Ankylosing Spondylitis (Axial Spondyloarthritis)

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Definition/Description

Dr. G. Vilke.SPONDYLITISdotORG. Areas of Inflammation in AS. Available from: http://www.youtube.com/watch?v=2s8eueQ4-eM[last accessed 24/08/12]

Ankylosing spondylitis (also called Bechterew's disease) is a <a href="Spondyloarthritis">spondyloarthritis</a> of the spine and pelvis. Affected joints progressively become stiff and sensitive due to a bone formation at the level of the joint capsule and cartilage. Regions most affected by the disease are the axial skeleton and sacroiliac joints. It causes a decreased range of motion and gives the spine an appearance similar to bamboo, hence the alternative name "bamboo spine".
Other joints such as hips, knees, ankles, shoulders and temporomandibular joints may also be affected by the disease but in the majority of cases, the back and neck are the most affected regions. Ankylosing spondylitis (AS) is often associated with other chronic inflammatory diseases such as <a href="Reactive Arthritis">reactive arthritis</a>, <a href="Psoriatic Arthritis">psoriatic arthritis</a>, <a href="Juvenile Chronic Arthritis">juvenile chronic arthritis</a>, ulcerative colitis, <a href="Anterior Uveitis">iritis</a> and <a href="Chron's Disease">Crohn’s disease</a>, which can be used as signs for the diagnosis of AS.

Clinically Relevant Anatomy

<img src="/images/thumb/3/30/Axial_skeleton.png/200px-Axial_skeleton.png" _fck_mw_filename="Axial skeleton.png" _fck_mw_location="center" _fck_mw_width="200" _fck_mw_type="thumb" alt="Axial Skeleton" class="fck_mw_frame fck_mw_center" />

<img src="/images/thumb/c/c6/Sacroiliac_joint.png/300px-Sacroiliac_joint.png" _fck_mw_filename="Sacroiliac joint.png" _fck_mw_location="center" _fck_mw_width="300" _fck_mw_type="thumb" alt="Sacroiliac Joint" class="fck_mw_frame fck_mw_center" />

Epidemiology /Etiology

The etiology of AS is not fully understood at this time, although a strong genetic link has been determined.van der Linden S, van der Heijde D. Clinical aspects, outcome assessment, and management of ankylosing spondylitis and postenteric reactive arthritis. Curr Opin Rheumatol. 2000;12(4):263-268.  In addition, a direct relationship between AS and the major histocompatibility human leukocyte antigen (HLA)-B27 has also been determined.Alvarez I, López de Castro JA. HLA-B27 and immunogenetics of spondyloarthropathies. Curr Opin Rheumatol. 2000;12(4):248-253  The exact role of this antigen is unknown but is believed to act as a receptor for an inciting antigen leading to AS.

Ninety percent of patients with AS seem to have a deficit of this antigen but not everyone with this deficit develops the condition. This is why the exact role of the B27 antigen is still to be determined in the cause of AS. Maksymowych W. Ankylosing spondylitis. Not just another pain in the back. Can Fam Physician. 2004;50:257-262.

The most supported information known about the pathological process of AS is that it affects the subchondral granulation tissue and creates small lesions, ultimately leading to joint erosion.McGonagle D, Emery P. Enthesitis, osteitis, microbes, biomechanics, and immune reactivity in ankylosing spondylitis. J Rheumatol. 2000;27(10):2302-2304.  In the spine this occurs at the junction of the vertebrae and the annular fibres of the <a href="Intervertebral disc">intervertebral disc</a>. These lesions in the annulus eventually undergo ossification, leading to a 'fusion' effect of the spinal segments and the similarity in appearance to bamboo.

<img src="/images/thumb/9/99/Ankylosing_process.jpg/400px-Ankylosing_process.jpg" _fck_mw_filename="Ankylosing process.jpg" _fck_mw_location="center" _fck_mw_width="400" _fck_mw_type="thumb" alt="Ankylosing Process" class="fck_mw_frame fck_mw_center" />

<img src="/images/thumb/1/14/Ankylosing_spondylitis_lumbar_spine.jpg/200px-Ankylosing_spondylitis_lumbar_spine.jpg" _fck_mw_filename="Ankylosing spondylitis lumbar spine.jpg" _fck_mw_location="center" _fck_mw_width="200" _fck_mw_type="thumb" alt=""Bamboo Spine" on X-ray" class="fck_mw_frame fck_mw_center" />

Characteristics/Clinical Presentation

AS is predominantly seen in males in a 3:1 ratio and the onset of symptoms generally occurs in late adolescent years to early adulthood.  Onset of symptoms past the age of 45 is uncommon, typically between the ages of 20-30.

