Ankylosing spondylosis and physiotherapy- Dr Gurjant Singh (PT)

Ankylosing spondylosis and physiotherapy, clinical diagnosis and treatment

1. Ankylosing Spondylitis ( Marie- Strumpell disease) Presented by:- Dr Gurjant Singh (PT) Assistant Professor, MMIPR

2. “ Ankylos ” – Bend or Fusion “ Spondylos ” – Vertebral Disc “ Itis ” – Inflammation Inflammatory disease of the spine that causes stiffening of the back. Dr Gurjant Singh, Assistant Professor, MMIPR

3. What is Ankylosing Spondylitis ? It is a chronic painful rheumatic disease that involves the back i.e. spine and the sacroiliac joints. It typically begins at the age of adolescence and rarely seen after the age of 45 yrs. It is seronegative HLA-B27 spondyloartropathy Dr Gurjant Singh, Assistant Professor, MMIPR

4. Prevalence & Incidence Prevalence : from 67.7/100000 to 197/100000 Incidence : 7.3 per 100,000 persons More common in males Familial predominance Dr Gurjant Singh, Assistant Professor, MMIPR

5. Etiology Age: - Onset is commonest between 15 to 45 years of age, rarely seen after 45 years Sex: - Male : Female is 3:1 Incidence: - 0.6% of adult males are affected Heredity: - The disease occurs 30 times more commonly in relatives of patients than general population Tissue type: - 95% of patients with AS are HLA-B27 positive. Dr Gurjant Singh, Assistant Professor, MMIPR

6. Pathology Sacroiliac joint synovitis ↓ Enthesitis ↓ Further calcification and ossification ↓ Formation of bony ridges ↓ Syndesmophytes ↓ Bamboo Spine

7. Enthesitis Calcaneal Spur (plantar fascia) Erosion (Achilles tendon) Dr Gurjant Singh, Assistant Professor, MMIPR

8. Syndesmophytes

9. Bamboo Spine

10. Clinical Features Onset – Insidious Morning stiffness – Common in early stages Fatigue – This is a common feature in AS Spinal features – Pain and stiffness in the lumbar spine Pain radiating down the back of leg Lumbar paravertebral muscles spasm Flattening of lumbar spine loss of movement and limited SLR

11. Thoracic features – Diminished costovertebral and manubriosternal movements result in the loss of thoracic expansion. Patient becomes dependent on diaphragm for respiration and there is reduction of vital capacity Dr Gurjant Singh, Assistant Professor, MMIPR

12. Deformity – The common deformities are as follows: - Hyperextension of upper cervical spine Flexion of lower cervical spine Increased thoracic kyphosis Flattened lumbar lordosis Hip flexion deformity Knee flexion deformity Peripheral joints – At later stages pain may develop in: - Shoulders Hips Knees Dr Gurjant Singh, Assistant Professor, MMIPR

13. Criteria of Ankylosing Spondylitis Low back pain of at least 3 months,duration improved by exercise, not relieved by rest Morning stiffness Limitation of lumbar spine in sagittal and frontal planes Reduced chest expansion Unilateral or Bilateral sacroiliitis Dr Gurjant Singh, Assistant Professor, MMIPR

14. Physical E xamination Evidence of sacroiliitis – Faber’s test Expansion of the lumbar spine – Schober test Chest expansion < below 5 cm Enthesitis Posture –forward sloop of the neck, stiffness of the spine, loss of lumbar lordosis , thoracic kyphosis Dr Gurjant Singh, Assistant Professor, MMIPR

15. Sacroilitis

16. Faber’s Test

17. Anthropometric Measurement According to Bath Ankylosing Spondylitis Metrology Index (BASMI) commonly used five measurement are as follows: - Tragus to wall Modified Schober’s test Cervical rotation Lumbar side-flexion Intermalleolar distance (hip abduction) Dr Gurjant Singh, Assistant Professor, MMIPR

18. Tragus to wall: - Starting position: - The patient stands with bare feet together and shoulders, hip and heels as close to the wall as possible. The chin is tucked in as far as possible. Method: - The distance is measured both sides with a rigid rule. The average of the two measurements is recorded. Normal= below 10cm

19. Schober’s test (modified) Starting position: - This measures the amount of lumbar spine flexion.The patient stands bare feet. Method : - Draw a line at L4-L5 junction. Mark 10 cms above and 5 cms below the line. The patient bends forward. Take the measurement between two points. Any increase beyond 15 cms is the lumbar flexion. Dr Gurjant Singh, Assistant Professor, MMIPR

20. Cervical rotation Starting position: - The patient lies supine with head at the end of the plinth and chin tucked in. Ensure shoulders do not move and the head is not tilted back. Method: - Place the goniometer lightly on the head. The patient rotates his/her head. Repeat on other side. Dr Gurjant Singh, Assistant Professor, MMIPR

21. Lumbar side-flexion: - Starting position: - The patient stands as straight as possible with bare feet and back against the wall. The feet are a standardized distance apart. Keep knees straight and heels on the floor. Method: - Place a long ruler at the outer edge of left foot. The patient reaches down the ruler to left with fingers straight keeping shoulders against the wall. Measure the middle finger tip to floor. Above 18cm is normal Repeat on other side. Dr Gurjant Singh, Assistant Professor, MMIPR

22. Intermalleolar distance: - Starting position: - The patient lies supine on the floor with legs apart, knees in extension and feet turned out. Method : - Measure between the medial malleoli . Dr Gurjant Singh, Assistant Professor, MMIPR

23. Extra skeletal manifestations Acute anterior uveitis Cardiovascular disease Pulmonary disease Neurological involvement Renal involvement Dr Gurjant Singh, Assistant Professor, MMIPR

