Nonpharmacological interventions are one of the mainstreams of treatment for patients with spondyloarthritis (SpA). They include education, measures regarding joint protection, posture and rest, therapeutic exercise, physical therapy modalities, orthoses, and acupuncture. A key component in the rehabilitation of patients with SpA entities is therapeutic exercise, which can be performed as land-based or water-based. Positive effects of the exercises are manifested in reducing pain, maintaining mobility, improving posture, increasing aerobic capacity and improving quality of life. The best effects can be obtained when exercise is performed under the supervision of a physiotherapist at a health institution. The majority of studies on therapeutic exercise in SpA are related to ankylosing spondylitis (AS), while there is a paucity of studies devoted to other conditions. Although progress has been made in the quantity and quality of research on this topic, there are still issues regarding the quality of studies and considerable variability among them, which makes it difficult to compare different methods and harmonize and develop rehabilitation protocols according to evidence-based medicine.
Khan M. An overview of clinical spectrum and heterogeneity of spondyloarthropathies. Rheum Dis Clin North Am. 1992;1–10.
2.
Rudwaleit M, Van Der Heijde D, Landewé R, Listing J, Akkoc N, Brandt J, et al. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis. 2009;777–83.
3.
Grazio S. Classification and diagnosis of axial spondyloarthritides -history, present state and perspectives. Reumatizam. 2016;(Suppl 1):1–17.
4.
Stolwijk C, Van Onna M, Boonen A, Van Tubergen A. Global prevalence of spondyloarthritis: a systematic review and meta-regression analysis. Arthritis Care Res (Hoboken). 2016;1320–31.
5.
Bostan E, Borman P, Bodur H, Barça N. Functional disability and quality of life in patients with ankylosing spondylitis. Rheumatol Int. 2003;121–6.
6.
Van Echteld I, Cieza A, Boonen A, Stucki G, Zochling J, Braun J, et al. Identification of the most common problems by patients with ankylosing spondylitis using the international classification of functioning, disability and health. J Rheumatol. 2006;2475–83.
7.
Boonen A, Chorus A, Miedema H, Van Der Heijde D, Van Der Tempel H, Van Der Linden S, et al. work disability, and work days lost in patients with ankylosing spondylitis: a cross sectional study of Dutch patients. Ann Rheum Dis. 2001;353–8.
8.
Gobelet C, Luthi F, Al-Khodairy A, Chamberlain M. Work in inflammatory and degenerative joint diseases. Disabil Rehabil. 2007;1331–9.
9.
Grazio S, Jajić Z, Nemčić T, Jajić I. Work capacity evaluation in patients with ankylosing spondylitis. Reumatizam. 1997;1–5.
10.
Husni M, Merola J, Davin. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017;351–60.
11.
Wu J, Penfold R, Primatesta P, Fox T, Stewart C, Reddy S, et al. The risk of depression, suicidal ideation and suicide attempt in patients with psoriasis, psoriatic arthritis or ankylosing spondylitis. J Eur Acad Dermatol Venereol. 2017;1168–75.
12.
Meesters J, Bremander A, Bergman S, Petersson I, Turkiewicz A, Englund M. The risk for depression in patients with ankylosing spondylitis: a populationbased cohort study. Arthritis Res Ther. 2014;418.
13.
Meesters J, Bergman S, Haglund E, Jacobsson L, Petersson I, Bremander A. Prognostic factors for change in self-reported anxiety and depression in spondyloarthritis patients: data from the population-based SpAScania cohort from southern Sweden. Scand J Rheumatol. 2018;185–93.
14.
Zochling J. Bath Ankylosing Spondylitis Metrology Index (BASMI), Dougados Functional Index (DFI), and Health Assessment Questionnaire for the Spondylarthropathies. Arthritis Care Res (Hoboken). 2011;(Suppl 11):47–58.
15.
Gladman D, Helliwell P, Mease P, Nash P, Ritchlin C, Taylor W. Assessment of patients with psoriatic arthritis: a review of currently available measures. Arthritis Rheum. 2004;24–35.