The clinical presentation is usually an insidious onset of back pain in the <a href="Sacroiliac joint">sacroiliac</a> (SI) joints and gluteal regions.  Morning stiffness lasting greater than 30 minutes is a common subjective complaint, as well as waking up in the second half of the night. Pain is usually exacerbated with rest and relieved with physical activity. Complaints of intermittent breathing difficulties may also be a common complaint because AS may cause a decrease in chest expansion.

Common physical findings include:

• Forward flexed, or stooped, posture
  

• Decreased spinal segmental mobility
  

• Tenderness on palpation of the SI regions
  

• Bamboo spine
  

Common non-movement related symptoms include:

• Night sweats
• Iritis
• Ulcerative colitis

Differential Diagnosis

Common disorders to consider as differential diagnoses with AS are:

• <a href="Degenerative Disc Disease">Degenerative Disc Disease</a>
  

• <a href="Disc Herniaton">Herniated Intervertebral Disc </a>
  

• Fractures and/or dislocation
  

• <a href="Osteoarthritis">Osteoarthritis</a>
  

• <a href="Spinal Stenosis">Spinal Stenosis</a>
  
• <a href="Spondylolisthesis">Spondylolisthesis</a>, <a href="Lumbosacral spondylolysis">Spondylolysis</a>, and <a href="Lumbar Spondylosis">Spondylosis</a>

Differential Diagnosis made easy:

1. Osteoarthritis:
o Presents with mechanical pain typically becoming worse at the end of the day and after activity, with no morning symptoms.
o May occur after lifting or bending.
o The history differentiates mechanical back pain from inflammatory back pain.

2. Diffuse idiopathic skeletal hyperostosis (DISH):
o Typically presents with mechanical symptoms.
o Age of onset may help differentiate this condition from AS, as onset tends to be in the 50- to 75-year age group.

3. Psoriatic arthritis:
• Tends to present in the 35- to 45-year age group. No sex bias.
• Sacroiliitis may be unilateral.
• History of psoriasis.

4. Reactive arthritis:
o Patients usually recall a specific infection: for example, a non-gonococcal urethritis or gastroenteritis.
o Dactylitis and skin manifestations occur more frequently than in AS.
o May present with keratoderma blennorrhagica, conjunctivitis, or urethral discharge.

5. Inflammatory bowel-related arthritis:
• History of Crohn's disease or ulcerative colitis.
• Peripheral joint involvement common.
• May have evidence of erythema nodosum or pyoderma gangrenosum.

Diagnostic Procedures

The diagnosis of AS is commonly made through a combination of thorough subjective and physical examinations, laboratory data and imaging studies. Common laboratory data include the presence of the HLA-B27 antigen, although its presence is not required for a diagnosis of AS.  In addition, high C-reactive proteins (CRP) are found in approximately 75% of people with AS.Dougados M, Gueguen A, Nakache JP, Velicitat P, Zeidler H, Veys E, et al. Clinical relevance of C-reactive protein in axial involvement of ankylosing spondylitis. J Rheumatol. 1999;26(4):971-974. However, this test is discouraged because it is associated with a high rate of false positives due to the fact that high CRP occurs in 10% of the caucasian population.

Standard questionnaires can be used as part of the assessment to sketch the evolution of the disease.Karatepe AG, Akkoc Y, Akar S, Kirazli Y, Akkoc N. The Turkish versions of the Bath Ankylosing Spondylitis and Dougados Functional Indices: reliability and validity. Rheumatol Int. 2005;25(8):612–618. Available questionnaires include:

• AMOR criteria
• BASDAI index
• BASFI index
• BAS-G index
  
  

The New York criteria for diagnosing AS combines physical findings with radiograph studies. Physical findings include limitations of lumbar spine motion in three planes, pain (or history of pain) at the thoraco-lumbar junction or lumbar spine and a limitation of chest expansion to one inch or less measured at the 4th intercostal space. Radiographic findings are graded on a scale of 0 to 4 where 0 represents normal findings and 4 represents complete ankylosis.van der Heijde D, Spoorenberg A. Plain radiographs as an outcome measure in ankylosing spondylitis. J Rheumatol. 1999;26(4):985-987. A definitive diagnosis is considered with the following combinations.

