Ankylosing spondylitis

Clinical aspects and physiotherapy management

1. What is the disease which improve pain & stiffness with exercise & worsen with rest… ??? Dr. P. Ratan Khuman (PT) M.P.T., (Orthopedic & Sports) ANKYLOSING SPONDYLITIS

2. What are synonyms? Ankylosing Spondylitis Ankylosing Polyarthritis Atrophic Ligamentous Spondylitis Atrophic Spondylitis Bamboo Spine Fibrosis Ankylopoietica Dorsi Infectious Spondylitis Juvenile-adolescent Spondylitis Ossifying Ligamentous Spondylitis Pelvospondylitis Ossificans Rheumatismal Ossifying Pelvospondylitis Poker Back Rheumatoid Spondylitis Rhizomelic Spondylosis Spondylitis Adolescens Spondylitis Ankyloarthritica Spondylitis Ankylopoëtica Spondylitis Ankylosans Spondylitis Atrophica Ligamentosa Spondylitis Deformans Spondylitis Ossificans Ligamentosa 8 October 2020 2 Ratankhuman (M.P.T., Ortho & Sports)

3. Contents Definition Serostatus Introduction Aetiology Pathology Clinical feature Radiological features Diagnosis & special test Lab test Differential diagnosis Prognosis Management Pharmacological Physical therapy Well known people References 8 October 2020 3 Ratankhuman (M.P.T., Ortho & Sports)

4. Definition It is a seronegative , progressive inflammatory disease presenting with pain & stiffness of spine leading to bony ankylosis of the sacroiliac & spinal joints. (Tidy’s, 12 th ed , 1991) It is an inflammatory systemic disease predominantly affecting the axial skeleton in genetically predisposed individuals. (Carol David, 1999) 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 4

5. Serostatus It is a term used to refer to presence or absence of specific substances in blood serum. Test is looking for specific antibodies in an effort to diagnose a particular disease. A person's test results can be – Sero -positive Sero -negative Indeterminate. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 5

6. Seronegative spondylarthropathy It is a group of diseases involving the axial skeleton & having a negative serostatus . " Seronegative " refers to the fact that these diseases are negative for rheumatoid factor, indicating a different pathophysiological mechanism of disease than what is commonly seen in RA. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 6

7. Conditions typically included within of S eronegative Spondylarthropathies Condition % of people with condition who are HLA-B27 positive Ankylosing Spondylitis Caucasians: 92 % African-Americans:50% Reactive arthritis (Reiter's syndrome) 60-80% Enteropathic spondylitis or spondylitis associated with inflammatory bowel & ulcerative colitis (including Crohn’s disease) 60% Psoriatic arthritis 60% Isolated acute anterior uveitis 50% Undifferentiated spondyloarthropathy 20-25% 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 7

8. Common Characteristics They are in relation to HLA-B27 Inflammatory arthritis, generally sacroiliitis & spondylitis Oligoarthritis , generally with asymmetrical presentation Enthesitis (inflammation of the sites where tendons or lig insert into the bone.) Familial aggregation occurs Rheumatoid factor is not present Extra-articular features, such as involvement of eyes, skin & genitourinary tract Overlap is likely between several of causative conditions 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 8

9. Introduction Ankylosis spondylitis (AS) - Greek word Ankylos = B ent = Stiffening = fusion. When the joint loses its mobility & becomes stiff/fuse it is said to be Ankylosed . Spondylitis = inflammation of the spinal vertebrae Spondylos = Vertebra Itis = Inflammation Describes as inflammation of the spine which can lead to fusion of the bone. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 9

10. AS is 1 st reported in medical literature by “Bernard O’Connor” , an Irish Physician in 1666 – 1698 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 10

11. Etiology Age – adolescence & young adulthood , c ommon between 15 to 40 years Gender – Male > Female [3:1] Incidence – 0.6% of adult male are affected Heredity – occurs 30 time more in relative of patients than general population Tissue types – 95% of patient with AS are Human Leucocyte Antigen (HLA-B27) positive Associated conditions – sacroilitis associated with Ulcerative colitis, Crohn’s disease or Reiter’s syndrome 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 11

