Objective: To assess available management strategies in ankylosing spondylitis (AS) using a systematic approach, as a part of the development of evidence based recommendations for the management of AS. Methods: A systematic search of Medline, Embase, CINAHL, PEDro, and the Cochrane Library was performed to identify relevant interventions for the management of AS. Evidence for each intervention was categorised by study type, and outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. The effect size, rate ratio, number needed to treat, and incremental cost effectiveness ratio were calculated for each intervention where possible. Results from randomised controlled trials were pooled where appropriate. Results: Both pharmacological and non-pharmacological interventions considered to be of interest to clinicians involved in the management of AS were identified. Good evidence (level Ib) exists supporting the use of non-steroidal anti-inflammatory drugs (NSAIDs) and coxibs for symptomatic treatment. Non-pharmacological treatments are also supported for maintaining function in AS. The use of conventional antirheumatoid arthritis drugs is not well supported by high level research evidence. Tumour necrosis factor inhibitors (infliximab and etanercept) have level Ib evidence supporting large treatment effects for spinal pain and function in AS over at least 6 months. Level IV evidence supports surgical interventions in specific patients. Conclusion: This extensive literature review forms the evidence base considered in the development of the new ASAS/EULAR recommendations for the management of AS.

https://ard.bmj.com/content/annrheumdis/65/4/423.full.pdf

Current evidence for the management of ankylosing spondylitis: a systematic literature review for the ASAS/EULAR management recommendations in ankylosing spondylitis

Background
Contractures are a common complication of neurological and non-neurological conditions, and are characterised by a reduction in joint mobility. Stretch is widely used for the treatment and prevention of contractures. However, it is not clear whether stretch is effective. This review is an update of the original 2010 version of this review.

Objectives
The aim of this review was to determine the effects of stretch on contractures in people with, or at risk of developing, contractures.The outcomes of interest were joint mobility, quality of life, pain, activity limitations, participation restrictions, spasticity and adverse events.

Search methods
In November 2015 we searched CENTRAL, DARE, HTA; MEDLINE; Embase; CINAHL; SCI-EXPANDED; PEDro and trials registries.

Selection criteria
We included randomised controlled trials and controlled clinical trials of stretch applied for the purpose of treating or preventing contractures.

Data collection and analysis
Two review authors independently selected trials, extracted data, and assessed risk of bias. The outcomes of interest were joint mobility, quality of life, pain, activity limitations, participation restrictions and adverse events. We evaluated outcomes in the short term (up to one week after the last stretch) and in the long term (more than one week). We expressed effects as mean differences (MD) or standardised mean differences (SMD) with 95% confidence intervals (CI). We conducted meta-analyses with a random-effects model. We assessed the quality of the body of evidence for the main outcomes using GRADE.

Main results
Forty-nine studies with 2135 participants met the inclusion criteria. No study performed stretch for more than seven months. Just over half the studies (51%) were at low risk of selection bias; all studies were at risk of detection bias for self reported outcomes such as pain and at risk of performance bias due to difficulty of blinding the intervention. However, most studies were at low risk of detection bias for objective outcomes including range of motion, and the majority of studies were free from attrition and selective reporting biases. The effect of these biases were unlikely to be important, given that there was little benefit with treatment. There was high-quality evidence that stretch did not have clinically important short-term effects on joint mobility in people with neurological conditions (MD 2°; 95% CI 0° to 3°; 26 studies with 699 participants) or non-neurological conditions (SMD 0.2, 95% CI 0 to 0.3, 19 studies with 925 participants).

In people with neurological conditions, it was uncertain whether stretch had clinically important short-term effects on pain (SMD 0.2; 95% CI -0.1 to 0.5; 5 studies with 174 participants) or activity limitations (SMD 0.2; 95% CI -0.1 to 0.5; 8 studies with 247 participants). No trials examined the short-term effects of stretch on quality of life or participation restrictions in people with neurological conditions. Five studies involving 145 participants reported eight adverse events including skin breakdown, bruising, blisters and pain but it was not possible to statistically analyse these data.

In people with non-neurological conditions, there was high-quality evidence that stretch did not have clinically important short-term effects on pain (SMD -0.2, 95% CI -0.4 to 0.1; 7 studies with 422 participants) and moderate-quality evidence that stretch did not have clinically important short-term effects on quality of life (SMD 0.3, 95% CI -0.1 to 0.7; 2 studies with 97 participants). The short-term effect of stretch on activity limitations (SMD 0.1; 95% CI -0.2 to 0.3; 5 studies with 356 participants) and participation restrictions were uncertain (SMD -0.2; 95% CI -0.6 to 0.1; 2 studies with 192 participants). Nine studies involving 635 participants reported 41 adverse events including numbness, pain, Raynauds’ phenomenon, venous thrombosis, need for manipulation under anaesthesia, wound infections, haematoma, flexion deficits and swelling but it was not possible to statistically analyse these data.

