Ankylosing Spondylitis: The Complete Guide

back pain
Contents

Lower back pain is one of the most common reasons for seeking medical help (1). Of the patients with lower back pain, 5% may have ankylosing spondylitis (2). Also called “axial spondylitis” or “rheumatic pelvispondylitis”, this pathology can be defined as: “Chronic inflammatory rheumatism affecting the sacroiliac joints and the spine.

This condition is observed especially in young men and is frequently accompanied by the presence of the HLA B 27 antigen” (3). Moreover, this affection ranks among the rheumatic affections most encountered by liberal physiotherapists. Indeed, its prevalence is 73%, just behind polyarthrosis and rheumatoid arthritis (4). In terms of prevalence, some studies propose a prevalence of 0,1 to 1% (2) while others compare it with that of rheumatoid arthritis. It would then affect between 0,9 and 1,4% of the population living in the United States (1).

At the pathophysiological level, it is important to note that this disease is included in chronic rheumatic diseases (with arthritis, psoriatic arthritis, Crohn's disease, etc.).

From a medical point of view, there is inflammation of the entheses (insertion link on the bone of a tendon) with consequent inflammation (enthesitis) and erosion of the underlying bone plate. In order to counter the inflammatory process, there is then a scarring which leads to fibrosis with enteresophytic processes. This then produces the classic vertebral syndesmophytosis. These inflammatory processes mainly affect the bones of the vertebral column, but also of the appendicular skeleton and other areas such as the capsules and all the areas of insertions on a bone. Synovitis and other manifestations may then occur (5).

It is interesting to note that this disease can manifest itself in different ways: pelvic-spinal syndrome (which corresponds to the best-known form), peripheral enthesitic syndrome, peripheral articular syndrome, but also by extra-rheumatological manifestations such as cutaneous (psoriasis, uveitis, etc.), heart damage (aortic insufficiency), kidney, lung, digestive, neurological or muscle damage. Sometimes, it can affect muscle insertion areas such as the Achilles tendon or the plantar fascia causing the appearance of an exostosis (calcaneal spur) (6). Thus, its spectrum of action seems imposing (5).

The best known, pelvic-spinal syndrome, is characterized by inflammatory-type lower back pain in which the articular surfaces of many articular surfaces of the spine are affected. There is then a progressive loss of mobility with the appearance of deformities. At the level of the spinal axis, it mainly affects the posterior inter apophyseal joints, the intervertebral discs, the sacroiliacs, the common ligaments. In the most advanced stages, the intervertebral disc can be replaced by bone formation, this is called ankylosis (2,5,7). In the long term, this results in a loss of quality of life as well as disabilities (6). Some studies even report a 50% increased risk of mortality (8)

Among the risk factors is gender. However, the literature does not seem to agree 100% at present. Some articles announce a predominance in men (5) while some advance equity (9,10). Age also seems to be a risk factor since young adults, between 26-27 years old, seem to be the preferred age group for the onset of the disease (5). It would also seem that the presence of the HLA-B27 antigen promotes the appearance of the disease since 90% of the affected population presents this antigen (compared to 7 to 8% in the general population).

Diagnostic

 

When a patient comes to the consultation, it usually has the diagnosis of ankylosing spondylitis and it has been derived by a doctor. We will come back to this aspect a little later.

 

However, some patients may be referred to us for lower back pain. In this case, it is essential for the therapist to see the warning signs allowing us to divert the patient to a doctor in doubt of ankylosing spondylitis.

When this patient presents, it is essential to be able to differentiate pain of mechanical origin from inflammatory pain. This pain is usually characterized by:

 

  • improvement with exercise,
  • A lack of improvement or even worsening with rest,
  • nocturnal pain,
  • An age of onset below 40 years and an insidious onset.

 

It is considered that the presence of 4 of these criteria is significant of inflammatory pain (with a sensitivity of 77% and a specificity of 80%) (2). Also, the patient may present with associated conditions that may alert the therapist: psoriasis, arthritis, uveitis, dactylitis, Crohn's disease (even if these are only insignificant signs).