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13. Who is At Risk? R isk factors that predispose a person to AS include: Positive HLA-B27 marker A family history of AS Frequent GIT infections 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 13

14. Pathology Synovitis of sacroiliac joints Cellular infiltration of periosteum to ligament or muscle junction ( Entheses & Enthesiopathy ). Chronic inflammation leads to fibrosis which gradually become calcified & ossified in spinal synovial & fibro-cartilaginous joints. Bony ridge form at periphery of IV joints leading to ossification of annulus fibrosis & surrounding tissue (seen in radiography & term as Syndesmophytes ) . 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 14

15. Syndesmophytes 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 15

16. The disease can progress to bony ankylosis of – SI joints Symphysis pubis Joints of lumbar, thoracic & cervical spines Costovertebral joints Menubriosternal junction Sometime the shoulder & knee also affected The changes undergo exacerbation & remissions 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 16

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18. Enthesitis It is an inflammation at the insertion of tendons, ligaments or capsules into bone which is a frequent manifestation in AS Occurred in 50% with long-standing AS & 39.4% with shorter disease duration. Most frequently affected at insertion of Achilles’ tendon &/or the plantar fascia at the calcaneus. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 18

19. Enthesitis in peripheral joints The sites affected can be both the synovium & the insertion of tendons/ligaments at bone. This implies that a peripheral joint might not be swollen, only painful (especially pain on local pressure and, if accessible, on movement). Hip involvement was reported in 27% Shoulder involvement was reported in 25% 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 19

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22. Clinical features Articular features Extra-articular features 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 22

23. Articular features Onsets – often insidious with mild pain & stiffness in lower lumbar spine & SI joints Morning stiffness – common in early stage Fatigue – very common 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 23

24. Articular features cont … Deformities – 'Question Mark ' Deformity Fixed spinal flexion deformities Hyper extended cervical spine 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 24

25. Articular features cont … Lumbar Spinal features – Pain & stiffness Pain radiating down the back of leg (Sciatica) Peraspinal muscle spasm Flattening of lumbar spine All movt are affected SLR is affected bilaterally As disease progress, the same feature are seen in thoracic & cervical 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 25

26. Articular features cont … Thoracic spine features – Diminished costovertebral & manubriosternal movt resulting loss of thoracic expansion Dependent on diaphragm for respiration Reduction in vital capacity Peripheral joints – Pain & stiffness at shoulder, hip & knee 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 26

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28. Extra-articular features Iritis – Painful inflammation around iris occurs in 10% – 30% of patients Cardiac features – Aortic incompetence Constitutional – Weakness General wasting Lassitude 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 28

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31. Extra-articular feature Skin – Associated psoriasis Neurological disease – Spine at risk when combine with fracture 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 31

32. Extra-articular feature Colon – Ulcerative colitis 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 32

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35. Radiographic features Sacroiliac joint – Erosion & sclerosis of bone near the articular surface Ankylos later Spine – Apophyseal joint erosion Squaring of the vertebral bodies with ossification of disc margins Syndesmophytes “Bamboo Spine” due to calcification of longitudinal ligaments & syndesmophytes 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 35

36. Radiographic features 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 36

37. 9 most significant physical problems rated by patients with AS ( Dziedzic 1998) Difficulty sleeping on the stomach Stiffness on waking Difficulty in standing for longer periods Difficulty in prolonged sitting Difficulty in bending Being a spectator rather than participating in activities Pain increasing with higher levels of stress Tiredness on waking Limitation of leisure activities 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 37

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41. Diagnosis & Special Tests Diagnosis criteria were first proposed by Kellgren et al . Rome, 1961 – 1963 Later in New York by Bennett & Burch , 1968 New York criteria have been modified by Cats et al. , 1987 Secondary AS is Dx if it is coexists with psoriatic arthritis, Reiter’s Syndrome & inflammatory bowel disease. ( Calin , 1993) 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 41

