Two Exercise Interventions for the Management of Patients with Ankylosing Spondylitis: A Randomized Controlled Trial The effects of combined spa therapy and rehabilitation on patients with ankylosing spondylitis being treated with TNF inhibitors Self- and manual mobilization improves spine mobility in men with ankylosing spondylitis — a randomized study Are swimming or aerobic exercise better than conventional exercise in ankylosing spondylitis patients? A randomized controlled study. One-Year Follow-up of Two Exercise Interventions for the Management of Patients with Ankylosing Spondylitis: A Randomized Controlled Trial Home-based exercise therapy in patients with ankylosing spondylitis: effects on pain, mobility, disease activity, quality of life, and respiratory functions Efficacy of rehabilitation for patients with ankylosing spondylitis: comparison of a four-week rehabilitation programme in a Mediterranean and a Norwegian setting. Efficacy of Incentive Spirometer Exercise on Pulmonary Functions of Patients with Ankylosing Spondylitis Stabilized by Tumor Necrosis Factor Inhibitor Therapy Evaluation of the effects of Global Postural Reeducation in patients with ankylosing spondylitis Combined spa-exercise therapy is effective in patients with ankylosing spondylitis: a randomized controlled trial. Effects of a combination treatment of an intensive rehabilitation program and etanercept in patients with ankylosing spondylitis: a pilot study. Effect of Pilates training on people with ankylosing spondylitis Rehabilitation Treatment in Patients with Ankylosing Spondylitis Stabilized with Tumor Necrosis Factor Inhibitor Therapy. A Randomized Controlled Trial Improvement of the clinical outcome in Ankylosing spondylitis by balneotherapy. The effect of balneotherapy on patients with ankylosing spondylitis Comparison of group-based exercise versus home-based exercise in patients with ankylosing spondylitis: effects on Bath Ankylosing Spondylitis Indices, quality of life and depression Stanger bath therapy for ankylosing spondylitis: illusion or reality? Spa therapy for ankylosing spondylltis at the Dead Sea. Effects of two exercise interventions on pulmonary functions in the patients with ankylosing spondylitis. The effect of a home based exercise intervention package on outcome in ankylosing spondylitis: a randomized controlled trial. Cost effectiveness of combined spa-exercise therapy in ankylosing spondylitis: a randomized controlled trial. The effectiveness of intensive group exercise on patients with ankylosing spondylitis Respiratory muscle performance as a possible determinant of exercise capacity in patients with ankylosing spondylitis. The effects of balneotherapy on disease activity, functional status, pulmonary function and quality of life in patients with ankylosing spondylitis. Occupational therapy in ankylosing spondylitis: Short-term prospective study in patients treated with anti-TNF-alpha drugs. Supervised training and home-based rehabilitation in patients with stabilized ankylosing spondylitis on TNF inhibitor treatment: a controlled clinical trial with a 12-month follow-up
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 Despite advances in pharmacological therapy , physical treatment continues to be important in the management of ankylosing spondylitis ( AS ) . The objective of the present study was to evaluate the effects and tolerability of combined spa therapy and rehabilitation in a group of AS patients being treated with TNF inhibitors . Thirty AS patients attending the Rheumatology Unit of the University of Padova being treated with TNF inhibitors for at least 3 months were r and omized and assessed by an investigator independent from the spa staff : 15 were prescribed 10 sessions of spa therapy ( mud packs and thermal baths ) and  rehabilitation ( exercises in a thermal pool ) and the other 15 were considered controls . The patients in both groups had been receiving anti-TNF agents for at least three months . The outcome measures utilized were BASFI , BASDAI , BASMI , VAS for back pain and HAQ . The evaluations were performed in all patients at the entry to the study , at the end of the spa treatment , and after 3 and 6 months . Most of the evaluation indices were significantly improved at the end of the spa treatment , as well as at the 3 and 6 months follow-up assessment s. No significant alterations in the evaluation indices were found in the control group . Combined spa therapy and rehabilitation caused a clear , long-term clinical improvement in AS patients being treated with TNF inhibitors . Thermal treatment was found to be well tolerated and none of the patients had disease relapse Aims : To evaluate effects of