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Ankylosing Spondylitis (AS) — Comprehensive ICF-Based Clinical Report

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DIAGNOSIS

1. Chronic inflammatory low back pain (>3 months duration)
2. Morning stiffness improving with activity (not rest — distinguishing from mechanical back pain)
3. Restricted spinal mobility with decreased lumbar lordosis and positive Schober's test

"Ankylosing spondylitis is diagnosed when there is a history of low back pain and stiffness for more than 3 months, limited chest wall expansion (<2.5 cm at the fourth intercostal space), limited lumbar spine motion in the sagittal and frontal planes, and radiographic evidence of sacroiliitis." — Goldman-Cecil Medicine

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PART 1 — ICF: BODY STRUCTURE IMPAIRMENTS

1.1 Sacroiliac Joints (b7 — Neuromusculoskeletal and Movement-Related Functions)

• Sacroiliitis is the hallmark of AS; it is bilateral and symmetrical
• Progresses from erosive sacroiliitis → partial ankylosis → complete bony fusion

"Sacroiliitis and enthesitis of the axial skeleton is the hallmark of AS. The earliest feature of sacroiliitis is detected with MRI as subchondral bone marrow oedema." — Grainger & Allison's Diagnostic Radiology

MRI of Sacroiliac Joints in AS:

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1.2 Lumbar Spine (Discovertebral Unit, Facet Joints, Posterior Elements)

• Romanus lesions: Enthesitis at insertion of Sharpey fibres → sclerotic "shiny corners" on lateral X-ray
• Syndesmophytes: Thin vertical bone outgrowths at vertebral corners → bridging → Bamboo spine (complete fusion)
• Facet joint ankylosis restricts all planes of spinal movement
• Decreased lumbar lordosis due to paraspinal muscle spasm and structural flattening

• Decreased lumbar lordosis: Paraspinal muscle spasm + structural flattening of vertebral bodies
• Schober's Test: Modified Schober's — mark 10 cm above and 5 cm below S1 dimple; <5 cm increase on full flexion = abnormal (normal >5 cm). Indicates restricted lumbar intersegmental movement from facet joint and disc ankylosis
• Loss of lateral flexion and rotation from facet joint involvement

Bamboo Spine X-ray (Advanced AS):

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1.3 Paraspinal Muscles and Entheses

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1.4 Rib Cage / Costovertebral Joints (In Advanced Disease)

"Fusion of the costovertebral and sternoclavicular joints produces relative fixation of the rib cage in an inspiratory position... Intercostal muscle atrophy secondary to decreased rib cage mobility may cause inspiratory muscle weakness." — Goldman-Cecil Medicine

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PART 2 — ICF: BODY FUNCTION IMPAIRMENTS

2.1 b7100 — Mobility of a Single Joint (Lumbar Spine, SI Joint)

• Modified Schober's Test: <5 cm increase = restricted lumbar flexion
• BASMI (Bath AS Metrology Index): Measures tragus-to-wall distance, lumbar side flexion, modified Schober's, cervical rotation, intermalleolar distance — validated AS-specific mobility tool
• Goniometry: ROM measurement in all lumbar planes
• Finger-to-floor distance: Assesses composite lumbar + hip flexion

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2.2 b7101 — Mobility of Multiple Joints / Stiffness

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2.3 b7300 — Power of Isolated Muscles / Muscle Groups

• Manual Muscle Testing (MMT) — erector spinae, gluteus maximus, hip abductors
• Pressure biofeedback unit — transversus abdominis and lumbar multifidus activation
• Dynamometry — quantify lumbar extensor torque

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2.4 b280 — Sensation of Pain

• VAS / NRS (0–10): Pain at rest, with activity, at worst
• BASDAI (Bath AS Disease Activity Index) — composite score including pain and stiffness subscales
• ASDAS (AS Disease Activity Score) — incorporates CRP; score >2.1 = high disease activity

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2.5 b4400–b4402 — Respiratory Functions

• Chest expansion at 4th ICS (<2.5 cm = significant)
• Pulmonary Function Tests (PFTs): FVC, FEV1/FVC, TLC — restrictive pattern
• 6-Minute Walk Test (6MWT) — functional aerobic capacity

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2.6 b7600 — Control of Voluntary Movement / Posture

• Tragus-to-wall distance (normal <15 cm)
• Occiput-to-wall distance (0 cm normal; any positive = cervical kyphosis)
• Sagittal vertical axis (SVA) on full-length standing X-ray
• Plumb-line analysis; photographic posture assessment

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PART 3 — PHYSIOTHERAPY MANAGEMENT

SHORT-TERM GOALS (0–6 Weeks)

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LONG-TERM GOALS (3–6 Months and Beyond)

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DETAILED PHYSIOTHERAPY INTERVENTIONS WITH DOSAGE

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A. PAIN MANAGEMENT PHASE (Weeks 1–2)

• Rationale: Warm water reduces pain, aids joint mobility, unloads spine. Highly evidence-based in AS (ASAS guidelines).
• Dosage: 30–45 min/session, 3×/week
• Exercises: Spinal extension in water, lateral side-bends, pelvic tilts, walking

• Rationale: Reduces muscle spasm; increases collagen extensibility before stretching
• Area: Lumbar paraspinals, thoracic spine
• Dosage: 20 minutes, pre-exercise, daily

• Type: Conventional TENS (high frequency 80–100 Hz, low intensity)
• Rationale: Gate control — reduces pain perception at dorsal horn
• Electrode placement: Paraspinal muscles L1–L5 bilaterally; over SI joints
• Dosage: 20–30 min/session, 1–2×/day during acute exacerbation

