Physiotherapy for ankylosing spondylitis: evidence

and application
Laura A. Passalenta,b
a
Toronto Western Hospital, University Health Network
and bDepartment of Physical Therapy, Faculty of
Medicine, University of Toronto, Toronto, Ontario,
Canada

Correspondence to Laura Passalent, BScPT, MHSc,

Physiotherapist Practitioner Toronto Western Hospital
University Health Network, 3EW-400, 399 Bathurst
Street, Toronto, ON M5T 2S8, Canada
Tel: +1 416 603 5800 x5761; fax: +1 416 603 5318;
e-mail: laura.passalent@uhn.on.ca
Current Opinion in Rheumatology 2011,
23:142147

Purpose of review
Ankylosing spondylitis (AS) is a disease that tends to affect younger individuals, many of
whom are in the prime of their lives; therefore, incorporating the most up-to-date
evidence into physiotherapy practice is critical. The purpose of this review is to update
the most recent evidence related to physiotherapy intervention for AS and highlight the
application of the findings to current physiotherapy research and clinical practice.
Recent findings
The results of this review add to the evidence supporting physiotherapy as an
intervention for AS. The emphasis continues to be on exercise as the most studied
physiotherapy modality, with very few studies examining other physiotherapy modalities.
Results of the studies reviewed support the use of exercise, spa therapy, manual therapy
and electrotherapeutic modalities. In addition, the results of this review help to
understand who might benefit from certain interventions, as well as barriers to
management.
Summary
A review of recently published articles has resulted in a number of studies that support
the body of literature describing physiotherapy as an effective form of intervention for
AS. In order to continue to build on the existing research, further examination into
physiotherapy modalities, beyond exercise-based intervention, needs to be explored.
Keywords
ankylosing spondylitis, exercise, physiotherapy
Curr Opin Rheumatol 23:142147
2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
1040-8711

Introduction
Nonpharmacological and pharmacological managements
are considered the cornerstone of intervention for ankylosing spondylitis (AS) and are endorsed by The Assessment in Spondylitis International Society (ASAS) and the
European League Against Rheumatism (EULAR) [1].
Often nonpharmacological intervention comes in the
form of physiotherapy. The primary goals of physiotherapy of the AS patient are to improve mobility and
strength; prevent or decrease spinal deformity; reduce
pain; and to improve ones overall function and quality of
life. In order to achieve these goals, there exists a spectrum of physiotherapy modalities that include exercise,
manual therapy, massage, hydrotherapy/spa therapy,
electrotherapy, acupuncture as well as patient information and education [2]. Although physiotherapy is
considered a cornerstone of AS intervention, the evidence to support it is somewhat sparse compared with
pharmacological treatments for AS. This was illustrated
in a review of AS intervention studies published between
1996 and 2004 when approximately 10% of the studies
reviewed were physiotherapy interventions [3].
1040-8711 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Despite this relatively small amount of evidence,

previous reviews have been produced supporting the role
of physiotherapy interventions for AS [26]. The interventions described in these reviews primarily focus on
exercise with a small number of studies examining other
physiotherapy modalities either in isolation, or in combination with exercise. Furthermore, there are relatively
few well designed studies examining the efficacy and
effectiveness of AS nonpharmacological interventions
compared with other similar inflammatory conditions
[7]. For example there is currently only one Cochrane
Review related to nonpharmacological intervention for
AS. The most recent update of this systematic review,
consisting of 11 randomized control trials (n 763), illustrated a moderate level of evidence that home-based or
supervised exercise is better than no exercise, group
exercise better than home exercise and the addition of
spa-based exercises to weekly group exercises is better
than weekly group exercises [8].
Given that AS is a disease that tends to affect younger
individuals, many of whom are in the prime of their
lives from educational, career and family perspectives,
DOI:10.1097/BOR.0b013e328342273a

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Physiotherapy for ankylosing spondylitis Passalent 143

incorporating the most recent evidence into physiotherapy practice is critical. Promoting the use of the most upto-date evidence-based physiotherapy intervention will
help to ensure that this patient population is able to
maintain and/or improve their current function and
quality of life. Therefore, the purpose of this study
is to update the most recent evidence related to physiotherapy intervention for AS and to highlight the
application of the findings to current physiotherapy
research and clinical practice.