• Grade 3 or 4 at bilateral SI joints on radiograph with at least one physical finding
  
• Grade 3 or 4 unilaterally (or Grade 2 bilaterally) with two physical findings
  

The modified New York (1984) classification criteria

1. Clinical criteria
a) Low back pain and stiffness for at least 3 months, which improves with exercise, but is not relieved by rest
b) Limited lumbar spinal motion in sagittal (sideways) and frontal (forward and backward) planes.
c) Chest expansion decreased relative to normal values corrected for age and sex

2. Radiologic criteria
1. Bilateral sacroiliitis grade 2 to 4
2. Unilateral sacroiliitis grade 3 or 4

3. Definite AS, if one radiologic criterion is associated with at least one clinical criterion

4. Probable AS, if three clinical criteria are present or one radiologic criterion is present without any clinical criterion Sjef Van Der Linden, Hans A. Valkenburg Evaluation of Diagnostic Criteria for Ankylosing Spondylitis. Arthritis &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; RheumatismfckLRVolume 27, Issue 4, pages 361–368, April 1984

Outcome Measures

Certain quality of life or global rating of change outcome measures may be most appropriate in the physical therapy setting because AS often affects the patient on a more general level. However, since AS affects the spine, outcome measures such as the <a href="Oswestry Disability Index">Oswestry Disability Index </a>(ODI) and Neck Disability Index (NDI) may also be appropriate. Laboratory values, such as the CRP, are used to monitor the effectiveness of medication treatments.

Examination

bjchealthAU. Modified Schober's Test. Available from: http://www.youtube.com/watch?v=B9RaFB5BwrQ [last accessed 01/12/12]

bjchealthAU. Lumbar Side Flexion Test. Available from: http://www.youtube.com/watch?v=c-IeFZkPEoE [last accessed 01/12/12]

bjchealthAU. Chest Expansion Test. Available from: http://www.youtube.com/watch?v=SumtVr5c1Qg [last accessed 01/12/12]

Medical Management

Nonsteroidal anti-inflammatory drugs (NSAIDs) and intra-articular coriticosteroids are accepted, often-used treatments for ankylosing spondylitis.Amor B, Dougados M, Mijiyawa M. Criteria for the classification of spondylarthropathies. Rev Rhum Mal Osteoartic 1990;57(2):85-89. Indomethacin, naproxen and diclofenac are among those most frequently used in AS. Calin A, Elswood J. A prospective nationwide cross-sectional study of NSAID usage in 1331 patients with ankylosing spondylitis. J Rheumatol. 1990;17(6):801-803. However, as in other rheumatic diseases, NSAIDs are valuable only to improve the symptoms of spinal inflammation. There is no evidence that long-term treatment affects the radiologic outcome or function. It is widely believed that relief from pain is associated with an improved ability to exercise daily which, over time, supports the maintenance of function and helps to prevent the joints from stiffening.
There are no established disease-modifying anti-rheumatic drugs (DMARDs) for AS as there are for <a href="Rheumatoid Arthritis">rheumatoid arthritis</a>. The best investigated DMARD for the treatment of ankylosing spondylitis is sulfasalazine. In two placebo-controlled studies, efficacy for peripheral arthritis but no clear effects on axial symptoms was reported. Dougados M, van der Linden S, Leirisalo-Repo M, Huitfeldt B, Juhlin R, Veys E, et al. Sulfasalazine in the treatment of spondylarthropathy. A randomized, multicenter, double-blind, placebo-controlled study. Arthritis Rheum. 1995;38(5):618-627.Clegg DO, Reda DJ, Abdellatif M. Comparison of sulfasalazine and placebo for the treatment of axial and peripheral articular manifestations of the seronegative spondylarthropathies: a Department of Veterans Affairs cooperative study. Arthritis Rheum. 1999;42(11):2325-2329 Sulfasalazine is thereby effective for peripheral arthritis in spondyloarthritis but there is no clear option for the axial manifestations. Less information is available about the efficacy of other DMARDs in AS.
Very limited data on steroid treatment for ankylosing spondylitis are available. The overall efficacy is not enormous but there are individual patients who seem to benefit in terms of reduced pain and disease activity. A positive effect on reduced bone mineral density can also be expected.
The efficacy of bisphosphonates in metastatic bone disease is well established. There have been two positive reports from small, open studies in the treatment of AS with pamidronate. Both spinal and peripheral disease were successfully treated by this intravenously applied bisphosphonate, Maksymowych WP, Jhangri GS, Leclercq S, Skeith K, Yan A, Russell AS. An open study of pamidronate in the treatment of refractory ankylosing spondylitis. J Rheumatol. 1998;25(4):714-717.Maksymowych WP, Lambert R, Jhangri GS, Leclercq S, Chiu P, Wong B, Aaron S, Russell AS. Clinical and radiological amelioration of refractory peripheral spondyloarthritis by pulse intravenous pamidronate therapy. J Rheumatol. 2001;28(1):144-155. which is active against osteoclasts and is occasionally used for the treatment of <a href="Osteoporosis">osteoporosis</a>. Braun J, Sieper J. Therapy of ankylosing spondylitis and other spondyloarthritides: established medical treatment, anti-TNF-α therapy and other novel approaches. Arthritis Res. 2002;4(5):307-21.

