Imaging and Physical Therapy: Ankylosing Spondylitis

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Clinical Presentation, Imaging Findings and Patient Management

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Ankylosing Spondylitis: Clinical Presentation, Imaging Findings and Patient Management:

Ankylosing Spondylitis : Clinical Presentation, Imaging Findings and Patient Management Karissa Moreland Christina Puckett Celeste Steggall October 13, 2013

Disease Description:

Disease Description Ankylosing spondylitis is a rheumatic condition that primarily involves the spine and sacroiliac joint. 1 It is considered a long-term type of arthritis that affects the entheses , or the attachment sites of ligaments and tendons to bone. 2 The first stage of the disease causes inflammation and pain in the affected areas. 2 The disease can progress to include destruction to the bones and joints of the spine and sacroiliac joint, causing the affected spine to fuse in an abnormal, kyphotic posture. 2 Picture to the right: This image points out a common site of inflammation of Ankylosing Spondylitis at the sacroiliac joint as highlighted in red. http://www.rheumatology.org

Signs and Symptoms:

Signs and Symptoms Pain and stiffness often begin in the low back, pelvis and hips. 3 Symptoms are intermittent, but are often more noticeable at night, in the morning and when you are less active. 2 Pain that wakes you up at night. 2 The pain and stiffness can migrate upward into the ribs and sternum, causing difficulty with chest expansion. 2 Less common symptoms include swelling of the eyes, heel pain, swelling of the shoulder, knee and ankle joints, loss of appetite, weight loss and fever. 2 Picture above: Denotes the abnormal spinal curvature that can occur with Ankylosing Spondylitis. http://www.rheumatology.org

Disease Incidence :

Disease Incidence There is no known cause of a nkylosing spondylitis. 3 Genes seem to play and role as most people who have ankylosing spondylitis have the HLA-B27 gene . 2,3 A family history of the disease increases your risk. 3 Men are more commonly affected than women. 1,2,3 People in their late teens and twenties are most often affected, but the disease can occur as early as 10 and as late as 40 years of age. 2,3

Disease Incidence Map:

Disease Incidence Map Shapira Y, Agmon -Levin N, Shoenfeld Y. Geopidemiology of autoimmune rheumatic diseases . Nature Reviews Rheumatology. http://www.nature.com/nrrheum/journal/v6/n8/fig_tab/nrrheum.2010.86_F3.html . Updated Aug 2010. Accessed Oct 10 th , 2013.

Diagnosis:

Diagnosis Early detection of the disease may be limited by the patient’s intermittent symptoms and delayed visit to a medical professional. 3 Imaging tests used to detect soft tissue and bony changes include: Plain film Radiograph, Computed Tomography and Magnetic Resonance Imaging. 2,3 Lab tests may include: Complete Blood Count (CBC) to measure to number of red blood cells. 2 Erythrocyte sedimentation rate (ESR) to measure inflammation. 2 HLA-B27 antigen which detects the gene linked to a nkylosing spondylitis . 2

Prognosis & Effects on Daily Life:

Prognosis & Effects on Daily Life Disease complications include : Intermittent pain, fatigue and stiffness 1,2,3 Blurred vision due to eye inflammation 3 Compression fractures due to osteoporosis 3 Difficulty breathing due to fused ribs 3 Heart problems due to an inflamed aorta 3 Psoriasis 3 Intestinal inflammation 2 Despite these complications, most patients with a nklosying s pondylitis can lead productive lives and have normal life spans. 2 Frequent exercise, along with anti-inflammatory medication, is considered key in disease management. 3 The American College of Rheumatology strongly recommends Physical Therapy for joint-based exercise and the promotion of spinal extension. 2

Role of Imaging in Ankylosing Spondylitis - Radiography :

Role of Imaging in Ankylosing Spondylitis - Radiography Traditionally, the form of imaging used for the diagnosis and management of ankylosing spondylitis has been conventional radiography. 4 The effects of this disease are most commonly seen in the sacroliliac joint (SIJ) and spinal column, but larger lower extremity joints can also be affected. 5 There are both early and late radiographic manifestations that can be used to diagnose the disease and also grade its’ progression . 4

Role of Imaging in Ankylosing Spondylitis – Radiography Continued :