16.
Who. International classification of functioning, disability and health. 2001;
17.
Stucki G. International Classification of Functioning, Disability, and Health (ICF). Am J Phys Med Rehabil. 2005;733–40.
18.
Boonen A, Braun J, Van Der H, Bruinsma I, Huang F, Maksymowych W, et al. ASAS/WHO ICF Core Sets for ankylosing spondylitis (AS): how to classify the impact of AS on functioning and health. Ann Rheum Dis. 2010;102–7.
19.
Van Der Heijde D, Landewé R, Baraliakos R, Van Den Bosch X, Sepriano F, Regel A, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017;978–91.
20.
Gossec L, Smolen J, Ramiro S, De Wit M, Cutolo M, Dougados M, et al. European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update. Ann Rheum Dis. 2016;499–510.
21.
Coates L, Kavanaugh A, Mease P, Soriano E, Acosta-Felquer L, Armstrong M, et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis 2015 Treatment recommendations for psoriatic arthritis. Arthritis Rheumatol. 2016;1060–71.
22.
Vlieland T, Van Den Ende C, Pinheiro J. EULAR Compendium on Rheumatic Diseases. 2009;590–600.
23.
Ehlebracht-Konig I, Bonisch A. Patient education in the early treatment of ankylosing spondylitis and related forms of spondyloarthritis. Wien Med Wochenschr. 2008;213–7.
24.
Leung Y, Tam L, Lee K, Leung M, Kun E, Li E. Involvement, satisfaction and unmet health care needs in patients with psoriatic arthritis. Rheumatology (Oxford). 2009;53–6.
25.
Franović A. The long-term positive effects of educational-motivational care of patients with ankylosing spondylitis. Reumatizam. 1985;10–6.
26.
Grubišić F, Grazio S, Znika M. Sport and recreation activities as the form of functional treatment of patients with ankylosing spondylitis. Acta Med Croat. 2007;(Supl 1):57–61.
27.
Feldtkeller E, Hammel L, Brenneis C, Song I, Rudwaleit M. Advice for patients diagnosed with ankylosing spondylitis: results of a representative patient survey in Germany. Z Rheumatol. 2011;431–7.
28.
Poddubnyy D, Haibel H, Listing J, Märker-Hermann E, Zeidler H, Braun J, et al. Baseline radiographic damage, elevated acute-phase reactant levels, and cigarette smoking status predict spinal radiographic progression in early axial spondylarthritis. Arthritis Rheum. 2012;1388–98.
29.
Chung H, Machado P, Van Der Heijde D, Agostino D, Dougados M, M. Smokers in early axial spondyloarthritis have earlier disease onset, more disease activity, inflammation and damage, and poorer function and health-related quality of life: results from the DESIR cohort. Ann Rheum Dis. 2012;809–16.
30.
Warsi A, Wang P, Lavalley M, Avorn J. Solomon DH. Self-management education programs in chronic disease: a systematic review and methodological critique of the literature. Arch Intern Med. 2004;1641–9.
31.
Hammond A, Bryan J, Hardy A. Effects of a modular behavioural arthritis education programme: a pragmatic parallel-group randomized controlled trial. Rheumatology (Oxford). 2008;1712–8.
32.
Williams B, Pace A. Problem based learning in chronic disease management: a review of the research. Patient Educ Couns. 2009;14–9.
33.
Steultjens E, Dekker J, Bouter L, Van Schaardenburg D, Van Kuyk M, Van Den Ende C. Occupational therapy for rheumatoid arthritis: a systematic review. Arthritis Rheum. 2002;(6):672–85.
34.
Masiero S, Boniolo A, Wassermann L, Machiedo H, Volante D, Punzi L. Effects of an educational-behavioral joint protection program on people with moderate to severe rheumatoid arthritis: a randomized controlled trial. Clin Rheumatol. 2007;2043–50.
35.
