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Living with an
inflammatory arthritis
Ankylosing Spondylitis
Information for patients, families and carers
Table of contents
Chapter 1
What is Ankylosing Spondylitis This booklet has been designed to help people with AS, their families and carers. It deals with some of the key chal enges for people who have AS. Chapter 2
Understanding the effects of AS This AS resource was developed by Arthritis NSW using an unrestricted educational grant from Wyeth Australia Pty Ltd. Chapter 3
Assemble your healthcare team We would like to acknowledge and thank the following contributors: Chapter 4
Get to know your medicines Dr Lionel Schachna Chapter 5
Mrs Margaret LewingtonArthritis NSW Education Committee and staff Chapter 6
AS needs exercise Mrs Diana Aspinall Chapter 7
Helpful contacts All the people with AS who are featured in the photos in this booklet. What is ankylosing spondylitis?
Ankylosing spondylitis (or AS for short) is a chronic rheumatic condition that • Reactive arthritis - this is an acute arthritis that
mainly affects the back and neck. The term ankylosing spondylitis is derived is triggered by certain bowel and genital infections from the Greek language and is pronounced ‘Ank-ill-ose-ing Spon-dill-eye-tis'.
such as Salmonella or Chlamydia.
Ankylosing means stiffening or joining together and is used to describe the • Arthritis with inflammatory bowel disease -
fusion of bones in the spine. Spondylitis means inflammation of the spine, a arthritis can sometimes occur in inflammatory characteristic feature of AS.
bowel disease such as Crohn's disease and ulcerative colitis.
Is ankylosing spondylitis the same as spondylosis?
Undifferentiated spondyloarthritis
- this usually presents with symptoms No. The term spondylosis is used to describe degenerative changes of the of AS without the characteristic X-ray spine and is more common in older people. This is unlike AS which is an changes in the sacroiliac joints. Over time, inflammatory condition, without degenerative changes, which can produce most individuals with undifferentiated overgrowth of bone and can lead to fusion (joining) of vertebrae (bones that spondyloarthritis will develop ankylosing e who take an active make up the spine). role in managing their arthritis feel less pain and AS is an inflammatory condition
disability. physica Who gets AS?
In AS, inflammation commonly occurs where ligaments or tendons attach to AS may affect as many as 1 in 300 people in bone (this is called an enthesis). Ligaments are made of fibrous tissue that [can be enhanced by] y the community. It is more common in men, with connects bone to bone while tendons connect muscles to bone.
3 times as many men having AS compared to o participate in all In the early stages of AS most of the pain and stiffness is caused by women. Symptoms usually begin between the aspects of daily life and inflammation. Over time, the process of spinal inflammation and associated ages of 15 and 45 years.
leisure activities." tissue damage may lead to bony overgrowths (called syndesmophytes, AS may affect children in different ways to Associate Professor Nick Manolios, Director pronounced ‘sin-de-moe-fye-tees') which extend from the edge of one vertebra adults. When AS appears in children (usually Sydney West Area He to the next. This process may lead to ankylosis or fusion of part of the spine adolescents), it commonly affects the ankles Westmead NSW and University of Sydney and sometimes the pelvis. Over time, the elasticity of the ligaments and and feet rather than the spine.
tendons may be replaced by rigid fused bone, and flexible movement of the spine may become increasingly restricted.
What causes AS?
Approximately 90% of people with AS carry a gene called HLA-B27 (Human Leucocyte Antigen-B27). This is a normal genetic variant and occurs in AS is part of a larger group of disorders called spondyloarthritis (pronounced approximately 8% of Caucasians. Only 10-15% of people with HLA-B27 will ‘spon-dill-oh' arthritis) which also includes: develop AS or another spondyloarthritis. The majority of people with HLA-B27 • Psoriatic arthritis (pronounced ‘sore-attic' arthritis) - this arthritis usually
will therefore not ever develop AS.
occurs with psoriasis (pronounced ‘sore-eye-a-sis'). Psoriasis is a scaly Finding the HLA-B27 gene does not necessarily mean a diagnosis of AS skin disorder characterised by scattered red patches covered with white because the gene on its own does not cause AS. AS is thought to be caused by a combination of unknown triggers in the auto-immune system of individuals genetically predisposed to developing AS.
What is ankylosing spondylitis?
Chest symptoms - Pain at the front of the chest or between the shoulder blades (made worse by coughing and sneezing) is also a common early complaint.
What happens as AS progresses?
The course of AS is highly variable. Some people have only brief episodes
of back pain with long periods of remission in between times. In others, the
symptoms are more persistent.
Most people with AS experience episodic flares of spinal pain and a slow
decline of spinal flexibility. The long-term outlook in AS can usual y be assessed
by the severity of symptoms over the first 10 years. People with only minor
People with HLA-B27 have a 50% chance of passing the gene on to restriction in spinal mobility and limitation of daily functioning after 10 years are their children so an HLA-B27 positive child, of an individual with AS, has unlikely to develop major problems with AS in the long term.
approximately a 1 in 5 chance of developing AS. If a parent has AS and is In people with AS, limitation of spinal mobility may appear several decades concerned they should discuss the option of genetic counselling with their after the onset of symptoms. The most wel recognised feature of AS, thoracic healthcare professional. kyphosis (pronounced ‘kigh-foh-sis' ), is a late feature of this disorder. Kyphosis is exaggerated forward curvature of the thoracic region of the spinal column How is AS diagnosed?
resulting in a rounded upper back.
