Ankylosing Spondylitis- The Keys to Good Management

Ankylosing Spondylitis (AS) is a chronic inflammatory arthritis affecting the sacroiliac joints (SIJ) and lumbar spine. It often presents before the age of 45 with back pain in the morning and following periods of rest. AS is a progressive disease that remains a challenge to diagnose and can be difficult to comprehensively manage. Here we explore the definition, classification of AS and important keys for optimal management.

Ankylosing Spondylitis presents before the age of 45 with back pain in the morning and following periods of rest #physio #as #backpain Click To Tweet

Definition

Spondyloarthritis (SpA) refers to a group of chronic, inflammatory diseases which include AS alongside psoriatic arthritis, inflammatory bowel disease, reactive arthritis, undifferentiated arthritis and groups of juvenile idiopathic arthritis. The Assessment of Spondyloarthritis International Society (ASAS) classifies SpA into axial (affecting the spine and or sacroiliac joints) or peripheral. AS affects the axial skeleton with characteristic changes in the spine and sacroiliac joints.

Ankylosing spondylitis is characterised by inflammatory back pain that is subacute in onset and starts before the age of 45. Inflammatory arthritis has the characteristic feature of enthesitis. Enthesitis is inflammation at the attachment  sites of tendons, ligaments, joint capsule or fascia to the bone. This is the main target area of immunopathology, with inflammation at these sites resulting in new bone formation leading to typical AS features of bridging and fusion of joints and ankylosis of the spine. AS is a slowly progressive disease and these x-ray changes often do not present until a decade after onset of symptoms.

Diagnosis

a. Patient History

Early diagnosis of AS remains a challenge and is typically delayed 8 to 10 years after initial symptom onset. ASAS classification of AS has several key features including back pain for three or more months with onset prior to the age of 45 years. In taking a patient history a number of questions will be used to identify features of inflammatory back pain:

• Did your back pain start when you were younger than 40 years?
• Did your back pain develop gradually?
• Does your back pain improve with movement?
• Do you find your back pain is worse with rest?
• Do you find your back pain worsens overnight and improves once you get up and moving?
• Does your back feel stiff for more than 30 minutes in the morning?
• Do you ever have pain that radiates into your buttocks?
• Dos your back respond well to anti-inflammatories (NSAIDs)?

Answering yes to multiple of these questions can give clues of inflammatory back pain and will require further investigation.

Early diagnosis of Ankylosing Spondylitis remains a challenge and is typically delayed 8 to 10 years after initial symptom onset #physio #backpain Click To Tweet

b. Blood and Genetic Markers

Diagnosis of AS also requires investigation of inflammatory markers (C reactive protein and erythrocyte sedimentation rate) that are often elevated. Normal levels however do not rule out a diagnosis of AS. Genetic risk factors are proposed to account for 80-90% of AS. It is therefore important in the assessment to identify any family history of AS. A major genetic risk factor for AS is HLA-B27, a protein found on white blood cells involved in the immune response. A positive HLA-B27 marker is found in 80-90% of people with AS, although only 10% of people who are HLA-B27 positive have AS. Therefore is testing this marker is often useful in confirming or supporting suspected AS diagnosis.

c. Extra-articular Features

Ankylosing spondylitis often occurs alongside other extra-articular manifestations of spondyloarthritis, including

• Uveitis (25.8%)
• Psoriasis (9.3%)
• Inflammatory bowel disease (6.8%)
• Enthesitis (often presents in the form of plantar fasciitis or Insertional Achilles tendinopathy)
• Dactylitis
• Aortic regurgitation

(Stolwijk, et al 2015)

These co-existing features can support diagnosis of AS.

d.  Investigations

A plain film x-ray remains the best investigation to diagnose AS and monitor disease progression. X-rays of the pelvis and lumbar spine are more sensitive than MRI for detecting new bone formation and will show structural changes including sub-chondral sclerosis, erosions and ankylosis (fusing) in later stages of disease. Typical x-ray changes of AS seen in the spine include shiny vertebral body corners (sclerosis), squaring of the vertebra body and bridging bone formation between vertebrae (syndesmophytes). MRI imaging can be used to detect early inflammatory bony changes not detectable on plain film x-ray. In those with a positive HLA-B27 and or a history of inflammatory back pain, it is prudent to carry out MRI imaging.

Management

The primary goal of managing AS is to maximize long term health-related quality of life through control of symptoms and inflammation, prevention of progressive structural damage, preservation of normal function and social participation (Braun et al, 2010). Treatment requires a multidisciplinary approach, led by shared decision making from between the patient and the rheumatologist. The optimal management of patients with AS requires a combination of non-pharmacological and pharmacological treatment modalities.

Education

Patient education is considered an integral part of managing AS (Zangi et al., 2015).  Educational programmes significantly improve disease knowledge, coping skills and physical and psychological health status. All people with inflammatory arthritis should have access to and be offered individually tailored patient education throughout the course of their disease. Patient education programmes should include aspects of self-management, cognitive behavioural therapy or stress management to assist in developing coping skills and strategies.

