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Physiotherapy interventions for ankylosing spondylitis

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Abstract

Background

Ankylosing spondylitis (AS) is a chronic, inflammatory rheumatic disease. Due to the consequences of the disease, physiotherapy is considered to be an important part of the overall management of AS.

Objectives

The objective of this review was to summarise the available scientific evidence on the effectiveness of physiotherapy interventions in the management of AS.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, CINAHL and PEDro up to February 2004 for all relevant publications, without any language restrictions. The reference lists of relevant articles were checked and the authors of included articles were contacted.

Selection criteria

We included randomised and quasi‐randomised studies with patients classified by the AS New York criteria and where at least one of the comparison groups received some kind of physiotherapy. The main outcomes of interest were pain, stiffness, spinal mobility, physical function and patient global assessment.

Data collection and analysis

Two reviewers independently selected trials for inclusion, extracted data and assessed trial quality. Investigators were contacted to obtain missing information.

Main results

Six trials with a total of 561 participants were included in this updated review as compared to three trials and 241 patients in the previous version. Two trials compared individualised home exercise programs with no intervention and reported low quality evidence for effects in spinal mobility (relative percentage differences (RPD) 37%) and physical function, in favour of the home exercise program. Three trials compared supervised group physiotherapy with an individualised home‐exercise program and reported moderate quality evidence for small differences in spinal mobility (RPD 18%) and patient global assessment in favour of supervised group exercises. Finally, in one study a three week inpatient spa‐exercise therapy followed by 37 weeks of weekly outpatient group physiotherapy (without spa) was compared with weekly outpatient group physiotherapy alone; there was moderate quality evidence for effects in pain (RPD 18%), physical function (RPD 24%) and patient global assessment (RPD 29%), in favour of the combined spa‐exercise therapy.

Authors' conclusions

The results of this review suggest that a home exercise program is better than no intervention, supervised group physiotherapy is better than home exercises, and that combined inpatient spa‐exercise therapy followed by supervised outpatient weekly group physiotherapy is better than weekly group physiotherapy alone. The tendency toward positive effects of physiotherapy in the management of AS calls for further research in this field. New trials should also address other physiotherapy interventions commonly used in clinical practice.

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Plain language summary

How well does physical therapy work for treating ankylosing spondylitis and how safe is it?

To answer this question, scientists working with the Cochrane Musculoskeletal Group found and analyzed 6 studies testing over 550 people who had ankylosing spondylitis. Studies compared people who did exercises at home, went to group exercise programmes, went to a spa resort for physiotherapy or had no therapy at all. These studies provide the best evidence we have today.

What is ankylosing spondylitis and how can physical therapy help?
Ankylosing spondylitis (AS) is a type of arthritis usually in the joints and ligaments of the spine. It may also affect shoulders, hips, or other joints and cause tendonitis. Pain and stiffness occurs and limits movement in the back and affected joints. The disease course is highly variable; it may last for long periods, and be quite severe. Physiotherapy is thought to be an important treatment for AS to maintain or improve movement in the spine, improve fitness and decrease pain.

How well does physical therapy work?
Two studies compared home exercises to no therapy at all. They found that home exercises improve movement in the spine and fitness more than no therapy at all. But home exercises did not improve pain or stiffness more than no therapy. Home exercises were done for 4 to 6 months and were tailored to the individual by a physiotherapist.
Three studies compared home exercises to supervised group exercises outside the home. They found that group exercises improve movement in the spine and overall well‐being. But group exercises did not improve fitness more than home exercises. Exercises were done for 3 weeks to 9 months and included exercises such as physical training, strengthening, aerobic exercises, hydrotherapy, sports activities and stretching.

One study compared two groups of people who both did weekly group exercises for 10 months but one of the groups also went to a spa resort for 3 weeks of physiotherapy. Spa therapy plus weekly group exercises improves pain, fitness and overall well‐being more than just weekly group exercises. But spa therapy plus weekly group exercises did not improve stiffness more than group exercises ‐ and movement of the spine was not measured.

Did physical therapy harm patients?
Harms to the patients were not reported in the studies.

What is the bottom line?
Physiotherapy or exercises are helpful to people with ankylosing spondylitis.

There is "silver" level evidence that home exercises are better than no exercises and improve movement in the spine and fitness. Group exercises are better than home exercises and improve pain, stiffness, movement in the spine and overall well‐being. Adding a few weeks of exercising at a spa resort to weekly group exercises is better than just weekly group exercises.

We still need more information about the different types of physiotherapy and exercise, and how long and how often physiotherapy should be done for the most improvement.