Role of Imaging in Ankylosing Spondylitis – Radiography Continued EARLY radiographic characteristics include: 4,5 Bilateral sacroiliitis at the SIJ that is symmetrical Erosion of the subchondral bone at the iliac side of the SIJ with adjacent reactive sclerosis Enthesitis at the edges of the discovertebral joints Sclerosis (“the shiny corner”) and erosion (“ Romanus lesion”) at the attachment of the annulus fibrosis Sclerosis and erosion at the superior and inferior corners of vertebral bodies LATER radiographic characteristics include: 5,6,7 Loss of normal concavity (“boxy” shape) of vertebral bodies Ossification of spinal ligaments (“trolley track sign”) Ossification of the intervertebral discs (“bamboo spine”) Inflammation of supraspinous ligaments Syndesmophytes at the anterior and lateral aspects of the vertebrae; fusion of facet joints Periosteal whiskering at sites of tendonous insertion

Role of Imaging in Ankylosing Spondylitis - Radiography:

Role of Imaging in Ankylosing Spondylitis - Radiography Diagnosis of ankylosing spondylitis is often made based on a combination of clinical criteria and radiographic sacroiliitis using the modified New York Criteria. 4 The disease may be diagnosed if one clinical criterion is present in combination WITH: Minimal sacroiliitis (loss of definition of the joint margins, minimal sclerosis, joint space narrowing and erosions) bilaterally = GRADE 2 Moderate sacroiliitis (definite sclerosis on both sides of the joint, erosions, and loss of joint space) = GRADE 3 Complete bony ankylosis unilaterally = GRADE 4 Through the use of radiographs, the diagnosis of disease can be delayed 7-10 years. 4 Radiography of the spine and SIJ can also be helpful in following the progression of the disease. 4 Courtesy of Radiopaedia.org, 2013

Role of Imaging in Ankylosing Spondylitis - MRI:

Role of Imaging in Ankylosing Spondylitis - MRI Magnetic resonance imaging (MRI) is the most sensitive imaging modality to detect early signs of ankylosing spondylitis , such as inflammation in soft tissue structures and bone. 4 Imaging characteristics of ankylosing spondylitis through MRI include: 4,5 Bone marrow edema and enhancement of the bone marrow and the joint space after contrast medium administration Bone spurs and ankylosis Arthritis of the facet, costovertebral and costotransverse joints Enthesitis of the interspinal and supraspinal ligaments of the spine, as well of the SIJ interosseous ligaments Periarticular fatty tissue accumulation Erosions and sclerosis MRI can also assist in a much earlier diagnosis of ankylosing spondylitis , with the presentation of one clinical sign and a positive MRI (bone marrow edema located in 2 sites or slices) being sufficient for diagnosis. 4,8 Courtesy of Ostergaard and Lambert, 2012

Role of Imaging in Ankylosing Spondylitis – CT:

Role of Imaging in Ankylosing Spondylitis – CT Computed tomography (CT) can play a role in ankylosing spondylitis by assisting in the visualization of bone erosion at a joint of enthesis or resulting fractures. However, it has a low sensitivity for soft tissue changes. 4 CT can produce multiplanar images showing pathological erosion, sclerosis and formation of new bone that eliminate superimposition of structures. 4 Regular CT can assist in the diagnosis of ankylosing spondylitis through the presentation of sacroiliitis , but it is not superior to conventional radiography. It may be used if a radiograph produces an unclear image of the SIJ. 4,9 Multi-detector CT (MDCT) is can be superior to radiography for advanced ankylosing spondylitis and those who may also have a cervical fracture. 9 CT has little indication for monitoring the progression of ankylosing spondylitis. 4 Courtesy of University of Washington, 2004

Imaging of Choice for Ankylosing Spondylitis:

Imaging of Choice for Ankylosing Spondylitis Conventional radiography remains the most important imaging modality for the detection, diagnosis and monitoring of ankylosing spondylitis . Even though limited in early detection of sacroillitis and vertebral body changes, radiography accurately detects specific bony changes, fusion of joints and ossification and inflammation of spinal and SIJ ligaments. 9 ,11

AP Radiograph 1:

AP Radiograph 1

AP Radiograph 1 Findings:

AP Radiograph 1 Findings Bilateral sacroilitis . Sacroilitis occurs early in the disease progression and is considered a hallmark of the disease. 12 Bilateral sacroiliac joint erosions. 12 Bilateral sacroiliac joint subchondral sclerosis. 12

Lateral Radiograph Findings:

