Ankylosing Spondylitis

 Ankylosing spondylitis (AS) is a chronic inflammatory disease of

the axial skeleton manifested by back pain and progressive
stiffness of the spine.

 Characteristically affects young adults with a peak age of onset

between 20 and 30 years.

 Classically thought of as a spinal disease, transient acute arthritis

of peripheral joints (hips, shoulders, knees) occurs in up to 50
percent of patients and chronic changes occur in 25 percent. In
addition, other organs, such as the eyes, lungs, and heart, can be
affected.
 AS is one of the spondyloarthropathies which show inflammation
around the enthesis (the site of ligament insertion into bone) and
an association with the human leukocyte antigen HLA-B27.

 Other spondyloarthropathies include Reiter's syndrome, the

reactive arthropathies, psoriatic arthritis, juvenile
spondyloarthropathy, and the axial arthropathy associated with
inflammatory bowel disease.
 Ankylosing Spondylitis
 There are three clinical criteria:
 Low back pain and (morning) stiffness of
greater than three months duration, improving
with exercise but not relieved by rest
 Limitation of motion of the lumbar spine in both
the sagittal and frontal planes, limitation of
chest expansion relative to normal values
corrected for age and sex
Ankylosing Spondylitis
Ankylosing Spondylitis
 Ankylosing Spondylitis

Squaring of the vertebral bodies, osteopenia, and ossification of the

anterior longitudinal ligament.
Ankylosing Spondylitis
Ankylosing Spondylitis
Sacro-iliitis
Fused sacro-iliac joints
 Bamboo spine
in ankylosing spondylitis
 Pathology
in ankylosing spondylitis
Ankylosing Spondylitis
 Symptom Magnification
Examination:
 Waddell signs: Presence of nonorganic signs
suggesting symptom magnification and
psychological distress
– Superficial or nonanatomic distribution of tenderness
– Nonanatomic or regional disturbance of motor or sensory impairment
– Inconsistency on positional SLR
– Inappropriate/excessive verbalization of pain or gesturing
– Pain with axial loading or rotation of spine

 Give-away weakness: Inconsistent effort on manual

motor testing with “ratcheting” rather than smooth
resistance
 Pathological Examination:
 Spurling’s maneuver: Lateral rotation and extension of spine
resulting in neuroforaminal narrowing and nerve root
encroachment, clinically reproducing extremity pain, usually in
dermatomal distribution

 Straight-leg raise (SLR): Elevation of lower extremity,

seated or standing, resulting in neural tension at S1 nerve root
with extremity pain

 Patrick’s maneuver: Crossed leg with unilateral pain

indicative of sacro-iliac (SI) joint dysfunction

 Femoral stretch: Hip extension stretch with heel pushed to

buttock in lateral supine or prone position resulting in anterior
thigh pain
 G. Treatment
 Medications
 NSAIDS
 Membrane stabilizers
 TCA / Neurontin
 re-establish sleep pain
 reduce radicular dysesthesias
 Muscle relaxers:
 re-establish sleep patterns
 more useful in myofascial/muscular pain
 Narcotics: rarely indicated
 Steroids: more useful for radiculitis
 Non-narcotic analgesics: Ultram
 Physical therapy
• Heat Therapy- Whirlpool/Hydrotherapy
• Postural education / body mechanics
• mobilization / myofascial release
• Stretching / body work
• Exercise / strengthening
• Pre-conditioning / work-conditioning
 D. Considerations of
PM & R Treatment:
• Physical therapy is initially usually one of modalities with
progression into more active exercise

• Pre-conditioning therapy is more functional with transition into

Work Conditioning (Work Hardening) program

• Always consider return to work, whether modified duty with

restrictions or limiting hours worked

• If patients poorly tolerate standard therapy, consider pool therapy

intervention which allows elimination of gravity effects

• Functional Capacity Evaluations utilized if patients are not

progressing through therapy or if have reached a plateau and
abilities as well as restrictions need to be assessed

• Job site evaluations appropriate if concerns re: ergonomics