Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2008 Jan 23;2008(1):CD002822.
doi: 10.1002/14651858.CD002822.pub3.

Physiotherapy interventions for ankylosing spondylitis

H Dagfinrud  1 , T K Kvien, K B Hagen
Affiliations
Meta-Analysis

Physiotherapy interventions for ankylosing spondylitis

H Dagfinrud et al. Cochrane Database Syst Rev. .

Abstract

Background: Ankylosing spondylitis (AS) is a chronic, inflammatory rheumatic disease. Physiotherapy is considered an important part of the overall management of AS.

Objectives: To summarise the available scientific evidence on the effectiveness of physiotherapy interventions in the management of AS.

Search strategy: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, CINAHL and PEDro up to January 2007 for all relevant publications, without any language restrictions. We checked the reference lists of relevant articles and contacted the authors of included articles.

Selection criteria: We included randomised and quasi-randomised studies with AS patients and where at least one of the comparison groups received physiotherapy. The main outcomes of interest were pain, stiffness, spinal mobility, physical function and patient global assessment.

Data collection and analysis: Two reviewers independently selected trials for inclusion, extracted data and assessed trial quality. Investigators were contacted to obtain missing information.

Main results: Eleven trials with a total of 763 participants were included in this updated review. Four trials compared individualised home exercise programs or a supervised exercise program with no intervention and reported low quality evidence for effects in spinal mobility (Relative percentage differences (RPDs) from 5-50%) and physical function (four points on a 33-point scale). Three trials compared supervised group physiotherapy with an individualised home-exercise program and reported moderate quality evidence for small differences in spinal mobility (RPDs 7.5-18%) and patient global assessment (1.46 cm) in favour of supervised group exercises. In one study, a three-week inpatient spa-exercise therapy followed by 37 weeks of weekly outpatient group physiotherapy (without spa) was compared with weekly outpatient group physiotherapy alone; there was moderate quality evidence for effects in pain (18%), physical function (24%) and patient global assessment (27%) in favour of the combined spa-exercise therapy. One study compared daily outpatient balneotherapy and an exercise program with only exercise program, and another study compared balneotherapy with fresh water therapy. None of these studies showed significant between-group differences. One study compared an experimental exercise program with a conventional program; statistically significant change scores were reported on nearly all spinal mobility measures and physical function in favour of the experimental program.

Authors' conclusions: The results of this review suggest that an individual home-based or supervised exercise program is better than no intervention; that supervised group physiotherapy is better than home exercises; and that combined inpatient spa-exercise therapy followed by group physiotherapy is better than group physiotherapy alone.

PubMed Disclaimer

Conflict of interest statement

None known.

