title: Two Exercise Interventions for the Management of Patients with Ankylosing Spondylitis: A Randomized Controlled Trial Effects of home-based daily exercise therapy on joint mobility, daily activity, pain, and depression in patients with ankylosing spondylitis Functional changes in patients with spondylarthropathy. A controlled trial of the effects of short-term rehabilitation and 3-year follow-up One-Year Follow-up of Two Exercise Interventions for the Management of Patients with Ankylosing Spondylitis: A Randomized Controlled Trial Exercise and changes in health status in patients with ankylosing spondylitis. A 3-year follow-up of temporomandibular disorders in rheumatoid arthritis and ankylosing spondylitis. Combined spa-exercise therapy is effective in patients with ankylosing spondylitis: a randomized controlled trial. Fifteen months' follow-up of intensive inpatient physiotherapy and exercise in ankylosing spondylitis Improvement of the clinical outcome in Ankylosing spondylitis by balneotherapy. The effect of balneotherapy on patients with ankylosing spondylitis The effects of comprehensive home physiotherapy and supervision on patients with ankylosing spondylitis--a randomized controlled trial. Cost effectiveness of group physical therapy compared to individualized therapy for ankylosing spondylitis. A randomized controlled trial. Effects of a multimodal exercise program for people with ankylosing spondylitis. Experts' beliefs on physiotherapy for patients with ankylosing spondylitis and assessment of their knowledge on published evidence in the field. Results of a questionnaire among international ASAS members. [Evaluation of the Amor criteria for spondylarthropathies and European Spondylarthropathy Study Group (ESSG). A cross-sectional analysis of 2,228 patients]. Spa therapy for ankylosing spondylltis at the Dead Sea. Continuation of group physical therapy is necessary in ankylosing spondylitis: results of a randomized controlled trial. The effects of comprehensive home physiotherapy and supervision on patients with ankylosing spondylitis--an 8-month followup. Physiotherapy in subtropic climate improves functional capacity and health‐related quality of life in Swedish patients with rheumatoid arthritis and spondylarthropathies still after 6 months The effect of a home based exercise intervention package on outcome in ankylosing spondylitis: a randomized controlled trial. Is group physical therapy superior to individualized therapy in ankylosing spondylitis? A randomized controlled trial. Cost effectiveness of combined spa-exercise therapy in ankylosing spondylitis: a randomized controlled trial. Home exercise and compliance in inflammatory rheumatic diseases--a prospective clinical trial. The effectiveness of intensive group exercise on patients with ankylosing spondylitis In-patient regime for the treatment of ankylosing spondylitis: an appraisal of improvement in spinal mobility and the effects of corticotrophin.
abstract: Fernández-de-las-Peñas C , Alonso-Blanco C , Morales-Cabezas M , Miangolarra-Page JC : Two exercise interventions for the management of patients with ankylosing spondylitis : A r and omized controlled trial . Am J Phys Med Rehabil 2005;84:407–419 . 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 : R and omized 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 r and om 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 vali date d scores from the Bath group : BASMI ( tragus to wall distance , modified Schöber 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 We investigated the effects of home-based daily exercise on joint mobility , functional capacity , pain , and depression in patients with ankylosing spondylitis ( AS ) . The patients were r and omly assigned to a wait-list control group or to an exercise-therapy group . The exercise-therapy group performed a 20-min exercise program once per day for 8 consecutive weeks . After 8 weeks , compared with the control group , the exercise group showed improvements in joint mobility ( cervical flexion , extension , shoulder flexion , abduction , hip abduction , and knee flexion ) , finger – floor distance , and functional capacity . Pain and depression scores were significantly lower after the exercise program in the exercise group than in the control group . These findings indicate that exercise therapy increases joint mobility and functional capacity , and decreases pain and depression in patients with AS .  Home-based exercise , which is easily accessible to patients , might be an effective intervention for AS Abstract . A cohort of 25 patients with spondylarthropathy ( SpA ) participated in a 3-year follow-up study of functional changes before and after an intensive 3-week inpatient course .  