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%.
Only one female is diagnosed with AS for every three males, and female patients' symptoms are often much milder and some may be missed as a diagnosis of AS. The most typical presenting group is young men under 40 years old, with under sixteen year olds making up to twenty percent of this group. The symptoms appear on average at twenty-five years of age and the diagnosis is rarely made above fifty years old. AS can look like mechanical back pain if sufficient attention to detail is not made. Strong and persistent stiffness is often an answer to the question of how they are in the morning.
Ankylosing spondylitis has similarities but distinct differences from the much more common low back pain:
Back pain and stiffness in the morning, lasting at least half an hour or more The back pain and stiffness are improved by exercising Resting worsens the stiffness and pain Pain is worse later in the night Thirty to fifty percent of patients exhibit other joint symptoms Fatigue is typical Systemic inflammatory affects include fever, loss of weight and unwellness.
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.
Physiotherapists will concentrate on treating the inflamed areas first such as the areas where the ligaments insert into the bone, using insoles, cold, ultrasound and stretching techniques. Routine spinal range of motion exercises are taught to patients with an emphasis on getting to end ranges, concentrating initially on the anti-gravity muscles such as thoracic and lumbar extensors. Neck rotation and retractions and thoracic rotations are also important functional movements not to lose. Patients should rest themselves in good postures such as prone or supine with only one pillow, to avoid accentuating the typical spinal deformities. Treatment for AS in a hydrotherapy pool is beneficial and soothing and patient education important so they keep up their programme.
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%.
Only one female is diagnosed with AS for every three males, and female patients' symptoms are often much milder and some may be missed as a diagnosis of AS. The most typical presenting group is young men under 40 years old, with under sixteen year olds making up to twenty percent of this group. The symptoms appear on average at twenty-five years of age and the diagnosis is rarely made above fifty years old. AS can look like mechanical back pain if sufficient attention to detail is not made. Strong and persistent stiffness is often an answer to the question of how they are in the morning.
Ankylosing spondylitis has similarities but distinct differences from the much more common low back pain:
Back pain and stiffness in the morning, lasting at least half an hour or more The back pain and stiffness are improved by exercising Resting worsens the stiffness and pain Pain is worse later in the night Thirty to fifty percent of patients exhibit other joint symptoms Fatigue is typical Systemic inflammatory affects include fever, loss of weight and unwellness.
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.
Physiotherapists will concentrate on treating the inflamed areas first such as the areas where the ligaments insert into the bone, using insoles, cold, ultrasound and stretching techniques. Routine spinal range of motion exercises are taught to patients with an emphasis on getting to end ranges, concentrating initially on the anti-gravity muscles such as thoracic and lumbar extensors. Neck rotation and retractions and thoracic rotations are also important functional movements not to lose. Patients should rest themselves in good postures such as prone or supine with only one pillow, to avoid accentuating the typical spinal deformities. Treatment for AS in a hydrotherapy pool is beneficial and soothing and patient education important so they keep up their programme.
About the Author:
Jonathan Blood Smyth is a Superintendent Physiotherapist 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 Bolton.
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