Figures

1.1
1.1. Analysis
Comparison 1 Individualised home exercise program versus no intervention, Outcome 1 SES pain (scale not reported) 6 months.
1.2
1.2. Analysis
Comparison 1 Individualised home exercise program versus no intervention, Outcome 2 Physical function (BASFI), VAS (cm), 6 months.
1.3
1.3. Analysis
Comparison 1 Individualised home exercise program versus no intervention, Outcome 3 Patient global (BAS‐G), VAS (cm).
1.4
1.4. Analysis
Comparison 1 Individualised home exercise program versus no intervention, Outcome 4 Self‐reported disease activity (BASDAI ), VAS (cm), 6 months.
2.1
2.1. Analysis
Comparison 2 Supervised exercises versus no intervention, Outcome 1 Chest expansion.
2.2
2.2. Analysis
Comparison 2 Supervised exercises versus no intervention, Outcome 2 Finger‐tip‐to‐floor distance.
2.3
2.3. Analysis
Comparison 2 Supervised exercises versus no intervention, Outcome 3 Occiput to wall distance.
2.4
2.4. Analysis
Comparison 2 Supervised exercises versus no intervention, Outcome 4 Modified Schober test.
2.5
2.5. Analysis
Comparison 2 Supervised exercises versus no intervention, Outcome 5 Chin to chest distance.
3.1
3.1. Analysis
Comparison 3 Group physiotherapy (inpatient) versus individualised home exercises, Outcome 1 Pain/stiffness, VAS (cm).
3.2
3.2. Analysis
Comparison 3 Group physiotherapy (inpatient) versus individualised home exercises, Outcome 2 Pain at rest, VAS (cm).
3.3
3.3. Analysis
Comparison 3 Group physiotherapy (inpatient) versus individualised home exercises, Outcome 3 Pain activity, VAS (cm).
3.4
3.4. Analysis
Comparison 3 Group physiotherapy (inpatient) versus individualised home exercises, Outcome 4 Morning stiffness (minutes).
3.5
3.5. Analysis
Comparison 3 Group physiotherapy (inpatient) versus individualised home exercises, Outcome 5 Cervical rotation (degrees).
3.6
3.6. Analysis
Comparison 3 Group physiotherapy (inpatient) versus individualised home exercises, Outcome 6 Chest expansion (cm).
3.7
3.7. Analysis
Comparison 3 Group physiotherapy (inpatient) versus individualised home exercises, Outcome 7 Schober test (cm).
3.8
3.8. Analysis
Comparison 3 Group physiotherapy (inpatient) versus individualised home exercises, Outcome 8 Finger tip to floor distance (cm).
3.9
3.9. Analysis
Comparison 3 Group physiotherapy (inpatient) versus individualised home exercises, Outcome 9 Tragus to wall distance (cm).
3.10
3.10. Analysis
Comparison 3 Group physiotherapy (inpatient) versus individualised home exercises, Outcome 10 BASFI.
4.1
4.1. Analysis
Comparison 4 Spa therapy in addition versus weekly group PT alone, Outcome 1 Pain, VAS (cm).
4.2
4.2. Analysis
Comparison 4 Spa therapy in addition versus weekly group PT alone, Outcome 2 BASFI.
4.3
4.3. Analysis
Comparison 4 Spa therapy in addition versus weekly group PT alone, Outcome 3 Patient global.
4.4
4.4. Analysis
Comparison 4 Spa therapy in addition versus weekly group PT alone, Outcome 4 BASDAI.
5.1
5.1. Analysis
Comparison 5 Two different exercise programs, Outcome 1 Tragus to wall.
5.2
5.2. Analysis
Comparison 5 Two different exercise programs, Outcome 2 Modified Schober.
5.3
5.3. Analysis
Comparison 5 Two different exercise programs, Outcome 3 Cervical rotation (degrees).
5.4
5.4. Analysis
Comparison 5 Two different exercise programs, Outcome 4 Lumbar side flexion.
5.5
5.5. Analysis
Comparison 5 Two different exercise programs, Outcome 5 Intermalleolar distance.
5.6
5.6. Analysis
Comparison 5 Two different exercise programs, Outcome 6 BASFI.
5.7
5.7. Analysis
Comparison 5 Two different exercise programs, Outcome 7 BASDAI.
6.1
6.1. Analysis
Comparison 6 Balneotherapy and exercises versus exercises alone, Outcome 1 Pain day.
6.2
6.2. Analysis
Comparison 6 Balneotherapy and exercises versus exercises alone, Outcome 2 Pain night.
6.3
6.3. Analysis
Comparison 6 Balneotherapy and exercises versus exercises alone, Outcome 3 Morning stiffness (0‐3).
6.4
6.4. Analysis
Comparison 6 Balneotherapy and exercises versus exercises alone, Outcome 4 Patient global evaluation of disease activity (1‐5).
6.5
6.5. Analysis
Comparison 6 Balneotherapy and exercises versus exercises alone, Outcome 5 Schober test (cm).
6.6
6.6. Analysis
Comparison 6 Balneotherapy and exercises versus exercises alone, Outcome 6 Fingertip‐to‐floor.
6.7
6.7. Analysis
Comparison 6 Balneotherapy and exercises versus exercises alone, Outcome 7 Chest expansion.
6.8
6.8. Analysis
Comparison 6 Balneotherapy and exercises versus exercises alone, Outcome 8 Occiput Wall distance.
6.9
6.9. Analysis
Comparison 6 Balneotherapy and exercises versus exercises alone, Outcome 9 BASFI.
6.10
6.10. Analysis
Comparison 6 Balneotherapy and exercises versus exercises alone, Outcome 10 BASDAI.
7.1
7.1. Analysis
Comparison 7 Balneotherapy therapy versus fresh water pool, Outcome 1 Pain.
7.2
7.2. Analysis
Comparison 7 Balneotherapy therapy versus fresh water pool, Outcome 2 Movement.
See this image and copyright information in PMC

