The effect of exercise on ankylosing spondylitis--a preliminary study

The efficacy of manual soft-tissue mobilization in ankylosing spondylitis: A randomized controlled study

AIM

The aim of this randomized controlled study was to investigate the effect of soft-tissue mobilization in patients with ankylosing spondylitis (AS).

METHOD

Twenty-one patients (mean age 44.57 ± 10.40 years) were randomly divided into two groups. There were 13 patients (11 females, 2 males, age 43.69 ± 9.94 years) in the intervention group and 8 patients (5 females, 3 males, age 46.00 ± 11.67 years) in the control group. In the intervention group, soft-tissue mobilization therapy and 20 spinal mobility exercises were applied. The control group received only 20 spinal mobility exercises. The Bath AS Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI), and Bath AS Metrology Index (BASMI) were used for assessment of disease activity, functional level, and mobility, respectively. Nottingham Health Profile (NHP) for quality of life and Roland Morris Disability Questionnaire (RMDQ) were used to determine disability levels.

RESULTS

We found significant differences between pretreatment and post-treatment scores of BASDAI (P = 0.049); BASFI (P = 0.009; lateral lumbar flexion (P = 0.005), maximal intermalleolar distance (P = 0.001) and total score (P = 0.001) of BASMI; pain subtest (P = 0.036) and total score (P = 0.036) of NHP; and RMDQ score (P = 0.004) in the intervention group. However, in the control group the BASMI score (P = 0.049) was observed to worsen significantly. Delta values were compared and differences in BASFI (P = 0.039), and in lateral lumbar flexion (P = 0.027), maximal intermalleolar distance (P = 0.045) and total score (P = 0.001) of BASMI were significant in favor of intervention group. Only tragus-to-wall distance (P = 0.039) of BASMI was observed to worsen significantly in the control group.

CONCLUSION

We recommend the use of soft-tissue mobilization in addition to the exercises to treat AS patients.

Combined home exercise is more effective than range-of-motion home exercise in patients with ankylosing spondylitis: a randomized controlled trial

Home exercise is often recommended for management of patients with ankylosing spondylitis (AS); however, what kind of home exercise is more beneficial for patients with AS has not been determined yet. We aimed to compare the effectiveness of combined home exercise (COMB) and range-of-motion home exercise (ROM) in patients with AS. Nineteen subjects with AS completed either COMB (n = 9) or ROM (n = 10) program. The COMB program included range-of-motion, strengthening, and aerobic exercise while the ROM program consisted of daily range-of-motion exercise only. After exercise instruction, subjects in each group performed home exercise for 3 months. Assessment included cardiopulmonary exercise test, pulmonary function test, spinal mobility measurement, chest expansion, Bath Ankylosing Spondylitis Functional Index (BASFI), and other functional ability and laboratory tests. After exercise, the COMB group showed significant improvement in peak oxygen uptake (12.3%, P = 0.008) and BASFI (P = 0.028), and the changed score between pre- and postexercise data was significantly greater in the COMB group regarding peak oxygen uptake and BASFI. Significant improvement in finger-to-floor distance after 3-month exercise was found only in the COMB group (P = 0.033). This study demonstrates that a combined home exercise is more effective than range-of-motion home exercise alone in aerobic capacity and functional ability.

Spinal instability in ankylosing spondylitis

BACKGROUND

Unstable spinal lesions in patients with ankylosing spondylitis are common and have a high incidence of associated neurological deficit. The evolution and presentation of these lesions is unclear and the management strategies can be confusing. We present retrospective analysis of the cases of ankylosing spondylitis developing spinal instability either due to spondylodiscitis or fractures for mechanisms of injury, presentations, management strategies and outcome.