24. Uveitis Anterior Acute and unilateral Red and painful eye Photophobia, lacrimation Attacks usually subside in 4-8 weeks More common in HLA-B27 positive Dr Gurjant Singh, Assistant Professor, MMIPR

25. Cardiovascular May be clinically silent although clinically important Aortitis Aortic valve incompetence Conduction abnormalities Cardiomegaly Pericarditis Dr Gurjant Singh, Assistant Professor, MMIPR

26. Aortic Insufficiency Dr Gurjant Singh, Assistant Professor, MMIPR

27. Pulmonary disease Progressive fibrosis of the upper lobes Eventual secondary colonization with aspergillus Impaired pulmonary ventilation due to involvement of thoracic joints Restrictive lung disease Dr Gurjant Singh, Assistant Professor, MMIPR

28. Neurologic involvement Fracture, instability or compression of vertebrae Ossification of the posterior longitudinal ligament resulting in compressive myelopathy Cauda equina syndrome: lumbosacral roots, pain, sensory loss, urinary & bowel symptoms Dr Gurjant Singh, Assistant Professor, MMIPR

29. Renal Involvement Immunoglobulin A ( IgA ) nephropathy Secondary amyloidosis High incidence of prostatitis Dr Gurjant Singh, Assistant Professor, MMIPR

30. Aims of Physiotherapy for AS patients Pain relief Reducing stiffness Increase of spinal mobility Increase of chest expansion Maintaining good posture Maintain / improve physical function Maintain / improve well-being Dr Gurjant Singh, Assistant Professor, MMIPR

31. Types of Physiotherapy Mainly two types of physiotherapy are given:- Individual Therapy Group Therapy Dr Gurjant Singh, Assistant Professor, MMIPR

32. Individual Physiotherapy Exercises Hydrotherapy Aerobics Education & instruction Dr Gurjant Singh, Assistant Professor, MMIPR

33. Treatment Regular physiotherapy is very essential in the management of an AS patient. This helps in moulding the fibrous tissue along the line of stress, which is continuously formed due to inflammation. It thus helps in preventing restriction of patient’s movement. Relief of pain and muscle spasm may be obtained by local application of hot packs Muscle spasm that persist after the acute inflammation has died down is treated best by hold relax technique. Relief of pain and muscle spasm together with restoration of mobility is readily obtained by hydrotherapy Dr Gurjant Singh, Assistant Professor, MMIPR

34. Hydrotherapy Float lying : - Relaxation practice. Arms and legs pushing down into the water and resting. Arms stretching sideways and upwards. Prone lying grasping rail : - Breast stroke action of the leg Lying on half-stretcher : - Leg pushing down Leg pushing down and out Deep breathing exercises Sitting : - Turning trunk side to side, progress by holding arms forward and grasping. Swimming :- Gradual progression to underwater swimming.

35. Positional Exercises Lying : - Physiological relaxation Practice feeling a position of a straight extended spine. Push arms and legs into the floor (static contractions for quadriceps, glutei and back extensors) Prone lying : - Alternate straight leg raising and lowering. Both legs raising and lowering. Hands clasped behind back, thrust hands towards feet with head and shoulders raising and relaxing. Place hands on floor, raise head and shoulders, walk hands to right and then left (side flexion in extension). Dr Gurjant Singh, Assistant Professor, MMIPR

36. Lying with knees bent (crook lying): - Knees rolling from side to side. Raise right arm upwards and outwards, turn head to watch hand. Repeat to left. Deep breathing exercises with hands over upper abdomen, feel air fill under the hands and then sigh out feeling the hands sink down to encourage full use of the diaphragm. Pelvic tilting forwards and backwards (The ROM is greater if the pelvis is on a small block). Dr Gurjant Singh, Assistant Professor, MMIPR

37. Sitting : - Stretch hand and neck upwards, posture correction. Hands on shoulders, trunk turning from side to side. Hands clasp, bend and twist to touch the right foot stretch upwards and backwards to the left watching hands. Repeat to opposite side. Head and neck turning from side to side. Standing : - Hands on shoulders – trunk turning from side to side. Deep breathing Trunk bending from side to side. Dr Gurjant Singh, Assistant Professor, MMIPR

38. Mobility Exercises Lumbar flexion – extension Lumbar side – flexion Thoracic rotation Thoracic extension Dr Gurjant Singh, Assistant Professor, MMIPR

39. Mobility Exercises

40. Mobility Exercises

41. Mobility Exercises

42. Mobility Exercises

43. Strengthening Exercises Thoracic spine extensors Lumbar spine extensors (glutei) Dr Gurjant Singh, Assistant Professor, MMIPR

44. Strengthening exercises – thoracic spine extensors

45. Strengthening exercises – lumbar spine extensors/glutei

46. Stretching Exercises Neck rotators Neck side – flexors Hamstrings Hip adductors Hip flexors Calf muscles Dr Gurjant Singh, Assistant Professor, MMIPR

47. Stretching Exercises

48. Stretching Exercises

49. Stretching Exercises

50. Stretching Exercises

51. Stretching Exercises

52. Stretching Exercises

53. Group Physiotherapy should comprise of: Exercises given previously Overhead ball throwing to partner Prone lying (over gymnastic ball supported on hands) stretch leg upwards and backwards. Stride standing, pass ball to partner with trunk turning. Dr Gurjant Singh, Assistant Professor, MMIPR

54. Sports to be encouraged Swimming Basketball Dr Gurjant Singh, Assistant Professor, MMIPR

55. Advantages of Group Therapy Patients offer mutual support Competition provides enjoyment at the same time promotes physical fitness. A forum is available for educational lectures on research, diet and cardiovascular fitness. Dr Gurjant Singh, Assistant Professor, MMIPR

56. THANK YOU Dr Gurjant Singh, Assistant Professor, MMIPR