MS PT-2S Lecture# 8 (I-R)

SPONDYLOARTHROPATHIES
ANKYLOSIS SPONDYLITIS

By: Dr.Chaman Lal PT

B.S.PT, PPDPT (M.Phil Physiotherapy), MPH (M.Phil Public Health),
Master in Physical Education & Sports Injuries (UOS),
Dip. in sports Injuries, PG in Clinical Electroneurophysiology (AKUH),
Registered. EEGT (USA), Member of ABRET, AANEM & ASET (USA),
MPPS(PAK), MPPTA(PAK), PhD Physiotherapy Scholar (Malaysia)
 SPONDYLOARTHROPATHIES
▪ Spondyloarthropathies are forms of arthritis that
usually strike the bones in your spine and nearby
joints.

▪ They can cause pain and sometimes damage joints like

your backbone, shoulders, and hips. Arthritis causes
inflammation (swelling, redness and pain) in your body's
joints. It's common in people as they get older.
By: Dr Chaman Lal PT
TYPES OF SPONDYLOARTHROPATHIES

a) Ankylosing Spondylitis (AS)

b) Psoriatic Arthritis
c) Reiter’s Syndrome
d) Reactive Arthritis
e) Ulcerative Collitis
f) Becheet’s Syndrome
g) Whippl’s Disease

By: Dr Chaman Lal PT

 Ankylosing Spondylitis
Definition: (aka Axial Spondyloarthritis)
Axial spondyloarthritis is a seronegative spondyloarthritis of the
spine and pelvis.
The term axial spondyloarthritis has only been used since 2009
when the Assessment of Spondyloarthritis International Society Axial
Spondyloarthritis (ASAS) classification criteria was developed.

The ASAS criteria allowed, for the first time, earlier identification of
axial spondyloarthritis through magnetic resonance imaging (MRI).

By: Dr Chaman Lal PT 4

 Ankylosing Spondylitis
Axial spondyloarthritis is used to describe patients who
have both non-radiographic and radiographic axial
spondyloarthritis.

Non-radiographic axial spondyloarthritis does not show on

x-ray, but there are changes on MRI.

Radiographic axial spondyloarthritis is also known as

Ankylosing Spondylitis (AS).
By: Dr Chaman Lal PT 5
 Ankylosing Spondylitis
• Axial spondyloarthritis predominantly affects the spine,
with inflammatory changes causing pain, stiffness and a
loss of motion in the back.
• It often causes changes in the sacroiliac joints,
apophyseal joints, costovertebral joints, and
intervertebral disc articulations.
• It causes characteristic inflammatory back pain,
resulting in structural and functional impairments and a
reduction in quality of life.
By: Dr Chaman Lal PT 6
Ankylosing Spondylitis

By: Dr Chaman Lal PT 7

 Symptoms of Ankylosing Spondylitis
▪ Back pain is the most common symptom of a
spondyloarthropathy. But there are a variety of other
symptoms that might point to an illness of this type:
• Joints like your hips, shoulders, knees, or elbows are painful
and swollen.
• The points where your tendons and ligaments meet bone
become inflamed. This is called enthesitis. The first sign is
usually a pain at the back or bottom of your heels.
• Dactylitis is an inflammation of the tendons in the fingers
and toes. This gives them a swollen, sausage-like
appearance.
• Uveitis causes pain or redness in one eye.
By: Dr Chaman Lal PT
 Ankylosing Spondylitis

• Affected joints progressively become stiff and

sensitive due to a bone formation at the level of
the joint capsule and cartilage.

• It causes a decreased range of motion and, in its

advanced stages, can give the spine an
appearance similar to bamboo, hence the
alternative name “Bamboo Spine".

By: Dr Chaman Lal PT 9

By: Dr Chaman Lal PT 10
 Clinically Relevant Anatomy
• Pain in AS can be caused by sacroiliitis, enthesitis, and
spondylitis. Initially the sacroiliac joints are damaged.
• Subsequently, the inflammation moves to entheses,
where ligaments and tendons integrate into the bone.
Eventually, the spine is affected by this inflammation.
• Patients diagnosed with AS form calcium deposits in the
ligaments between and around the intervertebral discs.
• An accumulation of the deposits leads to ossification,
starting from the vertebral rim towards the annulus
fibrosis and characterized by Syndesmophytes.
By: Dr Chaman Lal PT 11
 Syndesmophytes
▪ Syndesmophytes are bony growths that often occur
in the spine and can cause fusion of the joints.
Their formation is a clinical feature of ankylosing
spondylitis (AS), a rare type of arthritis.
Syndesmophytes, which form in the ligaments of the
spine, create irreversible spinal damage and can lead
to vertebrae fusing.
▪ Syndesmophytes indicate spine degeneration, similar
to osteophytes of spine; however, they bridge across
the joint as compared to osteophytes which are non-
bridging.
By: Dr Chaman Lal PT

12
 Syndesmophytes

Osteophyete

By: Dr Chaman Lal PT

Syndesmophytes are one of the main features of spinal
structural damage in ankylosing spondylitis.

