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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 12  |  Issue : 2  |  Page : 88-92

Long-term effectiveness of physiotherapy in a case of ankylosing spondylitis


Department of Musculoskeletal Sciences, Ashok and Rita Patel Institute of Physiotherapy, CHARUSAT, Anand, Gujarat, India

Date of Submission27-Jun-2018
Date of Acceptance18-Sep-2018
Date of Web Publication17-Dec-2018

Correspondence Address:
Prof. Ratan P Khuman
Department of Musculoskeletal Sciences, Ashok & Rita Patel Institute of Physiotherapy, CHARUSAT, Anand - 388 421, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/PJIAP.PJIAP_24_18

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  Abstract 

Ankylosing spondylitis (AS) is a relatively uncommon inflammatory arthritis that affects the axial joints. The diagnosis is often missed and markedly delayed. Here, we report a delayed diagnosis of AS in a 47-year-old male, 10 years after the onset of back symptoms, using the modified New York criteria. The objective of this case report is to outline the long-term effectiveness of physiotherapy interventions. The condition was managed with supervised physiotherapy intervention and unsupervised home exercises for 3 months and was followed for 1 year to investigate the long-term effectiveness of the interventions. It was found that the combination of supervised physiotherapy interventions and unsupervised home exercises had promising short term as well as long-term effects without deterioration in AS symptoms with increased patient satisfaction and confidence.

Keywords: Ankylosing spondylitis, long-term effectiveness, manual therapy, physical therapy, supervised intervention


How to cite this article:
Khuman RP. Long-term effectiveness of physiotherapy in a case of ankylosing spondylitis. Physiother - J Indian Assoc Physiother 2018;12:88-92

How to cite this URL:
Khuman RP. Long-term effectiveness of physiotherapy in a case of ankylosing spondylitis. Physiother - J Indian Assoc Physiother [serial online] 2018 [cited 2019 Mar 20];12:88-92. Available from: http://www.pjiap.org/text.asp?2018/12/2/88/247608


  Introduction Top


Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease with a diverse clinical presentation, primarily affecting the axial skeleton with chronic back pain and stiffness of the spine.[1] In the later stage of the disease, spinal stiffness progresses into bony ankyloses, flattening of lumbar lordosis, and exaggeration of thoracic kyphosis with limited chest excursion due to the involvement of costovertebral joints.[1] In India, around 0.25% population[2] is estimated to be affected by AS with seven cases per 10,000 population.[3] The key to successful management of the condition is early diagnosis of the disease. However, the diagnosis of AS is not only challenging but also commonly missed or delayed for 7–10 years from the onset of the symptoms.[4],[5]

In general, AS has been managed with a combination of anti-inflammatory medications, exercise, and surgery, if needed. Exercise has been recommended prominently in relevant clinical practice guidelines for the management of AS.[1],[6],[7],[8],[9] Conventionally, the goals of AS-specific exercises have focused on improving or maintaining physical function and posture using axial and peripheral joints mobility exercises, strengthening of antigravity muscles, and stretching of tight muscles with cardiorespiratory endurance exercises. However, there is limited evidence on the long-term benefits of AS-specific exercises.[7]


  Case Report Top


A 47-year-old male presented with the primary complaints of the progressive stiffness of the lower back and neck along with occasional pain which began in his mid-30. The stiffness in the lower back and neck that peaked when waking up in the morning and lasted for about an hour, and was progressively eased with movements or activities on most of the day. He also had restricted motion of both his shoulders (more in left) and hip joints, which on inquiry was discovered to have had it for 3 or more years. He reported to have limitations in his routine physical work/activities due to pain, stiffness (neck more than lower back), easy tiredness, and disturbed sleep.

Inquiry of his early symptoms revealed that he had frequent gastrointestinal (GIT) infection in his mid-30s which required seeking medical help. These incidences were followed by frequent low back pain that recovered spontaneously without medical consultation. However, in his early-40s, an episode of severe back pain, later diagnosed with sciatica, made him hospitalized for a few days. We assume that this might be the first missed opportunity for the diagnosis of AS symptoms. Retrospective inquiry of symptoms revealed findings which may be suggestive of bilateral sacroiliitis with back pain radiating to the right leg and spinal stiffness leading to limited activities of daily living (ADL). Thereafter, he had numerous episodes of back and neck pain, early morning stiffness, and limiting ADLs with easy tiredness for many years. Driving a two-wheeler was a part of his routine activity where he had maximum trouble with his neck. He reported that he had been reluctant to seek specialist consultation for his back complaints and had only presented to our physiotherapy outpatient department (OPD) upon the insistence of his relatives and friends.

