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Diagnosis. Photo by James Heilman, MD / CC BY-SA 4.0. Page 14. Bamboo Spine. • Extensive syndesmophyte formation and fusion of Bilateral Sacro-iliac joint.
Diagnosis, management and Rehabilitation strategies in Ankylosing spondylitis Surg.Lt.Cdr Farooq Rathore Consultant and HOD Department of Rehabilitation Medicine, PNS Shifa

Outline

• Introduction • Clinical Features and Demographics • Diagnosis • Treatment • Rehabilitation • Take home message

Medline

• Ankylosing Spondylitis- 17125 • Ankylosing Spondylitis AND Treatment - 7724 • Review Articles – 1500-2504

Search strategy

• Medline and Google Scholar • Time limit ( 2005-2018) • Randomized Controlled Trials ,Systematic Reviews, Meta-analysis

Ankylosing spondylitis (AS), a sero-negative

Introduction

spondyloarthropathy, is a chronic, multisystem inflammatory disorder involving primarily the sacroiliac (SI) joints and the axial skeleton.

• Ankylosing spondylitis

• Reactive arthritis

Spondyloarhropathies

• Psoriatic arthritis • Enteropathic arthritis/ IBD related

• Undifferentiated SpA

Non radiographic axial spondyloarthropathy

Patients who have a clinical picture of ankylosing spondylitis (AS) but do not

exhibit radiographic sacroiliitis

Undifferentiated spondyloarthropathy (USpA)

Patients with predominantly peripheral features and may represent an early phase

or incomplete form of AS or another spondyloarthropathy

Clinical Features

• Insidious onset of Inflammatory low backpain • Onset of symptoms before age 40 years • Presence of symptoms for more than 3 months • Symptoms worse in the morning or with

inactivity • Peripheral enthesitis and arthritis • Fatigue

Demographics

• Juvenile onset –AS • Onset rare after 50 Years • Delayed diagnosis ( 5.3-11 Years) • Male: Female ratio 3:1

• Men have more severe radiographic changes • Increased risk of mortality

Extra-Spinal manifestations of Ankylosing Spondylitis Neurological Ophthalmological -

Pulmonary

Cardiac

-

Skeletal -

-

...

Demographics

• Juvenile onset –AS • Onset rare after 50 Years • Delayed diagnosis ( 5.3-11 Years) • Male: Female ratio 3:1

• Men have more severe radiographic changes • Smoking worsens the progression • Increased risk of mortality Exarchou S et al.Mortality in ankylosing spondylitis: results from a nationwide population-based study. Ann Rheum Dis. 2016 Aug;75(8):1466-72.

https://www.medscape.com/viewarticle/846913

Diagnosis

Photo by James Heilman, MD / CC BY-SA 4.0

Bamboo Spine • Extensive syndesmophyte formation and fusion of Bilateral Sacro-iliac joint

Case courtesy of Radswiki, Radiopaedia.org, rID: 11189

Diagnosis Clinical examination Radiological investigations

Laboratory Investigations

Clinical Examination

Spinal Flexion Sacro-Iliac Joint Examination Chest Expansion

Measuring Spinal Flexion

Modified Schöber test

Measuring Chest expansion

Wall to occiput Wall to tragus distance

Sacro-Iliac Joint Assessment

Sacro-Iliac Joint Assessment

Local Tenderness FABER Gaenslen's test

SI Joint Distraction Tests

Radiological Investigation

X-Rays

CT Scan MRI SI Joints

• Sacroiliitis -usually the first manifestation and is symmetrical and bilateral

X-rays Sacroiliac joints

• SI joints first widen before they narrow • Subchondral erosions, sclerosis and proliferation on the iliac side of the SI joints • End-stage, the SI joint may be seen as a

thin line or not visible (Sclerosis)

• Early spondylitis -small erosions at the corners of vertebral bodies with reactive sclerosis:

Romanus lesions • Squaring of the vertebral bodies caused by

X-rays Spine

erosions of the superior and inferior margins of

these bodies • Ossification of the anulus fibrosus-radiographic appearance of syndesmophytes • Bridging Syndesmophytes-Fusion of spin

Squaring of Vertebra

Romanus Lesion Squaring of Vertebra

• Detects early sacroiliitis, erosions, and enthesitis • MRI with short tau inversion recovery

