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Physiotherapy in ankylosing spondylitis: What is the evidence ?

S. van der Linden1, A. van Tubergen1, A. Hidding2

1Department of Medicine, Division ofRheumatology, University Hospital Maastricht, Maastricht; 2Institute forRehabilitation Research, Hoensbroek,The Netherlands

Sjef van der Linden, MD, PhD, Professorof Rheumatology; Astrid van Tubergen,MD, Research Fellow; Alita Hidding,MSc, PT, PhD, Senior Research Fellow.

Please address correspondence to:Prof. Sjef van der Linden, MD, Depart-ment of Medicine, Division of Rheuma-tology, University Hospital Maastricht,PO Box 5800, 6202 AZ Maastricht, TheNetherlands. E-mail: [email protected]

Clin Exp Rheumatol 2002; 20 (Suppl. 28):S60-S64.

© Copyright CLINICAL AND EXPERI-MENTAL RHEUMATOLOGY 2002.

Key wo rd s : A n kylosing spondy l i t i s ,effectiveness, efficacy, evidence basedmedicine, exercises, hydrotherapy, out-come, physical therapy, physiotherapy,spa therapy.

web-based database of randomized tri-als and systematic reviews in physio-t h e rapy has now been produced (1).The evidence confi rms the value ofsome current physiotherapy practicesand the ineffectiveness of others (2). Dealing with evidence based medicine(EBM) in practice four stages can bedelineated.(1) The fo rmu l ation of answe rabl e

questions.This requires analytical skills, anawareness of knowledge gaps andthe compelling motivation to dosomething about them by orderlyinquiry.

(2) The search for the best evidence.This mandates for the selection ofthe most ap p ro p ri ate source ofinformation, their systematic inves-t i gation and the ap p l i c ation ofinformation technology competen-cies to the full range of printed andelectronic data.

(3) Critical appraisal of the evidence.This calls for ri go ro u s , s c i e n t i fi ctesting of accuracy and diagnosticvalidity in the literat u re or dat a ,with the help of statistical compe-tence and logical discri m i n at i o nbetween the costs and benefits ofalternative procedures.

(4) The decision to apply the conclu-sion to patients’ healthcare.

This demands the integration of theevidence with the practitioner’s clini-cal ex p e rtise to produce a soundlybased judgment of treatment. In fact,this point comprises an ap p ro a ch tod e c i s i o n - m a k i n g, in wh i ch the cl i n i-cian uses the option that suits thatp atient best, u n d e rlining the impor-tance of patients in the evidence basedapproach.

Evidence from the literature is usuallyc at ego ri zed into seve ral levels ofimportance ranging from highest quali-ty evidence to lowest quality evidencebased upon the strength of the studydesign (Table I). C l e a rly, these ge n e ral principles are

ABSTRACTEvidence on the value of some currentphysiotherapeutic practices and the in -effectiveness of others is accumulating.This paper addresses the best evidenceavailable on the efficacy and effective -ness of physiotherapeutic modalities inankylosing spondylitis. General issuesin the assessment of physiotherapy inthis disease are briefly discussed. Coresets for assessments are nowa d ay sava i l abl e. A recent Coch rane rev i ewon this topic supports the (at leastshort-term) positive effects of physio -therapy, in particular exercise, in themanagement of ankylosing spondylitis.Some details of the included studiesare provided.

Ankylosing spondylitis, the prototypeof the group of related diseases that arecollectively labeled as spondylarthro-pathies, is one of the most frequent in-flammatory rheumatic conditions. Liker h e u m atoid art h ri t i s , the disease isa s s o c i ated with significant disab i l i t yand increased socioeconomic costs.Currently available conventional thera-pies for ankylosing spondylitis are pal-liative at best, and often fail to controlsymptoms at the long run. Phy s i c a lt h e rapy including exe rcises is oftenconsidered as a necessary adjunct todrug therapy. However, the paucity ofdata makes it difficult to identify thebest administration mode of theseinterventions based upon scientific evi-dence. Nowadays, the question whether or notphysiotherapy is effective for patientswith musculoskeletal diseases in gen-eral and ankylosing spondylitis in par-ticular receives considerable attention.P u bl i c ation of ra n d o m i zed trials ands y s t e m atic rev i ews in phy s i o t h e rapyfor the whole field of musculoskeletalconditions has increased spectacularover the past few ye a rs. More than2700 randomized trials and systemicrev i ews in phy s i o t h e rapy are nowavailable of which more than 800 havebeen published since 1997 (1). A large

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Physiotherapy in AS / S. van der Linden et al.

