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Treatment of ankylosing spondylitis with biologics and targeted physical therapy

Positive effect on chest pain, diminished chest mobility, and respiratory function

Behandlung der ankylosierenden Spondylitis mit Biologika und gezielter Physiotherapie

Positive Wirkung auf Thoraxschmerz, verminderte Thoraxbeweglichkeit und Atemfunktion

Zeitschrift für Rheumatologie volume 72, pages 997–1004 (2013)Cite this article

Abstract

Objective

Biologics are highly effective in ankylosing spondylitis (AS). In this self-controlled study, we assessed the additive value of complex physiotherapy in decreasing chest pain and tenderness and improving respiratory function in AS patients treated with tumor necrosis factor α (TNF-α) inhibitors.

Patients and methods

The trial consisted of 2 parts. In study I, clinical data of AS patients with (n = 55) or without biological therapy (n = 20) were retrospectively analyzed and compared. Anthropometrical data, duration since diagnosis and patient assessment of disease activity, pain intensity, tender points, sacroiliac joint involvement determined by X-ray, functional condition, and physical activity level were recorded. Subjective, functional, and physical tests were performed. In study II, 10 voluntary patients (6 men and 4 women, age 52.4 ± 13.6 years) with definite AS and receiving anti-TNF therapy were recruited. It was a prospective, non-randomized physiotherapeutic trial. BASFI (Bath Ankylosing Spondylitis Functional Index), BASDAI (Bath Ankylosing Spondylitis Disease Activity Index), modified Schober Index, occiput-to-wall distance, and fingertip-to-floor distance were evaluated. Forced vital capacity, forced 1-s expiratory volume, peak expiratory flow, and maximum voluntary ventilation were recorded. Furthermore, typical tender points were recorded. A targeted physiotherapy program was conducted twice a week for 12 weeks and all above parameters were recorded at baseline and after 12 weeks.

Results

Differences in patient assessment of disease activity (p = 0.019) and pain intensity (p = 0.017) were found in study I. Pain and tenderness of the thoracic spine were observed in both groups. Back pain without biologic therapy was slightly higher than other group. In study II, we found that patient assessment of disease activity and pain intensity significantly improved after the physical therapy program (p = 0.002 and p < 0.001). BASFI and BASDAI increased after treatment (p = 0.004 and p < 0.001). The finger-to-floor distance, chest expansion, and modified Schober index increased (p = 0.008, p < 0.001, and p = 0.031, respectively). The respiratory functional parameters showed a tendency towards improvement.

Conclusion

AS patients already receiving biological therapy may benefit from additional targeted physiotherapy. Physical therapy may be of important additive value in AS patients being treated with biological. The exercise program presented here showed an improvement in functional parameters as well as spine and chest mobility, thereby enhancing the favorable effects of biological therapy.

Zusammenfassung

Ziel

Biologika sind hochwirksam bei ankylosierender Spondylitis (AS). In dieser eigenkontrollierten Studie wurde der Mehrwert einer komplexen Physiotherapie zur Linderung von Thoraxschmerzen und -empfindlichkeit sowie zur Verbesserung der Atemfunktion bei AS-Patienten untersucht, welche mit Tumornekrosefaktor-alpha(TNF-α)-Inhibitoren behandelt wurden.

