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At AStretch we are committed to ensuring that up to date information is made available to a wide audience. If you have anything you would like to contribute, please contact us on: 

Best Practice in Assessment:

The NICE GUIDANCE on Spondyloarthritis, covers the diagnosis and mangement of Spondyloarthritis. Raising awareness of the symptoms of inflammatory back pain can break through the challenges of diagnosis and reduce diagnostic delay. Physiotherapists are well placed in screening these patients as the physiotherapy department may be the first port of call. Early onward referral to Rheumatology when appropriate can improve diagnostic standards and improve outcomes for this group of patients.

Early Diagnosis of inflammatory back pain is essential for effective treatment and good management of Axial Spondyloarthritis.
AStretch members have worked tirelessly in promoting early recognition of inflammatory back pain.  We were involved in the delivery of facilitated workshops in the NASS Back Pain Seminars between 2012 and 2014 reaching almost 900 delegates throughout England and Wales The seminars informed delegates how to distinguish inflammatory back pain from mechanical back pain and other types of back pain. 

Back in Focus have produced e-learning modules to assist recognition, diagnosis and management of AxSpA.
These modules are now available for AHP EDUCATION: 

This presentation was devised as an interactive session for The British Society of Rheumatology 2014.  Combining some of the diagnostic principles in distiguishing back pains and based on two short videos. You can interact with this presentation by trying to answer the questions yourself and follow this up with the evidence based answers and discussions that follow. Unfortunately we cannot publish these videos, however, a short summary is provided for you to work from.

A DVD produced to educate potential referrers in recognition of inflammatory back pain, appears here : 
If you would like a copy of this DVD which contains voiceovers in English and Welsh, to present to local GPs or other education forums, please contact:

An article by Melanie Martin was recently published in Horizons  and gives some insight for extra scope and advanced physiotherapy practitioners in the musculoskeletal fields. It highlights the difficulties in teasing out some of the often subtle differences in back pain presentations found in clinical practice and subsequent diagnostic decision making.


Campaigning for early diagnosis, how to get involved:


Outcome Measures:

The Bath Indices, outcome measure information booklet, for use with ankylosing spondylitis patients was reviewed and edited by four members of the AStretch Committee-  Heather Harrison, Karen Irons, Amanda Thomas and Jane Martindale. The extensive reference section represent the vast literature search undertaken, this was supported by the librarians at Wrightington Wigan and Leigh NHS Foundation trust.


The updated version of the Bath Indices can be obtained from :

Evaluating Ankylosing Spondylitis Quality of Life with the EASi-QoL: a new patient-reported outcome measure for AS
Dr. Kirstie L Haywood

For further information pertaining to the development, evaluation and application of the EASi-QoL please contact:
Dr Kirstie Haywood
School of Health and Social Studies, University of Warwick (
Tel: 024761 50616

 EASi-QoL Evaluating Ankylosing Spondylitis Quality of Life. A patient - reported outcome measure


Useful links regarding Assessment & Treatment of Ankylosing Spondylitis / Axial Spondyloarthritis:

 Differentiating Inflammatory and Mechanical back pain
 What is Axial Spondyloarthritis?
 Assessing the signs, Symptoms, and clinical Manifestations of Axial Spondyloarthritus
 The treatment of Axial Spondyloarthritis


 Education modules for physiotherapists ppt


Patient Resources:

 First aid kit for flares
 Education and Exercise Programmes

 “Physical Interventions in the biological age”

Patient Case Studies:

 Presentation and Discussion of a case study of a female patient with longstanding “atypical" disease
 The Newly Diagnosed AS Patient