Authors' conclusions
There was high-quality evidence that stretch did not have clinically important effects on joint mobility in people with or without neurological conditions if performed for less than seven months. Sensitivity analyses indicate results were robust in studies at risk of selection and detection biases in comparison to studies at low risk of bias. Sub-group analyses also suggest the effect of stretch is consistent in people with different types of neurological or non-neurological conditions. The effects of stretch performed for periods longer than seven months have not been investigated. There was moderate- and high-quality evidence that stretch did not have clinically important short-term effects on quality of life or pain in people with non-neurological conditions, respectively. The short-term effects of stretch on quality of life and pain in people with neurological conditions, and the short-term effects of stretch on activity limitations and participation restrictions for people with and without neurological conditions are uncertain.

/pdf/stretch-for-the-treatment-and-prevention-of-contractures-4xmoo0z5js.pdf

Stretch for the treatment and prevention of contractures

Evidence for Effective Hydrotherapy

The aim of this article was to review current evidence about cryotherapy in inflammatory rheumatic diseases (therapeutic and biological effects). For therapeutic effects, we performed a systematic review (PubMed, EMBASE, Cochrane Library, LILACS databases, unpublished data) and selected studies including non-operated and non-infected arthritic patients treated with local cryotherapy or whole-body cryotherapy. By pooling 6 studies including 257 rheumatoid arthritis (RA) patients, we showed a significant decrease in pain visual analogic scale (mm) and 28-joint disease activity score after chronic cryotherapy in RA patients. For molecular pathways, local cryotherapy induces an intrajoint temperature decrease, which might downregulate several mediators involved in joint inflammation and destruction (cytokines, cartilage-degrading enzymes, proangiogenic factors), but studies in RA are rare. Cryotherapy should be included in RA therapeutic strategies as an adjunct therapy, with potential corticosteroid and nonsteroidal anti-inflammatory drug dose-sparing effects. However, techniques and protocols should be more precisely defined in randomized controlled trials with stronger methodology.

Cryotherapy in inflammatory rheumatic diseases: a systematic review

OBJECTIVE: To update the Cochrane review on the effectiveness of physiotherapy interventions in the management of ankylosing spondylitis (AS). METHODS: All randomized studies available in systematic searches (electronic databases, contact with authors, reference lists) up to February 2004 were included. Two reviewers independently selected trials for inclusion, assessed the validity of included trials, and extracted data. Investigators were contacted to obtain missing information. RESULTS: Six trials with a total of 561 participants were included. Two trials compared individualized home exercise programs with no intervention. Low quality evidence for effects in favor of the home exercise program was found in physical function and spinal mobility [absolute benefit 10.3 cm on fingertip to floor distance; relative percentage difference (RPD) 37%)]. Further, the trials showed low quality evidence for no group differences in pain. Three trials compared supervised group physiotherapy with an individualized home exercise program. Moderate quality evidence for effectiveness was found in patient global assessment and spinal mobility in favor of the supervised group. The trials showed moderate quality evidence for no differences in pain intensity between the groups. One trial compared a 3-week inpatient spa-exercise therapy followed by weekly outpatient group physiotherapy with weekly outpatient group physiotherapy alone. Moderate quality evidence was found for effects in pain (absolute benefit 0.9 cm on visual analog scale; RPD 19%), physical function (absolute benefit 1 cm; RPD 24%), and patient global assessment (absolute benefit 1.3 cm; RPD 27%), in favor of the combined spa-exercise therapy. CONCLUSION: The current best available evidence suggests that physiotherapy is beneficial for people with AS. However, it is still not clear which treatment protocol should be recommended in the management of AS.

https://www.jrheum.org/content/jrheum/32/10/1899.full.pdf

The Cochrane review of physiotherapy interventions for ankylosing spondylitis.

A controlled study of 39 consecutively-admitted patients with ankylosing spondylitis was conducted to assess the effects of daily passive stretching of the hip joints during a 3-week in-patient physiotherapy course. Measurements were performed by an independent assessor on admission, at discharge and six months after discharge. Results showed that passive stretching resulted in a significant increase in the range of all movements of the hip joints except flexion during the physiotherapy course. Follow-up at 6 months in seven patients suggested that this increase in range of movement could be maintained by patients who had been performing the stretching exercises regularly. We suggest that the inclusion of passive stretching of the hip joint in the treatment of patients with ankylosing spondylitis will increase the range of movement and thus improve function and influence posture.

The role of passive stretching in the treatment of ankylosing spondylitis

This article summarises the findings of a study which aimed to evaluate a selection of commercially available portable ramps in the United Kingdom. The ramps were tested by wheelchair users and amb...

An Evaluation of Portable Ramps

A controlled trial was conducted to study the effects of ice therapy on knee joint inflammation in rheumatoid arthritis. All patients were on strict bed rest for 5 consecutive days and carried out a supervised regimen of quadriceps exercises.During the trial period ice therapy was administered once a day for 10 min to 15 knee joints and a further 15 knee joints were monitored as controls. Objective measurements were made using infra red thermography and circumferential joint mesurements.Results of this study showed that ice therapy administered once a day was not effective in reducing joint inflammation or effusion in chronic arthritis, although it has been shown by other workers to have a beneficial effect on pain and stiffness.

A controlled trial to study the effects of ice therapy on joint inflammation in chronic arthritis

A critical evaluation of car seat belts for disabled people: the problems of upper limb mobility and manual dexterity.

An evaluation of back rests designed to relieve drivers' low back pain

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