect

Answer 3

intervetebral (between vertebraes) and sacroiliac (between sacrum and hip)

Question 4

How is AS characterised interms of pain and stiffness

Answer 4

Pain and stiffness in hips and lower back, that progresses upwards along spine/backbone

Question 5

What does ankylosing spondylitis treatment consist of

Answer 5

anti-inflammatory drugs, heat, massage and supervised exercise

Question 6

What is rheumatoid arthritis

Answer 6

systemic (many joints and systems involved)
Inflammatory (chronic inflammatory mediators such as monocytes/lymphocytes involved)
Autoimmune disease (immunoglobins and RF's)
It is multisystem chronic synovitis that causes destruction and ankylosis of joints

Question 7

How is RA involved with other diseases

Answer 7

Can get juvenile RA or stills disease (systemic-onset juvenile idopathic arthritis)
Multiple genes involved for disease onset
Feltys syndrome (long standing RA)–> pts have 3 conditions: RA, enlarged spleen and abnormally low blood count
AS

Question 8

How does RA affect joints

Answer 8

High association with RF’s
inflammation in synovial membrane
leads to cartilage destruction
instability of joint

Question 9

What gene increases the risk of an individual getting As

Answer 9

HLA-B27( increases risk by 90-95%)
It is a protein on the surface of WBC
Hence strong genetic predisposition for AS

Question 10

Where does the inflammatory process generally begin in AS

Answer 10

Inflammation at enthesis(where ligament/tendon/capsule attaches to bone)
Inflammation here results in chemical and inflammatory mediators being at the site
Due to long term inflammation, the site becomes ossified and results in enthesitis (ossifying the ligament)

Question 11

What is the process of joint fusion in AS

Answer 11

Enthesitis = fibrosis
Get fibrosis ankylosis–> a fibrous connective tissue process which results in decreased ROM
Proceeds to bony ankylosis/ossification–> osseous tissue fuses 2 bones together reducing mobility
Joint Fusion

Question 12

What are the early signs of primary AS

Answer 12

Decreased ROM (later get a more distinct lack of ROM)
Usually starts at the sacro-iliac joint--> get low back pain for no reason in young adolscents

Question 13

Why is sacro-iliac joint affected first

Answer 13

due to most of load/weight of body being placed on SIJ, it is more susceptible to damage and hence increased risk of fusing

Question 14

What is osseous tissue

Answer 14

tissue formed into bone, hence tissue is ossified

Question 15

What does fibrosis of tissue mean

Answer 15

thickening and scaring of connective tissue

Question 16

what is secondary AS

Answer 16

occurs in older age groups
assoicated with psoriasis (rash)–> a chronic autoimmune disease causing the rapid buildup of skin cells
Also associated with inflammatory bowel disease

Question 17

What is the prevelance of AS

Answer 17

greater occurence in white males
Mainly european–> 15/20 - 40yrs (end of growth spurt=increased ossification)
mainly localised to spine–> SIJ first
Females: spine involvement not as much or as severe (less dramatic changes), possible peripheral joint involvement and less rapid progression

Question 18

What does HLA stand for

Answer 18

Human leucocyte antigen

Found on surface of WBC

Question 19

How does HLA-B27 affect the inflammatory process in AS

Answer 19

Misfolding of HLA-B27 in endoplasmic reticulum (ER) upsets the normal cellular functions and causes a stress response of ER–> upsets the activaitona nd accumulation of inflammatory cytokines
Inflammatory cells (mainly macrophages and lymphocytes=signs of chronic inflammation) accumulate in joint capsule, fibrocartilage, periosteum(enthesis) hence enthesitis
Macrophages and lymphocytes erode–> leaves fibrocartilage hence repair begins
Fibroblasts proliferate–> secrete and synthesis collagen
Collagen organises into fibrous scar tissue
Fibrous scar tissue and chronic inflammation ossifies/calcifies scar tissue
Bone increases and activates osteoblasts to lay down new matric
New matrix becomes callus - fibrous - osseous- bone - changes enthesis
This new enthesis is called a syndesmophyte

Question 20

What are the signs and symptoms of AS

Answer 20

Inflammation causing lower back pain and stiffness
Sclerosis–> hardening of soft tissue (in x-ray sclerosis comes up as bright white)
Early 20’s is peak incidence
Lower back pain decreases with activity, however early morning stiffness present (occurs due to lying in one position)
These changes occur before x-ray changes are seen
Lumbar curvature flattens–> treatment is mobility, back extension
Thoracic curvature increased hence kyphotic
Hip and shoulders flexed as a result of joint fusion

Question 21

How does AS cause respiratory problems

Answer 21

As AS moves up spine, and affects thoracic joints and spine, costotransverse, costosternal and costovertebral also fuse
This decreases chest mobility and ROM and hence the ability for lungs to fully expand and deflate during breathing (rigid chest wall)
As a result, not able to empty lungs out fully due to inability to perform forced expiration
Hence there is ‘leftover’ air in the lungs, which increase the chance of an infection
The rigidity of the chest wall also limits overall lung capacity which can result in shortness of breath, coughing etc

Question 22

How can you examine AS

Answer 22

MRI
4 point test–> put occiput, shoulders, iliac crests and feet touching wall –> in AS one or more points will not touch
Wrigth-Schober test–> mark LS junction in stading and measure and mark 10cm above, get pt to flex at wait and normal increase in measurement is 5cm

Question 23

What are some AS imaging procedures

Answer 23

MRI (able to see inflammation=early diagnosis)
X-ray (can see sclerosis)
Squaring of vertebrae–> closing of waits of vertebrae due to calcification of the spine ligaments which cause loss of anterior contour of spine, hence anterior longitudinal ligament affected
sclerosis of periarticular bone
Obliteration of joint space
Syndesmophytes

Question 24

What is a physio treatment for AS

Answer 24

early diagnosis is better
Education
Continuous physio (continue ROM of spine and peripheral joints)
Physical therapy–> main skeletal mobility, prevent natural progression of contractures, prevention of deformity and maintenance of mobility require a continuous program, exercise performed several times a day
Maintain chest expansion, full extension of spine and complete ROM in proximal joints
Clinical visits and home programs–> monitor pt compliance

Question 25

What is a pharmacological treatment for AS

Answer 25

NSAIDS–> pain relief not prevention
NSAIDs= nonsterodial anti-inflammatory drugs
provide temporary symptom relief
medications don’t prevent disease progression