Early diagnosis of AS is important because spinal deformity can be minimised and progressive loss of mobility can be reduced with appropriate management. Is there a cure for AS?
The objectives of treatment are to reduce pain and stiffness, maintain erect There is no cure for AS but with new medicines the disease can be managed posture, and preserve mobility and normal daily functioning. Although there positively. The effects of AS wil vary with each individual and your healthcare is currently no cure or measure that prevents the onset of AS, the treatment team wil strive to achieve periods of remission. This brochure helps provide tips options have substantial y improved in recent years. to manage pain and maintain movement.
The diagnosis of AS is made from an assessment of your symptoms, physical examination findings, blood tests and X-rays or MRI scans. These wil be organised by your rheumatologist who can explain the result of each test. MRI is a diagnostic technique that produces computerised images of internal body tissues using magnetic waves.
Early symptoms
Sacroili tis (pronounced ‘sack-row-il -ee-eye-tis' ) is an early feature in most
people with AS. The pain caused by sacroili tis is usual y a dul ache felt deep in
the buttock region, due to inflammation of the joint between the tail bone and the
pelvis. The pain can also spread out over the buttocks. At first, it may come and
go, it may just involve one side or move from one side to the other.
Understanding the effects of AS
Back pain - mechanical or
prolapsed disc. In older people, Does AS affect other parts of the
degenerative or ‘wear and tear' changes of the lower spine are the Although AS mainly involves the spine, most common cause of backache other areas can be affected. and unlike AS, these conditions cause ‘mechanical back pain'. This pain is characteristical y made worse by activity and improved by Approximately 50% of the people rest. Stiffness of the spine in the with AS have inflammation of the limb morning is minimal and short- joints cal ed peripheral arthritis, which Enthesitis (pronounced ‘en-thess- lived, and the response to anti- causes pain, stiffness and swel ing. eye-tis') is the name given to inflammatory medicines is modest. The large joints (hips and shoulders) inflammation in areas where ligaments Short periods of rest, appropriate are most commonly affected. and tendons join to the bone and is exercise and physiotherapy People with AS who have hip joint a unique feature of spondyloarthritis. programs form a basis for the The spine is divided into three sections: problems often have a more severe Enthesitis commonly occurs around treatment of mechanical back pain.
overal course of their disorder. Less the heel in conditions cal ed Achil es • Cervical section: 7 vertebrae of the commonly, the knees, ankles, and wrist tendonitis and plantar fasci tis. This joints can become inflamed. Inflammatory back pain
can be chal enging to treat and often • Thoracic section: 12 vertebrae of requires management by a podiatrist the mid-spine, which also join up By contrast, AS causes or orthotist (see Chapter 3, Assemble inflammatory back pain, which is your healthcare team).
made worse by prolonged rest • Lumbar section: 5 vertebrae of the and inactivity. As a result, pain and stiffness in AS are usual y worse The lowest lumbar vertebra (the 5th) early in the morning and when you sits on a bone that forms the back first get out of bed. The severity portion of the pelvis cal ed the sacrum and duration of morning stiffness or tail bone. The sacrum looks like a is a good measure of the activity keystone in the bony ring or basin that forms the pelvis. The sacroiliac joints For people with inflammatory attach the sacrum to the ilium of the back pain, regular stretches pelvic bone on either side. and exercise relieve symptoms. In addition, anti-inflammatory Mechanical back pain
medicines usual y provide considerable relief. Back pain is a very common complaint You may feel pain in the buttocks in the community. Most people with and down your thighs. AS can also backache do not have AS. In middle affect the hips, knee and ankle joints.
age, the most common causes of backache are ligament strain and Understanding the effects of AS
make having sex painful and Inflammation of the eye (cal ed iritis AS can cause fatigue and blood uncomfortable. Sometimes you may or uveitis) may occur in about 30% tests can help identify whether there experience fatigue and tiredness, of people with AS. In some cases, is another cause so that appropriate which can have an impact on your an episode of iritis or uveitis is the treatment can be provided. Your sexual relationship. This may mean first sign of AS. Iritis or uveitis is healthcare team are the best people that you and your partner may inflammation of the middle layer of the to advise you on this.
need to find ways to cope with eye's protective covering.
these challenges. Seek help and advice from relevant healthcare Typical warning signs might include Depression and Mood
eye redness and pain, an intolerance and blood, cramping abdominal pain, of bright light, and blurry vision. and patches of bowel ulceration.
