ankylosing spondylitis

PowerPoint Presentation: 

Sunday, September 02, 2012 Ankylosing Spondylitis Made by Tuba begum 1

OBJECTIVE: 

OBJECTIVE 2 Introduction Epidemiology Etiology Pathophysiology Clinical Features Postural Changes Examination Assessment Rehabilitation Physical Therapy Management Conclusion

Introduction: 

Introduction Ankylosing spondylitis is a greek words in which Ankylos : stiff Spondylos : vertebrae It is a chronic progressive inflammatory disease of the sacroiliac joints and the axial skeleton. 3

Epidemiology: 

Epidemiology Age: Most often affects the young adults between the age of 20-30 years, may also begin in middle-aged(45 and 65) Gender: Males are affected more than females (M:F = 4:1) 4

Etiology: 

Etiology Idiopathic AS is found to be strongly associated with HLA-B 27 genetic factor 5

Pathophysiology: 

Pathophysiology 6

Pathophysiology: 

Pathophysiology 7

PowerPoint Presentation: 

8 Skeletal Axial Arthritis ( Eg , Sacroiliitis And Spondylitis ) Arthritis Of ‘Girdle Joints’ (Hips And Shoulders) Peripheral Arthritis Uncommon Others: Enthesitis Osteoporosis Vertebral Fractures Spondylodiscitis Costochondritis Extraskeletal Uveitis Iritis Cardiovascular Involvement Pulmonary Involvement Cauda Equina Syndrome Amyloidosis Achilles Tendinitis Fatigue Clinical Features of AS

PowerPoint Presentation: 

Spinal and sacroiliac involvement Hip and shoulder involvement Costovertebral , sternoclavicular , costochondral inflammation 9

Postural changes: 

Postural changes 10

Postural changes: 

Postural changes Normal Posture Advanced Ankylosing Spondylitis 11

PowerPoint Presentation: 

Progressive deformity due to Ankylosing Spondylitis over a period of 35 years 12

Examination: 

Examination History Inspection Investigation Test and measures 13

PowerPoint Presentation: 

4 of 5 criteria: Onset of back pain before age of 40 yrs Insidious onset Persistence for at least 3 months Associated with morning stiffness Improvement with exercise No Yes 25% probability of Ankylosing Spondylitis Consider another diagnosis History 14

Inspection: 

Inspection No Scoliosis Symmetrical Paraspinals Normal Shoulder And Gluteal Muscle Bulk & Symmetry Level Iliac Crests Normal Cervical And Lumbar Lordosis 15

Investigations: 

Investigations Blood tests HLA B27 ESR/CRP Radiology X ray CT scan MRI DEXA ultrasound 16

Cervical mobility: 

Cervical mobility Occiput -to-wall distance Tragus-to-wall distance Cervical rotation Chest expansion Thoracic mobility Lumber mobility Modified schober index Finger-to-floor distance Lumber lateral flexion TEST and MEASUREMENT for AS Test 17

Some Other Test: 

Some Other Test Pelvic compression test Fabre test Range of motion Gaenslen Test Test 18

Occiput To Wall Distance / Flesche Test: 

The occiput to wall distance should be zero 19 The severity of cervical flexion deformity in ankylosing spondylitis can be assessed by measuring the occiput to wall distance ( Flesche test). With the patient standing erect, the heels and the buttocks are placed against a wall The patient is then instructed to extend his or her neck maximally in an attempt to touch the wall with the occiput . The distance between the occiput and the wall is a measure of the degree of flexion deformity of the cervical spine. Occiput To Wall Distance / Flesche Test

Chest Expansion Test: 

Measured at level of 4th intercostal space The difference between maximum inspiration and expiration is measured An expansion less than 2.5cm is abnormal. Chest Expansion Test 20

Finger to floor distance: 

Finger to floor distance Expression of spinal column mobility when bending over forward; the dimension that is measured is the distance between the tips of the fingers and the floor when the patient is bent over forward with knees and arms fully extended. 21

Pelvic Compression Test: 

Pelvic Compression Test Test irritability by compressing the pelvis with the patient prone. Sacroiliac pain will be lateralised to the inflamed joint. 22

Patrick's test or FABER test: 

Patrick's test or FABER test The test is performed by having the tested leg flexed, abducted and externally rotated. If pain results, this is considered a positive Patrick's test . 23

Range of motion: 