They answered questions in the following functional status/disability indices : Bath ankylosing spondylitis functional index ( BASFI ) , Dougados functional index ( DFI ) , health assessment question naire for spondylarthropathy ( HAQ-S ) , Bath ankylosing spondylitis disease activity index ( BASDAI ) , Bath ankylosing spondylitis patient global assessment ( BAS-G ) , and horizontal visual analogue scale for stiffness ( stiffness VAS ) before and after the course and 3 years later by mail . A control group of 18 consecutive SpA patients from the waiting list for an inpatient course filled in the same question naires as study patients 3 months before entry and again 3 weeks later at home without rehabilitation . During the waiting time for the inpatient course , control group global assessment s ( BASDAI , BAS-G , and stiffness-VAS ) worsened slightly , and BASFI but not HAQ-S and DFI scores remained unchanged in the 3 weeks without treatment . The results of the 25 study patients showed small and not significant improvements in all functional index scores ( BASFI –0.5 points , DFI –1.1 , and HAQ-S –0.17 ) , whereas improvements were significant in BASDAI , BAS-G , and stiffness-VAS ( –13 mm , –13 mm , and –11 mm , respectively ) after the 3-week inpatient course . At 3-year follow-up , these small changes had disappeared and the changes were not significant . The global indices and BASFI worsened slightly ( 0.4 ) from baseline results , while DFI was slightly better ( –0.4 ) and HAQ-S remained at the post-treatment level after 3 years . Thus , BASFI was the most sensitive to changes , whereas DFI and HAQ-S were relatively insensitive . All six indices correlated highly significantly with each other ( ICC 0.53–0.94 ) . The natural course of spondylarthropathy leads to progression of functional impairments , which seems to be preventable with intensive rehabilitation , at least in the short term . Among the three functional indices , BASFI seems to be the most sensitive tool Fernández-de-las-Peñas C , Alonso-Blanco C , Alguacil-Diego IM , Miangolarra-Page JC : One-year follow-up of two exercise interventions for the management of patients with ankylosing spondylitis : A r and omized controlled trial . Am J Phys Med Rehabil 2006;85:559–567 . Objective : To assess the long-term effects on functional and mobility outcomes of two exercise interventions for the management of patients with ankylosing spondylitis . Design : In an extended 12-mo follow-up of a r and omized controlled trial , 40 patients who were diagnosed with ankylosing spondylitis according to the modified criteria of New York , allocated to control or experimental groups using a r and om numbers table , and who performed their respective exercise program at least three times per month , were included in this long-term study . The control group was treated during 15 sessions with a conventional exercise regimen in ankylosing spondylitis , whereas the experimental group received 15 sessions of exercises based on the treatment of the shortened muscle chains following the guidelines described by the Global Posture Reeducation method . These patients were followed up and assessed again 1 yr after entering the study , reapplying the same vali date d indexes : BASMI ( Bath Ankylosing Spondylitis Metrology Index [ tragus to wall distance , modified Schober test , cervical rotation , lumbar side flexion , and intermalleolar distance ] ) , BASDAI ( Bath Ankylosing Spondylitis Disease Activity Index ) , and BASFI ( Bath Ankylosing Spondylitis Functional Index ) . Results : The intragroup comparison between follow-up and postintervention data showed that both groups decrease their clinical and functional measures during the follow-up period . This decrease was only significant for lumbar side flexion and intermalleolar distance measurements , being more significant in the control group ( P = 0.001 and P = 0.002 , respectively ) . Intragroup differences between follow-up and preintervention assessment s revealed that improvements in all mobility measures of the BASMI index and in the BASFI index were partially maintained at the 12-mo follow-up in the experimental group but not in the control group . The intergroup comparison ( unpaired t test analysis ) between changes on each outcome during the long-term follow-up ( post – follow-up ; and pre – follow-up ) showed no significant differences in the decrease between postintervention and follow-up data between the study groups . On the other h and , the intergroup comparison between preintervention and follow-up data revealed significant differences in almost all mobility measures of the BASMI index ( except for cervical rotation ) and in the BASFI index , in favor of the experimental group . Conclusions : An exercise regimen based on the Global Posture Reeducation method and focusing on specific strengthening and flexibility exercises of the shortened muscle chains offers promising short- and long-term results in the management of patients who have ankylosing spondylitis BACKGROUND Although exercise is a commonly recommended treatment for ankylosing spondylitis ( AS ) , little is known about the effectiveness of unsupervised recreational and back exercises . We examined the effects of recreational exercise and back exercises on  patient-reported pain severity , stiffness severity , and functional disability  in a prospect i ve longitudinal study of 220 patients with AS . METHODS Participants provided information on exercise habits and health status every 6 months using mailed question naires ( median follow-up , 4.5 years ) . Pain severity and stiffness severity were measured using visual analog scales , and functional disability was measured using the Health Assessment Question naire ( HAQ ) Disability Index . RESULTS Among all patients , there were no associations between either the number of exercise minutes per week or the number of days of back exercise per week and short-term ( 6-month ) changes in pain , stiffness , or HAQ Disability Index . However , among those who had AS for 15 years or less , pain scores were 0.18 points lower ( on a scale of 0 - 3 ; P = .04 ) , and stiffness scores were 6.4 points lower ( on a scale of 0 - 100 ; P = .005 ) during periods with more than 200 minutes per week of exercise compared with periods with 0 to 30 minutes of exercise per week . Among those who had AS for more than 15 years , pain scores were 0.11 points lower ( on a scale of 0 - 3 ; P = . 