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 Table of Contents  
Year : 2020  |  Volume : 14  |  Issue : 1  |  Page : 50-54

Effectiveness of physiotherapy treatment in a case of diffuse idiopathic skeletal hyperostosis (DISH) in 65 year old male

Department of Musculoskeletal Science, Ashok & Rita Patel Institute of Physiotherapy, CHARUSAT, Anand, Gujarat, India

Date of Submission21-Oct-2019
Date of Decision14-Dec-2019
Date of Acceptance18-Feb-2020
Date of Web Publication29-Jun-2020

Correspondence Address:
Dr. Hemal M Patel
Department of Musculoskeletal Science, Ashok & Rita Patel Institute of Physiotherapy, CHARUSAT Campus, Changa, Petlad, Anand - 388 421, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/PJIAP.PJIAP_30_19

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Diffuse idiopathic skeletal hyperostosis (DISH) is common after 50 years, which is characterized by the ossification of the anterior longitudinal ligament. The purpose of this case report is to describe the physiotherapy intervention strategies and report its effectiveness in the symptomatic management of DISH in 65-year-old male who complains of severe lower back pain and difficulty in changing side while lying on the bed, prolonged standing, and walking for the last 1 month. The condition was managed based on clinical presentations with supervised and unsupervised physiotherapy for 6 weeks. The supervised physiotherapy intervention consisted of patient's education, postural correction, electrotherapeutic modalities, exercise therapy, and counseling for 45–60 min a day for 5 days/week. The effectiveness of physiotherapy is followed for 6 weeks and symptom-specific outcome measures such as Quebec disability index, Schober's test, visual analog scale, and lumbar lateral flexion test were used. Physiotherapy interventions are found to be effective in the symptom management of DISH with increased patient satisfaction.

Keywords: Diffuse idiopathic skeletal hyperososis, forestiers disease, physical therapy

How to cite this article:
Patel HM, Patel DV. Effectiveness of physiotherapy treatment in a case of diffuse idiopathic skeletal hyperostosis (DISH) in 65 year old male. Physiother - J Indian Assoc Physiother 2020;14:50-4

How to cite this URL:
Patel HM, Patel DV. Effectiveness of physiotherapy treatment in a case of diffuse idiopathic skeletal hyperostosis (DISH) in 65 year old male. Physiother - J Indian Assoc Physiother [serial online] 2020 [cited 2022 Aug 15];14:50-4. Available from: https://www.pjiap.org/text.asp?2020/14/1/50/288362

  Introduction Top

Diffuse idiopathic skeletal hyperostosis (DISH) is also known as Forestier's disease. It was first described by Jacques Forestier and his student Jaume Rotes-Querol in 1950. It is a systemic noninflammatory disease. DISH is characterized by thickening, ossification and calcification of ligament, tendon, and joint capsule.[1] A study was conducted in Japan on the prevalence of DISH. It was 19.5%. The prevalence of disease was 17%–19.5% in older subjects. Age and sex were significantly related to the presence of DISH, suggesting that men and older individuals have a higher probability of developing DISH.[2],[3] The most common site of involvement was thoracic (65.1%) and thoracolumbar (24.2%); other areas commonly involved are as follows: pelvis, patella, calcaneus, and olecranon.[2],[4] Certain studies showed that obesity, hypertension, diabetes mellitus Type 2, and dyslipidemia are common risk factors for developing DISH.[5] Usually, the disease is asymptomatic in most clinical cases; symptomatic cases show severe pain, reduced mobility, and stiffness.[6] The diagnosis of DISH is based on the radiological findings, defined by Resnick and Niwayana. According to the definition, the presence of flowing calcification and ossification mainly along the anterior longitudinal ligament (ALL) of at least four contiguous vertebrae with preserved disc height is indicative of the condition. There are three primary highlights for diagnosis:

  1. Flowing bony ossification along the anterolateral aspect of at least four contiguous vertebral bodies
  2. Preservation of the intervertebral disc height of the affected vertebra
  3. Absence of apophyseal joint bony ankylosis and sacroiliac (SI) joint erosion.[5],[6],[7]

Once a patient meets the criteria, we can use the Mata classification system to determine the amount of ossification of each vertebral level and the degree of bony bridging of the disc space.