• It is a osseous excrescences or bony outgrowths from

the spinal ligaments as they attach to adjacent
vertebral bodies.
• In highly advanced cases, the spine can fuse together as
a result of the bone formation.

By: Dr Chaman Lal PT 14

 Epidemiology /Etiology
• AS Affects 0.1 to 1.4% of the population.
• There is a male to female ratio of 2:1 for radiographic axial
spondyloarthritis and of 1:1 for non-radiographic axial
spondyloarthritis.
• The onset of symptoms generally occurs between 20-40 years
of age.
• Less than 5% of cases have an onset of symptoms over the
age of 45.
• AS is more prevalent within Europe (mean 23.8 per 10,000)
and Asia (mean 16.7 per 10,000) than within Latin America
(mean 10.2 per 10,000). By: Dr Chaman Lal PT 15
Ankylosing Spondylitis

By: Dr Chaman Lal PT 16

 Ankylosing Spondylitis
• Studies have shown factors such as:
✓Genetic background gene called ( HLA-B27),
✓Microbial infection,
✓Endocrinal abnormalities and
✓Immune reaction are related to the occurrence of AS.

❑ In addition, a direct relationship between AS and the

major histocompatibility human leukocyte antigen
(HLA)-B27 has also been determined.
By: Dr Chaman Lal PT 17
 Characteristics/Clinical Presentation of
Inflammatory Back Pain
Inflammatory back pain should be considered if two or more of the
following features are present. Additionally, the presence of four or
features is considered diagnostic:
1. Insidious onset of back pain in the sacroiliac (SI) joints and gluteal regions
(presenting as alternating buttock pain), which progress to involve the entire
spine
2. Age of onset less than 45 years
3. Duration of more than 3 months
4. Morning stiffness lasting greater than 30 minutes
5. Waking up in the second half of the night due to pain, but eases with arising
6. Pain and stiffness increase with inactivity and improve with exercise
By: Dr Chaman Lal PT 18
 Ankylosing Spondylitis

By: Dr Chaman Lal PT 19

 Ankylosing Spondylitis
More specific to AS the following clinical features may be described:
•Involvement of peripheral joints, eyes, skin, and the cardiac and intestinal systems
• Eye disease occurs in about 25% of the patients as either iridocyclitis or
conjunctivitis
• Joints other than those of the axial skeleton can be involved with
inflammatory arthritis and synovitis. The hips, shoulder and knees are
commonly and most severely affected of the extremity joints
•Complaints of intermittent breathing difficulties due to a reduction in chest
expansion. This reduction in chest wall excursion, notably less than 2 cm, can be a
characteristic of AS because chest wall excursion is an indicator of decreased axial
skeleton mobility.
•Intermittent low-grade fever, fatigue, or weight loss can occur.