Musculoskeletal examination revealed a marked forward head, protracted shoulder, thoracic kyphosis, flattening of the lumbar spine, a flexed hip, and knee in standing lateral view resembling “question mark” deformity. The decrease in muscle length was noted symmetrically in the pectoralis, upper trapezius, levator scapulae, suboccipital muscles, lumbar erectors, hamstrings, and hip flexors with articulated weakness in the sternocleidomastoid, deep cervical flexors, gluteal, abdominal, middle, and lower scapular stabilizer muscles. Palpation revealed tenderness over bilateral sacroiliac joints, bilateral upper trapezius, over the spinous processes of cervical vertebrae, and at the lumbosacral junction. The paraspinal muscles spasm was noted in the cervical region to a great extent compared to the lumbar region. The passive intervertebral accessory joint motion could not be detected on manual palpation of the lumbar spine in both prone and seated positions. There was a global decrease in active range of motion (ROM) of the cervical spine, lumbar spine, and shoulder and hip joints with tissue stretch end feel. Lumbar spine flexion assessed by the Schober's test was measured 2 cm, and chest expansion was limited to a difference of only 1 cm in all three levels (axilla, nipple, and xiphisternum). Straight leg raising was limited to 40° bilaterally with complaints of hamstring pull. FABER-Patrick's test reproduced pain over the lumbosacral area bilaterally with restricted hip joint motion. Screening of the neurological symptoms and extraarticular symptoms did not reveal any significant findings.

Radiographs of lumbopelvic hip (AP and lateral view) and cervical (AP and lateral view) confirmed the suspected diagnosis of AS. Radiographic characteristic included bilateral sacroiliac joint ankyloses, marginal syndesmophytes to the L1–L5 [Figure 1], and C2–C6 disc space [Figure 2] resembling “Bamboo spine.” Reactive sclerosis at the left hip joint was also visible.
Figure 1: Lumbopelvic-hip X-ray for ankylosing spondylitis

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Figure 2: Cervical spine X-ray for ankylosing spondylitis

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Ankylosing spondylitis specific outcome measures

As a part of disease-specific objective assessment, the Assessment of Spondyloarthritis International Society which includes bath AS disease activity index (BASDAI), bath AS functional index (BASFI), bath AS metrology index (BASMI), bath AS radiology index for the spine (BASRI-s), and modified stoke AS spine score (mSASSS)[10] was used. The condition was evaluated at baseline, at 3 months and after 1 year of interventions [Table 1].
Table 1: Change in the scores of condition-specific outcome measures

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A definite AS was diagnosed as per the modified New York criteria on the basis of the history of the disease, clinical presentation, and radiological findings.[11] On referral to the rheumatologist for the further care, he was advised to continue physiotherapy and prescribed COX-2 inhibitors (nonsteroidal anti-inflammatory drug) on the need basis with no further investigations.

Physical therapy management

The supervised program was planned to address the current clinical presentation of musculoskeletal consequences and secondary consequences (cardiorespiratory and balance) and to facilitate physical activity participation by modifying symptom severity as required. The supervised physiotherapy intervention consisted of patient education, exercise therapy, electrotherapy, and manual therapy, provided for 45–60 min a day, 6 days in a week for 3 months. The unsupervised home exercise program (HEP) was designed based on his daily activities to maintain exercise adherence [Table 2].[7]
Table 2: Physiotherapy interventions for ankylosing spondylitis patient

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The interventions targeted to reduce the symptoms included thermal modalities, postisometric relaxation (isometric contraction) Muscle Energy Technique (MET) for upper trapezius (B/L), and positional stretching in the supine position combined with pectoral tendon mobilization. The suboccipital, levator scapulae, lumbar erectors, hamstrings, hip flexors, and piriformis muscles were progressively stretched statically to maintain or improve muscle length in an attempt to prevent restriction of ROM and functional limitations. Active spinal mobility exercises were initiated using low-impact gym ball exercise in all three planes. These exercises were synchronized with the breathing pattern to enhance chest mobility and breath control. Progressive strength training for spinal extensor, scapular stabilizer, deep neck flexor, and hip extensor muscles was incorporated to control postural deformation and improve in physical functioning. Thera tubes, dumbbells, and sandbags were used as a mode of resistance.

