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Ankylosing spondylitis (Bechterew's disease)

Ankylosing spondylitis (Bechterew's disease) is inflammatory rheumatic disease which leads to connective tissue ossification. It encompasses sacroilliac joints, spine joints, costovertebral and costotransversal joints, root joints (shoulder and hip), temporomandibular, and sometimes small hand and foot joints.  
Disease is more common in men between the age of 18 and 35, and includes exacerbation and remission phases.

Symptoms:

  • early morning pain in lower back which tends to disappear after stretching
  • morning stiffness in lower back which can last from several minutes to several hours
  • pain and stiffness spread from lumbar part through thoracic part all the way to cervical spine
  • inflammatory process in both sacroilliac joints
  • "bowed tendon" – in thoracic lateral flexion, paravertebral muscles gain in tone on the side of lateral flexion. Muscles contract to stop the movement which feels painful.
  • positive "cervical flash" – patient's occipital bone cannot touch the wall from standing position
  • "rubber ball phenomenon" – while breathing, stomach pops out then is sucked in. This abdominal breathing is caused by reduced thoracic mobility.

In the final phase the spine looks like „bamboo stick“ due to connective tissue ossification.

Typical deformations inherent to ankylosing spondylitis, better known as „skier's stance“ are:

  • Flat lumbar lordosis
  • Greater thoracic kyphosis
  • Greater cervical lordosis
  • Contracted pectoral muscles
  • Drooping shoulders
  • Dented thorax
  • Stomach popping out
  • Flexed hips and knees

Treatment encompasses general measuring (weight regulation, prolonged daily rest – lying on the stomach), medicament therapy, physical therapy (while in remission, we conduct procedures for reducing paravertebral muscle tone), therapeutical exercises, work therapy, patient education, and operative treatment.
Therapeutical exercises are conducted immediately after diagnosis. Patient begins with the full program that includes:

BREATHING EXERCISES – thoracic breathing exercises are conducted in order to keep the mobility of rib cage or to slow down ossification of costovertebral and costotransversal joints.

STRENGTH EXERCISES – we focus on strengthening thoracic and extremities extensors muscles. Strengthening of abdominal muscles and upper leg flexors has been long debated, and should certainly be avoided in case of thoracic kyphosis or hip flexion contracture.
If coxitis appears, isometric exercises should be conducted – to strengthen pelvic-trochanteric muscles for hip stabilization, and hydrokinesitherapy is contraindicated.

EXERCISES FOR ENHANCING SPINE MOBILITY – conducted by active or secondary dynamic exercises (possibly in water as well)
For cervical spine we have characteristic assisted exercises with traction for doing all movements up to the pain limit, which are conducted sitting or lying down – same exercises can be done on suspension machines.
Stretching exercises enhance mobility of contracted chest, shoulders, and illiopsoas muscles. They are conducted with the help of a therapist, in suspension or near the wall bars.
EXERCISES TO ENHANCE JOINT MOBILITY – conducted with assisted exercises by the therapist, exercises in suspension devices, exercises with props (stick), and exercises in the water.
Whenever possible, we prefer exercises in the water, which should be between 36 and 38˚C warm. Beside the heat effect, water is good because of buoyancy effect which helps to achieve maximum relaxation, especially if floating „ducks“ are used.
Exercises should be conducted twice a day for 20 minutes, and should be continued at home in the same regime.
Absolute contraindications for kinesitherapy are spondylodiscitis and atlantoaxial dislocation.

EDUCATION
Patient should be informed about the disease and its course, in order to understand the rehabilitation process and to achieve active cooperation by the patient in this process.
Physical therapist should educate patients on preventing joint and muscle contractures, and the ways of changing their lifestyle in order to slow down the progression of disease, as well as correct continuous conducting of exercises.  
If the disease presents itself in young age, this diagnosis should be taken into consideration when choosing a vocation.

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