Methods
The Cochrane Database of Systematic Review, PubMed,
Medline, and CINAHL were searched using the following search terms: spondylitis, ankylosing and physical
therapy (specialty), or physical therapy modalities or
exercise therapy or rehabilitation. Publications were
limited to the English language and articles published
from January 2009 to June 2010. Studies involving physiotherapy intervention for AS were included for this
review, regardless of study design (i.e. randomized control studies, nonrandomized control studies, cohort studies were included). Physiotherapy studies associated
with outcome measures, complementary and alternative
medicine and healthcare utilization were excluded from
this review as they were beyond the scope of this study.
Abstracts were reviewed to ensure articles met the above
criteria and then relevant articles were reviewed.

Results
A review of the literature examining physiotherapy interventions for AS from January 2009 to June 2010 resulted
in a limited number of relevant studies (n 9) that mainly
focused on exercise (n 6), spa therapy (n 1), manual
therapy (n 1) and electrotherapy (n 1). The results of
this review will focus on the themes of exercise, spa
therapy, manual therapy, and electrotherapy, and will be
followed by discussion on their application to clinical
practice and research.
Exercise and ankylosing spondylitis

Exercise for AS comes in many forms. Home-based

exercise occurs when a patient is provided with a series
of exercises that are performed unsupervised and independently at a prescribed duration and frequency.
Historically, home-based exercises have been recognized
as an effective physiotherapy modality for AS with
respect to pain reduction, spinal mobility, function and
decreased disease activity [9,10]. A recent nonrandomized control trial [11] (n 43) from Turkey compared
a 12-week home-based daily exercise program with
pharmacological therapy. The patients enrolled in this
study had an average disease duration of approximately
10 years, had no coexistent systemic disease, had not

Key points
 Exercise is the most studied physiotherapy
modality for ankylosing spondylitis, with few studies examining other physiotherapy modalities.
 Exercise is an effective physiotherapy modality
with respect to pain, spinal mobility, function, disease activity, depression, fatigue, quality of life as
well as a number of respiratory measures.
 Other physiotherapy modalities such as manual
therapy show promising results in terms of chest
expansion, posture, spinal mobility and the Bath
Ankylosing Spondylitis Metrology Index.
 Although research in physiotherapy has grown significantly over the past several years, the number of
studies published examining the effects of physiotherapy interventions for ankylosing spondylitis
remains small.

been given antitumor necrosis factor (anti-TNF) treatment, and were at least able to function in their usual selfcare activities but limited in work and other activities.
Although the results of this study showed no significant
difference between groups, this study did provide further
support for home-based exercise in terms of improvement in function and disease activity, and extended
significant findings for this type of intervention to
improvements in depression, fatigue and quality of life.
In contrast to home-based exercise, group-based exercise
involves exercising with peers and is supervised by a
qualified instructor, such as a physiotherapist. In previous
research, group-based exercise has been shown to
improve spinal mobility and function [12,13]. In this
current review, Alsonso-Blanco et al. [14] examined
potential predictors for identifying AS patients who are
likely to benefit from group-based exercise. In this prospective cohort study, 35 AS patients participated in a
group-based exercise program and also received eight
physical therapy sessions over the span of 2 months.
Patients from this cohort had an average disease duration
of 10 years, an average Schober test of 2.05 cm, were
without current symptoms of other concomitant chronic
disease, and were taking some form of nonsteroidal antiinflammatory drug. Regression model analysis found
three predictor variables for success (defined as a 20%
reduction in the Bath Ankylosing Spondylitis Functional
Index and a self-perceived global rating of recovery) that
included a physical role score greater than 37 (from the
MOS 36-Item Short Form Health Survey); a bodily pain
score greater than 27 (from the MOS 36-Item Short Form
Health Survey); and a Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score greater than 31. The
authors established that if patients exhibited two of the
three variables, they were more likely to have success
with the group-based exercise program. In other words,

