# Exercise as it relates to Disease/Exercise on Ankylosing spondylitis
## Background to Ankylosing Spondylitis

Ankylosing Spondylitis (AS) is an inflammatory disease primarily affecting the axial skeleton and sacroiliac joints. Ankylosing Spondylitis is a rheumatic disease with no known cause but is genetically linked to the HLA-B27 gene. AS affects men more than women (2:1) and commonly presents in patients aged 20 to 30 years old. Ankylosing Spondylitis is typically characterised by back pain and reduced spinal mobility.
The back pain originates from the inflammation of and potential fusing of the joints. In an attempt to heal, the body forms new bone on the sites of inflammation, fusing sections of the spine.

## Management of Ankylosing Spondylitis

Management of AS is aimed at controlling disease activity (flare-ups) as there is no known cure for the condition. Physical therapy is highly recommended along with medication for the treatment of Ankylosing Spondylitis. Exercise for the treatment of Ankylosing Spondylitis largely focuses around controlling disease activity and improvement and maintenance of mobility. There is also focus on strengthening postural and breathing muscles, especially back, hip neck and shoulder extensors. The vertebral fusion and subsequent loss of lumbar spinal curve causes a spinal kyphosis and additionally there is a growing body of evidence that that patients with inflammatory rheumatic diseases are at increased risk of cardiovascular disease and Metabolic Syndrome (MetS). Exercise has been strongly linked to the reduction in inflammation markers (including IL-6 and C-reactive protein), therefore aerobic exercise in the disease management of patients with AS should be included.

# Exercise Management of Ankylosing Spondylitis=

As with any exercise prescription, the two main considerations are adherence and maximising benefits. For patients with AS this should also result in maintained function and quality of life. A Cochrane review suggested that much better spinal mobility, pain reduction, and fatigue is achieved with supervised sessions. Group physical therapy such as Pilates, Yoga and Physiocise twice a week for up to 60 minute duration, displayed a significant improvement in long term outcomes when compared to home-based programs. Conversely, with aerobic exercise for patients with Ankylosing Spondylitis, the type of exercise appears not to matter. Regular aerobic exercise is recommended for lowering the risk of CVD and most likely to succeed for AS patients is therefore choosing something they can fit into their daily lives. Daily aerobic exercise of 30 minute duration is recommended to reduce the risk of both CVD and MetS and daily exercise yields the greatest disease management for AS patients.

## Exercise Program Summary
### Twice weekly participation in supervised exercise program with specific exercises for AS

* strengthening postural and breathing muscles
* strengthening back and hip extensors
* strengthening neck and shoulder extensors

### 30 minutes minimum daily cardiorespiratory fitness training

* Any activity that is aerobic in nature, walking, cycling, running, swimming, team sports.
Adherence to exercise programs will result in reducing flare ups which will result in reduced pain and inflammation and an improvement in function and quality of life.
Management of weight and cardiorespiratory fitness will assist patients with AS in reducing their risks of CVD and MetS.

## Resources

http://www.nass.co.uk/exercise/
http://www.arthritisaustralia.com.au/images/stories/documents/info_sheets/2014/AnkylosingSpondylitis.dpf
http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-phys-act-guidelines#apaadult
http://www.health.gov/paguidelines/guidelines/#pag

## References

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* 1 2 Calin A. Ankylosing Spondylitis. Spondyloarthropathies. 2006; 34(10): 396-400
* 1 2 3 4 5 6 7 Halvorsen S, Vollestad NK, Fongen C, et al. Physical Fitness in Patients with Ankylosing: Comparison with population controls. Physical Therapy. 2012; 92:298-309
* ↑ Spondylitis Association of America (US). Ankylosing Spondylitis[internet]. Sherman Oakes (CA): Spondylities Association of America; 2014 [cited 2014 Sept 20].
* 1 2 Braun J, van den Berg R, Baraliakos X, et al. 2010 update of the ASAS/EULAR recommendations for the management of Ankylosing Sponylitis. Ann Rhuem Dis. 2011; 70:896-904
* 1 2 3 4 Dagfinrud H, Halvorsen S, Vollestad NK, et al. Exercise programs in trials for patients with Ankylosing Sponylitis: do they really have the potential for effectiveness? Arthritis Care Res (Hoboken). 2011; 63:597-603.
* 1 2 3 4 5 Ince G, Sarpel, T, Durgun B, et al. Effects of a Multimodal Exercise Program for People with Ankylosing Spondylitis. Physical Therapy.2006;86: 924-935
* 1 2 3 4 5 6 Dagfinrud H, Kvien TK and Hagen KB. Physiotherapy interventions for ankylosing spondylitis. Cochrane Database Syst Rev. 2008; 1:CD002822.
* 1 2 http://www.mayoclinic.org/diseases-conditions/ankylosing-spondylitis/basics/definition/con-20019766 [cited 2014 Sept 20]
* 1 2 Malesci D, Niglio A, Mennillo GA, et al. High Prevalence of metabolic syndrome in patients with ankylosing spondylitis. Clin Rheumatol. 2007;26:710-714
* 1 2 Ford ES. Does exercise reduce inflammation: physical activity and C-reactive protein among US adults. Epidemiology. 2002; 13:561-568
* 1 2 Troseid M, Lappegard KT, Claudi T, et al. Exercise reduces plasma levels of the chemokines MCP-1 and IL-8 in subjects with metabolic syndrome. Eur Heart J. 2004; 25:349-355
* 1 2 Fischer CP, Berntsen A, Perstrup LB, et al. Plasma levels of interleukin-6 and C-reactive protein are associated with physical activity independent of obesity. Scan J Med Sci Sports. 2007; 17:580-587.
* 1 2 Masiero S, Poli P, Bonaldo L, et al. Supervised training and home-based rehabilitation in patients with stabilized ankylosing spondylitis on TNF inhibitor treatment: a controlled clinical trial with a 12-month follow-up. Clinical Rehabilitation. 2014;28: 562-572
* 1 2 Falkenback A, Neger J, Tripathi R, et al. Recreational exercises and mobility in young patients with ankylosing spondylitis (AS). Sports Medicine, Training and Rehabilitation. 1999;9: 101-106.
* 1 2 Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39: 1423-1434
* 1 2 http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-phys-act-guidelines#apaadult (viewed September 2014)