The Star Excursion Balance Test (SEBT) grid (8 directions) was used for balance exercise where he performed five repetitions in each direction. Bicycle ergometer with exercise intensity 40% of targeted heart rate (THR) was used to maintain his cardiorespiratory functioning which was progressed to 65% of THR. Virtual video games which required spinal extension and overhead arm motion were also introduced to motivate and increased his physical activity participation. All the exercises were progressed as per his tolerance and responses not on the basis of duration. A graduated-intensity unsupervised HEP was also advised in the form of recreational activities such as playing cricket, flexibility regimen, and 30 min of daily walking to maintain his current level of function.


  Discussion Top


This case report is intended to present the long-term effectiveness of physiotherapy interventions in the incidental delayed diagnosis of AS with its classic features. This case is unique in many prospects. In our case, the condition started with several GIT infections which may have initiated the inflammatory process of the disease,[12] followed by multiple episodes of low back pain and stiffness. The condition was rapidly progressed over a period of 9 years with worsening of neck stiffness more than back; limited chest excursion and spinal mobility; and easy fatigability. Regardless of the classic feature of AS, it took 10 years to diagnose the condition and to initiate AS-specific exercises which is the mainstay of rehabilitation.[9] Supervised exercise program for 6 days, 270–360 min per week,[13] was found to have long-term effects on pain, stiffness, mobility, and function in this patient.

Patient-specific physiotherapy exercise interventions were intended to minimize or improve musculoskeletal consequences such as pain, postural deformities, reduced mobility, and muscle strength and secondary consequences such as cardiorespiratory changes, balance, and physical activities. These exercises led to the improvement in the scores of BASDAI, BASFI, and BASMI after 1 year of intervention; however, no changes were observed in BASRI-s and mSASSS scores in this case. It provided the evidence that exercise intervention aids in improving mobility, disease activity, and functional capacity[1],[6],[7],[8],[9] despite progressive joint pathology. However, further research is warranted to explore the impact of therapeutic exercises on the radiological index.

Thermal modality in the form of moist heat was provided in the initial 3 weeks to ease the symptoms of pain and stiffness as per patient preference; however, earlier studies have reported the limited short-term role of thermal modalities in AS.[1],[6],[7],[8],[9] Gunay et al., 2017, reported that balance exercises in water and on land could improve the benefits of physiotherapy.[14] In our case, balance training was performed in SEBT grid, which was interesting and feasible in AS patient. Postisometric MET for the bilateral upper trapezius[15] when combined with other AS-specific exercises reduced the cervical symptoms and improved mobility as reported by the patient. In agreement with Karahan 2016,[16] participation in virtual video games helped in increasing physical activity and decreasing pain scores in this case also.

Unsupervised HEP was initiated from the 1st week of supervised intervention. HEP could have had an additive effect in AS-specific outcome measures. Yigit et al., 2013, reported that HEP increased functional capacity and joint mobility, decreased disease activity, improved emotional state, fatigue, and Quality of Life for patient with AS,[17] which is in line with finding in this patient.


  Conclusion Top


The patient reported at physiotherapy OPD with a primary complaint of back pain with stiffness and limited spinal mobility among young adults should be assessed thoroughly as it has the potential for the incidental diagnosis of AS. The combination of supervised and unsupervised exercise intervention was evident to have a long-term effect in this neglected long-standing AS patient with severe spinal stiffness, reduced functional status, and increased fatigability. Despite the remarkable change in the scores of pain, disease activity, physical function, and mobility index, there was no evidence of beneficial change in the radiological index in this patient.

