The inflammatory arthritis diseases or spondyloarthropathies include various diseases such as Ankylosing spondylitis, the arthritis of bowel disease, reactive arthritis and the arthritis associated with psoriasis. The typical linking features of these diseases are enthesitis (an inflammation at the bone/ligament junction) and the presence of HLA B27, a gene on white blood cells. The inflammation at the entheses can develop into fibrosis and eventually to fusion of the joints from bone formation.
The commonest spondyloarthropathy is Ankylosing spondylitis, which occurs as a reflection of the occurrence of the HLA B27 gene in the population. The gene occurs much less commonly near the equator and much more commonly in northern latitudes, and this is also the pattern with the development of AS. White race people are more commonly affected with around 0.1 to 1.0 percent overall, varying with latitude. Only 1 or 2 people of a hundred with the HLA B27 gene actually develop AS, but if they have a close relative who has the condition the likelihood rises to 15 to 20%.
AS occurs more often in males, with a 3:1 ratio, but females may suffer much milder disease or have minor symptoms which are not diagnosed. AS is a disease of young men, with most presenting before they are 40 years old, and 10-20% presenting with the disease before they are 16. On average people get the symptoms of the disease around 25 years old and are rarely diagnosed when over 50 years of age. The condition is often missed initially as it presents as low back pain so it is important to take a proper history. A useful question is "how does your back feel when you wake up" and AS patients will all say "very stiff".
The presentation of Ankylosing spondylitis is similar but different from that of mechanical low back pain due to the inflammatory nature of AS:
Morning stiffness in the lumbar spine, lasting at least 30 minutes or longer Exercise improves the back pain and stiffness Rest worsens the pain and stiffness Pain is usually worse in the second half of the night, after a time of rest Peripheral joints are affected in 30 to 50% of patients Tiredness is common AS has systemic affects from its inflammatory nature which can include feeling unwell, fever and loss of weight.
A significant reduction in the ranges of spinal motion is usually recorded by the physiotherapy examination of an AS patient, with a flattened lumbar curve and an accentuated thoracic kyphosis. Later involvement can include reduced neck ranges of motion and reduced chest excursion from involvement of the rib joints. Peripheral inflammation at insertion sites occurs in about one third of patients, the commonest sites being the insertion of the tendo Achilles on to the calcaneum and the insertion of the plantar ligament in the foot. These areas cope with large mechanical loads which may be why they more commonly occur.
The physiotherapist initially notes the postural changes which have occurred in an AS patient such as any spinal deformities, round shoulders, bent knees or an increased cervico-thoracic curve and poking chin posture. The physio will record ranges of movement of the spine and include the neck, thorax and lumbar ranges, also assessing any peripheral joints which may be affected. Any entheses which are reported as painful are palpated to confirm the presence of an inflammatory process, and if the AS is very active then the physiotherapist might also find effusions in the joints, perhaps with a feeling of unwellness, night sweats and poor rest.
Initially a physiotherapist might treat an active, inflamed site such as the tendo Achilles insertion using ultrasound, ice and gentle stretching, with foot problems responding to insole use. Whole spine exercises are taught with encouragement to get to the end of the movements, concentrating on antigravity movements including extension of the lumbar and thoracic spine, rotation of the thorax and neck retraction and rotations. To counter the typical spinal deformities, patients are taught to rest in good positions such as flat on a firm surface with only one pillow and lying prone. Pool therapy is very popular and effective and patient education is vital to maintain therapy over time.
The commonest spondyloarthropathy is Ankylosing spondylitis, which occurs as a reflection of the occurrence of the HLA B27 gene in the population. The gene occurs much less commonly near the equator and much more commonly in northern latitudes, and this is also the pattern with the development of AS. White race people are more commonly affected with around 0.1 to 1.0 percent overall, varying with latitude. Only 1 or 2 people of a hundred with the HLA B27 gene actually develop AS, but if they have a close relative who has the condition the likelihood rises to 15 to 20%.
AS occurs more often in males, with a 3:1 ratio, but females may suffer much milder disease or have minor symptoms which are not diagnosed. AS is a disease of young men, with most presenting before they are 40 years old, and 10-20% presenting with the disease before they are 16. On average people get the symptoms of the disease around 25 years old and are rarely diagnosed when over 50 years of age. The condition is often missed initially as it presents as low back pain so it is important to take a proper history. A useful question is "how does your back feel when you wake up" and AS patients will all say "very stiff".
The presentation of Ankylosing spondylitis is similar but different from that of mechanical low back pain due to the inflammatory nature of AS:
Morning stiffness in the lumbar spine, lasting at least 30 minutes or longer Exercise improves the back pain and stiffness Rest worsens the pain and stiffness Pain is usually worse in the second half of the night, after a time of rest Peripheral joints are affected in 30 to 50% of patients Tiredness is common AS has systemic affects from its inflammatory nature which can include feeling unwell, fever and loss of weight.
A significant reduction in the ranges of spinal motion is usually recorded by the physiotherapy examination of an AS patient, with a flattened lumbar curve and an accentuated thoracic kyphosis. Later involvement can include reduced neck ranges of motion and reduced chest excursion from involvement of the rib joints. Peripheral inflammation at insertion sites occurs in about one third of patients, the commonest sites being the insertion of the tendo Achilles on to the calcaneum and the insertion of the plantar ligament in the foot. These areas cope with large mechanical loads which may be why they more commonly occur.
The physiotherapist initially notes the postural changes which have occurred in an AS patient such as any spinal deformities, round shoulders, bent knees or an increased cervico-thoracic curve and poking chin posture. The physio will record ranges of movement of the spine and include the neck, thorax and lumbar ranges, also assessing any peripheral joints which may be affected. Any entheses which are reported as painful are palpated to confirm the presence of an inflammatory process, and if the AS is very active then the physiotherapist might also find effusions in the joints, perhaps with a feeling of unwellness, night sweats and poor rest.
Initially a physiotherapist might treat an active, inflamed site such as the tendo Achilles insertion using ultrasound, ice and gentle stretching, with foot problems responding to insole use. Whole spine exercises are taught with encouragement to get to the end of the movements, concentrating on antigravity movements including extension of the lumbar and thoracic spine, rotation of the thorax and neck retraction and rotations. To counter the typical spinal deformities, patients are taught to rest in good positions such as flat on a firm surface with only one pillow and lying prone. Pool therapy is very popular and effective and patient education is vital to maintain therapy over time.
About the Author:
Jonathan Blood Smyth is a Superintendent of Physiotherapy at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in London.
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