Questions and Answers

To physiotherapy colleagues, if you have a question or problem that you would like us to consider, please email us

Pregnancy and AS

This question came from a committee member regarding a patient with AS, who is in her first pregnancy and has been told by her obstetrics team that she is most likely to to need a C-section due to sacroiliac fusion She also has hypermobility with a reported Beighton's Score of 9/9.

There is very little evidence or national guidelines to support a definitive answer here.

We must firstly emphasise that all decisions regarding delivery must be made on an individual basis. As mother with AS would be considered a high risk on the basis of her spinal symptoms, referral to an obstetrician is advised. Parents should take advice from the whole team and carry out their own research. Ensure regular monitoring and expect decisions to change dependant on circumstances.
  • As in all pregnancies the size of themother, baby and position is always a consideration.
  • An AS patient with fusion of SIJ would be considered high risk and on balance a c-section may be the safest option for mother and baby.
  • The presence of pelvic girdle pain is always a consideration, however pain free hip abduction is not considered a predictor for delivery type.
  • A fused sacrum will increase strain on the syphasis pubis which could lead to problems both anti-natally and post-natally.
  • It is generally felt that having AS does not automatically mean an elective c-section, however risk and co-morbidities may lead to the need.
  • Planning for pain medication and the feasability of epidural anaesthesia must also be taken into consideration.
  • If vaginal delivery is the desired option plans around potential birthing positions (4 point kneeling/side lying birthing pool) should be discussed and carefully documented. Also birth wishes should she fail to progress e.g. an earlier stage c-section?
  • All concerned should be fully aware and avoid uncontrolled pelvic/hip movement (crook lying legs suspended in stirrups whilst anaesthetised.
  • The physiotherapist can be a valuable asset at this time by providing appropriate anti and post natal exercise, monitoring progression and  comfortable range of axial and peripheral movements and inform decisions.
  • Hypermobility may not have a relevance in decision making.
  • Advice guidance and support may be necessary post child birth in either scenario and the parents should be made fully aware of possible restrictions in function.
References:
Jakobsson GL et al. Pregnancy outcomes in patients with ankylosing spondylitis: a nationwide register study, Ann. Rheum Dis 2016 Oct;75(10):1838-42. doi: 10.1136/annrheumdis-2015-207992. Epub 2015 Dec 23
Ostensen M, Ostensen H, Ankylosing Spondylitis, The female aspect; The Journal of Rheumatology, 1998, 25(1):120-124
Ostensen M, The Effect of Pregnancy on Ankylosing Spondylitis, Psoriatic Arthritis, and Juvenile Rheumatoid Arthritis; American Journal of Immunology Volume 28, Issue 3-4
October-December 1992  p.235–237
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To brace or not to brace – that is the question:

This question was referred to the AStretch committee:

"The Physio emailed in saying that she had a patient who had ‘end stage’ A.S.  He is very debilitated with a marked stoop and has a heavy, dropping head. The physio had given him a soft neck collar to help when driving and a soft body brace. However, she was wondering if she should go down the route of getting him a bespoke collar and back brace for him to wear more frequently to help. Her patient is overweight and spinal surgery has not been discussed."

Sometimes it is very difficult to answer these questions as we have limited information and obviously are unable to assess the patient for ourselves. But these were the comments from the AStretch committee:

Difficult case; generally the feeling is still not to brace but I think if the patient is functionally impeded and in lots of pain it may be worth considering. Not being an expert in bracing I assume he would need a bespoke brace if he has lots of postural deformity as I wonder if any soft brace will actually be of any benefit against his postural pull and the force of gravity overall. Also a standard brace may not be a comfort fit against his skin at the edges against he has some deformity.

Re: exercises, I would definitely utilise the hydro pool. It sounds as though it would be worth utilising the osteoporosis exercise for trunk extension as well i.e.: the unsupported sit for trunk extension etc.
***Agree that hydro is the very best route here. My only experience with back braces was to use one following fracture or discitis and these were always moulded to the patient and made by Appliances.  Really not sure this would do anything - sounds like spinal corrective surgery should be considered. I have given soft collars to help with reading position and resting in severe cases but only when I am convinced nothing else will help and there has been virtually no neck movement. Walking aide assessment may also help using sticks to promote posture control?

Sorry difficult to answer without seeing the patient and especially not knowing the degree also of hip and knee flexion contractures - this should be addressed in the pool and could help considerably.
***I agree Hydro is most likely to be the best place to exercise. I have only used a collar in a patient with severe osteoporosis and it gave a little comfort but only for short periods & rubbing was always a worry as she was very thin. I would think a collar would need to be made for the patient
***Agree hydro if available. I haven’t had a lot of experience with bespoke spinal braces but in the past when braces/belts were treatment of choice for any back pain it was a nightmare for them to wean off and most of the time function was even more compromised
***My experience of hard collars, even bespoke, was poor fit and skin breakdown. Soft collars offered some relief from pain, but long term? I would also check on neuro if the head is that heavy.
***I have no experience of bracing and have steered clear of this option.
If he is not an anaesthetic risk I would definitely explore the surgical option with the Rheumatologist initially there may be a good neurosurgeon who could work with Orthopaedics
I think an opinion is impossible without assessing the patient and perhaps the best person to give an opinion on a brace would be  someone from surgical appliances. The soft option I cannot see would be effective but it is cheap and worth a try.
Hydro might help this man with pain management but his long term daily function may require a specialist MDT approach.
***I would think that his neck posture would be a surgical concern re intubation etc, however that would be down to the anaesthetists and surgeons to consider.
A bespoke brace would need to be easy enough for him to put on and off either independently (or with the aid of his partner) and skin care would need to be a consideration especially if he also suffers from psoriasis.
Hydro would definitely be the exercise of choice although some carefully applied postural and core stability work would be good too
***Hydro, postural /balance promoting exercises with a combined OT/PT approach may help for general maintenance; small improvement may be achievable at this stage.
Bracing will impede movements even further and like some of you I am not keen on this option. Soft collar provision will be a short term option with limited benefits/ added adverse effects, require regular checking / alterations.
I would opt for a long term option - Request a ortho-rheum combined case review to assess the benefits over harms of carrying out appropriate spinal surgery to enable this patient to have a better quality of life- this depends on patient choice of course!