NSAIDs

Non-steroidal anti-inflammatory drugs (NSAIDs), particularly Coxibs remain a first line treatment for AS . Pain and stiffness relief can be seen in the first 24-72 hours of commencing a full-dose and there is evidence that continuous use (versus on demand use) can delay radiographic disease progression (evidence on x-ray). Management of medication is done under the care of a rheumatologist with the dose adjusted to the lowest effective dose. Patients having long-term use should be monitored for gastro-intestinal, renal and cardiovascular side effects.

Analgesics and Injections

Analgesics, such as paracetamol and opioid like drugs, may be considered for residual pain after previously recommended treatments have failed, are contraindicated, and or are poorly tolerated. Glucocorticoid (corticosteroid) injections directed to the local site of musculoskeletal inflammation may be considered without improvement from other interventions. The use of systemic glucocorticoids for axial disease is not supported by evidence

DMARDs

Disease-Modifying Antirheumatic Agents (DMARDs) such as methotrexate and sulfasalazine have no effect on AS symptom management or disease progression. DMARDs do however have a role in the management of any peripheral symptoms for Spondyloarthritis, however the supporting evidence for this is still unclear (Braun et al., 2010).

Tumour Necrosis Factor Inhibitors

Tumour necrosis factor alpha (TNFα) inhibitors such as etanercept, infliximab, golimumab and adalimumab have revolutionised AS treatment. These biological DMARDs have improved quality of life for greater than two thirds of patients with AS not responding to first line treatment. There is evidence that patients with advanced disease also have some benefit, but patients with early and very early will see the most beneficial outcomes. There is evidence that anti-TNF agents will additionally improve the signs and symptoms of peripheral arthritis and enthesitis that can occur alongside AS. The pharmaceutical benefits scheme (PBS) stipulate a three month trial of exercise and daily use of two different NSAIDs prior to TNF inhibitor therapy consideration. Use of this medication can be subsidised when there is evidence of sacroilitis changes on x-ray.

Physiotherapy

Physiotherapy is an effective treatment in improving pain, physical function, spinal mobility and patient global assessment scores (outcome measures for improvement).  Physiotherapists as first contact practitioners are well positioned to comprehensively assess clients presenting with inflammatory back pain and if suspected refer for further investigation to confirm diagnosis.  Arthritis groups recommend daily stretching and mobility routines to manage symptoms and potentially improve long-term outcomes. Evidence suggests that home exercises effective, however physiotherapy combined with supervised exercises are more effective. This could be in the form of hydrotherapy, circuit based classes or Pilates.

Disease Monitoring

Regular monitoring of disease progression is important, through assessment of patient history (eg, questionnaires and reported symptoms), clinical assessment and ROM, laboratory test and imaging. The frequency of monitoring should be decided on an individual basis depending on symptoms, severity and current treatment. Physiotherapists, due to teaching and progressing home exercises and conducting supervised exercise classes are in a good position to monitor symptoms and collaborate with other members of the multidisciplinary team. Over-arching care should be through a rheumatologist.

Ankylosing Spondylitis is a progressive inflammatory arthritis, which is important to detect and treat early. Optimal management requires a multidisciplinary approach with the care of a rheumatologist. First line treatment includes ongoing education, NSAIDS or TNF-inhibitors, a regular home exercise program which can be combined with physiotherapy and supervised exercise classes for added benefits.

 

Useful Websites/Resources

• Arthritis Australia
• Arthritis and Osteoporosis NSW
• Arthritis Victoria
• Arthritis Research UK
• Rheumatoid Arthritis

 

Lewis Craig (APAM)

 

 

 

 

 

Physiotherapist

References

1.Braun, J. V., Van den Berg, R., Baraliakos, X., Boehm, H., Burgos-Vargas, R., Collantes-Estevez, E., … & Geher, P. (2011). 2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitis. Annals of the rheumatic diseases, 70(6), 896-904.

2.Braun, J., & Sieper, J. “Ankylosing spondylitis.” The Lancet 369.9570 (2007): 1379-1390.

3. Dagfinrud H, Hagen KB, Kvien TK. Physiotherapy interventions for ankylosing spondylitis. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD002822. DOI: 10.1002/14651858.CD002822.pub3.

4. Ross, L. J., & Buchanan, R. R. (2016). Ankylosing spondylitis: new insights into an old disease. Medicine Today 17(1-2): 16-24.

5. Stolwijk, C., van Tubergen, A., Castillo-Ortiz, J. D., & Boonen, A. (2015). Prevalence of extra-articular manifestations in patients with ankylosing spondylitis: a systematic review and meta-analysis. Annals of the rheumatic diseases, 74(1), 65-73.

6. Dagfinrud H, Kvien TK, Hagen KB. Physiotherapy interventions for ankylosing spondylitis. Cochrane Database Syst Rev 2008; CD002822.

7. Zangi, H. A., Ndosi, M., Adams, J., Andersen, L., Bode, C., Boström, C., … & Niedermann, K. (2015). EULAR recommendations for patient education for people with inflammatory arthritis. Annals of the rheumatic diseases, 74(6), 954-962.

8. Zochling, J., van der Heijde, D., Burgos-Vargas, R., Collantes, E., Davis, J. C., Dijkmans, B., … & Kvien, T. K. (2006). ASAS/EULAR recommendations for the management of ankylosing spondylitis. Annals of the Rheumatic Diseases, 65(4), 442-452.