Bruce Rothschild
Choices for therapeutic intervention for ankylosing spondylitis have been traditionally predicated on its classification as a form of inflammatory arthritis. While this approach is effective for management of peripheral joint disease and may reduce back pain, the nature of axial joint disease is controversial. New information suggests that the latter is predominantly mechanical in nature (e.g., related to enthesial stresses) with any inflammation representing a part of the normal response to injury. Introduction of an extension exercise program, with modification of contributing aspects of activities of daily living, and avoidance of flexion activities usually resolved back discomfort and assures the best possible residual posture (as the spinal fusion progresses). No intervention is known to slow that process. Rheumatology perhaps started as codification empirical approaches. Approaching the axial involvement of ankylosing spondylitis as a mechanical phenomenon is not only clinically effective, but is also cost-effective, reducing the need for expensive biological agents.
The nature of axial skeleton involvement in ankylosing spondylitis is unclear. It is assumed by some to be an essentially inflammatory process, so much so that expensive biological therapies were considered and apparently result in significant improvement in back pain. It is unclear; however, if such agents alone alter the natural history of the disease, the propensity to vertebral fusion in positions that compromise lifestyle. Others have suggested stress or what Alphonse Masi calls “inate axial (spinal) myofascial hypertonicity” as the causes of eventual loss of motion. There is interesting clinical evidence to support the latter.