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==Overview==
==Overview==
Patients with [[ankylosing spondylitis]] usually appear normal. [[Physical examination]] of patients with [[ankylosing spondylitis]] is usually remarkable for three areas axial joints, peripheral joints, and [[Enthesis|entheses]]. Physical examination of AS includes a typical [[diagnostic]] process that includes exams and tests. The physical examination of AS includes [[cervical spine]], [[thoracic spine]], lateral spinal flexion, [[Schober's test|Schober test]], [[sacroiliac joint]] [[tenderness]] test and hip joint tests.
==Physical Examination==
==Physical Examination==
The [[Schober's test]] is a useful clinical measure of flexion of the lumbar spine performed during examination.<ref>{{cite journal | author = Thomas E, Silman AJ, Papageorgiou AC, Macfarlane GJ, Croft PR. | title = Association between measures of spinal mobility and low back pain. An analysis of new attenders in primary care. | journal = Spine | volume = 23 | issue = 2 | pages = 343-7 | year = 1998 | id = PMID 9507623}}</ref>
[[Physical examination]] of patients with [[ankylosing spondylitis]] is usually remarkable for three areas [[axial]] [[Joint|joints]], peripheral joints, and entheses.


The Bath Ankylosing Spondylitis Disease Activity Index ([[BASDAI]]), developed in Bath (Somerset,UK) is an index designed to detect the inflammatory burden of active disease. The BASDA can help to establish a diagnosis of AS in the presence of other factors such as HLA-B27 positivity, persistent buttock pain which resolves with exercise, and X-ray or MRI evident involvement of the sacroiliac joints. <ref>{{cite journal | author = Garrett S, Jenkinson T, Kennedy L, Whitelock H, Gaisford P, Calin A | title = A new approach to defining disease status in ankylosing spondylitis: the Bath Ankylosing Spondylitis Disease Activity Index. | journal = J Rheumatol | volume = 21 | issue = 12 | pages = 2286-91 | year = 1994 | id = PMID 7699630}}</ref> It can be easily calculated and accurately assesses a patient's need for additional therapy; a score of 4 out of a possible 10 points while on adequate NSAID therapy is usually considered a good candidate for biologic therapy.
===Appearance of the Patient===
*Patients with [[ankylosing spondylitis]] usually appear normal.
==='''Vital Signs'''===
*[[Vital signs]] are within normal limits in patients with AS.
===Cervical spine <ref name="pmid2423625522">{{cite journal |vauthors=Cho H, Kim T, Kim TH, Lee S, Lee KH |title=Spinal mobility, vertebral squaring, pulmonary function, pain, fatigue, and quality of life in patients with ankylosing spondylitis |journal=Ann Rehabil Med |volume=37 |issue=5 |pages=675–82 |date=October 2013 |pmid=24236255 |pmc=3825944 |doi=10.5535/arm.2013.37.5.675 |url=}}</ref>===
*Forward stooping of the [[thoracic]] and [[cervical]] [[spine]].
*The degree of [[flexion]] [[deformity]] is measured by asking the patient to stand erect with heels and buttocks against a wall and to [[extend]] the neck while keeping the [[mandible]] in the horizontal position and ask the patient to touch the wall.
*The degree of [[flexion]] deformity is measured by the distance between the occiput and the wall.
===Thoracic spine<ref name="pmid242362553">{{cite journal |vauthors=Cho H, Kim T, Kim TH, Lee S, Lee KH |title=Spinal mobility, vertebral squaring, pulmonary function, pain, fatigue, and quality of life in patients with ankylosing spondylitis |journal=Ann Rehabil Med |volume=37 |issue=5 |pages=675–82 |date=October 2013 |pmid=24236255 |pmc=3825944 |doi=10.5535/arm.2013.37.5.675 |url=}}</ref>===
*The degree of [[chest]] expansion is measured by the [[range of motion]] of the [[Costovertebral joints|costovertebral]] joints and is measured at the level of the [[xiphoid process]].
*The physician must ask the patient to raise their arms beyond their heads and then ask the patient to maximal forced [[expiration]] how much they can and that is followed by a maximal inspiration.
*In normal individuals the expansion is usually >2 cm.
*In normal individuals it is greater than 10 cm.
