What is ankylosing spondylitis?

What is ankylosing spondylitis?

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Ankylosing spondylitis (AS), sometimes referred to as Marie-Strumpell disease is a type of inflammatory arthritis that primarily affects the spine and sacroiliac joints (the joints that connect the lower spine to the pelvis). It is a chronic condition that causes inflammation, pain, and stiffness in the affected areas. It first appears in adolescence and “peaks” in mid 20’s. Over time, the inflammation can lead to new bone formation, which can result in the fusion of the vertebrae, causing the spine to become rigid and less flexible. The pain, resultant postural deformities, and complications associated with this disease are disabling.

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AS is classified as an autoimmune disease, which means the body's immune system mistakenly attacks its own healthy tissues, leading to inflammation in the joints and surrounding structures. The exact cause of ankylosing spondylitis is not fully understood, but genetic factors play a significant role, as a specific gene called HLA-B27 is commonly found in individuals with AS.

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Common symptoms of ankylosing spondylitis

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Common symptoms include:

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1. Chronic lower back pain and stiffness, increased by prolonged periods of inactivity and decreased by active movement. Coughing, sneezing, and twisting may worsen the pain. Significant morning stiffness, lasting more than 1 hour, is often present.
2. Pain may radiate to the thighs but does not usually go below the knees. Buttock pain is often unilateral but may alternate from side to side.
3. Enthesitis (inflammation of the tendons, ligaments, and capsular attachments to bone) may produce tenderness, pain and/or stiffness, and restricted mobility in the spine. 
4. Early loss of lumbar lordosis (lumbar curve) with accompanying increased kyphosis (forward rounding of the upper back). 
5. Fatigue and a general feeling of being unwell.
6. In some cases, inflammation can affect other organs, such as the eyes, heart, or lungs.

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Ankylosing spondylitis typically starts in late adolescence or early adulthood, and its progression can vary from person to person. The disease may lead to increased curvature of the spine, causing a stooped posture and limited mobility.

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Diagnosis of ankylosing spondylitis involves a combination of a thorough medical history, physical examination, blood tests (including HLA-B27), and imaging studies such as X-rays and magnetic resonance imaging (MRI) to assess the joints and detect any signs of inflammation and structural changes.

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While there is currently no cure for ankylosing spondylitis, the primary focus of intervention is to maximize the quality of life through the control of inflammation and stiffness in the joints, maintaining mobility and proper postural alignment of the spine to prevent structural damage, while providing pain relief. These may include nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), biologic medications, physical therapy, and exercises to improve flexibility and posture. Early diagnosis and appropriate management are essential to minimize the impact of AS on the spine and overall well-being. Regular medical follow-up and adherence to the treatment plan can help individuals with AS lead active and fulfilling lives.

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What causes ankylosing spondylitis?

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The exact cause of ankylosing spondylitis (AS) is not fully understood, but it is believed to result from a combination of genetic and environmental factors. Here are the primary factors that play a role in the development of ankylosing spondylitis:

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1. Genetic Factors: One of the most significant risk factors for ankylosing spondylitis is the presence of a specific genetic marker known as HLA-B27. HLA-B27 is a genetic variant of the human leukocyte antigen (HLA) system, which plays a crucial role in the body's immune response. Around 90-95% of people with AS have the HLA-B27 gene, but not everyone with the gene will develop the condition. Having the HLA-B27 gene is not a definitive diagnosis, but it does increase the risk of developing AS.
2. Gender and Age: These are both important factors related to the risk of developing AS. It typically affects young people, beginning between the ages of 15 and 30 years (rarely after the age of 40). Men are affected two to three times more often than women, although this disorder may be just as prevalent in women but diagnosed less often because of a milder disease course with fewer spinal problems and more involvement of joints such as the knees and ankles, confusing the clinical picture.
3. Immune System Dysfunction: Ankylosing spondylitis is classified as an autoimmune disease, where the immune system mistakenly attacks the body's own healthy tissues, leading to inflammation in the joints and surrounding areas. The exact trigger for the immune system dysfunction in AS is not fully understood, but it is likely related to the interaction between genetic and environmental factors.
4. Environmental Factors: While genetics play a significant role, environmental factors may also contribute to the development of ankylosing spondylitis. Certain infections, especially those of the gastrointestinal tract, have been associated with triggering or exacerbating AS in genetically susceptible individuals. The gut microbiome, which consists of trillions of bacteria in the digestive tract, is also being studied for its potential role in AS development.
5. Family History: Ankylosing spondylitis tends to run in families, suggesting a hereditary component. If you have a family member with AS, your risk of developing the condition may be higher.

