Physiotherapy Approaches and various therapies for Ankylosing Spondylitis where fusion of the spine causes restriction in movement. This presentation focuses on aqua therapy for this particular condition.

1. Physiotherapy Interventions for
Ankylosing Spondylitis
- Soniya Lohana

2. Introduction
• Ankylosing spondylitis (AS) is a chronic, inflammatory
rheumatic disease.
• Despite the advances in pharmacological therapy of
AS, Physical therapy remains an essential part in
management plan.
• It aims to alleviate pain, increase spinal mobility and
functional capacity, reduce morning stiffness, correct
postural deformities, increase mobility and improve
the psychosocial status of the patients.
• Some studies have suggested that exercise may
impact cytokine production.

3. • Treatment is essentially to minimize or prevent
deformities such as excessive dorsal kyphosis with
compensatory cervical lordosis and hip flexion
contracture. Do’s include:
• Proper sleeping posture on a solid, flat bed without
pillow. Frequent sleeping or lying in prone position.
• Posture exercises with upper back hyperextension
(performed with avoidance of lumbar hyperextension).
• Breathing exercises to increase or maintain rib cage
excursion, as well as proper instructions for
abdominothoracic breathing.
• Range of motion exercises for hips and knees to
prevent flexion limitation and contractures.
• Periodic rest periods with avoidance of fatigue.
• Bracing or corseting (combined with exercises).

4. • An individual home-based or supervised exercise
program is better than no intervention.
• Home exercise programs have been shown to
improve symptoms, mobility, function and overall
quality of life.

6. Group Therapy
• This is superior to individualised therapy in
improving thoracolumbar mobility and aerobic
fitness
• important effect on patient’s global health.
• Supervised group physiotherapy is better than
home exercises because group classes results in
greater improvement, due to mutual
encouragement, reciprocal motivation and
exchange of experiences within the group
environment.

8. • New exercise-based approaches, hydrotherapy and
Global Posture Re-education (GPR), offers
promising results in the management of patients
suffering AS.
• Combined spa-exercise therapy followed by group
physiotherapy is better than physiotherapy alone.
As, spa-therapy or hydrotherapy may improve
symptoms, function and overall sense of health.

9. Global Postural Re-education
(GPR)
• Global Postural Re-Education – involves a series of
active gentle movements and postures aimed at
realigning joints, stretching shortened muscles and
enhancing the contraction of antagonist muscles, thus
avoiding postural asymmetry .
• Physiotherapy, during the treatment, tries to reposition
the body with a gradual tension application on the
chain of muscles in combination with the proper
breathing.
• These postures are applied slowly, delicately and
progressively while always insisting on exhaling. It helps
to regain strength, length and flexibility to the muscles
responsible for the problem. GPR prevents long term
articular deterioration by helping healing and
eliminating pain and its symptom.

10. During each session, the PT
employs a series of gentle and
progressive therapeutically
sustained postural stretching's in
standing, sitting or lying down
positions.
During a session, they
work in their body,
stretching the tense
muscles while
strengthening at the
same time the weak
muscles, following the
chain that is causing the
pains or deviations.
Generally it is
recommended, one
session of 1 and a half
hour per week.

11. • Stanger bath therapy has beneficial effects in spinal
mobility, functional capacity, disease activity, and
quality of life on AS patients immediately after the
treatment period. Stanger bath therapy is
recommended for AS patients as a short-term
approach, but further research is imperative to
assess whether improvement is sustained over a
long-term follow-up.

12. Stanger Bath- a Hydro-Electric Bath Therapy
Stanger Bath tubs are made out of plastic and enhanced
with fiberglass. Metal plates are mount at the sides and
footboard of the tub are used as anode and cathode.
The electricity produces tingling sensation on the skin.
The water temperature is around 93℉. Enhancing
electricity from the anode lowers the muscle tension,
thus lowers the pain. Electricity from the cathode
increases the blood flow in the muscle tissue.

14. Aerobic Exercises
• In the short term aerobic exercise has a major
effect of all symptoms relating to Ankylosing
spondylitis.
• Swimming/hydrotherapy is the best for pulmonary
rehabilitation. Also high impact contact sports
should be avoided as this can have a negative
impact on symptoms relating to AS.
• Dosage: 1 hour per day, 5 days per week.
• Effect : Improved Chest Expansion, Improved
Functional Capacity and Decreases the Chance of
Respiratory Failure.

15. • In addition to conventional exercises (flexibility
exercises for cervical, thoracic and lumbar spine and
major muscle groups) and respiratory exercises,
aerobic exercises such as swimming/hydrotherapy
and walking are beneficial.
• Research has shown a significant increase in chest
expansion following swimming programs and a
significant increase in PvO2 and Six Minute Walk Test
distances in patients practising swimming and/or
walking aerobic exercises.
• Aerobic exercises lead to increase in chest expansion
and therefore a better functional capacity and also
decrease the chances of respiratory failure.

