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| '''Original Editors '''- [http://www.physio-pedia.com/index.php5?title=User:Adam_Bockey Adam Bockey] [[Pathophysiology of Complex Patient Problems|from Bellarmine University's Pathophysiology of Complex Patient Problems project.]]
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| '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} - Elaine Lonnemann.
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| </div>
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| == Definition/Description ==
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| '''Spondyloarthropathy''' represents a group of noninfectious, inflammatory, rheumatic diseases that primarily includes ankylosing spondylitis, Reiter’s syndrome, reactive arthritis, and the arthritis associated with psoriasis and inflammatory bowel diseases. The primary pathologic sites are the sacroiliac joints, the bony insertions of the annulus fibrosis of the intervertebral discs, and the apophyseal joints of the spine.<ref name="Differential Diagnosis">Goodman C, Snyder T. Differential Diagnosis for Physical Therapists: Screening for Referral. St. Louis, MO: Saunders Elsevier: 2007. 539</ref> [[Image:Spondy 1.png|thumb|right|Spondy 1.png]]
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| <br>'''Ankylosing Spondylitis (AS)''' also known as [http://www.medterms.com/script/main/art.asp?articlekey=30705 Marie- Strumpell disease] or bamboo spine, is an inflammatory arthropathy of the axial skeleton, usually involving the sacroiliac joints, apophyseal joints, costovertebral joints, and intervertebral disc articulations.<ref name="Pathology">Goodman C, Fuller K. Pathology: Implications for the Physical Therapist. 3rd ed. St. Louis: Saunders Elsevier; 2009.</ref> AS is a chronic progressing inflammatory disease that causes inflammation of the spinal joints that can lead to severe, chronic pain and discomfort. In advanced stages, the inflammation can lead to new bone formation of the spine, causing the spine to fuse in a fixed position often creating a forward stooped posture.<ref name="Association" />
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| {{#ev:youtube|2s8eueQ4-eM}}<ref name="Vilke">Vilke G. Areas of inflammation in ankylosing spondylitis. http://www.youtube.com/watch?v=2s8eueQ4-eM. Accessed on March 30, 2011</ref><br>
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| == Prevalence ==
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| Ankylosing Spondylitis is 3 times more common in men than in women and most often begins between the ages of 20-40.<ref name="The Merck Manual">Beers MH, et. al. eds. The Merck Manual of Diagnosis and Therapy. 18th ed. Whitehouse Station, NJ: Merck Research Laboratories; 2006.</ref> Recent studies have shown that AS 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. Prevalance of AS is nearly 2 million people or 0.1% to 0.2% of the general population in the United States. It occurs more often in Caucasions and some Native American than in African Americans, Asians, or other nonwhite groups.<ref name="Differential Diagnosis" /> AS is 10 to 20 times more common with first degree relatives of AS patients than in the general population. The risk of AS in first degree relatives with the HLA-B27 allele is about 20% occurrence.<ref name="The Merck Manual" /><br>
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| == <br>Characteristics/Clinical Presentation ==
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| The initial presenting complaints of AS is non-traumatic, insidious onset of low back, buttock, or hip pain and stiffness for more than 3 months in a person, usually male under 40 years of age.<ref name="Differential Diagnosis" /> It is usually worse in the morning lasting more than 1 hour and is described as a dull ache that is poorly localized, but it can be intermittently sharp or jolting. Overtime pain can become severe and constant and coughing, sneezing, and twisting motions may worsen the pain. Pain may radiate to the thighs, but does not typically go below the knee. Buttock pain is often unilateral, but may alternate from side to side.<ref name="Pathology" /> Paravertebral muscle spasm, aching, and stiffness are common making sacrioliac areas and spinous process very tender upon palpation.<ref name="Differential Diagnosis" /> A flexed posture eases the back pain and paraspinal muscle spasm; therefore, kyphosis is common in untreated patients.<ref name="The Merck Manual" /> Enthesitis (inflammation of tendons, ligaments, and capsular attachments to bone) may cause pain or stiffness and restriction of mobility in the axial skeleton.<ref name="Pathology" /> A positive Schober test is used to confirm reduction in spinal motion which is associated with AS. Since AS is a systemic disease an intermittent low grade fever, fatigue, or weight loss can occur.<ref name="Differential Diagnosis" /> In advanced stages the spine can become fused and a loss of normal lordosis with accompanying increased kyphosis of the thoracic spine, painful limitations of cervical joint motion, and loss of spine flexibility in all planes of motion. A decrease in chest wall excursion less than 2 cm could be an indicator of AS because chest wall excursion is an indicator of decreased axial skeleton mobility.<ref name="Pathology" />
