Scenario: A 38-year-old male presents with complaints of low back pain with insidious onset and duration of over 3 months. He reports that his neck is also stiff, and driving a car has been difficult. He works for a company that provides computer technical support to many local businesses and needs to drive for his work. He has morning stiffness that generally improves with activity and exercise. There has also been a recent onset of swelling in the left knee and heel pain. There are times when the pain wakes him from sleep in the middle of the night; however, if he gets up and walks around or takes a hot shower, his pain is relieved enough to be able to go back to sleep.

He is referred to physical therapy by her rheumatologist, and has the results of several tests. Pulmonary function tests show decreased vital capacity and total lung capacity, although residual and functional residual lung volumes were increased. Hematology tests showed a mild normocytic anemia, and a normal white count. Erythrocyte sedimentation rate and alkaline and creatinine phosphatase were elevated. There was no rheumatoid factor present. Posture shows a flattening of the lumbar lordosis and a dorsal stooping posture with an accentuation of the thoracic kyphosis. There is tenderness over the spinous processes of the lumbar and thoracic vertebrae. A bony spur is palpated at the right heel at the proximal insertion of the plantar fascia. AROM is severely diminished lateral flexion of the spine, forward flexion and extension are decreased by 50%. Left knee ROM is decreased both actively and passively by 10 degrees.

Question: What treatments should the physical therapist prioritize for this patient with ankylosing spondylitis?

A. Pain modulation, patient education on joint protection, Williams flexion protocol

B. Gentle mobility exercises, intense flexibility and mobility exercises, lumbar stabilization exercises

C. Pain modulation, breathing exercises, postural training, gentle mobility exercises

D. Breathing exercises, high impact aerobic exercises, core stabilization

Answer with rationale: C. Pain modulation, breathing exercises, postural training, gentle mobility exercises. Pain modulation will be a key aspect of rehabilitation, which should be assisted by the patient’s physician via medications. Breathing exercises will help the patient regain vital capacity and total lung capacity. Postural training will assist with recreating normal loading in the spine and alleviating some compression in the vertebral column. Gentle mobility exercises will help alleviate pain and regain mobility in the spine.

For more information see Chapter 112: Ankylosing Spondylitis in The Color Atlas of Physical Therapy