AS can contribute to mood changes This usual y occurs in one eye at a or depression. Please be aware of AS and pregnancy
time. Inflammation of the eye can any mood swings or changes and Having AS does not appear to have occasional y lead to a permanent discuss these with your healthcare any negative effects on fertility, loss of vision so it is important to team or visit Scaly or flaky skin rashes (called pregnancy or breastfeeding. treat symptoms early. If any of these or psoriasis) can occur in AS. The symptoms occur you should see an for assistance.
areas affected are often the scalp, If you are pregnant, your doctor or ophthalmologist (eye specialist), GP belly button, buttock crease, back physiotherapist may suggest gentle or go to the Emergency Department of elbows and top of the knees. An physical activity and weight relieving of an eye or local hospital. If you have arthritis called psoriatic arthritis may water exercises. already been diagnosed with AS, tell occur in one third of people with Clinical studies demonstrate that If you have any questions or your healthcare professional. up to 60% of patients with AS have concerns about the effect osteoporosis. Osteoporosis is a of medicines, pregnancy or disorder that results in a decrease breastfeeding please discuss these Heart and Lungs
in the amount of bone tissue in the with your doctor.
Inflammation of the lining of the bowel skeleton and increases the risk of Occasionally, AS can cause scarring wall may occur in more than half of having a fracture. Your doctor may of the upper lobes of the lungs and/or people with AS. Most of the time, this perform a bone mineral density a disturbance of the normal heart inflammation is very minor and does (BMD) test to assess the amount of rhythm. AS can inflame the rib joints not cause any symptoms. However, bone tissue in the skeleton.
(enthesitis) and affect the muscles some people with AS have symptoms between the ribs making breathing, of inflammatory bowel disease sneezing, coughing or yawning AS and sex
(usually Crohn's disease or ulcerative painful. In the later stages of AS the colitis). Crohn's disease is an rib joints may become quite fixed and As AS usually begins in early inflammatory condition that may affect exercise is recommended to help adulthood, sexual and reproductive the gastrointestinal tract. Ulcerative maintain normal movement of the health is important to consider. colitis is a chronic inflammatory chest wall. (See specific AS exercise Having AS should not interfere with disease of the colon that causes later in this booklet). Smoking should lovemaking but the inflammation diarrhoea with discharge of mucus in hip joints and lower back can Assemble your healthcare team
There are several healthcare Psychologist or Psychiatrist
professionals who can provide Physiotherapists can help with advice, support and treatment. You, The diagnosis of a chronic rheumatic mobilisation techniques, stretches, as the patient with AS, are the most illness can be difficult for both the and assisted movements and important member of this team. person with AS and their loved ones. exercises that are appropriate to Patient-centred care means that you Psychologists and psychiatrists are your condition and needs. They will and your team can develop, monitor trained to improve your emotional help tailor an exercise plan to meet and review your management plan wellbeing through counselling and your individual needs. This includes together. Your needs wil vary over medicines where appropriate. Visit ways to help manage your pain, your Occupational Therapists can provide time and your healthcare professionals or www.
daily activities, posture, sport and advice and assistance with activities of are the best people to assist you to daily living – such as rest and activity improve your quality of life.
periods, work place advice and home modification. If necessary they may Other medical specialists may Hydrotherapy (exercises in water) suggest the use of assistive devices be recommended by your GP or can be a more comfortable way of to make day-to-day activities easier to rheumatologist. These may include Your GP will help you to coordinate exercising. The warmth and support of perform. Further information is available an ophthalmologist for eye treatment, your care. They can arrange referral the water gives pain relief and allows from Independent Living Centres a dermatologist for skin treatments to a rheumatologist and assess if you a greater freedom of movement to Australia at and a gastroenterologist for bowel are eligible for a "Care Plan". A Care relieve stiffness. Group or individual Plan means you can access some sessions specifically for people short-term sessions by the Allied with AS can be helpful. Call 1800 Podiatrist or Orthotist
Health Care Team under Medicare. 011 041 for information about your A podiatrist or orthotist provides Ideally, all of your healthcare
nearest hydrotherapy class. Aquatic professional assessment and professionals will communicate
Physiotherapists can be found at with each other and with you to
management of your feet. Provision of orthotics may improve symptoms co-ordinate your care.
Rheumatologists are doctors who and some simple measures such as specialise in diagnosing and treating better shock absorbing soles can be bone, joint, and muscle disorders. Chiropractic, manipulation and
Ankylosing Spondylitis Support
Initially, your rheumatologist may be involved in diagnosing your Care is needed when using these AS support groups are a very AS. They will discuss your medical treatments for AS. It is very important valuable resource - providing support, history, as well as perform a physical to discuss the level of manipulation Your pharmacist is a valuable information and social interaction. examination, X-rays and blood tests. that is suitable for your condition member of your healthcare team People who have similar difficulties Once the diagnosis of AS is made, with your doctor or specialist before who can answer your medicine can provide empathy and share daily your rheumatologist will discuss commencing these treatments. related questions. They can provide a experiences and challenges. For more treatment options such as exercise Consumer Medicine Information (See information call 1800 011 041 or and the use of medicines. Regular Get to know your medicines section) visits to your rheumatologist are document which explains the benefits necessary to help manage your AS. and risks of each medicine you are taking for AS. Get to know your medicines
AS can be managed with a combination of medicines and specific exercises to relieve pain, maintain mobility and a correct posture, so that you can continue to do your daily activities. In this chapter we will discuss the medicines that may be used to treat AS. Although there is no cure for AS, treatment options have substantially improved in recent years. Before considering surgery, pregnancy or breast-feeding, the use of any medicine should be discussed with your doctor.
