The inflammatory arthritis diseases or spondyloarthropathies include various diseases such as Ankylosing spondylitis, the arthritis of bowel disease, reactive arthritis and the arthritis associated with psoriasis. The typical linking features of these diseases are enthesitis (an inflammation at the bone/ligament junction) and the presence of HLA B27, a gene on white blood cells. The inflammation at the entheses can develop into fibrosis and eventually to fusion of the joints from bone formation.
AS is the commonest of the spondyloarthropathies and its occurrence varies with the occurrence of the HLA B27 gene in the population, AS being less common in the tropics and more common in northern European countries. 0.1 to 1.0% of people are affected but this varies with latitude and is more common in white people. About 1-2% of people with the HLA B27 gene actually develop AS but this becomes 15-20% likelihood if they have a first degree relative with the disease.
Only one female is diagnosed with AS for every three males, and female patients' symptoms are often much milder and some may be missed as a diagnosis of AS. The most typical presenting group is young men under 40 years old, with under sixteen year olds making up to twenty percent of this group. The symptoms appear on average at twenty-five years of age and the diagnosis is rarely made above fifty years old. AS can look like mechanical back pain if sufficient attention to detail is not made. Strong and persistent stiffness is often an answer to the question of how they are in the morning.
The presentation of Ankylosing spondylitis is similar but different from that of mechanical low back pain due to the inflammatory nature of AS:
Morning back stiffness lasting half an hour and often longer Back pain improved with exercise Back pain worsened with rest Night pain later on in the night Other joints may be affected Fatigue is common Active inflammatory disease can cause systemic affects such as unwellness, weight loss or fever
On examination the physiotherapist can find a stiff lumbar spine with reduced movements from normal, postural abnormality such as a flat lumbar spine and an increased thoracic kyphosis. In later stages neck movements may also be involved and chest expansion will be reduced from normal. In the third of patients who get peripheral involvement, enthesitis develops in areas subject to mechanical stresses, the most common being the insertion of the plantar ligament in the foot and the insertion of the tendo Achilles to the heel. These areas will be palpated by the physio to help confirm the spread of the disease, helping to focus the treatment plan later on.
Physiotherapy assessment of patients with Ankylosing spondylitis begins with postural assessment of spinal deformity and perhaps flexed knees. Increased cervico-thoracic kyphosis is common with a poking chin and rounded shoulders. General spinal mobility is obviously limited in normal movement and assessments are made of the lumbar, thoracic and neck ranges of motion. Other standardized measurements are taken to gage the progress of the disease or the affect of therapy. Areas of peripheral involvement are noted, e.g. the hips, and the appropriate measurements made, with palpation of any painful enthesis sites. Joint effusions, e.g. in the knees, are also possible if the disease is active, along with sleeping problems, sweating and feeling unwell.
Physiotherapists will concentrate on treating the inflamed areas first such as the areas where the ligaments insert into the bone, using insoles, cold, ultrasound and stretching techniques. Routine spinal range of motion exercises are taught to patients with an emphasis on getting to end ranges, concentrating initially on the anti-gravity muscles such as thoracic and lumbar extensors. Neck rotation and retractions and thoracic rotations are also important functional movements not to lose. Patients should rest themselves in good postures such as prone or supine with only one pillow, to avoid accentuating the typical spinal deformities. Treatment for AS in a hydrotherapy pool is beneficial and soothing and patient education important so they keep up their programme.
AS is the commonest of the spondyloarthropathies and its occurrence varies with the occurrence of the HLA B27 gene in the population, AS being less common in the tropics and more common in northern European countries. 0.1 to 1.0% of people are affected but this varies with latitude and is more common in white people. About 1-2% of people with the HLA B27 gene actually develop AS but this becomes 15-20% likelihood if they have a first degree relative with the disease.
Only one female is diagnosed with AS for every three males, and female patients' symptoms are often much milder and some may be missed as a diagnosis of AS. The most typical presenting group is young men under 40 years old, with under sixteen year olds making up to twenty percent of this group. The symptoms appear on average at twenty-five years of age and the diagnosis is rarely made above fifty years old. AS can look like mechanical back pain if sufficient attention to detail is not made. Strong and persistent stiffness is often an answer to the question of how they are in the morning.
The presentation of Ankylosing spondylitis is similar but different from that of mechanical low back pain due to the inflammatory nature of AS:
Morning back stiffness lasting half an hour and often longer Back pain improved with exercise Back pain worsened with rest Night pain later on in the night Other joints may be affected Fatigue is common Active inflammatory disease can cause systemic affects such as unwellness, weight loss or fever
On examination the physiotherapist can find a stiff lumbar spine with reduced movements from normal, postural abnormality such as a flat lumbar spine and an increased thoracic kyphosis. In later stages neck movements may also be involved and chest expansion will be reduced from normal. In the third of patients who get peripheral involvement, enthesitis develops in areas subject to mechanical stresses, the most common being the insertion of the plantar ligament in the foot and the insertion of the tendo Achilles to the heel. These areas will be palpated by the physio to help confirm the spread of the disease, helping to focus the treatment plan later on.
Physiotherapy assessment of patients with Ankylosing spondylitis begins with postural assessment of spinal deformity and perhaps flexed knees. Increased cervico-thoracic kyphosis is common with a poking chin and rounded shoulders. General spinal mobility is obviously limited in normal movement and assessments are made of the lumbar, thoracic and neck ranges of motion. Other standardized measurements are taken to gage the progress of the disease or the affect of therapy. Areas of peripheral involvement are noted, e.g. the hips, and the appropriate measurements made, with palpation of any painful enthesis sites. Joint effusions, e.g. in the knees, are also possible if the disease is active, along with sleeping problems, sweating and feeling unwell.
Physiotherapists will concentrate on treating the inflamed areas first such as the areas where the ligaments insert into the bone, using insoles, cold, ultrasound and stretching techniques. Routine spinal range of motion exercises are taught to patients with an emphasis on getting to end ranges, concentrating initially on the anti-gravity muscles such as thoracic and lumbar extensors. Neck rotation and retractions and thoracic rotations are also important functional movements not to lose. Patients should rest themselves in good postures such as prone or supine with only one pillow, to avoid accentuating the typical spinal deformities. Treatment for AS in a hydrotherapy pool is beneficial and soothing and patient education important so they keep up their programme.
About the Author:
Jonathan Blood Smyth is a Superintendent Physiotherapist at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Bolton.
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