The Journal of Rheumatology Volume 32, no.

10

The Cochrane review of physiotherapy interventions for ankylosing spondylitis.

Hanne Dagfinrud, Tore K Kvien and Kåre B Hagen

J Rheumatol 2005;32;1899-1906
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The Cochrane Review of Physiotherapy Interventions
for Ankylosing Spondylitis
HANNE DAGFINRUD, TORE K. KVIEN, and KÅRE B. HAGEN

ABSTRACT. Objective. To update the Cochrane review on the effectiveness of physiotherapy interventions in the
management of ankylosing spondylitis (AS).
Methods. All randomized studies available in systematic searches (electronic databases, contact with
authors, reference lists) up to February 2004 were included. Two reviewers independently selected
trials for inclusion, assessed the validity of included trials, and extracted data. Investigators were
contacted to obtain missing information.
Results. Six trials with a total of 561 participants were included. Two trials compared individualized
home exercise programs with no intervention. Low quality evidence for effects in favor of the home
exercise program was found in physical function and spinal mobility [absolute benefit 10.3 cm on
fingertip to floor distance; relative percentage difference (RPD) 37%)]. Further, the trials showed
low quality evidence for no group differences in pain. Three trials compared supervised group phys-
iotherapy with an individualized home exercise program. Moderate quality evidence for effective-
ness was found in patient global assessment and spinal mobility in favor of the supervised group.
The trials showed moderate quality evidence for no differences in pain intensity between the groups.
One trial compared a 3-week inpatient spa-exercise therapy followed by weekly outpatient group
physiotherapy with weekly outpatient group physiotherapy alone. Moderate quality evidence was
found for effects in pain (absolute benefit 0.9 cm on visual analog scale; RPD 19%), physical func-
tion (absolute benefit 1 cm; RPD 24%), and patient global assessment (absolute benefit 1.3 cm; RPD
27%), in favor of the combined spa-exercise therapy.
Conclusion. The current best available evidence suggests that physiotherapy is beneficial for people
with AS. However, it is still not clear which treatment protocol should be recommended in the man-
agement of AS. (J Rheumatol 2005;32:1899–906)

Key Indexing Terms:

ANKYLOSING SPONDYLITIS PHYSIOTHERAPY
SYSTEMATIC REVIEW RANDOMIZED CONTROLLED TRIAL

Ankylosing spondylitis (AS) is a chronic, progressive, peripheral joint involvement and extraarticular manifesta-
inflammatory disease predominantly affecting young men tions like acute anterior uveitis and cardiac problems. AS is
and women. The disorder mainly affects the axial skeleton found worldwide, but more often in Caucasians than in other
and the sacroiliac joints, with an aseptic inflammation of races. The prevalence is most frequently reported to be 0.1%
synovial tissue, the spinal ligaments, intervertebral discs, to 0.2%3-5. Clinically, the disease is more commonly seen in
and facet joints. The sacroiliac joint involvement is often men, with a 2–3:1 male to female ratio3,5-7. The etiology of
regarded as the hallmark of the disease, and the presence of AS is unclear8-10.
radiographic sacroiliitis is considered obligatory for classi- The most active disease phase is between the ages of 20
fication of AS according to both the original and the modi- and 50 years, and patients with AS experience various
fied New York criteria1,2. Some patients also experience degrees of functional limitations. The main clinical charac-
teristics are pain, stiffness, reduced spinal mobility, and
From the Section for Health Science, University of Oslo; Norwegian reduced energy. Physiotherapy is therefore recognized as
Resource Centre for Rehabilitation in Rheumatology; and Department of being an important part of the management program in AS.
Rheumatology, Diakonhjemmet Hospital, Oslo, Norway. The main goals are to maintain the patient’s maximal poten-
Supported by The National Foundation for Postgraduate Physiotherapists.
tial movement, prevent postural deformities, improve mus-
H. Dagfinrud, RPT, MSc, PhD Student, Section for Health Science,
University of Oslo; K.B. Hagen, RPT, PhD, Norwegian Resource Centre cle strength and fitness, and relieve pain11-18. Further,
for Rehabilitation in Rheumatology, Oslo; T.K. Kvien, PhD, MD, advice and education about the condition are important fac-
Professor, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, tors, enabling patients to manage the disease better and to
Norway.
seek assistance at the appropriate time19.
Address reprint requests to H. Dagfinrud, Section for Health Science,
University of Oslo, PO Box 1153, Blindern, 0316 Oslo, Norway. The previous review included data from 3 randomized
E-mail: [Link]@[Link] controlled trials (RCT). The results indicated a positive
Accepted for publication May 30, 2005. effect of physiotherapy interventions for patients with AS,

