fizioterapia in spondilita anchilozanta

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Physiotherapy for ankylosing spondylitis: evidenceand applicationLaura A. Passalent

a,b

Introduction

Nonpharmacological and pharmacological managements

are considered the cornerstone of intervention for anky-

losing spondylitis (AS) and are endorsed by The Assess-

ment in Spondylitis International Society (ASAS) and the

European League Against Rheumatism (EULAR) [1].

Often nonpharmacological intervention comes in the

form of physiotherapy. The primary goals of physiother-

apy of the AS patient are to improve mobility and

strength; prevent or decrease spinal deformity; reduce

pain; and to improve one’s overall function and quality of life. In order to achieve these goals, there exists a spec-

trum of physiotherapy modalities that include exercise,

manual therapy, massage, hydrotherapy/spa therapy,

electrotherapy, acupuncture as well as patient infor-

mation and education [2]. Although physiotherapy is

considered a cornerstone of AS intervention, the evi-

dence to support it is somewhat sparse compared with

pharmacological treatments for AS. This was illustrated

in a review of AS intervention studies published between

1996 and 2004 when approximately 10% of the studies

reviewed were physiotherapy interventions [3].

Despite this relatively small amount of evidence,

previous reviews have been produced supporting the role

of physiotherapy interventions for AS [2–6]. The inter-

ventions described in these reviews primarily focus on

exercise with a small number of studies examining other

physiotherapy modalities either in isolation, or in com-

bination with exercise. Furthermore, there are relatively

few well designed studies examining the efficacy and

effectiveness of AS nonpharmacological interventions

compared with other similar inflammatory conditions

[7]. For example there is currently only one Cochrane

Review related to nonpharmacological intervention forAS. The most recent update of this systematic review,

consisting of 11 randomized control trials (n¼ 763), illus-

trated a moderate level of evidence that home-based or

supervised exercise is better than no exercise, group

exercise better than home exercise and the addition of

spa-based exercises to weekly group exercises is better

than weekly group exercises [8].

Given that AS is a disease that tends to affect younger

individuals, many of whom are in the prime of their

lives from educational, career and family perspectives,

aToronto Western Hospital, University Health Networkand bDepartment of Physical Therapy, Faculty of

Medicine, University of Toronto, Toronto, Ontario,Canada

Correspondence to Laura Passalent, BScPT, MHSc,Physiotherapist Practitioner Toronto Western HospitalUniversity Health Network, 3EW-400, 399 BathurstStreet, Toronto, ON M5T 2S8, CanadaTel: +1 416 603 5800 x5761; fax: +1 416 603 5318;e-mail: [email protected]

Current Opinion in Rheumatology 2011,23:142–147

Purpose of review

Ankylosing spondylitis (AS) is a disease that tends to affect younger individuals, many of

whom are in the prime of their lives; therefore, incorporating the most up-to-date

evidence into physiotherapy practice is critical. The purpose of this review is to update

the most recent evidence related to physiotherapy intervention for AS and highlight the

application of the findings to current physiotherapy research and clinical practice.

Recent findings

The results of this review add to the evidence supporting physiotherapy as an

intervention for AS. The emphasis continues to be on exercise as the most studied

physiotherapy modality, with very few studies examining other physiotherapy modalities.

Results of the studies reviewed support the use of exercise, spa therapy, manual therapy

and electrotherapeutic modalities. In addition, the results of this review help to

understand who might benefit from certain interventions, as well as barriers to

management.

SummaryA review of recently published articles has resulted in a number of studies that support

the body of literature describing physiotherapy as an effective form of intervention for

AS. In order to continue to build on the existing research, further examination into

physiotherapy modalities, beyond exercise-based intervention, needs to be explored.

Keywords

ankylosing spondylitis, exercise, physiotherapy

Curr Opin Rheumatol 23:142–147 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins1040-8711

1040-8711 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/BOR.0b013e328342273a

mailto:[email protected]

http://dx.doi.org/10.1097/BOR.0b013e328342273a

http://dx.doi.org/10.1097/BOR.0b013e328342273a

mailto:[email protected]



incorporating the most recent evidence into physiother-

apy practice is critical. Promoting the use of the most up-

to-date evidence-based physiotherapy intervention will

help to ensure that this patient population is able to

maintain and/or improve their current function and

quality of life. Therefore, the purpose of this study

is to update the most recent evidence related to phy-

siotherapy intervention for AS and to highlight theapplication of the findings to current physiotherapy

research and clinical practice.

