1. Exercise in Ankylosing Spondylitis Prof. Pál Géher MD

3. Ankylosing Spondylitis Prevalence: 0.1% to 1.4%. Prevalence: 0.1% to 1.4%. Significant burden of disease, similar to RA. Significant burden of disease, similar to RA. HLA B27 association. HLA B27 association. Diagnosed late. Diagnosed late. Underdiagnosed. Underdiagnosed. Unsatisfactory treatment. Unsatisfactory treatment.

4. Milestones of AS therapy 1921. X-ray treatment. 1921. X-ray treatment. 1949. Phenylbutazon. 1949. Phenylbutazon. 1965. Indometacinum. 1965. Indometacinum. ? Exercise ? Exercise 2000. Biologics. 2000. Biologics.

5. Studies on exercise in AS 1. Individual – conducted- exercise. 2. Group - conducted – exercise. 3. Individual exercise. No accepted protocol! 4. Underwater exercise – no study available.

6. ASessment in Ankylosing Spondylitis 1995.

7. ASAS 50 % response criteria 1. Patient’s opinion 2. Pain 3. Function = BASFI 4. Inflammation = BASDAI 5.& 6.questions At least  50% or in absolute value  10 mm (VAS 0-100 mm) improvement  3 domains:

9. Outcomes in exercise in AS Function. Function. Pain. Pain. Spinal mobility. Spinal mobility. Stiffness. Stiffness. Patient’s opinion. Patient’s opinion.

10. Individual- conducted - exercise 4 months, randomized, one center. 4 months, randomized, one center. 26 treated, 27 controll. 26 treated, 27 controll. Function - 23 % improvement. Function - 23 % improvement. Pain ? Pain ? Spinal mobility - 42 % improvement (finger- floor distance). Spinal mobility - 42 % improvement (finger- floor distance). Stiffness ? Stiffness ? Patient’s opinion ? Patient’s opinion ? Kraag G et al: J Rheumatol 1994; 21: 261-3.

11. Group - conducted – exercise 9 months, randomized, one center. 9 months, randomized, one center. 6 weeks, individual-conducted- exercise, 68 patients individual exercise at home, once weekly group exercise,76 patients individual exercise at home. 6 weeks, individual-conducted- exercise, 68 patients individual exercise at home, once weekly group exercise,76 patients individual exercise at home. Function - 32 % difference (4% improvement). Function - 32 % difference (4% improvement). Pain ? Pain ? Spinal mobility - 7 % improvement (Schöber). Spinal mobility - 7 % improvement (Schöber). Stiffness ? Stiffness ? Patient’s opinion - 28 % improvement. Patient’s opinion - 28 % improvement. Hidding A et al: Arthritis Care Res 1994; 7:90-6.

12. Evidence based studies 3 trials, 241 patients. 3 trials, 241 patients. Supervised vs. Individualised= supervised 50 % better (pain, stiffness) Supervised vs. Individualised= supervised 50 % better (pain, stiffness) Individual vs. None individual better. Individual vs. None individual better. Dagfinrud H et al: The Cochrane Library, 2003.

13. ASAS/EULAR recommandations

14. 10 recommandations. 10 recommandations. 3 general. 3 general. 5 pharma-therapy. 5 pharma-therapy. 1 surgery. 1 surgery. 1 non- pharmacological. 1 non- pharmacological.

15. Non-pharmacological recommandation Should include education, regular exercise and individual and group physical therapy….(level C) Should include education, regular exercise and individual and group physical therapy….(level C) C= directly based on category III evidence or extrapolated recommendation from category I or II evidence.

16. Thank you for your attention.