42. Diagnosis Criteria for AS HISTORY EXAMINATION RADIOLOGY SCREENING TEST Back pain:     1 . Commences <40 years 2 . Insidious onset 3 . Persists 3 > 3 months 4 . Associated morning stiffness 5 . Improves with exercise ROME CRITERIA 1 . LBP > 3 months Not relieved by rest 1. Limited motion of lumbar spine Bilateral sacro-iliitis 2 limited chest expansion 2 . Thoracic pain and stiffness 3. Iritis (past or present evidence) 3. Iritis (history) NEW YORK CRITERIA 1 . Pain in lumbar spine or at dorsolumbar junction 1. Limited movement of lumbar spine in 3 planes 1. Bilateral sacro-iliitis: grade 3-4 2. unilateral sacro-iliitis: grade 3-4 Or bilateral sacro-iliitis: grade 2 2. Chest expansion < 2.5 cm MODIFIED NEW YORK CRITERIA I . LBP 3 > 3 months, Improved by exercise and not Relieved by rest 1. Limitation of lumbar spine in Sagittal and frontal planes 1. Bilateral sacro-iliitis: grade 2-4 or 2. Limitation of Chest expansion relative to normal values corrected for age & sex 2. Unilateral sacro-iliitis: grade 3-4 Rome criteria: AS if bilateral sacro-iliitis and any clinical criterion are present or four of five clinical criteria. New York criteria: Definite AS if grade 3 or 4 bilateral sacro-iliitis with any clinical criterion or grade 2 bilateral or 3 or4 unilateral sacroiliitis with either clinical criterion 1 or both clinical criteria 2 and 3. Modified New York criteria: Definite AS if unilateral grade 3 or 4 or bilateral grade 2-4 sacro-iliitis and any clinical criterion are present. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 42

43. Modified New York criteria for AS Diagnosis – Clinical criteria – LBP & stiffness > 3 months which improves with ex, but not relieved by rest. Limitation of motion of the lumbar spine in both the sagittal & frontal planes. Limitation of chest expansion relative to normal values corrected for age & gender. Radiological criterion – Sacroiliitis grade 2 bilaterally Sacroiliitis grade 3–4 unilaterally. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 43

44. Modified New York criteria for AS Grading – Definite Ankylosing Spondylitis – If the radiological criterion is associated with at least 1 clinical criterion. Probably Ankylosing Spondylitis if – Three clinical criteria are present. The radiological criterion is present without any signs or symptoms satisfying the clinical criteria (other causes of sacroiliitis should be considered). 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 44

45. Enthesitis Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) Mander enthesitis index 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 45

46. Amor’s Classification Criteria for Spondyloarthritis ( SpA) 1 Clinical symptoms or past history of Lumbar or dorsal pain at night or morning stiffness of lumbar or dorsal pain 1 2 Asymmetrical oligoarthritis 2 3 Buttock pain 1 4 If alternate buttock pain 2 5 Sausage-like toe or digit 2 6 Heel pain or other well-defined enthesopathy 2 7 Iritis 1 8 Non- gonococcal urethritis or cervicitis within one month before the onset of arthritis 1 9 Acute diarrhea within one month before the onset of arthritis 1 10 Psoriasis, balanitis , or inflammatory bowel disease (ulcerative colitis or Crohn’s disease) 2 11 Radiological findings Sacroiliitis (bilateral grade 2 or unilateral grade 3) 3 12 Genetic background: Presence of HLA-B27 and/or family history of ankylosing spondylitis, reactive arthritis, uveitis , psoriasis or inflammatory bowel disease 2 13 Response to treatment: Clear-cut improvement within 48 hr after NSAIDS intake or rapid relapse of the pain after their discontinuation 2 Note: A patient is considered as suffering from SpA if the sums core is > 6 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 46

47. Domains and Instruments for All Three ASAS Core Sets Domain Recommended instrument Physical function BASFI a patient oriented questionnaire of 10 questions that are averaged to yield a score between 0 and 10. As an alternative the Dougados functional index including 20 questions on a 5-point Likert scale (range 0–40) is acceptable. Pain Two separate questions: (1) total pain in the spine due to AS, (2) pain at night in the spine due to AS. Patient global of disease activity Patient global-visual analogue scale ith 0 being no disease activity and 100 being severe disease activity Spinal mobility Four instruments: 1.Occiput to wall distance, 2. Chest expansion, 3. Modified schober index, 4. Lateral lumbar flexion or BASMIa Inflammation (spinal stiffness) Average of morning stiffness duration and intensity (e.g., BASDAI questions 5 and 6) or duration of morning stiffness only Fatigue Fatigue question from the BASDAI Peripheral joints & Entheses Number of swollen joints (44 joint count) Validated entheses index (no preferred instrument) Acute phase reactants ESR Radiographs of spine and hips X-pelvis (SI joints and hips) Lateral lumbar spine and lateral cervical spine ( mSASSS ) 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 47