MethodsThe Cochrane Database of Systematic Review, PubMed,

Medline, and CINAHL were searched using the follow-

ing search terms: ‘spondylitis, ankylosing’ and ‘physical

therapy (specialty)’, or ‘physical therapy modalities’ or

‘exercise therapy’ or ‘rehabilitation’. Publications were

limited to the English language and articles published

from January 2009 to June 2010. Studies involving phy-siotherapy intervention for AS were included for this

review, regardless of study design (i.e. randomized con-

trol studies, nonrandomized control studies, cohort stu-

dies were included). Physiotherapy studies associated

with outcome measures, complementary and alternative

medicine and healthcare utilization were excluded from

this review as they were beyond the scope of this study.

Abstracts were reviewed to ensure articles met the above

criteria and then relevant articles were reviewed.

Results

A review of the literature examining physiotherapy inter-ventions for AS from January 2009 to June 2010 resulted

in a limited number of relevant studies (n¼ 9) that mainly

focused on exercise (n¼6), spa therapy (n¼1), manual

therapy (n¼1) and electrotherapy (n¼ 1). The results of

this review will focus on the themes of exercise, spa

therapy, manual therapy, and electrotherapy, and will be

followed by discussion on their application to clinical

practice and research.

Exercise and ankylosing spondylitis

Exercise for AS comes in many forms. Home-based

exercise occurs when a patient is provided with a seriesof exercises that are performed unsupervised and inde-

pendently at a prescribed duration and frequency.

Historically, home-based exercises have been recognized

as an effective physiotherapy modality for AS with

respect to pain reduction, spinal mobility, function and

decreased disease activity [9,10]. A recent nonrando-

mized control trial [11] (n¼43) from Turkey compared

a 12-week home-based daily exercise program with

pharmacological therapy. The patients enrolled in this

study had an average disease duration of approximately

10 years, had no coexistent systemic disease, had not

been given antitumor necrosis factor (anti-TNF) treat-ment, and were at least able to function in their usual self-

care activities but limited in work and other activities.

Although the results of this study showed no significant

difference between groups, this study did provide further

support for home-based exercise in terms of improve-

ment in function and disease activity, and extended

significant findings for this type of intervention to

improvements in depression, fatigue and quality of life.

In contrast to home-based exercise, group-based exercise

involves exercising with peers and is supervised by a

qualified instructor, such as a physiotherapist. In previous

research, group-based exercise has been shown to

improve spinal mobility and function [12,13]. In this

current review, Alsonso-Blanco et al . [14] examined

potential predictors for identifying AS patients who are

likely to benefit from group-based exercise. In this pro-

spective cohort study, 35 AS patients participated in a

group-based exercise program and also received eight

physical therapy sessions over the span of 2 months.

Patients from this cohort had an average disease duration

of 10 years, an average Scho ¨ ber test of 2.05 cm, were

without current symptoms of other concomitant chronic

disease, and were taking some form of nonsteroidal anti-

inflammatory drug. Regression model analysis foundthree predictor variables for success (defined as a 20%

reduction in the Bath Ankylosing Spondylitis Functional

Index and a self-perceived global rating of recovery) that

included a physical role score greater than 37 (from the

MOS 36-Item Short Form Health Survey); a bodily pain

score greater than 27 (from the MOS 36-Item Short Form

Health Survey); and a Bath Ankylosing Spondylitis Dis-

ease Activity Index (BASDAI) score greater than 31. The

authors established that if patients exhibited two of the

three variables, they were more likely to have success

with the group-based exercise program. In other words,

Physiotherapy for ankylosing spondylitis Passalent 143

Key points

Exercise is the most studied physiotherapy

modality for ankylosing spondylitis, with few stu-

dies examining other physiotherapy modalities. Exercise is an effective physiotherapy modality

with respect to pain, spinal mobility, function, dis-

ease activity, depression, fatigue, quality of life as

well as a number of respiratory measures. Other physiotherapy modalities such as manual

therapy show promising results in terms of chest

expansion, posture, spinal mobility and the BathAnkylosing Spondylitis Metrology Index.

