Ankylosing Spondylitis (AS) is a chronic inflammatory rheumatic disease affecting primarily the sacroiliac joints (pelvis) and the spine. Age of onset usually begins between 15-30 years old with 80% of symptoms beginning before the age of 30 years old. AS is more common in men than women. The exact cause of the disease is unknown, but there is a combination of genetic and environmental factors seen with individuals with the disease. There is a gene called HLA-B27 that has been noted to be present in 90% of people with the diagnosis. However, only about 5% of people with this gene develop ankylosing spondylitis. The environmental factors that contribute to AS are less known but include mechanical stress to the entheses and pathological infections. Entheses is the attachment point of a tendon or ligament to the bone. Stresses occurring at this site are linked to the inflammatory response that occurs with AS.
The chief complaint of a person with ankylosing spondylitis will be back pain worse upon waking up or after rest which lasts greater than 30 minutes. The back pain will also improve with movement. A person will have spinal stiffness and loss of mobility in the spine due to the bony fusion that occurs at the joints. Other common symptoms are fever, generalized fatigue, loss of appetite, difficultly breathing, and uveitis which is swelling of the eye.
A diagnosis criteria for ankylosing spondylitis is called the Modified New York criteria. This includes the following: 1) Presence of either bilateral sacroiliitis greater than grade 2 or unilateral sacroiliitis greater than grade 3 on an x-ray. 2) Plus greater than one of the following: inflammatory low back pain for greater than 3 months that improves with exercise and does not improve with rest, limited lumbar spine motion in sagittal and frontal planes, and/or decreased chest expansion for age and sex. The Modified New York criteria for classification of grades include: grade 0 – normal sacroiliac joint, grade 1 – suspicious changes, grade 2 -minimal abnormality with erosions or sclerosis but normal joint width, grade 3 – unequivocal abnormality with erosion, sclerosis, widening, narrowing, or partial ankylosis, grade 4 – total ankylosis.
The American College of Rheumatology developed evidenced based 2015 guidelines and recommendation for the treatment of ankylosing spondylitis. The guidelines strongly recommend the use of nonsteriodal anti-inflammatory drugs (NSAIDs). Some common NSAIDs include ibuprofen, Advil, and aspirin. Other medications strongly recommended are tumor necrosis factor (TNF) inhibitors. Both these medications are used to decrease pain and inflammation. In addition, it is strongly recommended for treatment with physical therapy. Physical therapy interventions may improve pain and function in ankylosing spondylitis. Interventions include posture training, strengthening, stretching, and flexibility exercises, deep breathing exercises, and pain management techniques. Evidence based research has concluded that physical therapy with mobilization treatment for 8 weeks may improve chest expansion, posture, and spine mobility in patients with ankylosing spondylitis. Rehabilitation programs may reduce fatigue and increase spinal mobility following treatment with tumor necrosis factor inhibitors in patients with ankylosing spondylitis. Also addition of cardiovascular training to flexibility training may improve cardiovascular fitness and peripheral joint pain in patients with ankylosing spondylitis. In conclusion, a combination of medication and physical therapy is important for managing ankylosing spondylitis.
Hunter Huberty, SPT, University of North Dakota Physical Therapy Department, 2018
Ward MM, Deodhar A, Akl EA, et al. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis & rheumatology (Hoboken, NJ). 2016;68(2):282-298. doi:10.1002/art.39298.
DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 143424, Ankylosing spondylitis; [updated 2017 Aug 28; [about 32 screens]. Available from http://ezproxylr.med.und.edu:2838/login.aspx?direct=true&site=DynaMed&id=143424. Registration and login required.