Ankylosing spondylitis or AS is a long-term condition in which the spine and other areas of the body become inflamed. It’s a condition that tends to develop in young adults, either in their late teens or early 20s and affects both men and women equally. It is thought that it affects 1 in 200 people.
The condition can vary in severity and the symptoms tend to develop gradually over several months or years. It’s generally associated with back pain and stiffness, involving the sacroiliac joints, spine, and costovertebral joints. It also causes swelling in other parts of the body, caused by inflammation of the joints (arthritis) and inflammation where the tendons join the bones (enteritis). Another common symptom of ankylosing spondylitis is extreme fatigue.
Ankylosing spondylitis is a condition that fits under the umbrella of axial spondyloarthritis. The other condition is non radiographic axial spondyloarthritis.
Unfortunately, the diagnosis of all axial spondyloarthritic conditions is generally slow. At the moment the average diagnosis time is around 8 to 9 years. This is because the condition is not always easy to spot, and for those of us involved in physical therapy, such as osteopaths, physios and chiropractors, we haven’t always had the necessary training to spot it, which is a shame as we’re in the ideal position.
But that’s possibly being unfair on us as physical therapists. There’s been a lot of research over the last 15 to 20 years into these conditions. At least now we know the questions to ask and what to lookout for, so that we know when to refer to the rheumatologist. Rheumatologists are in a great position to be able to provide the correct medication, which is generally very well tolerated amongst the population. These medications improve people’s long term side effects of the condition and massively improve people’s quality of life.
Now, when I was at university, nearly 20 years ago, I remember learning about ankylosing spondylitis. At this stage of my career, the treatment for this condition was not so easily recognised or understood. I learnt that the ligaments that hold the spine together become stiffer and stiffer and slowly turn to bone (syndesmophytes). This can be seen on X-ray, and causes a bamboo effect, where it looks like the whole spine is fairly solid, with little bits of bamboo holding the vertebra together. The other thing that I learned was that the patient ends up developing a question mark like posture in their later life. If you can imagine the spine very bent over, with the head on top.
Fortunately, now the physical therapists that come out of UNI, and those of us that have chosen to do our continued professional development in this area, know more about this.
Spondyloarthritis is a group of inflammatory arthritic conditions with common features and is associated with extra articular inflammatory conditions: psoriasis, inflammatory bowel disease (ulcerated colitis and Crohn’s) and uveitis.
So, if someone comes in with one of these, or even a family history of one of these in their medical history and presents with persistent (3 months or more) or regular flare ups of lower back pain, under the age of 45, but more so, under the age of 35. And their pain is better for moving and generally worse for staying still, and it wakes them up in the second part of the night, around 4am, it might make us start to question the diagnosis. If they also happen to have a history of enteritis, which is very similar to tendonitis, but differs in location ever so slightly. A history of Dactylitis, which is basically a sausage finger or toe, we’d definitely be thinking about this.
Only 3 Symptoms Need to be Present
We only need three of these symptoms to be present for us to refer someone to a rheumatologist for blood tests and possible treatment, where they can get the appropriate medication to help with their condition.
Having said all of this, we still see a lot of people that have not had the diagnosis early enough and end up becoming very stiff. Even with people that are young, or have been diagnosed early, they can still get stiffness associated with this condition. There’s lots that we can do as osteopaths to help out with peoples stiffness. We use soft tissue work, harmonics, muscle energy techniques, joints articulation plus education on specific exercises to help keep people as mobile as possible.
But it’s also knowing what treatment techniques are not safe to use within the consultation. Unfortunately, the condition itself, can predispose people to get osteoporosis, and the medication can do the same. The ligaments are also affected, ruling out some treatment techniques.