16. Manual Mobilisation
• Manual mobilisation improves chest expansion, posture and
spinal mobility.Both active angular and passive mobility
exercises can be used in the physiological directions of the
joints.
• Both active angular and passive mobility exercises can be
used in the physiological directions of the joints in the spinal
column and the chest wall in flexion, extension, lateral
flexion and rotation and in different starting positions.
Passive mobility exercises consist of general, angular
movements and specific translatory movements.
• Dosage: 1 Hour Sessions, 2 Times Per Week, for 8 Weeks
• Effect: Improved Chest Expansion, Posture and Spinal
Mobility

17. Inspiratory Muscle Training
• These include, motion and flexibility exercises of the
cervical, thoracic, and lumbar spine; stretching of the
hamstring muscles, erector spine muscle, and shoulder
muscles; control abdominal and diaphragm breathing
exercises and chest expansion exercises.
• Dosage: 40 minute session (supervised), Once Per
Week, 5 Unsupervised Home Exercise Sessions Per
Week
• Effect: Increased Aerobic Capacity, Improved Resting
Pulmonary Function and Ventilatory Efficiency

18. Incentive spirometer
• This is a session of breath holding and controlling
breaths. Patients should carry out 3-5 second breath
holds and carry out Forced Expiratory Techniques
interspersed between breath holds. This treatment
should be combined with General Exercises and should
not be used as a sole treatment
• Dosage: 30 Minute Sessions, Once Per Day, For 16
Weeks
• Effect: Improved Chest Expansion and Improved Forced
Vital Capacity

19. Pilates
• Pilates also has many positive effects on AS, most
notably on improving physical capacity.
• There is a relationship between Pilates and an
improved quality of life particularly in patients who
are in the early stages of AS even after a relatively
short duration of treatment.
• While this method is easy to learn and adaptable to
individual variations, it can be easily implemented
in the rehabilitation treatment of Ankylosing
spondylitis.

20. Mindfulness Based Therapies
Non exercise-based interventions also have positive
effects in the management of AS.
Mindfulness courses such as meditation and Vitality
Training Programme show increase in self-efficacy,
pain and symptoms, emotional processing, fatigue,
self-care ability and overall well-being

21. Hydrotherapy

22. Hydrotherapy
• Hydrotherapy is one of the basic methods of
treatment widely used in the system of natural
medicine, which is also called as water therapy,
aqua therapy, aquatic therapy, pool therapy and
balneotherapy.
• Use of water in various forms and in various
temperatures can produce different effects on
different system of the body.

23. Hydrotherapy- definition
Hydrotherapy/ Aquatic exercise refers to the use of
water(in multi-depth immersion pools or tanks) that
facilitates the application of established therapeutic
interventions, including stretching, strengthening,
joint mobilization, balance and gait training and
endurance training.

24. Goals and Indications of
Hydrotherapy
• To facilitate ROM
• Initiate resistance training
• Facilitate weight bearing
• Provide 3D access to the patient
• Facilitate cardiovascular exercises
• Initiate functional activity replication
• Minimize the risk of injury/re-injury
• Enhance patient relaxation

25. Precautions
• Fear of water
• Neurological disorders
• Respiratory disorders
• Cardiac dysfunction- Angina
- Abnormal BP
- Heart diseases
- Compromised pump mechanism
• Small open wounds

26. Contra-indications
• Incipient cardiac failure & unstable angina
• Respiratory dysfunction (VC less than 1 litre)
• Severe PVD
• Danger of bleeding/ haemorrhage
• Severe kidney disease
• Open wounds/ Skin infections such as tinea pedis &
ringworm
• Uncontrolled bowel/bladder
• Water and air-borne infections or diseases (influenza,
GI infections, typhoid, cholera, poliomyelitis)
• Uncontrolled seizures

27. Properties of Water
• Buoyancy
• Hydrostatic pressure
• Viscosity
• Surface tension

28. • Buoyancy provides the patient with relative
weightlessness and joint unloading by reducing the
force of gravity. This allows the patient to perform
active motion with increased ease.
• Hydrostatic pressure reduces or limits effusion,
assists venous return, induces bradycardia, and
centralizes peripheral blood flow.
• Viscosity- increasing the velocity of movement
increases the resistance.
• Surface tension- using equipment at the surface of
the water increases the resistance.

29. Thermodynamics
• Water temperature has an effect on the body.
• Differences in the temperature between an immersed
object and water equilibrate with minimal change in
the temperature of the water
• In general, cooler temperatures are utilized for high
intensity exercises and warm temperatures for mobility
and flexibility exercises and for muscle relaxation.
• Temperature and pressure of water in aquatic or
hydrotherapy can block nociceptors by acting on
thermal receptors and mechanoreceptors and exert
positive effect on spinal segmental mechanisms, which
is useful for reducing pain.

