Neck Pain management in Ankylosing Spondylitis

•       The Ankylosing Spondylitis Special Interest Group North West are a group of special interest Rheumatology Physiotherapists who work together reviewing research, offering peer support, developing best practice guidelines and aiming to advance the care within our field.

•       The topic of neck pain management in AS was raised in 2014 which prompted a review of the literature and further discussion of how physiotherapists working with patients approach treatment strategies and choices.

•       The literature evidence search consisted of support from East Cheshire NHS Trust and University Hospitals of Morecambe Bay NHS Trust clinical librarian services. Search terms  included ‘Ankylosing spondylitis’, ‘neck’, ‘cervical spine’, ‘physiotherapy’ or ‘physical therapy’ from 1950 onwards. Databases used were: MEDLINE, CINHAL, AMED, Cochrane Library, NICE Guidelines. 15 references were identified.

Summary of the literature search

•       In general we found that very little literature existed with statistical evidence to support any specific physiotherapeutic modality or strategy for the treatment of neck pain in patients with AS.

•       Evidence was found to support using strengthening (Dimitriadis et al 2013 ) to help respiratory weakness in people with neck pain. It has been identified that exercise therapy appeared to be effective in neck pain management following an evidence review. This belief is certainly to this day purported in Axial Spondylitis

•       Recommendations from ASAS and EULAR 2016 and NASS guidelines (2015) which are generic rather than specific and don’t focus on neck pain management in AS. Dagfinrud H et al 2008 (Cochrane Database) reviewed 11 trials looking at Physiotherapy interventions for Ankylosing Spondylitis and found that exercise therapy was effective from a number of studies for improving spinal mobility and physical function but little mention to neck pain specifically.

•       Smidt, de Vet, Bouter and Dekker (2005) also supported the use of exercise therapy (no clear definition of which exercises) to be effective in the treatment of AS. One paper from 2001 suggested that neck pain (no specific reference to causative factors) without neurological signs or symptoms can be managed conservatively with physical therapy including intermittent traction (Hardin 2001 ).

•       As a group we discussed in detail the uncertainty of what works for patients with AS and what precautions, if any, were required to be taken. We subsequently arranged a Survey Monkey survey which was distributed through the group via email, used on a tablet platform at the British Society of Rheumatology Conference 2015, posted on the MSK and Rheumatology SIG iCSP discussion forums.

Survey Summary

There were a variety of different treatment strategies which are mainly focussed on education and advice. Interestingly within the top 5 of strategies currently used the top 3 with over 90% of responders are using posture advice, ROM exercises and education and advice which appears to fit with current recommendations. Retraction exercises and heat are identified by over 70% of respondents in the following top 2. Closely following were dynamic exercise rehab, driving and ergonomic advice.

Interestingly many Physios identified effective use of acupuncture for pain management in AS necks but the results may have been lesser in their numbers due to less staff being qualified in acupuncture as a treatment strategy and therefore have not been able to use it. However there is very little research evidence to support it in this specific patient group. There is also little specific evidence on exactly what types of exercises are most appropriate to teach/ perform in this client group.

Recommendations from the survey results

•       Posture and ergonomic advice should be taught to all patients with an emphasis on educating benefits and focusing on function

•       Self management should be recommended using a range of AROM and (PROM exercises ) and stretches

•       Heat (with precautions) is a safe non-pharmacological pain management option to help reduced muscle pain and stiffness in order to potentially improve outcomes from exercises and myofascial release techniques could be considered.

•       Likewise acupuncture could be considered as a non-pharmacological pain management option from practitioners with appropriate training and accreditation.   However there is a paucity of research into this treatment modality

•       Careful checking of VBI should be performed by questioning and if appropriate clinical examination prior to commencing end of range or combined movement techniques/ exercises

•       A combination of aerobic, stretching and strengthening exercises would appear most appropriate for this patient group in order to facilitate maintenance/ improvement in respiratory function, neck positioning, posture and flexibility.

•       More evidence is needed for the use of manual therapy in axial SpA. Cases should be assessed on an individual basis, to identify risk factors such as fracture.

•       Patients with axial SpA are at increased risk of osteoporosis and may suffer a fracture from even minor trauma. Other risk factors include instability and vertebrobasilar insufficiency. Discussion with the patient’s rheumatologist with regard to their bone health and risk factors should be considered. There are a number of contra-indications to spinal manipulation, including inflammatory conditions and fractures, therefore if there is any doubt over whether or not mobilisations are suitable for a patient, they should not be performed.