Table I. Levels of scientific evidence (A = highest; D = lowest).

(A1) Meta-analysis including consistent results of high quality double-blinded randomizedcontrolled clinical trials (RCTs)

(A2) High quality double-blinded randomized controlled clinical trials providing consistentresults

(B) Lower quality randomized controlled clinical trials and those with smaller numbers andother comparative (non-randomized) studies (cohort studies; case-control studies)

(C) Non-comparative studies

(D) Expert opinion

relevant not only for physiotherapy asit relates to musculoskeletal (or other)diseases in general. Their practical ap-plication to a disease such as ankylos-ing spondy l i t i s ,h oweve r, is no easy task.For example, what exactly do we meanif we use the word physiotherapy? Tra-ditionally, the mainstays of physiother-apy in the management of mu s c u-loskeletal conditions have been mas-s age, m a nual therapy (manipulat i o nand joint mobilization), electrotherapy(ultrasound, short-wave diathermy, orlow energy laser), and therapeutic ex-ercises. Therefore, physiotherapy com-prises a whole spectrum of – usuallyn o n - s t a n d a rd i zed – therapeutic inter-ventions applied by non-standardizedp hy s i o t h e rapists to diffe rent pat i e n t swhose disease (ankylosing spondylitis)might differ in important aspects suchas activity, severity or stage of the con-dition to be treated. Patients may havevarying degrees of involvement of theaxial skeleton ra n ging from ra d i o-graphic changes limited to the sacroili-ac joints to complete fusion of thespine. Braun et al. have recently pro-posed to stage the disease into 5 cate-go ries based upon ra d i o l ogical in-volvement of the spine (Table II). Also,

Table II. Radiological stages of ankylosing spondylitis (Braun et al. in preparation).

Stage I ≥ Grade II bilateral radiographic sacroiliitis

Stage II Minor radiographic evidence of spinal involvement in 1 spinal segment (≤ 3 vertebrae or < 15% of the spine)

Stage III Moderate radiographic evidence of spinal involvement in 2 spinal segments (4–12 vertebrae or 15-50% of the spine)

Stage IV Radiographic evidence of spinal involvement in 3 or more spinal segments (13–19 vertebrae or 50-80% of the spine)

Stage V Widespread (≥ 80%) fusion of the spine (≥ 20 vertebrae)

fe at u res such as peri p h e ral art h ri t i s ,e n t h e s i t i s , a n t e rior uve i t i s , or orga ninvolvement may or may not be pre-sent. All these stages may be associat-ed with diffe rent degrees of impair-ment, functional limitations or handi-cap and may require different physio-therapeutic approaches. Thereby, oneshould have realistic ex p e c t ations ifone pre s c ribes phy s i o t h e rapy to pa-tients with ankylosing spondy l i t i s .Probably, no one would reasonably ex-pect that phy s i o t h e rapy would affe c tacute phase reactants as indicators ofthe inflammatory process such as theerythrocyte sedimentation rate or theC-reactive protein level. Dealing withassessment of the effectiveness of phy-siotherapy, other important issues haveto be add ressed also. For ex a m p l e,what is the time horizon of the intend-ed effects of physiotherapy ? Are weopting for short-term efficacy or long-term effects? Maybe we want to rec-ommend physiotherapy aiming at pre -ve n t i o n of possible future complica-tions such as limited physical function-al ability due to a fused bend spine. Infact, we are dealing with a whole arrayof possible interventions (Table III)and many possible outcomes (or pre-

