1. Evidence Based Physical Therapy Treatment for Ankylosing Spondylitis
Dr. Erika Cyrus Barker TF. M.Sc, Ph.D
World Physiotherapists & Physicians Summit
July 24-26, 2017 Melbourne, Australia
Facing the Future of Health and Rehab Solution

2. Presented by Dr. Erika Cyrus Barker TF. M.Sc, Ph.D
Director and Professor of the School of Physical Therapy; Universidad Santa Paula, San José, Costa Rica.
Director of the Physical Therapy Master Program; Universidad Santa Paula, San José, Costa Rica.
PhD in Medical Sciences and Research. Salamanca University, Spain
Master in Functional Rehabilitation of the Elderly Person. Santa Paula University.
Specialization in Medical Research. Salamanca University, Spain.
Master's in Education with emphasis in Organization and management of educational centers. Universidad Internacional Iberoamericana UNINI-México
Member of the American Association of Physical Therapists APTA
Specialization in virtual learning environments. OPS

3. Outline: Ankylosing Spondylitis. Symptomatology Assessment Prognosis
Evidence-Based Treatment.

4. What is Ankylosing Spondylitis?
Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease.
The main features of AS are pain and stiffness caused by inflammation of the sacroiliac joints, which progressively extend to the other joints of the spine, producing numerous changes in the patient's posture. Cortes A. et al 2013

5. Prevalence of Rheumatoid Arthritis in the Adult Population of Various World Regions
Shapira Y, Agmon N, Shoenfeld Y, 2010

6. Once the disease is present, inflammation and formation of new bone occurs in different parts of the body.
New bone formation occurs only at sites where inflammation has been activated.
The pathology can cause peripheral manifestations in the knees, hands and feet, similar to those of rheumatic arthritis, experiencing pain and significant inflammation.
It is the inflammatory process that initiates the chain of events leading to ankylosis, these two processes continue inextricably linked in the progression of the disease.

7. Symptoms
Losing flexibility in a joint can be frustrating and painful. Preserving flexibility through exercise and treatment can help control pain. Rosenbaum JT 2015
Pain that interrupts sleep. Many people report that pain wakes them up, often in the second half of the night. Shaaron Leverment, Emily ClarkeAlison WadeleyRaj Sengupta 2017
Tenderness. Many people report tenderness over the area of inflammation. For example, pressing the skin over the base of the spine may be uncomfortable or painful. Dundar U, Solak O, Toktas H, et al. 2014
Painful flares. Almost everyone with AS reports experiencing painful flares—periods of time when symptoms are noticeably worse.
Flares can occur suddenly and cause pain and stiffness all over the body.
Flares may last days or weeks and are followed by periods of relative relief. Ivette Essers Annelies Boonen Matthias Busch, et al 2016

8. Symptoms
Unexplained fatigue. This body-wide fatigue can be overwhelming and last for days, regardless of how much sleep a person gets. Helen Davies author, Sinead Brophy, et al 2013
Fever. A persistent low-grade fever may occur as a result of the body-wide inflammation.
General feeling of illness. Some people report feeling unwell or “not quite right.” Younes M, Jalled A, Aydi Z, et al 2011
Weight loss and/or loss of appetite. The inflammation may cause people to lose their appetite and lose weight, similar to when having a cold or flu.
Swollen fingers or toes. Dactylitis, can be a sign of ankylosing spondylitis or another type of a spondyloarthritis. F. van Gaalen, D van der Heijde, M.Dougados 2016
UK, National Ankylosing Spondylitis Society

9. Understanding the relationship between inflammation and ankylosis is the pivot for future advances in drugs that allow modification of the disease.
Suppression of inflammation would prevent the development of ankylosis. At present we have the inhibitors of tumor necrosis factor (anti-TNFα)
Davis JC. Jr. et al., 2003, Van der Heijde D. et al. 2005
Boulos P. et al., Pharmacological treatment of ankylosing spondylitis: a systematic review, Drugs, 2005

10. Physiotherapeutic treatment in ankylosing spondylitis plays a very important role both in preventing the evolutionary process of the disease and in the treatment of it, once the symptoms have appeared.
Thus, one of the tools that the physiotherapist has for the treatment of AS in the long term is Therapeutic Exercise.
T.O´Dwyer, E.McGowan, F. O´sea, F. Wilson 2015