Acknowledgment

We are highly thankful to our valuable patient for his cooperation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Equipment Support by Ashok & Rita Patel Institute of Physiotherapy.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Zochling J, van der Heijde D, Burgos-Vargas R, Collantes E, Davis JC Jr., Dijkmans B, et al. ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann Rheum Dis 2006;65:442-52.  Back to cited text no. 1
    
2.
Ankylosing Spondylitis; 22 January, 2018. Available from: http://www.arthritis-india.com/ankylosing-spondylitis.html. [Last updated on 2018 Jan 22].  Back to cited text no. 2
    
3.
Dean LE, Jones GT, MacDonald AG, Downham C, Sturrock RD, Macfarlane GJ, et al. Global prevalence of ankylosing spondylitis. Rheumatology (Oxford) 2014;53:650-7.  Back to cited text no. 3
    
4.
Feldtkeller E, Khan MA, van der Heijde D, van der Linden S, Braun J. Age at disease onset and diagnosis delay in HLA-B27 negative vs. Positive patients with ankylosing spondylitis. Rheumatol Int 2003;23:61-6.  Back to cited text no. 4
    
5.
Shaikh SA. Ankylosing spondylitis: Recent breakthroughs in diagnosis and treatment. J Can Chiropr Assoc 2007;51:249-60.  Back to cited text no. 5
    
6.
van den Berg R, Baraliakos X, Braun J, van der Heijde D. First update of the current evidence for the management of ankylosing spondylitis with non-pharmacological treatment and non-biologic drugs: A systematic literature review for the ASAS/EULAR management recommendations in ankylosing spondylitis. Rheumatology (Oxford) 2012;51:1388-96.  Back to cited text no. 6
    
7.
Millner JR, Barron JS, Beinke KM, Butterworth RH, Chasle BE, Dutton LJ, et al. Exercise for ankylosing spondylitis: An evidence-based consensus statement. Semin Arthritis Rheum 2016;45:411-27.  Back to cited text no. 7
    
8.
van der Heijde D, Ramiro S, Landewé R, Baraliakos X, Van den Bosch F, Sepriano A, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis 2017;76:978-91.  Back to cited text no. 8
    
9.
Ozgocmen S, Akgul O, Altay Z, Altindag O, Baysal O, Calis M, et al. Expert opinion and key recommendations for the physical therapy and rehabilitation of patients with ankylosing spondylitis. Int J Rheum Dis 2012;15:229-38.  Back to cited text no. 9
    
10.
Sieper J, Rudwaleit M, Baraliakos X, Brandt J, Braun J, Burgos-Vargas R, et al. The assessment of spondyloArthritis international society (ASAS) handbook: A guide to assess spondyloarthritis. Ann Rheum Dis 2009;68 Suppl 2:ii1-44.  Back to cited text no. 10
    
11.
van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the new york criteria. Arthritis Rheum 1984;27:361-8.  Back to cited text no. 11
    
12.
Koehler L, Zeidler H, Hudson AP. Aetiological agents: Their molecular biology and phagocyte-host interaction. Baillieres Clin Rheumatol 1998;12:589-609.  Back to cited text no. 12
    
13.
Uhrin Z, Kuzis S, Ward MM. Exercise and changes in health status in patients with ankylosing spondylitis. Arch Intern Med 2000;160:2969-75.  Back to cited text no. 13
    
14.
Gunay SM, Keser I, Bicer ZT. The effects of balance and postural stability exercises on spa based rehabilitation programme in patients with ankylosing spondylitis. J Back Musculoskelet Rehabil 2018;31:337-46.  Back to cited text no. 14
    
15.
Seif G, Elliott J. Ankylosing spondylitis in a patient referred to physical therapy with low back pain. Physiother Theory Pract 2012;28:63-70.  Back to cited text no. 15
    
16.
Karahan AY, Tok F, Yildirim P, Ordahan B, Turkoglu G, Sahin N, et al. The effectiveness of exergames in patients with ankylosing spondylitis: A Randomized controlled trial. Adv Clin Exp Med 2016;25:931-6.  Back to cited text no. 16
    
17.
Yigit S, Sahin Z, Demir SE, Aytac DH. Home-based exercise therapy in ankylosing spondylitis: Short-term prospective study in patients receiving tumor necrosis factor alpha inhibitors. Rheumatol Int 2013;33:71-7.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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