vention of certain outcomes) over con-siderable periods of time. In order top romote standard i z ation in this fi e l dthe international Ankylosing Spondyli-tis Assessment group (ASAS) hasaddressed some of these questions. Acore set for the assessment physiother-apy is now available (Table IV) (3). In this paper searching for scientificevidence for effectiveness of physio-therapy we will deal with high qualityevidence (level A) only (Table I). Re-cently, a Cochrane review on physio-therapeutic interventions for ankylos-ing spondylitis has been completedwith the objective to summari ze theava i l able scientific evidence on thee ffe c t iveness of phy s i o t h e rapy inter-ventions in the management of anky-losing spondylitis (4). Only random-ized and quasi randomized studies onp atients fulfilling the modified New

Table III. Spectrum of physiotherapeuticmodalities for ankylosing spondylitis.

Supervised exercises for individual patientsSupervised exercises for groups of patientsUnsupervised exercisesTrainingManual therapyMassageHydrotherapySpa therapyElectrotherapyAcupuncturePatient information and education

Table IV. Core set of domains for assess-ment of efficacy of physiotherapeutic inter-ventions in patients with anky l o s i n gspondylitis as proposed by the internationalASAS group (3).

• Physical function• Pain• Spinal mobility• Stiffness• Patient global evaluation

York criteria for ankylosing spondylitis(5) were included in this review of theliterature if at least one of the compari-son groups re c e ived some kind ofphysiotherapy. As main outcomes theASAS core set was used (Table IV).Altogether 21 studies were consideredfor inclusion in this review, but 16 ofthem had to be excluded due to studydesign or due to the objection of the

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study leaving 5 studies (6-10). Of theseremaining studies 2 are follow-up orc ro s s over studies (8, 10) of prev i o u sstudies in this group and, therefore, donot provide independent results. Th eresults of these best evidence studieswill be discussed in more detail below.Remarkably, exercising is the experi-mental treatment in all these trials. Physiotherapy in ankylosing spondyli-tis is usually said to aim at maintainingand improving mobility of the spineand peripheral joints, strengthening themuscles of the trunk, the legs, the back,and the abdomen by exercises; stretch-ing of the back and improving fitnessby sporting activities; and by relaxationof the body and improving mobility byhydrotherapy (7,11,12). Several exer-cise regimens for ankylosing spondyli-tis can be distinguished: s u p e rv i s e d(individuals or groups) or unsupervised( Table III). Detailed info rm ation onvarious forms of these physical exercis-es has been described in the literature,although no unifo rm protocol is ye tavailable (6,11-15). In supervised individualized exercises,performed at a physiotherapy center or- to a lesser extent - at home, educationplays a central role. The physiothera-pist advices the patient how to move,how to rest in a particular position, andwh i ch sports are ap p ro p ri ate (bad-m i n t o n , vo l l ey b a l l , sw i m m i n g, c ro s s -country skiing) and which is less suitedor not suited at all (horse riding, cy-cl i n g, b ox i n g, fo o t b a l l , soccer). Th eaim of these exercises is to teach thepatient an individual exercise programthat he/she can subsequently continuedaily unsupervised at home (7). The unsupervised individualized exer-cises may consist of exercises based ona pre d e fined progra m , but may alsoi n clude re c re ational exe rcises. Th e s eexercises should become part of dailyroutine in a patient’s life.In practice, many patients find it diffi-cult to comply to a program of dailyexe rcises indiv i d u a l ly. Th e re fo re, s u p e r -vised group physical therapy is offeredmainly to stimulate and motivate thepatients to continue exercising, and toprovide social contacts with and con-trol by fellow-patients. Also, the super-vising phy s i o t h e rapist cl o s e ly guard s

the intensity of the exercises in order toachieve improvement. Group physicaltherapy usually consists of 1 hour ofphysical exercises, 1 hour of sports and1 hour of hydrotherapy. In-patient physiotherapy, consisting of2-4 weeks daily exercising at a special-ized clinic, in particular is frequentlyoffered to recently diagnosed patientsor to patients experiencing a flare oftheir disease. Tre atment usually con-sists of exercises and pool sessions, butalso other treatment modalities (for ex-ample ice or heat ap p l i c at i o n s , m a s-sages) may be applied. Also, educationabout the disease, the role of patientsocieties, and information about reim-bursement by insurance companies isextensively provided.

