Lecture: Musculoskeletal Physiotherapy Dr.

Mahdi
ANKYLOSING SPONDYLITIS
DEFINITION
It is a chronic autoimmune seronegative disease characterized by
progressive inflammatory stiffening of the joints with a predilection for the
joints of axial skeleton, especially the sacro-iliac joints. The disease is also
known as Spondyloarthropathy.

Aetiology
Age: Onset is most common between 15 and 40 years although it can
occur at any age.
Sex: It is most common is men than in women by a ratio of 3:1.
Incidence: 0.6% of adult males are affected.
Heredity: The disease occurs 30 times more commonly in relatives of patients than in general
population.
Tissue type: 95% of patients with ankylosing spondylitis are HLA-B27 positive.

Pathology
There is involvement of synovium, articular
capsule and ligaments where attached to bone.
Inflammation at the site of attachment of
ligaments to bone is known as entheses and
enthesopathy is the name given to formation
of new bone at these areas. As a result of
inflammatory change in spine, reactive bone
formation occurs and bridging takes place
between the vertebral bodies, usually from the
edge of one body to that of next along the outer
layers of the disc: this is known as marginal
syndesmophyte formation. Anterior and
posterior spinal ligaments are ossified. After bony fusion occurs, the pain may subside, leaving
the spine permanently stiff resulting in bamboo spine.

Clinical Features
Onset
This is often insidious with mild pain and stiffness in the lower lumbar spine. Sometimes the
onset is acute with severe pain over sacroiliac joints and lumbar spine.
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Clinical Presentations
The following clinical presentations may be seen:
• Classical Presentation: The patient is a young adult 15-30
years old male, presenting with gradual onset of pain and
stiffness of lower back. Initially, the stiffness may be noticed
only after a period of rest, and improves with movement. The
pain tends to be worst at night or in early morning, awakening
the patient from sleep. He gets better only after he walks about
or does some exercises. There may be pain in the heel, pubic
symphysis, manubrium sterni and costosternal joints. In later
stages, kyphotic deformity of spine and deformity of hips may
be prominent features.
• Unusual Presentation: The patient may occasionally
present with the involvement of the peripheral joints such as shoulders, hips and knees. Smaller
joints are rarely involved. Sometimes, a patient with ankylosing spondylitis may present with
chronic inflammatory bowel disease; the joint symptoms follow.

Signs and Symptoms

• Morning stiffness: This is common in early stages.
• Fatigue: This is also common.
• Spinal features (lumbar spine):
– Pain and stiffness in lumbar spine.
– Radiating pain down the leg.
– Spasm of lumbar paravertebral muscles.
– Flattening of lumbar spine.
– Loss of spinal movements.
• Thoracic features:
– Loss of thoracic expansion.
– Diminished costovertebral and manubriosternal movements.
– Reduction in vital capacity.
• Peripheral joints: Pain and stiffness may develop in shoulders, hips and knees.
Extra-Articular Manifestations
• Occular: About 25% may develop atleast one attack of acute iritis.
• Cardiovascular: may develop cardiovascular manifestations.
• Neurological may develop spontaneous dislocation and subluxation of atlantoaxial joints .
• Pulmonary: The involvement of costovertebral joints = restriction of thoracic cage.
• Systemic: Generalized osteoporosis occurs commonly.
• Skin: Associated psoriasis.
• Colon: Ulcerative colitis.
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General Posture
The patient is observed from anterior, posterior as well as from both the sides to detect the
overall postural deviations. Initially the whole spine assumes a stiff posture. Later on, it may
get totally fused. The spinal fusion gives rise to stiff and deformed posture where cervical
spine is fixed in flexion with atlantoaxial hyperextension. Thoracic spine is fused in marked
kyphosis leading to a rounded back. The hips and knees tend to assume compensatory attitude
of flexion. Accurate measurements of the posture are taken at regular intervals with the help of
spondylographs and/or clinical photographs.

Assessment
Tests for Detecting Sacroiliac Joint Involvement:
• Tenderness: Localised to the posterior superior iliac spine or deep in gluteal region.
• Sacro-iliac compression: Direct side to side compression of pelvis may cause pain at
sacroiliac joints.