===Lateral spinal flexion<ref name="pmid246651132">{{cite journal |vauthors=Ramiro S, van Tubergen A, Stolwijk C, van der Heijde D, Royston P, Landewé R |title=Reference intervals of spinal mobility measures in normal individuals: the MOBILITY study |journal=Ann. Rheum. Dis. |volume=74 |issue=6 |pages=1218–24 |date=June 2015 |pmid=24665113 |doi=10.1136/annrheumdis-2013-204953 |url=}}</ref>===
*Physician must ask the patient with AS to standing erect with heel and back against a wall and knees and hands extended and measure the distance between the tip of the middle finger and the floor.
*Then ask the patient to bend sideways without bending the [[Knee|knees]].
===Schober test<ref name="pmid262736012">{{cite journal |vauthors=Yen YR, Luo JF, Liu ML, Lu FJ, Wang SR |title=The Anthropometric Measurement of Schober's Test in Normal Taiwanese Population |journal=Biomed Res Int |volume=2015 |issue= |pages=256365 |date=2015 |pmid=26273601 |pmc=4530222 |doi=10.1155/2015/256365 |url=}}</ref><ref name="pmid77471502">{{cite journal |vauthors=Viitanen JV, Kautiainen H, Suni J, Kokko ML, Lehtinen K |title=The relative value of spinal and thoracic mobility measurements in ankylosing spondylitis |journal=Scand. J. Rheumatol. |volume=24 |issue=2 |pages=94–7 |date=1995 |pmid=7747150 |doi= |url=}}</ref><ref name="pmid151638322">{{cite journal |vauthors=Haywood KL, Garratt AM, Jordan K, Dziedzic K, Dawes PT |title=Spinal mobility in ankylosing spondylitis: reliability, validity and responsiveness |journal=Rheumatology (Oxford) |volume=43 |issue=6 |pages=750–7 |date=June 2004 |pmid=15163832 |doi=10.1093/rheumatology/keh169 |url=}}</ref><ref name="pmid215446332">{{cite journal |vauthors=Cidem M, Karacan I, Uludag M |title=Normal range of spinal mobility for healthy young adult Turkish men |journal=Rheumatol. Int. |volume=32 |issue=8 |pages=2265–9 |date=August 2012 |pmid=21544633 |doi=10.1007/s00296-011-1953-4 |url=}}</ref>===
*In patients with AS [[Schober's test|Schober]] test is used to measure forward flexion of the [[lumbar]] spine.
*Physician must ask the patient to stands erect then a point is placed at the middle of a line joining the [[posterior]] [[superior]] [[iliac]] spines, another mark is made above 10 cm in the midline then ask the patient to bends forward how much they can without bending the knees and measure the distance.
*In normal individuals  should exceed 2 cm.
===Sacroiliac joint tenderness<ref name="pmid246792102">{{cite journal |vauthors=Miller TL, Cass N, Siegel C |title=Ankylosing spondylitis in an athlete with chronic sacroiliac joint pain |journal=Orthopedics |volume=37 |issue=2 |pages=e207–10 |date=February 2014 |pmid=24679210 |doi=10.3928/01477447-20140124-27 |url=}}</ref>===
*In AS patients to bring out [[Sacroiliac joint|sacroiliac]] pain apply direct pressure over the [[Sacroiliac joint|sacroiliac]] joint.
*[[Sacroiliac joint|Sacroiliac]] joint tenderness is also elicit by the following
**Ask the patient to be [[supine]] position, then apply direct pressure on the [[anterior]] [[superior]] iliac spine and, at the same time physician must apply force on iliac spine laterally.
**Ask the patient to be on the side, then physician must apply pressure to compress the [[pelvis]].
**Ask the patient to be supine position, physician must ask the patient to flex one of the knees and then to [[abduct]] as well as externally rotate the corresponding [[Hip (anatomy)|hip]], then apply pressure on the knee which is flexed and this elicit pain on the [[Sacroiliac joint|sacroiliac]] joint.
===Hip joint<ref name="Söker20142">{{cite journal|last1=Söker|first1=Gökhan|title=Early Diagnosis of Hip Joint Involvement of Ankylosing Spondylitis Using Magnetic Resonance Imaging in the Absence of Clinical and X-Ray Findings|journal=Archives of Rheumatology|volume=29|issue=2|year=2014|pages=99–104|issn=21485046|doi=10.5606/ArchRheumatol.2014.3999}}</ref><ref name="pmid9424992">{{cite journal |vauthors=Dwosh IL, Resnick D, Becker MA |title=Hip involvement in ankylosing spondylitis |journal=Arthritis Rheum. |volume=19 |issue=4 |pages=683–92 |date=1976 |pmid=942499 |doi= |url=}}</ref>===
*When a patient with AS is exhibiting abnormal gait [[Hip (anatomy)|hip]] involvement should be suspected.
*In AS patients hip involvement lead to [[flexion]] deformities and can be assessed by [[internal]] and external rotation of the hip.


