Ankylosing spondylitis (AS) is a chronic inflammatory disease that affects mainly young men. This disease can affect axial and peripheral joints as well as specific organs, thus impairing quality of life in these patients. There are three types of treatment interventions in these patients: medical treatment, surgical treatment and physical-rehabilitation therapy. Physical-rehabilitation therapy includes distinct mo-dalities such as hydrotherapy, electrochemotherapy, massage, rest, ergotherapy and physical therapy (PT). Among these options, PT is the most important in the treatment of AS. The main objective of PT is to preserve the normal range of movement in affected joints, depending on the stage of the disease. In this setting, many exercises for peripheral and axial joints can be performed, through reha bilitation, breathing exercises and mildly aerobic sports. Although comparison of the results of different PT interventions is difficult, a review of the literature on this subject reveals that spa-exercise therapy is better than supervised group PT, and that the latter is better than individualized PT in the home. Several extrinsic factors influence the results of the above-mentioned interventions. A clear finding is that benefits are obtained if exercise is consistently performed.
It is important to briefly remember the alterations in the dynamics of the spine that occur in this entity to better understand the potential benefits of kinesitherapy. These alterations usually begin with the verticalization of the sacrum, which occurs to relieve tension in the ligaments of the sacroiliac joints, which implies a decrease in lumbar lordosis and hyperextension of the hip joints, a gesture that determines the advancement of the center of gravity . This shift in the center of gravity, as well as the involvement of higher levels of the spine, usually produce an increase in dorsal kyphosis with compensatory cervical hyperlordosis to maintain the balance of the visual field. The hip joints may be intrinsically affected by the presence of coccyx or develop compensatory flexion in cases of severe kyphosis. In some cases, the flexion of the hips is not compensated by the hyperextension of the spine and there is a secondary flexion of the knees, necessary to maintain balance in the standing position. This is how the classic posture is developed in relation to the lateral plane of: cervical hyperlordosis, dorsal hyperkyphosis, effacement of the lumbar lordosis and flexion of the hips and knees.
In the early stages of the disease, prior to soft tissue ossification, the limitation of joint mobility is reversible. If flexibility is not recovered due to the structuring of the different joint positions, there is a sustained shortening of the muscle masses that results in the loss of elasticity and power 2 .
Lung function can be affected both by the decrease in the elasticity of the rib cage, due to the involvement of the costotransverse and chondrosternal joints, and by the development of a progressive kyphosis that conditions an alteration in the sagittal diameter of the chest, thus favoring the development of a restrictive ventilatory disorder . Sometimes pulmonary function can be altered by intrinsic involvement of the parenchyma due to inflammation of the small airway and by the presence of subclinical alveolitis. In the early stages, the repercussions on lung function are minimal, since compensatory diaphragmatic breathing occurs and in most cases a mild-moderate restrictive disorder appears
Due to all of the above, an early diagnosis is important to start rehabilitation programs and health education as soon as possible.
QUALITY OF LIFE AND DISABILITY
The WHO defines quality of life as “the perception that an individual has of his place in existence, in the context of the culture and value system in which he lives and in relation to his objectives, his expectations, his norms, their concerns. It is a very broad concept that is influenced in a complex way by the physical health of the subject, their psychological state, their level of independence, their social relationships, as well as their relationship with the essential elements of their environment “. AS affects the quality of life of patients who suffer from it, both due to the symptoms derived from the disease itself and due to the alterations that occur in physical function, due to the possibility of affecting the ability to work, due to the social interaction and psychological functioning,
In a survey conducted with 99 patients with AS, the interviewed subjects indicated pain, followed at a distance by stiffness, as the factors that most affected their social and work life, as the most defining of disease activity .
Although not much information is available, it seems that few patients have problems with social interaction, and depression is the most common. There is a close relationship between the psychological state of the patient and different disease assessment tests, such as BASFI, BASDAI and BASMI, and the latter is the one that is least affected. It follows that the psychological situation of the patient must be taken into account to interpret the scores of the different measurement tests in AWS, since it can be important when monitoring patients and deciding their treatment .
Currently, with the availability of new treatments, a marked disability rarely develops, and most patients maintain an active working life. Disability of AS follows a progressive course, and it has been seen to have a strong correlation with spinal mobility, activity and duration of the disease and peripheral involvement 7Therefore, as we will see later, it can be diminished with rehabilitative treatment. It is convenient to assess the functional limitations of each patient before starting treatment. In this way, the values can be compared over time and an idea of the evolution of the disease, as well as the response to the treatments carried out, can be obtained. The functional assessment can include metrological indices, such as the Schöber test, thoracic expansion, finger-floor distance, cervical and lumbar arrows, etc., as well as validated functional scales, such as BASFI, BASDAI, BASMI, HAQ-S, EVA , etc. .