Durmus B, Altay Z, Esoy Y, Baysal O, Dogan E. Postural stability in patients with ankylosing spondylitis. Disabil Rehabil. 2010;1156–62.
36.
Swann J. Ankylosing spondylitis: living with the condition. Br J Healthcare Assistants (BJHA). 2009;235–7.
37.
Grazio S, Znika M. A Guide to safe exercise for people with rheumatic diseases. 1st ed. Zagreb: Croatian League Against Rheumatism. 2004;1–112.
38.
Roberts C, Hevener A, Barnard R. Metabolic syndrome and insulin resistance: underlying causes and modification by exercise training. Compr Physiol. 2013;1–58.
39.
Stewart K, Bacher A, Turner K, Lim J, Hees P, Shapiro E, et al. Exercise and risk factors associated with metabolic syndrome in older adults. Am J Prev Med. 2005;9–18.
40.
Lautenschlager N, Cox K, Flicker L, Foster J, Van Bockxmeer F, Greenop X, et al. Effect of physical activity on cognitive function in older adults at risk for Alzheimer disease: a randomized trial. J Am Med Assoc. 2008;1027–37.
41.
Rubenstein L, Josephson K, Trueblood P, Loy S, Harker J, Pietruszka F, et al. Effects of a group exercise program on strength, mobility, and falls among fall-prone elderly men. J Gerontol A Biol Sci Med Sci. 2000;317–21.
42.
Franco M, Pereira L, Ferreira P. Exercise interventions for preventing falls in older people living in the community. Br J Sports Med. 2014;867–8.
43.
Harding A, Beck B. Exercise, Osteoporosis, and Bone Geometry. Sports (Basel). 2017;
44.
Mikkelsen K, Stojanovska L, Polenakovic M, Bosevski M, Apostolopoulos V. Exercise and mental health. Maturitas. 2017;48–56.
45.
Pedersen B. Muscle as a secretory organ. Compr Physiol. 2013;1337–62.
46.
Pedersen B. Muscles and their myokines. J Exp Biol. 2011;337–46.
47.
Pedersen B, Febbraio M. Muscle as an endocrine organ: focus on muscle-derived interleukin-6. Physiol Rev. 2008;1379–406.
48.
Pedersen B, Saltin B. Exercise as medicine -evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports. 2015;(Suppl 3):1–72.
49.
Osthoff R, Niedermann A, Braun K, Adams J, Brodin J, Dagfinrud N, et al. EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Ann Rheum Dis. 2018;1251–60.
50.
O’hea J, Barlow J. Physiotherapy management of ankylosing spondylitis. 2008;519–39.
51.
Vlieland V, Li T, L. Rehabilitation in rheumatoid arthritis and ankylosing spondylitis: difference and similarities. Clin Exp Rheumatol. 2009;171–8.
52.
Costa D, Dritsa D, Ring M, Fitzcharles A, M. Mental health status and leisure-time physical activity contribute to fatigue intensity in patients with spondyloarthropathy. Arthritis Rheum. 2004;1004–8.
53.
Pécourneau V, Degboé Y, Barnetche T, Cantagrel A, Constantin A, Ruyssen-Witrand A. Effectiveness of exercise programs in ankylosing spondylitis: a metaanalysis of randomized Controlled Trials. Arch Phys Med Rehabil. 2018;383–9.
54.
Aytekin E, Caglar N, Ozgonenel L, Tutun S, Demiryontar D, Demir S. Home-based exercise therapy in patients with ankylosing spondylitis: effects on pain, mobility, disease activity, quality of life, and respiratory functions. Clin Rheumatol. 2012;91–7.
55.
Liang H, Zhang H, Ji H, Wang C. Effects of homebased exercise intervention on health-related quality of life for patients with ankylosing spondylitis: a meta-analysis. Clin Rheumatol. 2015;1737–44.
56.
Braun J, Van Den Berg R, Baraliakos X, Boehm H, Vargas B, R.
57.