11. Ankylosing Spondylitis has a significant effect on the patient's life affecting his work, family relationships and social activities, which increases the risk of depression, so early management of the pathology and its functional alterations is vital to prevent damage and disability.
The approach for this patients is interdisciplinary :Rheumatologist, Physical Therapy and Psychology as first onboard.
G. Arin, P. Kisacik, A. Akdogan, L. Kilic,et al 2016

12. Symptomatology reported by the patient:
Usually the patient reports:
Pain that improves with exercise and gets worse with rest.
Night pain that wakes the patient the second half of the night.
Morning stiffness lasting at least 30 minutes
Pain in the gluteal – sacral zone.

13. The greatest loss of function occurs in the early years of the disease, and correlates with the occurrence of peripheral arthritis including the hip and shoulder joints. - Laura A. et al 1998

14. With the Progression of the Disease ... ..
Difficulty breathing is caused by the fusion of the thoracic vertebrae and the limitation of the thoracic expansion. Khan 2003.
Fatigue, constant tiredness that is not restored with sleep. Mengshoel 2010.
Pain, which develops and gradually increases over the years. Spier et al. 2009
Fever or night sweats (nocturnal hyperhidrosis) Mold et al 2012
Risk of myocardial infarction Peters et al 2010
Greater chance of developing comorbidities such as hypertension, DM or hypercholesterolaemia. Khan 2003

16. Assessment Morning stiffness. Discomfort improves with exercise.
Complete Clinical History, Comorbilities
Morning stiffness.
Discomfort improves with exercise.
Back pain started before age 40.
The problem started gradually.
The pain has persisted for more than 3 months.
Screening of 5 Questions (4/5 indicates 95% sensitivity, 85% specificity for AS)
Akgul O. et al 2011

17. Assessment Measurement of total height. Occipucious-wall distance.
Aside from Magee’s neuromusculoskeletal evaluation, it is essential to include:
Measurement of total height.
Occipucious-wall distance.  
Left and right spine lateralizations.
Thoracic expansion.
Schober's test, pain (cervical, dorsal and lumbar)
*BASMI
Pain Evaluation
Dagfinrud H1. et al Physiotherapy interventions for ankylosing spondylitis, Cochrane Database Syst Rev., 2008 (Level of evidence 2A)

18. Assessment Balance test: Berg, Romberg.
Cardiorespiratory function and resistance.
Integrity of the PNS, and cranial nerves.
Ergonomics: mechanics suitable for transfers, transfers, mobility in bed and functional activities. Adaptation of the Roles of life etc. (OT)
Muscular strength.
Palpation
ROM
Reflexes
Dagfinrud H1. et al Physiotherapy interventions for ankylosing spondylitis, Cochrane Database Syst Rev., 2008 (Level of evidence 2A)

19. Prognosis:
It varies according to the course and progression of the disease, the treatment and the moment of diagnosis. There are usually functional deficits. Sometimes it is self-limited with remission. Must be referred to psychology, social work, OT.

20. Treatment
In a study by Wordsworth et al. it was emphasized that physical exercise plays such an important role as the administration of medication for ankylosing spondylitis.

21. Treatment
Exercise may decrease pain, improve spinal mobility, function, fatigue, and quality of life in patients with AS.
Manual Therapy can improve posture, spinal mobility, and thoracic expansion
Janet R.MillnerPTa..Kirsty M.BeinkeBPTc. Rachael H.ButterworthBHSc et al 2015
Millner JR, et al. 2016
M Husakova, K Pavelka, M Spiritovic, A Levitova 2017

22. A study by Viitanen et al; provides a very important data for our investigation.
The results showed that the duration of the disease does not affect the results: the effects of physical exercise on these patients are independent of the progression of the disease or of the stage of the pathology in which the patient is found.
So that age would not be an inconvenience for the inclusion of these Patients in a physical exercise program.