MATERIALS AND METHODS

In a retrospective analysis of 16 cases of ankylosing spondylitis, treated surgically for unstable spinal lesions over a period of 12 years (1995-2007); 87.5% (n=14) patients had low energy (no obvious/trivial) trauma while 12.5% (n=2) patients sustained high energy trauma. The most common presentation was pain associated with neurological deficit. The surgical indications included neurological deficit, chronic pain due to instability and progressive deformity. All patients were treated surgically with anterior surgery in 18.8% (n=3) patients, posterior in 56.2% (n=9) patients and combined approach in 25% (n=4) patients. Instrumented fusion was carried out in 87.5% (n=14) patients. Average surgical duration was 3.84 (Range 2-7.5) hours, blood loss 765.6 (+/- 472.5) ml and follow-up 54.5 (Range 18-54) months. The patients were evaluated for pain score, Frankel neurological grading, deformity progression and radiological fusion. One patient died of medical complications a week following surgery.

RESULTS

Intra-operative adverse events like dural tears and inadequate deformity correction occurred in 18.7% (n=3) patients (Cases 6, 7 and 8) which could be managed conservatively. There was a significant improvement in the Visual analogue score for pain from a pre-surgical median of 8 to post-surgical median of 2 (P=0.001), while the neurological status improved in 90% (n=9) patients among those with preoperative neurological deficit who could be followed-up (n =10). Frankel grading improved from C to E in 31.25% (n=5) patients, D to E in 12.5% (n=2) and B to D in 12.5% (n=2), while it remained unchanged in the remaining - E in 31.25% (n=5), B in 6.25% (n=1) and D in 6.25% (n=1). Fusion occurred in 11 (68.7%) patients, while 12.5% (n=2) had pseudoarthrosis and 12.5% (n=2) patients had evidence of inadequate fusion. 68.7% (n=11) patients regained their pre-injury functional status, with no spine related complaints and 25% (n=4) patients had complaints like chronic back pain and deformity progression. In one patient (6.2%) who died of medical complications a week following surgery, the neurological function remained unchanged (Frankel grade D). Persistent back pain attributed to inadequate fusion/ pseudoarthrosis could be managed conservatively in 12.5% (n=2) patients. Progression of deformity and pain secondary to pseudoarthrosis, requiring revision surgery was noted in one patient (6.2%). One patient (6.2%) had no neurological recovery following the surgery and continued to have nonfunctional neurological status.

CONCLUSION

In ankylosing spondylitis, the diagnosis of unstable spinal lesions needs high index of suspicion and extensive radiological evaluation Surgery is indicated if neurological deficit, two/three column injury, significant pain and progressive deformity are present. Long segment instrumentation and fusion is ideal.

Living with Ankylosing Spondylitis

Ankylosing Spondylitis (AS) is a potentially debilitating chronic condition that necessitates a biopsychosocial approach for successful long-term management. However, the psychosocial consequences of AS are not well understood. In this study patients ( N = 68) reported impacts of AS across a wide range of life domains; negative impacts included physical effects of AS, changes in mood or personality, effects on social life and relationships with friends and family, low self-esteem, stigma and worry about the future; positive impacts included increased exercise, feelings of achievement and empathy, stronger relationships, slower pace of life and a more positive perspective. Implications for treatment are discussed.

Physiotherapy interventions for ankylosing spondylitis

BACKGROUND

Ankylosing spondylitis (AS) is a chronic, inflammatory rheumatic disease. Physiotherapy is considered an important part of the overall management of AS.

OBJECTIVES

To summarise the available scientific evidence on the effectiveness of physiotherapy interventions in the management of AS.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, CINAHL and PEDro up to January 2007 for all relevant publications, without any language restrictions. We checked the reference lists of relevant articles and contacted the authors of included articles.

SELECTION CRITERIA

We included randomised and quasi-randomised studies with AS patients and where at least one of the comparison groups received physiotherapy. The main outcomes of interest were pain, stiffness, spinal mobility, physical function and patient global assessment.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion, extracted data and assessed trial quality. Investigators were contacted to obtain missing information.

