pathology: ankylosing spondylitis

yogabook / pathologie / ankylosing spondylitis

ankylosing spondylitis / Bechterew’s disease / Pierre-Marie-Strümpell-Bechterew’s disease, ancylopoietic spondylarthritis, rheumatoid spondylitis)

Definition of

Chronic, inflammatory, presumably autoimmunological, rheumatoid disease of the SI joints, the small vertebral joints(facet joints and costotransverse joints), especially of the lumbar spine and thoracic spine, and the ligamentous apparatus of the spine. In addition to the joints of the spine, the hip joint is also affected in 50% of cases and the shoulder joint in 1/3 of cases. In general, an asymmetrical oligoarthritis
oligoarthritis, which tends towards joint destruction. As with Reiter’s disease, ankylosing spondylitis is often preceded by a UGT or GIT infection. The role of frequently elevated antibody titres against enterobacteria in the blood has not yet been clarified. IgA antibodies against Klebsiella pneumoniae appear to react autoimmunologically against parts of the HLAB-27 molecule due to their similarity. Ankylosing spondylitis is probably not a consequence of the western civilized way of life; comparable cases were already described in the late Middle Ages and there is a 5000-year-old Egyptian mummy with clear evidence of ankylosing spondylitis. In pigs, there is a very similar disease caused by a bacterium: chronic erysipeloid (erysipelas). There are 2 forms of the disease:

  1. chronically progressive in the sense of continuous
  2. in batches

Prevalence according to a study of blood donors in Berlin: 1.9%. Estimated 1.6 million in Germany, many of them subclinical or with mild symptoms. According to the German Ankylosing Spondylitis Association, 100,000 – 150,000 people in Germany, M:W 1:1, in women usually with a milder course in terms of ossification of the spine, therefore fewer diagnoses in women. Onset of the disease usually between the ages of 20 and 25. Only in 5% after the age of 40. Stops in 85% before the stage of hyperkyphosis.

The disease often progresses in three phases as follows:

  1. Initial stage of 3 to 6 months with pain in the lower back and buttocks that usually occurs after resting, stiffness of the back when standing up, pain and stiffness subsiding with movement, pressure sensitivity at various points such as: heels, hip region, ischium, iliac crests, ribs, vertebrae and clavicle
  2. Manifest stage of 10 to 20 years with radiologically detectable changes in the ISG and frequent pain on movement, intermittent progression and increasing restrictions on mobility of the spine with simultaneous deformations
  3. Late stage after 20 years with a dying down of the inflammatory activity, bamboo spine, hyperkyphosis, bulging belly and restricted inspiration

ICD M45

Cause

  1. unknown, in 95% HLA-B27 is positive; familial clustering

Predisposing

  1. HLA-B27 positive: risk increased 90-fold

Diagnosis

  1. X-rays of the SI joint show (only after the early stages) its narrowing and ossification (complete thickening, simultaneous bone resorption and bone formation, subchondral sclerosis)
  2. Highlight: X-ray: Bamboo rod spine due to syndesmophytes (subligamentous osteophytes at the edges of the vertebral body edges) from a certain stage onwards
  3. X-ray: osteoporosis and osteoarthritis of the edges of the vertebral bodies, inflammation and destruction of the vertebralbody-intervertebral disc junctions
  4. MRI shows sacroiliitis years before the X-ray!
  5. Tests and signs: Schober (lumbar spine: 10 cm cranial from L1: up to 4 cm is path.), Ott (thoracic spine: 30 cm caudal from C7: up to 3 cm is path.), Mênell, Flêche, respiratory displacement of the lung borders, respiratory excursion (usually less than 2 cm), occiput-wall distance
  6. Laboratory: HLA-B27 positive in 95%; however, it is present in 9% of the German population
  7. In severe cases also occasional increase in AP
  8. Rheumatoid factor negative (autoantibodies of various subclasses (IgM, IgG, IgA, IgE) directed against the Fc fragment of IgG)
  9. in 30-40% pronounced ESR and CRP in relapse, less pronounced in continuous course, not pronounced in remissions
  10. Ca alternating
  11. Inflammation of the tendon insertions(enthesopathies (insertional tendinopathy) mostly on the Achilles tendon, plantar aponeurosis of the sole of the foot, tendon insertions on the femur and pelvis (trochanter, ischium, iliac crest) with edema and damage to the bone marrow, which then ossifies, involvement of the capsule, formation of granulation tissue under the cartilage and finally ossification of the entire joint
  12. Diagnosis based on medical history and the diagnostic criteria of the ESSG (European Spondyloarthropathy Study Group) from 1991: one of the criteria :
    • Ankylosing spondylitis in the family
    • Psoriasis (diagnosed or occurring)
    • CED
    • Alternating buttock pain on both sides
    • Heel pain
    • sacroiliitis
    • Urethritis or cervicitis or acute diarrhea within one month before arthritis
    • Enthesiopathy (insertional tendinopathy) (tendon insertion pain)

      and additionally at least one of the criteria: In addition, there are the New York criteria from 1984:
      • deep-seated back pain and stiffness that improves with movement for at least 3 months
      • limited flexibility of the lumbar spine in the sagittal and frontal plane
      • limited thoracic excursion
      • Bilateral sacroiliitis grade 2-4
      • unilateral sacroiliitis grade 3-4

