Ankylosing Spondylitis & Exercise

Hello and welcome back to the ThreeSpires Physiotherapy blog where we take a look at all things physiotherapy and health related. In the first physiotherapy blog of its kind this year (2019!!) we will continue looking at some of the latest research in the world of physiotherapy. In this case we will have a look at a new systematic review that has come out about ankylosing spondylitis and whether or not exercise helps and is safe. We will also try to have a look at what ankylosing spondylitis is, its symptoms, diagnosis and how it can be managed.

What is Ankylosing Spondilitis?

Before having a look at the research about ankylosing spondylitis and exercise it is probably best to have a look at exactly what it is first! Ankylosing spondylitis is an inflammatory type of arthritis that comes under the family of rheumatoid arthritis conditions. Most people will have heard of osteoarthritis (usually shortened to arthritis) which is the most common type of arthritis and is basically wear and tear to the joints of the body. However ankylosing spondylitis is different in that it is a systemic condition (it affects the whole body) and that it is inflammatory which means that it is not really wear and tear that causes the damage to the joints, rather it is a specific inflammation of the joints that causes the damage. It mostly affects the vertebral/spinal joints and causes pain and stiffening up but can also cause pain in other joints. As the image shows, as the condition progresses the joints of the spine may become fused and form a typical "bamboo spine".

What are the Symptoms of Ankylosing Spondylitis?

Ankylosing spondilitis has a range of symptoms that will usually have come on gradually over a period of time. Generally stiffness and pain in the joints of the back are common symptoms that usually worsen over time. As it causes stiffness in the joints of the spine, people with ankylosing spondylitis tend slowly to lose flexibility in their back and it can also cause difficulties with breathing due to restrictions in the movement of the rib cage. Waking up with pain in the night is common and patients often experience pain and stiffness if at rest for too long with movement helping ease things. 

Who is at Risk of Getting Ankylosing Spondylitis?

It affects around 200,000 people in the UK and will most commonly have begun developing as a teenager or adult under 30. Males are much more at risk of developing ankylosing spondylitis although it is present in females as well. 

What are the Causes of Ankylosing Spondylitis?

The exact causes are currently not known but current research suggests that it is most likely genetic with associations being found between ankylosing spondylitis and various genes. 

How is Ankylosing Spondilitis Diagnosed?

Diagnosis for ankylosing spondilitis is normally made via taking a thorough history and also examining X-ray findings for changes in the joints of the back - usually the sacro-iliac joint. It can often take a lengthy period for a diagnosis to be made as there is no definitive blood test and the symptoms of ankylosing spondylitis initially can present as vague and can look like an episode of normal back pain. A diagnosis will usually be made by a rheumatological consultant after referral via the GP who will be suspecting some form of inflammatory arthritis. The key features of ankylosing spondylitis are long standing back pain with the patient being under 40yrs old, getting pain at night and pain improves with exercise.

Treatment for Ankylosing Spondylitis

It is important to note that there is no cure for ankylosing spondylitis and treatments are aimed at managing the condition and reducing symptoms. Below are some generally accepted ways of managing the condition:

1. Getting a Diagnosis: okay, this is not actually a treatment but before you can know how to manage things the first step in the journey will be to have a series of investigations and eventually receive a diagnosis of ankylosing spondylitis from a rheumatolgist. This is an important step as from this point on you will be able to understand and start to manage your ankylosing spondilitis. 

2. Non Steroidal Anti-Inflammatories (NSAIDS): this will be the first line of medication used to help with ankylosing spondylitis and the inflammation associated with it. NSAIDS such as ibuprofen, diclofenac and naproxen are commonly used to reduce inflammation and pain associated with ankylosing spondylitis. It is important that if you think that you might have ankylosing spondylitis that you see your GP and have some investigations before considering self-medicating with anti-inflammatories.

3. Disease Modifying Anti- Rheaumatic Drugs (DMARDS): in cases where NSAIDS are not working or the symptoms of ankylosing spondylits are too severe the rheumatolgist may presecribe DMARDS such as methotrexate.

4. Physiotherapy: although not a cure for ankylosing spondylitis, physiotherapy can be helpful with managing symptoms of back pain and stiffness through a combination of manual therapy and exercises. Physiotherapy is recommended by current NICE guidelines and an assessment by a physiotherapist will enable a patient to understand the condition in detail, manage their ankylosing spondylitis and also create an exercise programme.

What Professionals will be Involved with Ankylosing Spondylitis?

For many people a diagnosis of ankylosing spondylitis will be there first significant interaction with the medical profession and initially the array of doctors and professionals available to help can appear daunting and confusing. The list below aims to clarify who does what and their involvement with ankylosing spondylitis:

1. Rheumatologist: this will be a consultant doctor who has specialised in rheumatological conditions such as ankylosing spondylitis and it will be this doctor that makes the initial diagnosis and decides on the best management plan. After the initial diagnosis, if you are able to manage your symptoms of ankylosing spondylitis then you may have little to do with this person for a long period.