03 ) , and HAQ Disability Indexes were 0.08 points lower ( on a scale of 0 - 3 ; P<.001 ) during periods with 5 to 7 days per week of back exercise compared with periods when back exercises were not performed . Less intense levels of exercise were not associated with improvements in health status . CONCLUSIONS Unsupervised recreational exercise improves pain and stiffness , and back exercise improves pain and function in patients with AS , but these effects differ with the duration of AS . Health status is improved when patients perform recreational exercise at least 30 minutes per day and back exercises at least 5 days per week . Arch Intern Med . 2000;160:2969 - Sixteen individuals with rheumatoid arthritis ( RA ) and 19 individuals with ankylosing spondylitis ( AS ) participated in this 3-year follow-up study . The individuals in each disease group were allocated to an experimental group ( E group ) and a comparison group ( C group ) . They were investigated by question naire , clinical examination of the stomatognathic system , and laboratory tests . The individuals of the two E groups had performed a physical training program of the stomatognathic system during 3 weeks . After 3 years most of the patients in the E groups reported an unaltered or decreased severity of symptoms and signs from the stomatognathic system compared with the initial status . The clinical dysfunction score according to Helkimo ( CDS ) was lower in the RA group , and the mouth opening capacity was larger than before training . In the AS group there was no long-term change in the CDS but an increase of mouth opening capacity . The general inflammatory disease process in the RA group showed an increased activity during this follow-up period as assessed by erythrocyte sedimentation rate . This study suggests that local physical training of the stomatognathic system has a positive effect in individuals with RA OBJECTIVE To determine the efficacy of combined spa-exercise therapy in addition to st and ard treatment with drugs and weekly group physical therapy in patients with ankylosing spondylitis ( AS ) . METHODS A total of 120 Dutch out patients with AS were r and omly allocated into 3 groups of 40 patients each . Group 1 ( mean age 48 + /- 10 years ; male : female ratio 25:15 ) was treated in a spa resort in Bad Hofgastein , Austria ; group 2 ( mean age 49 + /- 9 years ; male : female ratio 28:12 ) in a spa resort in Arcen , The Netherl and s. The control group ( mean age 48 + /- 10 years ; male : female ratio 34:6 ) stayed at home and continued their usual drug treatment and weekly group physical therapy during the intervention weeks . St and ardized spa-exercise therapy of 3 weeks duration consisted of group physical exercises , walking , correction therapy ( lying supine on a bed ) , hydrotherapy , sports , and visits to either the Gasteiner Heilstollen ( Austria ) or sauna ( Netherl and s ) . After spa-exercise therapy all patients followed weekly group physical therapy for another 37 weeks . Primary outcomes were functional ability , patient 's global well-being , pain , and duration of morning stiffness , aggregated in a pooled index of change ( PIC ) . RESULTS Analysis of variance showed a statistically significant time-effect ( P < 0.001 ) and time-by-treatment interaction ( P = 0.004 ) , indicating that the 3 groups differed over time with respect to the course of the PIC . Four weeks after start of spa-exercise therapy , the mean difference in PIC between group 1 and controls was 0.49 ( 95 % confidence interval [ CI ] 0.16 - 0.82 , P = 0.004 ) and between group 2 and controls was 0.46 ( 95 % CI 0.15 - 0.78 , P = 0.005 ) . At 16 weeks , the difference between group 1 and controls was 0.63 ( 95 % CI 0.23 - 1.02 , P = 0.002 ) and between group 2 and controls was 0.34 ( 95 % CI--0.05 - 0.73 ; P = 0.086 ) . At 28 and 40 weeks , more improvement was found for group 1 compared with controls ( P = 0.012 and P = 0.062 , respectively ) but not for group 2 compared with controls . CONCLUSION In patients with AS , a 3-week course of combined spa-exercise therapy , in addition to drug treatment and weekly group physical therapy alone , provides beneficial effects . These beneficial effects may last for at least 40 weeks Summary 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 AIMS This study is design ed to show the efficacy of balneotherapy and balneotherapy ( BT ) + nonsteroid antiinflammatory drug ( NSAID ) use in Ankylosing spondylitis ( AS ) patients . METHODS