Symptoms

  1. the younger, the more likely monarthritis (of any joint) at first, in 99% bilateral sacroiliitis with deep localized persistent low back pain(pain at rest) at first
  2. later also oligoarthritis, usually asymmetrical
  3. Ischialgiform pain alternating between right and left, extending into the thighs at knee level and then ending abruptly. No neurological deficits
  4. Morning stiffness, back pain especially in the second half of the night, which improves with movement, the pain can be so severe in the morning that it prevents further sleep. Stiffness after periods of rest.
  5. Pressure pain over the ISG
  6. Heel pain
  7. In the further course, loss of movement of the caudal spine, steep position of the lumbar spine and hyperkyphosis of the thoracic spine and compensatory posture of the cervical spine(hyperlordosis)
  8. Increasing loss of function of the spine in terms of flexibility(flexion, extension, rotation), typically turning the whole body when approached from the side
  9. Additional concomitant arthritis, especially in joints close to the trunk such as hip, knee, shoulder
  10. in 30% iritis or iridocyclitis (ciliary apparatus also affected)
  11. due to stiffness of the thoracic spine and involvement of the costotransverse joints: inspiratory ventilation disorders, increased transition to diaphragmatic breathing, resulting in increased susceptibility to respiratory infections.
  12. Disappearing lumbar lordosis
  13. After years of disease activity, this usually subsides, the inflammation and pain stop, but the acquired deformity remains. Painful restriction of movement of the hip joints or even stiffening may occur. Therapy is usually still required.
  14. in more severe cases: bilateral coxarthritis, arthritis of the limb joints, extra-articular manifestation
  15. in more severe cases: no longer being able to look the other person in the eye
  16. subfebrile temperature
  17. Night sweats
  18. rapid fatigability
  19. unwanted weight loss
  20. Loss of appetite

Complications

  1. Mostly unilateral photophobic acute anterior uveitis(inflammation of the middle part of the eye) with increased tear secretion
  2. Vertebral body fractures due to even minor trauma
  3. Cataract, glaucoma
  4. Mostly asymptomatic colitis, ileitis(inflammation of the ileum, the last 60% of the small intestine), in 10% transition to IBD
  5. Damage to the lungs, functional disorders of the heart, especially conduction disorders (1st degree AV block), aortic valve insufficiency due to dilatation of the aortic valve ring
  6. Loss of quality of life, life expectancy (due to heart/lung, spinal cord injuries, GIT bleeding, treatment side effects), ability to work

Therapy

  1. PT, flexibility maintenance by means of Bechterew’s gymnastics, yoga, Pilates for self-application several times a day, if necessary with analgesic medication. In the case of the thoracic spine, also respiratory gymnastics
  2. NSAIDs, sometimes ASA is also effective
  3. Avoid postures and occupational activities that promote kyphosis, e.g. driving motor vehicles for long periods, working in a stooped position
  4. if necessary: cortisone, sulphazalazine, low-dose cytostatics
  5. Pamidronate (a bisphosphonate), thalidomide (the active ingredient in thalidomide), radium 224 isotope, expensive and risky TNF-alpha blockers receptor fusion protein etanercept and monoclonal antibody adalimumab (high therapy costs)
  6. In the case of progressive spinal fusion in kyphosis, if necessary, surgical breaking open, wedge osteotomy, risky!
  7. if required: Hip TEP

Asana practice and movement therapy

Even though the sacroiliac joint has a range of motion of around 4 degrees and a spring effect for the partial body weight above it, the more serious disorder in Bechterew’s disease is probably the ossification of the spine with a tendency to hyperkyphosis of the thoracic spine, which in more severe cases can even impair the ability of the heart and lungs to expand. Maintaining mobility, particularly of the thoracic spine, is the priority here and may even be pursued with pain, if necessary even with pain medication. Of the three dimensions of movement of the spine, the loss of lateral flexion and rotation means a significant loss of opportunities for self-expression and difficulties with many activities, However, the loss of extensibility of the spine and the increasing kyphosis also pose a risk to the internal organs and also predispose to compensatory hyperlordosis of the cervical spine. Therefore, both passive mobility and active mobility must be restored and maintained as best as possible and progression of the restrictions prevented as far as possible. The passive mobility of the thoracic spine can be improved very easily and with little effort by lying on the roller. For active mobility, it is particularly important to promote the strength endurance of the autochthonous muscles in the lumbar spine. At the same time, it must be checked to what extent the affected person tends to protract the shoulder blades, as the centre of gravity of the shoulder-arm system is shifted ventrally and additional flexion moments come into the spine. Any shortening of the pectoralis major as an indirect protractor and, secondarily, the direct protractor pectoralis minor must therefore be addressed. Excessive tension in the rectus abdominis or the obliqui-abdomini also leads to kyphosis of the thoracic spine via traction on the costal arch and sternum, which is why any hypertonicity must be eliminated. If a lumbar spine hyperlordosisis present, which the body tends to counter with a hyperkyphosis of the thoracic spine anyway, this cause must also be investigated. In this respect, sufficient strength endurance of the hip extensors is also of advantage.