MRI Scan

(STIR) or MRI with gadolinium is sensitive

for inflammatory lesions of enthesitis • Can be used as an adjunct to evaluate the

inflammatory changes • Not recommended routinely

Assessment of SpondyloArthritis international Society (ASAS)

Clinical Criteria

1984 Modified New York Criteria for AS

• Low back pain ≥ 3 months, improved by exercise and not relieved by rest • Limitation of lumbar spine in sagittal and frontal planes • Limitation of chest expansion (relative to normal values corrected for age and sex)

Radiological Criteria • Bilateral grade 2-4 sacroiliitis OR • Unilateral 3-4 sacroiliitis

van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modific ation of the New York criteria. Arthritis Rheum. 1984 Apr;27(4):361-8.

Markers of inflammation HLA B-27

Laboratory investigations

Hemoglobin Serum Alkaline Phosphatase

Treatment

Look in the slide notes below for topics to consider talking about

Patient education in the natural history of the disease, treatment options, and the patient’s role in disease modifying behavior

Goals of management in AS

Relief of pain and stiffness

Maintenance of spinal and overall mobility

Prevention of disability through physical therapy and pharmacological disease modifying agents

American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis

Ward MM, Deodhar A, Akl EA, Lui et alAmerican College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2016 Feb;68(2):282-98. doi: 10.1002/art.39298.

• The guideline was developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach

• GRADE rates both the quality of available evidence and the strength of recommendations made

Strength of recommendations in GRADE

When to start Biologic agents

Biologic agents reduce spinal radiographic progression in patients with AS Molnar C, Scherer A et al. TNF blockers inhibit spinal radiographic progression in ankylosing spondylitis by reducing disease activity: results from the Swiss Clinical Quality Management cohort. Ann Rheum Dis. 2018 Jan;77(1):63-69.

Anti-TNFs are clinically effective, although more so in AS than in nr-AxSpA Corbett M, Soares M et al.. Tumour necrosis factor-α inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis: a systematic review and economic evaluation. Health Technol Assess. 2016 Feb;20(9):1-334, v-vi. doi: 10.3310/hta20090.

Functional status and spinal mobility of patients with established AS remained stable during longterm antiTNF-α therapy despite radiographic progression. Poddubnyy D et al. Physical Function and Spinal Mobility Remain Stable Despite Radiographic Spinal Progression in Patients with Ankylosing Spondylitis Treated with TNF-α Inhibitors for Up to 10 Years. J Rheumatol. 2016 Dec;43(12):2142-2148.

Patient education

• Patient and family counseling • Keep active • Natural course of disease • Treatment options • Compliance to home based exercises • Peer support groups • Audio visual aids • Participation in drug trials

Pain relief NSAIDs Physical Modalities Intra-Articular Steroids

Hydrotherapy/Aquatic therapy works

• Water-based exercises produced better improvement in pain score and quality of life of the patients with AS compared with home-based exercise. • Physical exercise plus aquatic relaxation provides benefits to spondyloarthritis patients

Dundar U, Solak O, Toktas H, Demirdal US, Subasi V, Kavuncu V, Evcik D. Effect of aquatic exercise on ankylosing spondylitis: a randomized controlled trial. Rheumatol Int. 2014 Nov;34(11):1505 -11. Fernández García R, et al[Effects of an exercise and relaxation aquatic program in patients with spondyloarthritis: A randomized trial]. Med Clin (Barc). 2015 Nov 6;145(9):380-4. doi:

Hubbard tank

Pilates are effective

Three , 50-minute weekly sessions of exercises designed for the spine, including Pilates and other disciplines, reduced pain and improved spine flexibility in people with AS

Altan L, Korkmaz N, Dizdar M, Yurtkuran M. Effect of Pilates training on people with ankylosing spondylitis. Rheumatol Int. 2012 Jul;32(7):2093-9.

Ultrasound therapy helps

Ultrasound treatment increases the effect of exercise in patients with ankylosing spondylitis. ( Pain, flexibility, BASDI, ASQoL)

Şilte Karamanlioğlu D,Effectiveness of ultrasound treatment applied with exercise therapy on patients with ankylosing spondylitis: a double-blind, randomized, placebo-controlled trial. Rheumatol Int. 2016 May;36(5):

Uncommon but not rare

Local Perspectives on AS

The eye cannot see what the mind does not know Delayed diagnosis

Wrong investigations and increased cost of care

Thank you

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