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| In a recent review, four out of five positive responses to the following questions may help with the determining of AS: <br> 1. Did the back discomfort begin before age 40 <br> 2. Did the discomfort begin slowly <br> 3. Has the discomfort persisted for 3 months<br> 4. Was morning stiffness a problem <br> 5. Did the discomfort improve with exercise
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| Specificity= 0.82, Sensitivity =0.23
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| LR for four out of five positive responses = 1.3<ref name="Rudwaleit" /><br>
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| [[Image:Spondy4.jpg|frame|center|300x422px]] <ref name="Health">Health writings. Ankylosing spondylitis drug. http://www.health-writings.com/category/0/1/543/ Access March 30, 2011</ref>
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| == Associated Co-Morbidities ==
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| Uveitis, conjunctivitis, or iritis occurs in nearly 25% of the people with AS.<ref name="Differential Diagnosis" /> Signs of iritis or uveitis are: eye(s) becoming painful, watery, red, and sometimes blurred vision or sensitivity to bright light.<ref name="Association" /> Pulmonary changes such as chronic infiltrative or fibrotic bullous changes of the upper lobe occur in 1% to 3% of the people with AS.<ref name="Differential Diagnosis" /> Cardiomegaly, conduction defects, and pericarditis are all common complications of AS.<ref name="Merck">Beers MH, ed. The Merck Manual of Diagnosis and Therapy, 18th edition. Whitehouse Station, NJ: Merck and CO; 2006</ref> Also many people with AS experience bowel inflammation, which can be associated with Crohn’s Disease or ulcerative colitis.<ref name="Association" /> <br>
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| == Medications ==
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| NSAIDs (nonsteroidal anti-inflammatory drugs) reduce pain and suppress joint inflammation and muscle spasm, in return increasing range of motion.<ref name="Merck" /> NSAIDs can cause significant side effects, in particular, damage to the gastrointestinal tract.<ref name="Association" /> In some cases disease modifying anti-rheumatic drugs (DMARDS) such as methotrexate (MTX) or sulfasalazine (SSZ) may be used for peripheral disease.<ref name="Pathology" /> Corticosteroid injections into the sacroiliac joints may help severe sacroiliitis. Topical corticosteroids can also be used for acute uveitis or iritis.<ref name="Merck" /> The most recent medication for AS are the biologics or TNF Blockers. These agents have been shown effective in preventing the progression of AS by reducing disease activity, decreasing inflammation, and improving spinal mobility.<ref name="Pathology" /><br>Examples of TNF blockers include: <ref name="mayoclinic" /><br>- Adalimumab (Humira)<br>- Etanercept (Enbrel)<br>- Infliximab (Remicade)<br>- Golimumab (Simponi)<br>
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| == Diagnostic Tests/Lab Tests/Lab Values ==
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| AS can be diagnosed by the modified New York criteria, the patient must have radiographic evidence of sacroiliitis and one of the following: (1) restriction of the lumbar spine motion in both the sagittal and frontal planes, (2) restriction of chest expansion (usually < 2.5 cm) (3) a history of back pain includes onset at <40 year, gradual onset, morning stiffness, improvement with activity, and duration >3 months.<ref name="Merck" /> <br>
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| '''Imaging tests<ref name="mayoclinic" />''' <br>- X-rays. Radiographic findsing of symmetric, bilateral sacroiliitis include blurring of joint margins, extaarticular sclerosis, erosion, and joint space narrowing. As bony tissue bridges the vertebral bodies and posterior arches, the lumbar and thoracic spine creates a “bamboo spine” image on radiographs.<ref name="Pathology" /> <br>- Computerized tomography (CT). CT scans combine X-ray views taken from many different angles into a cross-sectional image of internal structures. CT scans provide more detail, and more radiation exposure, than do plain X-rays.<ref name="mayoclinic" /><br>- Magnetic resonance imaging (MRI). Intraarticular inflammation, early cartilage changes and underlying bone marrow edema and osteitis can be seen using an MRI technique called short tau inversion recovery (STIR).<ref name="Pathology" /> Using radio waves and a strong magnetic field, MRI scans are better at visualizing soft tissues such as cartilage.<ref name="mayoclinic" /><br>- Lab tests. There is no current laboratory testing in the diagnostic of AS, laboratory tests are primarily for ruling out other diseases. The presence of the HLA-B27 antigen is a useful adjunct to the diagnosis, but cannot be diagnostic alone.<ref name="Pathology" /><br>
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| [[Image:Spine-t ankylosing spondylitis.jpg|frame|center|312x593px]] <ref name="Jalbum">Jalbum, Chameleon. Spine-t ankylosing spondylitis. http://www.e-radiography.net/ibase8/Spine-t/slides/Spine-t_ankylosing_spondylitis.htm. Access March 30, 2011</ref>