48. Diagnostic Procedures of As Symptoms Positive family history of AS Inflammatory back pain Thoracic pain Fractures of spine after minor trauma Oligoarthritis Anterior uveitis Diarrhea Shortness of breath 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 48

49. Diagnostic Procedures of As Physical examination BP & Pulse rate Skin: psoriatic lesions ? Eyes: redness, irregular pupil ? Heart: murmur ? Lungs Costovertebral , costotransverse & manubriosternal joints Cervical spine: flexion, extension, rotation, occiput to wall distance Thoracic spine: chest expansion Lumbar spine; Schober’s test, fingers–floor distance, lateral flexion Peripheral joints: arthritis ? Enthesitis lesions ? 8 October 2020 49 Ratankhuman (M.P.T., Ortho & Sports)

50. Diagnostic Procedures of As Laboratory tests ESR or CRP Blood count HLA-B27 antigen (in case of doubtful diagnosis) Urine: erythrocytes, protein ? Radiology Pelvis: sacroiliitis , hip involvement ? Cervical, thoracic, lumbar spine 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 50

51. Laboratory Tests Elevated ESR or CRP Platelet Count may be slightly elevated & mild normochromic, normocytic anemia , due to a chronic disease Positive RA factor & antinuclear antibodies (ANA) do not occur HLA-B27 antigen present in majority of AS patients Adolescent patients, radiographic confirmation of sacroiliitis can be difficult, HLA-B27 testing could be helpful in Rx. Raised levels of Alkaline Phosphatase , primarily derived from bone, & serum immunoglobulin A (IgA) Urine might show protein or erythrocytes in renal involvement. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 51

52. Radiology The radiograph of pelvis show signs of sacroiliitis Severity of sacroiliitis can be graded from 0 to IV of the SI joints. At early stages, sacroiliitis can be detected with CT & MRI before the abnormalities at plain radiograph of pelvis . 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 52

53. Radiology cont... Vertebral column often shows – Bony sclerosis with squaring of vertebral bodies Ossification of annulus fibrosis with syndesmophytes . This might lead to fusion of vertebral column with a classical “Bamboo Spine”. Involvement of hip & shoulder joints – Joint space narrowing can be detected by conventional X-rays. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 53

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62. Differential Diagnosis Other types of spondyloarthropathies Psoriatic arthritis Inflammatory bowel disease: Ulcerative colitis or Crohn’s disease Reactive arthritis Juvenile spondyloarthropathy Other types of arthritis Rheumatoid arthritis 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 62

63. Differential Diagnosis Other causes of back pain Non-inflammatory back pain Fibromyalgia Spine diseases: prolapsed intervertebral disc, spinal tumors , bone tumors Infections: tuberculosis, and others Metabolic diseases Diffuse idiopathic skeletal hyperosthosis (DISH or Forestier’disease 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 63

64. Differential Diagnosis Other causes of sacroiliitis Osteitis condensans ilii, septic sacroiliitis, paraplegia, paget’s disease, dialysis associated Spondylarthropathy, hyperparathyroidism, etc. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 64

65. Prognosis C an range from mild to progressively debilitating & from medically controlled to refractive. Some have active inflammation followed by remission, while others never have remission & have acute inflammation & pain. Unattended cases of AS accompanied by enthesitis , especially when spine inflammation is not yet active, may result in misdiagnosis of normal rheumatism. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 65

66. Prognosis … In long-term undiagnosed – Osteopenia or osteoporosis of spine may occur, causing eventual compression fractures & back "hump". Typical signs of progressed AS are – Syndesmophytes formation on X-rays & abnormal bone outgrowths similar to osteophytes affecting the spine. In fusion of the vertebrae – Paresthesia is a complication due to the inflammation of the tissue surrounding nerves. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 66

