# Exercise as it relates to Disease/Ankylosing Spondylitis and Exercise
## Ankylosing Spondylitis and Exercise
### Background

Ankylosing spondylitis (AS) is an chronic, rheumatic disease part of a group of diseases known as spondyloarthropathier (SpA). Ankylosing spondylitis is a result of inflammation in the spine affecting the synovial tissue, ligament insertions and invertebral discs affecting the spine as well as the hips, knees and shoulders. Inflammation of these areas causes trunk stiffness and pain. Additional calcification to these structures leads to mobility loss throughout the spine and over time can progress to spinal deformity and loss of flexibility.

### Symptoms/Diagnosis

Symptoms of ankylosing spondylitis can begin as early in the late teens, affecting males at a rate of 3:1 compared to females. Males tend to have the spine affected to greater severity, where females have greater peripheral involvement. AS is characterised by:
* Lower back or buttocks pain, radiating between sides
* Persistent symptoms for >3months
* Reduction of stiffness with exercises
* Stiffness in morning or with inactivity
Progression: As the inflammation continues new bone builds around the affected area causing increased fusing of the vertebrae
Diagnosis is regarded as having the above symptoms. Other diagnostic tools that can be used include:
* Radiology – to grade severity of AS
* Laboratory tests – it is thought that the HLA-B27 gene influences AS

### Treatment/Management

There is no cure for ankylosing spondylitis, however treatment is designed to:
* delay the progression of the disease
* relieve pain
* minimise inflammation
* maintain function
* improve quality of life
Methods of management of AS include:
* education and counselling
* physiotherapy and chiropractic - to correct deformity and minimise spinal joint restriction
* pharmaceutical - non-steroidal anti-inflammatory drugs (NSAIDs) or disease-modifying anti-rheumatoid drugs (DMARDs)
* exercise and stretching

#### Exercise and Stretching as management of ankylosing spondylitis

Exercise preserves mobility and prevents further deterioration in those with AS. Exercise programs should include a variety of the following types of exercises:
| Exercise Type | Frequency | Benefits | Examples |
| Breathing Exercises | as appropriate | improves mobility of joints between head and abdomen improved vital capacity | diaphragmatic, abdominal and segmental breathing techniques |
| Mobility Exercises | daily | relieves pain and stiffness improves mobility and function | exercises that use maximal ranges of motion. e.g. flexion, extension and rotation of the neck, spine and hips and free swinging of the major limbs |
| Flexibility Exercises | daily | relieves pain and stiffness and improves mobility and function passive stretches increase range of movement | Stretches of the neck, shoulders, hips, knees and ankles |
| Strength Training | 1-3 times/week | improves posture | back extensors, shoulder retractors, hip extensors exercises performed on a gym ball |
| Cardiovascular Exercises (includes sport activities) | minimum 200min/week | improves cardiovascular fitness decreases pain and stiffness improved mobility and strength recreational and social benefits | sports encouraging trunk rotation and extension while avoiding contact sports |
| Hydrotherapy | as directed by a professional | decrease pain intensity mobilize and strengthens joints | breaststroke strokes aid in posture and breathing due to stoke motion opening up chest |
Home exercise programs should be designed to fit into daily routines and not all exercises need to be completed in one session. It is recommended that you complete exercise when feels appropriate, e.g. if morning stiffness of hips occurs, stretch hips in the morning.

### Recommendation

* Those with severe AS complications should have an exercise tolerance test conducted before starting a fitness program
* Exercise at least 30 minutes per day
* Complete back extension exercises minimum 5 days per week
* Exercising in the water decreases the load on the body, so AS patients can exercise longer and more vigorously

### Recommended Readings

Exercises - world arthritis day
Exercises - Arthritis Research UK
Fact sheet - Arthritis Australia

### Reference List

* 1 2 3 4 5 6 Keat A. Ankylosing Spondylitis. Spondyloarthropathies. 2010;38(4):185-189
* 1 2 3 Ince G, Sarpel T, Durgun B, Erdogan S. Effects of a multimodal exercise program for people with ankylosing spondylitis. Phys Ther. 2006; 86:924-935.
* ↑ Viitanen J, Suni J. Management principles of physiotherapy in ankylosing spondylitis - which treatments are effective? Physiotherapy. 1995; 81(6):322-329
* 1 2 3 4 5 Calin A. Ankylosing spondylitis. Spondyloarthropathies. 2006; 34(10): 396-400
* ↑ Spondylitis Association of America (US). Ankylosing Spondylitis[Internet]. Sherman Oaks (CA): Spondylitis Association of America; 2013 [cited 2013 Oct 12]. Available from:http://www.spondylitis.org/about/as.aspx
* ↑ Rutherford SM, Nicolson CF, Crowther ER. Symptomatic improvement in function and disease activity in patient with ankylosing spondylitis utilizing a course of chiropractic therapy: a prospective case study.J Can Chiropr Assoc. 2005; 49(2):81-91
* 1 2 3 4 5 Nolte K, van Rensburg CJ. The role of exercise in the rehabilitation of ankylosing spondylitis. Int SportMed J. 2001;2(4):1-12
* 1 2 Falkenbach A. Disability motivates patients with ankylosing spondylitis for more frequent physical exercise. Arch Phys Med Rehabil. 2003; 84:382-383