AS Knowledge Disparity Among Healthcare Providers: A Physical Therapist's Perspective

While attending school to become a physical therapist, and prior to my diagnosis, ankylosing spondylitis was a diagnosis I learned about. However, the concepts I committed to memory I later came to discover were quite incorrect.

I had beliefs about AS

Before diagnosis, when I thought of AS three things came to mind: bamboo spine, more common in men, and curved spine. Bamboo spine means just what it sounds like: on x-ray, the entire spine looks like a shoot of bamboo due to the spinal fusion. This image would stick in my mind as a hallmark characteristic of AS. We were also taught that AS was more common in men in a 2-3:1 ratio. Another characteristic sign was an immobile spine, those with AS I believed had very poor spine range of motion and would come to me stooped over and curved at the spine.

About 6 months into practicing physical therapy, my first experience with an AS patient just so happened to be the “typical” type. This patient was male, he was completely fused, and had little to no spinal mobility on examination. After working with him my understanding of how AS presented seemed to be confirmed. I had no reason to believe that what I memorized about AS in school was misinformed.

Then, they were disproven

Months later, I had another patient come in for ankle pain. Not only was she female, but she was also very active, had fairly normal spinal mobility, looked “normal” in terms of her posture. She had a diagnosis of AS. Her main issue at the time of treatment was Achilles tendonitis. She did not have back pain, which I would come to find out later is also quite common in AS. My understanding of the “typical” AS patient began to change.

Soon after, a rheumatologist gave a lecture to our medical group regarding AS and I was fortunate enough to attend.

What I've learned

I learned that imaging was not always sensitive enough to diagnose AS. Not only that but also, a bamboo spine is usually the result of longstanding or untreated AS. They also discussed that although AS occurs more commonly in males, many women also experience AS. A male to female ratio of 2-3:1 does not mean women are not affected. In addition, although mobility restrictions are a cardinal sign of AS, early on in the disease prior to fusion a person’s posture may appear normal. I also was made aware of the tendon inflammation, uveitis, and costochondritis issues these patients deal with. Prior to this lecture, I did not associate these other issues with AS.

Myths debunked

Myth #1Bamboo spine is characteristic of AS on imaging.Myth #2AS is a man’s disease.Myth #3The curvature of the spine is noticeable.I came to realize that what I had learned was not wrong but was typical of what you see in severe and end-stage disease. Physical therapists like myself, often act as the first line of defense in conservative treatment of low back pain. We have a key role in helping to identify those that show early signs of AS to ensure a more timely diagnosis. I hope that what I have learned will help me to educate other PTs on the misconceptions I once believed.

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