Mata scoring system:[7],[8]

  • 0: No ossification
  • 1: Ossification without bridging
  • 2: Ossification with incomplete bridging
  • 3: Ossification with complete bridging.

Certain medications such as anti-inflammatory, analgesics, and muscle relaxants have been used to manage symptoms of the disease process.[4] No treatment has been suggested to alter the natural history of DISH,[6] many physicians refer patients for physiotherapy. However, exercise therapy is very rarely studied for the DISH patient. This case report is focused on symptomatic management of patients with low back pain (LBP) due to DISH.

  Case Report Top

In our physiotherapy department, a 65-year-old male presented with severe lower back pain and difficulty in changing side while lying on the bed, prolonged standing and walking. The patient had a gradual onset LBP for the past 10 years, but the pain became unbearable in the past 1 month. The patient complained of morning stiffness and repetitive catch while changing the position. He described the pain as continuous and aching pain which increases with changing posture and scored it 6/10 during rest and 8/10 during activity on the numerical pain rating scale. His sleep was also disturbed due to constant pain. There was no history of trauma. He is a known case of hypertension for the last 10 years and he is on regular medication.

He is retired for the last 5 years and he lives a sedentary lifestyle. According to his height and weight, his body mass index is 34.2 which show he falls in the category of obese. He usually spends more time sitting and reading. Although for the last 2 months, he started taking evening walk for half an hour, not regularly.

Before a 1 month pain was so severe that is consulted the orthopedic doctor, he advised for X-ray report. After the X-ray was done it was found that he has a disease known as DISH or Forestier's disease. Then, the doctor advised for Diclofenac and Tylenol twice a day and also he was referred to physiotherapy for pain management and restoration of the movement. Furthermore, the lumbar brace was suggested. He took medication for the next 10 days, but there was no improvement, then after he visited the physiotherapy department with complaint of LBP which was affecting his routine activities. On observation of patient posture, he has kyphosis in the thoracic region and anterior pelvic tilting. His gait was also affected; he was having an antalgic gait with a longer swing phase on the left side; there is lateral lean on the left side while single-leg support. Gait parameters such as cadence, step length, stride length, step width, and degree of toe-out were also reduced. On palpation, tenderness was present over L3 and L4 spinous process and left side SI joint Grade 2 (complains of pain and winces). Furthermore, there is muscle spasm in the para-spinal muscles.

Following the physical examination of the active lumbar movements is restricted and painful, also left side flexion and rotations are more affected than right. The entire neurological dysfunction test was negative. All reflexes and sensations are normal. The patient has muscle tightness of hamstring, iliopsoas, and piriformis. Furthermore, while assessing joint mobility, there was decreased mobility in L1 to L4. He underwent plain film radiography; it was found that he has ossification of posterior longitudinal ligament [Figure 1].
Figure 1: Lateral view of lumbar spine

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According to the X-ray, we can conclude that:

  • There is a partial bony bridge formation between L4-L5 and L2–L3 i.e., Grade 2
  • There is a complete bony bridge formation between T11–T12, T12–L1, L1–L2, L3–L4 i.e., Grade 3.

Also patient functional activity is assessed using the Quebec back pain disability scale before the physiotherapy intervention score 84 which was reduced to 54 [Table 1].
Table 1: Change in the scores of condition-specific outcome measures

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Physical therapy management

As per the history and findings in physical examination, physiotherapy rehabilitation program was designed for 5 days a week for 6 weeks and 3 months follow-up. The primary aim of the treatment was designed to reduce pain and improve range of motion to prevent further complications, a second aim was to improve the strength of back muscles and to improve the functional activities of daily living (ADL), and supervised physiotherapy intervention consisted of patient education exercise therapy, electrotherapy, and manual therapy, provided for 45 min–60 min. The unsupervised home exercise program (HEP) was designed based on his pain tolerance, improvement and to maintain exercise adherence.