Consumer Medicine Information (CMI)
Risks and benefits
CMIs are available to help For further information on Some medicines may have side supplements, as well as drinking consumers use the medicines any of the medicines listed in effects. Your doctor has weighed alcohol can affect the way they take appropriately. There this brochure please refer to the risks of using this medicine is a CMI available for all against the benefits they expect If you experience any side prescription and some CMIs are also available from the it will have for you.
effects please discuss these company making the medicine It is important that your doctor with your doctor, healthcare A CMI is factual, contains no or the National Prescribing is aware of your full medical professional or pharmacist. advertising material, and must Service (NPS) Medicines Line history, including any family If you experience a serious comply with the requirements 1300 888 763 available history of medical problems and side effect or have questions, set down in the Commonwealth Monday to Friday 9am – 6pm medicines that you are currently seek medical advice quickly or Therapeutic Goods Regulations. or taking, so they can make an contact the Medicines Line on Ask your pharmacist or doctor See Chapter 7, Helpful contacts. accurate assessment of the 1300 888 763.
for a CMI and they will print it risk and benefits of prescribing from their computer. Sometimes medicines for you.
the CMI is provided inside Other medicines including the packet or box with your over the counter, herbal, complementary medicines and Get to know your medicines
Analgesics (pain relievers)
Disease Modifying Anti-
Corticosteroids (or steroids)
Pain relievers, such as paracetamol, Rheumatic Drugs (DMARDs)
Corticosteroids are man-made may be useful in combination with DMARDs are medicines commonly substances that resemble hormones other medicines that your doctor has used in rheumatoid arthritis that may natural y produced by our body. They prescribed. They can help to manage improve some of the symptoms of AS, relieve pain and are powerful anti- the pain that may be associated in particular inflammation of the limb with AS. If the pain is severe and You may be prescribed corticosteroid unrelenting, you should see your tablets, most commonly prednisolone. GP or rheumatologist and have your treatment reviewed.
Sulfasalazine (Salazopyrin®)
These medicines have possible side effects and require careful monitoring Sulfasalazine is helpful in patients with of blood pressure, cholesterol, glucose AS who have pain and swel ing in a Non Steroidal Anti-Inflammatory
limb joint (e.g. knee, ankle, toes). The Biologic Medicines
levels and bone density.
Drugs (NSAIDs)
ful effect of sulfasalazine is usual y Biologic medicines are the latest Corticosteroids may also be given as NSAIDs are usually the first not seen for 1-3 months. The most disease modifying medicines available a local injection into an inflamed joint. medicines used in the treatment common side effects are nausea, skin for treating severe AS. They target the This injection can provide rapid control of AS. Examples of NSAIDs are rash and headache. Sulfasalazine individual molecules that are involved of pain and swel ing as a short-term ibuprofen, piroxicam and naproxen. should not be used in individuals with in inflammation and joint damage. A newer class of NSAIDs are the an al ergy to sulfa-drugs (such as COX-2 inhibitors, which include A number of these medicines are Bactrim® or Septrin®). celecoxib (Celebrex®), meloxicam directed against a molecule that Regular monitoring of blood counts (Mobic®) and lumiracoxib (Prexige®). promotes inflammation cal ed tumour and liver tests are mandatory.
NSAIDs can improve pain and necrosis factor (TNF) which is a stiffness by reducing inflammation. natural substance cal ed a cytokine. In They are commonly used with other people with AS, TNF is present in the Methotrexate (Methoblastin®)
types of medicines to get the best blood and joints in excessive amounts. Methotrexate is also useful for patients TNF inhibitors block or neutralise with pain and swel ing in a limb joint. TNF, reducing the inflammation and Common side effects include The ful effect is usual y not seen for heartburn, raised blood pressure and 1-3 months. The most common side swelling of the ankles. These side The biologic medicines are given effects are nausea, mouth ulcers effects are more likely to occur in either by injection under the skin, or and fatigue. Folic acid is routinely individuals over the age of 65 years. by infusion into a vein. They can only prescribed to minimise these side As everybody reacts differently to be prescribed by a rheumatologist. effects. Routine monitoring of blood NSAIDs you may need to switch to a counts and liver tests are mandatory. The biologics that are currently different NSAID to find the one that Report any infection immediately to available for use in AS include: best controls your symptoms with your doctor.
etanercept (Enbrel®), infliximab the least side effects. Your doctor or (Remicade®) and adalimumab pharmacist can advise you on how these medicines may affect you.
Living with AS
Tips for living with AS
If you manage your AS carefully, you When standing, keep your bodyweight balanced and even on both feet. should be able to carry out most of Think tall through your whole body, ensuring that you are not flexed at the hips, your usual activities. For the vast that you have some curve in your lower back, that your chest is lifted off your majority of people AS is not a barrier belt line, shoulders are relaxed (back and down), and that the back of your to employment, raising a family, or neck is long, allowing your chin to drop slightly forwards. Do not stand still for keeping physically active.
too long. When you move and walk, try to maintain this tall posture, but also The effects of AS are different in each remain relaxed.
person. Learning about your condition and what you can do, along with help Lying down & sleeping
from others, is vital to making the Make good posture a habit. Changes most of your life.
happen slowly, so we often don't A good night's sleep is essential for rest and repair of the body. The best notice them at the time. It is important mattress is one that is firm and gives support, but is not too hard. Use only to check your posture regularly and one pillow if possible, which fits snugly into your neck and supports the head. discuss with your healthcare team.