 

A recent medical consensus advises referral of the patient to a rheumatologist when the patient has 4 of the following signs:

 

  • Lower back pain that began before age 35,
  • The patient walks during the second part of the night because of the pain,
  • buttock pain,
  • Improvement of pain with movement,
  • Improvement of pain within 48 hours after taking an anti-inflammatory,
  • A first-degree relative with ankylosing spondylitis,
  • Present or past arthritis, enthesitis, psoriasis (9).

 

The reading of x-rays can also provide a lot of information to the therapist even if very often the patient is diagnosed when the x-rays show signs of ankylosing spondylitis. Among the observable signs, we will note: widening of the joint space, blurring of the edges, irregular contours with osteosclerosis (7). In early cases, erosion ofe the anterior part is visible (anterior erosive spondylitis of Romanus). In advanced cases, merging articular during ankylosis or the bamboo-like column (with syndesmopytes) will be observable (5).

Once derived, the doctor will analyze the blood tests (HLA-B27 antigen, sedimentation rate, CRP), imaging (radiology, CT, MRI) and the patient's clinic. He can use the Amor scale, the New York criteria or the ESSG criteria to validate his diagnosis (5).

Having seen how to spot possible ankylosing spondylitis, let's now take a look at a new doctor-derived patient.

When he arrives, it will be important to draw up a report in order to be able to assess his progress or regression. To do this, various tools are at our disposal:

Mobility measures (7,11)

 

Dorsal and lumbar mobility (with Schober's test, Schober Mac Rae or Schober stepped), dorso-lumbo-pelvi-femoral, cervical, costovertebral, and peripheral joint mobility (see below). It will also be important to assess possible deformities: dorsal curvature, lumbar, cervical posture (wall-neck distance), standing posture

The measure of pain (7,11)

 

Using a VAS, it is interesting to know the evolution of the pain with the intake of NSAIDs (and therefore to know it over 48 hours). We can also couple the number of nocturnal awakenings

Stiffness measurement (11)

 

It will be a question of evaluating the rigidity that the patient feels on waking but also of evaluating the rigidity of the rib cage which can lead to a restrictive respiratory syndrome.

The general feeling of the patient (11) 

 

We will evaluate it with the ASQoL.

Fatigue (11)

 

It can be assessed using a visual analogue scale.

The scales

 

The latter seem very important in view of the information they bring us. If there are different ones, each brings information to the therapist (11):

 

o BASFI (6–8,12): Known as the “Bath Ankylosing Spondylitis Funcional index, it is a functional score that allows the degree of functional impotence of patients with spondyloarthropathy to be expressed. The score ranges from 0 to 10 where the highest value reflects the greatest impotence.

  • Dougados Functional Index (6,7): Resembling the BASFI, it is composed of 20 criteria against 10 for the BASFI. To our knowledge, it is not available in French.
  • BASDAI (2,5,6,8,12): This is a scale to assess disease activity. This scale is made up of 5 aspects: fatigue, vertebral pain, peripheral pain, areas of tenderness and rigidity. The score for each question is added and the total is divided by 5 to obtain a score out of 10 which will be immediately proportionate to the activity of the disease.
  • ASDAS (6): Similar to the BASDAI, this score relates the activity of the disease taking into account the CRP. For some authors, it would be more reliable than the BASDAI (13).
  • KILL (8,14): This is a test to assess the mobility of the spine. It is composed of 5 items including: cervical rotation, tragus wall distance, lateral flexion of the spine, lumbar flexion and the intermalleolar distance. The score for each item is added together to arrive at a score out of 10.
  • The Modified Health Assessment Questionnaire (2)
  • mSASSS (5): This is a score used to assess the radiological progress of the pathology. Its evaluation is based on the state of the anterior corners of the cervical and lumbar in profile. The score goes from 0 to 72.
  • ASQoL (6,12): Score validated in French in 2010 (15), it is made up of 18 double-choice items (yes/no). All the points obtained are added together and divided by the maximum possible total.
  • The WPAI:Spa Scale (12): This is a self-administered questionnaire where the assessment is based on the patient's absenteeism, his presence and his difficulties in carrying out his work or his outside activities. The higher the score, the more difficult the patient is.