•       There is limited evidence for manual therapy to the joints (i.e. Vertebral accessory mobilisation techniques) but there is some for more soft tissue related manual therapy techniques which may aid restoration of ROM and pain relief.

•       For those patients who have significant neck fusion it may be advisable to wear CPR bracelets to warn fist aiders not to try to extend the neck for resuscitation – chin tilt only if at all possible. 

•       Likewise if a whiplash injury has occurred it is advisable not to move the person without a cervical collar and to alert medical staff to the potential nee for urgent scanning to rule out cervical fracture or atlanto-axial subluxation. 

Future Plans

The outcomes of this national survey and the discussions it has prompted has led us to create a home exercise booklet for patients specifically focussed on the neck pain of Ank Spond. We are currently using this across the ASSIGNw network, but also looking at National publication.

The ASSIGNw Team, 4th Dec 2017.

Survey raw data, we had 89 people respond, wth the following distribution of treaments offered:

Why Tai Chi in Axial Spondyloarthritis?

I have been teaching Tai Chi to this patient group for more than fifteen years; the thing that strikes me is how much they enjoy it and how it enables them to increase their function very quickly.

Why should this be? certainly not magic!!

If we think about the symptoms that most of these people experience, pain, stiffness, postural changes, fatigue, sometimes reduced chest expansion and general mobility (walking).

It is generally agreed that exercise has a beneficial effect on these symptoms.

“I was afraid to go out, my pain had become intolerable and I was afraid of falling. The Tai Chi classes have given me a reason to get out of bed on a Monday morning, I now go for a walk after class and at six weeks I can now manage two hours after the forty-minute class, thank you”.

This lady had obviously been struggling for some time and had tried many other forms of exercise, swimming and daily strenghtening and stretching, often recommenend in Spondyloarthritis and also afford benefits such as improved mobility, muscle strength and subsequent pain and fatigue management.

However, these exercises do not fully address the issue of balance.

Balance is the ability of the body to remain steady in a chosen position; to move smoothly and safely through small body adjustments. Postural control requires complex interactions within the musculoskeletal system, sensory and cognitive systems. Joint stiffness at spinal, hip, knee and ankle joints reduces the body’s ability to right itself and reduces proprioceptive awareness. Postural changes also affect balance due to the alteration in the centre of gravity. Ankylosing Spondylitis patients have been found to have a poorer balance in comparison to healthy subjects and it is recommended that postural awareness be included in early treatment plans.

So, we get back to this lady and her fear of falling, a fear of falling is one of the biggest predictors of a fall, and the increased propensity to osteoporosis in this patient group will increase the fracture risk. Inactivity reduces one’s ability to compensate and contributes to other problems, including loss of bone and muscle mass, heart disease, and obesity as well as social isolation.

Tai Chi is practiced in a normal balanced standing position, constant movement of the limbs and weight transference improves flexibility and strength in the lower limbs particularly around the knees and ankles has a positive effect on proprioception and balance reactions and on circulatory systems to joints muscles and vital organs. Co-ordinating arm movements challenges balance and improves positional awareness giving better sense of position in space, over time this is translated into daily activities. Slow repetitive movement helps to re-educate neural pathways improving the system interactions and therefore normal movement patterns.

What else? Well; this lady obviously enjoyed her Monday morning classes, certainly social interaction can have a positive psychological effect which cannot be overplayed. Tai Chi is a “mindful” exercise. Participants are encouraged to concentrate on the here and now and only on their breathing and development of their movements. This can have a calming and relaxing effect which in turn aids concentration and memory which improves pain and fatigue. Of course, the inclusion of breathing exercise throughout the programme has the added value of increasing chest expansion and vital capacity.

In short Tai Chi is an integrated form of exercise which can be included in exercise prescription at any stage of the disease.

Sue, 29th June 2017.

Singing

I have always enjoyed singing. At school we made records (we are talking about the 70s), sang in concerts and managed to get on Songs of Praise! Over the years wherever I lived, I joined a choir or operatic society and performed in various shows.

One day a female Barbershop Chorus called Spinnaker Chorus came to my town and they sang acapella style (without sheet music) in four-part harmony. I listened and marvelled at the sound. Their faces expressed the passion of the song, their bodies swayed with the music and they stood tall. What fabulous postures they all had. To top it all, they really looked like they were enjoying themselves! I joined up immediately. That was 10 years ago.