Range of motion Cervical Spine Forward flexion: 0 to 45 degrees Extension: 0 to 45 degrees Left Lateral Flexion: 0 to 45 Right Lateral Flexion: 0 to 45 Left Lateral Rotation: 0 to 80 Right Lateral Rotation: 0 to 80 Thoracolumbar spine Forward flexion: 0 to 90 degrees Extension: 0 to 30 degrees Left Lateral Flexion: 0 to 30 Right Lateral Flexion: 0 to 30 Left Lateral Rotation: 0 to 30 Right Lateral Rotation: 0 to 30 24

Gaenslen Test: 

Gaenslen test stresses the sacroiliac joints, Increased pain during this test could be indicative of joint disease. Gaenslen Test 25

Modified New York Criteria For AS(1984): 

Modified New York Criteria For AS(1984) Clinical criteria Low back bain and stiffness For more than 3months Improves with exercise Is not relived by rest Limitation of motion of the lumber spine in both sagittal and frontal plane Limitation of chest expansion relative to normal velues correlated for age and sex Radiological criterion Grade 0 =normal Grade 1 =suspicious Grade 2 =sclerosis, some erosions Grade 3 =severe erosions, widening of the joints space, some ankylosis Grade 4 =complete ankylosis 26

Assessment of AS: 

Assessment of AS 27

Disease Specific Instruments For The Measurement In Ankylosing Spondylitis: 

Disease Specific Instruments For The Measurement In Ankylosing Spondylitis Instrument Measures Bath ankylosing spondylitis disease activity index (BASDAI) Disease activity Bath ankylosing spondylitis functional index (BASFI) Function Dougados functional index (DFI) Function Bath ankylosing spondylitis metrology index (BASMI) Function Modified stoke ankylosing spondylitis spinal score (m- sasss ) Structural damage 28

Bath Ankylosing Spondylitis Disease Activity Index (BASDAI): 

Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) How would you describe the overall level of fatigue / tiredness you have experienced in the past week? How would you describe the overall level of AS neck, back or hip pain you have had in the past week? How would you describe the overall level of pain / swelling in joints other than neck, back or hips you have had in the past week? How would you describe the overall level of discomfort you have had in the past week from any areas tender to touch or pressure? How would you describe the overall level of morning stiffness you have had in the past week from the time you wake up? How long did your morning stiffness last from the time you wake up? 0 ,¼ ,½, ¾, 1, 1¼, 1½, 1¾, 2 hours Acomposite index made up of 6 questions, each measured on a 0-100mm visual analog scale: 29

Bath Ankylosing Spondylitis Functional Index (BASFI): 

Bath Ankylosing Spondylitis Functional Index (BASFI) Putting on your socks or tights without help or aids Bending forward from the waist to pick up a pen from the floor without an aid Reaching up to a high shelf without help or aids Getting up out of an armless dining room chair without using your hands or any other help Getting up off the floor without help from lying on your back Standing unsupported for 10 minutes without discomfort Climbing 12–15 steps without using a handrail or walking aid, one foot on each step Looking over your shoulder without turning your body Doing physically demanding activities (e.g. physiotherapy exercises, gardening or sports) Doing a full day‘s activities whether it be at home or at work Acomposite index made up of 10 questions, covering basic daily functions, each measured on a 0-100mm VAS 30

Dougados functional index (DFI): 

Dougados functional index (DFI) Put on your shoes? Pull on trousers? Pull on pullover? Get in bath tub? Remain standing for 10 minutes? Climb flight of stairs? Run? Sit down? Get up from a chair? Get into a car? Bend over to pick up an object? Squat? Lie down? Turn in bed? Get out of bed? Sleep on your back? Sleep on your stomach? Do your job or house work? Cough or sneeze? Breathe deeply? DFI composes of 20 questions about ADL: Can you: Score Without any difficulty (0) Yes with difficulty (1) No (2) 31

Bath Ankylosing Spondylitis Metrology Index (BASMI): 

Bath Ankylosing Spondylitis Metrology Index (BASMI) A combined index to assess the spinal mobility in patients with ankylosing spondylitis , it has 5 clinical measurements Lateral spinal flexion Tragus to wall distance Lumbar flexion (modified Schober ) Maximal intermalleolar distance Cervical rotation 32

Lateral spinal flexion: 