Although research in physiotherapy has grown sig-

nificantly over the past several years, the number of studies published examining the effects of phy-

siotherapy interventions for ankylosing spondylitis

remains small.



patients with less disease severity will likely have better

outcomes with group-based exercise. Knowing that exer-

cise is an effective physiotherapy modality is an import-

ant first step in the management of patients with AS;

however, understanding who will likely benefit from an

exercise program is important to ensure successful inter-

vention in this population

Swimming is often recommended for patients with AS;

however, there is limited evidence to support its use as an

exercise intervention. This review found a randomized

control study (n¼37) that compared freestyle swimming

30 min, 3 days per week for 6 weeks and daily conven-

tional land-based exercise; walking for 30 min, 3 days per

week for 6 weeks, and daily conventional land-based

exercise; and daily conventional land-based exercise

alone (control group) [15]. Patients in this study were

excluded if they had, among other criteria, active per-

ipheral joint involvement, severe comorbidities or had

previous anti-TNF treatment. Significant improvementswere observed in pulmonary and exercise tolerance out-

come measures in the swimming and walking groups

compared with the control. This study provides support

for both swimming and walking as an effective form of

aerobic exercise intervention for AS patients. This study

also emphasizes the importance of pulmonary outcomes

in this patient population, as AS can affect the thoracic

spine, costo-sternal junctions and the lungs themselves,

thereby causing pulmonary impairment [16,17]. These

important pulmonary outcomes were also examined in a

prospective cohort study [18] that examined the benefits

of a 6-week home-based exercise program. In this study,

22 patients with AS were taught breathing exercises and

upper extremity exercises that were performed daily at

home for a 6-week period. The average disease duration

for this patient group was 7 years, with baseline measures

that included chest expansion of 3.1 cm, modified Scho ¨ -

ber test of 3.9 cm and BASDAI score of 2.2. The results

showed significant improvement in a number of respir-

atory outcomes including chest expansion, maximal

inspiratory pressure and maximal expiratory pressure

values, as well as improvement in overall function. Pul-

monary function was also examined by Durmas et al . [19]

comparing global posture re-education (GPR) exercise

[20], conventional exercise and no exercise. This pro-spective nonrandomized control study found both exer-

cise groups showed significant improvement in pulmon-

ary function measures, chest expansion and pain, with

the GPR exercise prescription demonstrating greater

improvements in forced vital capacity, forced expiratory

volume in 1 min and peak expiratory flow.

In order to gain a deeper understanding of exercise and

the AS patient, Passalent et al. [21] examined 61 patients

with AS (mean disease duration of 15 years, 53% of

patients having axial disease and an average BASDAI

score of 4.3) to establish the type and extent of exercises

used by AS patients and to also determine their percep-

tions of exercise. This prospective cohort study found

AS patients report participating in evidence-based exer-

cise (such as home-based exercise, walking and swim-

ming); however, the majority of participants do not

report participating on a frequent basis (i.e. more than

three times per week), despite positive perceptions of exercise such as improvement in physical fitness and

cardiovascular function. The majority of barriers to

exercise identified in this study centered on the concept

of fatigue. The authors question if these patients are

fatigued due to the disease itself or are they fatigued

because exercise as an intervention is not adequately

impacting their disease. The authors suggest that future

research is needed to address the barriers identified

in their study to ensure optimal uptake of exercise in

patients with AS.

Spa therapy and ankylosing spondylitisSpa therapy involves therapeutic exercise in natural

mineral waters, immersion in thermal water, the use of

mud packs and/or massage [22]. This physiotherapy

modality has been traditionally used in the treatment of

AS, with evidence to support its use in the improvement of

spinal mobility, pain and disease activity [23,24]. This

review revealed one study [25] examining the effects of

combination treatment with etanercept and spa rehabilita-

tion versus etanercept alone. This study compared 30 AS

patients who combined etanercept therapy with 7 days of

spa rehabilitation in a thermal bath center with 30 AS

patients who took etanercept therapy alone. The results

indicated significant improvement in function and quality

of life in the combination therapy group at 3 months

postintervention and these improvements were main-

tained at 6 months postintervention.