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| <br>
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| == Outcome Measures ==
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| -[http://www.iche.edu/newsletter/MHAQ.pdf Modified Health Assessment Questionnaire (MHAQ)]
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| -[http://basdai.com/BASDAI.pdf and http://www.basdai.com/BASDAI.php Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)] <br><br>
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| == Etiology/Causes ==
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| AS is believed to be genetically inherited, and nearly 90% of people with AS are HLA-B27 positive.6 However, only 2% of the people with this antigen develop AS.<ref name="Pathology" /> Additionally, 10% to 20% of people who have a first degree relative with AS and how inherit the HLA-B27 antigen eventually develop AS.<ref name="Walton" /> Recently, two more genes have been identified that are associated with AS. These genes, ARTS1 and IL23R, seem to play a role in influencing immune function.<ref name="MedicineNet" /> The IL23R gene plays a role in the immune response to infection and making a receptor present on the surface of several types of immune system cells. The receptor is involved in triggering certain chemical signals inside the cell that promote inflammation and help coordinate the immune system's response to infection. It is already recognized as playing a role in a number of autoimmune diseases, such as Crohn's disease and psoriasis, which often are associated Co-morbidities.<ref name="Brierley">Brierley C.Major genetic breakthrough for ankylosing spondylitis brings treatment hope. http://www.eurekalert.org/pub_releases/2007-10/wt-mgb101907.php. Oct 2007.</ref>
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| <br>
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| == Systemic Involvement<ref name="Walton">Walton C, Reed C. Ophthalmologic Manifestations of Ankylosing Spondylitis. http://emedicine.medscape.com/article/1193119-overview. 2010, April.</ref> ==
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| -Neurologic involvement - Symptoms associated with spinal dislocations, subluxations, fractures, cauda equina syndrome<br>- Cardiovascular manifestations - Aortitis, aortic/mitral insufficiency, conduction defects<br>- Hip/shoulder involvement<br>- Chronic back stiffness and pain<br>
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| == Medical Management (current best evidence) ==
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| The primary medical focus with AS is to reduce inflammation and stiffness in the joints, maintain mobility and correct posture alignment, while relieving pain. NSAIDS or DMARDs are the most commonly medications used for joint pain and inflammation. For more progressive forms of AS surgery may be indicated; however, this may only be appropriate for individuals with sever deformities that impedes vision, ambulating, eating, chest excursion, or respiratory function. Other targeted therapies may be indicated to treat specific organ involvement, such as eye inflammation to avoid lifelong complications. <ref name="Pathology" /> No treatment has been proven to prevent the progression of AS, but further research is needed. The key to maintaining comfort and spinal mobility is regular exercise. Intermittent physical therapy may be necessary to correct or minimize deformity or joint restrictions as well as to maintain motivation.<ref name="Keat">Keat A. Ankylosing Spondylitis. Medicine2010; 38:4.185-189.</ref>
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| <br>
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| == Physical Therapy Management (current best evidence) ==
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| '''<br>'''A multimodal physical therapy program including aerobic, stretching, education and pulmonary exercises in conjunction with routine medical management has been shown to produce greater improvements in spinal mobility, work capacity, and chest expansion compared with medical care alone.<ref name="Pathology" /> Since the severity of AS is very different among individuals, there is no specific exercise program that showed the greatest improvements. Some studies showed that a 50 minute, three times a week multimodal exercise program showed significant improvements after 3 months in chest wall excursion, chin to chest distance, occiput to wall distance, and the modified Schober flexion test.<ref name="Pathology" />
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| EXERCISE:
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| A few recommended exercises for an individual with AS is to focus on breathing capacity should be evaluated and established. Stretching of the shortened muscles and chest expansion should be encouraged. Improving and maintaining cardiovascular fitness with aerobic exercise is also important. Strengthening of the hypomobile trunk extensors is also important to encourage an upright erect posture, so when spinal fusion occurs, the spine is aligned in the most functional position. Posture education can be a very important component to the patient to maintain an erect posture as well. Aquatic therapy can be an excellent option for most to provide low impact extension and rotation principles.<ref name="Pathology" /> <br>Exercises that should be avoided include high impact and flexion exercises. Over exercising can be potentially harmful and could exacerbate the inflammatory process.<ref name="Pathology" /> <br>