2. GP: your GP will be the doctor who makes the initial referral for further investigations such as an x-ray or blood tests to investigate the likelihood of your having ankylosing spondylitis and it will be the GP who makes the referral to the rheumatologist for a diagnosis. It will also be the GP who manages your medication and makes any further referrals associated with your ankylosing spondylitis. So, it is in general important that you keep your GP up to date about any changes in symptom or any changes in your ankylosing spondylitis in general.

3. Physiotherapist: depending upon the severity of your symptoms you may well be referred through to NHS physiotherapy for assessment and a discussion about exercises and how best to manage your ankylosing spondylitis. This can be very helpful, as your physio will likely have a lot more time to discuss things and talk about how best to manage this than your rheumatologist. I would strongly advise that if you do not see an NHS physio that you find a local physio and build up a relationship with them over a period of time. 

Exercise & Ankylosing Spondylitis

Okay, so at last we should actually have a look at what the latest research shows about the effects of exercise on ankylosing spondylitis. Although, for a long period of time it has generally been accepted that exercise and keeping fit was a good idea for anyone with ankylosing spondylitis. There has been a large amount of change in the medications prescribed for the condition and a recent systematic review looked at whether or not exercise was a good idea given these new medications. The review (full information is available here https://discover.dc.nihr.ac.uk/content/signal-000509/exercise-improves-symptoms-and-function-for-people-with-ankylosing-spondylitis) included 8 randomised controlled trials and showed that exercise helped patients with ankylosing spondylitis and that it was safe to exercise. For anyone with ankylosing spondylitis, this is great news, because it means that it continues to be safe and helpful to exercise which obviously comes with wide ranging health benefits.

This review also re-affirms the current NICE guidance from 2017 that states that patients should be referred to a physiotherapist for a programme of exercises aimed at strengthening muscles and promoting range of motion in the spinal joints.

So, overall good news for anyone with ankylosing spondylitis and again shows that exercise often really is the best medicine. To be clear though, if you suspect that you may be suffering from ankylosing spondylitis it is important that you seek medical attention for an accurate diagnosis and information on how best to manage your condition.

Can ThreeSpires Physiotherapy Help with my Ankylosing Spondylitis?

Well. I always mention this: but clearly I am biased here! In my opinion the answer would be yes absolutely we can be of assistance in helping manage your symptoms of ankylosing spondylitis and developing an effective exercise and management plan. As discussed earlier current NICE guidance recommends being referred to a physiotherapist and if you would prefer not to wait for NHS services or would like to build up a relationship with a local physio to help manage your flare ups then we can help. To understand how we might be able to help, it might be useful to look at an example of someone with ankylosing spondylitis and how our physiotherapy service might work for them:

Firstly after booking an appointment (can be done either via phone or email) an initial physiotherapy assessment takes place at the patient's home - this usually takes approximately 1 hr and begins with a discussion of how ankylosing spondylitis is affecting them and what they would like to achieve from physiotherapy. The discussion part of this assessment (as any physio will tell you) is a vital part as it enables the physiotherapist to understand how you are being affected by the ankylosing spondylitis and what you would like to get out of physiotherapy, it also allows the patient themselves to voice concerns and discuss their goals. Having a full and frank discussion early on allows both the physio and the patient to make sure they are working towards the same goals.

Next, a full physical assessment then takes place which looks at strength, range of motion and spinal mobility in order to determine how the ankylosing spondylitis has affected them and the best management plan. During this part the physiotherapist will ask you to move all of your limbs, put your back and spine into different positions and may also look at general strength tests such as a squat, bridging and your core strength. After this physical assessment usually some manual therapy such as soft tissue massage or spinal manipulation will take place in order to help the patient's symptoms of pain and stiffness from the ankylosing spondylitis. The physiotherapist will then design an exercise programme aimed at improving the patient's symptoms from the ankylosing spondylitis and maintaining spinal mobility and strength and discuss how best to manage symptoms and flare ups in the future. After this initial assessment, further appointments are booked and the physiotherapist will advise on the regularity of sessions needed- some patients like to have regular follow ups (often monthly) to keep their symptoms at bay whereas other patients like to manage their symptoms themselves and get in touch during flare ups. 

Okay, I hope that you have enjoyed reading this blog about ankylosing spondylitis and have found it helpful, if you would like to know more about our physiotherapy service or how we might be able to help with ankylosing spondylitis then please get in touch. For anyone reading this blog who isn’t aware of our service. We are a home visit physiotherapy service based in Lichfield but serving anywhere within 20 minutes such as Sutton Coldfield, Tamworth, Rugeley, Cannock and Walsall.