Ankylosing Spondylitis (AS) is an inflammatory rheumatic disease which affects the axial skeleton (Braun and Sieper, 2007). It causes inflammatory back pain, early morning stiffness, fatigue ad leads to functional impairments and decreased quality of life. There are many interventions required for a patient with AS, each specifically tailored to each individual case. John has expressed many issues caused by his AS. Firstly, John’s fatigue should be managed in order to be able to fully participate in any other intervention. He has reported that he cannot concentrate or focus in work, and that he does not participate in many leisurely activities due to pain and stiffness. His fatigue is a factor contributing largely to this. Fatigue is responsible for pain (eg. back, neck and shoulder pain), cognitive disturbances (e.g reduced concentration) and has psychological effects (e.g anxiety, lack of social interaction) (Hammond, 2010). Once it is controlled and his energy is conserved, he will be on the way towards being able to participate in the occupations most meaningful to him again. Fatigue is a very common symptom amongst those with AS. With all inflammatory diseases, when inflammation is present, a person’s body uses up a lot of energy to counteract it, resulting in fatigue. Therefore energy conservation is an important part of fatigue management for John. Burkin (2012) states that to conserve energy, three things are involved: Planning, pacing and prioritising. The planning involves considering which times of the day are best, and spacing activities out over the week instead of all in one day. For example, John states that he is least focused in the afternoons, so a rest period should be taken during this time. Pacing involves taking the time to carry out a task, even if it means taking short breaks in between. The alternative, completing a task quickly but using up all energy, will only make the fatigue worse. It is better to use a “little and often” approach. This could apply to John at work. It has been found that rheumatic diseases such as ankylosing spondylitis contribute to loss of work (Connolly, O’Toole, Fitzpatrick, Doran & O’Shea, 2016). Boonen (2001) found that patients with AS are 3.1 times more likely to leave work than the general population. John’s work is meaningful to him so one important goal is for him to continue working. He has mentioned how supportive his employer and co-workers are, so perhaps a decreased workload would mean that John can still remain at the job he loves doing, but afford to take the breaks that are necessary. Prioritising involves thinking about what is most important and what you want to use your energy on. If John wants to bake with his children one day, he may need to prioritise that over other household tasks for example. Joint protection can be described as an active coping strategy, which aims to improve one’s daily activities, performance and reduce stress (Goodacre & McArthur, 2013). Joint protection techniques are used not only to manage fatigue but also pain and stiffness. They also reduce flare-ups. John reports early morning stiffness, a common symptom of AS, and shoulder, neck and back pain. Hammond (1999), as cited by Goodacre and McArthur (2013) state how the aims of joint protection is to reduce pain at rest and after activity, force, fatigue and disease progression, and to improve/maintain function. According to Hammond (1999), this can be achieved by respecting pain and using it as a sign to take a break or change the activity, distribute the load over several joints, use the strongest, largest available joint appropriate for the job, avoid maintaining the one position for too long, and be conscious of posture. These techniques would help to protect Johns joints in his shoulders, neck and back, reduce the pain, reduce his fatigue and conserve his energy. Ultimately this would lead to more activity and engagement for John. An intervention in self-management is crucial for John. Research suggests that 90% of the management of a chronic condition must be performed by the patient themselves, and not in fact the healthcare professional (California Healthcare Foundation, 2008). John wishes to be able to manage both his roles at work and at home, but fears with the progression of his condition that he will not be able to do so. John can achieve this by continuing to manage his fatigue, conserve his energy and protect his joints when he returns home. This will also manage and reduce flare ups – an important aspect of self management in AS. Due to the episodic nature of AS, flare-ups can happen quite regularly. A study by Brophy and Calin (2002), found that some common triggers of flares were stress, too much activity, jarring a joint and remaining in the one position for too long. With this in mind, it is important to follow these steps outlined by the Ankylosing Spondylitis Association of Ireland (ASAI) (2013) when experiencing a flare up. The first thing to do is to recognise the flare and be aware of how it feels – do not ignore the flare. To manage the flare, it is important to stay calm. If stress can trigger a flare, panic will only make it worse. John should then start practising the energy conservation techniques outlined above. He should plan, pace and prioritise his activities, and find a balance between his activities and rest. A good night’s sleep is another important step in managing a flare. Light exercise is also recommended. Leisurely walks could be beneficial for John. He would not only be managing his flare, but also introducing a new leisure occupation and getting out into his community. Exercise has been proven to be a crucial part of the management of AS (Mihai, van der Linden, de Bie & Stucki, 2005). Specifically, unsupervised recreational exercise plays an important role in AS, reducing pain and stiffness (Uhrin, Kuzis & Ward, 2000). Comfortable seating is a necessary part of John’s intervention. John has reported back, neck and shoulder pain and stiffness, and has included in his initial interview that he feels uncomfortable sitting for too long, both at work and at home. Effective seating would reduce the pain, stiffness and discomfort. It aims to enhance posture and comfort, accommodate and prevent deformity, prevent injury and assist and enable function and performance (Radomski & Latham, 2014). A trial period is necessary with each new seat. The ideal seat for John should help him maintain good posture. In the case of AS, good posture involves evenly distributed weight with no muscles being overworked, and is enabling of tasks and activities with the least fatigue possible (Pain, McLellan and Gore, 2002). The goal of a comfortable office chair to accommodate back pain would be to prevent strain in the back by keeping the spine and neck in a position that prevents this. John’s centre of gravity should fall slightly in front of the ischial tuberosities (Myhr and von Wendt, 1991). The ASAI (2013) also states that the lumbar support of a chair should support one’s natural curve of their spine. A seat that fits this criteria would have a very positive on John at work, with his posture improved, pain and stiffness reduced, discomfort counteracted, and therefore his concentration and work ability enhanced. John described difficulty in the mornings, with stiffness, getting out of bed and getting dressed. While the fatigue management, energy conservation and joint protection techniques should contribute to the management of this, there are other measures that can be taken in the form of assistive equipment. Assistive equipment includes devices, guidelines and practices, which aim to facilitate, maintain or enhance the performance of activities of daily living (Tuntland et al., 2010). For John, who experiences back pain, it may be difficult for him to bend over. A bed rail may facilitate him in getting out of bed in the mornings without experiencing pain in his back. While dressing, a dressing stick would be useful for him to pull his clothes over his feet and up his legs without having to bend over. Reachers can be used to pick grab clothes out of drawers or off the floor. Sock aids and shoe horns would also be beneficial to John (Radomski & Latham, 2014).
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