Physical Therapy Management

Physical therapy is an essential part in the treatment of AS.Dagfinrud H, Kvien TK, Hagen KB. The Cochrane review of physiotherapy interventions for ankylosing spondylitis. J Rheumatol. 2005;32(10):1899-1906. It aims to alleviate pain, increase spinal mobility and functional capacity, reduce morning stiffness, correct postural deformities, increase mobility and improve the psychosocial status of the patients.

Global Postural Re-education 

The Global Postural Re-education (GPR)/ Rééducation Posturale Globale (RPG) method was developed by a French Physiotherapist called Phillipe Souchard in 1980. It is a physiotherapy approach that is constantly looking for the source of the problem. The objective is to track back from the consequence to the cause of the lesion by following the networks of muscular rigidity that the patient has, and correcting them little by littleAction Sport Physio. GLOBAL POSTURAL RE-EDUCATION (CPR). http://www.actionsportphysio.com/en/services/recovery/global-postural-re-education-cpr/ (accessed 17th January 2016)..

In order to do this, three key aspects are focused onGrossi E. What is Global Postural Re-education?. http://www.fisioclinic.com/public/sito/documenti/ext/Global_Postural_Reeducation%20-%20Emiliano%20Grossi.pdf (accessed 17th January 2016).;

• INDIVIDUALITY – It is a necessity to study the patient and not only act according to the standardized protocol.

• CAUSALITY – Combat the cause not just the symptoms. This avoids just a short fix.

• GLOBALITY – Look at the patient as a whole e.g. over pronated ankle resulting in compensations causing back pain

Treatment consists of a series of specific stretching positions (Postures). These postures are; supine, side lying, sitting or standing. The patient actively stretches to elongate their back progressively till a final tension is reached. The amount of stretch the patient is able to achieve may depend on their condition. The therapist uses their hands to guide the movement to happen and to provide support to supply comfort for the patient. Many different evolutive postures are used by therapists due to specific needs of patients. Therapists normally use two postures per sessionRPG Souchard. Treatment and Results. https://sites.google.com/site/rpguk123/treatment-and-results (accessed 17th January 2016)..

The main outcomes expected are; reduction in pain long-term, correction of compensations and correction of postural ailments. As with other physiotherapy treatments, the patient must be the protagonist in their treatmentRPG Souchard. Goals and Indications. https://sites.google.com/site/rpguk123/goals-and-indications (accessed 17th January 2016).. They must continue the treatment advised at home but also make small changes in their lifestyle if that certain element could be the cause of the problem, i.e. the way they get in and out of a car.

The Global Postural Reeducation method has shown promising short- and long-term results.What is Global Postural Re-education?fckLREmiliano Grossi, Centre of Global Postural Re-education Fisio-Clinic – Rome, Italy  It includes specific strengthening and flexibility exercises in which the shortened muscle chains are stretched. Once these shortened muscle chains have been identified, the imbalances can be corrected. It is important to be aware that an isolated muscular action does not exist. As a result of this, a global and functional approach is more efficient than analytic exercises in AS patients.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 randomized controlled trial. Am J Phys Med Rehabil. 2006; 85(7):559-567. Muscle chains are constituted by gravitational muscles (erector spine muscles, piriformis muscle, scalene muscles, suboccipital muscles) which work synergistically with each other. The analytic stretching of any individual gravitational muscle would be inefficient if not associated with a stretching of the whole muscle chain.