In this prospect i ve study , BT , BT+ NSAID and NSAID therapy in 61 patients with AS were evaluated by ASAS core set . BT  group ( 21 patients ) was treated only with BT for 20 min , once a day , 5 days a week , over a period of 3 weeks . BT+NSAID group ( 20 patients ) was treated with 1000 mg naproxen as well as BT . NSAID group ( 20 patients ) was treated with 1000 mg naproxen . All of the participants did respiratory and postural exercises for 20 min a day and for the whole study period . Each patient was evaluated on admission ( before treatment ) , at the end of the therapy and 6 months after the treatment . RESULTS At the end of the study , statistically significant improvement was observed in all the clinical parameters of the patients in BT ( G1 ) , BT+NSAID ( G2 ) and NSAID ( G3 ) groups . This significant symptomatic and clinical improvement was maintained even 6 months after the treatment . The changes from baseline to follow up were similar in G1 and G2 except duration of morning stiffness ( DMS ) and chest expansion ( CE ) . Improvements in CE and DMS were better in G1 and G2 , respectively . Improvements observed in G1 and G2 were superior to the improvements observed in G3 for the variables of morning pain , nocturnal pain , DMS , global well being of the patient , occiput-wall distance , CE , finger to floor distance and functional index . In Schober test , improvement observed in G1 was statistically superior to G3 . CONCLUSION We concluded that BT can be suggested as an effective symptomatic treatment modality in patients with AS . Furthermore , sufficient improvement in clinical parameters can be obtained by BT alone Objective : To compare the effect of balneotherapy on physical activity and quality of life as well as the symptoms of pain and stiffness with exercise alone in ankylosing spondylitis ( AS ) patients . Methods : A total of 60 patients who had a diagnosis of AS according to the modified New York criteria were included in the study . The patients were r and omly assigned to two groups . In Group I ( n = 30 ) the patients received balneotherapy in a therapeutic pool for 30 min once a day for 3 weeks . All patients received instructions on the exercise programme , which they were requested to repeat once a day for 30 min during the study . The patients in this group continued the same exercise programme after the end of the balneotherapy protocol to complete a course of 6 months . In Group II the patients were given the same exercise protocol but did not receive balneotherapy . Patients were evaluated before the start of the study and at 3 weeks and 24 weeks . Evaluation parameters were daily and night pain , morning stiffness , the patient 's global evaluation and the physician 's global evaluation ( according to a scoring system of 1 to 5 ) , the Bath Ankylosing Spondilitis Disease Activity Index ( BASDAI ) , Bath Ankylosing Spondylitis Functional Index ( BASFI ) , Dougados Functional Index ( DFI ) , tragus – wall distance , chest expansion , modified Shober test ( MST ) , fingertip – fibula head distance , and Nottingham Health Profile ( NHP ) . Results : Evaluations were completed in 54 patients in the two groups . Comparison of the groups showed significantly superior results for Group I for parameters of BASDAI , NHP total , pain , physical activity , tiredness and sleep score , patient 's global evaluation and the physician 's global evaluation at 3 weeks , but only for the parameters of patient 's global evaluation and MST at 24 weeks . Conclusion : Balneotherapy has a supplementary effect on improvement in disease activity and functional parameters in AS patients immediately after the treatment period . However , in the light of our medium‐term evaluation results , we suggest that further research is needed to assess the role of balneotherapy applied for longer duration s in AS patients Fifty-three patients with ankylosing spondylitis ( AS ) were r and omly allocated ; 26 experimental patients received physiotherapy and disease education , 27 control patients received neither . The primary treatment outcome was change in spinal mobility measured at 4 months by fingertip-to-floor distance . Experimental patients had more improvement in fingertip-to-floor distance ( p2 less than 0.004 ) and in function ( p2 less than 0.001 ) than control patients . Physiotherapy with disease education is effective in the treatment of patients with AS OBJECTIVE Cost effectiveness analysis is helpful in setting priorities for funding of health care programs . We studied the cost effectiveness of supervised group physical therapy compared to unsupervised exercises at home in patients with ankylosing spondylitis ( AS ) . METHODS A total of 144 patients with AS ( modified New York criteria ; mean age : 43 years ) were r and omized to unsupervised daily individualized exercises at home for 9 months or the same plus supervised group physical therapy ( 3 h weekly ) . At baseline and after 9 months we measured spinal mobility ( thoracolumbar flexion and extension ) , fitness ( maximum work capacity by ergometry ) , and patient 's global assessment of change as measured on a visual analog scale . We used a question naire at baseline and a diary during the trial to