30. • Warm water provides a relaxation effect on the tight
musculature around the back.
• Buoyancy of water allows stretching to feel easier than
on land.
• Reduced pain while stretching/exercising as water
provides shock absorption.
• Easier to stay upright as effect of gravity reduced in
water.
• Effort required is reduced due to upward thrust of the
water. In water, at the level of ASIS, body weight is half
of what it would have be on land.

32. • The rationale for the use of hydrotherapy in
patients with Ankylosing Spondylitis looks at
addressing common symptoms such as stiffness
and associated back pain, stooped posture and
fatigue.
• The temperature of water is usually between 32-
33 ℃ however it may vary depending upon the
environment, and a program consists of 1 hour
sessions, 5 times per week

33. Aquatic Exercises
• Aqua Yoga
• Ai Chi
• Aqua Stretching
• Aqua Strengthening
• Aqua walking/running

35. Stretching Exercises
• Manual Stretching Techniques
• Spine stretching techniques
• Shoulder stretching techniques
• Hip stretching techniques
• Knee stretching techniques

36. Manual Stretching Techniques
Practitioner position: Describes the orientation of the
therapist to the patient
Patient position: Includes buoyancy-assisted (BA)
seated or upright positioning and buoyancy
supported (BS) supine positioning.
Hand placement: One hand stabilizes the patient and
the other hand may be used to apply movement and
is positioned distally
Direction of movement: Describes the motion of the
movement hand

37. Spine Stretching Techinques
• Cervical Spine: Flexion
• Cervical Spine: Lateral Flexion
Stretching to increase cervical lateral flexion

38. • Thoracic and Lumbar Spine: Lateral Flexion/Side
Bending
Stretching to increase lateral trunk flexion

39. • Shoulder Stretching Techniques
Stretching to increase shoulder flexion

40. • Hip and Knee Stretching Techniques
Stretching to increase knee flexion

41. Self-Stretching with Aquatic
Equipment
Self-stretching technique to increase hip flexion

42. Strengthening exercises
• Manual resistance exercises
• Upper extremity manual resistance techniques
• Lower extremity manual resistance techniques
• Dynamic trunk stabilization
• Lumbar spine strengthening
• Trunk strengthening

43. Upper Extremity Manual
Resistance Techniques
Manual resistance exercise for
strengthening shoulder flexion.

44. Manual resistance exercise for strengthening the shoulder
external rotation

45. Unilateral diagonal D2 flexion/extension
of the upper extremity
Bilateral diagonal D2 flexion/extension
of the upper extremity

46. Lower Extremity Manual
Resistance Techniques
Manual resistance exercise
for strengthening hip
abduction with resistance
applied to lateral aspect of
the leg
Manual resistance exercise
for strengthening hip and
knee flexion.

47. Dynamic Trunk Stabilization
Isometric trunk stabilization exercise using side to side
motions of the trunk.

48. Independent Strengthening
Exercises
Mechanical resistance
for strengthening
1.shoulder internal and
external rotation
2.elbow flexion and
extension,
3. hip flexion and
extension,
4.functional squat-ting,
and
5.ankle plantar flexion

50. Deep water walking/running
Deep water walking/jogging

51. • Deep water cardiovascular training eliminates the
effects of impact on the lower extremities and spine.
• Physiological Responses to deep water
Walking/Running:
Cardiovascular response: Patients without
cardiovascular compromise may experience dampened
elevation of heart rate, ventilation and VO2max
compared to similar land-based exercise.
Training effect: Patients experience carryover gains in
VO2max from aquatic to land conditions. Additionally,
aquatic cardiovascular training maintains leg strength
and maximum oxygen consumption.

52. • Evidence for the use of hydrotherapy/aquatic
physiotherapy
Dunbar et al looked at the effect of hydrotherapy
for patients with AS compared to home-based
exercise programs. It concluded that an intensive
hydrotherapy programme produced better
outcomes in terms of pain and quality of life for AS
patients compared to the home exercise group and
is a popular way to exercise, although
physiotherapist led formal hydrotherapy classes are
not always easy to access.

53. Also research shows that, in AS patients, balneotherapy
has statistically improved pain; physical activity;
tiredness and sleep score; Bath Ankylosing Spondylitis
Disease Activity Index (BASDAI). It also improves disease
activity and functional parameters in AS.
Infrared sauna, a form of total-body hyperthermia was
well tolerated with no adverse effects; and no
exacerbation of diseases in patients with RA and AS in
whom pain, stiffness, and fatigue showed clinical
improvements during the 4 weeks of treatment.