Patienten und Methoden

Die Studie bestand aus 2 Teilen. In Studie I wurden die klinischen Daten von AS-Patienten mit (n = 55) oder ohne (n = 20) biologische Therapie retrospektiv ausgewertet und verglichen. Anthropometrische Daten, Zeit seit Diagnose und Patientenbeurteilung der Krankheitsaktivität, Schmerzintensität, Druckpunkte, Beteiligung des Sakroiliakalgelenks gemäß Röntgenbild, Funktionszustand und körperliches Aktivitätsniveau wurden dokumentiert. Es wurden subjektive, funktionelle und körperliche Tests durchgeführt. In Studie II wurden 10 freiwillig teilnehmende Patienten (6 Männer, 4 Frauen, Alter: 52,4 ± 13,6 Jahre) mit gesicherter AS und unter Anti-TNF-Therapie aufgenommen. Es handelte sich um eine prospektive nichtrandomisierte physiotherapeutische Studie. BASFI (Bath Ankylosing Spondylitis Functional Index), BASDAI (Bath Ankylosing Spondylitis Disease Activity Index), modifizierter Schober-Index, Hinterkopf-Wand-Abstand und Finger-Boden-Abstand wurden untersucht. Auch die forcierte Vitalkapazität, das forcierte expiratorische 1-s-Volumen, der expiratorische Spitzenfluss und die maximale willkürliche Ventilation wurden dokumentiert. Außerdem wurden typische Druckpunkte aufgezeichnet. Ein gezieltes Physiotherapieprogramm wurde 2-mal pro Woche durchgeführt und sämtliche genannten Parameter zu Beginn der Studie und nach 12 Wochen dokumentiert.

Results

In Studie I stellten sich Unterschiede bei der Patientenbeurteilung der Krankheitsaktivität (p = 0,019) und Schmerzintensität (p = 0,017) heraus. Schmerz und Empfindlichkeit der Brustwirbelsäule wurden in beiden Gruppen beobachtet. Rückenschmerzen ohne biologische Therapie waren etwas stärker als in der anderen Gruppe. In Studie II stellte sich heraus, dass die Patientenbeurteilung der Krankheitsaktivität und Schmerzintensität sich signifikant nach dem Physiotherapieprogramm besserte (p = 0,002 bzw. p < 0,001). BASFI und BASDAI stiegen nach Behandlung an (p = 0,004 bzw. p < 0,001). Der Finger-Boden-Abstand, die Thoraxausdehnung und der modifizierte Schober-Index nahmen zu (p = 0,008; p < 0,001 bzw. p = 0,031). Die funktionellen Atemparameter wiesen eine Tendenz in Richtung der Verbesserung auf.

Schlussfolgerung

AS-Patienten, die bereits eine biologische Therapie erhalten, ziehen möglicherweise einen Nutzen aus zusätzlicher gezielter Physiotherapie. Für AS-Patienten unter Biologikatherapie kann die Physiotherapie einen bedeutenden zusätzlichen Wert darstellen. Das hier vorgestellte Trainingsprogramm führte zu Besserung funktioneller Parameter sowie der Wirbelsäulen- und Thoraxbeweglichkeit, somit konnten die günstigen Wirkungen der biologischen Therapie verstärkt werden.

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Affiliations

  1. Department of Physiotherapy, University of Debrecen Medical and Health Sciences Center, Debrecen, Hungary

    Z. Gyurcsik

  2. Department of Rheumatology, Institute of Medicine, University of Debrecen Medical and Health Science Center, 98 Nagyerdei Str., 4012, Debrecen, Hungary

    N. Bodnár,  Z. Szekanecz M.D., Ph.D., D.Sc. & S. Szántó

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  1. Z. Gyurcsik
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  2. N. Bodnár
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  3. Z. Szekanecz M.D., Ph.D., D.Sc.
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  4. S. Szántó
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Correspondence to Z. Szekanecz M.D., Ph.D., D.Sc..

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Gyurcsik, Z., Bodnár, N., Szekanecz, Z. et al. Treatment of ankylosing spondylitis with biologics and targeted physical therapy. Z. Rheumatol. 72, 997–1004 (2013). https://doi.org/10.1007/s00393-013-1240-8

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Keywords

  • Breathing exercises
  • Physiotherapy
  • Biological therapy
  • Anti-TNF therapy
  • Respiration

Schlüsselwörter

  • Atemübungen
  • Physiotherapie
  • Biologische Therapie
  • Anti-TNF-Therapie
  • Atmung