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| MANUAL THERAPY
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| Some have advocated the efficacy and use of gentle non-thrust manipulation in the spine.<ref name="AS Widberg">Widberg K, Karimi H, Hafström I. Self- and manual mobilization improves spine mobility in men with ankylosing spondylitis--a randomized study. Clin Rehabil. 2009;23(7):599-608</ref>
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| COCHRANE REVIEW
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| In 2008 a Cochrane Review was published that reviewed the effectiveness of Physiotherapy Management in patients with AS. Below is the summary from Dagfinrud H, Hagen KB, and Kvien TK. <ref name="Cochrane Review 2008 Ankylosing Spondylitis">Dagfinrud H, Hagen KB, Kvien TK. Physiotherapy interventions for ankylosing spondylitis. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD002822. DOI: 10.1002/14651858.CD002822.pub3</ref><br>
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| == Differential Diagnosis ==
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| '''<br>'''Most Common differential diagnosis<ref name="Pathology" />
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| • Rheumatoid arthritis<br>• Psoriasis<br>• Reiter's syndrome<br>• Fracture<br>• Osteoarthritis<br>• Ulcerative colitis<br>• Crohn’s disease<br><br> Differential Diagnosis of Ankylosing Spondylitis and Thoracic Spinal Stenosis<ref name="Magee">Magee D. Orthopedic Physical Assessment. Fifth edition. St. Louis, MO: Saunders Elsevier: 2008. 513.</ref>
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| {| style="width: 656px; height: 314px" border="1" cellspacing="1" cellpadding="1" width="656"
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| |-
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| | Ankylosing Spondylitis
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| | Thoracic Spinal Stenosis
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| | History
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| | Morning stiffness<br>Intermittent aching pain<br>Male predominance<br>Sharp pain/ach<br>Bilateral scroiliac pain may refer to posterior thigh<br>
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| | Intermittent aching pain<br>Pain may refer to both legs with walking<br>
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| |-
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| | Active movements
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| | Restricted
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| | May be normal
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| |-
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| | Passive movements
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| | Restricted
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| | May be normal
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| |-
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| | Resisted isometric movements
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| | Normal
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| | Normal
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| |-
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| | Special tests
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| | None
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| | Bicycle test of van Gelderen may be positive<br>Stoop test may be positive<br>
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| |-
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| | Reflexes
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| | Normal
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| | May be affected in long standing cases
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| |-
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| | Sensory deficit
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| | None
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| | Usually temporary
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| |-
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| | Diagnostic imaging
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| | Plain films are diagnostic
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| | Computed tomography scans are diagnostic
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| |}
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| In the early stages of ankylosing spondylitis,the changes in the sacroiliac joint are similar to that of rheumatoid arthritis, however the changes are almost always bilateral and symmetrical. This fact allows ankylosing spondylitis to be distinguished from psoriasis, Reiter's syndrome, and infection. Changes at the sacroiliac joint occur throughout the joint, but are predominantly found on the iliac side.