Interest of the extremities

 

Finally, it will be more than important to evaluate the peripheral zones. Among the areas to monitor, the hip and the shoulder seem to have priority due to their proximity to the dorsal area. Indeed, from 7 to 78% of patients see their shoulder involved in the painful process (2). We can find pseudo capsulitis for the shoulder and loss of mobility at the hip (and in particular in internal rotation).

Treatment

 

After developing the diagnosis of the patient, it is now time to carry out an adequate treatment of the latter.

 

Generally, it is recognized that the treatment must be a “global” management of the patient both from a physiotherapy and a medical point of view.

 

At the medical level, the following drugs are generally found (5):

 

  • Anti-inflammatories: this is a flagship first-line treatment for ankylosing spondylitis as symptom control is so important.

 

  • Corticosteroids: they are applied in the form of intra-articular injections because their effect by the oral route is only slightly sufficient in this pathology.

 

  • Background treatment or immunomodulators: sulfazanine would only be effective on peripheral disorders

 

  • Anti TNF-alpha: Recently, this new class of drugs has improved the symptomatic management of the patient through a drug: infliximab. However, they are intended for only a few patients due to their side effects (5).

 

After discussing the medical treatment, let's look at the physiotherapy treatment. Recently, a medical consensus adopted as major lines of physiotherapy treatment the following points (9):

 

  • Stretching, strengthening and postural exercises
  • deep breathing
  • Spinal extension
  • Range of motion of the cervical, thoracic and cervical areas of the spine
  • Aerobic exercises.

This correlates with the treatment goals proposed by a 2011 expert consensus (11):

 

  • Decrease pain and discomfort
  • Maintain or improve muscle strength and endurance
  • Maintain or improve flexibility, mobility and balance
  • Maintain or improve physical fitness and social participation
  • Prevent deformities of spinal curves or spinal joints.

 

It is important to note that physiotherapy and rehabilitation should be implemented as soon as the patient is diagnosed, without waiting (11). In order to better understand the means available to the physiotherapist, we will first propose the most found and approved recommendations in the literature before directing us to innovative interventions that have caught our attention.

Most Frequently Encountered Recommendations 

 

  • Stretching and flexibility: Manual therapy (simple mobilizations), exercises of mobility (round back, hollow back, etc.) can be used as can postures on certain occasions (7,11,14). The learning of self-mobilizations is equally important (2). We can we focus on stretching at the cervical, thoracic, triceps, shoulder, paraspinal and hip levels (16).
  • Respiratory exercises: these can be offered in the form of respiratory gymnastics (11). We will focus mainly on learning abdominal-diaphragmatic breathing (16).
  • Active exercises: muscle strengthening exercises will be intended to strengthen the muscles avoiding the adoption of bad postures such as the knee extensors, the nuchal muscles, the dorsal and lumbar extensors, the hip extensors (11).
  • Aerobic exercises: The use of high intensity running type 4 minutes at 90% of HRmax followed by 3 minutes at 70% of HRmax repeated 4 times, twice a week could improve fatigue, emotional distress of patients (6) . Also, exercises on steps can be proposed (16).
  • Therapeutic Education: discussions on the definition of symptoms, pharmacology, the impact of sport, BMI control and diet associated with notions of anatomy and physiology seems to be a crucial point of compliance of the patient to his rehabilitation (6).
  • Hydrotherapy: Swimming appears to improve chest expansion (11) as does water aerobics-type exercises (pain and activity improvement) (17).
  • Physiotherapy: although few studies prove its effectiveness in this pathology, it would seem to be useful in similar pathologies and could improve certain dimensions of the disease. However, it seems more interesting to consider it as an adjunctive treatment (11).
  • Orthoses: if they are referenced in the oldest articles (7), we have nohave found recent recommendations for them.

 

After seeing these classic and recognized treatments, recent studies have been able to highlight the effectiveness of certain treatments. If they are not always the subject of a systematic review, it may be interesting to test them clinically.

  • Qiqong: Qiqong, a popular Chinese practice, is easy to learn. A program consisting of 8 movements generally lasts 15-20 minutes (18).