Sleep in the position that you find most comfortable, whether on your back, Good posture is vital. It's very front or side. To enhance freedom of movement during sleep, some people For more information see the posture important to pay attention to how with AS prefer silk sheets and silken nightwear.
exercises included within this booklet.
you stand and sit at all times. Stand If lying on your front, don't always have your head turned to the same side. as tall and straight as possible. Sit On your sides, avoid curling up with a lot of flexion (bending) at the hips and well supported and upright in a knees. A pillow placed under your top knee may ease back pain at times. If good chair. These everyday skills will When sitting, ensure that you have a lying on your back, pillows and other supports may be useful - but avoid using help you change the tendency to good supportive chair - at home and them all the time as they may encourage muscle shortening. Try not to put bend forwards and stoop. It is also at work. It should be firm, upright and pillows under your knees.
important to be aware of posture as allow the feet to touch the floor with Many people wake in the early hours the knees and hips at a right angle. To and find it hard to settle again, as Poor posture may have a negative avoid neck strain, if you are working they are feeling pain and stiffness. impact on the position and function of at a desk or using a computer, ensure A few simple stretching exercises your spine. When experiencing pain that the screen is level with your eyes. in the evening before going to bed in the spine, there is a tendency to Back supports, lumbar rolls, wedge may improve your sleep. This ensures stoop. If the position is not corrected, cushions and other devices may help that you are inactive for the shortest there will be chronic joint strain, to improve the seat you have. Advice period of time. Alternatively, get up difficulty breathing, compression of on these items can be obtained from and do a few stretches and then abdominal organs and tightness on Independent Living Centres Australia go back to bed. If you continue to the front of the shoulders. It becomes at have problems with sleeping please increasingly difficult to straighten up discuss them with your healthcare but with practice, you can improve. Living with AS
sure you stretch and reverse the a small cushion or back support to It is necessary to keep the whole posture you have been using. Contact maintain a correct and comfortable body as flexible as possible to and collision sports are usually not position whilst driving. If your AS is minimise rigidity and avoid injuries as advised. High impact sports like affecting your neck, ensure that the much as possible.
football and parachuting are usually head restraints are correctly adjusted not recommended.
for you. If you have some neck rigidity Try to move your spine regularly. Not from AS your peripheral vision can be even the best position is as good as While sports and other physical decreased. Investigate whether you moving. Allow yourself to bend and activities are beneficial, they cannot can install more mirrors to assist you. straighten your spine, bend sideways be totally relied upon to ensure erect and turn often. Do not sit for more posture and flexibility. You still need to Manage your energy
than 20 minutes at a time. Stand up do the AS-specific exercises daily.
It is quite common for people with Make life easier
and walk about. Stretch and move AS to complain that they feel tired. To help you to continue with your Work choices
As the body is using a lot of energy regular activities, extra resources are to fight the inflammation that is available. Specially designed chairs Having AS usually does not make it present, fatigue is a recognised and supportive cushions are available more difficult to find employment or symptom of AS. Mild anaemia (which to help you maintain correct posture People with AS can participate in a have a fulfilling life. Most people are contributes to lowered levels of while driving or sitting at a desk and wide variety of sports and activities. able to continue in their choice of oxygen in the blood) may also be simple devices are available to make Sports and activities that encourage occupation. During bad times with present. Your doctor can check for gardening and other activities easier. good posture and spinal extension are significant inflammation, you may this with a simple blood test. It can For more information on these, talk recommended. Swimming, walking, need to modify what and how you do be managed with medicine and there with your healthcare team and/or have tennis and low impact aerobics are all things. Some time off work may be are also ways that you can help a look at some of the support sites good. Golf, cycling and bowling may necessary. Research has shown that yourself. Plan your day and week, listed at the end of this booklet.
be good but these activities need to on average, you will not need more pace yourself, vary your activities, be tailored to your physical capability time off work than the rest of the organise yourself and give yourself and fitness. After any exercise make time to rest and relax. Moderate If you are choosing or changing jobs, exercise and activity is also helpful.
it is helpful to choose something where you can have a range of postures, positions, tasks and time Take extra care when driving
management. An active job, although Prolonged periods of driving can physically hard at times with AS, is increase pain and stiffness. Make better than sitting in a chair all day. If frequent stops and use your your job prevents you moving much, exercises to assist your joints to be compensate by moving more at other flexible and not stiff. You may need times. In some work settings the staff OH&S officer can undertake an ergonomic assessment of your physical environment.