Since joining Spinnaker Chorus ( www.spinnakerchorus.co.uk ) I have never looked back. At last, I was taught how to sing effectively. Using the mouth, larynx, facial muscles, rib cage and good posture, we are taught how to perfect the sound. Then in time to the music, and maintaining our posture, we move with the rhythm. The work out begins. For some of the songs choreographed moves increase the work out still further. We learn how to breathe, holding onto the breath throughout a phrase, then snatching a breath in unison at certain intervals. By the end of the song, the rib cage has moved to its limit and we are breathless from the aerobic nature of the exercise.

There have been articles written about singing and its positive effect on our physical and mental health. The release of endorphins certainly plays its part, the work out another. So too does being part of a group of people with the same passion. If you are thinking about singing in a choir or a chorus, it has to be worth a try. The physical, emotional and psychological benefits can be dazzling.

Juliette.

The power of the Voice

Having been diagnosed with a Chronic life changing condition is not an easy thing to accept.

One of my hobbies has always been music, when my lungs became a problem I decided to take up singing seriously. I sat my theory exams with young children. I had better mention that at this time I was 60 years old. For the singing exam I waited patiently with these youngsters who were brimming with confidence. Me? I was shaking in my shoes. However, I passed all my exams with distinction. I did notice as I studied and practiced during those hours, was that my pain became less pronounced, I became so focused.

I still belong to a choir “The Melody Makers” we practice once a week. I’ve found that I have gone to practice feeling unwell and in pain. Once I start singing the pain recedes, it becomes less dominant. It does make me feel tired but when I get home I am able to totally relax.

I find it is not just the music that helps it is also contact with other people. Many of the choir members have got physical problems but there love of music seems to help.

After finding how much my music had helped me to control my pain I joined other groups, art and a swimming club. The time spent with all these groups I actually feel normal. All I have to do is prepare for each activity in advance and realise there is a small price to pay; the next day I rest.

Jan.

Bollywood Dancing and Ankylosing Spondylitis (AS)

Dance is reported as the UK’s fastest growing art form with more than 4.8 million people regularly attending community dance groups each year in England alone. One added advantage in dancing is that while you’re having fun moving to music and meeting new people, you’re getting all the health benefits of a good workout.

As a physiotherapist I strongly feel regular dancing is great for maintaining strong bones, improving posture and muscle strength, increasing balance and co-ordination, beating stress levels and losing weight.

Bollywood dancing: Bollywood dancing stems from the Indian film industry and has increased in popularity throughout the world since the beginning of the 20th century. Bollywood dance is known for being upbeat; it blends the unique traditional Indian dance forms with the modern western hip-hop and jazz dance styles.

Bollywood and AS: My Husband Raj is a music/dance lover and a choreographer, using our whole family effort over the past 5 years we have conducted few local Bollywood programmes. Grimsby NASS group member and Treasurer Jeanne Murray attended our local Bollywood programme and expressed interest in including some dance routines at our NASS group. The members enjoyed the 5 minutes dance work-out and evaluated the session to be different, easy to exercise, enjoyable, fun-filling and did not report any adverse effects. We gradually started including Zumba and line dance forms, we plan to include few more routines in the future.

Big High five to the Grimsby NASS group members! Big Cheers to all the Bollywood dance lovers.

Susimala.

Laughter and the love of life

A few weeks ago I had a conversation with a colleague about a patient of hers who I had met in the hydrotherapy pool. This patient had presented in the department suffering from long-term musculoskeletal disease and chronic pain. She was morose and lacking in motivation both with exercise and socially, in fact she rarely left the house. Following initial assessment and treatment she was referred for a course of hydrotherapy.

This lady struck up a friendship with a fellow patient attending the same treatment session as they travelled together on the same hospital transport. This pair soon became the life and soul of the sessions, encouraging other patients and creating havoc and amusement in equal measure. On review, her physiotherapist was amazed at the change in this lady, her posture and physicality had improved dramatically along with her sense of well being and her ability to manage her chronic condition. She is continuing to socialise and exercise with her new friend.

What had brought about this dramatic change? The magic warm water and exercise, skilfully taught by her physiotherapist? Or, the power of friendship, interacting, sharing, offloading and laughing with another human being?

Sue.

About us

AStretch is a not for profit organisation; our main aim is to provide a co-ordinated approach to the planning and delivery of education and best practice. Also to support physiotherapists working with people who have Axial Spondyloarthritis (AxSpA) and Ankylosing Spondylitis (AS).

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