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144 Rehabilitation medicine in rheumatic diseases

patients with less disease severity will likely have better

outcomes with group-based exercise. Knowing that exercise is an effective physiotherapy modality is an important first step in the management of patients with AS;
however, understanding who will likely benefit from an
exercise program is important to ensure successful intervention in this population
Swimming is often recommended for patients with AS;
however, there is limited evidence to support its use as an
exercise intervention. This review found a randomized
control study (n 37) that compared freestyle swimming
30 min, 3 days per week for 6 weeks and daily conventional land-based exercise; walking for 30 min, 3 days per
week for 6 weeks, and daily conventional land-based
exercise; and daily conventional land-based exercise
alone (control group) [15]. Patients in this study were
excluded if they had, among other criteria, active peripheral joint involvement, severe comorbidities or had
previous anti-TNF treatment. Significant improvements
were observed in pulmonary and exercise tolerance outcome measures in the swimming and walking groups
compared with the control. This study provides support
for both swimming and walking as an effective form of
aerobic exercise intervention for AS patients. This study
also emphasizes the importance of pulmonary outcomes
in this patient population, as AS can affect the thoracic
spine, costo-sternal junctions and the lungs themselves,
thereby causing pulmonary impairment [16,17]. These
important pulmonary outcomes were also examined in a
prospective cohort study [18] that examined the benefits
of a 6-week home-based exercise program. In this study,
22 patients with AS were taught breathing exercises and
upper extremity exercises that were performed daily at
home for a 6-week period. The average disease duration
for this patient group was 7 years, with baseline measures
that included chest expansion of 3.1 cm, modified Schober test of 3.9 cm and BASDAI score of 2.2. The results
showed significant improvement in a number of respiratory outcomes including chest expansion, maximal
inspiratory pressure and maximal expiratory pressure
values, as well as improvement in overall function. Pulmonary function was also examined by Durmas et al. [19]
comparing global posture re-education (GPR) exercise
[20], conventional exercise and no exercise. This prospective nonrandomized control study found both exercise groups showed significant improvement in pulmonary function measures, chest expansion and pain, with
the GPR exercise prescription demonstrating greater
improvements in forced vital capacity, forced expiratory
volume in 1 min and peak expiratory flow.
In order to gain a deeper understanding of exercise and
the AS patient, Passalent et al. [21] examined 61 patients
with AS (mean disease duration of 15 years, 53% of
patients having axial disease and an average BASDAI

score of 4.3) to establish the type and extent of exercises

used by AS patients and to also determine their perceptions of exercise. This prospective cohort study found
AS patients report participating in evidence-based exercise (such as home-based exercise, walking and swimming); however, the majority of participants do not
report participating on a frequent basis (i.e. more than
three times per week), despite positive perceptions of
exercise such as improvement in physical fitness and
cardiovascular function. The majority of barriers to
exercise identified in this study centered on the concept
of fatigue. The authors question if these patients are
fatigued due to the disease itself or are they fatigued
because exercise as an intervention is not adequately
impacting their disease. The authors suggest that future
research is needed to address the barriers identified
in their study to ensure optimal uptake of exercise in
patients with AS.
Spa therapy and ankylosing spondylitis

Spa therapy involves therapeutic exercise in natural

mineral waters, immersion in thermal water, the use of
mud packs and/or massage [22]. This physiotherapy
modality has been traditionally used in the treatment of
AS, with evidence to support its use in the improvement of
spinal mobility, pain and disease activity [23,24]. This
review revealed one study [25] examining the effects of
combination treatment with etanercept and spa rehabilitation versus etanercept alone. This study compared 30 AS
patients who combined etanercept therapy with 7 days of
spa rehabilitation in a thermal bath center with 30 AS
patients who took etanercept therapy alone. The results
indicated significant improvement in function and quality
of life in the combination therapy group at 3 months
postintervention and these improvements were maintained at 6 months postintervention.
Manual therapy and ankylosing spondylitis