MAIN RESULTS

Eleven trials with a total of 763 participants were included in this updated review. Four trials compared individualised home exercise programs or a supervised exercise program with no intervention and reported low quality evidence for effects in spinal mobility (Relative percentage differences (RPDs) from 5-50%) and physical function (four points on a 33-point scale). Three trials compared supervised group physiotherapy with an individualised home-exercise program and reported moderate quality evidence for small differences in spinal mobility (RPDs 7.5-18%) and patient global assessment (1.46 cm) in favour of supervised group exercises. In one study, a three-week inpatient spa-exercise therapy followed by 37 weeks of weekly outpatient group physiotherapy (without spa) was compared with weekly outpatient group physiotherapy alone; there was moderate quality evidence for effects in pain (18%), physical function (24%) and patient global assessment (27%) in favour of the combined spa-exercise therapy. One study compared daily outpatient balneotherapy and an exercise program with only exercise program, and another study compared balneotherapy with fresh water therapy. None of these studies showed significant between-group differences. One study compared an experimental exercise program with a conventional program; statistically significant change scores were reported on nearly all spinal mobility measures and physical function in favour of the experimental program.

AUTHORS' CONCLUSIONS

The results of this review suggest that an individual home-based or supervised exercise program is better than no intervention; that supervised group physiotherapy is better than home exercises; and that combined inpatient spa-exercise therapy followed by group physiotherapy is better than group physiotherapy alone.

Two Exercise Interventions for the Management of Patients with Ankylosing Spondylitis

OBJECTIVE

The purpose of this clinical trial was to evaluate the impact of a 4-month comprehensive protocol of strengthening and flexibility exercises developed by our research group versus conventional exercises for patients with Ankylosing Spondylitis (AS) on functional and mobility outcomes.

DESIGN

Randomized controlled trial. Forty-five patients diagnosed with AS according to the modified criteria of New York were allocated to control or experimental groups using a random numbers table. The control group was treated with a conventional protocol of physical therapy in AS, whereas the experimental group was treated with the protocol suggested by our research group. The conventional intervention consisted of 20 exercises: motion and flexibility exercises of the cervical, thoracic, and lumbar spine; stretching of the shortened muscles; and chest expansion exercises. The experimental protocol is based on the postural affectation of the AS and the treatment of the shortened muscle chains in these patients according to the Global Posture Reeducation (GPR) method. This intervention employs specific strengthening and flexibility exercises in which the shortened muscle chains are stretched and strengthened. The study lasted 4 mos. During this period, patients received a weekly group session managed by an experienced physiotherapist. Each session lasted an hour, and there were 15 total sessions. Changes in activity, mobility, and functional capacity were evaluated by an assessor blinded to the intervention, using the following previously validated scores from the Bath group: BASMI (tragus to wall distance, modified Schober test, cervical rotation, lumbar side flexion, and intermalleolar distance), BASDAI (The Bath Ankylosing Spondylitis Disease Activity Index), and BASFI (The Bath Ankylosing Spondylitis Functional Index).

RESULTS

Both groups showed an improvement (prepost scores) in all the outcome measures, mobility measures of the BASMI index, as well as in BASFI and BASDAI indexes. In the control group, the improvement in tragus to wall distance (P=0.009) and in lumbar side flexion (P=0.02) was statistically significant. Although the rest of the outcomes also improved, they did not reach a significant level (P>0.05). In the experimental group, the improvement in all the clinical measures of the BASMI index (P<0.01) and in the BASFI index (P=0.003) was statistically significant. The intergroup comparison between the improvement (prepost scores) in both groups showed that the experimental group obtained a greater improvement than the control group in all the clinical measures of the BASMI index, except in tragus to wall distance, as well as in the BASFI index.

CONCLUSIONS

The experimental protocol developed by our research group, based on the GPR method and specific strengthening and flexibility exercises of the muscle chains, offers promising results in the management of patients suffering from AS. Further trials on this topic are required.

Physiotherapy interventions for ankylosing spondylitis

BACKGROUND

Ankylosing spondylitis (AS) is a chronic, inflammatory rheumatic disease. Due to the consequences of the disease, physiotherapy is considered to be an important part of the overall management of AS.

OBJECTIVES

The objective of this review was to summarise the available scientific evidence on the effectiveness of physiotherapy interventions in the management of AS.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, CINAHL and PEDro up to February 2004 for all relevant publications, without any language restrictions. The reference lists of relevant articles were checked and the authors of included articles were contacted.