Update of

Similar articles

See all similar articles

Cited by

See all "Cited by" articles

References

References to studies included in this review

Altan 2006 {published and unpublished data}
    1. Altan L, Bingol U, Aslan M, Yurtkuran M. The effect of balneotherapy on patients with ankylosing spondylitis. Scandinavian Journal of Rheumatology 2006;35:283‐9. - PubMed
Analay 2003 {published data only}
    1. Analay Y, Ozcan E, Karan A, Diracoglu D, Aydin R. The effectiveness of intensive group exercise on patients with ankylosing spondylitis. Clinical Rehabilitation 2003;17(6):631‐6. - PubMed
Codish 2005 {published data only}
    1. Codish S, Dobrovinsky S, Abu SM, Flusser D, Sukenik S. Spa therapy for ankylosing spondylltis at the Dead Sea. The Israel Medical Association Journal 2005;7:443‐6. - PubMed
D'Las Peñas 2005 {published and unpublished data}
    1. Fernandez‐de‐Las‐Penas C, Alonso‐Blanco C, et al. Middle term follow‐up physical function improvement after rehabilitation treatment by working the muscle chain in ankylosing spondylitis [Seguimiento a medio plazo de la mejora fifica y funcional tras tratamiento rehabilitador mediante el trabajo de cadenas musculares en la espondilitis anquilosante]. Rehabilitacion 2005;39(5):222‐8.
    1. Fernandez‐de‐Las‐Penas C, Alonso‐Blanco C, Alquacil‐Diego IM, Miangolorra‐Page JC. One‐year follow‐up of two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. American Journal of Physical Medicine and Rehabilitation 2006;85(7):559‐67. - PubMed
    1. Fernandez‐de‐Las‐Penas C, Alonso‐Blanco C, Morales‐Cabezas M, Miangolorra‐Page JC. Two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. American Journal of Physical Medicine and Rehabilitation 2005;84:407‐19. - PubMed
Helliwell 1996 {published and unpublished data}
    1. Helliwell P, Abbott CA, Chamberlain MA. A randomised trial of three different physiotherapy regimes in ankylosing spondylitis. Physiotherapy 1996. 82 Vol. 82, issue 2:85‐90.
Hidding 1993 {published data only}
    1. Hidding A, Linden S, Boers M, Gielen X, Witte L, Kester A, et al. Is group physical therapy superior to individualized therapy in ankylosing spondylitis? A randomized controlled trial. Arthritis Care and Research 1993;6(3):117‐25. - PubMed
Ince 2006 {published and unpublished data}
    1. Ince G, Sarpel T, Durgun B, Erdogan S. Effects of a multimodal exercise program for people with ankylosing spondylitis. Physical Therapy 2006;86(7):924‐35. - PubMed
Kraag 1990 {published data only}
    1. Kraag G, Stokes B, Groh J, Helewa A, Goldsmith C. The effects of comprehensive home physiotherapy and supervision on patients with ankylosing spondylitis‐‐a randomized controlled trial. The Journal of Rheumatology 1990;17(2):228‐33. - PubMed
Lim 2005 {published data only}
    1. Lim H‐J, Moon Y‐I, Lee MS. Effects of home‐based daily exercise therapy on joint mobility, daily activity, pain, and depression in patients with ankylosing spondylitis. Rheumatol International 2005;25(3):225‐9. - PubMed
Sweeney 2002 {published data only}
    1. Sweeney S, Taylor G, Calin A. The effect of a home based exercise intervention package on outcome in ankylosing spondylitis: a randomized controlled trial. The Journal of Rheumatology 2002;29(4):763‐6. - PubMed
Van Tubergen 2001 {published and unpublished data}
    1. Tubergen A, Landewe R, HD, Hidding A, Wolter N, Asscher M, et al. Combined spa‐exercise therapy is effective in patients with ankylosing spondylitis: a randomized controlled trial. Arthritis and Rheumatism 2001;45(5):430‐8. - PubMed