Manual therapy is a traditional modality used in physiotherapy intervention; however, there has been a lack of
randomized clinical trials examining the efficacy of such
modalities in the AS population [8]. In order to address
this gap in the evidence, Widberg et al. [26] recently
examined a small cohort (n 32) of AS patients who were
randomized to self and manual spinal mobilization for
8 weeks or to a control group. Patients included in this
study were all men between the ages of 23 and 60 years;
had an average disease duration of approximately 3 years;
and had stable pharmacological treatment. Patients were
excluded if they demonstrated radiological ossification
between the thoracic vertebrae, among other exclusion
criteria. The treatment protocol consisted of warming
the soft tissues of the back muscles; active and passive
spinal column mobility exercises; stretching of tight
muscles using a contractrelax technique; and manual
massage. Chest expansion, vital capacity, posture and

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Physiotherapy for ankylosing spondylitis Passalent 145

spinal mobility were assessed, in addition to the Bath

Ankylosing Spondylitis scales. Results showed significant
improvements in chest expansion, posture, spinal mobility and the Bath Ankylosing Spondylitis Metrology
Index (BASMI). This study also examined long-term
effects of this intervention and found that significant
gains in posture, spinal mobility and BASMI measures
were maintained over a 6-month time period.
Electrotherapy and ankylosing spondylitis

There is a wide range of electrotherapy agents used in

physiotherapy and their use is well established in
clinical practice [27]. One example of an electrotherapeutic agent used in physiotherapy practice is infrared
radiation [28]. This technology is currently available in
Europe and a recent pilot study examined the effects of
infrared sauna on a prospective cohort of 18 AS patients
[29]. This study found significant reductions in pain
and stiffness, immediately following the application of
the agent; however, these effects were not maintained
4 weeks after the study intervention in patients
with AS.
Application to physiotherapy research and practice

The reviewed studies add to the evidence supporting

physiotherapy as an intervention for AS. The emphasis
continues to be on exercise as the most studied physiotherapy modality, with few studies examining other
physiotherapy modalities. The studies reviewed in
this study also help us begin to understand who might
benefit from certain interventions as well as barriers
to management.
There are number of issues related to the results of this
review that must be discussed in terms of research and
clinical practice. The variation in exercise protocols
described in the reviewed literature makes it difficult
to compare the overall effect of physiotherapy as an
intervention to manage AS. In terms of home-based
exercise, the reviewed studies describe different
duration, frequency and exercise prescriptions. For
example, the study by Durmas et al. [11] describes a
set of 20 static exercises for relaxation, flexibility,
strength, breathing and posture, whereas other studies
reviewed incorporated other exercise programs that are
performed in both static and dynamic postures [14,20].
Very few studies have included details such as the
number of repetitions, and sets for their described
exercise protocols, not to mention a full description
of the exercise technique. As exercise appears to be the
focus of physiotherapy intervention for AS, specific
detail regarding all aspects of the exercise program
need to be provided in order to accurately apply these
methods to clinical practice. Furthermore, harmonization of exercise protocols across research initiatives
may allow better comparison of the intervention in