The Bath Ankylosing Spondylitis Functional Index (BASFI) is a functional index which can accurately assess a patient's functional impairment due to the disease, as well as improvements following therapy.<ref>{{cite journal | author = Calin A, Garrett S, Whitelock H, Kennedy L, O'Hea J, Mallorie P, Jenkinson T | title = A new approach to defining functional ability in ankylosing spondylitis: the development of the Bath Ankylosing Spondylitis Functional Index. | journal = J Rheumatol | volume = 21 | issue = 12 | pages = 2281-5 | year = 1994 | id = PMID 7699629}}</ref> The BASFI is not usually used as a diagnostic tool, but as a tool to establish a patient's current baseline and subsequent response to therapy.
=== Dactylitis<ref name="pmid19433414">{{cite journal |vauthors=Sieper J, Rudwaleit M, Baraliakos X, Brandt J, Braun J, Burgos-Vargas R, Dougados M, Hermann KG, Landewé R, Maksymowych W, van der Heijde D |title=The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis |journal=Ann. Rheum. Dis. |volume=68 Suppl 2 |issue= |pages=ii1–44 |date=June 2009 |pmid=19433414 |doi=10.1136/ard.2008.104018 |url=}}</ref> ===
* [[Dactylitis]] also called as sausage [[digits]].In AS patients the fingers looks like in appearance.


===Lungs<ref name="pmid242362553" />===
*[[Restrictive lung disease]]
*Upper lobe [[fibrosis]]
===Cardiovascular<ref name="pmid169812962">{{cite journal |vauthors=Han C, Robinson DW, Hackett MV, Paramore LC, Fraeman KH, Bala MV |title=Cardiovascular disease and risk factors in patients with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis |journal=J. Rheumatol. |volume=33 |issue=11 |pages=2167–72 |date=November 2006 |pmid=16981296 |doi= |url=}}</ref><ref name="BremanderPetersson20112">{{cite journal|last1=Bremander|first1=Ann|last2=Petersson|first2=Ingemar F.|last3=Bergman|first3=Stefan|last4=Englund|first4=Martin|title=Population-based estimates of common comorbidities and cardiovascular disease in ankylosing spondylitis|journal=Arthritis Care & Research|volume=63|issue=4|year=2011|pages=550–556|issn=2151464X|doi=10.1002/acr.20408}}</ref><ref name="Petersvan der Horst-Bruinsma20042">{{cite journal|last1=Peters|first1=Mike J.|last2=van der Horst-Bruinsma|first2=Irene E.|last3=Dijkmans|first3=Ben A.|last4=Nurmohamed|first4=Michael T.|title=Cardiovascular risk profile of patients with spondylarthropathies, particularly ankylosing spondylitis and psoriatic arthritis|journal=Seminars in Arthritis and Rheumatism|volume=34|issue=3|year=2004|pages=585–592|issn=00490172|doi=10.1016/j.semarthrit.2004.07.010}}</ref><ref name="MomeniTaylor20112">{{cite journal|last1=Momeni|first1=Mahnaz|last2=Taylor|first2=Nora|last3=Tehrani|first3=Mahsa|title=Cardiopulmonary Manifestations of Ankylosing Spondylitis|journal=International Journal of Rheumatology|volume=2011|year=2011|pages=1–6|issn=1687-9260|doi=10.1155/2011/728471}}</ref>===
*Patients with AS present with following [[cardiovascular]] features
**[[Valvular heart disease]]
**[[Aortitis]]
**[[Conduction disorders|Conduction]] disturbance
==References==
==References==
{{reflist|2}}
{{reflist|2}}