By: Dr Chaman Lal PT 20

 Differential Diagnosis
Common disorders to consider as differential diagnoses with AS are:
1. Degenerative Disc Disease
2. Herniated Intervertebral Disc
3. Fractures and/or dislocation
4. Osteoarthritis
5. Spinal Stenosis
6. Spondylolisthesis, Spondylolysis, and Spondylosis
7. Reactive arthritis
8. Inflammatory bowel-related arthritis
9. Diffuse idiopathic skeletal hyperostosis (DISH)
10. Rheumatoid arthritis
11. Psoriatic arthritis
12. Reiter's syndrome (milder with asymmetric sacroiliitis)
By: Dr Chaman Lal PT 21
 Spondylosis, Spondylolysis, and Spondylolisthesis
▪ SPONDYLOSIS is a term that references general
degenerative changes in the spine, commonly caused by
age, osteoarthritis, and/or degenerative disc disease;
▪ SPONDYLOLYSIS is a more specific diagnosis of a spinal
injury, commonly involving a crack or fracture of the pars
articularis caused by overuse.
▪ SPONDYLOLISTHESIS refers to anterior slippage of one
vertebra over another (in the front of the spine).
▪ When spondylosis is left untreated, it may lead to
spondylolisthesis. When one bone of the spine slips
forward over another, it causes damage to the spinal
structure.
By: Dr Chaman Lal PT
22
By: Dr Chaman Lal PT 23
 Ankylosing Spondylitis
Peripheral manifestations, such as dactylitis, enthesitis or arthritis,
especially of the plantar fascia or Achilles tendon.
o A family history of AS or related disorders. A first-degree or second-
degree relative with ankylosing spondylitis, psoriasis, uveitis, reactive
arthritis or inflammatory bowel disease
o Inflammatory back pain symptoms
o Psoriasis, inflammatory bowel disease or a history of uveitis
o Elevated C-reactive protein (CRP), where causes such as spinal
infection or cancer have been excluded. This is also a marker of
inflammation and is found in 50-70% of people with AS. Patients with
AS may have CRP levels ranging from > 6 mg/L (slightly elevated) to
20 – 30 mg/L
By: Dr Chaman Lal PT 24
o Back pain which improves after 24 – 48 hours of treatment with non-
steroidal anti-inflammatory
o Positive HLA-B27 test: HLA B27 is positive in 80-90% of AS patients,
more so in the Caucasian population and African Americans. The HLA-
B27 antigen is also present in other inflammatory conditions of intestines
or joints
o Sacroiliitis on X-ray or MRI
o Erythrocyte sedimentation rate (ESR): This is a blood test for
inflammation, in approximately one-third of the AS patients there is a
raised ESR observable in exacerbations of the disease, but other
conditions can also cause a high ESR.
o Laboratory tests are specific and often more helpful to exclude other
diagnoses rather than confirming AS. In combination with other clinical
symptoms, the diagnosis can often be made more accurate. 25
By: Dr Chaman Lal PT
 Ankylosing Spondylitis
Diagnostic Procedures:
The diagnosis of AS is commonly made through a combination of thorough
subjective and physical examinations, laboratory data and imaging studies.
Common laboratory data include blood tests to determine the presence of the HLA-
B27 antigen or substances that indicate an inflammatory process:

• X-rays have traditionally been considered the most useful imaging modality in
established disease, although they may be normal in the early phases.

• X-ray shows up areas where the bone has been worn away by the condition. The
vertebrae of the spine may start to fuse together because the ligaments between
them become calcified.

By: Dr Chaman Lal PT 26

 Ankylosing Spondylitis
• Early X-ray changes are vertebral body squaring
following erosion of anterior column of spine.
• The shiny corner sign is a spinal finding in ankylosing
spondylitis, representing reactive sclerosis secondary to
inflammatory erosions at the superior and inferior
endplates (corners on lateral radiograph) of the vertebral
bodies which are known as Romanus lesions.
• Eventually, the vertebral bodies become squared
(Squaring of the vertebra).
By: Dr Chaman Lal PT 27
 Shiny Corner Sign

By: Dr Chaman Lal PT 28

 Ankylosing Spondylitis
➢ MRI scanning is also used to detect inflammation on MRI that is suggestive of sacroiliitis.
➢ MRI of the sacroiliac joints is more sensitive than either plain X-ray or CT scan in
demonstrating sacroiliitis.
➢ Sacroiliitis initially shows as blurring in the lower part of the joint, then bony erosions or
sclerosis occur and widening or eventual fusion of the joint.
➢ Vertebral body squaring
➢ Bamboo spine appearance
➢ Dagger sign: central dense line seen on AP radiography of spine and pelvis following
ossification of supraspinous and interspinous ligaments.
➢ Tram- track sign: Ossification of the apophyseal joint capsules forming two vertical
radiodense lines lateral to this central line on frontal view
➢ Trolley-track sign: combining a central “dagger” sign and a peripheral tram-like track
➢ Hatchet deformity
➢ Subchondral erosions, sclerosis and proliferation on iliac side of SI joints
➢ Bridging or fusion of the pubic symphysis
By: Dr Chaman Lal PT 29
(INACTIVE ROMANUS LESIONS)

By: Dr Chaman Lal PT 30

 Ankylosing Spondylitis
The modified New York Classification Criteria (mNYCC)
The modified New York Classification Criteria (mNYCC) was previously used to
diagnose axial spondyloarthritis.
The mNYCC combines clinical findings with radiograph studies. Radiographic
findings are graded on a scale of 0 to 4 where 0 represents normal findings and 4
represents complete ankylosis.
❑ A definitive diagnosis is considered with the following radiographic
combinations:
Grade 3 or 4 at bilateral SI joints on radiograph with at least one clinical finding
Grade 3 or 4 unilaterally (or Grade 2 bilaterally) with two clinical findings

By: Dr Chaman Lal PT 31

By: Dr Chaman Lal PT 32
 33
By: Dr Chaman Lal PT
 Ankylosing Spondylitis
The patient must also fulfill at least one of the following clinical criteria:
✓ Low back pain and stiffness for at least 3 months, which improves with exercise,
but is not relieved by rest
✓ Limited lumbar spinal motion in sagittal (sideways) and frontal (forward and
backward) plane
✓ Chest expansion decreased relative to normal values corrected for age and sex
Grading:
• A patient can be classified as having definite AS if at least 1 clinical criterion
plus the radiologic criterion are fulfilled.
• A probable diagnosis of AS is made if three clinical criteria are present or the
radiologic criterion is present without any signs or symptoms satisfying the
clinical criteria.