Useful References:
AS and Balance:
Zimi Sawacha et al. Biomechanical assessment of balance and posture in subjects with ankylosing spondylitisJournal of NeuroEngineering and Rehabilitation
Cardiovascular risk in AxSpA:
Patients with spondyloarthritis (SpA) were at elevated risk for acute coronary syndrome (ACS) and venous thromboembolism (VTE) vs the general population (GP).
Stroke was also a higher risk in those with ankylosing spondylitis (AS) and psoriatic arthritis (PsA).Bengtsson K, Forsblad-d'Elia H, Lie E, Klingberg E, Dehlin M, Exarchou S, Lindström U, Askling J, Jacobsson LTH. Are ankylosing spondylitis, psoriatic arthritis and undifferentiated spondyloarthritis associated with an increased risk of cardiovascular events.
Patients with ankylosing spondylitis (AS) are at a 30%-50% increased risk of incident cardiovascular (CV) events compared with the general population.
Compared with patients with rheumatoid arthritis (RA), those with AS have about the same stroke risk, but only half the risk for thrombotic events or acute coronary syndromes
Survival benefit of statin use in ankylosing spondylitis and psoriatic arthritis: A general population-based cohort study | ACR
Recent studies have shown an increase in cardiovascular and all-cause mortality in ankylosing spondylitis and psoriatic arthritis. The hypothesized dual role of statins in both lowering lipids and reducing inflammation may thus lead to survival benefits in patients with these seronegative spondyloarthropathies.
Presented at the 2016 annual meeting of the American College of Rheumatology
This 2017 study suggests a 
more pronounced benfit and reduction in mortality rate than that observed in several meta-analyses of statin use for primary prevention in those who don’t have the disease.
Diagnostic Dilema:
Axial spondyloarthritis, as common as rheumatoid arthritis, goes undiagnosed for years:
Exercise Interventions:
Swiss ball exercises improve muscle strength and walking performance in ankylosing spondylitis: a randomized controlled trial.

Behaviour change intervention increases physical activity, spinal mobility and quality of life in adults with ankylosing spondylitis: a randomised trial?
Fracture Risk:
Clinical outcomes following spinal fracture in patients with ankylosing spondylitis 
Efficacy and safety of non-pharmacological and non-biological pharmacological treatment: a systematic literature review informing the 2016 update of the ASAS/EULAR recommendations for

Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs. National Institute for Health and Care Excellence. 2017 May 24.
In patients with active psoriatic arthritis, secukinumab inhibited radiographic disease progression.

Inflammatory Bowel Disease:Patients with IBD often suffer from extraintestinal rheumatic manifestations, prevalently including inflammatory back disorders like ankylosing spondylitis (AS), axial spondylarthropathy (axial SpA) and inflammatory back pain (IBP):

The prevalence of axial spondylarthropathy (SpA) and (ankylosing spondylitis) AS in IBD patients late in the disease course was higher than the prevalence reported in general populations.
Presented at the annual 2017 meeting of the European Crohn's and Colitis Organisation:
Spondyloarthritis (SpA)-associated musculoskeletal manifestations were frequently reported by inflammatory bowel disease (IBD) patients on TNF inhibitors; increased recognition of SpA accompanied use of a SpA self-reported questionnaire, which could alter management and improve patient outcomes.
Enthesitis is thought to be the key to the inflammatory arthritis, this site provides information on the latest research and expert knowledge on the way forward.
Treating axial spondyloarthritis and peripheral spondyloarthritis, especially psoriatic arthritis, to target: 2017 update of recommendations by an international task force
Risk factors for RA and spondyloarthritis flare in pregnancy:
Patients with RA or AS often experience disease flares during pregnancy, but it is unknown whether changes in treatment around the time of conception influence flare risk
This study suggests; to prevent flares, consider continuing medication for axial spondyloarthritis (AS) and rheumatoid arthritis (RA) after conception in pregnant patients.
Tai Chi:
Agrawal Y et al. Disorders of balanceand vestibular function in US adults. ArchIntern Med. 2009;169(10):938–944.
Fuzhong L, et al.Tai Chi and fall reductions in older adults: a randomized controlled trial. J Gerontol. 2005;60A:187–194.
Gauchard GC, Beneficial effect of proprioceptive physical activities on balance control in elderly human subjects. Neuroscience Lett. 1999;273:81–84.
Horak FB. Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls? Age Ageing.2006;35(suppl 2):ii7–ii11
McGibbon CA, Krebs  DE, et al Tai Chi and vestibular rehabilitation improve vestibulopathic gait via different neuromuscular mechanisms: preliminary report. Bio Med Neurol. 2005;5(3).
Stevens J, Sogolow ED. Preventing Falls: What Works—A Compendium of Effective Community-based Interventions from
Work Issues:
Dr Jane Martindale, a committed  AStretch member since 2009  recently published valuable research in the field of Ankylosing Spondylitis: The impact of ankylosing spondylitis/axial spondyloarthritis on work productivity. Bailliè re s Best Practice and Research in Clinical Rheumatology 05/2015; DOI: 10.1016/j.berh.2015.04.002

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