Manual therapy and ankylosing spondylitis

Manual therapy is a traditional modality used in phy-

siotherapy intervention; however, there has been a lack of

randomized clinical trials examining the efficacy of such

modalities in the AS population [8]. In order to address

this gap in the evidence, Widberg et al. [26] recently

examined a small cohort (n¼ 32) of AS patients who were

randomized to self and manual spinal mobilization for8 weeks or to a control group. Patients included in this

study were all men between the ages of 23 and 60 years;

had an average disease duration of approximately 3 years;

and had stable pharmacological treatment. Patients were

excluded if they demonstrated radiological ossification

between the thoracic vertebrae, among other exclusion

criteria. The treatment protocol consisted of warming

the soft tissues of the back muscles; active and passive

spinal column mobility exercises; stretching of tight

muscles using a contract–relax technique; and manual

massage. Chest expansion, vital capacity, posture and

144 Rehabilitation medicine in rheumatic diseases



spinal mobility were assessed, in addition to the Bath

Ankylosing Spondylitis scales. Results showed significant

improvements in chest expansion, posture, spinal mobi-

lity and the Bath Ankylosing Spondylitis Metrology

Index (BASMI). This study also examined long-term

effects of this intervention and found that significant

gains in posture, spinal mobility and BASMI measures

were maintained over a 6-month time period.

Electrotherapy and ankylosing spondylitis

There is a wide range of electrotherapy agents used in

physiotherapy and their use is well established in

clinical practice [27]. One example of an electrother-

apeutic agent used in physiotherapy practice is infrared

radiation [28]. This technology is currently available in

Europe and a recent pilot study examined the effects of

infrared sauna on a prospective cohort of 18 AS patients

[29]. This study found significant reductions in pain

and stiffness, immediately following the application of

the agent; however, these effects were not maintained4 weeks after the study intervention in patients

with AS.

Application to physiotherapy research and practice

The reviewed studies add to the evidence supporting

physiotherapy as an intervention for AS. The emphasis

continues to be on exercise as the most studied phy-

siotherapy modality, with few studies examining other

physiotherapy modalities. The studies reviewed in

this study also help us begin to understand who might

benefit from certain interventions as well as barriers

to management.

There are number of issues related to the results of this

review that must be discussed in terms of research and

clinical practice. The variation in exercise protocols

described in the reviewed literature makes it difficult

to compare the overall effect of physiotherapy as an

intervention to manage AS. In terms of home-based

exercise, the reviewed studies describe different

duration, frequency and exercise prescriptions. For

example, the study by Durmas et al. [11] describes a

set of 20 static exercises for relaxation, flexibility,

strength, breathing and posture, whereas other studies

reviewed incorporated other exercise programs that areperformed in both static and dynamic postures [14,20].

Very few studies have included details such as the

number of repetitions, and sets for their described

exercise protocols, not to mention a full description

of the exercise technique. As exercise appears to be the

focus of physiotherapy intervention for AS, specific

detail regarding all aspects of the exercise program

need to be provided in order to accurately apply these

methods to clinical practice. Furthermore, harmoniza-

tion of exercise protocols across research initiatives

may allow better comparison of the intervention in

AS research. Lastly, identification of optimal frequency,

duration and type of exercise for AS patients represents

a gap in the current literature and requires future

research.

Similar to variation in exercise protocols, there is also

variation in the outcomes used to assess the effects of

physiotherapy interventions. Although all studiesincluded in this review utilized some or all of the Bath

Ankylosing Spondylitis scales, other studies, particularly

those investigating the effects of a physiotherapy inter-

vention on pulmonary function showed great variation in

the use of outcome measures. For example, Widberg et al.

[26] used chest expansion and vital capacity to measure

the effect of spinal mobilization, whereas Karapolat et al.

[15] used more detailed measures such as forced vital

capacity, forced expiratory volume in 1 min and respir-

atory exchange rate to measure the aerobic effects of

swimming. The ASAS Working Group of OMERACT IV

recommended a number of core set endpoints in physicaltherapy clinical studies that included physical function,

pain, spinal mobility, spinal stiffness, and patient global

assessment [30]. The above endpoints are included in the

articles presented in this review; however, given the

important role of physiotherapy in pulmonary outcomes,

consideration of such pulmonary-based endpoints

should be included in future review of the core sets in

AS research.