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It's important to note that ankylosing spondylitis is a complex and multifactorial condition, and not all individuals with genetic predisposition or HLA-B27 will develop the disease. Likewise, not all cases of AS have a known family history of the condition. The interplay of genetic and environmental factors is likely responsible for the development and progression of the disease.

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Early diagnosis and appropriate management are essential to minimize the impact of AS on the spine and overall well-being. If you suspect you may have symptoms of ankylosing spondylitis, it is essential to consult a healthcare professional for a comprehensive evaluation and proper diagnosis.

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How can physical therapy help?

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Physical therapy plays a crucial role in managing ankylosing spondylitis (AS) by improving mobility, flexibility, and overall function, reducing pain, and promoting a better quality of life. Here's how physical therapy can help individuals with AS:

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1. Posture/Kinesthetic Training:  AS can lead to changes in posture, including a stooped or rounded back. This type of training aims to develop patient awareness of safe spinal positions and spinal movement as well as the effects of positions (e.g. lying, sitting, standing) have on the spine. Awareness of what posture makes the symptoms better or worse and identifying the neutral spine position or position of bias are important in helping patients manage their symptoms. Physical therapists provide guidance on maintaining proper posture and body alignment during daily activities, which helps reduce strain on the spine and joints.
2. Pain Management: Physical therapists use various techniques and modalities such as heat, ice, electrical stimulation, ultrasound and manual therapy to manage pain and reduce muscle tension around the affected areas.
3. Breathing Exercises: AS can affect the chest and ribcage, leading to reduced lung capacity and respiratory issues. Physical therapists teach breathing exercises to help maintain lung function and promote optimal chest expansion.
4. Gait Training: Individuals with AS may experience gait abnormalities due to changes in the spine and hips. Physical therapists work on gait training to improve walking patterns and stability.
5. Joint Mobility: Physical therapists use gentle joint mobilization techniques to maintain or improve joint mobility and for pain modulation at the non-ankylosed segments. 
6. Stretching Exercises: Stretching or flexibility exercises are prescribed to increase mobility of restricting tissues, so the patient can assume an effective position of the spine as well as to maintain hip extension and shoulder flexion, as lumbar (low back) and thoracic (mid back) extension may eventually be lost.
7. Stabilization Exercises: This type of exercise is initiated to increase spinal control and stability. It includes stabilization training of deep muscles for segmental stability and global muscles for general stability. 
8. Strengthening Exercises: Once the patient has learned effective stabilization and management of symptoms, dynamic neck and trunk strengthening exercises are initiated to improve strength, endurance and performance of the muscles surrounding the spine.
9. Functional Training: As the patient’s spinal muscle strength, endurance, flexibility as well as spinal control and stabilization improves, components of his or her daily tasks are incorporated into the exercise program and then into the patient’s daily lifestyle. Safe body mechanics are included in all aspects of care.
10. Swimming/Aquatic Exercises: Swimming or pool-based exercises may also be prescribed. It is beneficial for patients with ankylosing spondylitis as it helps reduce pain and improve flexibility of the spine as well as the cardiopulmonary endurance, which can therefore improve the patient’s overall quality of life.
11. Home Exercise Program: Physical therapists provide patients with a home exercise program, and teach them how to safely and effectively incorporate it into their daily routine to reinforce the interventions and promote optimal recovery. 
12. Education: Physical therapists educate individuals with AS about their condition, its causes and symptoms as well as the role and importance of rehabilitation programs in managing the condition. They also teach patients about proper body mechanics, and strategies to manage symptoms and prevent flare-ups.
13. Assistive Devices: Physical therapists may recommend the use of assistive devices such as braces, canes, or walkers to provide support and reduce pressure on the spine during activities.
14. Fatigue Management: AS can cause fatigue, affecting overall energy levels and function. Physical therapists help patients manage fatigue through activity pacing and energy conservation strategies.
15. Patient Empowerment: Physical therapists work collaboratively with individuals with AS, empowering them to actively manage their condition through exercise and self-care techniques.

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It's essential for individuals with AS to be proactive in managing their condition, and physical therapy is an essential component of a comprehensive treatment plan. Regular physical therapy sessions, along with ongoing home exercise programs, can help individuals with AS maintain their functional abilities, reduce pain and stiffness, and improve overall quality of life. By working with a physical therapist, individuals with AS can learn to adapt to the challenges posed by the condition and continue to lead active and fulfilling lives. It is essential to consult with a healthcare professional, such as a rheumatologist or orthopedic specialist, to develop an individualized treatment plan that includes physical therapy based on the specific needs and severity of AS.

Trust PeteHealth for treating ankylosing spondylitis 

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