Best evidence for efficacy or effectivenessSupervised individualized exercisesThe effects of supervised indiv i d u a l-ized physical exercises have been stud-ied in a RCT (9) with an additional fol-l ow-up period (10), and in an openstudy (16). Kraag et al. randomly allo-cated patients to either physiotherapyand disease education at home (n = 26),or to no therapy (n = 27) (9). After 4months, the patients from the controlgroup were also offered physiotherapysessions at home (10). In comparisonwith the control group, the interventiongroup showed at 4 months (end of trialperiod) statistically significantly morei m p rovement in fi n ge r- t o - floor dis-tance (mean re l at ive betwe e n - gro u pi m p rovement [scores of interve n t i o ngroup minus those of controls]: 42%)and function (23%) (9). At 8 months(end of open follow-up period), onlyfunction had significantly changed inboth study groups compared with re-sults at 4 months (10). Interestingly, theintervention group showed significant-ly more improvement at 4 months incomparison with the control group at 8months. The authors suggested that thisreduced treatment effect may be due tothe fact that the intervention group hadreceived more therapy sessions in thefirst 4 months compared with the con-trols in the second period of 4 months,implying that more therapy given on aregular basis will be more effe c t ive (10).

Supervised group physical therapy The effects of weekly-supervised groupphysical therapy in addition to unsuper-vised exercises have been investigatedin a RCT (7), which was followed by asecond RCT after the end of the firsts t u dy period in wh i ch the effects ofcontinuation of group physical therapywere assessed (8). In the first study,patients were randomly allocated to agroup that fo l l owed we e k ly gro u pphysical therapy in addition to daily-unsupervised exercises at home (n =68) or to a group that only daily exer-cised at home (n = 76) (7). Both groupshad re c e ived 6 weeks of superv i s e dindividualized therapy before random-ization (16). After 9 months, statistical-ly significantly more improvement infavor of the intervention group wa sfound for thoraco-lumbar flexion andextension (mean betwe e n - group im-provement: 7%), physical fitness (5%),and global health (28%). In a second,c o n s e c u t ive study, the interve n t i o ngroup was ra n d o m i zed again into agroup continuing weekly group physi-cal therapy for another 9 months (n =30),and a group discontinuing this (n =34) (8). Both groups were advised tocontinue exercising at home. After 9months, statistically significantly moreimprovement was found in the continu-ation group compared with the discon-tinuation group in global health (28%).Function did not improve much in thecontinuation group (4%), but deterio-rated in the discontinu ation group (-28%), the difference being statisticallys i g n i ficant. During the study peri o d,the time spent on exe rcises at homeap p e a red to be signifi c a n t ly higher inthe continu ation group than in the dis-c o n t i nu ation group. An ex p l a n at i o nfor this could be peer pre s s u re and en-c o u ragement by the supervisor of thec o n t i nu ation group stimu l ating homeexe rcising (8). This may consequentlyalso have had effects on the outcomesof the study. Alongside this RCT (7), ac o s t - e ffe c t iveness study was per-fo rmed (17). Only direct (health care )costs we re incl u d e d. Costs of annu a lwe e k ly group physical therapy we ree s t i m ated at (1993 fi g u res) USD 531per patient per ye a r. In compari s o nwith the pre - t rial peri o d, the total me-


dical costs for the intervention gro u pd e c reased with a mean of USD 257(35%) per patient per year for the indi-v i d u a l i zed exe rcise group and USD379 (44%) per patient per year for su-pervised group therapy.