Collantes-Estevez E, Dagfinrud H, Dijkmans B, Dougados M, Emery P, Geher P, et al. 2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann Rheum Dis. 2011;896–904.
58.
Dagfinrud H, Kvien T, Hagen K. Physiotherapy interventions for ankylosing spondylitis. Cochrane Database Syst Rev. 2008;(1).
59.
Viitanen J, Lehtinen K, Suni J, Kautiainen H. Fifteen months’ follow-up of intensive inpatient physiotherapy and exercise in ankylosing spondylitis. Clin Rheumatol. 1995;413–9.
60.
Hidding A, Van Der Linden S, Witte D, L. Therapeutic effects on individual physical therapy in ankylosing spondylitis related to duration of disease. Clin Rheumatol. 1993;334–40.
61.
Levitova A, Hulejova H, Spiritovic M, Pavelka K, Senolt L, Husakova M. Clinical improvement and reduction in serum calprotectin levels after an intensive exercise programme for patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis. Arthritis Res Ther. 2016;275.
62.
Cameron M. Physical agents in rehabilitation: from research to practice. 2nd ed. 2003;261–306.
63.
Bulstrode S, Barefoot J, Harrison R, Clarcke A. The role of passive stretching in the treatment of ankylosing spondylitis. Br J Rheumatol. 1987;40–2.
64.
Ortancil O, Sarikaya S, Sapmaz P, Basaran A. Ozdolap S. The effect(s) of a six-week home-based exercise program on the respiratory muscle and functional status in ankylosing spondylitis. J Clin Rheumatol. 2009;68–70.
65.
Calik B, B, Kabul G, Taskın E, H, Atalay T, et al. The efficiency of inspiratory muscle training in patients with ankylosing spondylitis. Rheumatol Int. 2018;1713–20.
66.
Baker J, Feldt V, Mostoufi-Moab J, Noaiseh S, Taratuta G, Kim E, et al. Deficits in muscle mass, muscle density, and modified associations with fat in rheumatoid arthritis. Arthritis Care Res (Hoboken). 2014;1612–8.
67.
Ekdahl C, Broman G. Muscle strength, endurance, and aerobic capacity in rheumatoid arthritis: a comparative study with healthy subjects. Ann Rheum Dis. 1992;35–40.
68.
Hsieh L, Watson C, Mao H. Physical medicine and rehabilitation. 2015;665–84.
69.
Demontis A, Trainito S, Felice D, Masiero A, S. Favorable effect of rehabilitation on balance in ankylosing spondylitis: a quasi-randomized controlled clinical trial. Rheumatol Int. 2016;333–9.
70.
Gunay S, Keser I, Bicer Z. The effects of balance and postural stability exercises on spa based rehabilitation programme in patients with ankylosing spondylitis. J Back Musculoskelet Rehabil. 2018;337–46.
71.
Souchard P. Global posture reeducation method. 1998;
72.
Fernandez-De-Las-Penas C, Blanco A, Morales-Cabezas C, M, Page M, J. Two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2005;407–19.
73.
Fernández-De-Las-Peñas C, Blanco A, Alguacil-Diego C, I, Page M, J. One-year follow-up of two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2006;559–67.
74.
Durmuş D, Alayli G, Uzun O, Tander B, Cantürk F, Bek Y, et al. Effects of two exercise interventions on pulmonary functions in the patients with ankylosing spondylitis. Joint Bone Spine. 2009;150–5.
75.
Karapolat H, Eyigor S, Zoghi M, Akkoc Y, Kirazli Y, Keser G. Are swimming or aerobic exercise better than conventional exercise in ankylosing spondylitis patients? A randomized controlled study. Eur J Phys Rehabil Med. 2009;449–57.
76.
Jennings F, Oliveira H, De Souza M, Vda C, Natour G, J. Effects of Aerobic Training in Patients with Ankylosing Spondylitis. J Rheumatol. 2015;2347–53.
77.
