Ankylosing spondylitis has
similarities but distinct differences from the much more common low
back pain:
Morning stiffness in the lumbar spine, lasting at least
30 minutes or longer Exercise improves the back pain and stiffness Rest
worsens the pain and stiffness Pain is usually worse in the second half
of the night, after a time of rest Peripheral joints are affected in 30
to 50% of patients Tiredness is common AS has systemic affects from its
inflammatory nature which can include feeling unwell, fever and loss of
weight.
Physiotherapy examination of the spine in an AS patient
usually uncovers significantly reduced ranges of spinal movement from
normal, with perhaps a reduced lumbar lordosis and an increased
thoracic curve. Neck movements may also be limited in later stages and
a reduction in chest expansion noted due to rib joint involvement.
Peripheral symptoms occur in around a third of patients and the physio
will palpate the tender areas, searching for evidence of enthesitis in
the insertions of the Achilles tendon and plantar ligament of the foot.
These are areas of high mechanical stress and commonly affected.
Postural analysis of the AS patient is the first thing a
physiotherapist notes after the subjective examination, recording
spinal abnormalities, flexed knees, rounded shoulders or poking head
posture. The ranges of movement of the cervical, thoracic and lumbar
spine are measured and a battery of standard measures taken which
allows assessment of the disease progression. The hips or other
peripheral joints may be affected and these need to be measured also,
with the physio likely testing out sites where the enthesis is likely
to be painful and inflamed. If the disease is active then the patient
may also have joint effusions and may appear unwell, be sweating and
not have slept well.
Initially a physiotherapist might treat an active,
inflamed site such as the tendo Achilles insertion using ultrasound,
ice and gentle stretching, with foot problems responding to insole use.
Whole spine exercises are taught with encouragement to get to the end
of the movements, concentrating on antigravity movements including
extension of the lumbar and thoracic spine, rotation of the thorax and
neck retraction and rotations. To counter the typical spinal
deformities, patients are taught to rest in good positions such as flat
on a firm surface with only one pillow and lying prone. Pool therapy is
very popular and effective and patient education is vital to maintain
therapy over time.
