ANKYLOSING

SPONDYLITIS
Definition
This is a chronic progressive inflammatory disease of the
sacroiliac joints and the axial skeleton
Ankylosing spondylitis otherwise known as Marie-strumpell
disease.
Causes
Unknown
Strongly associated with HLA B27 genetic marker about 85%
The infective trigger are gram negative organisms klebsiella
Common in young male adults (M:F =10:1)
Pathology
The initial inflammation of the joints is followed by
synovitis, arthritis, and cartilage destruction, fibrous and
later bony ankyloses.
The joints commonly affected are SI joints, spine, hip,
knee and TMJ, manubrium sterni and costochondral joints.
Clinical features
Early morning stiffness
Pain in the back
On examination stiff spine
 Cervicalspine tested by asking the patient to touch
back of the head on the wall without raising the chin
( Fleches test)
Chest expansion is less than 5cm indicates thoracic
spine involvement
Pump handle test (knee to opposite shoulder) and
fabres test, pelvic compression test to identify the
sacroiliac involvement.
Pokedchin and progressive kyphotic deformity is the
characteristic feature of ankylosing spondylitis.
Diagnostic criteria for ankylosing spondylitis
Insidious onset
Age< 40 years
Persistence for > 3 months
Morning stiffness
Improvement with exercise
Extra-articular manifestations
Acute iritis
Pericarditis
Aortic incompetence
Subluxation of atlantoaxial joints
Apical lobe fibrosis
Generalized osteoporosis
Uveitis
Investigations
Radiographs:
Squaring of vertebra
Loss of lumbar lordosis
Calcification of anterior longitudinal ligament bridging
osteophytes
Bamboo spine appearance
Other investigations CT, MRI and bone scan
Laboratory investigations - HLA-B27 is raised
ESR raised
 Treatment
General measures
Patient education
Family education
Genetic counselling
Avoid smoking
Regular exercises, especially swimming is of
tremendous help
Physiotherapy and occupational therapy
 Conservative management
Rest, NSAID, exercise
Surgical management
Spinal osteotomy to correct spine deformity
Total hip replacement
Total knee replacement
 Physiotherapy management
Aims:
To relieve pain
To improve joint mobility
To improve respiration
To improve body ergonomics
To improve muscle power and endurance
 MEANS
TO RELIEVE PAIN
Superficial heating agents and cryotherapy are useful in reducing pain
and muscle spasm during the acute stage of AS
Deep heating modalities are effective in chronic stage
Steam bath preceding the exercise controls pain and induces relaxation
TO IMPROVE MOBILITY
Main emphasis is given for spinal intervertebral joints
Mobilization of facet joints by using specialized Maitland technique is
useful to maintain and to improve spinal ROM
Small range of mobilization in daily activity is incorporated, pool therapy
is an excellent means of providing pain relief
 To improve respiration
Free active exercises with deep breathing maintain the mobility and
improve respiratory capacity
Localized thoracic breathing without back support improves the
breathing capacity
Incentive spirometry, balloon blowing, whistling are helpful in
improving lung volumes and capacities as well as the endurance of
the respiratory muscles.
To improve body ergonomics
Deformity producing body attitude should be discouraged
Maximum emphasis needs to be given to the static and dynamic
postural attitudes
Repeated chin tucks, prone lying extension with forearm support,
hip hyper extension in prone, trunk lateral bending with deep
The usual tendency of stooping should be strictly discouraged
Advise to keep the chest forward with the shoulder retraction
will be helpful to the patient
Repeated isometrics, gentle stretching of pectorals, shoulder
bracing, retraction in daily routine will reduce some of the
stooping posture
To improve muscle power and endurance
Repeated strong contractions of the muscle and correct
posture will be useful in improving the muscle imbalances
To induce relaxation and to improve mobility active free
movement plays an important role.
The progression of disease stops after 10 -15 years
leaving a permanent residual deformity.
In majority of the patients total functional
independence returns except the fused spine
Surgery may be needed for fixed deformities
Physiotherapy management given based on the
surgical procedure.
 METABOLIC ARTHRITIS
Gout
Definition:
Excessive concentrations of uric acid and some purine bodies
in blood precipitate gout.
The kidney is unable to separate this concentration of uric acid
and purine bodies
The uric acid salt accumulates in the blood.
It mainly affects the first metatarsophalangeal and
metacarpophalangeal joints in men over the age of 40 years
The deposits of biurate of soda occur around the affected joint
The joint changes include subchondral cysts, osteophyte
formation and in the late stages reduction in joint space.
Acute stage
Clinical features:
Night pain and pain free joint in day time
Signs acute inflammation
Tender nodule chalk stones / tophi
Fever
 TREATMENT
Acute stage
Medical management:
Colchicine, probenecid, indomethacin
Anti-inflammatory analgesic drugs are prescribed along with
colchicine.
Lithium ionization is sometimes done in between acute attacks.
Iontophoresis forms lithium urate in place of insoluble sodium
urate.
Cryotherapy in the form of crushed ice packs and other non
thermal modalities may be tried to reduce inflammation and pain.
 PERTHES DISEASE
Perthes disease is a disease of childhood characterized b avascular
necrosis of the femoral head.
Unknown cause
Clinical feature:
Femoral head become necrotic and soft
Deformed
Affects children b/w 5 10 years
Unilateral / bilateral
All movements of the hip limited, especially abduction and internal
rotation
Radiograph confirms the disease and shows the stages of the
disease ( grade I to IV)
Treatment:
Acute stage the limb immobilized in skin traction, the hip is
mobilized as soon as the pain and spasm disappear.
Grade I and II - no treatment, observation, supervised neglect
Grade III and IV with no head deformation plaster or splint to
maintain the hip in abduction, surgery varus osteotomy of proximal
femur or osteotomy of pelvis
Grade III and IV with head deformation no treatment is possible,
osteoarthritis will develop eventually, need surgery total hip
replacement.
Physiotherapy management
1. Reduction of muscular spasm, pain and
inflammation
2. Isometric painless contractions
3. Intermittent compression of the joint
4. Maintenance of the range of motion
5. Prevention of contractures
6. increase of muscle strength
7. ambulation
 Cryotherapy techniques and moist heat techniques
with the leg maintained in traction
Isometrics
for hip extensors and abductors and
quadriceps
Intermittent
compression by slow relaxed passive
movements to nourish cartilage
Maintenance of ROM is by passive range of
movement, usually extension, abduction, internal
rotation is limited, if capsular laxity present splints
may be used .
Toprevent contractures especially flexion contracture
of the hip, gentle stretching of hip flexors, gravity
assisted hip extension and prone lying are useful.
 Toincrease the muscle strength- as the pain and
spasm reduces, active assisted, active or resisted
exercise started depending on the level of
discomfort. The emphasis should be on the eccentric
and isometrics at the terminal range of abductors
and extensors of the hip, quadriceps and hamstrings
and dorsiflexors and plantarflexors and intrinsic
muscles of the foot.
POP cast or abduction splint may be applied during
the immobilization period, so non weight bearing
standing and walking are taught in parallel bars,
then progressed to a walker and axillary crutches by
using special synder sling.
 Special braces for weight bearing with hip containment
Scottish
Rite brace allows flexion of the hip joint while it is
maintained in abduction
Petrie
plaster maintains the hip in 30 degrees of abduction and 20
degrees of internal rotation and 15 degrees of flexion at knees
After
removal of splint/ POP active mobilization used from passive
movement to active resisted movements. Hydrotherapy pool
exercise are very useful at this stage.
Physiotherapy following surgery:
Depends on the surgery and immobilization period, mobilization
started and the gradual exercise programme given to the patient.