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but the few studies, examining a small range of modalities, extent to which people, interventions, and outcome measures are similar to
represented limited evidence. Recently, 3 more RCT have those of interest). The following definitions in grading the quality of evi-
dence for each outcome were used.
been conducted, and the purpose of this updated review was High: Further research is very unlikely to change our confidence in the
to assess the effectiveness of various physiotherapy inter- estimate of effect.
ventions in the management of patients with AS. Moderate: Further research is likely to have an important influence on
The following main comparisons were made: (1) physio- our confidence in the estimate of effect and may change the estimate.
therapy versus other interventions (including no interven- Low: Further research is very likely to have an important influence on
our confidence in the estimate of effect and may change the estimate.
tion); and (2) comparison of different modalities or applica- Very low: Any estimate of effect is very uncertain.
tions of physiotherapy. In addition, there are some considerations that can lower or raise the qual-
ity of evidence that were not employed in this review22.
MATERIALS AND METHODS
Criteria for considering studies for this review Data extraction and analyses
Studies. Randomized or quasi-randomized controlled studies examining the Data were independently extracted by 2 reviewers (KBH and HD) using a
effectiveness of physiotherapy in AS were evaluated. pilot-tested data extraction form. Disagreement was resolved by discussion.
If the articles did not provide sufficient information for methodological
Participants. Men and women with the diagnosis of AS according to the assessment or necessary data for statistical analyses, letters were sent to
classification system described in the modified New York criteria2. Trials investigators to collect missing data. Six letters were sent and 4 of the
were excluded if the diagnostic criteria were unclear or were not met. authors replied to our request. Two provided additional information regard-
Interventions. Studies were included if the interventions were any physio- ing methodological quality and 2 provided additional data for statistical
therapy modality considered relevant in the management of AS. If cointer- analyses.
ventions were included, they had to be similar in the comparison groups. For Main comparison 1 (physiotherapy interventions versus other inter-
Relevant physiotherapy modalities included: supervised and unsupervised ventions or no intervention), the preplanned stratified analyses were: Trials
exercises, training, manual therapy, massage, hydrotherapy, electrotherapy, comparing home programs of therapeutic exercises and disease education
acupuncture, and patient information and educational programs. with no intervention.
Outcome measures. As designated by the ASsessments in AS (ASAS) For Main comparison 2 (different modalities or applications of physio-
Working Group20, the main outcomes of interest were pain, stiffness, spinal therapy), the preplanned stratified analyses were:
mobility, physical function, and patient global assessment. Other relevant (1) trials comparing home exercise regimes with supervised, inpatient or
outcome measures were also considered. outpatient group physiotherapy (including hydrotherapy);
Search strategy for identification of studies. Relevant studies were identi- (2) trials comparing inpatient spa-exercise therapy with supervised, week-
fied by searching the Cochrane Central Register of Controlled Trials (CEN- ly group physiotherapy.
TRAL), AMED, Medline, Embase, CINAHL and PEDro (up to February Where possible, weighted mean differences (WMD) with correspon-
2004), with no language restrictions. ding 95% confidence intervals (CI) were calculated23. Both random effect
The search strategy recommended in the Cochrane Collaboration models and fixed effect models were employed. For studies not providing
Handbook was used. The reference lists of retrieved studies were scanned sufficient data, qualitative analyses were undertaken. In one trial24, 2 inter-
to identify additional relevant trials, and authors of relevant studies were vention arms were considered clinically similar and were therefore com-
contacted. bined for analytical purposes.
Methods of the review. Trials included in the review were independently
Clinical relevance
selected by the 2 reviewers (HD and KBH) using a standard form that had
In order to improve the clinical relevance of the review, absolute benefit
been pilot-tested.
and relative percentage differences (RPD) were calculated, if possible, for
Methodological quality. Internal validity was independently assessed by 2 statistically significant differences. Absolute benefit was calculated as the
reviewers (HD and KBH) using the criteria described in the Cochrane improvement in the treatment group less the improvement in the control
Collaboration Reviewers’ Handbook21. The criteria included assessment of group using the original units. RPD was calculated as the absolute benefit
the following: concealment of allocation, use or control with cointerven- divided by the baseline mean in the control group25. According to the
tions, use of intention-to-treat analysis and losses to followup, outcome Philadelphia Panel, an improvement at 15% relative to a control group was
assessment, and blinding of patients. These 5 criteria were rated as “met,” considered clinically relevant26.
“unclear,” or “not met.” The operationalization of the 5 methodological
quality criteria is presented in Table 1. Disagreement was easily resolved
by discussion. Blinding of providers is clearly not possible, so the outcome RESULTS
criteria focus upon blinding of assessors and patients. However, the includ- We considered 43 studies for inclusion in this review.
ed trials compared exercises and educational programs in different settings, Thirty-three of them were excluded due to study design, the
and blinding of patients was therefore rated as not met in these trials. An participants, the interventions, or the outcome measures.
overall assessment of internal validity was based on a summary of these 5
Two conference abstracts27,28 were considered potentially
criteria: low risk of bias means that 4 to 5 criteria were met; moderate risk
of bias means that 3 criteria were met; and high risk of bias means that less
eligible, but full reports were not available. Eight published
than 3 criteria were met (Appendix). studies were RCT and investigated the effects of physio-
Finally, the quality of evidence was assessed according to a recently therapy in the management of patients with AS12,13,16,29,30.
developed systematic and explicit method22. To indicate the extent to which However, 2 of these were crossover or followup studies that
one can be confident that an estimate of effect is correct, judgments about did not provide independent results and they were conse-
the quality of evidence were made for each comparison and outcome. These
judgments considered study design (RCT, quasi-RCT, or observational
quently excluded from the review30,31. Six studies with a
study), study quality (detailed study design and execution), consistency of total of 561 participants were included in this updated
results (similarity of estimates of effect across studies), and directness (the review, compared to 3 trials and 241 patients in the previous