54. References
1. Carolyn Kisner, Lynn Allen Colby , Therapeutic Exercises; Aquatic Exercises
Chapter 9
2. Physiotherapy interventions for ankylosing spondylitis by Dagfinrud H,et al.
Cochrane Database Syst Rev. 2008
3. Andersson B.J. G. et al., Lumbar spine syndromes, evaluation and treatment,
Springer-Verlag Wien New York, 1989: 180-181. (Level of Evidence 5)
4. Braggings S., Back care, a clinical approach, Churchill livingstone; 2000: 49-
50. (Level of evidence 5)
5. Baaj. A.A. et al., Handbook of spine surgery, Thieme, 2010: 180-182. (Level of
evidence 5)
6. Alvarez I, López de Castro JA. HLA-B27 and immunogenetics of
spondyloarthropathies. Curr Opin Rheumatol. 2000;12(4):248-253
7. Mandl P. et al., EULAR recommendations for the use of imaging in the
diagnosis and management of spondyloarthritis in clinical practice, Ann
Rheum Dis, 2015 (Level of evidence: 1A)

55. 8. Altan L, Korkmaz N, Dizdar M, Yurtkuran M. Effect of Pilates training on
people with ankylosing spondylitis. Rheumatology international. 2012 Jul
1;32(7):2093-9.
9. So MW, Heo HM, San Koo B, Kim YG, Lee CK, Yoo B. Efficacy of incentive
spirometer exercise on pulmonary functions of patients with ankylosing
spondylitis stabilized by tumor necrosis factor inhibitor therapy. The Journal
of rheumatology. 2012 Sep 1;39(9):1854-8.
10. Drăgoi RG, Amaricai E, Drăgoi M, Popoviciu H, Avram C. Inspiratory muscle
training improves aerobic capacity and pulmonary function in patients with
ankylosing spondylitis: A randomized controlled study. Clinical rehabilitation.
2015 Mar 25:0269215515578292.
11. Widberg K, Karimi H, Hafström I. Self-and manual mobilization improves
spine mobility in men with ankylosing spondylitis-a randomized study.
Clinical rehabilitation. 2009 Apr 29.
12. Ozgocmen S, Akgul O, Altay Z, Altindag O, Baysal O, Calis M, Capkin E, Cevik R,
Durmus B, Gur A, Kamanli A. Expert opinion and key recommendations for
the physical therapy and rehabilitation of patients with ankylosing
spondylitis. International journal of rheumatic diseases. 2012 Jun
1;15(3):229-38.

56. 13. Dundar U, Solak O, Toktas H, Demirdal US, Subasi V, Kavuncu V, Evcik D. Effect of aquatic exercise on
ankylosing spondylitis: a randomized controlled trial. Rheumatology international. 2014 Nov
1;34(11):1505-11.
14. Davies H, Brophy S, Dennis M, Cooksey R, Irvine E, Siebert S. Patient perspectives of managing
fatigue in Ankylosing Spondylitis, and views on potential interventions: a qualitative study. BMC
musculoskeletal disorders. 2013 May 9;14(1):163.
15. Ward MM, Deodhar A, Akl EA, Lui A, Ermann J, Gensler LS, Smith JA, Borenstein D, Hiratzka J, Weiss
PF, Inman RD. American College of Rheumatology/Spondylitis Association of
America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the
Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis &
Rheumatology. 2015 Sep 1.
16. Scholten-Peeters GGM, Dijkstra PU, Vaes P, Verhagen AP. Bohn Stafleu Van Longhum. Jaarboek
Kinesitherapie. 2004.
17. Hidding A, van der Linden S, Boers M, Gielen X, de Witte L, Kester A, Dijkmans B, Moolenburgh D. Is
group physical therapy superior to individualized therapy in ankylosing spondylitis? A randomized
controlled trial. Arthritis & Rheumatism. 1993 Sep 1;6(3):117-25.
18. Altan L, Korkmaz N, Dizdar M, Yurtkuran M. Effect of Pilates training on people with ankylosing
spondylitis. Rheumatology international. 2012 Jul 1;32(7):2093-9.
19. Berea S, Ancuţa C, Miu S, Chirieac R. The Pilates method in ankylosing spondylitis. rehabilitation.
2012 May 1;2:3.
20. A mindfulness-based group intervention to reduce psychological distress and fatigue in patients
with inflammatory rheumatic joint diseases: a randomised controlled trial 2012
21. Davies H, Brophy S, Dennis M, Cooksey R, Irvine E, Siebert S. Patient perspectives of managing
fatigue in Ankylosing Spondylitis, and views on potential interventions: a qualitative study. BMC
musculoskeletal disorders. 2013 May 9;14(1):163.

57. THANK-YOU