• Area: SI joints, lumbar paraspinal entheses
• Parameters: Pulsed (1:4 duty cycle), 1 MHz, 0.5–1.0 W/cm², 5–8 min/area
• Dosage: 5 sessions/week × 2 weeks (acute phase)

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B. FLEXIBILITY AND MOBILITY PHASE (Weeks 1–6, ongoing)

• Rationale: Counteracts the natural tendency toward flexion deformity (kyphosis). The deformity of AS, if it occurs, must be in maximum extension to preserve function.
• Exercises:
  • Prone lying (passive extension stretch): Start 5 min → build to 20–30 min/day
  • Prone press-ups (cobra stretch): Hold 10 sec × 10 reps
  • Standing wall extension: Spine flat against wall, feet 30 cm away, head contact maintained
  • "Wall standing" daily posture check (Hoppenfeld): Heels, buttocks, shoulders, occiput against wall — 5 min/day
• Dosage: 2–3×/day, 7 days/week (crucial — consistency matters more than intensity)

• Rationale: Prevents costovertebral ankylosis in fixed inspiration position; maintains vital capacity
• Exercises:
  • Deep diaphragmatic breathing: 5 deep breaths × 5 sets/day
  • Lateral costal breathing: Therapist applies resistance to lateral rib cage
  • Incentive spirometry: 10 breaths × 3 sets, 2×/day
  • Arm elevation with deep inspiration: 3×/day
• Dosage: Chest physiotherapy 15–20 min twice daily

• Rationale: Hip flexors shorten as compensation for lost lumbar lordosis (Hoppenfeld)
• Exercises:
  • Thomas stretch position: 30-second holds × 3 reps, 2×/day
  • Prone hip extension stretch
• Dosage: 2×/day, 5 days/week

• Technique: Maitland Grades I–II (in acute phase) → Grades III–IV (subacute)
• Area: Thoracic facet joints, costovertebral joints
• Dosage: 3 sets × 30 sec/level, 3×/week

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C. STRENGTHENING PHASE (Weeks 3–8)

• Rationale (Brotzman): Specific impairment of deep stabilisers in chronic inflammatory back pain. Restoring co-contraction protects the spine dynamically.
• Progression:
  • Stage 1: Abdominal hollowing in supine (PBU target 4–10 mmHg below resting) × 10 sec holds × 10 reps
  • Stage 2: Four-point kneeling arm/leg raises (bird-dog)
  • Stage 3: Side plank, prone plank (progress as tolerated)
• Dosage: 3 sets × 10 reps, 3×/day

• Exercises: Bridging, clamshell, prone hip extension with knee bent
• Dosage: 3 sets × 15 reps, 2×/day, 4×/week

• Exercises:
  • Prone back extension (Superman) on mat: 3 × 10 reps
  • Romanian deadlift (light resistance): 3 × 12 reps
  • Pull-down exercises for thoracic extensor
• Dosage: 3×/week

• Rationale: Counteracts thoracic kyphosis and forward head posture
• Exercises: Rows, reverse flies, prone Y–T–W exercises
• Dosage: 3 sets × 12 reps, 3×/week

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D. AEROBIC / CARDIOVASCULAR RECONDITIONING (Weeks 4–12)

• Preferred modalities: Swimming (MOST recommended — non-impact, promotes spinal extension), cycling (upright posture), walking
• Rationale: Improves cardiorespiratory fitness (impaired by restrictive chest), reduces systemic inflammation, improves 6MWT performance
• Target: 50–70% HRmax (moderate intensity)
• Dosage: 30 min/session, 3–5×/week
• Progression: Add 5 min/week until 45–60 min sustained

"Exercise and physiotherapy programs can enhance cardiorespiratory fitness and spinal mobility." — Goldman-Cecil Medicine

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E. POSTURAL CORRECTION AND EDUCATION (Ongoing)

• Key principle (Hoppenfeld): Educate patient to maintain maximum extension. If the spine fuses, it must fuse in as straight a position as possible.
• Techniques:
  • Wall-standing exercise (daily posture check against wall)
  • Ergonomic advice: Firm mattress, low pillow, sleeping prone or supine (NOT side-lying fetal position)
  • Workstation modification: Monitor at eye level, lumbar roll, standing desk intervals
  • Avoid prolonged flexed postures (forward bending, stooping)
• Sleep posture education: Prone lying or supine with one pillow — prevents flexion contracture during prolonged nocturnal rest

• Disease process explanation and long-term course
• Importance of lifelong daily exercise — even during remission
• Warning signs of disease flare vs. fracture (catastrophic risk in fused rigid spine)
• Medication adherence (NSAIDs, biologics — TNF-α inhibitors) in conjunction with physiotherapy
• Joining AS support groups / NASS (National Ankylosing Spondylitis Society)

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PRECAUTIONS IN PHYSIOTHERAPY

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OUTCOME MEASURES SUMMARY

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MULTIDISCIPLINARY TEAM

• Rheumatologist: NSAIDs (first-line), TNF-α inhibitors (e.g., etanercept, adalimumab), IL-17 inhibitors (secukinumab) for refractory disease
• Physiotherapist: Core of management — spinal mobility, strengthening, aerobic conditioning, postural correction
• Occupational Therapist: Workstation ergonomics, adaptive aids, energy conservation
• Respiratory Physiotherapist: Chest expansion exercises, breathing training
• Orthopaedic Surgeon: Corrective osteotomy for severe kyphotic deformity; hip replacement for hip joint ankylosis

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