SELECTION CRITERIA

We included randomised and quasi-randomised studies with patients classified by the AS New York criteria and where at least one of the comparison groups received some kind of physiotherapy. The main outcomes of interest were pain, stiffness, spinal mobility, physical function and patient global assessment.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion, extracted data and assessed trial quality. Investigators were contacted to obtain missing information.

MAIN RESULTS

Six trials with a total of 561 participants were included in this updated review as compared to three trials and 241 patients in the previous version. Two trials compared individualised home exercise programs with no intervention and reported low quality evidence for effects in spinal mobility (relative percentage differences (RPD) 37%) and physical function, in favour of the home exercise program. Three trials compared supervised group physiotherapy with an individualised home-exercise program and reported moderate quality evidence for small differences in spinal mobility (RPD 18%) and patient global assessment in favour of supervised group exercises. Finally, in one study a three week inpatient spa-exercise therapy followed by 37 weeks of weekly outpatient group physiotherapy (without spa) was compared with weekly outpatient group physiotherapy alone; there was moderate quality evidence for effects in pain (RPD 18%), physical function (RPD 24%) and patient global assessment (RPD 29%), in favour of the combined spa-exercise therapy.

REVIEWERS' CONCLUSIONS

The results of this review suggest that a home exercise program is better than no intervention, supervised group physiotherapy is better than home exercises, and that combined inpatient spa-exercise therapy followed by supervised outpatient weekly group physiotherapy is better than weekly group physiotherapy alone. The tendency toward positive effects of physiotherapy in the management of AS calls for further research in this field. New trials should also address other physiotherapy interventions commonly used in clinical practice.

Spinal position sense and disease progression in ankylosing spondylitis: a longitudinal study

STUDY DESIGN

A longitudinal study of spinal position sense in 27 patients with mild ankylosing spondylitis (AS).

OBJECTIVES

To test the hypothesis that disease progression in AS is associated with deficits in spinal position sense.

SUMMARY OF BACKGROUND DATA

AS is a progressive disease that frequently leads to deterioration in spinal posture. The cause of postural change is unknown. However, pathologic involvement of spinal entheses that contain proprioceptive afferents suggests that impaired pro-prioception may play a role. This study investigates whether longitudinal changes in posture and other measures of disease progression are associated with deficits in spinal position sense in patients with mild AS.

METHODS

Position sense was assessed using an electromagnetic movement analysis system, the 3-Space Fastrak, to determine the absolute error in reproducing flexed and upright spinal postures. Measurements were taken from sensors at T1, T7, L1, and S2 and repeated following a mean time interval of 13.7 months. Assessments of posture, disease activity, and function were also made on both occasions.

RESULTS

Patients showed a significant increase in disease activity, and losses in spinal mobility, over time. However, no significant changes in spinal posture or position sense were found. Repositioning errors in flexed postures were < or = 3.50 at the first testing session and < or = 3.77 degrees at follow-up. Corresponding values for upright postures were < or = 2.71 degrees and < or = 2.25 degrees, respectively.

CONCLUSIONS

Spinal position sense appears unaffected by disease progression in patients with mild AS. Longer follow-ups may help determine any association between disease-related postural change and spinal position sense in AS.

The effectiveness of intensive group exercise on patients with ankylosing spondylitis

OBJECTIVE

To compare, in patients with ankylosing spondylitis (AS), the effectiveness on pain, functional and psychological status of an intensive group exercise programme under the supervision of a physiotherapist and a home physiotherapy programme.

DESIGN

Fifty-one patients with AS were randomly allocated into study and control groups. The study was designed as a prospective, double-blind study.

SETTING

Outpatient department, Istanbul Medical Faculty.

SUBJECTS

Patients who consulted with complaints of pain, morning stiffness and restricted range of movement with a confirmed diagnosis of ankylosing spondylitis.

INTERVENTIONS

Before exercise, both groups were given an education programme about AS. For group I patients an intensive exercise programme was organized under the supervision of a physiotherapist for six weeks. Group II patients had to practise exercises individually at home.

MAIN OUTCOME MEASURES

Both groups were evaluated and compared for pain, functional and psychological status before treatment, at the end of treatment and three months after treatment using a visual analogue scale (VAS) for pain, Beck Depression Scale and Bath Ankylosing Spondylitis Functional Index (BASFI).