physiotherapeutic intervention in terms of self- and manual mobilization on chest expansion , vital capacity , posture , spine mobility and experienced consequences of the disease in patients with ankylosing spondylitis . Design : A prospect i ve , r and omized controlled study . Methods : Thirty-two men , aged between 23 and 60 years , with ankylosing spondylitis were r and omized to active or no treatment for eight weeks . Physiotherapeutic intervention included individualized self- and manual mobilization for 1 hour twice a week and individually adjusted home exercises . Two blinded investigators made the assessment s of chest expansion , posture and spinal mobility before and after the treatment period . The patient filled in three and the physiotherapist one of the four Bath Ankylosing Spondylitis scales ( BAS scales ) . Results : In the treatment group chest expansion increased at the level of processus xiphoideus ( P<0.01 ) , with no difference in vital capacity compared with the control group . The posture improved in the cervical ( C7—wall distance ) ( P<0.001 ) and in the thoracic spine ( P<0.05 ) . Thoracic and lumbar spine flexion improved ( P<0.01 ) as did sagittal range of motion P<0.001 and P<0.01 , respectively . The Bath Ankylosing Spondylitis Metrology Index total scoring improved ( P<0.001 ) in the treatment group compared with the control group . The other three BAS scales showed no differences between groups . At four months follow-up of the treatment group , cervical spine posture , lumbar flexion and range of motion as well as BAS Metrology Index were still improved . Conclusion : This study shows that eight weeks of self- and manual mobilization treatment improved chest expansion , posture and spine mobility in patients with ankylosing spondylitis AIM The aim of the study was to compare the effects of conventional exercise ( CE ) , swimming and walking on the pulmonary functions , aerobic capacity , quality of life , Bath indexes and psychological symptoms in patients with ankylosing spondylitis ( AS ) . METHODS Forty-five patients were r and omised into either swimming ( group 1 ) , walking ( group 2 ) , CE group ( group 3 ) . Patients in Group 1 performed CE and swimming , patients in Group 2 performed CE and walking and patients in Group 3 performed CE only . Exercise sessions were performed three times a week for a period of six weeks . Patients were assessed before and after the rehabilitation program , with respect to , pulmonary function test ( forced vital capacity [ FVC , mL ] , forced expiration volume in one second [ FEV1 , mL ] , FEV1/FVC ( % ) and vital capacity [ VC , mL ] ) , maximal oxygen uptake ( pV.O2 ) , 6-minute walking test ( 6MWT ) , Bath Ankylosing Spondylitis Functional Index , Bath Ankylosing Spondylitis Disease Activity Index , Bath Ankylosing Spondylitis Metrology Index , Nottingham Health Profile and Beck Depression Inventory . RESULTS There were significant increases in pVO2 and 6MWT after treatment in Groups 1 and 2 ( P<0.05 ) . FeV1 , FVC and VC improved significantly with treatment in all three groups ( P<0.05 ) . A statistically significant improvement was observed in energy , emotional reaction and physical mobility sub-scores of NHP in three exercise groups after completion of the exercise program ( P<0.05 ) . CONCLUSIONS Swimming , walking and CE had beneficial effects on the quality of life and pulmonary functions . Aerobic exercises such as swimming and walking in addition to CE increased functional capacities of 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 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 The home-based exercise therapy recommended to the patients with ankylosing spondylitis ( AS ) is a simply applicable and cheap method . The aim of this study was to investigate the effects of home-based exercise therapy on pain , mobility , function , disease activity , quality of life , and respiratory functions in patients with AS . Eighty patients diagnosed with AS according to the modified New York criteria were included in the study .  