Lateral spinal flexion Patient standing with heels and buttocks touching the wall, knees straight, shoulders back, outer edges of feet 30 cm apart, feet parallel. Measure minimal fingertip-to-floor distance in full lateral flexion without flexion, extension or rotation of the trunk or bending the knees. Greater than 10cm is normal. 33 >>>> >>>>

Tragus-to-wall distance: 

Tragus-to-wall distance Maintain starting position that is Ensure head in as neutral position (anatomical alignment) as possible, chin drawn in as far as possible. Measure distance between tragus of the ear and wall on both sides, using a rigid ruler. Ensure no cervical extension, rotation, flexion or side flexion occurs. 34

Lumbar flexion (modified Schober): 

Lumbar flexion (modified Schober ) With the patient standing upright, place a mark at the lumbosacral junction (at the level of the dimples of Venus on both sides). Further marks are placed 5 cm below and 10 cm above. Measure the distraction of these two marks when the patient bends forward as far as possible, keeping the knees straight 35 The distance less than 5 cm is abnormal

Maximal Intermalleolar Distance: 

Maximal Intermalleolar Distance Patient supine on the floor or a wide plinth, with the knees straight and the feet pointing straight up. Patient is asked to separate legs along the resting surface as far as possible. Distance between medial malleoli is measured. 36

Cervical rotation: 

Cervical rotation patient supine on plinth, head in neutral position, forehead horizontal (if necessary head on pillow or foam block to allow this, must be documented for future reassessments). Gravity goniometer / bubble inclinometer placed centrally on the forehead. Patient rotates head as far as possible, keeping shoulders still, ensure no neck flexion or side flexion occurs. 37 Normal ROM: 70-90 0

Modified Stoke Ankylosing Spondylitis Spinal Score (m-SASSS): 

Modified Stoke Ankylosing Spondylitis Spinal Score (m-SASSS) X ray scoring system for the lateral cervical and lateral lumber spine 38

PowerPoint Presentation: 

0 normal 0 normal 1 erosion 1 sclerosis 1 squaring 2 syndesmophyte 2 syndesmophyte 3 complete bridging 3 complete bridging 39

PowerPoint Presentation: 

40

REHABILITATION: 

REHABILITATION 41

Rehabilitation: 

Rehabilitation Medication NSAIDS : to relieve pain and stiffness . DMARDS: used to treat individuals with severe AS e.g. Sulfasalazine and methotrexate . Anti-TNF agents Physical therapy Surgery: rarely used in treatment but it is important in restoring movement to a damaged joint e.g. Hip replacement, osteotomy of the spine 42

Physical Therapy Management: 

Physical Therapy Management 43

Goals / Plan Of Care: 

Goals / Plan Of Care As a physical therapist , our goal would be: Relieve pain and spasm Improve breathing Maintain and restore spinal and joint mobility. Maintain and improve erect posture as much as possible Prevent spine curvature. Improve muscle power Expand chest maximally to minimize limited breathing capacity Prevent flexion deformity in cervical spine 44

Interventions: 

Interventions Physical modalities Cryotherapy Thermotherapy Ultrasound Hydrotherapy Pool therapy Electrotherapy TENS IFC DDC LASER Postural training Ergonomics Exercises Range-of-motion exercises/ stretching Strengthening exercises/resisted Endurance/aerobic exercises Breathing exercises Orthotics Lumbar supports ( lumbar support pillows) Back braces Thoracolumbar sacral orthotic Assistive devices Canes Walkers 45

Heat And Cold / Thermotherapy & Cryotherapy: 

Heat And Cold / Thermotherapy & Cryotherapy Heat applied to the painful area can help relax aching muscles, and reduce pain . It promotes blood circulation, which nourishes and detoxifies muscle fibers. Taking a hot shower is a great way to help reduce pain and stiffness. To avoid making symptoms worse, heat should not be applied to an already inflamed joint. Cold applied to inflamed joints reduces pain and swelling by constricting blood flow. Applying ice or cold packs appears to decrease inflammation and is recommended when joints are inflamed. You should not use ice if you have circulatory problems such as Raynaud’s disease. 46

PowerPoint Presentation: 

Multimodal Exercise Program For Ankylosing Spondylitis Patients 47

Stretching exercises: 

