I see patients with various back problems; some are relatively easy to manage, others, however, fall outside my scope of practice and competence. Ankylosing spondylitis (AS) is one of those conditions where physiotherapy has an important role to play in combination with pharmacological options.
What is AS?
First of all, it is a chronic, rheumatological, condition and unfortunately can’t be cured. It tends to first develop in teenagers and young adults. AS usually affects 3 times more men than women.
AS starts with pain around the pelvis as sacroiliac joints connecting the pelvis with the spine are affected. Later, it spreads up to the lumbar spine and other parts of the spine.
Main symptoms that tend to get worse with time:
• Pain in the pelvis and the spine; patients have characteristic bilateral pain which gets better with exercises, but rest tend to make the pain worse
• Pain and inflammation in other parts of the body as a result of affected joints
Patients frequently suffer from low grade fevers and tiredness.
Although there is no cure, advances of modern medicine make this illness much more manageable today. AS only minimally affects the life span and patients learn to cope with and manage it throughout the life. There are several treatment options that can slow it down and help greatly with pain and discomfort. The outlook is varied to a great extent; some patients have long periods of remission whereas in others AS seems to progress quickly. It is said that up to 90% patients live independently with AS. Sadly, AS eventually leads to the disability through fused spinal joints, pain and associated deformity.
Diagnosing AS is difficult as there is a number of other conditions with similar symptoms. Physiotherapists can run several diagnostic tests to rule AS out, but further investigations are usually needed.
A Referral to a rheumatologist has to be made. They would request appropriate blood and imaging tests (X-ray and MRI); all these can be helpful, but is not uncommon that these do not pick up any abnormalities, especially in the early stage of the condition.
AS is linked to the presence of the HLA –B27 gene, and therefore, an additional, genetic, test may be undertaken.
In terms of treatment and managing AS, there are several pharmacological options for patients and these can be successfully combined with physiotherapy
Physical treatment can help with slowing down AS. Its main role is to reduce pain, increase spinal mobility and functional capacity, reduce morning stiffness, correct postural deformities, enhance mobility and may have a powerful effect on psychological functioning. Manual therapy combined with soft tissue techniques such as massage, hydrotherapy and general stretches are all good. Patients are encouraged to keep fit and active as much as they can. What is important is that patients understand that they can often modify the course of illness and help themselves a lot. Their input in the treatment is a must if the condition is to be managed successfully.
Patients are also advised:
• To maintain a proper sleeping posture and use a solid bed without pillow.
• Frequent sleeping or lying on the front (this position is also beneficial in many other back pain conditions).
• Posture exercises with flexion of the upper spine to the back
• Breathing exercises as AS affects the joints within the ribcage
• Various motion exercises for hips and knees to prevent flexion limitation and contractures.
• Periodic rest periods with avoidance of fatigue.
• Bracing or corseting (combined with exercises).
Not my area of expertise, but it is worth mentioning that the following pharmacological options can be utilised:
- First line: Non-steroidal anti-inflammatory drugs
- Second line: corticosteroids and disease-modifying antirheumatic drugs
Also can be used:
- Tumor necrosis factor inhibitors