Home-based exercise program including range of motion , stretching , strengthening , posture , and respiratory exercises was practically demonstrated by a physiotherapist . A training and exercise manual booklet was given to all patients . Patients following home-based exercise program five times a week at least 30 min per session ( exercise group ) for 3 months were compared with those exercising less than five times a week ( control group ) . Visual analog scale pain ( VASp ) values at baseline were significantly higher in the exercise group . The exercise group showed improvements in VASp , tragus – wall distance , morning stiffness , finger – floor distance , modified Schober 's test , chest expansion , the Bath Ankylosing Spondylitis Disease Activity Index , the Bath Ankylosing Spondylitis Functional Index , Ankylosing Spondylitis Quality of Life Question naire ( ASQoL ) , forced expiratory volume in first second , and forced vital capacity at third month . There was significant difference in ASQoL scores between the two groups in favor of the exercise group at third month . Regular home-based exercise therapy should be a part of main therapy in patients with AS . Physicians should recommend that patients with AS do exercise at least five times a week at least 30 min per session OBJECTIVE To investigate the sustained effect of a rehabilitation programme for patients with ankylosing spondylitis , and to compare the effect of this intervention given in a Mediterranean vs a Norwegian setting . METHODS A total of 107 patients with ankylosing spondylitis applying for rehabilitation were r and omized to a  4-week inpatient rehabilitation programme in a Mediterranean country or in Norway . The participants were evaluated clinical ly before and after the rehabilitation period ( week 0 and 4 ) and in week 16 . The ASsessment s in Ankylosing Spondylitis working group 's Improvement Criteria ( ASAS-IC ) , and tests of spinal mobility and physical capacity were used to measure treatment response . RESULTS An ASAS20 improvement was still present at week 16 in 50 % of the patients treated in a Mediterranean and 23 % in a Norwegian centre ( p = 0.006 ) . The tests of spinal mobility , physical capacity , and almost all patient 's assessment s of health status ( ASAS-IC components ) were still improved at week 16 after therapy in both climatic setting s. While the improvements in physical capacity were comparable , the spinal mobility and ASAS-IC components improved more , and improvements were sustained longer , after rehabilitation in a Mediterranean setting . CONCLUSION Patients with ankylosing spondylitis benefit from a 4-week rehabilitation programme in Norway , but even more so from a similar programme in a Mediterranean setting Objective . To evaluate the effect of combining incentive spirometer exercise ( ISE ) with a conventional exercise ( CE ) on patients with ankylosing spondylitis ( AS ) stabilized by tumor necrosis factor ( TNF ) inhibitor therapy by comparing a combination group with a CE-alone group . Methods . Forty-six patients ( 44 men , 2 women ) were r and omized to the combination group ( ISE plus CE ; n = 23 ) or the CE group ( n = 23 ) . The CE regimen of both groups consisted of 20 exercises performed for 30 min once a day . The ISE was performed once a day for 30 min . The trial duration was 16 weeks . Patients were assessed before and at the end of treatment by measuring the Bath Ankylosing Spondylitis Disease Activity Index , Bath Ankylosing Spondylitis Functional Index ( BASFI ) , chest expansion , finger to floor distance , pulmonary function measures , and 6-min walk distance . Results . Both groups improved significantly in terms of chest expansion ( p < 0.01 ) , finger to floor distance ( p < 0.01 ) , and BASFI ( p < 0.05 ) after completing the exercise program . However , only the combination group showed significant improvements in the forced vital capacity ( p < 0.05 ) , total lung capacity ( p < 0.01 ) , and vital capacity ( p < 0.05 ) . Although this did not achieve statistical significance , the combination group was mildly superior to the CE-alone group in functional disability and pulmonary function measures . Conclusion . Combining ISE with a CE can provide positive results in patients whose AS has been clinical ly stabilized by TNF inhibitor therapy The objective of this study is to assess the effects of Global Postural Reeducation ( GPR ) in patients with ankylosing spondylitis and compare GPR with group conventional segmental self-stretching and breathing exercises . This is a controlled interventional study of 38 patients divided into 2 groups : a GPR group ( n = 22 ) and a control group ( n = 16 ) . Both groups were treated for more than 4 months . With the GPR group patients , positions that stretched the shortened muscle chains were used . With the control group patients , conventional segmental self-stretching and breathing exercises were performed . The variables analyzed were pain intensity , morning stiffness , spine mobility , chest expansion , functional capacity ( Health Assessment Question naire – Spondyloarthropathies – HAQ-S ) , quality of life ( Medical Outcome Study Short Form 36 Healthy Survey – SF-36 ) , and disease activity ( Bath Ankylosing Spondylitis Disease Activity Index – BASDAI ) . Statistical analysis was used with