Papagoras C, Voulgari P, Drosos A. Atherosclerosis and cardiovascular disease in the spondyloarthritides, particularly ankylosing spondylitis and psoriatic arthritis. Clin Exp Rheumatol. 2013;612–20.
78.
Altan L, Korkmaz N, Dizdar M, Yurtkuran M. Effect of Pilates training on people with ankylosing spondylitis. Rheumatol Int. 2012;2093–9.
79.
Roşu M, Ţopa I, Chirieac R, Ancuta C. Effects of Pilates, McKenzie and Heckscher training on disease activity, spinal motility and pulmonary function in patients with ankylosing spondylitis: a randomized controlled trial. Rheumatol Int. 2014;367–72.
80.
Lee E, Kim Y, Chung W, Lee M. Tai chi for disease activity and flexibility in patients with ankylosing spondylitis--a controlled clinical trial. Evid Based Complement Alternat Med. 2008;457–62.
81.
Akyuz G, Kenis-Coskun O. The efficacy of Tai Chi and Yoga in rheumatoid arthritis and spondyloarthropathies: a narrative biomedical review. Rheumatol Int. 2018;321–30.
82.
Danve A, Deodhar A. Complementary medicine for axial spondyloarthritis: is there any scientific evidence? Curr Opin Rheumatol. 2018;310–8.
83.
Liang H, Li W, Zhang H, Tian X, Wei W, Wang C. Concurrent intervention with exercises and stabilized tumor necrosis factor inhibitor therapy reduced the disease activity in patients with ankylosing spondylitis: a meta-analysis. Medicine (Baltimore). 2015;2254.
84.
Lubrano E, Spadaro A, Parsons W. Rehabilitation in psoriatic arthritis. J Rheumatol Suppl. 2009;81–2.
85.
Roger-Silva D, Natour J, Moreira E, Jennings F. A resistance exercise program improves functional capacity of patients with psoriatic arthritis: a randomized controlled trial. Clin Rheumatol. 2018;389–95.
86.
Medina-Mirapeix F, Escolar-Reina P, Gascon-Canovas J, Montilla-Herrador J, Collins S. Personal characteristics influencing patients’ adherence to home exercise during chronic pain: a qualitative study. J Rehabil Med. 2009;347–52.
87.
Iversen M, Ayers K, Palmsten A, Wang H, Daltroy L. Predictors of exercise behavior at six months in patients with rheumatoid arthritis. Phys Ther. 2004;706–16.
88.
Falkenbach A. Disability motivates patients with ankylosing spondylitis for more frequent physical exercise. Arch Phys Med Rehabil. 2003;382–3.
89.
Barlow J. Understanding exercise in the context of chronic disease: an exploratory investigation of selfefficacy. Percept Mot Skills. 1998;439–46.
90.
Swinnen T, Vlaeyen J, Dankaerts W, Westhovens R, De Vlam K. Activity Limitations in patients with axial spondyloarthritis: a role for fear of movement and (re)injury beliefs. J Rheumatol. 2018;357–66.
91.
Santos H, Brophy S, Calin A. Exercise in ankylosing spondylitis: How much is optimum? J Rheumatol. 1998;2156–60.
92.
Passalent L, Soever L, Shea O, Inman F, R. Exercise in ankylosing spondylitis: discrepancies between recommendations and reality. J Rheumatol. 2010;835–41.
93.
Roberts V, B. Ankylosing spondylitis: Pathology. 1998;181–6.
94.
Sukenik S, Abu-Shakra M, Flusser D. Balneotherapy in autoimmune disease. Isr J Med Sci. 1997;258–61.
95.
Altan L, Bingöl U, Aslan M, Yurtkuran M. The effect of balneotherapy on patients with ankylosing spondylitis. Scand J Rheumatol. 2006;283–9.
96.
Oláh M, Koncz A, Fehér J, Kálmánczhey J, Oláh C, Balogh S, et al. The effect of balneotherapy on C-reactive protein, serum cholesterol, triglyceride, total antioxidant status and HSP-60 levels. Int J Biometeorol. 2010;249–54.
