Ankylosing Spondylitis treatment includes physiotherapy. A stiff spine caused by Ankylosing Spondylitis can impact your quality of life by restricting your freedom of movement. Ankylosing Spondylitis pain is an autoimmune disease that leads to changes in bone function and structure. It is more common in men and diagnosed between the ages of 17 – 45 years. Ankylosing Spondylitis mainly affects the lower back, sacroiliac (SIJ) and hip joints, but can lead to shoulder and neck movement restrictions, inflammation of the eyes, irritable bowel disease and decreased lung capacity.

The Anatomy of your Spine

The bones that form your spine

Your spine is the scaffolding of your back. The vertebrae provide static stability, protection for your spinal cord and attachment site for muscles, which provide further dynamic stability. You have 24 vertebrae, from your neck down to your tailbone, stacked on top of each other. The vertebral bodies have discs in between them, which act as shock absorbers, together with the natural curvatures of the spine seen from the side. Between each vertebra, a nerve root exits on each side, branching out to connect to form peripheral nerves.

The curves of your spine

Viewed from the side, your cervical and lumbar spine is curved forward. This curvature, or lordosis, is normal. Your thoracic spine and sacrum & coccyx are curved backwards, this kyphosis is normal. Without these curves in your spine, you would be limited in movement, like folding forward to put on your shoes or reaching upwards to hang the laundry.

Discs, ligaments, and nerves

Between each vertebra, there is a disc, made up out of a gel-like material. These discs act as shock absorbers when you walk, run and jump. They are responsible for increasing the available movement of your spine, without sacrificing the supportive strength of your vertebral column.

Inside the vertebral canal, you can find your spinal cord which runs all the way from your brain to your lumbar and sacral vertebrae. This thick cord of nerves connects your brain to the nerves in the rest of your body. Nerve roots branch out from your spinal cord and exits in between each vertebra.

To aid in the stability of our 3D block tower, numerous different ligaments connect one vertebra to the next. They crisscross from one bone to the next, making sure each vertebra stays in place.

Back muscles

Your back muscles provide dynamic stability and allow movement in all three planes.

  • Extensor muscles make it possible for you to straighten up and lift objects.
  • Flexor muscles allow you to bend forward and reach your toes.
  • Lateral flexor and rotator muscles rotate your spine and bend sideways to lift and load luggage.

The Function of Your Spine

Except for the big, visible functions of providing stability, protection and movement, your spine plays a vital role in some invisible work. Like a flower is visibly pretty and smells nice, it provides an ecosystem for bees and other insects with pollen and nutrients that we can’t see. Bones are a living organ system that maintains mineral homeostasis, pH balance and storage unit of growth factors and blood cell production.

Bones continuously undergo restructuring and maintenance work with the invisible process of bone absorption and resorption. Oseoclast cells are like little Pacman cells that break down bone cells to release calcium from your bones into your blood. Osteoblast cells are like Bob the Builder that turn protein into bone matrix to heal and remodel old bone. This cycle happens continuously without any effort from you.

Different types of Ankylosing Spondylitis

Nonradiographic axial spondyloarthritis is the early stage of ankylosing spondylitis where minimal to no change is visible on X-rays.

Radiographic axial spondyloarthritis is the progressing stage of ankylosing spondylitis where evidence of the disease is visible on X-rays or other imaging.

What does Ankylosing Spondylitis do to bones?

The pathology of Ankylosing Spondylitis is still being researched and not fully understood. The gross movement limitations are caused by uncontrolled ossification.

Initially, inflammation of the joints causes the pain and stiffness of most commonly your lower back and SIJ. Once inflammation infiltrates the bone it causes granulation and joint erosion. This can feel like sand inside of your joints, swollen and like the joint doesn’t have a smooth gliding surface as it moves.

When the joint lining, synovium, is affected the soft tissue of cartilage is replaced by harder scar tissue. This can rapidly lead to ossification. Now the abnormal immune response allows inflammation to spread from your joints to the attachment sites of ligaments and tendons. Calcium deposits form between the bones, ligaments, muscle attachments and discs. The more calcium deposits collect in these soft tissue structures, the harder and less pliable they become, ultimately turning to bone by ossification. The further the disease advances the spine can fuse entirely.