There are 3 basic pillars for the management of AD: medical, surgical and physical-rehabilitative treatment. Each of them is closely related to the others. Thus, a well-medicated patient will reduce inflammation, pain and muscle contracture, and perform rehabilitation exercises better. In the event of any surgery, early rehabilitation will help to avoid joint stiffness and deformities, facilitating its greatest functional benefit.
Medical treatment. It consists of the use of non-steroidal anti-inflammatory drugs (NSAIDs) as the first choice. In the event of poor clinical control with persistence of disease activity after 3 months of treatment with at least 2 NSAIDs and exclusively axial involvement, treatment with anti-tumor necrosis factor-alpha (anti-TNF a) will be transferred directly. If there is peripheral involvement, after trying treatment with NSAIDs, sulfasalazine can be combined for 3 months and local treatments can be performed when appropriate. If the disease still remains active, treatment with anti-TNF- 8 is started.COMPLICATIONS OF ANKYLOSING SPONDYLITIS
Surgical treatment. Two types of interventions are carried out mainly:
Vertebral interventions. Indicated in unstable injuries, painful spinal deformities, functionally or aesthetically unacceptable, and if there is a neurological compromise . Reduction and arthrodesis of the cervico-occipital hinge are performed with or without prior fixation, or laminectomy at lower levels. There is an improvement in pain, but an increase in stiffness with these interventions. The main indication is very severe kyphosis 4 .
Peripheral interventions. Indicated due to the appearance of severe and progressively destructive arthritis in extra vertebral locations, especially in the hip (more frequent) and knee. They usually require the placement of a prosthesis, with good results. When there are severe misalignments, femoral or tibial osteotomies must be performed 4 .
After surgery, it is essential to carry out rehabilitation, both respiratory physiotherapy to avoid atelectasis and pneumonia in the immediate postoperative period, and kinesitherapy, as early as possible, in order to avoid or decrease the rigidity of the operated area and adjacent areas.
Physical-rehabilitation treatment. Considered of fundamental importance in AS, it is a basic therapy to increase functional capacity and prevent deformities. It also improves coordination, maintains joint mobility and flexibility, and increases strength, muscular endurance and cardiovascular capacity . 10 It includes several techniques that complement each other: electrothermotherapy, massage therapy, ergotherapy, hydrotherapy and kinesitherapy; the latter is the most important. Although exercise is more important than rest, local immobilization with orthoses may have some indication .
It is defined as any therapeutic form in which the electrical source constitutes the main part of the physical agent. It plays little role in the treatment of patients with AS since measures that the patient can use independently are considered a priority. This type of therapy includes the short wave or microwave, which has a sedative and relaxing effect on the muscles; ultrasound, with a sedative effect, especially useful in enthesitis, and TENS.
It is the manipulation of the soft tissues of a body area aimed at producing general effects on health (relaxation, improvement of sleep) and local benefits (improvement of muscle disorders and pain). It is not used as a single treatment but is considered a complementary treatment, or as preparation of the patient for other interventions.
It consists of the use of the activity or occupation as a therapeutic means. It is both about instructing patients on technical aids for activities of daily living (long shoelaces, etc.), especially in more advanced stages of the disease, as well as about the adequacy of the home (adaptations for the bathroom, etc. .). Their role is also important in job retraining since it has been seen that ergonomic factors are the most important when maintaining a job for these patients 11.
Set of external applications of water in its different forms, general or partial, for therapeutic purposes.
The water in the pools facilitates flexible exercise, both of the peripheral joints and the axial skeleton since it is worked in the absence of gravity. It must be at a mesothermal temperature (36-37 ° C), in this way it has an ideal sedative effect to start an exercise session that is carried out for 15-20 min and is oriented according to the patient’s pathology (for example, If there are significant tendencies, swim back crawl style; if there is a knee flexion, the patient walks backwards into the pool, etc.). After carrying out the exercises and at the end of the session, hot water jets are applied to the patient’s spine to provoke a Thermo- analgesic effect .
Apart from the analgesic and relaxing effects on the muscles that mesothermal water has, it seems that its composition also has some added effect that contributes to the reduction of inflammation and pain through different mechanisms.
