The management of ankylosing spondylitis is complicated by an undefined etiology, by exacerbations and remissions and by the linear progression of the disease. Current management strategies may include pharmaceuticals, exercise and diet.
Pharmaceutical therapies for AS include NSAIDs, anti-rheumatic disease modifying drugs and newly developed therapies targeting tumor necrosis factor alpha.22
There is no consistent evidence in the literature that NSAIDs have a beneficial effect on skeletal mobility23
and no drug therapies have been shown to prevent structural damage in spondyloarthritis.24
Our patient chose to discontinue his prescription NSAID use because of gastrointestinal side effects. Other pharmaceutical therapies available at the time may have offered benefit to this patient, but he expressed an interest in decreasing his reliance on pharmaceuticals to manage his condition.
Exercise is traditionally recommended to preserve flexibility, mobility and the upright posture.25
One study concluded that regular exercise over a 5-year period prevented the decline in spinal mobility.25
Moderate and regular exercise may be beneficial for both functional status and disease activity, but it may be the consistency and not the quantity of the exercise that is most important.14
In a systematic review of physiotherapy interventions in AS by Dagfinrud,26
three robust randomized control trials utilized exercise as the main treatment intervention.27,28,29
The results of these studies were mixed with some short term benefits for pain, stiffness and spinal mobility reported, but there was insufficient evidence to support or refute the use of physiotherapy interventions for AS.26
The patient in our study, as outlined previously, was on a self regimented exercise program that remained unchanged prior to treatment and throughout the course of treatment. Any exercise benefits in this study were controlled by the patient’s consistent exercise program prior to and during our treatment.
Although, dietary modifications were not attempted in this case, there are reports of patients who use diet to alleviate rheumatic symptoms.30
In two specific case studies a vegan diet,31
and a low starch diet32
provided improvement in AS symptoms. As no dietary modifications were attempted in our study, diet was considered an unlikely confounding factor.
This case supports the use of chiropractic treatment in AS. The patient stated that the treatment caused an increase in symptoms shortly after treatment, but this was followed by a long term decrease in symptoms over the treatment plan. This subjective finding was supported in his BASFI and BASDAI scores over the 18-week course of treatment. The BASDAI consists of six visual analogue questions relating to the five major symptoms pertaining to AS: fatigue, spinal pain, joint pain/swelling, localized tenderness and morning stiffness.21
The Spondylitis Disease Activity Index has been shown to be quick, simple, reliable (r
= 0.93; p
< 0.001), sensitive to change and evaluates the entire spectrum of AS.21
It also shows good test-retest-reliability and good internal consistency.33
The BASFI consists of eight questions on activities relating to functional anatomy and two questions assessing the patient’s ability to cope with their life.11
The questions are answered on a 10 cm visual analogue scale and a mean of the 10 questions gives the overall BASFI score (0–10).11
The reproducibility of the BASFI is good (r
= 0.89, p
and has been shown to be sensitive in documenting improvement in the functional ability of patients over a 3-week period (mean score change = −1.07, p
Patient’s BASFI scores compared well with functional tests performed by an external observer.11
For this case study, the BASFI was chosen since it is thought to be more responsive than the Dougados Functional Index (DFI) and the AS specific version of the Health Assessment Questionnaire (HAQ-S).34
Additionally the BASFI has been shown to be superior in detecting changes in functional performance, is sensitive to change across the whole spectrum of the disease11
and is quick and easy to complete. Chest expansion and finger-tip-to-floor distance were also assessed to measure the disease severity in AS.35
In addition to improvement in both the BASFI and BASDAI, improvements were also noted in chest expansion and finger-tip-to-floor distance. These tests are empirical and objective in nature and support the efficacy of chiropractic therapy, including chiropractic manipulative therapy, in increasing function and decreasing disease activity in this patient with AS.
Chiropractic manipulative therapy may be an effective treatment option to decrease pain and increase joint function in patients with AS. However, patients with AS may be discouraged from seeking chiropractic manipulative therapy by their physician or by their support society.36,37
A number of risk factors must be considered to ensure safe utilization of chiropractic manipulative therapy in the management of AS. Patients with AS may have acutely inflamed joints and chiropractic practice guidelines advise that manipulation of acutely inflamed joints is contraindicated.38
Osteoporosis may occur early in the disease, predisposing patients to an increase in vertebral compression fractures and traumatic spinal fractures of the cervical spine.39
There is also an increased risk of traumatic spinal cord compression, which is estimated to be 11 times greater in the AS population compared to the population at large.40
It has been suggested that the prevention of sudden neck movements is of vital importance in patients with ankylosing spondylitis of the cervical spine.41
There is one reported case of paraplegia following chiropractic manipulation of a patient with ankylosing spondylitis.42
While these risk factors are considerable, they are present in only a minority of AS cases. However, in subacute and chronic cases of AS, without local indications of ligamentous laxity, anatomic subluxation or ankylosis, chiropractic manipulation is not contraindicated.38
The authors agree with the cautious use of joint manipulation in AS, however in this case, spinal manipulation of the non-contraindicated joints was continued throughout the 18 weeks of treatment.
