Physiotherapy for ankylosing spondylitis

How well does physical therapy work for treating ankylosing spondylitis and how safe is it?
To answer this question, scientists working with the Cochrane Musculoskeletal Group found and analyzed 11 studies testing over 700 people who had ankylosing spondylitis (AS). Studies compared people who did exercises at home, went to group exercise programs, went to spa or balneotherapy, performed different exercise programs or had no therapy at all. These studies provide the best evidence we have today.

What is ankylosing spondylitis and how can physical therapy help?
AS is a type of arthritis most typically affecting the joints and ligaments of the spine, and results in varying degree of pain, stiffness and disability. Physiotherapy is an important treatment to maintain or improve movement in the spine, improve fitness and decrease pain.

How well does physical therapy work?
Four studies compared individual or supervised exercises to no therapy at all. They found that both individual and supervised exercise programs improve spinal movement more than no therapy. The exercise programs were done for two to six months.
Three studies compared home exercises to supervised group exercises. They found that group exercises improve movement in the spine and overall well-being, but did not improve self-reported physical function more than home exercises. Exercises were done for three weeks to nine months, and included strengthening, aerobic exercises, hydrotherapy, sports activities and stretching.
One study compared two groups who both did weekly group exercises for 10 months, but one of the groups also went to a spa resort for three weeks of physiotherapy. Spa therapy plus weekly group exercises improves pain and overall well-being more than just weekly group exercises. One study compared balneotherapy and daily exercises with only daily exercises, and another study compared balneotherapy with fresh water therapy. Both these studies showed improvements after treatment for several outcomes, but no significant differences between the groups were found. One study compared a four-month experimental exercise program with a conventional program. Both groups improved, but the experimental exercise group improved more on spinal mobility and physical function than the conventional exercise group.

Did physical therapy harm patients?
Harms to the patients were not reported in the studies.

What is the bottom line?
Physiotherapy or exercises are helpful to people with ankylosing spondylitis.

There is "silver" level evidence (www.cochranemsk.org) that exercise programs, home-based or supervised, are better than no exercises and improve movement and physical function. Group exercises are better than home exercises, and improve movement and overall well-being. Adding a few weeks of exercising at a spa resort to weekly group exercises is better than just weekly group exercises. Balneotherapy in addition to exercise program did not show additional effect, nor did balneotherapy compared to fresh water therapy. An experimental exercise program showed more improvement on mobility and physical function than conventional exercises, but differences between groups were not statistically significant. We still need more information about the different types of physiotherapy and exercise, and how long, how intensive and how often physiotherapy should be done for the most improvement.

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.

Read the full abstract...
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.

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