Living with AS
• Imagery – imagine doing Except for people with gout, most A relevant exercise program is a big something that is very important to foods wil not have an effect on help for people with AS, but this needs you. Imagine the positive outcome. AS or arthritis. Be very cautious of to be balanced with appropriate rest Daydreaming yourself to this special diets or supplements that and relaxation. Relaxation can help special place can act as a mental claim to ‘cure' arthritis or to control its to prevent and reduce excessive levels of tension and anxiety that often • Progressive muscle relaxation accompany AS and arthritis. It can also – tense and relax muscles in a A good balanced diet is important decrease muscle tension and spasm. specific order. This helps relax part for maintaining your general health If you are having trouble sleeping, then of your body that you may not have because it wil positively affect your If you can't eat these foods regularly, it is important to include a dedicated realised needed it total wel being. Remember, your Omega 3 supplements that contain period of relaxation just before • Meditation – this is an excel ent body relies on you to feed it the around 4 to 6g (4000-6000mg) per relaxation technique that involves nutrients it needs to fight disease day of fish oil are recommended. Managing your stress is very important focusing on breathing, clearing and resist deterioration. Achieving It's best to talk with your health as many people report that high stress your mind and concentrating on an and maintaining a healthy weight is professionals about the safety and levels tend to make their symptoms important for everyone.
effectiveness of dietary supplements.
• Massage – there are several types of massage. Swedish (therapeutic) Omega 3 may reduce
Tips for effective relaxation:
massage promotes relaxation, Professional dietary advice can be Shiatsu (trigger point) therapy While it's been said that there are a lot • Find a quiet place, free from found at the Australian National Health relieves pain and Deep Tissue of unproven food claims, there is good interruptions and loud noises and Medical Research Council at massage relieves tension.
scientific evidence that inflammation • Timing – not after exercise or a can be reduced by eating foods that contain Omega 3 fatty acids six times • A comfortable position – more often than foods containing supporting painful joints Can certain foods affect arthritis?
Omega 6 fatty acids (found in vegetable oils and grains). • A positive attitude - necessary to There are many myths about food al ow your mind and body to relax and arthritis. Unfortunately, most of it is wishful thinking. There is very little Foods that are rich in Omega 3 fatty • Regular practice – relaxing is a skill scientific evidence that diet has an that gets better with practice effect on any form of arthritis, including • Fish (salmon, tuna, herrings and • Control ed breathing – take in AS. For example, it is unproven sardines, canned fish is fine) several big, slow, deep breaths that ‘acidic' foods or ‘nightshade' • Linseed and linseed oil (also cal ed • Mental focus – avoid distracting vegetables, such as potatoes, thoughts, perhaps by repeating a eggplants, capsicum and tomatoes, • Canola oil (also cal ed rapeseed oil) word each time you breathe out cause arthritis to flare up.
• Look at a calming visual image - to • Walnuts and pecans.
AS needs exercise
Exercise is one of the most effective strengthening and stretching routines. • If you are having a flare of your treatments for AS. It helps to slow This may include walking, jogging, symptoms, temporarily reduce or down the stiffening of the joints and dancing, swimming, yoga, tai chi, modify your exercise, but do not soft tissues around the joints and gym programs, weight training, can help you manage your pain. It bushwalking, cycling, etc.
• Set short-term goals and celebrate is wel known that regular exercise your successes.
can strengthen your muscles, relieve tension and general y improve your Tips to keep you exercising
• Keep an exercise diary, so you can overal health. This means you wil be It is important to plan your exercise for see how you are progressing.
able to feel more in control of your AS times when you're least tired and when • Work with your physiotherapist to may have lost. Some of the exercises and do more in your daily life. your medicine is having maximum ensure that your exercise plan is involve stretching a specific muscle effect (times of least pain). best for you.
and some stretch several muscles and other tissues at once.
Exercise to specifically combat AS
It is important to do these exercises It is essential to perform exercises that • Do activities that you enjoy! Vary Your exercise programme
with some vigour – but without hurting are designed to stretch tight muscles them so you don't get bored.
the body. It is usual to feel some and ligaments, encourage ful mobility • It's more fun to exercise with a Stiffness and loss of flexibility are the discomfort, as you try to go as far as and to strengthen your postural friend or in a group. greatest problems for people with you can. If there is pain, check that you muscles. A range of these exercises, • Be aware of joint pain and swel ing. AS, so the most important exercises are doing it correctly. Good technique developed by a physiotherapist who You should feel some stretching encourage movement. Specifical y, is vital to obtain the best results and specialises in the treatment of AS, has and discomfort with the exercises, exercises that help the body to loosen minimise injury.
been included in this chapter to either but stop the activity if it causes you up and feel free work best.
help get you started or to compliment additional pain.
your current exercise regimen.
Regular stretching improves the How to stretch muscles:
flexibility of muscles, tendons and Specific AS exercises for 30 other soft tissues, which as a result • Warm up first mins per day, at least 5 times per of inflammation can become sore • Don't hold your breath. Paying week (preferably every day), are and difficult to move. If they are not attention to your breathing can recommended. A moderate, consistent stretched, they become shorter and make the exercise more effective. exercise program has been shown to tighter. This can make it harder to It also helps you relax be the most beneficial in achieving stand up straight, to turn and bend, or results for your AS. It should be • Keep stretches slow and gradual to take a deep breath.