97.
Françon A, Forestier R. Spa therapy in rheumatology. Indications based on the clinical guidelines of the French National Authority for health and the European League Against Rheumatism, and the results of 19 randomized clinical trials. Bull Acad Natl Med. 2009;1345–56.
98.
Ciprian L, Nigro L, Rizzo A, Gava M, Ramonda A, Punzi R, et al. The effects of combined spa therapy and rehabilitation on patients with ankylosing spondylitis being treated with TNF inhibitors. Rheumatol Int. 2013;241–5.
99.
Mustur D, Vujasinović-Stupar N, Ille T. Influence of physical treatment on disease activity and health status of patients with chronic arthritis. Srp Arh Celok Lek. 2008;104–9.
100.
Ozgocmen S, Akgul O, Altay Z, Altindag O, Baysal O, Calis M, et al. Anatolian Group for the Assessment in Rheumatic Diseases. Expert opinion and key recommendations for the physical therapy and rehabilitation of patients with ankylosing spondylitis. Int J Rheum Dis. 2012;229–38.
101.
Gemignani G, Olivieri I, Ruju G, Pasero G. Transcutaneous electrical nerve stimulation in ankylosing spondylitis: a double-blind study. Arthritis Rheum. 1991;788–9.
102.
Chen F, Jin Z, Wang D. A retrospective study of transcutaneous electrical nerve stimulation for chronic pain following ankylosing spondylitis. Medicine (Baltimore). 2018;11265.
103.
Turan Y, Bayraktar K, Kahvecioglu F, Tastaban E, Aydin E, Omurlu K, et al. Is magnetotherapy applied to bilateral hips effective in ankylosing spondylitis patients? A randomized, double-blind, controlled study. Rheumatol Int. 2014;357–65.
104.
Karamanlioglu D, Aktas I, Ozkan F, Kaysin M, Girgin N. Effectiveness of ultrasound treatment applied with exercise therapy on patients with ankylosing spondylitis: a double-blind, randomized, placebo-controlled trial. Rheumatol Int. 2016;653–61.
105.
Oosterveld F, Rasker J, Floors M, Landkroon R, Van Rennes B, Zwijnenberg J, et al. Infrared sauna in patients with rheumatoid arthritis and ankylosing spondylitis. A pilot study showing good tolerance, short-term improvement of pain and stiffness, and a trend towards long-term beneficial effects. Clin Rheumatol. 2009;29–34.
106.
Straburzyńska-Lupa A, Kasprzak M, Romanowski M, Kwaśniewska A, Romanowski W, Iskra M, et al. The effect of whole-body cryotherapy at different temperatures on proinflammatory cytokines, oxidative stress parameters, and disease activity in patients with ankylosing spondylitis. Oxid Med Cell Longev. 2018;2157496.
107.
Clark H, Rome K, Plant M, Hare O, Gray K, J. A critical review of foot orthoses in the rheumatoid arthritic foot. Rheumatology (Oxford). 2006;139–45.
108.
Farrow S, Kingsley G, Scott D. Interventions for foot disease in rheumatoid arthritis: a systematic review. Arthritis Rheum. 2005;593–602.
109.
Widberg K, Karimi H, Hafstrom I. Self-and manual mobilization improves spine mobility in men with ankylosing spondylitis: a randomized study. Clin Rehabil. 2009;599–601.
110.
Urruela A, Suarez-Almazor M, M. Acupuncture in the treatment of rheumatic diseases. Curr Rheumatol Rep. 2012;589–97.
111.
Lv Z, Zhou X, Chen A. Acupuncture therapy versus disease-modifying antirheumatic drugs for the treatment of ankylosing spondylitis-a meta-analysis. Forsch Komplementmed. 2015;395–402.
The statements, opinions and data contained in the journal are solely those of the individual authors and contributors and not of the publisher and the editor(s). We stay neutral with regard to jurisdictional claims in published maps and institutional affiliations.