References to studies excluded from this review

Ammer 1997 {published data only}
    1. Ammer K. Physiotherapy in seronegative spondylarthropathies. A systematic review. European Journal of Physical Rehabilitation 1997;4:114‐9.
Backlund, 1998 {published data only}
    1. Backlund M, Lundmark H, Niklasson K, Sundelin G. [Förändringar i ryggradens rörlighet hos patienter me Bechterews sjukdom‐en femårsuppföljning]. Nordisk Fysioterapi 1998. 2. Scandinavian University Press, Vol. 2:67‐72.
Bakker et al 1994 {published data only}
    1. Bakker C, Hidding A, Linden S, Doorslaer E. Cost effectiveness of group physical therapy compared to individualized therapy for ankylosing spondylitis. A randomized controlled trial. The Journal of Rheumatology 1994;21(2):264‐68. - PubMed
Band 1997 {published data only}
    1. Band DA, Jones SD, Kennedy LG, Garrett SL, Porter J, Gay L, et al. Which patients with ankylosing spondylitis derive most benefit from an inpatient management program?. The Journal of Rheumatology 1997;24(12):2381‐4. - PubMed
Bender 2005 {published data only}
    1. Bender T, Karagülle Z, Bálint G, Gutenbrunner C, Bálint PV, Sukenik S. Hydrotherapy, balneotherapy, and spa treatment in pain management. Rheumatol International 2005;25(3):220‐4. - PubMed
Bulstrode 1986 {published data only}
    1. Bulstrode SJ, Barefoot J, Harrison RA, Clarke AK. The role of passive stretching in the treatment of ankylosing spondylitis. British Journal of Rheumatology 1987;26(1):40‐2. - PubMed
D'Las Peñas c2005 {published data only}
    1. Fernandez‐de‐Las‐Penas C, Alonso‐Blanco C, et al. Middle term follow‐up physical function improvement after rehabilitation treatment by working the muscle chain in ankylosing spondylitis [Seguimiento a medio plazo de la mejora fifica y funcional tras tratamiento rehabilitador mediante el trabajo de cadenas musculares en la espondilitis anquilosante]. Rehabilitacion 2005;39(5):222‐8.
Falkenbach 2003 {published data only}
    1. Falkenbach A. Disability motivates patients with ankylosing spondylitis for more frequent physical exercise. Archives of Physical Medicine and Rehabilitation 2003;84(3):382‐3. - PubMed
Fisher 1990 {published data only}
    1. Fisher LR, Cawley MI, Holgate ST. Relation between chest expansion, pulmonary function, and exercise tolerance in patients with ankylosing spondylitis. Annals of the Rheumatic Diseases 1990;49(11):921‐5. - PMC - PubMed
Gall 1994 {published data only}
    1. Gall V. Exercise in the spondyloarthropathies. Arthritis Care and Research 1994;7(4):215‐20. - PubMed
Hafstrom 2003 {published data only}
    1. Hafstrom I, Hallengren M. Physiotherapy in subtropic climate improves functional capacity and health‐related quality of life in Swedish patients with rheumatoid arthritis and spondylarthropathies still after 6 months. Scandanavian Journal of Rheumatology 2003;32(2):108‐13. - PubMed
Heikkila 2000 {published data only}
