What physiotherapy program is recommended for a typical adult with ankylosing spondylitis?

Physiotherapy Management of Ankylosing Spondylitis

Adults with ankylosing spondylitis should receive supervised physical therapy with instruction in back exercises, followed by a regular home exercise program, as this improves disease activity and physical functioning with minimal risk of harm. 1

Core Physiotherapy Recommendations

Supervised Physical Therapy (Initial Phase)

• Strongly recommend formal physical therapy over no treatment for all AS patients, whether active or stable disease. 1 This provides improvement in disease activity and physical functioning, though evidence shows limited impact on pain or stiffness. 1

• Supervised group physiotherapy demonstrates superior outcomes compared to home exercises alone, particularly for patient global assessment (improvement of 1.46 cm) and spinal mobility (7.5-18% relative improvement). 1, 2

• The primary role of supervised therapy in stable patients is periodic reassessment and appropriate modifications of home exercise programs. 1

Home Exercise Program (Maintenance Phase)

• Conditionally recommend unsupervised back exercises as part of ongoing management, but these should never substitute for initial instruction by a physical therapist. 1

• Home-based exercise programs show significant improvements in previously sedentary young AS patients (mean age 28 years), with pain effect size of 1.99 and function effect size of 0.80 after 8 weeks. 1

• Exercise frequency should be regular and ongoing, as the literature demonstrates that different types of exercise-based interventions can impact disease outcomes. 1

Specific Exercise Modalities

Multimodal Approach

• Recommend a multimodal program including educational sessions, conducted in group settings, supervised by a physiotherapist, followed by maintaining home-based regimen. 3

• Complex individualized programs should include: general posture reeducation, manual mobilization of the spine, pelvic/upper/lower extremity exercises, stretching with joint prevention strategies, and functional exercises. 4

McKenzie Method

• McKenzie training shows significant benefits in early AS, with improvements in pain (P=0.003), metrology (modified Schober test P=0.001), disease activity (BASDAI P=0.001), and function (BASFI P=0.001) after 24 weeks. 5

• Protocol consists of 50-minute sessions performed 3 times weekly, with 12 weeks of supervised learning followed by 12 weeks of home-based continuation. 5

Manual and Self-Mobilization

• Eight weeks of combined self- and manual mobilization (1 hour twice weekly plus home exercises) improves chest expansion at xiphoid level (P<0.01), cervical posture (C7-wall distance P<0.001), and thoracic/lumbar spine flexion (P<0.01). 6

• Benefits persist at 4-month follow-up for cervical spine posture, lumbar flexion, and range of motion. 6

Cardiovascular Training

• Cardiovascular training performed according to American College of Sports Medicine guidelines is safe and effective and should be included in AS rehabilitation protocols. 3

Spa-Exercise Therapy

• Combined inpatient spa-exercise therapy (3 weeks) followed by 37 weeks of weekly outpatient group physiotherapy shows moderate quality evidence for improvements in pain (18%), physical function (24%), and patient global assessment (27%) compared to group physiotherapy alone. 2

• Cost-effectiveness analysis shows incremental cost-effectiveness ratio of €7,465 to €18,575 per quality of life year gained. 1

Critical Safety Contraindications

Spinal Manipulation

• Strongly recommend AGAINST spinal manipulation with high-velocity thrusts in patients with spinal fusion or advanced spinal osteoporosis. 1 Case reports document catastrophic complications including spine fractures, spinal cord injury, and paraplegia, particularly with cervical spine manipulation. 1

Monitoring and Disease Activity Assessment

Regular Monitoring

• Conditionally recommend regular-interval use of validated AS disease activity measures (Bath AS Disease Activity Index or AS Disease Activity Score) for patients with active symptoms to guide treatment adjustments. 1

• Monitoring is most helpful in active disease and not necessary at every clinic visit for clinically stable patients. 1

• Regular assessment of CRP concentrations or ESR should be performed alongside clinical measures. 1

Modalities with Insufficient Evidence

Limited or No Benefit

• TENS (transcutaneous electrical nerve stimulation) shows effect size of 0.92 but does not reach statistical significance (95% CI -0.01 to 1.86, p=0.05). 1

• Heat or whole-body cryotherapy lacks Level Ib evidence support. 1

• Passive stretching improves hip range of motion but lacks assessment of pain and function outcomes. 1

• Unsupervised home exercise packages without prior training show no improvement in pain or function compared to controls over 6 months. 1

Common Pitfalls to Avoid

• Do not allow unsupervised back exercises to replace initial professional instruction - patients require proper technique training before independent exercise. 1

• Do not expect significant pain reduction from exercise alone - while function and mobility improve, pain relief is inconsistent across studies. 1

• Do not perform spinal manipulation in patients with fusion or osteoporosis - the risk of catastrophic neurological injury outweighs any theoretical benefit. 1

• Do not rely on isolated education programs - while self-management courses improve self-efficacy and motivation, they fail to show significant improvements in pain or function at 6 months without accompanying exercise. 1