Causes of Ankylosing Spondylitis

Studies have shown that up to 90% of Ankylosing Spondylitis patients test positive for the HLA-B27 gene. While only 2% of the general population with a positive HLA-B27 gene will develop Ankylosing Spondylitis. Leaving the debate to epigenetics wide open, how much of this diagnosis is your genetic make up and how much of it is your environment?

Microbial infection, and endocrine and immune system abnormalities can also predispose one to developing Ankylosing Spondylitis.

Symptoms of Ankylosing Spondylitis

Early

  • Mild stiffness in your lower back
  • Pain in your sacroiliac joints
  • Symptoms occur spontaneously
  • Pain is worse in the morning and better with movement
  • Stiffness comes & goes
  • Getting up after sitting for a long time causes pain
  • Activities, like bending down to tie shoes feel harder than usual

Progressing

  • Stiffness when turning over in bed
  • Painful to get up in the morning
  • It takes a while for you to straighten your back after getting up
  • Putting on pants and shoes is hard because of the lack of movement
  • Heat helps to relieve the pain for a while
  • Gentle stretches ease the pain but don’t take it away
  • Limited range of movement
  • You can’t turn your neck as far as you could before
  • Uveitis
  • IBS symptoms
  • General fatigue

Advanced

  • Constant pain
  • Severely limited movement of your back, neck and hips
  • Ribcage pain with forced breathing and coughing
  • Decreased lung capacity
  • Need help to put on pants
  • Chest pain with exertion
  • Cardiac disease
  • Decreased bone density with increased risk of fractures

Tests that you can do to see if you have movement restrictions related to Ankylosing Spondylitis

The next few tests will identify movement restrictions that are common in Ankylosing Spondylitis. The tests are not meant to diagnose Ankylosing Spondylitis but will identify movement restrictions.

  • Stand comfortably with your back touching a wall, feet slightly apart and arms hanging next to your sides
  • Allow your heals, lower and upper back to touch the wall
  • Aim to get the back of your head to touch the wall
  • If you cannot touch the back of your head to the wall you have restriction of your upper cervical vertebrae

  • Stand comfortably with your back touching a wall, feet slightly apart and arms hanging next to your sides
  • Allow your heals, lower and upper back to touch the wall
  • Slide your arm down your leg by bending to the side
  • Do not allow your back to move away from the wall
  • Repeat on the other side
  • If your hand moves less than a palm’s distance down your leg you have restricted lumbar side flexion

  • You will need a tape measure for the next test
  • Sit comfortably on a chair
  • Wrap a tape measure around your chest, just underneath your arm pits
  • Loosely grip the measure to allow movement as you breath
  • Note what the measurement is at rest
  • Take a deep breath in to fill your lungs all the way to the brim and allow the tape measure to expand with your chest
  • Less than 2 cm expansion shows rigidity of your ribcage

What are the signs of Ankylosing Spondylitis progression?

Early Ankylosing Spondylitis

During the early stages of ankylosing spondylitis pain, you experience frequent but mild back pain and stiffness that is usually worse in the morning and better with movement. Recurrent spontaneous episodes of back pain and sacroiliitis that do not respond to exercise and activity modification may be the first sign of ankylosing spondylitis.

Progressing Ankylosing Spondylitis

Symptoms can now spread up to include your upper back and neck too as your ankylosing spondylitis progresses.  Stiffness will become worse between episodes of pain and limit your movement, you may notice this when checking your blind spot. Decreased disc space increases the risk of nerve root compression and referred pain into your arms or legs. Inflammation can spread to other systems and cause uveitis (inflammation of the eyes), blurred vision and light sensitivity. You may experience digestive symptoms similar to irritable bowel disease as the inflammation spreads to your intestines. The long term use of over the counter anti-inflammatories can cause kidney damage, it is therefore important to discuss any side effects of your medication with your doctor.