    1. Heikkila S, Viitanen JV, Kautiainen H, Kauppi M. Sensitivity to change of mobility tests; effect of short term intensive physiotherapy and exercise on spinal, hip, and shoulder measurements in spondyloarthropathy. The Journal of Rheumatology 2000;27(5):1251‐6. - PubMed
Hidding 1994 {published data only}
    1. Hidding A, Linden S, Gielen X, Witte L, Dijkmans B, Moolenburgh D. Continuation of group physical therapy is necessary in ankylosing spondylitis: results of a randomized controlled trial. Arthritis Care and Research 1994;7(2):90‐6. - PubMed
Hidding 1995 {published data only}
    1. Hidding A, LS. Factors related to change in global health after group physical therapy in ankylosing spondylitis. Clinical Rheumatology 1995;14(3):347‐51. - PubMed
Hider 2002 {published data only}
    1. Hider S, Wong M, Ortiz M, Dulku A, Mulherin D. Does a regular exercise program for ankylosing spondylitis influence body image?. Scandanavian Journal of Rheumatology 2002;31(3):168‐71. - PubMed
Horslev‐Petersen1985 {published data only}
    1. Horslev‐Petersen K, Rasmussen JO, Helin P. [Continuing training of patients with advanced ankylosing spondylitis]. Ugeskr Laeger 7‐1‐1985;147(2):99‐101. - PubMed
Kraag 1994 {published data only}
    1. Kraag G, Stokes B, Groh J, Helewa A, Goldsmith CH. The effects of comprehensive home physiotherapy and supervision on patients with ankylosing spondylitis ‐ an 8‐month followup. The Journal of Rheumatology 1994;21(2):261‐3. - PubMed
O'Driscoll 1978 {published data only}
    1. O'Driscoll SL, Jayson MI, Baddeley H. Neck movements in ankylosing spondylitis and their responses to physiotherapy. Annals of the Rheumatic Diseases 1978. - PMC - PubMed
Rasmussen 1989 {published data only}
    1. Rasmussen JO, Hansen TM. Physical training for patients with ankylosing spondylitis. Arthritis Care and Research 1989;2(1):25‐7. - PubMed
Russell 1992 {published data only}
    1. Russell P, Unsworth A, Haslock I. The effect of exercise on ankylosing spondylitis‐‐a preliminary study. British Journal of Rheumatology 1993;32(6):498‐506. - PubMed
Santos 1998 {published data only}
    1. Santos H, Brophy S, Calin A. Exercise in ankylosing spondylitis: how much is optimum?. The Journal of Rheumatology 1998. - PubMed
Seckin 2000 {published data only}
    1. Seckin U, Bolukbasi N, Gursel G, Eroz S, Sepici V, Ekim N. Relationship between pulmonary function and exercise tolerance in patients with ankylosing spondylitis. Clinical and Experimental Rheumatology 2000;18(4):503‐6. - PubMed
Stenstrom 1997 {published data only}
    1. Stenstrom CH, Arge B, Sundbom A. Home exercise and compliance in inflammatory rheumatic diseases‐‐a prospective clinical trial. The Journal of Rheumatology 1997;24(3):470‐6. - PubMed
Sundstrom 2002 {published data only}
    1. Sundstrom B, Ekergard H, Sundelin G. Exercise habits among patients with ankylosing spondylitis. A questionnaire based survey in the County of Vasterbotten, Sweden.PG ‐. Scandanavian Journal of Rheumatology 2002;31(3). - PubMed