RESULTS

Six patients withdrew, four from group I. Results from the remaining 45 showed more positive changes in the patients undertaking group exercise at six weeks and three months after treatment. Values showed a statistical significant difference in favour of group I.

CONCLUSION

Group exercise in hospital may be more effective than home-based exercises at reducing impairment associated with ankylosing spondylitis.

Spa and exercise treatment in ankylosing spondylitis: fact or fancy?

Physical therapy plays an important role in the overall treatment of ankylosing spondylitis. Apart from exercising at home, patients are advised to follow weekly group physical therapy. In addition, many patients often follow annual courses of in-patient physiotherapy or spa therapy in which exercises also play a central role. This chapter focuses on evidence for benefits of physical therapy and spa therapy in ankylosing spondylitis.

Fractures of the thoracolumbar spine complicating ankylosing spondylitis

Object. In this clinical review of ankylosing spondylitis, the authors emphasize the fragility of the spine and the degree of neurological deficit that can result from minor injury. The management of thoracolumbar fractures complicating ankylosing spondylitis is discussed.

Methods. Six thoracic and five lumbar fractures were identified in a review of patients in whom ankylosing spondylitis had been diagnosed. Nine fractures were associated with an extension deformity. The mechanism of injury was regarded as major in three and minor in eight.

The mean age in patients suffering fractures after minor traumatic injury was 59.6 ± 14.5 years (± standard deviation), whereas the mean age in patients suffering fractures after major traumatic injury was 49.3 ± 10.1 years. Two patients were treated with bedrest and brace therapy, and nine underwent instrument-assisted fusion. Postinjury neurological deficits were demonstrated in six patients, in three of whom neurological improvement was observed.

Conclusions. Patients with ankylosing spondylitis are at risk of injury, particularly extension fractures of the thoracic and lumbar spine. The incidence of trauma-induced neurological deficit is by no means negligible. Management consists of surgery in patients with vertebral instability and neural compression, and recumbency in those with stable fractures.

Kinematic approach to gait analysis in patients with rheumatoid arthritis involving the knee joint

OBJECTIVE

To analyze abnormal gait patterns in patients with rheumatoid arthritis involving the knee joint.

METHODS

In 2 patient groups with rheumatoid arthritis, changes in relevant angular parameters in the sagittal plane were analyzed by an electromagnetic tracking instrument. One group consisted of patients with knee joint involvement and severe inflammation without progressive destruction; the other group had knee joint involvement with progressive destruction and low disease activity. Knee angle was measured as the projected angle in the sagittal plane formed by 3 sensors (hip-knee-ankle); the changing mean angle, angular velocity, and angular acceleration were displayed. Furthermore, the angle formed by the vector element's endpoints for each sensor's displacement (designated alpha angle) was measured continuously.

RESULTS

Compared with age-matched controls, patients with severe inflammatory knee joint involvement showed limitation of alpha angle change in the stance phase, and patients with knee joint destruction had shortened swing phase duration and decreased alpha angle change in the swing phase. A sharpened alpha angular velocity change curve was observed in the latter. Characteristic differences between groups with inflammation and destruction were more clearly evident from the alpha angle than from the knee angle itself.

CONCLUSION

We observed gait differences between rheumatoid arthritis patients with active inflammatory arthritic knee joint involvement without progressive destruction and those with joint destruction and minimal inflammation. Features of gait disturbance in rheumatoid arthritis were not simple, even with a single major site. Therefore, techniques such as biokinetic gait analysis can provide practical information about functional joint integrity in this patient population that could aid in therapeutic decision making.

Do patients with ankylosing spondylitis have poorer balance than normal subjects?

OBJECTIVES

To investigate whether patients with ankylosing spondylitis have poorer balance than normal subjects, and to study the relationship between balance and posture.

METHODS

Balance was studied in 30 ankylosing spondylitis subjects using sway magnetometry, making quantitative measurements of movement at the hips with eyes open and eyes closed. The results were compared with data from 58 normal subjects. Balance was also compared with quantitative measurements of posture.