measure AS related direct medical costs , such as doctor visits , paramedical treatment , medication and hospitalization . RESULTS The mean effects of group therapy and home exercises were , respectively , + 0.9 cm ( 16 % ) and + 0.5 cm ( 9 % ) for mobility , + 7 watts ( 4 % ) and -2 watts ( -1 % ) for fitness , and + 1.7 ( 34 % ) and + 0.3 ( 6 % ) for global health . These 3 differences were significant ( p < 0.01 for mobility , p = 0.05 for fitness and p < 0.01 for global health ) . During the trial total medical costs decreased by an average of US $ 379 ( 44 % ) for group therapy , and by $ 257 (35%)/patient/year for the " home " group . Additional costs of group therapy were estimated at $ 531/patient/year ( $ 177 for accommodation , $ 256 for therapist and $ 98 for material s ) . After the study 75 % of the patients wanted to continue group physical therapy and were willing to pay for it . CONCLUSION Compared to therapy at home , additional benefits of group therapy cost $ 531/year , but reduced direct medical costs by $ 122/year . Hence , the beneficial effects of group therapy cost $ 409/patient with AS/year BACKGROUND AND PURPOSE Few r and omized controlled studies have examined the effects of exercise in patients with ankylosing spondylitis ( AS ) . This study investigated the effects of a 12-week , multimodal exercise program in patients with AS . SUBJECTS A convenience sample of 30 patients with AS ( 18 male , 12 female ) , with a mean age of 34.9 years ( SD=6.28 ) , participated in the study . Twenty-six subjects were classified as having stage I AS and 4 subjects were classified as having stage II AS according to the modified New York Criteria . METHODS This study was a r and omized controlled trial . Subjects were assigned to either a group that received an exercise program or to a control group . The exercise program consisted of 50 minutes of multimodal exercise , including aerobic , stretching , and pulmonary exercises , 3 times a week for 3 months . Subjects in both groups received medical treatment for AS , but the exercise group received the exercise program in addition to the medical treatment . All subjects received a physical examination at baseline and at 12 weeks . The examinations were conducted under the supervision of a physician who specialized in physical medicine and rehabilitation and included the assessment of spinal mobility using 2 methods : clinical measurements ( chin-to-chest distance , Modified Schober Flexion Test , occiput-to-wall distance , finger-to-floor distance , and chest expansion ) and inclinometer measurements ( gross hip flexion , gross lumbar flexion , and gross thoracic flexion ) . In addition , vital capacity was measured by a physiologist , and physical work capacity was evaluated by a doctorally prepared exercise instructor . RESULTS The measurements of the exercise group for chest expansion , chin-to-chest distance , Modified Schober Flexion Test , and occiput-to-wall distance were significantly better than those of the control group after the 3-month exercise period . The spinal movements of the exercise group improved significantly at the end of exercise program , but those of the control group showed no significant change . In addition , the results showed that the posttraining value of gross thoracic flexion of the exercise group was significantly higher than that of the control group . Physical work capacity and vital capacity values improved in the exercise group but decreased in the control group . DISCUSSION AND CONCLUSION In this study , a multimodal exercise program including aerobic , stretching , and pulmonary exercises provided in conjunction with routine medical management yielded greater improvements in spinal mobility , work capacity , and chest expansion AIM The aim of this study was to assess both the opinion of an international group of experts about the place and importance of physiotherapy in the management of ankylosing spondylitis ( AS ) as well as the awareness of the responders about scientific evidence on efficacy and cost-effectiveness of physiotherapy in AS . METHODS An e-mail question naire ' ' Experts ' Beliefs on Physiotherapy for Patients with Ankylosing Spondylitis ' ' has been sent to all 71 international ASsessment of Ankylosing Spondylitis ( ASAS ) members . Completion of the twenty-eight-item question naire was done through the ASAS website ( www.ASAS-group.org ) . RESULTS The number of responders was 53 ( response rate 73 % ) . Altogether 94 % of the responders regard themselves as experts in the field of clinical care for AS patients . There is almost unanimous ( 86 - 92 % ) consensus on the efficacy of physiotherapy ( widely defined , i.e. as physical therapy-including exercises , application of physical modalities and spa-therapy ) for patients with axial and peripheral joint manifestations of AS . Physiotherapy is considered to be indicated for both early AS ( less than 2 years after diagnosis ) ( 88 % ) and AS of longer duration ( 2 to 10 years ) ( 94 % ) , implying that this non-pharmaceutical intervention should be made available for or should be prescribed to AS patients . Also daily exercises at home are considered indicated for both early ( less than 2 years after diagnosis ) AS ( 90 % ) and AS of longer duration of disease ( 90 % ) . High-level evidence ( Cochrane review s or publications of one or more r and omized controlled clinical trials ) favoring efficacy of  physiotherapy  was considered available by 33 % of the participants , whereas 43 % replied ' ' no ' ' and 24 % did not know . Finally , excluding the costs of the intervention , 39 % of the participants reported that  Spa-therapy might reduce health care costs as usage of NSAIDs , physician visits and ability to work or sick leave , whereas 26 % said ' ' no ' ' and 35 % did not know . CONCLUSIONS The international ASAS experts hold a favorable opinion on the efficacy of physiotherapy in AS , including group exercises and spa therapy , almost irrespective of disease duration and type of articular involvement ( axial/peripheral ) . Awareness of published evidence on physiotherapy in AS is unsatisfactory Two sets of criteria have been proposed to discriminate spondylarthropathies ( SA ) from other rheumatic diseases . To evaluate their performance , we conducted a cross-sectional study in the patients observed during one week in 28 French Departments of Rheumatology by 91 staff-teaching physicians . The physicians had to apply these criteria to all their patients and had to classify them as definite SA , definite other rheumatic disease or possible SA . The analysis performed on the 2,088 patients with a definite diagnosis ( 124 SA and 1,964 controls ) showed the following results : ( table ; see text ) Of the 140 patients with possible SA , 37 fulfilled both sets of criteria , 22 the ESSG criteria alone and 12 the Amor criteria alone . These data suggest that a ) the overall performance of these two sets of criteria is similar ; b ) this performance is better in the group of patients with a definite diagnosis ; c ) the patients without a definite diagnosis require a longer follow-up to assess the clinical relevance of these two sets of criteria BACKGROUND The efficacy of spa therapy in ankylosing spondylitis has not been investigated extensively . OBJECTIVE To study the efficacy of balneotherapy and climatic therapy ( climatotherapy ) at the Dead Sea area in patients with ankylosing spondylitis . METHODS In a single-blind r and omized controlled study , 28 patients suffering from ankylosing spondylitis were allocated into two groups of 14 patients each . The first group ( the combined treatment group ) received balneotherapy ( mud packs and sulfur pool ) and exposure to the unique climatic conditions of the Dead Sea . The second group ( the climatotherapy group ) used the fresh water pool and experienced the same climatic conditions . The duration of treatment was 2 weeks and the follow-up period 3 months . RESULTS For both patient groups a significant improvement was found in the outcome measures : Bath AS Disease Activity Index ( P = 0.002 ) , VisuarAnalog Scale for pain ( P = 0.002 ) and VAS for spinal movement ( P = 0.011 ) . The variability was explained by the effect of time ( within group effect ) rather than the type of treatment ( between group effect ) . Quality of life , assessed by the SF-36 question naire , was very low prior to the study , but improved in terms of pain amelioration in the combined treatment group . CONCLUSIONS Climatotherapy at the Dead Sea area can improve the condition of patients suffering from long-st and ing ankylosing spondylitis PURPOSE Group physical therapy in patients with ankylosing spondylitis was studied to determine whether beneficial effects persisted after cessation of the intervention . METHODS After a 9-month period of supervised group physical therapy , 68 patients were r and omized for another 9 months to unsupervised daily exercises at home ( discontinuation group ) or continuation of weekly sessions of supervised group physical therapy ( continuation group ) . Endpoints were spinal mobility ( thoraco-lumbar flexion and extension , chest expansion , cervical rotation ) , fitness ( maximum work capacity ) , functioning ( Sickness Impact Profile ( SIP ) , Health Assessment Question naire for the Spondylarthropathies [ HAQ-S ] , Functional Index [ FI ] ) , and patient 's global health assessment on a visual analogue scale . RESULTS Time for exercises at home was significantly higher in the continuation than in the discontinuation group ( mean duration 1.9 versus 1.2 hr per week , P < 0.05 ) . The continuation group improved in global health ( mean improvement 1.6 ; 32 % ) and in SIP score . Scores for thoraco-lumbar mobility and HAQ-S did not change very much , whereas chest expansion , cervical rotation , fitness , and FI deteriorated . The average attendance for group therapy sessions was 62 % . The discontinuation group improved only marginally ( 0.2 ; 4 % ) in global health , whereas all other endpoints decreased . Only for global health and HAQ-S were the differences statistically significant in favor of the continuation group . CONCLUSIONS Global health and functioning are sustained or even improved further if group physical therapy is continued . Spinal mobility decreased slightly in both groups OBJECTIVE Our previous r and omized clinical trial showed a 4-month home physiotherapy program was effective for patients with