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| <br>
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| == Case Reports/ Case Studies ==
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| '''[http://www.ncbi.nlm.nih.gov/pubmed/?term=Ankylosing+spondylitis+in+a+patient+referred+to+physical+therapy+with+low+back+pain Ankylosing Spondylitis in a Patient referred to Physical Therapy with Low Back Pain] '''by Gretchen Seif & James Elliott<br>January 2012
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| [http://www.jospt.org/issues/id.2788/article_detail.asp '''Differential Diagnosis and Management of Ankyosing Spondylitis Masked as Adhesive Capsulitis: A Resident’s Case Problem.''']by Jordan CL, Rhon DI'''<ref>ordan CL, Rhon DI. Differential Diagnosis and Management of Ankyosing Spondylitis Masked as Adhesive Capsulitis: A Resident’s Case Problem. J Orthop Sport Phys. 2012;42(10):842-852.</ref> '''<br> [https://my.usa.edu/ICS/icsfs/Ankylosing_Spondylitis_Radiographs.ppt?target=aa7d4134-1918-4e5b-938c-e296dccefdc9 Link to PowerPoint from Resident's Case Problem]
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| <br>
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| '''[http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B6WBJ-4717YF1-C-1&_cdi=6712&_user=6406088&_pii=S1521694202902408&_origin=gateway&_coverDate=09%2F30%2F2002&_sk=999839995&view=c&wchp=dGLbVtz-zSkzk&md5=a9d7a9f48591a72f1c1e9a8406c5da67&ie=/sdarticle.pdf Spa and exercise treatment in ankylosing spondylitis: fact or fancy?]<ref name="Tubergen">Tubergen A, Hidding A. Spa and exercise treatment in ankylosing spondylitis: fact or fancy? Best Practive and Research Clinical Rheumatology. 2002; 16:4. 653-666.</ref>'''<br>
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| '''[http://onlinelibrary.wiley.com/doi/10.1002/art.21619/pdf Inflammatory Back Pain in Ankylosing SpondylitisResources]<ref name="Rudwaleit">Rudwaleit M, Metter A, Listing J, Sieper J, Braun J. Inflammatory back pain in ankylosing spondylitis; a reassessment of the clinical history for application as classification and diagnostic criteria. Arthritis and Rheumatism. 2005; 54:2. 569-578.</ref> '''<br>
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| Self- and manual mobilization improves spine mobility in men with ankylosing spondylitis – a randomized study<ref name="Widberg">Widberg K, Hafstrom I. Self-and manual mobilization improves spine mobility in men with ankylosing spondylitis- a randomized study. Clinical Rehabilitation. 2009; 23: 599-608.</ref><br>
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| Shoulder, Knee, and Hip Pain as Initial Symptoms of Juvenile Ankylosing Spondylitis: A Case Report<ref name="Frey">Frey L, Haftel H. Shoulder, knee, and hip pain as initial symptoms of juvenile ankylosing spondylitis: a case report. Journal of Orthopedic and Sports Physical Therapy. 1998; 17:2. 167- 172.</ref>
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| <br>
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| == Resources ==
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| [http://www.spondylitis.org/ Spondylitis Association of America<ref name="Association">Spondylitis Association of America. http://www.spondylitis.org/main.aspx. 2011. March 13, 2011.</ref>]
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| [http://www.medicinenet.com/ankylosing_spondylitis/article.htm MedicineNet.com]<ref name="MedicineNet">MedicineNet.com Ankylosing Spondylitis. http://www.medicinenet.com/ankylosing_spondylitis/article.htm. 2011. March 4, 2011.</ref>
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| [http://www.mayoclinic.com/health/ankylosing-spondylitis/DS00483 Mayo Clinic]<ref name="mayoclinic">Ankylosing Spondylitis. http://www.mayoclinic.com/health/ankylosing-spondylitis/DS00483. March 20, 2011.</ref>
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| <br>
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| == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) ==
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| see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]
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| <div class="researchbox"><rss>view-source:http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1Hi5ZYwmE-2AynAf6YInR-qJq3PnLCA2I1YHlF62z1YfDjks8r|charset=UTF-8|short|max=10</rss></div>
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| == References ==
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| see [[Adding References|adding references tutorial]].
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| <references />
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| [[Category:Bellarmine_Student_Project]]
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