67. Disease-specific Instruments Bath AS disease activity index [BASDAI] Bath AS functional index [BASFI] Bath AS metrology index [BASMI] Bath AS radiology index [BASRI] Modified stroke AS spinal score [ mSASSS ] 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 67

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71. Bath AS Metrology Index (BASMI) 5 clinical measurements that reflect axial mobility: Tragus to wall Lumbar flexion Cervical rotation Lumbar side flexion Inter-malleolar distance Grading 0–2 or grading 0–10 or linear function. Total score 0–10. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 71

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75. Management of as 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 75 Education, Exercise, Physical therapy, Rehabilitation, Patient Associations, Self help group NSAIDs Axial Disease Peripheral Disease TNF Blockers Local Corticosteroid DMARD (Sulfasalazine) Analgesics Surgery

76. Management Pharmacology – NSAIDS Analgesic & Cortico-gluco-corticoid injections Disease-modifying Anti-rheumatic Drugs (DMAD) Biological Agents Tumour Necrosis Factor blockers (TNF) Physiotherapy & Exercise Surgical Rx Hip surgery Spinal surgery Atlanto axial dislocation Vertebral fractures 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 76

77. Pharmacology R x The NSAIDs for AS – Recommended as 1 st Line Drug Rx for AS with pain & stiffness Good anti-inflammatory capacity Reducing pain & stiffness rapidly after 48–72 hours With Gastrointestinal (GI) Risk , non-selective NSAIDs plus a gastro protective agent, or a selective COX-2 inhibitor could be used . Analgesics for AS – Might be considered for pain control in whom NSAIDs are insufficient, C/I & poorly tolerated. E.g. Paracetamol & Opioids 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 77

78. Pharmacology Rx 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 78

79. Pharmacology r x Cont … Cortico - gluco -corticoid injections – Directed to the local site of musculoskeletal inflammation may be considered. Disease-Modifying Anti-Rheumatic Drugs (DMARD) The use of DMARDs for the Rx of axial disease in spondyloarthritides (SpA) has been disappointing. Sulfasalazine improves peripheral arthritis associated with SpA, but not spinal pain. Methotrexate is generally used in patients with RA to improve symptoms & slow progression of erosive disease. Bisphosphonates could be useful for spinal symptoms with AS 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 79

80. Pharmacology r x Cont … Use of Biological Agents in AS – Success of anti Tumour Necrosis Factor blockers (TNF) Rx in SpA is probably class “A ” effect. Recommended drugs: e.g. Infliximab, Etanercept , Adalimumab 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 80

81. Pharmacology r x Cont… The following criteria should be fulfilled before initiating biological agents: A definitive diagnosis of AS P resence of active disease for at least 4 weeks as defined by both a sustained BASDAI of at least 4 (on a scale of 0-10) & an expert opinion based on clinical features, acute phase reactants & imaging modalities. P resence of refractory disease defined by failure of at least two NSAIDS during a 3-month period , failure of intra-articular glucocorticoids if indicated & failure of sulfasalazine in patients with peripheral arthritis. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 81

82. Physiotherapy Management 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 82

83. Physiotherapy Management There are ample of evidence that Physiotherapy in the form of exercises is effective (level A evidence) in management of AS - SpA . However, scientific evidence of long-term effectiveness is not yet available. But some suggested, ex should be continue life time. Most AS feel too stiff to ex in morning, so taking a warm bath before ex tends to ease this discomfort. Choose a time of day that works best for patient. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 83

84. Aims of Physio Rx To educate the patient To relieve pain & spasm To maintain & improve mobility of the spine & peripheral joints. To strengthen the muscles of the trunk, the legs, the back & the abdomen To minimize deformities To regain fitness To relax the body 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 84

85. Patient Education Before starting an exercise program Patient education plays a central role in successful management of AS. Soon after Dx of AS, patients should be explained about possible progression of symptoms & other C/F, prognosis & treatment. Informing the patient about the possible occurrence of spinal ankylosis will enhance compliance with proposed treatments. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 85