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Table 1. Criteria used for rating internal validity. An overall assessment of internal validity was based on a summary of these 4 criteria: low risk of bias means
that all criteria were met; moderate risk of bias means that 3 criteria were met; and high risk of bias means that < 3 criteria were met.

Criteria Met Unclear Not Met

Concealment of Randomization independent of provider Concealment approach not reported and Alternative allocation, case record
allocation and investigator, i.e., use of centralized could not be verified by contacting the numbers, dates of birth, day of week,
computer system or sequentially investigators and any allocation procedure that was
numbered, sealed, opaque envelopes entirely transparent before assignment
Cointervention Interventions other than physiotherapy Cointerventions not reported and could Dissimilar use of interventions other
were avoided or used similarly across not be verified by contacting investigators than physiotherapy
comparison groups
Intention-to-treat Intention-to-treat analysis performed and Intention-to-treat analysis or losses to Exclusion not reported and could not be
analysis and losses to followup < 20% and equally followup not reported and could not be verified by contacting the investigators
losses to followup distributed between comparison groups verified by contacting the authors or losses to followup > 20%
Outcome Assessors unaware of the assigned treatment Blinding of assessor not reported, and Assessor aware of the assigned treatment
assessment when collecting outcome measures could not be verified by contacting the when collecting outcome measures
investigators
Blinding of Patients unaware of the assigned treatment Blinding of patients not reported Patients aware of the assigned treatment
patients or blinding of patient not possible