Latest revision as of 03:12, 30 July 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Manpreet Kaur, MD [2]

Overview

Patients with ankylosing spondylitis usually appear normal. Physical examination of patients with ankylosing spondylitis is usually remarkable for three areas axial joints, peripheral joints, and entheses. Physical examination of AS includes a typical diagnostic process that includes exams and tests. The physical examination of AS includes cervical spine, thoracic spine, lateral spinal flexion, Schober test, sacroiliac joint tenderness test and hip joint tests.

Physical Examination

Physical examination of patients with ankylosing spondylitis is usually remarkable for three areas axial joints, peripheral joints, and entheses.

Appearance of the Patient

Vital Signs

  • Vital signs are within normal limits in patients with AS.

Cervical spine [1]

  • Forward stooping of the thoracic and cervical spine.
  • The degree of flexion deformity is measured by asking the patient to stand erect with heels and buttocks against a wall and to extend the neck while keeping the mandible in the horizontal position and ask the patient to touch the wall.
  • The degree of flexion deformity is measured by the distance between the occiput and the wall.

Thoracic spine[2]

  • The degree of chest expansion is measured by the range of motion of the costovertebral joints and is measured at the level of the xiphoid process.
  • The physician must ask the patient to raise their arms beyond their heads and then ask the patient to maximal forced expiration how much they can and that is followed by a maximal inspiration.
  • In normal individuals the expansion is usually >2 cm.
  • In normal individuals it is greater than 10 cm.

Lateral spinal flexion[3]

  • Physician must ask the patient with AS to standing erect with heel and back against a wall and knees and hands extended and measure the distance between the tip of the middle finger and the floor.
  • Then ask the patient to bend sideways without bending the knees.

Schober test[4][5][6][7]

  • In patients with AS Schober test is used to measure forward flexion of the lumbar spine.
  • Physician must ask the patient to stands erect then a point is placed at the middle of a line joining the posterior superior iliac spines, another mark is made above 10 cm in the midline then ask the patient to bends forward how much they can without bending the knees and measure the distance.
  • In normal individuals  should exceed 2 cm.

Sacroiliac joint tenderness[8]

  • In AS patients to bring out sacroiliac pain apply direct pressure over the sacroiliac joint.
  • Sacroiliac joint tenderness is also elicit by the following
    • Ask the patient to be supine position, then apply direct pressure on the anterior superior iliac spine and, at the same time physician must apply force on iliac spine laterally.
    • Ask the patient to be on the side, then physician must apply pressure to compress the pelvis.
    • Ask the patient to be supine position, physician must ask the patient to flex one of the knees and then to abduct as well as externally rotate the corresponding hip, then apply pressure on the knee which is flexed and this elicit pain on the sacroiliac joint.

Hip joint[9][10]

  • When a patient with AS is exhibiting abnormal gait hip involvement should be suspected.
  • In AS patients hip involvement lead to flexion deformities and can be assessed by internal and external rotation of the hip.

Dactylitis[11]

  • Dactylitis also called as sausage digits.In AS patients the fingers looks like in appearance.

Lungs[2]

Cardiovascular[12][13][14][15]