Question:

Dear AStretch,

I have a patient who has recently been diagnosed with AS. His chest expansion is pretty poor and he complains of tightness across the chest, in-keeping with AS symptoms. I have performed basic lung function testing this afternoon using a spirometer and the results were expectedly low. I was wondering if:
  1. You had any normative values for lung function of an AS patient/knew where I could find them? I’ve been looking through the literature but of the ones I have read so far I couldn’t see anything conclusive.
  2. If you had any thoughts around inspiratory muscle training devices?
I would appreciate any input/advice you could give me on this.

Kind regards.


Answer:
Many thanks for your most interesting question which has certainly stimulated quite a discussion amongst the AStretch committee, but unfortunately none of us knew of documentation that gave normative values for lung function of an AS patient.
I have attached 10 references, that you may have already read, but if not they may be of some use and interest related to chest expansion and pulmonary function in AS patients.
As far as inspiratory muscle training devices, all of the committee agreed that they would have to ask their Respiratory team colleagues as it is not normally something they use themselves.

Included here are some of the committee’s comments around general respiratory training for AS patients that they find useful:
  • The Modified New York Criteria has chest expansion as a component - it is measured against normal range for sex and age (which you can find online).
  • Re inspiratory training, I would liaise with the respiratory team but doesn't immersion (hydro) provide some resistance and therefore training effect which can be varied according to the depth of immersion? Obviously their ability to cope with this will depend upon how poor their current level is. The other benefits of hydro may also then be helpful for his other AS chest symptoms (assuming that all cardiac possibilities have been excluded).
  • I find that using a theraband is a good resistance and muscle training device for the inspiratory muscles.
  • Outcome measures: Chest expansion (5-8 cms), lung function test using spirometry and Incentive spirometry readings matched against age, sex and height - being largest at around 20-25 years The general lung function test normative values can be found from google search including : http://www.netfit.co.uk/fitness/test/lung-capacity-test.htm
  • Therapy plan: Deep breathing  with inspiratory end hold techniques, work with incentive spirometer, exercises with towel assistance, theraband resisted pectoral stretches/ upper & mid trunk flexor stretches, manual rib springing manual techniques in crook lying position. Aerobic based exercise such as swimming, running, cycling will all help increase your lung volume /function.
Sorry that we have been unable to answer your question directly.

References:
1.    van der Esch et al.  Respiratory muscle performance as a determinant of exercise capacity in patients with Ankylosing spondylitis, Australian Journal of Physiotherapy 2004; Vol. 50 :41
2.    Fisher L R et al. Relation between chest expansion, pulmonary function, and exercise tolerance in patients with ankylosing spondylitis  Annals ofthe Rheumatic Diseases 1990; 49: 921-925
3.    Romagnoli I et al. Chest wall kinematics and respiratory muscle action in ankylosing spondylitis patients, Eur Respir J 2004; 24: 453–460
4.    Ortancil O et al. The Effect(s) of a Six-Week Home-Based Exercise Program on the Respiratory Muscle and Functional Status in Ankylosing Spondylitis, JCR: Journal of Clinical Rheumatology  2009; Volume 15, 68-70
5.    Sahin G. et al. A comparison of respiratory muscle strength, pulmonary function  tests and endurance in patients with early and late stage ankylosing spondylitis, Z Rheumatol. 2006 Oct;65(6):535-8, 540
6.    Carter R et al. An investigation of factors limiting aerobic capacity in patients with ankylosing spondylitis, Respir Med. 1999 Oct;93(10):700-8
7.    Dragoi R-G et al. Rehabilitation of pulmonary dysfunction in patients with ankylosing spondylitis,  ERJ September 1, 2011 vol. 38 no. Suppl 55 p3646
8.    Sharma J et al. Comparison of chest expansion measurements in clients with Ankylosing spondylitis and healthy individuals, J. Phys. Ther. Sci. 2003; 15: 47-51
9.    OLS É N M F et al. Measuring chest expansion; A study comparing two different instructions, Advances in Physiotherapy, 2011; 13: 128–132
10.    Dragoi R-G et al. Inspiratory muscle training improves aerobic capacity and pulmonary function in patients with ankylosing spondylitis: A randomized controlled study, Clinical Rehabilitation downloaded from cre.sagepub.com

 

 
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