Advanced Ankylosing Spondylitis

As the disease advances you will experience gross limitation in movement due to fusion of adjacent vertebrae. Maintaining an upright posture can be difficult and painful. Bone density is influenced and may progress into osteoporosis which increases your risk for fractures. Limitation of ribcage movement can influence your lung capacity and function, making it difficult to breathe. Inflammation of your aorta can influence the aortic valve to the heart and increase risk of cardiac diseases like aortitis, arrhythmias and cardiomyopathy.

Diagnosis of Ankylosing Spondylitis

There is no single gold standard test to diagnose Ankylosing Spondylitis, like an X-ray to diagnose a fracture. Your GP may have run blood tests and ordered X-rays without any conclusive diagnosis. A combination of evidence from a detailed family history, imaging and laboratory tests to determine gene presence and inflammation markers are needed to make a final diagnosis of Ankylosing Spondylitis by a specialist rheumatologist.

X-rays

X-rays will show evidence of established disease, and in the early stages of Ankylosing Spondylitis X-rays may appear normal. Only far-progressed fusion from Ankylosing Spondylitis will be visible as a “bamboo spine” on X-rays. Bridging, vertebral body squaring and ossification of spinous ligaments will be visible on X-rays.

MRI

An MRI scan can image all of the structures of your back, including soft tissue, discs, nerves and bones. It will detect change earlier than an X-ray. This is a costly image and needs to be ordered by a specialist.

Labarotory tests

If the HLA-B27 gene is found in your blood test you have a higher risk for developing autoimmune disease, like Ankylosing Spondylitis. However, 8% of people of European descent have the gene, but only a quarter will develop symptoms.

Why is my ankylosing spondylitis pain not going away?

Unfortunately, there is no cure for Ankylosing Spondylitis. Without the right diagnosis, this can lead to great frustration, especially when caught in a cycle of pain, remission and then the return of symptoms. Make sure you are getting the right treatment from the start. Build your supporting team of specialists to set goals and maintain your freedom of movement, strength and endurance.

What NOT to do

  • Continuous use of over the counter anti-inflammatory medication

  • Manage the pain by only taking pain medication or muscle relaxants. You are only masking the symptoms of something more serious

  • Do not ignore your ongoing symptoms, it’s time to make a plan of action to manage your symptoms

  • Don’t wait for your symptoms to go away, you may already be experiencing a flare vs remission cycle

What you SHOULD do

  • Rest as needed

  • Avoid activities that is flaring up your pain, like sitting for long hours

  • Make a list of movement or activities that brings on your pain and rank them

  • Make an appointment to plan managing your diagnosis

  • Explore movement modalities to incorporate into your long term plan, like swimming, hiking, pilates or yoga

Making it worse

  • Smoking

  • Diet rich in sugar and processed food

  • Sedentary lifestyle/inactivity

  • Working at your computer for prolonged periods of time

  • Driving long distances repeatedly

  • Excessive alcohol use influences bone density in the long term

Problems we see when patients come to us with ankylosing spondylitis pain

Patients have misconceptions about ankylosing spondylitis treatment. You probably feel frustrated at the pain you experience and the impact it has on your day to day life. There is no magic bullet or treatment that will cure you. There are options to manage your symptom severity and slow disease progression. Do not fall into the trap of continuously searching for the next treatment that promises to take your pain away. The basics done consistently are still the best option out there.

The long term use of back braces, guards or walking aids is not recommended as this might lead to dependence.

When in remission keep doing the right things as this is when you will make the most gains.

Physiotherapy Ankylosing Spondylitis Treatment

Our physiotherapists have years of experience in clinical evaluation and diagnosis. This enables them to recognise patterns and what contributes to your symptoms. We know anatomy and understand how biomechanics influence local structures but also the repercussions certain movements can have on other structures further away. Our aim is to help you understand your problem and empower you to make responsible choices in the management of ankylosing spondylitis.