It is difficult to draw strong conclusions regarding hydrotherapy, as there are few controlled clinical trials and, furthermore, they include few participants. They are short-term studies and different measurement instruments are used. The only thing that can be stated is that this type of therapy produces beneficial effects in the short-medium term, persisting for a maximum of 10 months, and not in all the parameters analyzed.
It is defined as the set of procedures for the treatment of diseases through movement. It is the basis of physical-rehabilitative treatment. Its objective is the maintenance of functional joint routes, for which an early start is very important. The aim is to bring each affected joint region to the limit of its mobility and maintain the isometric contraction in the extreme position for 3 s. It is recommended to perform each exercise 3 to 5 consecutive times, along with corrective posture exercises. The most advisable thing is to perform it daily, although if this is not possible, at least do it weekly so as not to lose mobility. The most important exercises are the vertebral ones, since it is usually the most affected area (especially the extension ones, in the opposite direction to the deformity),
There are several exercise programs with multiple variations of each. The ideal is to vary them to improve compliance by the patient. Some examples of exercises that can be performed divided according to the body area worked are the following:
Exercises for peripheral joints. The external rotators of the shoulders, the approximators of the scapulae, the gluteus maximus, and the quadriceps must be strengthened. Some examples would be putting out a military-style chest approaching the scapulae, and in the supine position, with knee flexion, elevating the pelvis
Figure 1 In a supine position, with knee flexion, raise the pelvis.
Exercises for the axial skeleton.Both postural corrective exercises and wide joint travel must be performed in each segment of the spine in order to maintain a good postural attitude and optimal flexibility. With exercises in quadrupeds, such as raising and lowering the entire spine in an arc or raising the crossed limbs horizontally (figs. 2 and 3), cervical, thoracic and lumbar rotations and inclinations (fig. 4) and self-stretching (fig. 5) Either standing or supine, flexibility is worked. The latter also have rectifying effects on kyphosis and cervical hyperlordosis. Other epiphyseal exercisesstrengthen the erector trunk muscles (eg, in a prone position, perform trunk extensions with or without accompanying lower limbs). It is also convenient to strengthen the abs,
Figure 2 Arch elevation and descent of the entire spinal column.
Figure 3 Horizontal elevation of crossed limbs.
Figure 4 Cervical and thoracic rotations and lateral inclinations.
Figure 5 Stretching exercise.
Figure 6 Exercise for strengthening abdominal muscles.
Respiratory. With them, the aim is to maintain elasticity and inspiratory reserve. In the initial stages of the disease, the inspiratory muscles must be strengthened with rib breathing exercises, while in more advanced stages, the diaphragm is strengthened, since thoracic elasticity has been lost. It has been found that after a period of rehabilitation in 505 patients diagnosed with EA significantly improved chest expansion and vital capacity, both men and women 15 .
Sports. They should be soft and aerobic, such as back swimming, volleyball and basketball, avoiding both those that favor kyphose rowing and racing bike positions as well as abrupt exercises and those that have a high risk of falls to avoid fractures, since this pathology has an increased incidence of osteoporosis 16 .
The number of exercise programs available is very wide, and ideally use one that has been shown effective in a clinical trial and is easy to learn and perform at home without supervision
There is hardly any indication in the EA, and it should be as short as possible. The patient must spend long periods in the supine or prone position as stretched as possible, avoiding the lateral position that favors kyphosis and flexes of the hips and knees. A variety of rest could be considered postural treatment, which aims to prevent or correct an initial kyphosis or hip flexion. This type of treatment should be carried out gradually and without pain. The lower extremities should be kept in the maximum tolerable extension and placed in the prone position to add antiphosting effects. A good example would be reading in a sphinx pose. At the same time, the patient must be instructed on the postures to be seated, in chairs with a high and firm backrest, the use of lecterns or inclined planes for work to avoid sustained hyperflexion of the spine, etc. In the car, it is advisable to always wear the seat belt and use the headrest, as moderate trauma could cause life-threatening spinal fractures.