23. It should be noted that all exercises in the program must be related to the alterations that ankylosing spondylitis patients suffer as a result of it. Not all exercises are beneficial for this condition.
Sieper J,Rudwaleit M, Baraliakos X, Brandt J, Braun J, Burgos-Vargas R, Dougados M, Hermann KG, 2009

24. Ankilosing Spondylositis Excercise Plan
Prior to the start of the exercise plan you must: Approach the crossed syndromes, contractures in ANTIGRAVITATORY musculature and postural reeducation. Thoracic enlargement exercises, inspiratory exercises. Widberg K, Karimi H, Hafström I 2009 Abdominal bracing. Mobilizations AA hips and shoulders to tolerance. Ince G, Sarpel T, Durgun B, Erdogan S HOT PACK

25. Multimodal Exercise Program Consisting of:
Aerobic Exercise. Bicycling, swimming, walking.  
Muscle lengthing in the antigravity muscles.
Strengthening of the 3 strata of CORE
Exercises to improve lung function.
Thoracic Mobility Exercises
Postural reeducation.
Periarticular strengthening of shoulders and hips.
Hot Packs. Massages. Electrotherapy.
Twice a day postural exercises, stretching and respiratory
Aytekin E, Caglar NS, Ozgonenel L, Tutun S, Demiryontar DY, Demir SE, 2012
Yigit S, Sahin Z, Demir SE, Aytac DH, 2013

26. Therapeutic Proposal:
One hour of daily exercise that includes:
Mobility exercises, ESPECIALLY TORAX, hip.
PT work based on the affected muscle chains: posterior trunk chain, anterior diaphragmatic chain, antero-internal chain of the pelvic and scapular waist
All exercises should be performed actively emphasizing both ligamentous and muscular work.
Passalent LA 2011, Dagfinrud H, Kvien TK, Hagen KB 2008

27. Therapeutic Proposal:
CORE. Important eccentric work of the paravertebral musculature, and prioritize the work of the sacroiliac joint.
Active respiratory kinesiotherapy through active work specific to the anterior diaphragmatic chain. Toracolumbar mobility.
Cardiovascular Exercise: walking, cycling, swimming, 40 MIN MINIMUM. Do not run.
Myofascial induction for the management of shortenings and restrictions.
Karapolat H, Eyigor S, Zoghi M, Akkoc Y, Kirazli Y, Keser G 2009

28. Most recently, the American College of Rheumatology (2015) published evidence based recommendations for the treatment of AS.
A Randomized Control Trial (2014) has looked at the effect of hydrotherapy for patients with AS compared to home-based exercise programs.
It concluded that an intensive hydrotherapy program produced better outcomes in terms of pain and quality of life for AS patients compared to the home exercise group.
American College of Rheumatology 2015
U Dunbar, O.Solak, H.Tokyas 2014

29. When the Functional Compromise is Greater:
Physiotherapeutic intervention focuses on:
Support for pain management.
Postural Reeducation
Gait Reeducation.
Approach to muscle contractures and soft tissue injury.
Respiratory dynamics.
Teamwork with OT for home adaptations.
Dagfinrud H, Kvien TK, Hagen KB. The Cochrane review of physiotherapy interventions for ankylosing spondylitis. J Rheumatol. 2005;32(10): (Level of evidence 1A)

30. Common Complications in Patients with AS
Enthesitis. Heuft-Dorenbosch L. et al 2003
Temporomandibular ankylosis. Dachowski MT1, Dolan EA, Angelillo JC.
Uveitis. Jean Deschênes, MD, Hampton Roy, Sr, MD 2016
Constipation.  M.Cojocaru MD, PhD, et al 2011

31. Common Complications in Patients with AS
Vascular disease. Experts estimate people with ankylosing spondylitis are 36% more likely to die from vascular disease than the general population. Haroon NN, Paterson JM, Li P, Inman RD, Haroon N 2015
Vascular disease includes:
Cardiovascular and Cerebrovascular disease. I Essers, C Stolwijk, A Boonen, 2016
Pulmonary disease. Anyklosing spondylitis can affect the rib cage and the lungs making breathing difficult or uncomfortable. Karin Bengtsson, Helena Forsblad-d’Elia, Elisabeth Lie, et al 2017

32. Conclusions:
The exercise conducted by a physical therapist is the Gold Standard to maintain functionality in patients with AS.**
The exercise must have the correct dosage according to the patient's condition.
Do not forget the cardiovascular part.
Emphasis on the posterior chain.
Exercise should not generate more pain than the patient perceives.
Prior to the beginning of the exercise, the functional and postural alterations of the patient should be addressed.

33. Contact Information:
Dr. Erika Cyrus Barker PT, M.Sc, Ph.D
erika.cyrus
erikacyrus

34. References
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