Variation within the patient population makes it difficult

to compare the overall effectiveness of physiotherapy as a

management strategy in AS. For example, the disease

location of patients described in this review may be

exclusively axial in nature, as described by Karapolat

et al. [15], inclusive of both peripheral and axial disease

location [21], or for the majority of studies included in this

review, not identified. Given the heterogeneity of the AS

disease population, information of this kind is important

if practitioners are to apply the results of such studies into

clinical practice. Similar detail regarding disease severity,

concomitant pharmacological management, and comor-

bidity would assist the clinician in targeting appropriate

physiotherapy interventions to their particular patient

population.

The evidence behind home-based exercise programs is

difficult to assess due to questions of patient adherence. A

number of the studies reviewed above indicated that the

patients were contacted by telephone on a weekly basis

as a method of ensuring adherence [11,20,18]; however,

it remains uncertain if patients actually complied to the

prescribed frequency and duration and whether or not

they employed the correct exercise technique. It may be

that group-based exercise protocols would be better

suited to ensure adherence as there is supervision

and peer support during the exercise program. Further




study comparing home-based exercise and group-based

exercise is required to understand issues of patient

adherence in this patient population.

Investigation into the effects of manual therapy modal-

ities for AS intervention has been limited as evident by

the one article identified in this update. One explanation

for this gap in the literature may be that the effects of such modalities are difficult to accurately measure due to

practitioner variability in manual therapy experience.

Furthermore, variation in patient severity may also play

a role in assessing the effects of manual therapy tech-

niques. From a clinical perspective, one may need to use

caution when employing such techniques as manual

therapy may be contraindicated, for example, in the

presence of osteoporosis, acute inflammatory flare, or

advanced ankylosis.

The advent of biologics as an effective management

strategy for patients with AS [31] requires examinationinto the effects of the combination of both pharmaco-

logical and nonpharmacological intervention in order to

determine the degree of further clinical gains this patient

population may expect. Significant improvement in func-

tion and quality of life was found in the study presented

by Colina et al. [25], suggesting that physiotherapy and

exercise will continue to play an important management

role in an era of biologic intervention. Further study into

the combined effects of biologics and physiotherapy

is warranted.

In terms of research design, the validity of the control

studies included in this review is limited, mainly due to

the small sample size. For this review the sample size

ranged from 30 to 60. Small sample size may lead to

inadequately powered studies and therefore put the

study at risk for incorrectly identifying differences

between intervention and control groups. Pooling of

studies may be an option; however, given the variation

in treatment protocols and outcome measures as

described above, it is unlikely that such action would

strengthen study results. It is therefore important that

adequate sample size is considered in order for the results

of physiotherapy and AS research to be translated into the

best possible clinical practice.

Overall the intervention studies reviewed in this study

add to the growing body of literature examining the

effectiveness of physiotherapy for AS. Unfortunately,

the number of studies published remains small.

Although research in physiotherapy has grown signifi-

cantly over the past several years [32,33] it has been

suggested that a combination of relatively little research

funding, a lack of adequately powered randomized trials,

and the inability to blind patients and healthcare provi-

ders to physiotherapy intervention research has led to a

gap of research evaluating physiotherapy interventions

[7,34,35]. Despite the limited evidence available for

physiotherapy intervention for AS, clinicians must strive

to translate the current research into practice.

Conclusion

A review of the recently published literature has resultedin a number of studies that support the body of literature

describing various physiotherapy modalities as an effec-

tive form of intervention for AS. In order to continue to

build on the existing research, further examination into

physiotherapy modalities, beyond exercise-based inter-

vention, needs to be explored.

AcknowledgementsThe author has no conflict of interest or sponsorships to declare. Theauthor would like to thank Dr Aileen Davis and Ms Crystal MacKay fortheir valuable feedback in the development of this manuscript.

References and recommended readingPapers of particular interest, published within the annual period of review, havebeen highlighted as: of special interest of outstanding interest

Additional references related to this topic can also be found in the CurrentWorld Literature section in this issue (pp. 219–220).

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