The GPR method results in greater improvement with a group physical therapy program than with home exercises. This can be explained by the mutual encouragement, reciprocal motivation, and exchange of experience in group therapy.

Effects of Physical Therapy on Pulmonary Function

Since a decrease in chest expansion is secondary to ankylosis in AS, there is also pulmonary involvement. This may even further decrease the low psychological status and quality of life in patients with AS. There are a few ways in which PT can improve chest expansion and lead to a better functional capacityMillner JR, Barron JS, Beinke KM, Butterworth RH, Chasle BE, Dutton LJ, Lewington MA, Lim EG, Morley TB, O’Reilly JE, Pickering KA. Exercise for ankylosing spondylitis: An evidence-based consensus statement. InSeminars in arthritis and rheumatism 2015 Aug 18. WB Saunders. There has recently been a Meta Analysis resulting in numerous recommendations on how to improve symptoms in ASMillner JR, Barron JS, Beinke KM, Butterworth RH, Chasle BE, Dutton LJ, Lewington MA, Lim EG, Morley TB, O’Reilly JE, Pickering KA. Exercise for ankylosing spondylitis: An evidence-based consensus statement. InSeminars in arthritis and rheumatism 2015 Aug 18. WB Saunders.

Exercise Type	Methods	Recommended Dosage	Effects on Pulmonary Function
General Exercises	See Table 2 below for recommended exercises to include in the exercise programInce G, Sarpel T, Durgun B, Erdogan S. Effects of a multimodal exercise program for people with ankylosing spondylitis. Physical therapy. 2006 Jul 1;86(7):924-35.	2 Times Per Week Minimum, For 6 Months	Increased Functional Capacity, Improved Chest Expansion.
PilatesAltan L, Korkmaz N, Dizdar M, Yurtkuran M. Effect of Pilates training on people with ankylosing spondylitis. Rheumatology international. 2012 Jul 1;32(7):2093-9.	Consists of a supervised Pilates session which follows the accepted Pilates method of movement. The difficulty of the movements should be easy to moderate difficulty and not exceed 14 on the BORG scale.	1 Hour Sessions, 3 Times Per Week, For 12 Weeks	Significant Improvements In Chest Expansion.
Incentive SpirometrySo MW, Heo HM, San Koo B, Kim YG, Lee CK, Yoo B. Efficacy of incentive spirometer exercise on pulmonary functions of patients with ankylosing spondylitis stabilized by tumor necrosis factor inhibitor therapy. The Journal of rheumatology. 2012 Sep 1;39(9):1854-8.	This is a session of breath holding and controlling breaths. Patients should carry out 3-5 second breath holds and carry out Forced Expiratory Techniques interspersed between breath holds. This treatment should be combine with General Exercises and should not be used as a sole treatment (see above for general exercises	30 Minute Sessions, Once Per Day, For 16 Weeks	Improved Chest Expansion and Improved Forced Vital Capacity
Inspiratory Muscle TrainingDrăgoi RG, Amaricai E, Drăgoi M, Popoviciu H, Avram C. Inspiratory muscle training improves aerobic capacity and pulmonary function in patients with ankylosing spondylitis: A randomized controlled study. Clinical rehabilitation. 2015 Mar 25:0269215515578292.	The supervised exercise program, delivered by a qualified physiotherapist, should include; motion and flexibility exercises of the cervical, thoracic, and lumbar spine; stretching of the hamstring muscles, erector spine muscle, and shoulder muscles; control abdominal and diaphragm breathing exercises and chest expansion exercises. In addition to these exercises, at home patients should perform six loaded inspirations with a 60 second rest period between each inspiration. This sequence of six exercises continued with 45, 30, 15, 10 and five second rest periods up to 36 loaded inspirations. A rating of more than 17 on the BORG requires the patient to stop exercising.	40 minute session (supervised), Once Per Week, 5 Unsupervised Home Exercise Sessions Per Week	Increased Aerobic Capacity, Improved Resting Pulmonary Function and Ventilatory Efficiency.
Manual Mobilisation Widberg K, Karimi H, Hafström I. Self-and manual mobilization improves spine mobility in men with ankylosing spondylitis-a randomized study. Clinical rehabilitation. 2009 Apr 29.	Both active angular and passive mobility exercises can be used in the physiological directions of the joints in the spinal column and the chest wall in flexion, extension, lateral flexion and rotation and in different starting positions. Passive mobility exercises consist of general, angular movements and specific translatory movements.	1 Hour Sessions, 2 Times Per Week, for 8 Weeks	Improved Chest Expansion, Posture and Spinal Mobility
Aerobic ExerciseOzgocmen S, Akgul O, Altay Z, Altindag O, Baysal O, Calis M, Capkin E, Cevik R, Durmus B, Gur A, Kamanli A. Expert opinion and key recommendations for the physical therapy and rehabilitation of patients with ankylosing spondylitis. International journal of rheumatic diseases. 2012 Jun 1;15(3):229-38.	Research shows that in the short term aerobic exercise has a major effect of all symptoms relating to ankylosing spondylitis. Although there is no bad form of aerobic exercise, studies show that swimming is the best for pulmonary rehabilitation. Studies also show that high impact contact sports should be avoided as this can have a negative impact on symptoms relating to AS	1 hour per day, 5 days per week. (more can be done however should not achieve more than 17 on the BORG Scale	Improved Chest Expansion, Improved Functional Capacity and Decreases the Chance of Respiratory Failure.