version. The included studies were undertaken in Canada12, significant difference was found in the Schober test (RPD
The Netherlands16, United Kingdom13,32, Austria, Germany 2.3%). Sweeney, et al32 did not measure spinal mobility. We
and Netherlands24, and Turkey29. A description of the stud- conclude that there is low quality evidence for a positive
ies is presented in the Appendix. effect of a home exercise program on some measures of
The overall assessment of the methodological quality of spinal mobility.
the trials in this review was as follows: Two studies16,24 met Physical function. Physical function score was significantly
4 criteria of internal validity and were rated to have low risk better at end of trial in the experimental group than in the
of bias. Two studies12,29 met 3 criteria and were assessed to no-intervention group in the study of Kraag, et al12. Mean
have moderate risk of bias; and 2 studies did not meet any difference after treatment was about 4 points on a 33-point
of the criteria and were assessed to have high risk of scale (p < 0.001, modified Toronto Activities of Daily
bias13,32. The overall assessment and the assessments of Living Questionnaire). Sweeney, et al32 reported no signifi-
each criterion are presented in the Appendix. cant group difference after treatment (at 6 months) on the
Bath Ankylosing Spondylitis Functional Index (BASFI)34
Comparisons (RPD 7.5%). In conclusion, there is low quality evidence for
Main comparison 1: physiotherapy versus other a treatment effect on self-reported physical function.
treatment (including no treatment) Patient global assessment. Patient global assessment was
Two trials compared home exercise and educational pro- not measured in Kraag, et al12. Sweeney, et al reported no
grams with no intervention12,32. In one of the studies, 3 of group differences on the Bath Ankylosing Spondylitis
the methodological quality criteria were met, and the study Patient Global Score (BAS-G)35. Thus, there is low quality
was assessed to have moderate risk of bias12. In one study, of evidence for no difference between the groups on patient
less than 3 methodological criteria were met, and the study global assessment.
was assessed to have high risk of bias32. The results are
summarized in Table 2. Main comparison 2: different modalities or applications
Pain. None of the included studies reported any clinically of physiotherapy
relevant differences in pain. We therefore conclude that A. Trials comparing supervised group physiotherapy
there is low quality evidence for no group differences in (including hydrotherapy) with home exercise regimes.
pain reduction. Three trials were included in this comparison. One trial
Stiffness. Stiffness was not measured in the studies, except met all the methodological quality criteria, and was assessed
one, where it was reported as part of the Bath Ankylosing to have low risk of bias16; one trial met 3 criteria and was
Spondylitis Disease Activity Index (BASDAI)33. No group assessed to have moderate risk of bias29; and one trial met
differences were found on the BASDAI in the study of less than 3 methodological quality criteria, and was assessed
Sweeney, et al32. to have high risk of bias13. The results are summarized in
Spinal mobility. Kraag, et al12 found a significant difference Table 3.
in fingertip-to-floor distance in favor of the home exercise Pain. Hidding, et al16 found no significant differences in
program at 4 months (end of trial; RPD 37%). However, no pain between the groups (RPD 10%). Analay, et al measured

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Table 2. Results from individual studies in main comparison 1 (physiotherapy vs other treatment, including no treatment), trials comparing home exercise,
and educational program with no treatment.

Study Treatment Outcome No. of Baseline End of Absolute Relative Percentage

Group (scale) Patients Mean Study Mean Benefit Difference

Sweeney, 2002 Home SES, pain 75 6.49 6.80 0.13 2.1 (?)*
Control (1–10*) 80 6.06 6.24 NS
Sweeney, 2002 Home BASDAI 75 3.9 3.65 –0.06 1.6 (W)
Control (0–100) 80 3.8 3.49 NS
Kraag, 1994 Home FFD, cm 26 23.6 15.3 10.3 37 (I)
Control 27 27.5 29.5
Kraag, 1994 Home Schober test, cm 25 13.7 11.3 –0.3 2.3 (W)
Control 27 13.3 10.6 NS
Sweeney, 2002 Home BASFI 75 3.5 3.06 0.27 7.5 (I)
Control (0-100) 80 3.6 3.43 NS
Sweeney, 2002 Home BAS-G 75 4.0 3.60 0.31 8.4 (I)
Control (0–100) 80 3.7 3.61 NS

NS: no statistically significant differences between groups; SES pain: Stanford Self-Efficacy Scale (* direction of scale not reported); BASDAI: Bath Ankylosing
Spondylitis Disease Activity Index; FFD: Fingertip-to-floor distance; BASFI: Bath Ankylosing Spondylitis Functional Index; BAS-G: Bath Ankylosing
Spondylitis Patient Global Score; I: improvement; W: worsening.

Table 3. Results from individual studies in main comparison 2 (different modalities or applications of physiotherapy). Comparison 2A, trials comparing super-
vised group physiotherapy (including hydrotherapy) with home exercise regimes.