a significance level of P < 0.05 . There was a statistically significant improvement for all the parameters analyzed between pre- and post-treatment in both groups . In the intergroup comparison , the GPR group showed a significantly greater improvement in morning stiffness ( P = 0.013 ) , spine mobility parameters , except finger-floor distance ( P = 0.118 ) , in chest expansion ( P = 0.028 ) , and in the physical aspect component of the SF-36 ( P = 0.001 ) . The results of this study showed that individual treatment with GPR ( overall stretching ) seems to have better clinical outcomes than group treatment with conventional segmental self-stretching and breathing exercises for patients with ankylosing spondylitis 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 OBJECTIVE To determine the effects of a combination treatment including rehabilitation and etanercept versus rehabilitation only , on function , disability , and quality of life in a group of patients with active ankylosing spondylitis ( AS ) . METHODS Nineteen patients with AS consecutively admitted to a rehabilitation inpatient clinic were enrolled . Patients first participated in an intensive rehabilitation program and after a 6-month interval started etanercept therapy . After 3 weeks , they started a combination of rehabilitation and etanercept . The primary outcome measure was an improvement of the Bath Ankylosing Spondylitis Functional Index ( BASFI ) defined as the difference ( Delta ) between the 2 measurements ( beginning and end ) . The difference between the 2 measurements for the first rehabilitation program was expressed as Delta1 and for the second as Delta2 ; the comparison between Delta1 and Delta2 for each outcome measure was taken into account . Secondary outcome measures included an improvement in the Revised Leeds Disability Question naire ( LDQ ) , anthropometric measures , EuroQol ( EQ-5Dvas ) , and the 6 minute walking test ( 6-MWT ) . RESULTS A statistically significant improvement was observed both for BASFI ( Delta1 = -0.71 + /- 0.23 ; Delta2 = -1.19 + /- 0.36 , p < 0.001 ) and for LDQ ( Delta1 = -0.28 + /- 0.08 ; Delta2 = -0.46 + /- 0.17 , p = 0.001 ) . All anthropometric measures as well as 6-MWT were statistically improved . Finally , EQ5Dvas showed a statistically significant difference ( Delta1 = 6.63 + /- 2.81 ; Delta2 = 20.26 + /- 4.89 , p < 0.001 ) . No adverse effects were seen during treatment with etanercept . CONCLUSION This combination treatment seems to improve function , disability , and quality of life in patients with active AS The objective of this study was to investigate the effects of Pilates on pain , functional status , and quality of life in patients with ankylosing spondylitis . The study was performed as a r and omized , prospect i ve , controlled , and single-blind trial . Fifty-five participants ( 30 men , 25 women ) who were under a regular follow-up protocol in our Rheumatology Clinic with the diagnosis of AS according to the modified New York criteria were included in the study . The participants were r and omly assigned into two groups : in group I , Pilates exercise program of 1 h was given by a certified trainer to 30 participants 3 times a week for 12 weeks , and in group II , design ed as the control group , 25 participants continued previous st and ard treatment programs . In groups , pre-(week 0 ) and post treatment ( week 12 and week 24 ) evaluation was performed by one of the authors who was blind to the group allocation . Primary outcome measure was functional capacity . Evaluation was done using the Bath Ankylosing Spondylitis Functional Index ( BASFI ) . Exploratory outcome measures were Bath Ankylosing Spondylitis Disease Activity Index ( BASDAI ) , Bath Ankylosing Spondylitis Metrology Index ( BASMI ) , Chest expansion , and ankylosing spondylitis quality of life ( ASQOL ) question naire . In group I , BASFI showed significant improvement at week 12 ( P = 0.031 ) and week 24 ( P = 0.007 ) . In group II , this parameter was not found to have significantly changed at week 12 and week 24 . Comparison of the groups showed significantly superior results for group I at week 24 ( P = 0.023 ) . We suggest Pilates exercises as an effective and safe method to improve physical capacity in AS patients . Our study is the first clinical study design ed to investigate the role of Pilates method in AS treatment . We believe that further research with more participants and longer follow-up periods could help assess the therapeutic value of this popular physical exercise method in AS Objective . To assess the 2- ( T1 ) and 6-month ( T2 ) followup effects on pain , spine mobility , physical function , and disability outcome of a