The initial treatment protocol was based on counseling and education regarding the condition and its prognosis to facilitate exercise adherence. Physiotherapy intervention consists of interferential current and muscle energy technique of back muscle, also stretching of all lower limb muscles and back to reduce pain spasm and improve range of motion. Strengthening exercises are given to improve ADL. During the rehabilitation program, he was taking painkillers when required. A HEP was designed based on FITT Principle (Frequency, Intensity, Time, Type of exercises) and progressed as appropriate for better maintenance of the condition [Table 2]. He was given manual for HEP to follow strictly. HEP consist of self-stretching of back and lower limb. Active range of motion exercise of lower limb and back, also walking for half an hour, was suggested. HEP program was based on pain tolerance, point of fatigue and quality of movement. Heat bag was suggested when required to relieve pain and spasm.
Table 2: Physiotherapy intervention for Forestier's disease patient

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To strengthen the muscles we started with multiple-angle isometrics exercise of the group of back extensor, hamstrings, group of abdominal, glutei, adductor, and abductors. He was also given MET of back extensors, rotators and hamstring and isotonic exercise of lower limb muscles with progressive doses [Table 2].

In 6 weeks, he received 30 supervised physiotherapy sessions approximately 45 min–60 min a day and discharged with advice to resume daily activities and walking for 30 min. On discharge he has minimal pain (3/10 visual analogue scale), he was able to perform his ADL and there is an improvement in the back range of motion also there is a reduction in the disability index. He was advised for follow-up once in 15 days. He came for 3 follow-up sessions; at the end of sessions, he was able to do his ADL.

  Discussion Top

This case report was intended to outline DISH with its clinical feature, to provide an insight into physiotherapy management strategies, to highlight its symptomatic management. In our case, the patient was symptomatic for the last 1 month and he was having difficulty in turning, getting in and out of bed, bending and even walking. The entire physiotherapy management was based on symptoms.

Few conditions may mimic DISH based on the presence of bony excrescences similar to those seen in the condition. Spondylosis deformans and Ankylosing spondylitis are, however, the two conditions that are most similar to DISH. Spondylosis deformans is the more common of the two. It can be differentiated from DISH based on the fact that it spares the ALL of the spine. Ankylosing spondylitis, on the other hand, is a relatively rare condition with an incidence of 0.05%–1.4% as against DISH that has an incidence of 2.9%–25% of the population.[9],[10] This condition is a chronic inflammatory rheumatoid disorder that characteristically affects young Caucasian males.[9],[10] In as, the patients, usually have symptoms and also present with associated conditions such as ulcerative colitis, iritis, and oruveitis. Pathologically, there is the presence of SI and apophyseal joint fusion or sclerosis and SI joint inflammation.[10] The earliest symptoms of these include back pain and stiffness. The inflammation progressively involves the intervertebral joints, leading to spondylitis, as well as the large peripheral joints including the knees, the hips, and the shoulders. The patient in very severe cases may after many years develop characteristic postural abnormalities like “Bechterew scoop”. The cause is attributed to a combination of environmental and genetic factors which are still unknown. Research has however revealed the influence of several genes in the development of the disorder. The implicated genes include HLA-B27, ERAP1, IL1A, and IL23R.[10]

The frequency, severity, and nature of complaints among the patients with DISH vary depending on the location of the ossification. Many patients with this condition based on incidental X-ray findings may, however, be free of any form of symptoms.[11] The most common manifestations of DISH are directly related to the effects on the spine. These include spinal pain, and radicular symptoms such as pain, paraesthesia, numbness, and weakness in the extremities. They can also present with a reduced range of motion in the spine and predisposition to the development of unstable spinal fractures. Airway obstruction may occur due to tracheal compression by large osteophytes. Dysphagia can also occur generally as a result of a combination of factors. The factors include mass effect by osteophytes, injury to the recurrent laryngeal nerve, inflammation, and fibrosis of the esophageal wall due irritation by osteophytes.[11] In our study, we found all these clinical features and based on this clinical symptoms we planned our intervention for this case.