 

  • RPG: Global Postural Rehabilitation® works on stretching shortened muscle chains (in the case of ankylosing spondylitis, the posterior chain, the internal antero of the pelvis and the shoulder (8,19).

 

  • Pilates: the practice of pilates would allow a improvement in pain, spinal mobility and functionality of the patient by improving the muscles
    abs and back (20,21). A systematic review of 2017 also supports the application of Pilates in this type of patient (22).

 

  • McKenzie Method: Seeking to empower the patient in their treatment. McKenzie suggests exercises based on spinal extension with contraction of the spinal erectors (23).

 

Finally, it seems interesting to note that in terms of modalities, some articles consider that the effectiveness of the treatment will be equal in an inpatient at the clinic or on an outpatient basis (11), others think that the effectiveness is better in outpatient (6) while a recent review considers that the most effective approach is the clinical approach associated with a TPE program (6). In all cases, exercises supervised by a physiotherapist (in a group or alone with the patient) seem more effective than the patient alone (10).

 

 

References 

 

  1. Taurog JD, Chhabra A, Colbert RA. Ankylosing Spondylitis and Axial Spondyloarthritis. Longo DL, editor. N Engl J Med. 2016 Jun 30;374(26):2563–74.
  2. Jordan CL, Rho DI. Differential Diagnosis and Management of Ankylosing Spondylitis Masked as Adhesive Capsulitis: A Resident's Case Problem. J Orthop Sports Phys Ther. 2012 Oct;42(10):842–52.
  3. Quevauvilliers J, Somogyi A, Fingerhut A. Medical Dictionary with Anatomical Atlas. Elsevier Masson; 2009.
  4. Panchout E, Doury-Panchout F, Launay F, Coulliandre A. Prevalence of pathologies encountered in liberal physiotherapy: a tool for rethinking physiotherapy teaching? Physiotherapy Rev. 2017 Dec 1;17(192):3–10.
  5. Claudepierre P, Wendling D. Ankylosing spondylitis. EMC – Locomotor Apparatus. 2009 Jan;4(2):1–18.
  6. Perrotta FM, Musto A, Lubrano E. New Insights in Physical Therapy and Rehabilitation in Axial Spondyloarthritis: A Review. Rheumatol Ther. 2019 Dec;6(4):479–86.
  7. Revel M, Poiraudeau S, Lefevre-Colau MM, Rabourdin JP, Ghanem N, Mayoux-Benhamou MA, et al. Rehabilitation in rheumatic pelvispondylitis. EMC – Physiotherapy – Phys Medicine – Rehabilitation. 2006 Jan;1(1):1–12.
  8. Fernandez-de-las-Penas C, Alonso-Blanco C, Morales-Cabezas M, Miangolarra-Page JC. Two Exercise Interventions for the Management of Patients with Ankylosing Spondylitis: A Randomized Controlled Trial. Am J Phys Med Rehabilitation. 2005 Jun;84(6):407–19.
  9. National Institute for Health and Care Excellence. Spondyloarthritis in over 16s: diagnosis and management. NICE. 2017;
  10. Dagfinrud H, Hagen KB, Kvien TK. Physiotherapy interventions for ankylosing spondylitis. Cochrane Musculoskeletal Group, editor. Cochrane Database System Rev [Internet]. 2008 Jan 23 [cited 2020 Jan 28]; Available from: http://doi.wiley.com/10.1002/14651858.CD002822.pub3
  11. Ozgocmen S, Akgul O, Altay Z, Altindag O, Baysal O, Calis M, et al. Expert opinion and key recommendations for the physical therapy and rehabilitation of patients with ankylosing spondylitis: Recommendations for physiotherapy in AS. Int J Rheum Dis. 2012 Jun;15(3):229–38.
  12. Paul L, Coulter EH, Cameron S, McDonald MT, Brandon M, Cook D, et al. Web-based physiotherapy for people with axial spondyloarthritis (WEBPASS) – a study protocol. BMC Musculoskeletal Disord. 2016 Dec;17(1):360.
  13. Brehier Q. BASDAI or ASDAS: according to CRP, which score to choose to assess the response to anti-TNF alpha in axial spondyloarthritis? 2012.
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