<img src="/images/e/ea/Table_of_AS_Exs.jpg" _fck_mw_filename="Table of AS Exs.jpg" alt="" />

Hydrotherapy/Aquatic Physiotherpy

Hydrotherapy is used for many pathology’s relating to back pain.Baena-Beato PÁ, Artero EG, Arroyo-Morales M, Robles-Fuentes A, Gatto-Cardia MC, Delgado-Fernández M. Aquatic therapy improves pain, disability, quality of life, body composition and fitness in sedentary adults with chronic low back pain. A controlled clinical trial. Clinical rehabilitation. 2014 Apr 1;28(4):350-60.
The clinical rational for the use of Hydrotherapy for Ankylosing Spondylitis looks at addressing common symptoms such as stiffness and pain in the back, a stooped posture and fatigue.

These factors include:
- Warm water relaxes tight muscles around the back.
- Buoyancy of water allows stretching to feel easier than on land.
- Reduced pain while stretching/exercising as water provides shock absorption.
- Easier to stay upright as effect of gravity reduced in water.
- Effort required is reduced due to upward thrust of the water. In waist high water, body weight is half of what it would be on land.
(NASS, April 2015)National Ankylosing Spondylitis Society (NASS). Hydrotherapy (Aquatic Physiotherapy). http://nass.co.uk/exercise/exercise-for-your-as/hydrotherapy-aquatic-physiotherapy/ (accessed 16 January 2016).

Literature for the use of Hydrotherapy
A Randomised Control Trial (2014) has looked at the effect of hydrotherapy for patients with AS compared to home-based exercise programs. It concluded that an intensive hydrotherapy program produced better outcomes in terms of pain and quality of life for AS patients compared to the home exercise group.Dundar U, Solak O, Toktas H, Demirdal US, Subasi V, Kavuncu V, Evcik D. Effect of aquatic exercise on ankylosing spondylitis: a randomized controlled trial. Rheumatology international. 2014 Nov 1;34(11):1505-11.

Furthermore, a qualitative research study (2012) looked into AS patient’s views on treatment options. Hydrotherapy proved popular amongst AS patients who partook in the study, however it was reported that access to a Hydrotherapy pool proved problematic.Davies H, Brophy S, Dennis M, Cooksey R, Irvine E, Siebert S. Patient perspectives of managing fatigue in Ankylosing Spondylitis, and views on potential interventions: a qualitative study. BMC musculoskeletal disorders. 2013 May 9;14(1):163.

Most recently, the American College of Rheumatology (2015) published evidence based recommendations for the treatment of AS. A small section of the report recommends Land based exercises over Hydrotherapy. However, this was mainly due to accessibility and cost implications because the study they looked at did show improvements for the use of Hydrotherapy, but they were not significant when compared to land based exercise.Ward MM, Deodhar A, Akl EA, Lui A, Ermann J, Gensler LS, Smith JA, Borenstein D, Hiratzka J, Weiss PF, Inman RD. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis &amp;amp;amp; Rheumatology. 2015 Sep 1.

Overall, Hydrotherapy appears popular amongst AS patients, but difficult to access.
Further research should investigate the initial use of Hydrotherapy to educate patients on beneficial exercises in the pool, followed up by patients self-managing in local leisure centres as this could benefit patients finding it difficult to access formal hydrotherapy classes led by physiotherapists.