In-patient physiotherapyOne RCT reported the effects of in-patient physiotherapy (6). Three groupsof patients were studied: group A (n =15) followed 3 weeks of intensive in-patient physiotherapy, group B (n = 15)followed during a 6 weeks period twiceweekly hydrotherapy sessions and per-formed individual exercises twice dailyat home, group C (n = 14) only per-formed individual exercises at home.All groups were advised to continueexercising at home after the treatmentperiod. Significant differences betweenthe three groups were found immedi-ately after treatment in pain, stiffness,and cervical ro t at i o n , with most im-provement found in the two interven-tion groups. At 6 months no significantd i ffe rences between the groups we refound in any of the outcome measures.

Spa therapyEvidence for the effects of the therapyknown as Spa therapy, also – at least inc e n t ral Europe - often called “ Ku rTherapie” may need particular atten-tion. It can be described as an intensive- usually up to 3 weeks lasting – combi-nation of physiotherapeutic modalities,including hydrotherapy and exercises.It can be offered to groups of patientsor to individuals. It is mostly super-vised and takes place (at least partly)in-house. A recently conducted study evaluatedthe efficacy of 3 weeks of combinedspa-exercise therapy as an adjunct tos t a n d a rd tre atment with drugs andweekly group physical therapy in pa-tients with ankylosing spondylitis (18).Two groups of 40 patients each wererandomly allocated to treatment at 2different spas (one in Austria, the otherone in the Netherlands) A contro lgroup (n = 40) stayed at home andreceived weekly group therapy for 40weeks. The “spa” patients followed aregimen of combined spa/group physi-cal exercises for 3 weeks, followed by

weekly group physical therapy for ana dditional 37 weeks. The improve-ments in function and global well beingin the spa-exercise therapy groups weregreatest early in the study. At 4 weeksafter the start of spa-exercise therapy,significant improvements were seen inthe pooled index of change (which wasan aggregate of the following primaryo u t c o m e s : BA S F I , p at i e n t ’s globalwell-being, pain, and duration of morn-ing stiffness) in the “spa” group, com-pared to the control group (p ≤ 0.004).B e n e fit was maintained over the 40-week study period in patients receivings p a - exe rcise therapy, although at 40weeks, the improvement in the pooledindex of change had lost statistical sig-nificance, as compared to controls. The cost-effe c t iveness of combineds p a - exe rcise therapy has also beenassesses alongside this RCT. The incre-mental (= additional) cost-effectivenessand cost-utility ratios of the 3-we e kcourse of spa-exercise therapy as com-pared to standard treatment were inves-t i gated (19). Direct (health care andnon-health care) as well as indire c t(non-health care) costs were included.The incremental cost-effe c t ive n e s sratio per unit effect gained in functionalability a 0-10 scale (based on the BathA n kylosing Spondylitis FunctionalIndex) was Euro 1269 and Euro 2477for the Austrian and Dutch group re-spectively. The costs per QALY (Quali-ty Adjusted Life Year) gained (assessedby EuroQol) were Euro 7465 (spa ther-apy in Bad Gastein, Austria) and Euro18575 (spa therapy in Arcen, The Ne-therlands) for the 2 groups respectively.No substantial ch a n ges in the costratios were found in sensitivity analy-ses for a whole range of variables.

ConclusionIn summary, the available data support(at least short term) positive effects ofphysiotherapy, in particular exercises,and spa therapy in the management ofankylosing spondylitis. However, fur-ther research is needed to determine themost effe c t ive phy s i o t h e rapy modali-ties and applications and to establishthe precise role of physiotherapy inter-ventions for this potentially disablinginflammatory rheumatic condition. In

the meantime, patients should considerexercising as part of their daily routine.Depending on their personal needs andpreferences, disease activity and severi-ty, patients with ankylosing spondylitismay opt for unsupervised (recreationalor ankylosing spondylitis-specific) ex-ercises alone, may additionally attendgroup physical therapy sessions, or ifnecessary follow an in-patient courseof physiotherapy or engage in spa ther-apy. Self-management is a prerequisiteto success, with the basis lying initiallyat the physician convinced of the needof exercising and referring the patientto a physiotherapist, and second at thephysiotherapist who inspires and moti-vates the patient to follow a time con-suming program, which however mayeventually lead to a better outcome oftheir disease (20).

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