A Rheumatologist is a specialist physician who has expertise in diagnosing and treating arthritis, musculoskeletal conditions and autoimmune diseases. This includes diseases related to joints, muscles, tendons and bones, and also many other parts of the body including eyes, skin, internal organs and the nervous system.
One of the major groups of conditions that a Rheumatologist treats is arthritis (joint inflammation). There are hundreds of forms of arthritis and one of the subgroups is called Spondyloarthritis. Ankylosing Spondylitis (AS) sits within this group of conditions.
AS is an inflammatory rheumatic condition characterized by inflammation of the joints of the spine. Inflammation particularly affects the sites where tendons or ligaments attach to bone. The most commonly affected joints are the sacroiliac joints that are part of the pelvis at the base of the spine. AS, however, is not just limited to this area. Any joints of the body can be affected, for example joints of the fingers or toes. Also, inflammation can occur within organs such as the eyes, intestines, heart and lungs.
AS is present in approximately 0.5-2% of the population. Although this may seem like a small amount, it is often under recognized in those suffering with back pain and historically has taken 5-10 years to be diagnosed.
The cause of AS is not yet completely understood. There is a strong genetic component with the protein HLA B27 being present in a high percentage of persons diagnosed with AS. This protein plays an important role in the action of the immune system. Confusingly, this gene can also be present in people who never go on to develop AS so this is not a definitive way to diagnose the condition. There continues to be advances in medicine as to possible other genetic factors related to this disease.
Diagnosis of AS comes from a number of clinical and radiological features. Unfortunately, there is no one single test available to diagnose AS.
Clinical criteria
Low back pain and stiffness for more than 3 months which improves with exercise, but is not relieved by rest
Limitation of motion of the lumbar spine in both sagittal (front-back) and frontal planes (side-side)
Limitation of chest expansion relative to normal values correlated for age and sex
Radiological criteria
Sacroilitis grade 2 or more bilaterally or grade 3-4 unilaterally
Definite AS is diagnosed if the radiologic criterion is satisfied with the presence of at least 1 clinical criterion.
There are a number of other investigations that are helpful for a Rheumatologist in the assessment of AS even though they may not be necessary for diagnosis. These involve the likes of blood tests, ultrasound imaging and MRI. These may be helpful towards diagnosing early inflammatory arthritis (Spondyloarthritis) which has not yet or may not progress to AS.
As previously mentioned, the common feature of AS is inflammation of the pelvic joints. The thoracic spine (midback), lumbar spine (lower back) and cervical spine (neck) can become affected as the disease progresses. The Assessment of Spondyloarthritis International Society (ASAS) has given signs and symptoms suggestive of an inflammatory (Spondyloarthritis) cause of pain.
Age at onset <40 years
Insidious onset
Improvement with exercise
No improvement with rest
Pain at night with improvement upon getting out of bed
When at least 4 out of 5 features are present, the pain is essentially related to an inflammatory cause (Spondyloarthritis).
There are also some other features that may indicate an inflammatory process. These include:
Duration of back pain extending beyond 3 months
Morning stiffness lasting more than 30mins
Alternating buttock pain
Waking during the second half of the night only
Stiffness and loss of movement of the spine
Fatigue
Enthesitis (inflammation of tendon attachment to bone)
Dactylitis (inflammation of an entire digit – finger or toe)
Uveitis/Iritis (inflammation of the eyes)
Crohn’s Disease/Ulcerative Colitis (inflammation of the bowel)
Aortitis (inflammation of the aortic valve)
Pneumonitis (inflammation of the lung)
Treatment for AS is essentially divided into two groups which compliment each other and must work together for optimum outcomes. Firstly, there are the pharmatological treatments that have the aim of managing the disease through symptom control. Treatments include anti-inflammatory medication, disease modifying anti-rheumatic drugs (DMARDs) and more recently TNF inhibitors. Your rheumatologist manages this part of treatment.
The second part and as equally as important as the first, is exercise therapy. Although some physiotherapists may be aware of Ankylosing Spondylitis, very few have had exposure to the treatment of this disease. This is a very important factor to consider when searching out a Physiotherapist to help you. Here at Auckland Physiotherapy we have Katy Street and Robyn Atkinson, who have expertise in this field.
The role of physiotherapy in AS is to:
Provide progressive, tailored, specific exercise programs
Constantly be in contact with all persons involved in your treatment at your consent, including your rheumatologist
Provide continued long-term support and treatment
Be a central point of contact for you
The outcomes of such physiotherapy involvement have been shown to reduce pain and stiffness, increase mobility and function and have a positive effect on mood, attitude, health and quality of life.
If you are interested in further information regarding AS, please click on this link http://www.bjchealth.com.au/ankylosing-spondylitis and at the bottom of the page you can download a free ebook.