Study Treatment Outcome No. of Baseline End of Absolute Relative Percentage

Group (scale) Patients Mean Study Mean Benefit Difference

Analay, 2003 Supervised PT Pain at rest 23 3.8 3.3 0.5 16 (I)

Control (0-100) 22 3.1 3.1 NS
Analay, 2003 Supervised PT Pain activity 23 4.5 4.2 0 0
Control (0–100) 22 4.6 4.3
Helliwell, 1996 Supervised PT Pain and stiffness 15 8.1 4.1 3.9 48 (I)
Control (0–200) 14 8.1 8.0
Analay, 2003 Supervised PT Morning stiffness, 23 38.7 20.9 18.2 49.7 (I)
Control minutes 22 36.6 37.0 NS
Helliwell, 1996 Supervised PT Cervical rotation, 15 95.3 112 14.9 17 (I)
Control degrees 14 88.8 90.6 NS
Analay, 2003 Supervised PT FFD, cm 23 20.8 15.5 4.3 22.5 (I)
Control 22 19.1 18.1 NS
Analay, 2003 Supervised PT TWD, cm 23 17.0 14.0 2.3 14.8 (I)
Control 22 15.5 14.8 NS
Analay, 2003 Supervised PT BASFI, cm 23 26.3 20.0 6.0 21.7 (I)
Control 22 27.6 27.3 NS

NS: no statistically significant differences between groups; FFD: Fingertip-to-floor distance; TWD: Tragus-wall distance; BASFI: Bath Ankylosing
Spondylitis Functional Index; I: improvement; W: worsening.

pain at rest and during activity and found no significant dif- measured duration of morning stiffness in minutes. The
ferences after treatment or after 3 months. Helliwell, et al authors reported statistically significant within-group
combined pain and stiffness in one variable. The RPD was improvement after treatment and after 3 months. However,
48% immediately after treatment in favor of the supervised between-group analyses showed no significant differences
group. However, this study was assessed to have high risk of at the 2 measurement points. The quality of evidence for no
bias and the results were therefore given low weight. Six group difference is therefore considered to be moderate.
months after the intervention no significant differences were Spinal mobility. Hidding, et al16 found a statistically signif-
found. Thus, it is reasonable to state that there is moderate
icant difference for thoraco-lumbar mobility in favor of
quality evidence for no difference in pain intensity between
the groups. group physiotherapy after the 9-month intervention period
(RPD 7.5%). This group also performed slightly but not sig-
Stiffness. No significant differences in stiffness were found nificantly better on the other spinal mobility outcomes. The
after 9 months in Hidding, et al (RPD 8%). Analay, et al29 pooled analyses of chest expansion and the Schober test

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(lumbar flexion)13,29 showed no significant differences, but Pain. Significant effects of the spa-exercise intervention
Analay, et al29 found a significant difference in Schober were found regarding pain 1 and 4 months after start of the
score at 3 months (RPD 18%). 3-week intervention (RPD 19%). It may be reasonable to
Further, no difference in cervical rotation was found in conclude that there is moderate quality evidence for a clini-
Helliwell, et al13; and Analay, et al29 found no difference cally relevant effect of the spa-exercise intervention on pain.
between the groups on fingertip-to-floor distance or tragus- Stiffness. Stiffness was measured as duration (minutes) of
to-wall distance. In conclusion, the quality of evidence for morning stiffness. Significant differences between the spa-
small differences on some measures of spinal mobility is exercise groups and the control group were not found. Thus,
considered to be moderate. the quality of evidence for no group differences is moderate.
Physical function. No significant differences in self-report- Spinal mobility. Spinal mobility was not measured in this
ed physical function measured after intervention were found study.
in the study of Hidding16 (RPD 7%) or in the study of Physical function. Physical function was measured with the
Analay29 (RPD 22%) (Table 3). The quality of evidence is BASFI, included in the pooled index of change. Evaluated
moderate. as a separate variable, the BASFI results were not statistical-
Patient global assessment. The supervised group reported ly significant. However, the RDP were 24% and 17% (1 and
significantly better scores on the patient global assessment 4 months, respectively), and may thus be considered clini-
after the 9-month intervention period in the study of cally relevant26. No statistically significant group differences
Hidding, et al16 [mean change difference 1.46 cm (10 cm were found, and the quality of evidence is moderate.
scale); 95% CI 1.05 to 1.87]. Relative difference was not Patient global assessment. Significant positive effects of the
calculated due to insufficient reporting of baseline data. spa-exercise interventions were found for patient global
Patient global assessment was not measured in the 2 other assessment at 1, 4, and 7 months (RPD 26.5%, 29%, and
studies13,29. The quality of evidence for a difference in favor 29%, respectively) in favor of the spa-exercise group. At 10
of group physiotherapy is considered to be moderate. months no differences between the groups were found.
There is moderate quality evidence for a clinically relevant
Main comparison 2 – different modalities or effect in favor of an additional combined spa-exercises
applications of physiotherapy course.
B. Trials comparing the effectiveness of spa therapy with
weekly group physiotherapy. DISCUSSION
One study was included, meeting all the methodological The results of this review showed that patients with AS had
quality criteria and assessed as having low risk of bias24. some beneficial effects from individualized home exercise
The 2 spa-exercise interventions took place at 2 different spa programs compared to no intervention. Further, supervised
resorts, but the therapy programs were standardized for both group physiotherapy programs were better than individual-
spa resorts. The 2 interventions were therefore considered
ized home exercise regimes, and a 3-week combined spa-
clinically similar, and they were combined to perform as one
exercise intervention was better than weekly group physio-
group in this review (intervention group: IG), which was
therapy alone. Six studies met the inclusion criteria of this
compared to weekly group physiotherapy alone (control
group: CG). The authors expressed the primary outcomes review, with a total of 561 patients with AS. Two of the
(BASFI, BAS-G, pain intensity, and morning stiffness) as a studies were assessed to have low risk of bias, 2 studies
pooled index of change (PIC). Both the pooled index and the were assessed to have moderate, and 2 to have high risk of
individual variables were reported. The results are summa- bias. Patients or providers were not blinded in the included
rized in Table 4. trials.