It is important to re-assess the cervical spine of patients with AS who are receiving cervical spinal manipulation. AS may affect the cervical spine and with progression may result in a decrease in neck motion and an increase in cervical kyphosis.43
In a study of 61 AS patients in the Moroccan population, 70% had a history of cervical night pain with associated morning stiffness.43
Radiological involvement of the cervical spine was observed in 54%, with vertebral body squaring and facet joint involvement occurring most frequently. The cervical spine radiological and clinical involvement increased with age and disease duration. The prevalence of cervical spine radiographic abnormalities was: 19.6% after 5 years, 29.9% after 10 years, 45.1% after 15 years and 70% after 20 years. Of the 61 Moroccan AS patients observed, 12 patients with neck pain presented with no cervical radiological signs and notably, two patients with cervical radiological signs did not report neck pain. Since neck pain does not adequately predict radiographic changes, there is a need for frequent reassessment of the cervical spine of patients with AS to rule out local contraindications to cervical spinal manipulative therapy.
Spontaneous atlantoaxial subluxation (AAS) may be a serious complication in rheumatic disorders including seronegative spondyloarthropathies like AS.44,45,46
This poses a considerable risk for upper cervical manipulation. The transverse ligament instability is a potentially life threatening complication that has traditionally been considered a late finding in AS.45
However, current studies contradict the notion that AAS is a late finding in the disease.44,47,48
and has been an early presenting complication in some patients with AS.47,48
Furthermore, the presence of atlantoaxial subluxation is not associated with an increase in the duration of the disease.44
The prevalence of AAS was investigated in 103 consecutive patients with a 10-year mean AS duration and there was a 21% anterior AAS and a 2% vertical AAS prevalence.44
This finding is higher than previously reported in other studies, which have reported a 2–15% atlantoaxial incidence.49,50,51
Anterior AAS was shown to be associated with an increase in the degree of radiological sacroiliitis, while other factors, including disease duration, peripheral arthritis, current symptoms, functional index, use of steroids and HLA-B27 were not statistically associated with anterior AAS.44
Thus, clinical symptoms do not appear to predict the presence of ASS, and only radiographic findings are shown to be robust. A two-year followup of the patients with AAS by Ramos-Remus52
revealed that 32% of patients with AAS showed radiological progression with or without neurological symptoms.
AAS may produce a number of different neurological signs and symptoms, but most AS patients with AAS present with little or no neurological signs and symptoms at all.44
The lack of signs and symptoms of AAS may mask the underlying pathology, creating a potential for disaster if managed inappropriately by the chiropractor. Ligamentous instability, such as AAS, is a local absolute contraindication to high velocity thrust procedures.38
Presently, there is no agreement in the literature on the minimal distance required to diagnose anterior AAS. AAS has been suggested if the ADI is 4 mm or greater.44
Recently, AAS was diagnosed clinically with an ADI equal to or greater than 3 mm.43
Our patient who has confirmed AS, a probable cervical spine involvement at C5–C6, and an ADI of 3 mm suggests AAS. Hence, manipulation of C0–C1, C1–C2 and C5–C6 spinal segments were considered a contraindication in this case. The patient in our study had received upper cervical manipulations within the year prior to his presentation to the authors. Lateral cervical spine radiographs obtained in flexion are essential to bring this clinical issue to the foreground and decrease the patient’s risk associated with upper cervical spine manipulation. The increased incidence and the potentially silent nature of the transverse ligament involvement, with few clinically significant neurological symptoms, combined with our clinical experience, highlight the importance of obtaining lateral cervical spine flexion radiographs in patients with AS. The authors of this case study advise that flexion radiographs be considered for all patients with AS, prior to upper cervical spine manipulation, regardless of disease duration or current symptoms. The increase in ADI creates a local contraindication to manipulation, but as suggested in this case, patients with local contraindications to manipulation may still benefit from manipulation of other joints. Thus, these patients should not be discouraged from seeking chiropractic manipulative therapy.
This study was limited in sample size, experimental design and by uncontrolled variables. Specifically other modalities such as soft tissue therapy, rib mobilizations and interferential current were used in addition to chiropractic spinal manipulation and mobilization. The soft tissue therapy and interferential current were reported by the patient to decrease the initial sensitivity associated with receiving spinal manipulation. An attempt was made to ensure that this patient’s exercise program, diet and supplement intake remained constant throughout, but some variability may have occurred over the 18 weeks of study. As well, ankylosing spondylitis is characterized by periods of exacerbations, which may further confound the results. Specifically, it is not possible to prove that the change in BASDAI or BASFI was a treatment effect and not simply an improvement or remission in symptoms following an exacerbation. The patient in our study was functioning at a high level prior to beginning treatment, as indicated by a low baseline BASFI score. This created a situation where there was less range to measure the treatment effect. So unlike the BASDAI, the BASFI values were limited to the lower end of the scale, ranging from 0.52 to 0.08, pre and post treatment. However, an important goal of treatment is to maintain and/or improve function in patients with AS, and even a small change in the BASFI score is a favorable outcome. As well, functional disability is the most important patient outcome in decreasing the financial costs associated with AS.53
In retrospect, continued follow-up assessments possibly at 6 and 12 months would have been helpful to determine if these benefits were long lasting. However, the results of this case study suggest that chiropractic manipulation and mobilization may improve function, disease activity and symptomatology in patients with AS.
Chiropractic manipulative therapy has been well supported as a useful adjunct to limit pain and improve function in individuals with non-specific back pain.54
In this patient, chiropractic manipulative therapy has also been shown to be a useful adjunct for the treatment of specific back pain and symptomatology due to ankylosing spondylitis. Chiropractic therapy has facilitated an increase in function and a decrease in disease activity in this patient with AS. Therefore, chiropractic manipulative therapy may provide an integral and effective treatment option in the clinical management of this disease. Further research is required to substantiate a conclusive cause/effect relationship between chiropractic manipulative therapy and improvement in individuals with ankylosing spondylitis.