There is limited literature describing the specific physiotherapy management for symptomatic management of DISH. Studies show that there are symptomatic benefits from mild analgesic, local heat, local corticosteroids, bracing, and massage therapy. Only a few articles suggest spinal surgery for DISH with a severe disability.[1],[4],[5] Physical therapy is used to reduce pain, improve range of motion and function of the person.[4]

Physical therapy can be used as an adjunct therapy along with medications to relieve pain, improve range of motion and to improve ADL.[4],[5] In our case, we used electrotherapeutic modalities with exercise therapy and unsupervised home-based protocol to give satisfactory symptomatic treatment. The patient was benefited with the exercises and symptoms were relieved.

  Conclusion Top

Physiotherapy intervention in the form of electrotherapy, exercise therapy, and unsupervised home-based exercise program is effective in symptom management as well as in functional activity (ADL) in the case of DISH. Further trials need to be carried before generalizing the findings for other patients.

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


Conflicts of interest

There are no conflicts of interest.

  References Top

Nascimento FA, Gatto LA, Lages RO, Neto HM, Demartini Z, Koppe GL. Diffuse idiopathic skeletal hyperostosis: A review. Surg Neurol Int 2014;5:S122-5.  Back to cited text no. 1
Hiyama A, Katoh H, Sakai D, Sato M, Tanaka M, Watanabe M. Prevalence of diffuse idiopathic skeletal hyperostosis (DISH) assessed with whole-spine computed tomography in 1479 subjects. BMC Musculoskelet Disord 2018;19:178.  Back to cited text no. 2
Westerveld LA, van Ufford HM, Verlaan JJ, Oner FC. The prevalence of diffuse idiopathic skeletal hyperostosis in an outpatient population in The Netherlands. J Rheumatol 2008;35:1635-8.  Back to cited text no. 3
Al-Herz A, Snip JP, Clark B, Esdaile JM. Exercise therapy for patients with diffuse idiopathic skeletal hyperostosis. Clin Rheumatol 2008;27:207-10.  Back to cited text no. 4
Hannallah D, White AP, Goldberg G, Albert TJ. Diffuse idiopathic skeletal hyperostosis. Oper Tech Orthop 2007;17:174-7.  Back to cited text no. 5
Holgate RL, Steyn M. Diffuse idiopathic skeletal hyperostosis: Diagnostic, clinical, and paleopathological considerations. Clin Anat 2016;29:870-7.  Back to cited text no. 6
Holton KF, Denard PJ, Yoo JU, Kado DM, Barrett-Connor E, Marshall LM, et al. Diffuse idiopathic skeletal hyperostosis and its relation to back pain among older men: The MrOS Study. Semin Arthritis Rheum 2011;41:131-8.  Back to cited text no. 7
Mata S, Chhem RK, Fortin PR, Joseph L, Esdaile JM. Comprehensive radiographic evaluation of diffuse idiopathic skeletal hyperostosis: Development and interrater reliability of a scoring system. Semin Arthritis Rheum 1998;28:88-96.  Back to cited text no. 8
Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: A systematic review of the literature on treatment, neurological status and complications. Eur Spine J 2009;18:145-56.  Back to cited text no. 9
Ghasemi-Rad M, Attaya H, Lesha E, Vegh A, Maleki-Miandoab T, Nosair E, et al. Ankylosing spondylitis: A state of the art factual backbone. World J Radiol 2015;7:236-52.  Back to cited text no. 10
Verlaan JJ, Boswijk PF, de Ru JA, Dhert WJ, Oner FC. Diffuse idiopathic skeletal hyperostosis of the cervical spine: An underestimated cause of dysphagia and airway obstruction. Spine J 2011;11:1058-67.  Back to cited text no. 11


  [Figure 1]

  [Table 1], [Table 2]


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