Table 4. Results from individual studies in main comparison 2 (different modalities or applications of physiotherapy). Comparison 2B, trials comparing the
effects of spa therapy with weekly group physiotherapy.

Study Treatment Outcome No. of Baseline End of Absolute Relative Percentage

Group (scale) Patients Mean Study Mean Benefit Difference

Van Tubergen, Spa exercise Pain 80 4.6 3.6 0.9 19 (I)

2001 Control (0–10) 40 4.8 4.7
Van Tubergen, Spa exercise BASFI 80 4.6 3.6 1.0 24 (I)
2001 Control (0–10) 40 4.2 4.2
Van Tubergen, Spa exercise BAS-G 80 5.3 3.7 1.3 26.5 (I)
2001 Control (0–10) 40 4.9 4.6

BASFI: Bath Ankylosing Spondylitis Functional Index; BAS-G: Bath Ankylosing Spondylitis Patient Global Score; I: improvement.

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 Nearly all the studies in this review included more than being of the AS patients, but does not give evidence to iden-
70% men in the participant groups. Among the exclusion tify the most appropriate and effective exercise program.
criteria were patients using disease modifying antirheumat- The random allocation of patients in physiotherapy stud-
ic drugs, patients with peripheral joint involvement, severe ies may lead to reduced effectiveness of the interventions.
comorbidity, and diagnosis of AS more than 20 years ago. Physiotherapy interventions are often time-consuming and
Thus, the applicability of the results to women and patients compliance is dependent on highly motivated patients.
severely affected with AS may be limited. Helliwell, et al13 addressed this problem in their study, con-
The main goal of the 6 trials in this review was to study sidering that the large number of dropouts may have been
the effectiveness of physiotherapy in the management of due to lack of motivation and a time-consuming treatment
AS. However, the interventions were often poorly program that the patients had not chosen. With use of inten-
described, so that the exact content of the programs tion-to-treat analyses, the high degree of noncompliance
remained partly unclear, and the external validity was there- will influence the treatment effects negatively. To avoid
by unclear. Another problem related to the external validity noncompliance or poor recruitment, physiotherapy
was the somewhat unusual interventions in some of the researchers may have a tendency to compare active and
included trials, such as treatment programs in spa resorts. quite similar interventions. Significant differences of clini-
Although the spa-exercise intervention showed favorable cally relevant treatment effects may therefore be hard to
cost-effectiveness and cost-utility ratios compared to self- obtain.
exercising and group-exercising36, spa resorts are not readi- The trials included in this review compared different
ly available in many parts of the world and the generaliz- active interventions, and blinding of the participants was
ability of the results may therefore be limited. therefore not considered as a methodological quality criteri-
The included studies measured spinal mobility with dif- on. Blinding of providers and patients is regarded as very
ferent methods and for different parts of the spinal column. difficult in physiotherapy studies. However, lack of blinding
The varying results may indicate that mobilizing exercises weakens the methodological quality of trials and should
have to be specifically designed for each part of the column, therefore be used if possible, for example in electrotherapy
and a general effect of exercising on spinal mobility is not modalities, and possibly by means of different kinds of
to be expected. Further, measures of spinal extension range attention placebos.
of motion are lacking in the included studies, and future tri- Publication bias is discussed as a problem when devel-
als should aspire to include more specific spinal mobility oping systematic reviews. Research has suggested that stud-
movements and measurements. ies with positive results are more likely to be published than
Compared to the previous version of this review37 (not studies with negative results38. Further, our literature search
published in a paper journal), 2 substantial changes have identified reports of 2 possibly eligible studies, published as
been made. First, 3 new studies with a total of 320 patients conference abstracts, that did not provide sufficient data to
have been included. Second, the clinical relevance of the be included27,28. Due to the small number of included stud-
effect sizes and the quality of evidence has been assessed ies and insufficient data reporting, the possible extent of
according to systematic and explicit methods22,26. These publication bias could not be explored further in this review.
changes have reinforced the tendency toward positive No randomized trials investigating relevant physiothera-
effects of physiotherapy in terms of exercise programs in the py interventions other than exercise programs were found
management of AS. A new high quality study is added in through this systematic search strategy. Other commonly
this update, showing good results of combined spa-exercise used physiotherapy interventions (e.g., different hands-on
therapy24. Another study with moderate methodological techniques such as manual therapy, electrotherapy, and
quality indicates positive results, although not statistically information and education programs) should be investigat-
significant, of intensive group physiotherapy compared to ed. Future trials should compare different treatment and
home exercises29. exercise programs, and aspire to an accurate description of
The trials included in this review compared therapeutic the content, dose and application of training and exercise
exercises applied in group settings to exercises performed programs, as well as duration and frequency of the interven-
individually. Thus, the comparisons may provide informa- tions. Further, future trials should apply standardized, vali-
tion on the effect of the group setting rather than the effect dated outcome measures suitable for assessing effects of
of the specific content of the exercise programs. That the physiotherapy interventions.
patients who participated in the groups (both inpatients and According to the current research evidence, we do not
outpatients) improved more than the patients who did exer- know which particular treatment protocol should be recom-
cises on their own may be ascribed partly to the contribution mended in the management of AS.
of nonphysical factors, such as mutual encouragement, This review identified and summarized data from all
increased motivation, and exchange of experiences with fel- available RCT investigating the effects of physiotherapy in
low sufferers. These are important factors for the total well the management of AS. Due to a small number of partici-