By: Dr Chaman Lal PT 34

 Physiotherapy Management
Ankylosing Spondylitis
Physiotherapy is an essential part of the treatment of AS.

It aims to alleviate pain, increase spinal mobility and functional capacity, reduce
morning stiffness, correct postural deformities, increase mobility and improve the
psychosocial status of the patients.

According to a Cochrane review completed by Dagfinrud and colleagues, a

supervised or individual home-based exercise program is better than no intervention,

The main aspects of rehabilitation include education, a program of personalized

exercises and outline of physical activities to be completed at home or in a group
based environment.
By: Dr Chaman Lal PT 35
By: Dr Chaman Lal PT 36
 Ankylosing Spondylitis-Treatment Phase
Initial/Acute Phase
The initial phase of AS is characterized by morning stiffness and pain in the
spine.
Primary Objective
•Control of the diffuse and intense pain secondary to joint stiffness,
• Recovery of proprioception, joint stability, restoring normal postural
patterns and reduction of pain
•Interventions for pain management along with pharmacological treatment
prevents compensatory postures
Secondary Objective
•Maintain the elasticity of the pelvis and spine to enable good respiratory
function. By: Dr Chaman Lal PT 37
 Ankylosing Spondylitis-Treatment Phase
Remission Phase:
The remission phase of AS is characterized by pain,
restricted mobility of the spine +/- peripheral joints.
Primary Objective:
•Divided into short and long term goals.
• Short term goals include the improvement of body function and reduction of
pain,
• Long-term goals include pain control, improvement in activities of daily
living, general function and quality of life.
Chronic Phase:
The Chronic phase of AS is characterized by formation of diffused ankyloses,
resulting in total rigidity of the spine, and assuming a curved orthostatic posture.
By: Dr Chaman Lal PT 38
 Ankylosing Spondylitis-Treatment Phase

Primary Objective:
o To enable the patient to maintain their residual function to guarantee
the most autonomy possible.
o Education on the importance of physiotherapy and body awareness is
key in this phase of AS.
o In-clinic sessions with manual therapy are essential to enable the
patient to continue their home exercise program.

By: Dr Chaman Lal PT 39

 Considerations for Physiotherapy Management
• Fatigue is a common complain in rheumatological conditions. It can be managed
by taking regular microbreaks, avoiding sitting in the same position for long
periods, maintaining physical activity and having good sleep hygiene.
• AS patients can suffer from flare-ups of increased disease activity, which can
last from days to weeks. During the flare-up the patient may benefit from gentle
stretching exercise, taking breaks and medications.
• Joint protection management applies the ergonomic principles to ADL activities
to preserve the functional ability.
• Patient compliance can be achieved by determining the barriers facing the
individual, including the patient’s exercise preference in the program, using
different exercise varieties to avoid boredom and group therapy.
By: Dr Chaman Lal PT 40
 Considerations for Physiotherapy Management
• Educating the patient about his condition and how to manage it,
besides having a patient-provider relationship are important for
patients’ self managing.
• ADL activities can be made easier using assistive devices and
alternative techniques. For example, managing shoes; slip-on shoes
can be used or the patient can raise their leg on a stool or place it on
the opposite knee.
• Driving can be difficult due to neck pain and stiffness, advice for
driving can include taking breaks on long journeys and using a small
pillow behind their back or under their buttock to promote better
posture.
By: Dr Chaman Lal PT 41
 Clinical Bottom Line
• Axial spondyloarthritis is a chronic inflammatory rheumatic disease
with unknown etiology. Affected joints progressively become stiff and
sensitive due to a bone formation at the level of the joint capsule and
cartilage.
• This can lead to structural and functional impairments and a decrease
in quality of life. Regions most affected by the disease are the axial
skeleton and sacroiliac joints.
• A combination of medicines (such as non-steroidal anti-inflammatory
drugs and biological medications) and physical therapy is
recommended. Physiotherapy primarily consists of range of motion
and respiratory exercises as well as working on postural corrections.
By: Dr Chaman Lal PT 42
By: Dr Chaman Lal PT 43