References

  1. ↑ Cho H, Kim T, Kim TH, Lee S, Lee KH (October 2013). "Spinal mobility, vertebral squaring, pulmonary function, pain, fatigue, and quality of life in patients with ankylosing spondylitis". Ann Rehabil Med. 37 (5): 675–82. doi:10.5535/arm.2013.37.5.675. PMC 3825944. PMID 24236255.
  2. ↑ 2.0 2.1 Cho H, Kim T, Kim TH, Lee S, Lee KH (October 2013). "Spinal mobility, vertebral squaring, pulmonary function, pain, fatigue, and quality of life in patients with ankylosing spondylitis". Ann Rehabil Med. 37 (5): 675–82. doi:10.5535/arm.2013.37.5.675. PMC 3825944. PMID 24236255.
  3. ↑ Ramiro S, van Tubergen A, Stolwijk C, van der Heijde D, Royston P, Landewé R (June 2015). "Reference intervals of spinal mobility measures in normal individuals: the MOBILITY study". Ann. Rheum. Dis. 74 (6): 1218–24. doi:10.1136/annrheumdis-2013-204953. PMID 24665113.
  4. ↑ Yen YR, Luo JF, Liu ML, Lu FJ, Wang SR (2015). "The Anthropometric Measurement of Schober's Test in Normal Taiwanese Population". Biomed Res Int. 2015: 256365. doi:10.1155/2015/256365. PMC 4530222. PMID 26273601.
  5. ↑ Viitanen JV, Kautiainen H, Suni J, Kokko ML, Lehtinen K (1995). "The relative value of spinal and thoracic mobility measurements in ankylosing spondylitis". Scand. J. Rheumatol. 24 (2): 94–7. PMID 7747150.
  6. ↑ Haywood KL, Garratt AM, Jordan K, Dziedzic K, Dawes PT (June 2004). "Spinal mobility in ankylosing spondylitis: reliability, validity and responsiveness". Rheumatology (Oxford). 43 (6): 750–7. doi:10.1093/rheumatology/keh169. PMID 15163832.
  7. ↑ Cidem M, Karacan I, Uludag M (August 2012). "Normal range of spinal mobility for healthy young adult Turkish men". Rheumatol. Int. 32 (8): 2265–9. doi:10.1007/s00296-011-1953-4. PMID 21544633.
  8. ↑ Miller TL, Cass N, Siegel C (February 2014). "Ankylosing spondylitis in an athlete with chronic sacroiliac joint pain". Orthopedics. 37 (2): e207–10. doi:10.3928/01477447-20140124-27. PMID 24679210.
  9. ↑ Söker, Gökhan (2014). "Early Diagnosis of Hip Joint Involvement of Ankylosing Spondylitis Using Magnetic Resonance Imaging in the Absence of Clinical and X-Ray Findings". Archives of Rheumatology. 29 (2): 99–104. doi:10.5606/ArchRheumatol.2014.3999. ISSN 2148-5046.
  10. ↑ Dwosh IL, Resnick D, Becker MA (1976). "Hip involvement in ankylosing spondylitis". Arthritis Rheum. 19 (4): 683–92. PMID 942499.
  11. ↑ Sieper J, Rudwaleit M, Baraliakos X, Brandt J, Braun J, Burgos-Vargas R, Dougados M, Hermann KG, Landewé R, Maksymowych W, van der Heijde D (June 2009). "The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis". Ann. Rheum. Dis. 68 Suppl 2: ii1–44. doi:10.1136/ard.2008.104018. PMID 19433414.
  12. ↑ Han C, Robinson DW, Hackett MV, Paramore LC, Fraeman KH, Bala MV (November 2006). "Cardiovascular disease and risk factors in patients with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis". J. Rheumatol. 33 (11): 2167–72. PMID 16981296.
  13. ↑ Bremander, Ann; Petersson, Ingemar F.; Bergman, Stefan; Englund, Martin (2011). "Population-based estimates of common comorbidities and cardiovascular disease in ankylosing spondylitis". Arthritis Care & Research. 63 (4): 550–556. doi:10.1002/acr.20408. ISSN 2151-464X.
  14. ↑ Peters, Mike J.; van der Horst-Bruinsma, Irene E.; Dijkmans, Ben A.; Nurmohamed, Michael T. (2004). "Cardiovascular risk profile of patients with spondylarthropathies, particularly ankylosing spondylitis and psoriatic arthritis". Seminars in Arthritis and Rheumatism. 34 (3): 585–592. doi:10.1016/j.semarthrit.2004.07.010. ISSN 0049-0172.
  15. ↑ Momeni, Mahnaz; Taylor, Nora; Tehrani, Mahsa (2011). "Cardiopulmonary Manifestations of Ankylosing Spondylitis". International Journal of Rheumatology. 2011: 1–6. doi:10.1155/2011/728471. ISSN 1687-9260.

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