Phases of Ankylosing Spondylitis Treatment

Early Phase of Ankylosing Spondylitis Treatment: Education & Goal Setting

If you are concerned about recurring symptoms or experience any of the general complications outlined above, you may wish to discuss the possibility of Ankylosing Spondylitis with your GP, physiotherapist or rheumatologist. Once your diagnosis is established you need to gather a team of practitioners that you want to work with. In terms of functional/fitness goal setting, what you can expect of symptoms, disease progression and flare ups vs remission, we are able to answer your questions and establish your game plan.

We want to establish a base line of your range of motion, cardiovascular fitness and chest expansion. You don’t have to be in pain to seek care from our physiotherapists.

Progression Phase of Ankylosing Spondylitis Treatment: Maintenance 

The aim of physiotherapy is to slow the rate of progression, we wish to keep you mobile. General range of motion exercises, stretches, nerve glides, strength training and breathing exercises will be part of your home exercise program.

You need to be consistent and persistent with your maintenance routine and do it frequently, what you don’t use, you’ll lose.

Remission Phase of Ankylosing Spondylitis Treatment: Keep on track

Don’t be fooled by the name of this phase, just because your Ankylosing Spondylitis isn’t causing symptoms, doesn’t mean it is gone. Now, while you are feeling well, experiencing less pain and more freedom of movement is the time to possibly make some gains, fly through your rehabilitation program and feel energised. You won’t need to see us often but you still need to put in the work.

Advanced Phase of Ankylosing Spondylitis Treatment: Pain Control and Chest Expansion

If managed well, we hope your disease never progresses to the advanced stage of bony fusion and gross limitation of movement. Here we aim to keep you breathing well and manage symptoms of pain with joint mobilisation, electrotherapy and myofascial work.

Flare-up Phase of Ankylosing Spondylitis Treatment: Symptom Management

Flare-ups are bound to happen and shouldn’t discourage you from moving and training. Our treatment sessions may be more frequent and hands-on during this phase of your treatment. We will incorporate techniques to decrease your pain and increase your freedom of movement.

Healing time for Ankylosing Spondylitis Pain

Ankylosing Spondylitis has no cure. Physiotherapy treatment aims to decrease symptom severity and slow disease progression. This will prevent long term complications, reduce joint damage and ease pain.

Other Ankylosing Spondylitis Treatment Options

You need a multidisciplinary team on your side to manage Ankylosing Spondylitis symptoms.

  • Your rheumatologist will assist with imaging or blood tests to track disease progression. Part of your treatment will be oral medications to alleviate symptoms, like anti-inflammatories, corticosteroids, analgesics or disease-modifying anti-rheumatic drugs (DMARDs), like biological treatments. This will reduce joint swelling and pain and change the immune response.
  • A dietician or nutritionist will assist you with weight management and maintaining a healthy diet loaded with nutrients.
  • Seeing a psychologist can be helpful to discuss the impact of a chronic condition on your life.
  • A biokineticist will assist with supervised exercise sessions to keep you agile and strong.
  • You can explore different types of movement and exercise to find something you enjoy and can form part of a sustainable habit, like swimming, pilates, yoga or hiking.

Is surgery an option for Ankylosing Spondylitis treatment?

Surgery is a last resort option and is only considered where symptoms cause severe limitations in function. Osteotomy with fusion can be considered to straighten a kyphotic upper back or hip replacement can be done for hip pain. Surgery is not a quick fix and requires aftercare and rehabilitation. Your bone density may determine if you are a surgical candidate.

What else could it be?

Muscular back pain will improve with rest and have an incident to blame for your symptoms.

Facet joint pain increases with back bending and improves with forward bending.

  • Costochondritis

Inflammation of the sternochondral joints causes pain with deep inhalations and forceful exhalations, like coughing.

Although the symptoms may be similar to ankylosing spondylitis, the age of onset for degenerative disc disease is 50 years and older.

Also known as

  • Axial Spondyloarthritis
  • Non radiographic axial spondyloarthritis
  • Bamboo Spine

Conditions associated with Ankylosing Spondylitis

  • Psoriatic Arthritis
  • Crohn’s Disease
  • Ulcerative Colitis
  • Juvenile Idiopathic Arthritis