Ankylosing spondylitis (AS) is a chronic, progressive, inflammatory disorder mainly affecting the axial skeleton with aseptic inflammation of synovial tissue, spinal ligaments, intervertebral discs and facet joints. For the diagnosis of AS a person must have inflammation of joints in the pelvis (the sacroiliac joints) when looked at with an X ray or MRI, limited movement of the lower back, inflammatory back pain for more than 3 months (ie stiffness of the back lasting for more than one hour in the morning), improved by exercise, unrelieved by rest, difficulty in taking deep breaths (restricted chest expansion)
AS leads to variable degrees of pain, reduced spinal mobility and limitations in physical functioning. Physiotherapy is, therefore, considered important to maintain or improve spinal mobility and fitness and to reduce pain.
In a Cochrane review, Dagfinrud et al (2008) assess the effectiveness of various physiotherapy interventions (active and passive modalities) in the management of patients with AS. Their aim was to compare the effectiveness of physiotherapy interventions compared to other interventions as well as a comparison between various physiotherapy management modalities as well.
The review included randomised control trials or quasi randomised control trials on patients presenting with a diagnosis of AS based on the New York Classification Criteria and assessing the effectiveness of various physiotherapy interventions. The relevant physiotherapy modalities in the management of AS include: supervised and unsupervised exercises, training, manual therapy, massage, hydrotherapy, electrotherapy, acupuncture, patient information and educational programs. The principal outcomes assessed included pain, stiffness, spinal mobility, physical function and patient global assessment.
After screening against the criteria, a total of 11 studies studying 763 participants were included in the review. Three of the studies were assessed to have low risk of bias; three studies were assessed to have moderate, and five to have high risk of bias.
The main results of the review were –
1. Patients with AS have some beneficial effects from individualised home exercise programs compared to no intervention.
2. Supervised group physiotherapy programs are slightly better than individualised home exercise regimes.
3. A three-week combined spa-exercise intervention is better than weekly group physiotherapy alone.
4. An experimental chain muscle exercise program showed larger improvement than a conventional exercise program.
The authors have stressed that small numbers of participants, heterogeneous interventions and outcome measures, together with deficient reporting of data in these studies do not provide strong evidence. The authors have emphasised the need for further trials comparing different treatment and exercise programs and aspire to provide an accurate description of the content, dose, application and adherence to the interventions.
Reference: Dagfinrud H,Hagen KB, Kvien TK. Physiotherapy interventions for ankylosing spondylitis. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD002822. DOI: 10.1002/14651858.CD002822.pub3.