Sacro-iliac compression test Ganslen’s test

• Ganslen’s test: The hip and knee of opposite side are flexed to fix the pelvis, and the hip joint
of the side under test is hyperextended over the edge of the table. This will exert a rotational
strain over sacroiliac joint and will give rise to pain.
• Straight leg raising test: The patient is asked to lift the leg up with the knee extended. This
will cause pain at the affected sacroiliac joint.
• Fleche test: The patient stands with his heel and back against the wall and tries to touch the
wall with the back of his head without raising the chin. The inability to touch the head to the
• Respiratory function: An early involvement of costrovertebral joints results in gradual
restriction of the movements of ribs and reduces the respiratory capacity. The chest expansion
is markedly reduced often less than 2.5 cm. Chest expansion should be recorded at two levels:
at xiphoid process (seventh rib) and at the nipple (fourth rib). The vital capacity, peak flow
and forced expiratory volume should be recorded.

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Radiological Examination

Physiotherapy Management
Regular physiotherapy is essential in the management of patient with ankylosing spondylitis.
Fibrous tissue is being continuously laid down as a result of mild inflammation and regular
physiotherapy with monitored exercise programme moulds these fibrous tissue lines of stress
which do not restrict the patient’s movements.
Aims of Treatment
• To relieve pain.
• To mobilize the affected joints.
• To minimize deformity.
• To improve respiration.
• To improve body ergonomics.
• Improvement of muscle power and endurance.
Intervention
Pain and muscle spasm:
• The pain and muscular spasm in the acute stage are controlled by superficial modalities such
as hydrocollateral packs or cryotherapy which can be applied locally to the specific joints and
muscles affected.
• Muscle spasm that persists after the acute inflammation is treated best by hold-relax technique.
Deep heating is effective in the chronic stage.
• Steam bath preceding the exercise controls pain and induces relaxation.

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Mobility:
The objective is to maintain mobility of spinal intervertebral joints and peripheral joints by
various procedures. The most important technique is repeated small range mobilization
incorporated in activities of daily routine. The patient should be educated on the correct
procedure. Suitable exercises to improve mobility can be enumerated as:
• Lying:
– Physiological relaxation.
– Practice feeling a position of straight extended spine.
– Push arms and legs into the floor (Static contractions for quadriceps, glutei and back
extensors).

• 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 diaphragm.
– Pelvic tilting forwards and backwards.

• Prone lying:
– Alternate straight leg raising (SLR) and lowering.
– Both legs raising and lowering.
– Hands clasped behind the back, thrust hands towards feet with head and shoulders raising
and relaxing.
– Place hands on the floor, raise head and shoulders:
o Walk hands to right and then to left (side flexion in extension).
o Arms stretch above head.
o Raise arms and ball plus head, shoulders and legs and then lowering.
• Sitting:
– Stretch head and neck upwards (postural correction).
– Hands on shoulders: trunk turning from side to side.
– Hands clasp: bend and twist to touch right foot, stretch upwards and backwards to the left
and 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.

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Deformity:
The body attitudes promoting the deformities should be discouraged. Maximum emphasis needs
to be given to the static as well as dynamic postural attitudes.

Respiration:
Free active exercises with deep breathing maintain the mobility and improves respiratory
capacity. Localized thoracic breathing without back support improves breathing capacity.
Body ergonomics:
The usual tendency to stoop should be strictly discouraged. Instead, the chest should be held
up and forward with the shoulders retracted. Repetitions of isometric shoulder bracing are
valuable and should be made a part of daily routine.
Postural attitudes should be emphasized upon:
• Keep the chin tucked in.
• Repeated prone lying with hyperextension at dorsal spine on forearm supports.
• Hip hyperextension in prone.
• Trunk lateral bending with deep breathing.
Muscle power and endurance:
Muscles which are strong and capable of maintaining contractions will provide the necessary
force to sustain correct posture. To induce relaxation and to improve mobility, active free
movements play an important role. Muscles will be strengthened by the increase in exercise
taken by the patient. Muscle power is retained by working against maximal resistance for a
short time. Endurance is improved by working muscles against submaximal resistance for
progressively longer times.
Importance of Hydrotherapy in Treatment of Ankylosing Spondylitis
Relief of pain and muscle spasm together with restoration of mobility is readily obtained by
hydrotherapy. The warmth of the water effectively reduces protective muscle guarding thereby
enabling the patient to make full use of available joint ranges by formal exercises or free
swimming. Bad Ragaz patterns for arms, legs and trunk are effective in restoring mobility.
Procedures
• Float lying: Relaxation practice.
• Float lying: Arms and legs pushing down into water and resting.
• Lying on half stretches: Deep breathing exercises
• Lying on half stretches: Legs pushing down and out.
• Float lying: Arms stretching sideways and upwards.
• Sitting: Trunk turning side to side. Progress by holding arms forwards and grasping a bat.
• Prone lying grasping rail: Breast stroke action of legs.
• Swimming: Progress to underwater swimming.

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