individual y tailored to meet your needs and avoid jerky movements so as to provide quicker and better It is very easy to become a little stiffer • Hold muscle stretches for at least results for you. and a little less straight without being aware of it – the process happens so As wel as your AS specific exercises, slowly. The exercises in this book are • Position correctly / watch your it is important to do general exercise designed to combat the damaging for fitness and wel -being. Regular effects of AS. In many cases, when exercise wil also improve your you start exercising and stretching, you overal health and enhance your can regain some of the movement you AS needs exercise
The PNF method
strengthen are the ones that hold us Exercise 2. Bridging
To effectively stretch muscles, a long, up straight – the postural or anti- Time your breathing with the exercise. Lift your buttocks off the floor. Hold for slow sustained stretch is necessary, gravity muscles. These exercises are This helps you to relax, to focus and to 5 sec and lower slowly. Try to lift your while keeping the body relaxed. designed to increase the strength and involve the chest appropriately. Do not buttocks enough to have your shoulders, endurance of these muscles, to make PNF stands for Proprioceptive hold your breath.
hips and knees in a straight line.
it easier to keep in an upright position Neuromuscular Facilitation and it is with good posture.
a method of stretching muscles to A. LYING ON YOUR BACK
maximize their flexibility. A muscle wil stretch further and more easily if Exercise 1. Knee Rocking
it is first made to contract or work, These exercises have been designed Lie on your back with your arms straight, then relax completely, fol owed by a physiotherapist specifical y for palms up and out from your sides, at by a firm and steady stretch. The people with AS. They target the areas shoulder level if possible. Bend both sequence is ‘contract, relax, and then most commonly affected and wil give knees and place your feet on the floor. passively stretch'. The objective is to you a general workout. It is advised Rock knees from side to side. have muscles contract isometrical y that you consult a physiotherapist to Gradual y make the movement larger, (without movement), then after help you with identifying which are but keep your shoulders stil . You may relaxing, be passively stretched. Hold the most important exercises for you. turn your head to the opposite side.
this stretched position, but keep They wil also be able to check that yourself relaxed (don't hold your breath Exercise 3. Arm Sweeps
you have correct technique and that or tense your body). Repeat this you are doing them safely. They can Take your arms from your sides, sequence another 2 times, each one also provide modifications to suit your sliding along the floor, to up and from the advanced starting position.
particular needs. Regular reviews with over your head keeping the backs a physiotherapist are recommended.
of your fingertips touching the floor throughout. Slide back again. Breathe in and out Each gain may be smal , but it al adds as you stretch.
up. Giving a stiff joint another few It can be helpful to warm up before degrees of movement is worth having. you exercise. A few minutes walking If you don't stretch your muscles, on the spot, or moving about, or a in time they wil become tighter. warm shower can help.
Remember to use the extra movement you gain from the exercises in your daily life. Reach up to tal er shelves and turn and look further behind you.
Do each exercise at least 5 times. If the exercise is for one side of your body then make sure you do an equal number for the opposite side – for Strong muscles support the body. The muscles that are important to AS needs exercise
Exercise 4. Legs Wide
Exercise 6. Upper Body Roll
Exercise 8. Arm and Leg Lift
Slide your feet apart, pushing the ankles Keep knees together and slightly bent. On al fours: position yourself on your Keep your body steady and balanced, out, heels leading. Take legs as wide as Reach forward with your top arm as far hands and knees, keep your elbows slowly lift your right arm forwards, you can, but keep your legs straight and as possible, al owing your chest to roll keeping it close to your ear, and your bottom flat. Slide back together.
forwards. Then lift this arm up and over straighten your left leg behind you, Exercise 7. Cat Stretch
your body and back behind you, aiming leading with your heel. Stretch long to touch the floor with back of your Let your head relax down between your through your body, from finger tip to hand. Let your chest rol backwards. arms and arch your back upwards. Feel toe. Hold this position for 10 sec, then Look at your hand throughout the a stretch in the upper back as wel as lower and repeat with the other limbs. the low back. Now relax the back and Look forward at your hand.
let it sag towards the floor. Feel this stretch in both the upper back and the lower back as wel . Look forwards, not upwards, with your head, lifting your chest.
Make sure you are on your side, not
leaning forward or back, especial y at
the hip.
Exercise 9. Back Stretch
Exercise 5. Cycle
Rock back onto your haunches, leaving Bend your top leg up towards your your arms in front. Try to drop your chest and then stretch it down straight. chest as low as possible to the floor You can also make a cycling action and look down at the floor. You may with this top leg. Lead with the heel also do this with both hands to one when the straight leg goes backward.
side (b) and then to the other, to help stretch the sides of the body.
AS needs exercise
Exercise 13. Back Stretch and Arch
Stretch 1. Hamstring / Back of

Exercise 10. Chest Lift
Let your hands reach towards the Have a firm, straight chair. Sit with your floor, curling your whole back. Go feet supported. Sit tal and straight.
Standing – Place your heel on a small Lie on your tummy with your arms as far as you can – reach through stool in front of you. Keep your knee relaxed at shoulder height. You may under the chair if you can. Hang and straight, your toes pointing up and lean prefer a smal pil ow under your chest. Exercise 12. Side Stretch
relax for a few seconds and then your trunk forwards towards your knee. Lift your upper body – head, chest, sit up straight, arch your back away Keep your chest up and look at your and arms - off the floor. Do not lift too Let your hands hang by your sides. from the back of the chair, place your foot, to avoid curling your back.
high, but make sure you straighten your Lean to one side as far as possible, hands on your shoulders and take back. Keep looking down at the same keeping your buttocks firmly on the your elbows wide, feeling a stretch spot on the floor. Hold for 5 sec, and seat. Avoid letting your trunk turn or roll across the front of the chest. then relax before repeating.
and keep your face looking forwards. You may also take your other arm up F. STRETCHES
and over your head and over to the same side. Come back to straight and then lean to the other side.