Stretching exercises Forward and backward head stretch Sideways head stretch Chest and shoulders stretch Deltoid muscle stretch Triceps muscle stretch Overhead stretch Lateral trunk muscle stretch Arched back stretch Leg extensor stretch Spinal twist stretch Paravertebral muscle stretch loosen-up stretch Upper back prayer Double knee-to-chest stretch Chest expansion 48

PowerPoint Presentation: 

Forward and backward head stretch: (left) backward head stretch, (right) forward head stretch. 49

PowerPoint Presentation: 

Sideways head stretch: (left) right sideways head stretch (in flexion), left sideways head stretch not shown; (right) right sideways head stretch (in rotation), left sideways head stretch not shown. 50

PowerPoint Presentation: 

Chest and shoulders stretch: (left) shoulders stretch, (right) chest stretch. 51

PowerPoint Presentation: 

Deltoid muscle stretch 52

PowerPoint Presentation: 

Triceps muscle stretch. 53

PowerPoint Presentation: 

Overhead stretch / Upper back and shoulder stretch 54

PowerPoint Presentation: 

Lateral trunk muscle stretch. 55

PowerPoint Presentation: 

Arched back stretch. 56

PowerPoint Presentation: 

Leg extensor stretch . 57

PowerPoint Presentation: 

Spinal twist stretch. 58

PowerPoint Presentation: 

Paravertebral muscle stretch. 59

PowerPoint Presentation: 

Loosen-up stretch: (left) downward, (right) upward. 60

PowerPoint Presentation: 

Upper Back Prayer / Full Back Stretch 61 <<<< <<<<

PowerPoint Presentation: 

Double knee-to-chest stretch. 62

PowerPoint Presentation: 

Chest expansion 63

PowerPoint Presentation: 

64 TRUNK CURL AND STRETCH >>>>

Strengthening Exercises: 

Strengthening Exercises Lunge Side Plank Bird Dog Hip Bridge Back Extension Seated rotation Back kick Tabletop Forearm plank 65

Lunge: 

Lunge 66

Side Plank: 

Side Plank 67

Bird Dog: 

Bird Dog 68

Hip Bridge: 

Hip Bridge 69

Back Extension: 

Back Extension 70

SEATED ROTATION: 

SEATED ROTATION 71 >>>>

Back kick: 

Back kick 72

Tabletop: 

Tabletop 73

Forearm plank: 

Forearm plank 74

Aerobic Exercises: 

Aerobic Exercises 75

PowerPoint Presentation: 

76

PULMONARY EXERCISES: 

PULMONARY EXERCISES To increase chest expansion, the following pulmonary exercises are applied: Twice the normal rate of inspiration through the nose and expiration through the mouth Respiration through the chest and abdomen Deep breathing and then expiration through the mouth slowly. Resistance exercises for the inspiratory pulmonary muscles were performed while each subject pressed on the chest with his or her hand and breathed strongly. 77

EXERCISES WHICH MUST BE AVOIDED IN ANKYLOSING SPONDYLITIS: 

EXERCISES WHICH MUST BE AVOIDED IN ANKYLOSING SPONDYLITIS Running Heavy weight liffting Kick boxing Burpees Cross training Jumping Leg lifts 78

PowerPoint Presentation: 

79

Orthotics: 

Orthotics 80 Lumbar supports ( lumbar support pillows) Back braces Thoracolumbar sacral orthotic

PowerPoint Presentation: 

Assistive devices Canes walkers 81

Instruction For Patient: 

Instruction For Patient You should always use your joints in ways that avoid excess stress. This allows you to experience less pain, perform tasks more easily, and protect your joints from damage. Pacing by alternating heavy or repeated tasks with lighter tasks or breaks or frequently changing positions reduces the stress on painful joints and conserves energy by allowing weakened muscles to rest. Maintain proper posture and carrying heavy objects close to you. Lie on your stomach daily to promote upright posture. Adapting your daily activities and using helpful devices can help to conserve energy and make daily tasks easier. Avoid positions that may cause excess stress, such as bending forward. Instead, raise seat levels to decrease stress on hip and back joints. Extend mirrors in your car to help with driving; use reaching aids to help with bending over. Sleep on a firm, supportive mattress to maintain good spinal alignment. Support your neck with special neck supports or pillows. 82

PowerPoint Presentation: 

83

Conclusion: 

84 Exercise is an integral part of any spondylitis program. This exercise program helps in: To maintain good posture To maintain flexibility To lessen pain Conclusion

Thank You: 

Thank You 85