ankylosing spondylitis . This followup study reports on 22 control patients who received the previously withheld treatment and 24 experimental patients who received followup treatment as needed . METHODS The primary outcome measure was spinal mobility measured by fingertip-to-floor distance using a portable measuring device specially design ed and vali date d for this study . RESULTS Following treatment , fingertip-to-floor distance did not change in control patients ( P2 = 0.145 ) . Between 4 and 8 months , fingertip-to-floor distance did not change in experimental patients ( P2 = 0.143 ) ; however , initial improvement achieved was maintained . The experimental group at 4 months was better than the control group at 8 months ( P2 = 0.038 ) . CONCLUSION The home physiotherapy treatment program must be delivered as rigorously as it was in the initial trial to be effective . The benefit from this treatment program can be maintained with very little intervention Objective : The objective was to prospect ively evaluate the short as well as the long‐term effects of intensive physiotherapy in a stable , sunny and warm climate on physical function and health related quality of life in patients with rheumatoid arthritis ( RA ) and spondylarthropathies ( SpA ) . Methods : Ninety‐three Swedish patients with RA and SpA receiving physiotherapy for 4 weeks in Israel or Tenerife were followed for 6 months . Physical function was evaluated by the Swedish version of Stanford Health Assessment Question naire ( HAQ ) and quality of life by the  Nottingham Health Profile ( NHP )  question naire . Results : There were significant improvements in HAQ‐scores and global NHP‐scores as well as all subcategories of NHP immediately after the treatment abroad , effects that were still measurable after six months . At that time point nearly half of the patients had clinical ly meaningful reduction of HAQ‐scores ( ≥0.25 ) . Conclusion : Physiotherapy in a warm and stable climate , with many hours of daily sunshine , is a valuable treatment complement for Swedish patients with RA and OBJECTIVE Home based self-care is essential for successful management of ankylosing spondylitis ( AS ) . We design ed an intervention package aim ed at promoting self-care and regular longterm exercise and evaluated its effect on outcome . METHOD Members of our data base ( n = 4569 ) were r and omly selected and r and omized to an intervention group ( IG ) or a followup control group ( CG ) . The intervention consisted of an exercise/information video , exercise progress chart , patient education booklet , and AS exercise reminder stickers . The outcome measures were function ( BASFI ) , disease activity ( BASDAI ) , global well being ( BAS-G ) , exercise self-efficacy ( ESE ) , arthritis self-efficacy ( SES ) , and quantity of AS mobility/aerobic exercise assessed at baseline and 6 months . RESULTS Of the 200 subjects , 155 completed the study ( 75 IG and 80 CG ) . Baseline analysis showed no differences between the CG and the IG . At 6 months , analysis revealed no statistically significant between-group differences for the BASFI , BASDAI , and BAS-G. although the p value of 0.08 for function approached significance . Self-efficacy for exercise showed a significant improvement in the IG ( p = 0.045 ) . There were no between-group differences for the SES pain and other symptoms subscales . Finally , there was a significant increase in self-reported AS mobility ( p < 0.001 ) and aerobic exercise ( p < 0.05 ) in the IG . CONCLUSION An exercise intervention package design ed to promote self-management in AS ( 1 ) significantly improves self-efficacy for exercise ; ( 2 ) significantly improves self-reported levels of exercise ; ( 3 ) reveals a trend for improvement in function ( BASFI ) PURPOSE To study the effects of adding supervised group physical therapy to unsupervised individualized therapy in ankylosing spondylitis . METHODS One hundred forty-four patients were  r and omized to exercises at home , or the same plus weekly group physical therapy for 9 months . Endpoints were spinal mobility , fitness ( maximum work capacity by ergometry ) , functioning ( Sickness Impact Profile , Health Assessment Question naire for the Spondylarthropathies , and Functional Index ) , and patient 's global assessment of change on a 10-cm visual analogue scale . RESULTS Thoracolumbar flexion and extension increased by an average of 0.5 cm ( 9 % ) after home exercises , and by 0.9 cm ( 16 % ) after group therapy . Maximum load in ergometry decreased by 2 W ( 1 % ) after home exercises , but increased by 7 W ( 4 % ) after group therapy . Global assessment improved by 0.3 ( 6 % ) after home exercises , and by 1.7 ( 34 % ) after group therapy . These three differences were statistically significant . There were no significant differences in chest expansion , cervical rotation , or the self- assessment s of functioning . CONCLUSIONS Group physical therapy proved superior to individualized therapy in improving thoracolumbar mobility and fitness , and had an important effect on global health reported by the patients OBJECTIVE To evaluate the cost effectiveness and cost utility of a 3-week course of combined spa therapy and exercise therapy in addition to