Exercise 11. Press-up
Lying – Lie on your back, one leg Lie flat on your tummy. Place your out straight and bend the other knee hands on the floor just in front of your towards your chest. Straighten this shoulders. Push through your hands to leg to the ceiling. You may support it straighten your arms. Keep your hips There are several muscles, which are behind the thigh or you may hold the on the floor and al ow your back to important to stretch regularly. A few foot with a towel.
arch. Look forwards and lift your chest.
are described here. Others include the calf, hip adductors, and quadriceps in the leg and the pectoral muscles at the front of the shoulder.
AS needs exercise
Stretch 2. Hip Flexors /
Stretch 3. Piriformis /
Stretch 4. Neck – Rotation /
Front of Thigh
Deep Buttock
Throughout the day, the effects of a. Stand beside a firm chair with one Lie on your back, bend your left knee Sit straight in a firm chair, feet on the gravity try to pul you forward and knee/shin on the chair. towards your chest and hold it with floor. Look to the right as far as you make it hard to keep straight. Several your left hand. Hold your left foot with can. Bring your right hand up to your b. Step through with your standing leg positions can help you reverse these your right hand. Let your knee drop face and place it on your left/front to place it in front of your bent leg. stresses and help you to check if you out and then pull with both hands to cheek. Keep your left shoulder back, Tuck your tummy in, flatten the arch are keeping straight.
bring your shin towards (sit on your hand or place it behind the in your lower back and lift your chest. your right shoulder.
chair). Use your right hand to help your c. Bend your standing leg and move head around just a little bit further. Take Long Neck
your trunk forwards a little. Do not this gently but firm, no jerking. Keep Lie flat on your back on a firm surface. lean sideways.
your chin up and eyes level.
Keep your chin gently tucked in, avoiding the chin pointing up. Keep the back of your neck long. This may also be done in sitting and standing.
It is also important to stretch your neck forwards, backwards, side-bending and diagonal y. It is important that a physiotherapist demonstrates these stretches.
AS needs exercise (continued)
Hip Stretch
Stand Tall
To contact your Arthritis State office – Freecal : 1800 011 041 Lie on your tummy. This position helps Stand with your back to a wal . Your Arthritis NSW:
Independent Living Centres
to keep the front of the hips stretched. buttocks, shoulders and head should Australia:
You may wish to have a smal pil ow al touch the wal . Look straight ahead, Arthritis Australia
under your chest, and it is helpful to tuck your chin in and feel long and (National and ACT):
Australian Government
turn your head to each side for some tal through your spine and back of Health Website:
of the time.
the neck. Walk away from the wal , Challenging Arthritis
keeping in this tal posture.
by Arthritis NSW:
Medicines Information Line:
Phone tol free: 1300 888 763 AS Support Groups:
Beyond Blue: Arthritis Victoria:
Black Dog:
Arthritis Queensland:
Australian Physiotherapy
Arthritis Foundation of WA:
Rheumatology Health
Lie on your back on a bed, with your Professionals Association:
Arthritis and Osteoporosis
lower legs hanging over the edge. Tasmania:
This position also helps to stretch the Osteoporosis Australia:
front of your hips without being on Arthritis South Australia:
your tummy. Do not let your back arch.
National Prescribing Service:
Arthritis Northern Territory:
Talking with your doctor or pharmacist about medicines is Ankylosing Spondylitis
always recommended.
Contact the Arthritis National AS Society (UK):
Foundation in your state on 1800 011 041 to US Arthritis Foundation:
find out what support is available in your area.
Spondylitis Association
of America:
Ankylosing Spondylitis
Information for patients, families and carers
Arthritis NSW, 13 Harold Street, North Parramatta NSW 2151Mail: Locked Bag 16, Post Office, North Parramatta NSW 2151 Australia Phone: 02 9683 1622Fax: Email: [email protected]: telephone advice: 1800 332 131 Enbrel® and Wyeth® are registered trademarks of Wyeth Australia Pty Limited, 17-19 Solent Circuit, Baulkham Hills NSW, 2153. Celebrex®, Mobic®, Prexige®, Salazopyrin®, Methoblastin®, Remicade® and Humira® are registered trademarks. H&T WYE0163 W20060950.


Mics4 preliminary findings

Monitoring the situation of children and women Multiple Indicator Cluster Survey SUMMARY REPORT Federal Republic of Nigeria National Bureau of Statistics MICS Nigeria, 2011 Summary Report In Memory This report is dedicated to the 24 people killed, and those who were injured, by the bomb attack on UN House in Abuja on the 26th August 2011. Amongst the people who lost their lives was Johnson Awotunde who devoted his time, energy and personal resources to the success of the survey until his untimely departure.

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