rehabilitation intervention in patients with ankylosing spondylitis ( AS ) stabilized with tumor necrosis factor ( TNF ) inhibitor therapy . Methods . Sixty-two out patients ( 49 men , 13 women , mean age 47.5 ± 10.6 yrs ) were r and omized to rehabilitation plus an educational-behavioral ( n = 20 ) program , to an educational-behavioral program only ( n = 20 ) , or to a control group ( n = 22 ) . The educational-behavioral program included 2 educational meetings and 12 rehabilitation exercise sessions ( stretching , strengthening , chest and spine/hip joint flexibility exercises ) , which patients then performed at home . Outcome assessment at the end of rehabilitation training ( T1 ) and at T2 was based on spinal pain intensity in the previous 4 weeks by self-report visual analog scale ( VAS ; 100 mm : 0 = no pain , 100 = maximum pain ) , BASMI , BASFI , BASDAI , and on chest expansion and the active range of motion of the cervical and lumbar spine measured by a pocket goniometer . Results . The 3 groups were comparable at baseline . On intragroup comparison at T1 , the rehabilitation group showed significant improvement in the BASMI and BASDAI , in chest expansion , and in most spinal active range of motion measurements . BASFI and cervical and lumbar VAS scores improved in both the rehabilitation and educational-behavioral groups . The positive results achieved in the rehabilitation group were maintained at the 6-month followup . Conclusion . Combining intensive group exercise with an educational-behavioral program can provide promising results in the management of patients with clinical ly stabilized AS on TNF inhibitor treatment 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 The objective of this non-r and omised controlled trial was to evaluate the impact of group-based exercise programme and a home-based exercise programme on Bath Ankylosing Spondylitis Indices , depression and quality of life in patients with ankylosing spondylitis ( AS ) . Approximately 41 patients in a rehabilitation unit were divided into two groups , either group- or home-based exercise programme . Exercise sessions were performed three times a week for a period of 6 weeks . The patients were compared before and after the rehabilitation programme , with respect to Bath Ankylosing Spondylitis Functional Index ( BASFI ) , Bath Ankylosing Spondylitis Disease Assessment Index ( BASDAI ) , Bath Ankylosing Spondylitis Metrology Index ( BASMI ) , Beck Depression Inventory ( BDI ) and The Nottingham Health Profile ( NHP ) . A statistically significant improvement was observed on BASDAI , BASMI and energy , pain , reaction of emotional and sleep subscores of NHP in both exercise groups after the exercise programme ( p < 0.05 ) . No statistically significant changes were detected in BASFI , BDI and social and mobility subscores of NHP in both exercise groups ( p > 0.05 ) . No statistically significant differences were found between the two exercise programmes ( p > 0.05 ) . Group and home-based exercise programmes are efficient in improving symptoms and mobility and had an important effect on quality of life in patients with AS . Home-based exercise programme , as it is cheaper , more easily performed and efficient , may be preferable for the management programme in AS We compared the short-term effects of Stanger bath therapy and conventional exercises on spinal mobility , functional capacity , disease activity , and quality of life with conventional exercise alone in ankylosing spondylitis ( AS ) patients . A total of 58 patients with a diagnosis of AS according to the modified New York criteria were included in this r and omized prospect i ve study . The patients were divided into two groups . Patients in group I ( n = 30 ) received Stanger bath therapy and an exercise program . Group II ( n = 28 ) patients were given the same exercise program but did not receive Stanger bath therapy . Patients were evaluated before ( T0 ) and at the end of the treatments ( T1 ) . Evaluation parameters were the Bath AS Metrology Index ( BASMI ) , Bath AS Functional Index ( BASFI ) , Bath AS Disease Activity Index ( BASDAI ) , and AS Quality of Life ( ASQoL ) . In both patient groups , a significant improvement was determined in all clinical outcomes between T0 and T1 except for BASMI in group II . Comparison of the groups showed significantly superior results in group I parameters of BASMI , BASFI , BASDAI , and ASQoL.  