Ankylosing Spondylitis (Marie-Strumpell Disease or

ANKYLOSING SPONDYLITIS
(Marie-Strumpell Disease or
Bechterew's disease)
Contents
• Definition
• Signs and symptoms
• Clinical features
• Pathothology.
• Radiological features
• Deformities
• Medical management
• PT assessment and management
Definition
• A chronic progressive inflammatory disease of the sacroiliac joints and the axial
skeleton.
• (Axial skeleton-includes the bones that form the skull, laryngeal skeleton, vertebral
column, and thoracic cage.)
• (Appendicular skeleton -includes all the bones that form the upper and lower
limbs)
Causes
• Strongly associated with HLA-B27 genetic marker (85 percent).
(Presence of HLA-B27 means higher than average risk for developing

auto immune disease.)
• Age/sex Common in young male adults (M: F = 10:1).
• Exact aetiology is not known.
• The onset of symptoms generally occurs between 20 to 40 years of age.

Signs and symptoms
• Lumbosacral pain and stiffness
worse in morning
insidious onset in 3rd decade of life
• Early morning stiffness and pain in the back.
• Restricted movement in spine, pelvis, hip and shoulder.
• Kyphotic spine deformity
• (Symptom is subjective , Signs is objective evidence of the disease observed by others)

Other symptoms seen during the early
stage of the disease
• Malaise
• Anorexia
• Low grade fever
• Weight loss
• Fatigue
Cont..
• Involvement of peripheral joints, eyes, skin,cardiac and intestinal
systems.
• Eye disease occurs in 25% of the patients as iridocyclitis or
conjunctivitis.
• Hip, shoulder and knee are extremely affected.
• Complains of intermittent breathing difficulties due to reduction in
chest expansion.
Pathology
• Initially synovitis of the joint.
• Followed by cartilage damage and bony erosion.

• Syndesmophyte (is a bony growth originating inside a ligament, specifically the
ligaments in intervertebral joints ) formation.
• Results in fibrosis followed by bony ankylosis.
• Ossification occurs in anterior longitudinal ligament and other ligaments of the spine.
Radiological features
Radiographic findings are graded on a scale of 0 to 4 where 0 represents normal findings and 4
represents complete ankylosis.
Grade 0: normal
Grade I: some blurring of the joint margins - suspicious
Grade II: minimal sclerosis with some erosion
Grade III
• definite sclerosis on both sides of joint
• severe erosions with widening of joint space with or without ankylosis
Grade IV: complete ankylosis

X Ray features of SI joint
Sclerosis-an abnormal increase in density and

hardening of bone
Investigations
• Laboratory investigations:
Raised HLA B 27,ESR, CRP,ANA and increased lymphocytes.
• Radiograph of SI joint
Shows haziness, subchondral erosions, sclerosis, widening

of SI joint.
• Radiograph of spine
Squaring of vertebra, loss of lumbar lordosis, calcification of

anterior longitudinal ligament, osteophytes, bamboo spine.
• The modified New York criteria (1984) for diagnosing AS combines physical findings with
radiograph studies:
•
Clinical criteria
• Low back pain and stiffness for at least 3 months, which improves with exercise, but is not
relieved by rest
• Limited lumbar spinal motion in sagittal (sideways) and frontal (forward and backward)
planes
• Chest expansion decreased relative to normal values corrected for age and sex
Radiologic criteria
• Bilateral sacroiliitis grade 2 to 4
• Unilateral sacroiliitis grade 3 or 4
Deformity
• Exaggeration of
thoracic kyphosis
• Inability to extend
the neck
• Compensatory hip
flexion deformity.
• Loss of lumbar
lordosis
Medical management
First line drug treatment : NSAIDs (naproxen, diclofenac and

indomethacin)
Second line treatments: corticosteroids and DMARDs (methotrexate

and sulfasalazine)
PT ASSESSMENT
• Examination of the sacroiliac joints and the spine (including the neck),
measurement of chest expansion and range of motion of the hip and
shoulder joints.
• The aim of the Schober Test is to assess the mobility of the lumbar
spine.
• The lumbar spine side flexion test
• When ankylosing spondylitis affects the mid-back region, normal chest
expansion may be compromised. The aim of the chest expansion test is
to assess the thoracic mobility.
• Tragus to wall test
For SI Joint dysfunction
PHYSIOTHERAPY MANAGEMENT
• Measures to relieve pain and spasm
Cryotherapy, thermotherapy are effective in relieving pain. Deep heating
techniques are required during the chronic stages.
• Pool therapy is an excellent modality of treatment
• Measures to improve spine mobility
Repeated extension and rotational exercises of the spine
• Measures to improve breathing
Deep breathing exercises to improve the vital capacity of the lungs.
• Measures to improve muscle power
Passive ROM exercises, active ROM exercises and PRE for the spine, hip and
other joints
• Measures to improve posture
Proper postural attitudes and body ergonomics.
Posture leading to deformities should be strictly discouraged.
The following measures are suggested:
— Chin should be tucked in.
— Repeated prone lying to prevent hip flexion contractures and dorsal kyphosis.
— Avoid stooping posture, chest should be held up and the shoulders should be
braced back. Active shoulder bracing.
— Sleep on firm mattresses.
— Avoid using of spinal supports for a long time.
— Avoid prolonged bed rest.
— Swimming is encouraged particularly the front crawl and breast stroke.
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ANKYLOSING SPONDYLITIS

• Strongly associated with HLA-B27 genetic marker (85 percent).

(Presence of HLA-B27 means higher than average risk for developing

• Age/sex Common in young male adults (M: F = 10:1).

• Exact aetiology is not known.

• The onset of symptoms generally occurs between 20 to 40 years of age.

• Early morning stiffness and pain in the back.

• Restricted movement in spine, pelvis, hip and shoulder.

• Kyphotic spine deformity

• (Symptom is subjective , Signs is objective evidence of the disease observed by others)

• Followed by cartilage damage and bony erosion.

• Results in fibrosis followed by bony ankylosis.

Grade I: some blurring of the joint margins - suspicious

Grade II: minimal sclerosis with some erosion

Grade IV: complete ankylosis

Sclerosis-an abnormal increase in density and

Raised HLA B 27,ESR, CRP,ANA and increased lymphocytes.

Shows haziness, subchondral erosions, sclerosis, widening

Squaring of vertebra, loss of lumbar lordosis, calcification of

First line drug treatment : NSAIDs (naproxen, diclofenac and

Second line treatments: corticosteroids and DMARDs (methotrexate

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