Patients with ankylosing spondylitis face substantially elevated risks of vertebral, hip, and other fractures as progressive spinal rigidity and kyphosis limit mobility and increase skeletal fragility. A new review suggested that multimodal rehabilitation may help preserve function, improve bone health, and potentially reduce progression to major orthopedic complications.
Published in the Journal of Orthopaedics, the review synthesized evidence from randomized controlled trials, meta-analyses, systematic reviews, network meta-analyses, and observational studies evaluating rehabilitation strategies in patients with ankylosing spondylitis (AS). Outcomes included disease activity, physical function, spinal mobility, pain, bone mineral density (BMD), adherence, and perioperative recovery.
The researchers cited prior studies reporting a 3.3-fold increase in vertebral fracture odds, a 4-fold increase in overall fracture odds, and a 2.5-fold increase in hip fracture odds among patients with AS compared with controls.
The review emphasized that rehabilitation in AS extends beyond symptom control because relying solely on pharmacologic pain reduction without preserving objective spinal mobility may mask ongoing structural progression and ankylosis. The researchers highlighted the Bath Ankylosing Spondylitis Metrology Index as an important measure of irreversible mobility loss and structural fusion.
Exercise programs were generally associated with moderate improvements in disease activity, physical function, and spinal mobility. Combined flexibility and strengthening programs appeared to produce the largest mobility gains, although the review noted that improvements in objective spinal mobility were often modest, and evidence quality varied across studies.
However, the review also cited Cochrane evidence suggesting that exercise programs may have little or no clinically meaningful effect on function or pain compared with usual care, underscoring variability in study quality and treatment protocols.
The researchers also highlighted evidence suggesting supervised rehabilitation may provide greater benefit than unsupervised home exercise. Supervised physical therapy and neuromuscular training were associated with greater improvements in disease activity, function, and spinal flexibility compared with standard care or home-based programs. In supervised settings, patients completed approximately 75% of prescribed sessions over 12 weeks and spent more time performing home exercise programs compared with patients without supervision, averaging 1.9 vs 1.2 hours weekly.
The review also discussed cost-effectiveness data supporting supervised therapy. One analysis found that supervised group physical therapy incurred approximately $531 in additional annual costs per patient compared with home exercise but reduced direct medical costs by approximately $122 annually, resulting in a net additional cost of about $409 per patient each year.
Aquatic therapy appeared particularly useful for patients whose pain limited participation in land-based exercise. In one randomized trial involving 69 patients, a 4-week aquatic exercise program performed 5 times weekly in 32°C to 33°C water produced greater improvements in bodily pain, general health, vitality, social functioning, emotional role limitations, and mental health compared with a home-based land exercise program. Benefits persisted at 4- and 12-week follow-up assessments.
The researchers also reviewed balneotherapy as a distinct rehabilitation modality. In addition to improvements in disease activity and function, balneotherapy may exert anti-inflammatory effects through reductions in prostaglandin E2, leukotriene B4, interleukin-1 beta, and tumor necrosis factor-alpha levels.
Bone health emerged as a major focus of the review because osteoporosis and fracture risk remain common in AS. The researchers noted that lumbar spine dual-energy x-ray absorptiometry measurements may be unreliable in AS because syndesmophytes and vertebral sclerosis can artifactually elevate lumbar spine BMD readings, potentially masking osteoporosis risk. Femoral neck measurements may therefore provide a more accurate assessment of skeletal fragility.
Exercise interventions appeared to improve BMD, particularly at the hip and femoral neck. Progressive resistance exercise programs were associated with standardized mean differences of 1.54 for femoral neck BMD and 1.34 for total hip BMD. Network meta-analysis findings suggested that mind-body exercise ranked highest for improving femoral neck BMD, whereas resistance training ranked highest for total hip BMD.
Despite these functional and skeletal benefits, the review found limited evidence that rehabilitation alters the biological pathways driving structural ankylosis. The researchers discussed the Wnt-beta-catenin signaling pathway, which contributes to syndesmophyte formation in AS. Sclerostin normally inhibits this pathway, and low serum sclerostin levels have been associated with radiographic progression and new bone formation.
However, studies evaluating exercise interventions did not demonstrate statistically significant changes in serum sclerostin levels, suggesting that current rehabilitation protocols may improve symptoms and function without substantially modifying the underlying mechanisms of spinal fusion.
The review also examined telerehabilitation strategies. Remote rehabilitation programs improved disease activity, mobility, and physical function compared with baseline measures, but in-person supervision generally produced stronger outcomes. In one randomized trial comparing face-to-face clinical Pilates with synchronous video-based rehabilitation, several functional and psychological outcomes—including the Ankylosing Spondylitis Performance Index sock test, Hospital Anxiety and Depression Scale scores, and Assessment of SpondyloArthritis International Society Health Index scores—did not improve significantly in the telerehabilitation group.
By contrast, a separate 12-week randomized trial found that online Baduanjin qigong improved spinal mobility, chest expansion, and fatigue, suggesting that lower-complexity mind-body modalities may translate more effectively to remote delivery than biomechanically intensive corrective exercise.
The researchers additionally emphasized the importance of perioperative rehabilitation in patients undergoing spinal osteotomy or total hip arthroplasty. The review cited National Inpatient Sample data showing postoperative complication rates approaching 41% among patients with AS and spinal fractures.
Prehabilitation recommendations included smoking cessation at least 1 month prior to surgery, vitamin D optimization to levels above 30 ng/mL, hemoglobin targets above 12 g/dL in women and 13 g/dL in men, opioid cessation ideally 6 to 8 weeks preoperatively, and maintenance of physical conditioning until several days prior to surgery.
Postoperative rehabilitation focused on staged mobilization, core strengthening, and strict hip precautions following arthroplasty because spinal rigidity may transfer greater rotational stress to the hip joint capsule. The review also emphasized that heterotopic ossification prophylaxis following total hip arthroplasty is considered mandatory in patients with AS. Recommended strategies included low-dose radiotherapy with 7 to 8 Gy administered either less than 4 hours preoperatively or within 72 hours postoperatively, or nonsteroidal anti-inflammatory drugs, particularly cyclooxygenase-2 inhibitors such as etoricoxib 60 mg daily for 2 weeks. Long-term monitoring using the Brooker classification system was also recommended because heterotopic ossification may progress years following surgery.
“Physical rehabilitation in Ankylosing Spondylitis is a cornerstone of orthopaedic management,” wrote lead study author Naveen Jeyaraman, of Agathisha Institute of Stem Cell and Regenerative Medicine and ACS Medical College and Hospital in Chennai, India, and colleagues. The researchers added that future studies should identify mechanical loading strategies capable of influencing structural disease progression without exacerbating inflammation.
Disclosures: The researchers reported no competing interests and no external funding.
Source: Journal of Orthopaedics
