Spondyloarthritis or ankylosing spondylitis (AS) is a type of chronic
spondyloarthropathy. According to the Spanish Society of Rheumatology (SER),
spondyloarthropathies constitute a heterogeneous family of interrelated rheumatic
diseases that share clinical, pathogenic, genetic, radiological, epidemiological and
therapeutic response characteristics. From an epidemiological point of view, they are
increasingly frequent diseases, accounting for more than 13% of patients diagnosed in
rheumatology units. Specifically, international reference studies place AD as the most
frequent, with an estimated incidence of 7 new cases per 100,000 inhabitants per year. It
is more frequent in men than in women (in a ratio of 3:1) and the age range is between 20
and 30 years. In Extremadura the incidence is no less. According to the National
Institute of Statistics (INE), there are currently 24 cases per 1000 people diagnosed
with rheumatoid arthritis or AD, and 55 cases per 1000 people diagnosed with arthritis.
In terms of clinical manifestations, early symptoms include back pain and stiffness. Over
time, AS can fuse vertebrae and limit movement, causing severe and constant pain.
Diagnosis and follow-up of the disease is based on clinical history and physical
examination. Radiological tests may also be used to complement the diagnosis. Over the
years, the concept of spondyloarthropathy has evolved, and is now defined as a
combination of axial spondyloarthritis (SpA), psoriatic arthritis (PsA) and inflammatory
bowel disease (IBD).
With regard to the criteria according to the Assessment of Spondyloarthritis
International Society (ASAS) and the latest update of the Clinical Practice Guideline for
the treatment of SpA and psoriatic arthritis, within SpA the investigators find AD as the
most representative pathology of this group, being the one the investigators will focus
on in this research project.
The diagnosis of axial SpA requires: a) imaging evidence confirming sacroiliitis and b)
at least one sign of SpA or HLA-B27 marker and two of the signs determined according to
ASAS (inflammatory low back pain, arthritis, enthesitis, uveitis, dactylitis, psoriasis,
Crohn's disease, good response to NSAIDs, family history of SpA, presence of HLA-B27
antigen or presence of increased C-reactive protein). In this regard, in addition to
imaging and laboratory tests, the International Society for the Evaluation of SpA
classification considers common clinical features as the main diagnostic axis.
Based on the latest SER review, the mechanism by which the disease occurs is still not
entirely clear, although there is a genetic predisposition. Among the factors involved,
the most important is the presence of the positive HLA-B27 antigen, which is present in
the vast majority of patients with AD and less frequently in the rest of the diseases of
the SpA group. Taking into account that only 10% of HLA-B27 antigen carriers will present
with the disease, it is essential to present clinical signs to support the diagnosis.
According to the best available scientific evidence, physiotherapy is the main effective
rehabilitation treatment measure for patients with SpA, and specifically for the most
widespread form of the disease such as AD.
Several rehabilitation modalities exist, although, to date, there is limited consensus on
a sequenced and standardised protocol. The review analysed 28 studies in which at least
one intervention group received physiotherapy treatment. A total of 1926 subjects with AS
were analysed, with pain, stiffness, mobility (spine and chest wall) and physical
function (disease activity, ABVD and global function) being the main variables studied.
The results reported that doing physiotherapy through therapeutic exercise performed by
physiotherapists is better than doing nothing. Within the exercise modalities, supervised
exercise by external control or focus is showing better results in regulating pain
modulatory mechanisms, also improving pain intensity, range of motion and perceived
disability in subjects with spinal pathology.
On the other hand, electrophysical agents have also been routinely applied in subjects
with spinal pathology, as they are inexpensive procedures with no reported adverse
effects and can be easily accessible to the general population. Among these,
transcutaneous electrical stimulation procedures with TENS-type currents stand out. This
modality is applied via adhesive electrodes placed on the skin or on the affected nerve
in question, as well as those that use medium-frequency interferential currents, showing
clinical efficacy in reducing perceived pain. However, there are limited studies that
apply these interventions in subjects diagnosed with AD, and as far as the authors of
this project are aware, there are no clinical trials that analyse the effects of
combining both interventions in a multimodal programme.
On the other hand, there are studies that demonstrate the importance of satisfaction as
an influential factor in both the clinical benefits and the quality of the health care
provided. If the investigators focus exclusively on the field of physiotherapy, similar
benefits have been reported between those who receive an educational briefing and those
who receive a standardised physiotherapy treatment without adequate information. Accurate
information about the disease in question and about the stages of treatment will
therefore ensure that the user's expectations are in line with reality, favouring overall
satisfaction and adherence to treatment.
In this context, there has been a growing interest in analysing multimodal physiotherapy
programmes in the approach to chronic musculoskeletal pathology.