Tegelberg 1988 {published data only}
    1. Tegelberg A, Kopp S. Short‐term effect of physical training on temporomandibular joint disorder in individuals with rheumatoid arthritis and ankylosing spondylitis. Acta Odontologica Scandinavica 1988;46(1):49‐56. - PubMed
Tegelberg 1996 {published data only}
    1. Tegelberg A, Kopp S. A 3‐year follow‐up of temporomandibular disorders in rheumatoid arthritis and ankylosing spondylitis. Acta Odontologica Scandinavica 1996;54(1):14‐8. - PubMed
Tishler 1995 {published data only}
    1. Tishler M, Brostovski Y, Yaron M. Effect of spa therapy in Tiberias on patients with ankylosing spondylitis. Clinical Rheumatology 1995;14(1):21‐5. - PubMed
Tomlinson 1986 {published data only}
    1. Tomlinson M J, Barefoot J, Dixon A S. Intensive in‐patient physiotherapy courses improve movement and posture in ankylosing spondylitis. Physiotherapy 1986; Vol. 72, issue 5:238‐40.
Uhrin 2000 {published data only}
    1. Uhrin Z, Kuzis S, Ward MM. Exercise and changes in health status in patients with ankylosing spondylitis. Archives of Internal Medicine 2000;160(19):2969‐75. - PubMed
Van Tubergen 2002 {published data only}
    1. Tubergen A, Boonen A, Landewe R, Rutten‐van Molken M, HD, Hidding A, et al. Cost effectiveness of combined spa‐exercise therapy in ankylosing spondylitis: a randomized controlled trial. Arthritis and Rheumatism 2002;47(5):459‐67. - PubMed
Van Tubergen 2002 b {published data only}
    1. Tubergen A, Hidding A. Spa and exercise treatment in ankylosing spondylitis: fact or fancy?. Best Practice and Research Clinical Rheumatology 2002;16(4):653‐66. - PubMed
Viitanen 1992 {published data only}
    1. Viitanen JV, Suni J, Kautiainen H, Liimatainen M, Takala H. Effect of physiotherapy on spinal mobility in ankylosing spondylitis. Scandinavian Journal of Rheumatology 1992;21(1):38‐41. - PubMed
Viitanen 1995 {published data only}
    1. Viitanen JV, Lehtinen K, Suni J, Kautiainen H. Fifteen months' follow‐up of intensive inpatient physiotherapy and exercise in ankylosing spondylitis. Clinical Rheumatology 1995;14(4):413‐9. - PubMed
Viitanen 2001 {published data only}
    1. Viitanen JV, Heikkila S. Functional changes in patients with spondylarthropathy. A controlled trial of the effects of short‐term rehabilitation and 3‐year follow‐up. Rheumatology International 2001;20(5):211‐4. - PubMed
Wordsworth 1983 {published data only}
    1. Wordsworth BP, Pearcy MJ, Mowat AG. In‐patient regime for the treatment of ankylosing spondylitis: an appraisal of improvement in spinal mobility and the effects of corticotrophin. British Journal of Rheumatology 1984;23(1):39‐43. - PubMed
Yurtukan M {published data only}
    1. Yurtukan M, Ay A, Karakoc Y. Improvement of the clinical outcome in Ankylosing Spondylitis by balneotherapy. Joint Bone Spine 2005;72:303‐8. - PubMed