Stanger bath therapy showed beneficial effects in spinal mobility , functional capacity , disease activity , and quality of life in AS patients immediately after the treatment period . We recommend Stanger bath therapy for AS patients in the short-term , but further research is imperative to assess whether improvement is sustained over a long-term follow-up 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 OBJECTIVE The aim of this study was to evaluate the impact of two different home-based daily exercise programs on pulmonary functions in the patients with ankylosing spondylitis ( AS ) . METHODS Fifty-one patients with AS were distributed into three groups . Group 1 ( n=19 ) was given a conventional exercise regimen . Group 2 ( n=19 ) received exercises based on the Global Posture Reeducation ( GPR ) method . Group 3 ( n=13 ) was accepted as the control group . Patients were assessed according to pain , functional capacity ( The Bath Ankylosing Spondylitis Functional Index - BASFI ) , disease activity ( The Bath Ankylosing Spondylitis Disease Activity Index - BASDAI ) , chest expansion , pulmonary function parameters , and 6-min walk distance ( 6MWD ) test . RESULTS Although there were significant improvements for BASDAI and BASFI scores in all groups , significant improvements in the VAS pain , chest expansion , pulmonary function parameters and 6MWD test were observed in the exercise groups . The improvements in pain , functional capacity , disease activity , chest expansion , pulmonary function parameters and 6MWD test were better in the exercise groups than in the control group . The GPR method result ed in greater improvements than the conventional exercise program in specific pulmonary function parameters like forced vital capacity , forced expiratory volume in 1s , and peak expiratory flow parameters . CONCLUSION Both exercises are efficient in improving pulmonary functions . Since the improvements in pulmonary function tests were greater in the patients who performed the exercise according to GPR method , motivated patients should be encouraged to perform this exercise program 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 ) 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 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 Reduction of exercise capacity in patients with ankylosing spondylitis is associated with skeletal muscle performance . The contribution of respiratory muscle performance is question able . This pilot study was design ed to investigate the relationship between respiratory muscle performance and exercise capacity in ankylosing spondylitis . Subjects were 12 patients with ankylosing spondylitis . Measurements of maximal respiratory pressures and inspiratory muscle endurance were performed and correlated with maximal exercise capacity . Lung function and chest wall expansion were reduced on average . Maximal inspiratory and expiratory pressures were reduced to 82 + /- 20 % of predicted values and 75 + /- 22 % of predicted values respectively . On average there was no reduction in inspiratory muscle endurance which remained at 103 + /- 36 % of predicted values . No overall reduction was found in maximal exercise capacity , either expressed as maximal workload or as peak oxygen uptake ; however , a wide range was found . Maximal workload and peak oxygen uptake correlated significantly with maximal respiratory pressures and respiratory muscle endurance . The best regression model for explaining the total variation of maximal workload and peak oxygen uptake selected maximal inspiratory pressures as the independent variable ( r(2 ) = 59.6 % , p = 0.003 and r(2 ) = 62.5 % , p = 0.05 respectively . ) These data suggest respiratory pressure and respiratory muscle endurance , in particular maximal inspiratory pressure , may be determinants of exercise capacity in patients with ankylosing spondylitis OBJECTIVE This study aim ed to determine the effects of balneotherapy on disease activity , functional status , metrology index , pulmonary function and quality of life in patients with ankylosing spondylitis ( AS ) . MATERIAL S AND METHODS The study included 28 patients ( 27 male and 1 female ) diagnosed with AS according to modified New York criteria . The patients were treated with balneotherapy for 3 weeks ( 30 min/day , 5 days/week ) . The patients were evaluated using the global index , Bath ankylosing spondylitis disease activity index ( BASDAI ) , disease functional index ( BASFI ) , metrology index ( BASMI ) , chest expansion measures , pulmonary function testing , and the medical outcomes study -short form-36 Health Survey ( SF-36 ) ( measure of quality of life ) before balneotherapy and 1 month after treatment . RESULTS Post balneotherapy  BASDAI and global index decreased , BASMI parameters improved , chest expansion increased , and some SF-36 parameters improved ; however , none of these changes were statistically significant ( P > 0.05 ) , except for the decrease