Ankylosing Spondylitis

Question 1

Ankylosing Spondylitis

Answer 1

A chronic inflammatory arthritis of the axial skeleton
- may also affect the periphery
- may progress to complete spinal fusion

Question 2

Disease onset & progession characteristics…

Answer 2

Onset
- Insidious onset
- Pain & stiffness in low back & SIJ
- START: in SIJ joints - more stiffness than pain
- Pain is inflammatory
Worse in the morning
Stiffness & pain last at least 30-40 minutes (does not go past 1 hr - contrast to RA)
Sleep disturbed by pain (nocturnal back pain)

Progression
- Variable course: Mild self-limiting to severe disease w/ complete spinal fusion
- Periods of exacerbation and remission
- Progress from caudal to cephald (bottom up)

Question 3

S/S

(4)

Answer 3

1. Low back and glute pain & stiffness
2. Loss of ROM
   Mostly spine but can also occur in peripheral joints (girdle mm)
   Ex. Shoulder FLEX > not only affected b/c of AS in the shoulder BUT also if T/S is affected (most cases) > T/S = more kyphotic positions - fusion in FLEX
3. Postural abnormalities
   Posture does matter - want to go into reverse postures that they are going to be fixated in
4. Tenderness over sites of enthesitis
   Insertion of a mm - where ever it inserts is tender
   itis = inflammation of the mm at that point

Question 4

Postural changes in advanced disease…

(5)

Answer 4

1. INC thoracic kyphosis
2. DEC lumbar lordosis
3. Eye upward gaze d/t C/S flexion deformity
4. Fixed thoracic cage
   Going to act like a restrictive disease = more shallow & quicker breaths
5. Hip flexion & knee flexion in an attempt to maintain upright posture may lead to contractures
   To create a new BOS - flex hip & knee to make sure Cog stays w/in BOS

Question 5

S/S: Systemic

(4)

Answer 5

1. Fatigue
   INC metabolic activity d/t the disease process & fixed rib cage = breathing is affected - deconditioning as a result
2. Eye involvement
   Anterior uveitis (iritis)
3. Cardiovascular Involvement
   INC risk of CV morbidity & mortality
   Heart pathologies like electrical irregularities (scarring & inflammation) = can affect HR - slow it down
4. Pulmonary Involvement
   Functional lung impairment - Not getting typical bucket handle expansion of rib cage = restrictive = cannot take as much air in

Question 6

Radiographic Findings

(5) + details

Answer 6

1. Sacroiliitis - HALLMARK signs
   Early Stage:
   - Irregular SIJ spaces (pseudo-widening)
   - Subchondral bone erosions
   - Increased sclerosis around SIJ
   Advantage Stage:
   - SIJ thin or not visible - becomes more “black” - not as opaque
2. Syndemophytes - bone growth inside a ligament
   “Bamboo” Spine = bony growth in the outer fiber ring of annulus fibrosis
   More common
   “Railroad Track” Spine = affecting the Longitudinal ligaments
3. Thoracic Kyphosis
4. Enthesitis
   Plantar fascia insertion
   ITB insertion - may see this on x-ray of hips & spine
5. Arthritis
   Hip - may require a TKA in later stages

Question 7

Outcome Measures: Physical Assessment & Self-Report Tools

Answer 7

Physical Assessment:
Bath ankylosing spondylitis metrology index (BASMI)
1. Cervical rotation
2. Tragus to wall - C/S retraction w/ head, back, feet against the wall
3. Modified Schober - 10 cm above PSIS & 5 cm below PSIS > measure b/t lines in standing & bend forward (L/S flexion)
4. Finger to floor lateral flexion - Keep hands against the sides - everything else is touching the wall
5. Intermalleolar distance - SUPINE - ask pt to ABDUCT legs as far apart as they can & use tape to measure to each MEDIAL malleolus
Chest Expansion

Self-report Tools:
- Bath ankylosing spondylitis disease activity index (BASDAI)
- Bath ankylosing spondylitis functional index (BASFI)

Question 8

Modified New York Criteria

Used to Dx AK - 2 Criterias + Dx

Answer 8

Clinical Criteria
1. Low back pain present for >3 months; improved by exercise but not relieved with rest
** Rest does not help - feel better when they are moving - encourage & educate patient
2. Limitation of L/S motion in both the sagittal & frontal planes
3. Limitations of chest expansion relative to normal values for age & sex

Radiological criterion
1. Sacriliitis on x-ray

Diagnosis
1. Definite ankylosing spodylitis:
If the radiological criterion is present (sacroiliitis) + at least one criterion
2. Probable ankylosing spondylitis:
If all 3 clinical criteria are present alone, or if the radiological criterion is present but no clincial criteria are present