86. To Relieve Pain & Spasm Heat therapy as a hot pack can be applied locally to the specific joint & muscle affected. Hold-relax technique are best in relieving muscle spasm after acute inflammatory changes . Hydrotherapy helps in minimizing pain & spasm & also restored mobility . Recreational exercise – Improves pain and stiffness & improves function. Exercise at least 30 min/day Exercises at least 5 days/week 8 October 2020 86 Ratankhuman (M.P.T., Ortho & Sports)

87. Application of Heat Warm shower or application of local heat promote relaxation & help in stretching of tight muscles. Should not apply local heat to an area >15min at a time Avoid areas overlying artificial joints. Keep the temperature of the heating pad at low or medium level, never on high setting. Do not lie on back with the heating, it increase the risk of burn due to decreased blood circulation in the area by pressure of body weight. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 87

88. Swimming Swimming is an ideal exercise because it gently uses all the muscles & is very relaxing. It provides aerobic exercise to enhance general fitness & enhance lung capacity. Warm or even hot pool is generally most comfortable. Heated swimming pool or spa helps to decrease pain and stiffness. Low-impact exercises in the water (swimming & water aerobics) & stationary bicycling can help improve ex capability, muscle strength & ROM. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 88

89. Sona/ SPA 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 89

90. Swimming cont … Regular free-style swimming is considered to be one of the best exercises for people with AS. Using a snorkel may be helpful. Careful not to slip on wet surfaces in the pool area & it is also wise to avoid diving. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 90

91. Spinal Extension & Deep Breathing Ex Spinal extension exercises in prone lying Hold time: 5 seconds and then relax Repeat the exercise about 20 times. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 91

92. Spinal extension and deep breathing exercises cont… Chest Expansion Exercise in supine – Clasping hands behind head & extending your elbows outwards towards the bed while taking a deep breath. Hold the breath for a count of 10 before exhaling and relaxing for about 10 seconds. Repeat the exercise about 20 times. Give up smoking , in order to prevent its adverse effects on the lungs and heart. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 92

93. Spinal extension and deep breathing exercises cont… Combine spinal extension & chest expansion exs – Performing corner push-ups Take in a deep breath during this manoeuvre. After a count of 10, exhale while returning. Repeat exercise about 20 times thrice daily if possible . 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 93

94. Muscle-strengthening and stretching exercises Strengthening of back extensor & hip muscles to keep the spine mobile & erect. Try achieving functional ROM of hip & shoulder joint Daily stretching of involved joints to improve mobility of the back, hips, shoulders, or other involved joints. Needs of Ex are – To prevent stiffness To regain muscle strength & prevent muscle wasting & weakness. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 94

95. Examples of exercises BRIDGING 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 95

96. CAT & Camel EXERCISE 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 96

97. SIDE BENDING 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 97

98. ROTATION 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 98

99. ROTATION 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 99

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102. SHOULDER ROM EX 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 102

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104. group exercise Use of large Swiss balls & group exercise sessions that include hydrotherapy are enjoyable and very helpful . In some European countries, professionally supervised special physiotherapy and hydrotherapy group sessions for AS patients have been organized by AS patient organizations. Group physical therapy is cost-effective compared to individualized therapy. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 104

105. Living with as: some hints If you have physical limitations due to advanced AS, there are devices to help perform daily tasks: Walking canes, Special chairs and desks, Special shoes, and Devices that assist in putting on socks or stockings and shoes, or for scratching or applying soap on back, etc. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 105

106. Avoiding falls Always wear a good pair of skid-resistant shoes. Use grab bars in the shower and toilets, shower seats, raised toilet seats, and floor lighting at night. Avoid slippery surfaces and loose carpets. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 106

107. Posture Sleep on a firm bed to maintain a good resting posture at night. Preferably make a habit of sleeping prone, to prevent hip joints and the back flexion. Avoid a pillow under knees because it increase the tendency to muscle and tendon shortening. Avoid a saggy mattress or a waterbed. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 107

108. Avoid using a pillow if possible, or use one just thick enough to allow a horizontal position of the face to prevent pain from overextension of neck. Practice lying prone e.g. for 5 minutes or more before getting out of the bed in the morning, and also before going to bed at night. People with AS need to practice good posture habits at all times, and should be taught about dynamic, resting, and occupational postures. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 108