in BASMI total score ( P < 0.05 ) . Before balneotherapy 6 patients had restrictive pulmonary disorder , according to pulmonary function test results . Pulmonary function test results in 3 ( 50 % ) patients were normalized following balneotherapy ; however , as for the other index , balneotherapy did not significantly affect pulmonary function test results . CONCLUSION The AS patients ' symptoms , clinical findings , pulmonary function test results , and quality of life showed a trend to improve following balneotherapy , although without reaching significant differences . Comprehensive r and omized controlled spa intervention studies with longer follow-up periods may be helpful in further delineating the therapeutic efficacy of balneotherapy in AS patients OBJECTIVE To assess the effect of occupational therapy ( OT ) on functional status in ankylosing spondylitis ( AS ) patients treated with anti-TNF-alpha drugs  in a short-term open controlled prospect i ve study . METHODS Twenty-seven AS subjects treated with anti-TNF-alpha drugs  , were allocated to OT ( n=14 ) or control ( n=13 ) group . At the study entry and at the 16th week we evaluated the following outcome parameters including BASFI , BASDAI , BASMI , Short-Form Health Survey ( SF-36 ) , pain , erythrocyte sedimentation rate ( ESR ) , C-reactive protein CRP ) and the adherence reported using self management methods , related to joint protection and energy conservation . RESULTS At baseline , OT and control group had similar demographic and clinical features . After 16 weeks , we found that the changes from baseline of BASFI ( p<0.05 ) , BASDAI ( p<0.02 ) , SF-36 CMS ( p<0.02 ) and pain ( p<0.02 ) score improved more significantly in OT group than in control group , where the scores remained invariable . After 16 weeks from baseline , the OT group reported a significantly more frequent use of self management methods , related to joint protection and energy conservation , than the control group . CONCLUSION Our controlled study indicates that a combination treatment with anti-TNFalpha agents and OT was beneficial for patients with AS , with synergistic effects on pain , function and disability . Thus OT intervention could be also considered when the disease is stable and well controlled with drugs because it may represent a further tool to improve the health status of patients Objective : To assess the 12-month ’s follow-up effects on pain , mobility , and physical function outcomes of a supervised training and home-based rehabilitation for ankylosing spondylitis patients stabilized with TNF-inhibitor therapy . Design : Controlled clinical trial ( sequentially determined allocation ) with 12-months ’ follow-up . Setting : Patients ’ homes . Subjects : A total of 69 subjects were allocated to either a rehabilitation programme ( rehabilitation group , n = 22 ) , an educational-behavioural programme ( educational group , n = 24 ) , and to neither programme ( control group , n = 23 ) . Interventions : Rehabilitation programme included supervised training and home exercises ( stretching , strengthening , aerobic , chest , and spine/hip joint flexibility exercises ) ; educational-behavioural programme included information on ankylosing spondylitis , pain and stress mechanisms , and control . Main measures : Spinal pain intensity , Bath Ankylosing Spondylitis Metrology Index , Bath Ankylosing Spondylitis Functional Index , Bath Ankylosing Spondylitis Disease Activity Index , chest expansion , and cervical and lumbar spine active range of motion measured by a pocket goniometer . Results : At baseline , the three groups exhibited comparable demographic characteristics and basal evaluations . Intra-group changes in the rehabilitation group from baseline to 12 months yielded statistically significant gains ( p < 0.05 ) for all outcomes . At 12-months follow-up , compared with the control and educational-behavioural , the rehabilitation group exhibited significant differences in chest expansion ( p = 0.001 and p < 0.001 ) , Bath Ankylosing Spondylitis Disease Activity Index ( p = 0.012 and p = 0.050 ) , and in some goniometric measurements as cervical rotation ( p = 0.007 and p = 0.014 ) , toraco-lumbar rotation ( p = 0.009 and p = 0.050 ) , and total cervical movements ( p = 0.009 and p = 0.001 ) . Conclusion : In comparison with the educational-behavioural programme or no intervention , supervised training and home exercises improved long-term outcome in patients with ankylosing spondylitis
OBJECTIVES To systematic ally review the evidence for a synergistic effect of combining rehabilitation with biological anti-tumour necrosis factor ( TNF ) therapy in patients with ankylosing spondylitis ( AS ) .