RESULTS

The numbers of patients with poor balance, above the 95th percentile for normal, were significantly greater than expected; 18% for eyes open (P = 0. 03) and 23% for eyes closed (P = 0.004). No significant relationships between balance and any of the quantitative descriptions of posture were demonstrated.

CONCLUSION

A significant proportion of ankylosing spondylitis patients have poorer balance than normal subjects.

Spinal position sense is independent of the magnitude of movement

STUDY DESIGN

Position sense in the spine was recorded at T1, T7, L1, and S2 in three incremental angular ranges of flexion and on return to upright standing from these movements.

OBJECTIVES

To determine the effect of angular range of movement on position sense. The main purpose was to establish a protocol for whole spine assessment of position sense in healthy and pathologic spines.

SUMMARY OF BACKGROUND DATA

Position sense is one dimension of proprioception, classically assessed by the ability to reproduce preselected target positions. This approach was used in the current study to determine whether spinal position sense is affected by the magnitude of movement traversed in repositioning tasks.

METHODS

Spinal position sense was assessed in 20 healthy subjects during repeated flexion movements carried out in one-third, half, and two thirds of the full range of movement in the sagittal and coronal planes. During each movement, the 3-Space Fastrak (Polhemus Inc., Colchester, VT) was used to record angular movement of the spine at four sensor locations (T1, T7, L1, and S2). The absolute difference in the sensor angles between repeated trials was calculated for each flexed position and on return to upright standing from these. These absolute differences were used as a measure of position sense.

RESULTS

Absolute position sense after one-third angular movements was accurate to within 4.30 degrees +/- 2.84 degrees in flexed positions and 2.70 degrees +/- 2.20 degrees in upright postures. Corresponding results for two-thirds movements were 4.75 degrees +/- 2.63 degrees and 3.33 degrees +/- 2.60 degrees, respectively. Range of movement had no significant influence on the accuracy of position sense.

CONCLUSIONS

1) Healthy individuals are able to reposition their spine accurately under conditions of incremental increases in angular range. 2) Range-related variations in position sense are small and unlikely to be of clinical significance.

Quality of life in patients with ankylosing spondylitis

Quality of life encompasses the net effects that a patient perceives an illness to have on his or her life. Quality of life commonly includes symptoms, physical functioning, work ability, social interaction, psychological functioning, treatment side effects, and financial costs. In ankylosing spondylitis, although symptoms of pain, stiffness, and fatigue are common and moderately severe, few patients develop severe functional disability and most remain employed. The limited information available suggests that most patients with ankylosing spondylitis have few problems with social interactions, although depression is not uncommon. Direct medical costs of ankylosing spondylitis are low, compared with those of other rheumatic diseases.

Fifteen months' follow-up of intensive inpatient physiotherapy and exercise in ankylosing spondylitis

Long-term effects of three or four-week inpatient physiotherapy and exercise courses were studied in 141 adult patients with ankylosing spondylitis (AS). Eight cervical and thoracolumbar range of motion (ROM) measurements and straight leg raise test, vital capacity (VC) and fitness index were measured at the beginning and end of an intensive course and 15 months later. All nine mobility measurements, vital capacity and fitness index were significantly improved after the course. Fifteen months later only chest expansion and vital capacity had significantly deteriorated from the baseline, while CR, FFD and fitness index were still significantly better. Disease duration did not influence treatment results. We conclude that it is possible by means of intensive rehabilitation courses to prevent for more than one year deterioration of spinal function and fitness in AS patients irrespective of disease duration.

Exercise tests as outcome measures

Outcome assessments of physical fitness attributes such as endurance, strength, and flexibility are not measured routinely in clinical trials or clinical practice in either adults or children with rheumatic diseases. Although physical fitness is not a measure of disease severity, it can be a critical indicator of capacity to function. Adequate fitness is necessary for the performance of positive health behaviors that enhance health status and wellness in spite of chronic disease. The purpose of this paper is to explore the conceptual, methodologic, and analytic issues related to the use of exercise tests as outcome measurements of physical functioning in persons with rheumatic disease.