References to studies awaiting assessment

Ahmad 2000 {published data only}
    1. Ahmad N. A randomised comparison of intensive versus less intensive exercise for ankylosing spondylitis and the spondylarthropathies.. Australian and New Zealand Journal of Medicine 30(4):536.
Pickering 2000 {published data only}
    1. Pickering K. Two arm clinical trial evaluating exercise in ankylosing spondylitis with a metrology index as the primary outcome variable.. Australian and New Zealand Journal of Medicine 30(4):548.

Additional references

Alderson 2004
    1. Alderson P, Green S, Higgins JPT, editors. Cochrane Reviewers' Handbook 4.2.1 (updated December 2003). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd..
Amor 1991
    1. Amor B, Dougados M, Listrat V, Menkes CJ, Dubost JJ, Roux H, et al. [Evaluation of the Amor criteria for spondylarthropathies and European Spondylarthropathy Study Group (ESSG). A cross‐sectional analysis of 2,228 patients]. Annales de Medecine Interne (Paris) 1991;142(2):85‐9. - PubMed
D'Las Peñas b2005
    1. Fernandez‐de‐Las‐Penas C, Alonso‐Blanco C, Alguacil‐Diego IM, Miangolorra‐Page JC D. One‐year follow‐up of two exercise interventions for the management of patients with ankylosing spondylitis. American Journal of Physical Medicine and Rehabilitation 2006;85(7):559‐67. - PubMed
Dagfinrud 2005
    1. Dagfinrud H, Kjeken I, Mowinckel P, Hagen KB, Kvien TK. Impact of functional impairment in ankylosing spondylitis: impairment, activity limitation, and participation restrictions. The Journal of Rheumatology 2005;32(3):516‐23. - PubMed
Deeks J 2004
    1. Deeks J, Higgins J, Altman DG, editors. Analysing and presenting results. In: Alderson P, Green S, Higgins J, editors. The Cochrane Reviewers Handbook 4.2.1 (updated December 2003) Section 8. In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.
Dougados 1995
    1. Dougados M. Diagnostic features of ankylosing spondylitis. British Journal of Rheumatology 1995;34:301‐5. - PubMed
Grade Working Group
    1. Grade Working Group. Grading the quality of evidence and the strength of recommendations. BMJ 2004 In Press.
Gran 1993
    1. Gran JT, Husby G. The epidemiology of ankylosing spondylitis. Seminars in Arthritis and Rheumatism 1993;22(5):319‐34. - PubMed
Herbert 2005
    1. Herbert RD, Bo K. Analysis of quality of interventions in systematic reviews. BMJ 2005;331(7515):507‐9. - PMC - PubMed
Hidding A 1993
    1. Hidding A, LS, Witte L. Therapeutic effects of individual physical therapy in ankylosing spondylitis related to duration of disease. Clinical Rheumatology 1993;12(3):334‐40. - PubMed
Higgins 2006
    1. Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions 4.2.6 [updated September 2006].. The Cochrane Library, Issue 4, 2006. Chichester, UK: John Wiley & Sons, Ltd. 2006.
Khan 2002
    1. Khan MA. Update on spondyloarthropathies. Annals of Internal Medicine 2002;136(12):896‐907. - PubMed
Lee 2007
    1. Lee W, Reveille J, Davis JC Jr, Learch TJ, Ward MM, Weisman MH. Are there gender differences in severity of AS? Results from the PSOAS cohort. Annals of the Rheumatic Diseases 2007;66:633‐8. - PMC - PubMed
Mihai 2005
    1. Mihai B, Linden S, Bie R, Stucki G. Experts' beliefs on physiotherapy for patients with ankylosing spondylitis and assessment of their knowledge on published evidence in the field. Results of a questionnaire among international ASAS members. Europa Medicophysica 2005;41(2):149‐53. - PubMed
Philadelphia Panel
    1. Philadelphia Panel. Philadelphia Panel evidence‐based clinical practice guidelines on selected rehabilitation interventions for low‐back pain. Physical Therapies 2001;81(10):1641‐74. - PubMed
Robbins 2001
    1. Robbins L, Burckhardt CS, Hannan MT. Clinical Care. 2nd Edition. ACR, 2001.
Sieper 2002
    1. Sieper J, Braun J, Rudwaleit M, Boonen A, Zink A. Ankylosing spondylitis: an overview. Annals of the Rheumatic Diseases 2002;61, suppl 3:8‐18. - PMC - PubMed
Sieper 2006
    1. Sieper J, Rudwaleit M, Khan MA, Braun J. Concepts and epidemiology of spondyloarthritis. Best Practice & Research. Clinical Rheumatology 2006;20(3):401‐17. - PubMed
Tugwell 2004
    1. Tugwell P, Shea B, Boers M, Simons L, Strand V, et al. Evidence‐based Rheumatology. BMJ Books 2004.
Van der Heijde 1999
    1. Heijde D, Calin A, Dougados M, Khan MA, Linden S, Bellamy N. Selection of instruments in the core set for DC‐ART, SMARD, physical therapy, and clinical record keeping in ankylosing spondylitis. Progress report of the ASAS Working Group. Assessments in Ankylosing Spondylitis. The Journal of Rheumatology 1999;26(4):951‐4. - PubMed
Van der Linden 1984
    1. Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis and Rheumatism 1984;27(4):361‐8. - PubMed
Zochling 2006
    1. Zochling J, Heijde D, Burgos‐Vargas R, Collantes E, Davis JC Jr, Dijkmans B, et al. ASAS/EULAR recommendations for the management of ankylosing spondylitis. Annals of the Rheumatic Diseases 2006;65:442‐52. - PMC - PubMed