AS research. Lastly, identification of optimal frequency,

duration and type of exercise for AS patients represents
a gap in the current literature and requires future
research.
Similar to variation in exercise protocols, there is also
variation in the outcomes used to assess the effects of
physiotherapy interventions. Although all studies
included in this review utilized some or all of the Bath
Ankylosing Spondylitis scales, other studies, particularly
those investigating the effects of a physiotherapy intervention on pulmonary function showed great variation in
the use of outcome measures. For example, Widberg et al.
[26] used chest expansion and vital capacity to measure
the effect of spinal mobilization, whereas Karapolat et al.
[15] used more detailed measures such as forced vital
capacity, forced expiratory volume in 1 min and respiratory exchange rate to measure the aerobic effects of
swimming. The ASAS Working Group of OMERACT IV
recommended a number of core set endpoints in physical
therapy clinical studies that included physical function,
pain, spinal mobility, spinal stiffness, and patient global
assessment [30]. The above endpoints are included in the
articles presented in this review; however, given the
important role of physiotherapy in pulmonary outcomes,
consideration of such pulmonary-based endpoints
should be included in future review of the core sets in
AS research.
Variation within the patient population makes it difficult
to compare the overall effectiveness of physiotherapy as a
management strategy in AS. For example, the disease
location of patients described in this review may be
exclusively axial in nature, as described by Karapolat
et al. [15], inclusive of both peripheral and axial disease
location [21], or for the majority of studies included in this
review, not identified. Given the heterogeneity of the AS
disease population, information of this kind is important
if practitioners are to apply the results of such studies into
clinical practice. Similar detail regarding disease severity,
concomitant pharmacological management, and comorbidity would assist the clinician in targeting appropriate
physiotherapy interventions to their particular patient
population.
The evidence behind home-based exercise programs is
difficult to assess due to questions of patient adherence. A
number of the studies reviewed above indicated that the
patients were contacted by telephone on a weekly basis
as a method of ensuring adherence [11,20,18]; however,
it remains uncertain if patients actually complied to the
prescribed frequency and duration and whether or not
they employed the correct exercise technique. It may be
that group-based exercise protocols would be better
suited to ensure adherence as there is supervision
and peer support during the exercise program. Further

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146 Rehabilitation medicine in rheumatic diseases

study comparing home-based exercise and group-based

exercise is required to understand issues of patient
adherence in this patient population.
Investigation into the effects of manual therapy modalities for AS intervention has been limited as evident by
the one article identified in this update. One explanation
for this gap in the literature may be that the effects of
such modalities are difficult to accurately measure due to
practitioner variability in manual therapy experience.
Furthermore, variation in patient severity may also play
a role in assessing the effects of manual therapy techniques. From a clinical perspective, one may need to use
caution when employing such techniques as manual
therapy may be contraindicated, for example, in the
presence of osteoporosis, acute inflammatory flare, or
advanced ankylosis.
The advent of biologics as an effective management
strategy for patients with AS [31] requires examination
into the effects of the combination of both pharmacological and nonpharmacological intervention in order to
determine the degree of further clinical gains this patient
population may expect. Significant improvement in function and quality of life was found in the study presented
by Colina et al. [25], suggesting that physiotherapy and
exercise will continue to play an important management
role in an era of biologic intervention. Further study into
the combined effects of biologics and physiotherapy
is warranted.
In terms of research design, the validity of the control
studies included in this review is limited, mainly due to
the small sample size. For this review the sample size
ranged from 30 to 60. Small sample size may lead to
inadequately powered studies and therefore put the
study at risk for incorrectly identifying differences
between intervention and control groups. Pooling of
studies may be an option; however, given the variation
in treatment protocols and outcome measures as
described above, it is unlikely that such action would
strengthen study results. It is therefore important that
adequate sample size is considered in order for the results
of physiotherapy and AS research to be translated into the
best possible clinical practice.
Overall the intervention studies reviewed in this study
add to the growing body of literature examining the
effectiveness of physiotherapy for AS. Unfortunately,
the number of studies published remains small.
Although research in physiotherapy has grown significantly over the past several years [32,33] it has been
suggested that a combination of relatively little research
funding, a lack of adequately powered randomized trials,
and the inability to blind patients and healthcare providers to physiotherapy intervention research has led to a

gap of research evaluating physiotherapy interventions

[7,34,35]. Despite the limited evidence available for
physiotherapy intervention for AS, clinicians must strive
to translate the current research into practice.

Conclusion
A review of the recently published literature has resulted
in a number of studies that support the body of literature
describing various physiotherapy modalities as an effective form of intervention for AS. In order to continue to
build on the existing research, further examination into
physiotherapy modalities, beyond exercise-based intervention, needs to be explored.

Acknowledgements
The author has no conflict of interest or sponsorships to declare. The
author would like to thank Dr Aileen Davis and Ms Crystal MacKay for
their valuable feedback in the development of this manuscript.

References and recommended reading

Papers of particular interest, published within the annual period of review, have
been highlighted as:

of special interest
 of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (pp. 219220).
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