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110. Dynamic posture Be aware of standing posture & try to maintain an erect posture, with the spine as straight as possible. Avoid any tendency to slump forward. Splints, braces and corsets are generally not helpful and are not advised. Some form of bracing may be necessary on rarely. e.g. after injury to the back or neck 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 110

111. Occupational posture Analyse habitual and work postures and modify working positions to maintain a good posture. E.g, a drafting table with tilting work surface may be better than an ordinary office desk for writing and reading & avoiding stress on neck. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 111

112. Occupational posture cont… Avoid physical activity that places prolonged strain on back & neck muscles, and prolonged stooping or bending. Alternate between sitting and standing positions to perform jobs that take a long time to finish. Maintain a good posture while sitting, and avoid sitting for prolong periods, especially in low soft sofas and chairs. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 112

113. Occupational posture cont… During your mid-day break at work, lie flat for a few minutes, and do some corner push-ups to stretch the back. A daily routine of deep breathing and spinal motion/stretching exercises may minimize the fusion, and at least preserve better posture. Do deep breathing exercises at frequent intervals during the day. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 113

114. Sports and recreational activities Sports and recreational activities that encourage good posture & arching of the back (extension) and rotation of the trunk are recommended. E.g. walking, hiking, swimming, tennis, badminton, cross-country skiing, and archery. Volleyball and basketball are excellent sports for people however, not everyone can tolerate. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 114

115. Sports and recreational activities cont… Sports activities that require prolonged spinal flexion may not be recommended. E.g. golf, bowling & long distance cycling Body contact sports (boxing, rugby, soccer, American football & hockey) and downhill skiing, are also not recommended due to greater potential for injury. Stationary cycle are good, but the handlebars must be properly adjusted not to lean forward while exercising. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 115

116. Sports & recreational activities cont … Cycling is good for general cardiovascular conditioning, strengthening the leg muscles, and exercising the hip and knee joints. Aerobic exercises with machines that enhance back, leg, and shoulder extension are helpful, but should avoid undue stress on the neck. 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 116

117. Well-known people with AS Pope John Paul Mötley Crüe's guitarist Ed Sullivan , US World Chess Champion Vladimir Kramnik England cricket captain Mike Atherton Australian cricketer Michael Slater Norwegian Prime Minister Jens Stolenberg Scottish snooker player Chris Small US Major League baseball player Rico Brogna Taiwanese musician Jay Chou Czech writer Karel Capek Ian Woosnam British golfer French tennis player Tatiana Golovin Lee Hurst comedian 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 117

118. Pope John Paul 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 118

119. World Chess Champion Vladimir Kramnik 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 119

120. England cricket captain Mike Atherton 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 120

121. Australian cricketer - Michael Slater 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 121

122. French tennis player Tatiana Golovin 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 122

123. Norwegian Prime Minister Jens Stolenberg 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 123

124. Scottish snooker player Chris Small 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 124

125. US baseball player Rico Brogna 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 125

126. Comedian - Lee Hurst 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 126

127. Reference Joachim Sieper, ankylosing spondylitis in clinical practice, 2011 Barend J. Van Royen , ankylosing spondylitis diagnosis and management, 2006 Karen Atkinson, Physiotherapy in Orthopaedics: A problem-solving approach, 2005 Muhammad asim khan, Ankylosing Spondylitis: the facts, 2002 Stuart Porter, Tidy Physiotherapy , 13 th ed, 2003 Ann Thomson, Tidy Physiotherapy , 12 th ed, 1995 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 127

128. Reference cont… Van Der Linden, Evaluation Of Diagnostic Criteria for Ankylosing Spondylitis: A Comparison of the Rome, New York & Modified New York Criteria in Patients with a Positive Clinical History Screening Test for Ankylosing SpondylitiS, British Journal Of Rheumatology 1985;24:242-249 Joachim Sieper Ankylosing Spondylitis, Seminar, Medical Department I, Rheumatology, April 21, 2007 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 128

129. Reference cont… J Sieper et al., The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess SpA, Ann Rheum Dis 2009;68;ii1-ii44 AN Malaviya et al., Indian Rheumatology Association consensus statement on the diagnosis and treatment of axial SpA, 8 October 2020 Ratankhuman (M.P.T., Ortho & Sports) 129