Spa therapy has shown significant positive short- and long-term effects on pain, stiffness, well-being and functioning of patients with AS.Scholten-Peeters GGM, Dijkstra PU, Vaes P, Verhagen AP. Bohn Stafleu Van Longhum. Jaarboek Kinesitherapie. 2004. However, this treatment is very expensive and since the optimal length of therapy is four weeks, this is unfeasible for many people, especially those who are in the workforce or have families at home.

Group Therapy

Group therapy has been reported to be superior to individualised therapy in improving thoracolumbar mobility and aerobic fitness, as well as having an important effect on patient reported global healthHidding A, van der Linden S, Boers M, Gielen X, de Witte L, Kester A, Dijkmans B, Moolenburgh D. Is group physical therapy superior to individualized therapy in ankylosing spondylitis? A randomized controlled trial. Arthritis &amp;amp; Rheumatism. 1993 Sep 1;6(3):117-25..

Pilates has also been shown to have many positive effects on AS, most notably on improving physical capacityAltan L, Korkmaz N, Dizdar M, Yurtkuran M. Effect of Pilates training on people with ankylosing spondylitis. Rheumatology international. 2012 Jul 1;32(7):2093-9.. Other studies have noted a relationship between plates and an improved quality of life particularly in patients who are in the early stages of AS even after a relatively short duration of treatment. While the method is easy to learn and adaptable to individual variations, it can be easily implemented in the rehabilitation treatment of ankylosing spondylitisBerea S, Ancuţa C, Miu S, Chirieac R. The Pilates method in ankylosing spondylitis. rehabilitation. 2012 May 1;2:3.

Mindfulness Based Therapies

Non exercise-based interventions have also been shown to have positive effects in the management of AS; in a 2012 RCT, a 10-week group-based mindfulness course was administered to 73 people with a diagnosis of AS in the form of a Vitality Training Program (VTP), following a 6-month follow up session statistically significant improvements were reported in psychological distress (measured by the general health questionnaire). In addition to this other improvements were reported in self-efficacy, pain and symptoms, emotional processing, fatigue, self-care ability and overall well-beingA mindfulness-based group intervention to reduce psychological distress and fatigue in patients with inflammatory rheumatic joint diseases: a randomised controlled trial 2012.

Due to existing evidence suggesting the effectiveness of mindfulness interventions, scope has been established for its use in a group session in order to manage patient fatigue (which has been further sub-categorised into physical emotional, and psychological components). This is due to patients reporting that they often feel lost without any formal guidance or support, in addition to the fact that patients have expressed a preference for psychological therapies as opposed to pharmacological one for managing fatigue; information on Mindfulness-Based Stress Reduction (MBSR) was received with interest Davies H, Brophy S, Dennis M, Cooksey R, Irvine E, Siebert S. Patient perspectives of managing fatigue in Ankylosing Spondylitis, and views on potential interventions: a qualitative study. BMC musculoskeletal disorders. 2013 May 9;14(1):163..

Presentations

fckLRImage:Ankylosing spondylitis ppt.PNG|200px|border|left|fckLRrect 0 0 830 452 [1]fckLRdesc nonefckLR

<a href="https://http://www.youtube.com/watch?v=hci1ea2coy8">Ankylosing Spondylitis</a> This presentation, created by Kyle Martin, Robby Martin, Haley Metzner, and Stacey Potter; Texas State DPT Class. <a href="https://http://http://www.youtube.com/watch?v=hci1ea2coy8/">View the presentation</a>

Recent Related Research (from <a href="http://www.ncbi.nlm.nih.gov/pubmed/">Pubmed</a>)

http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1p9j2Ia0knT9gkJRpfmqWR4Pk3y8v7JBAfSH2f31CW8M6bzsAK%7Ccharset=UTF-8%7Cshort%7Cmax=10

References

<a _fcknotitle="true" href="Category:Condition">Condition</a> <a _fcknotitle="true" href="Category:Lumbar_Conditions">Lumbar_Conditions</a> <a _fcknotitle="true" href="Category:Rheumatology">Rheumatology</a> <a _fcknotitle="true" href="Category:Lumbar">Lumbar</a> <a _fcknotitle="true" href="Category:Sacroiliac_Conditions">Sacroiliac_Conditions</a> <a href="Category:Musculoskeletal/Orthopaedics">Orthopaedics</a> <a _fcknotitle="true" href="Category:Vrije_Universiteit_Brussel_Project">Vrije_Universiteit_Brussel_Project</a>