Phases of physical treatment
When proceeding with a rehabilitative treatment, the patient should always receive an individualized functional assessment for the realization of a personalized program by a rehabilitating physician. The type of exercises indicated depends on the stage of evolution in which the disease is found. In initial phases, in which there is no alteration or perhaps a minimal postural alteration, the teaching of an exercise program in the fewest possible sessions and individual performance is indicated daily for 10-20 min, checking the patient in the consult annually. In more advanced phases, it is necessary to carry out more teaching sessions led by a physiotherapist, urging the patient to do them at home with a closer follow-up in consultation, assessing the stabilization or improvement of the measurements. In severe phases, in which ankylosis already exists, passive mobilizations are not indicated due to the risk of fracture of the syndesmophytes, and isometric exercises are recommended. A rapid increase in cases of a cervical arrow or decreased lumbar arrow is indicated the use of orthotics. Regardless of the phase in which the patient is, aerobic exercise and complementary therapies such as hydrotherapy, thermotherapy and electrotherapy are always indicated, the latter especially in more advanced phases, as well as rest in the prone position. for about 30 min daily. Exercises should always be done without pain and out of disease flare-ups. In the exacerbation phase, self-immobilization and postural hygiene are indicated
Regarding how much exercise to do, it seems that continuity is more important than quantity. It has been seen that in patients who perform moderate exercise (2-4 h per week) there is an improvement in both function and disease activity, while in those who perform an intense exercise (> 10 h per week) only there is an improvement in function.Modern principles of treatment of ankylosing spondylitis
It is clear that exercise is always beneficial, but studies show that it is only beneficial in the short-medium term, that is, if it is not practiced continuously, the beneficial effects disappear. It is, therefore, a long and constant self-rehabilitation. This is the reason why it is very important to educate patients, to inform them about the disease, about its progressive and flare-up tendency, about the development of abnormalities in posture and flexibility, and about the beneficial effects it may have. the exercise so that they introduce it into their life habits, thus facilitating its compliance. It has been seen that there is a direct relationship between adherence to exercise and follow-up by a rheumatologist, which motivates the patient and explains the importance of exercise,18 . For there to be greater cooperation on the part of the patient, it is necessary to explain the objective of the rehabilitative treatment and not give unrealistic expectations, since they can generate negative reactions and jeopardize the program. In a very broad survey of patients diagnosed with AS, it was observed that most of the patients performed some type of exercise but with a very low frequency and duration. The main obstacle that the surveyed patients put was the lack of time, followed by fatigue. Only a small number of patients had increased symptoms of the disease due to exercise 19. Although the obstacles to exercising in AS patients are similar to those in the general population, getting an AS patient to exercise is probably easier than in the healthy population, which is supported by a study that shows that disability motivates the patient to carry out more physical exercise 20 .
In a Cochrane review, the objective of which was to summarize the available scientific evidence on physiotherapy interventions in the treatment of AS, 6 randomized clinical trials (RCTs) were included with a total of 561 participants, both male and female, diagnosed of AE according to New York criteria 1 . This review has unclear external validity, since of the total number of patients, 70% were male and only patients with intermediate involvement were included, as initial cases and patients in an advanced phase with significant comorbidity were excluded from the studies. On the other hand, the absence of interventions and standardized measurement instruments and the inadequate reporting of the data made it difficult to compare the different RCTs 21.
Of the 6 included RCTs, 2 compared individualized home exercise programs, with brief prior learning, versus no intervention 22,23 ; 3 compared supervised group physiotherapy programs versus individualized home exercise programs 24-26 , and one, the combined intervention of group exercise and balneotherapy versus group physiotherapy in isolation
The review authors demonstrated that the improvement achieved with the different exercise programs, apart from being statistically significant, was clinically relevant (relative differences> 15%). It was observed that exercises can improve mobility, physical function, and general evaluation of the patient, but they do not influence pain. Due to the variability obtained in the results of spinal mobility, it can be thought that specific exercises could have specific effects on spinal mobility, without expecting a general effect.
The review reaches three conclusions:
1. Based on 2 RCTs, it can be stated that individualized home exercise programs, with a brief prior learning, produce significant improvements compared to no intervention.
2. Based on 3 RCTs, it is concluded that supervised group physiotherapy programs were significantly better than individualized home exercise programs.
3. Based on an RCT, it can be stated that the combined intervention of group exercise and balneotherapy is superior to group physiotherapy in isolation.
Exercise is beneficial in the treatment of AS, better group than individualized, and even better if hydrotherapy is added. The aim of this form of therapeutic intervention is to introduce physical activity into the life habits of patients from the early stages of the disease, as well as to inform them of its benefits and encourage them to carry it out to improve compliance. It is not necessary to carry out intensive training programs, but to practice moderate exercise maintained over time in order to preserve its beneficial effects.
In sum, physical therapy is beneficial in AS, especially as part of a comprehensive treatment of the disease, but more studies are needed to investigate the different common techniques used in physical therapy and to see which are the most effective.