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pants, some of the studies may be underpowered and prone 17. van der Linden S, van Tubergen A, Hidding A. Physiotherapy in
to bias due to baseline differences. Further, because of het- ankylosing spondylitis: what is the evidence? Clin Exp Rheumatol
2002;20 Suppl 28:S60-S64.
erogeneous interventions and outcome measures, varying 18. Gall V. Exercise in the spondyloarthropathies. Arthritis Care Res
methodological quality, and deficient reporting of data in the 1994;7:215-20.
included studies, the review does not provide strong evi- 19. David C, Lloyd J, editors. Rheumatological physiotherapy. London:
dence. However, systematic reviews also have the potential Mosby; 1999.
20. van der Heijde D, Calin A, Dougados M, Khan MA, van der
to identify areas of poor knowledge, leading to new Linden S, Bellamy N. Selection of instruments in the core set for
hypotheses and constituting a valuable guide for further DC-ART, SMARD, physical therapy, and clinical record keeping in
research. The tendency toward positive effects of physio- ankylosing spondylitis. Progress Report of the ASAS Working
therapy in the management of AS calls for further research, Group. J Rheumatol 1999;26:951-4.
21. Alderson P, Green S, Higgins J. Cochrane Reviewers Handbook,
and future trials should address other physiotherapy inter- 4.2.1. Chichester, UK: John Wiley & Sons Ltd.; 2004.
ventions commonly used in clinical practice. 22. Atkins D, Best D, Briss PA, et al. Grading quality of evidence and
strength of recommendations. BMJ 2004;328:1490.
ACKNOWLEDGMENT 23. Deeks J, Higgins J, Altman DG. Analysing and presenting results.
The Cochrane Reviewers Handbook, 4.2.1. Chichester, UK: John
Louise Falzon at the editorial office of the Cochrane Musculoskeletal
Wiley & Sons Ltd.; 2004:68.
Group conducted the literature searches for this updated version. The
24. Van Tubergen A, Landewe R, van der Heijde D, et al. Combined
authors of the primary studies are acknowledged for their cooperation.
spa-exercise therapy is effective in patients with ankylosing
spondylitis: a randomized controlled trial. Arthritis Rheum
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APPENDIX The RCT included in this review.

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