Ankylosing Spondylitis (Inflammatory Arthritides)

Question 1

1. What are Inflammatory Arthritides?
2. What is Ankylosing Spondylitis?

Answer 1

1. Inflammatory Arthritides:

A group of inflammatory diseases affecting connective tissue including joints

2. Ankylosing Spondylitis;

AS is a chronic, systemic inflammatory disorder that involves specific areas of the body, primarily the spine

The cause is idiopathic, but it is associated with HLA-B27 antigen and may be genetic

The onset is insidious, usually beginning in early adulthood, with the inflammatory stage of the disease usually ending by age 40

The development of AS is highly variable, with spontaneous remissions and periods of flare-up

A flare-up is when the disease is active or when symptoms are exacerbated

The disease begins with symptoms at the SI joints and over many years, proceeds gradually up the spine

Inflammation at the junctions of ligaments and vertebrae result in fibrosing of the ligaments, bone erosion and later its replacement with new bone

The vertical bone growths replacing the intervertebral discs are called “syndesmophytes”

With severe, long standing AS, the vertebrae take on a fused appearance called “bamboo spine” that when viewed on an x-ray, looks like bamboo

Inflammation of the iris (uveitis), leading to pain, blurred vision and edema can be present in some people with AS

Question 2

stages

Answer 2

1. In the early stages:

The client experiences fatigue, morning stiffness in the lumbar spine and pain the buttocks, low back and occasionally down the posterior legs

Lumbar lordosis is lost due to spasm

Flexion contractures occur in the hips

Symptoms are worse after a period of immobility such as prolonged sitting

2. In the later stages:

Movement in the spine is severely reduced and muscle wasting due to disuse atrophy may be present

With the loss of lumbar lordosis, the thoracic curve becomes more evident

The chest becomes fixed and flattened and the thoracic muscles atrophy

Chest expansion is reduced as a result of costovertebral joint involvement and breathing becomes primarily diaphragmatic

As the disease progresses, neck movements are lost and a head-forward posture develops

Ankylosing of the spine occurs at variable rates and in different patterns

Sometimes, it only affects the SI joints and lumbar spine, but in extreme cases, the whole spine is fused into flexion, causing the person to look down instead of ahead

Pain may diminish over the years with fusion

Medically, it is managed with anti-inflammatories

There is no cure for AS, but spinal deformity is prevented or minimized by regular therapeutic exercises

Question 3

Contraindications

Answer 3

Testing, except for active free ROM is CI’d on acutely inflamed joints

Hot hydrotherapy applications are CI’d during acute inflammation

General massage is CI’d with significant fever (38C, 101.5F)

Lymphatic drainage techniques proximal to the affected joint are avoided with acute infectious arthritis

Local massage is avoided on acutely inflamed joints or over open lesions. Avoid distal techniques that will painfully increase circulation through the joint

Joint play is CI’d on acutely inflamed joints to prevent aggravation of the condition

In tx and self-care, PROM or AROM used as remedial exercise is avoided on acutely inflamed joints

Between flare-ups, deep, vigorous techniques such as frictions and direct fascial techniques may provoke inflammation

With joint laxity and hypermobility, stretching techniques are used with caution

Question 4

Health History Questions

Answer 4

How is your general health?

What specific inflammatory arthritide do you have?

When was the onset?

Is there a history of this arthritide in your family?

What is the frequency of acute attacks? When was the most recent flare-up?

What are your current symptoms?

What are your AD:’s?

How do you feel first thing in the morning?

Which joints are affected? Is ROM affected? Are there any associated systemic concerns?

Are you taking any specific medication for the arthritide?

Has there been any surgery for affected joints?

Are you doing any other therapies?

Question 5

Further Assessment:

Answer 5

1. Health History Questions:

Has the onset of the low back pain been insidious and has stiffness occurred for more than 3 months?

Is there a family history of AS?

Are the symptoms worse with rest and better with exercise?

2. Observations:

Gait assessment will reveal a rigid gait with some knee flexion due to hip flexion contractures

Postural assessment will show lateral views with decreased lordotic curve, increased hyperkyphosis and head-forward posture. With increasing severity of the condition, the hyperkyphosis worsens, rib movement is reduced or absent with breathing and the abdomen may protrude

3. Testing:

AF ROM of the hips and SI joints and spine may be reduced due to stiffness and pain. All ranges may be affected

AF ROM of the spine and AF trunk and hip flexion tests are positive
PR anterior and lateral spinous challenges reveal hypomobility of the affected vertebrae, while rib motion and rib palpation tests reveal hypomobility of the affected ribs

PR ROM of other affected joints is also assessed revealing reduced range and either muscle spasm or leathery end feel

Question 6

Massage

Answer 6

1. Tx goals include:

Decreasing pain, HT and TP’s

Maintaining thoracolumbar mobility and respiratory function

Preventing or reducing postural changes

Educating the client about correct posture and exercises

2. Positioning, Hydrotherapy & Massage:

• Prone and supine:

Hot hydrotherapy applications are used on affected tissues between flare-ups

The massage is a combination of stress reduction and hyperkyphosis treatments

Fascial techniques are used on the anterior thorax

Swedish massage is used on the hip flexors, pecs, scalenes, SCM, intercostals and rotator cuff muscles

Posteriorly, the back extensors, QL’s and scapular retractors are treated as in a hyperkyphosis treatment

Compensatory structures such as hamstrings and lateral rotators of the hip are also treated

PIR () is used to lengthen shortened muscles such as hip flexors and pectorals

Joint play techniques are indicate to maintain mobility in hypomobile joints, such as hips, SI joints, vertebrae, ribs, scapulothoracic articulations and SC joints

Question 7

Self-Care

Answer 7

Exercise to maintain mobility and strength of the hips, entire spine and shoulders. These exercises may become repetitive and boring for the client, but they should be encouraged to continue them as it’s important for prevention

Posterior pelvic tilt exercises and strengthening for the back extensors and scapular retractors are also useful. Swimming is a great exercise that doesn’t stress the affected joints

Diaphragmatic breathing exercises with emphasis on lateral rib motion and sternal lifting help to maintain thoracic mobility

Several 15 minutes rest periods during the day are recommended where the client can lie prone with the arms above the head to prevent hyperkyphosis

Sleeping on a firm mattress with no pillowing and sleeping supine instead of curled up in sidelying to prevent flexion deformities are also suggested