st and ard treatment consisting of antiinflammatory drugs and weekly group physical therapy in ankylosing spondylitis ( AS ) patients . METHODS A total of 120 Dutch out patients with AS were r and omly allocated into 3 groups of 40 patients each . Group 1 was treated in a  spa resort in Bad Hofgastein , Austria ; group 2 in a spa resort in Arcen , The Netherl and s. The control group stayed at home and continued their usual activities and st and ard treatment during the intervention weeks . After the intervention , all patients followed weekly group physical therapy . The total study period was 40 weeks . Effectiveness of the intervention was assessed by functional ability using the Bath Ankylosing Spondylitis Function Index ( BASFI ) . Utilities were measured with the EuroQoL ( EQ-5D(utility ) ) . A time-integrated summary score defined the clinical effects ( BASFI-area under the curve [ AUC ] ) and utilities ( EQ-5D(utility)-AUC ) over time . Both direct ( health care and non-health care ) and indirect costs were included . Re source utilization and absence from work were registered weekly by the patients in a diary . All costs were calculated from a societal perspective . RESULTS A total of 111 patients completed the diary . The between-group difference for the BASFI-AUC was 1.0 ( 95 % confidence interval [ 95 % CI ] 0.4 - 1.6 ; P = 0.001 ) for group 1 versus controls , and 0.6 ( 95 % CI 0.1 - 1.1 ; P = 0.020 ) for group 2 versus controls . The between-group difference for EQ-5D(utility)-AUC was 0.17 ( 95 % CI 0.09 - 0.25 ; P < 0.001 ) for group 1 versus controls , and 0.08 ( 95 % CI 0.00 - 0.15 ; P = 0.04 ) for group 2 versus controls . The mean total costs per patient ( including costs for spa therapy ) in Euros ( euro ; ) during the study period were euro;3,023 for group 1 , euro;3,240 for group 2 , and euro;1,754 for the control group . The incremental cost-effectiveness ratio per unit effect gained in functional ability ( 0 - 10 scale ) was euro;1,269 ( 95 % CI 497 - 3,316 ) for group 1 , and euro;2,477 ( 95 % CI 601 - 12,098 ) for group 2 . The costs per quality -adjusted life year gained were euro;7,465 ( 95 % CI 3,294 - 14,686 ) for group 1 , and euro;18,575 ( 95 % CI 3,678 - 114,257 ) for group 2 . CONCLUSION Combined spa-exercise therapy besides st and ard treatment with drugs and weekly group physical therapy is more effective and shows favorable cost-effectiveness and cost-utility ratios compared with st and ard treatment alone in patients with AS OBJECTIVE To survey and to compare the one year effects of dynamic muscle training and progressive muscle relaxation as home exercise for patients with inflammatory rheumatic diseases ; and to identify predictors for compliance with a longterm home exercise regimen . METHODS Fifty-four patients ( mean age 54 yrs , mean symptom duration 14 yrs ) were assessed for health related quality of life , exercise motivation , joint tenderness , and physical capacities .  After r and omization into 2 groups , every patient was instructed on one occasion in a 30 min program of either dynamic training or muscle relaxation to carry out at home , 5 times a week during 3 months , and then 2 - 3 times a week for another 9 months . RESULTS Seventeen patients in each group completed the one year exercise protocol , while 10 from each group did not . Compliance with the one year exercise regimen seemed to be predicted by high self-efficacy for exercise , regular range-of-motion exercises before the intervention , and being unmarried . After one year , minor improvements in physical effect ( p < or = 0.05 ) and work effect ( p < or = 0.05 ) were found in the dynamic training group , while minor improvements in pain effect ( p < or = 0.05 ) , emotional reactions ( p < or = 0.05 ) , and arm endurance ( p < or = 0.01 ) were found in the muscle relaxation group . No differences between the groups regarding changes in health status , joint tenderness , or physical capacities during the intervention period were found . CONCLUSION These results may improve the selection of patients for home exercise , and form a basis for improved administration of home exercise programs 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 r and omly allocated into study and control groups . The study was design ed as a prospect i ve , 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 Twenty-one patients with ankylosing spondylitis were admitted for two weeks bedrest , postural and mobilizing exercises . Eleven received low-dose corticotrophin and 10 received placebo injections during their admission and all were review ed after two months . In-patient therapy result ed in significant improvements in function , early morning stiffness , spinal pain , lumbar extension and lateral flexion , finger-floor distance and wall-tragus distance . These improvements were maintained at two months . Biplanar radiography confirmed significant improvements of lumbar spine mobility in 14 male subjects studied . Less improvement occurred in neck movements and these were not maintained . There were no differences between the two treatment groups
target: 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
background: 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 .