Lateral Radiograph Findings Vertebral body squaring of L3 and L4 vertebral bodies. 12 L3/4 anterior syndesmophyte. 12 Lumbar facet fusion at L3/4 through L5/S1. 12

AP Radiograph 2 Findings:

AP Radiograph 2 Findings Bamboo spine with the “trolley track” appearance. 12 Complete fusion of the vertebral bodies. 12 Extensive facet joint ankylosis. 12 Posterior ligamentous ossification. 12

Axial CT Scan :

Axial CT Scan

Axial CT Scan Findings:

Axial CT Scan Findings Bilateral sacroilitis. 12 Bilateral erosions of the ilium. 12 Subchondral sclerosis of bilateral sacroiliac joints. 12

Biomechanical Impairments:

Biomechanical Impairments Decreased spinal segmental mobility from sacrum to occiput 13 in all planes: flexion, extension, rotation and sidebending . Hyperkyphosis leads to the center of mass moving anterior. Patients compensate with a flexed hip and knee posture leading to decreased extension of these joints. 14 Impaired gait due to decreased hip and knee extension . 14

Physical Impairments:

Physical Impairments Dorsal hyperkyphosis may induce the patients to stand in a stooped position unable to see the horizon . 13 Impaired balance secondary to severe joint deformities and poor posture . 14 Pain in the sacral and gluteus region. Also a possible extension of the pain from the thigh to the proximal calf has been reported. 13 Patients may have trouble with ADL’s such as driving a car, walking in the grocery store and difficulty maintaining personal hygiene. 13

Questions for our classmates::

Questions for our classmates: What are the early radiographic findings of ankylosing spondyolitis and what would you expect the clinical presentation of a patient in this stage to look like? Base on the presentation of ‘trolley tracks’ signs in a plain film radiograph, what would appropriate physical therapy interventions be for a treatment session? Please list at least two interventions and explain your rational for what you chose.

References:

References American College of Rheumatology. Diseases and Conditions: Spondylarthritis . Available at http://www.rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/Spondylarthritis_%28Spondylarthropathy%29/. Updated November 2012. Accessed 10/10/2013. PubMed Health. Ankylosing spondylitis . Available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001457/. Updated 4/20/2013. Accessed 10/10/2013. Mayo Clinic. Akylosing spondylitis . Available at http://www.mayoclinic.com/health/ankylosingspondylitis/DS00483/DS ECTION=tests-and-diagnosis. Updated 02/03/2011. Accessed 10/10/2013. Ostergaard M, Lambert RG. Imaging in ankylosing spondylitis . Ther AdvMusculoskelet Dis . 2012;4(4):301-11. Langdon L. Imaging for Physical Therapy. Course Notes. University of St. Augustine for Health Sciences. Fall 2013. Accessed October 9, 2013.

References:

References Herring W. Learning Radiology.  Ankylosing Spondylitis . Available at http://www.Learningradiology.com/archives05/COW%20134Ankylosing%20Spondylitis/ankspondylocorrect.htm. Published 2005. Accessed October 8, 2013. McKinnis LN. Fundamentals of Musculoskeletal Imaging . 3 rd Edition. Philadelphia, PA: FA Davis Company; 2010. Rudwaleit M, van der Heijde D, Landewe R, Listing J, Akkoc N, Brandt J, et al. The development of assessment of spondyloarthritis international society classification criteria for axial spondyloarthritis (part II): validation and final selection.  Ann Rheum Dis . 2009;68:777–783. Jones J, et al. Ankylosing Spondylitis . Radiopaedia Web site. Available at http:// radiopaedia.org/articles/ ankylosing_spondylitis . Accessed October 8, 2013.

References:

References Ankylosing Spondylitis . University of Washington Medical Center Website. Available at http://uwmsk.org/residentprojects/ankylosingspondylitis.html. Published October 19, 2004. Accessed October 10, 2013. Imaging in Ankylosing Spondylitis . MedScape Web site. Published April 2011. Accessed October 10, 2013 Wilfred CG. Imaging in Ankylosing Spondylitis . Available at http://emedicine.medscape.com/article/386639-overview#a19. Updated April 12, 2011. Accessed on October 8, 2013 Sawacha Z, et al. Biomechanical assessment of balance and posture in subjects with ankylosing spondylitis . Journal of NeuroEngineering and Rehabilitation. 2012;9:63. Del Din S, et al. Impaired gait in ankylosing spondylitis . Med Biol Eng Comput . 2011; 49(7):801-809. Thank you!

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