Rheumatol Int (2014) 34:15051511

DOI 10.1007/s00296-014-2980-8

ORIGINAL ARTICLE

Effect ofaquatic exercise onankylosing spondylitis: a randomized

controlled trial
U.Dundar O.Solak H.Toktas U.S.Demirdal
V.Subasi V.Kavuncu D.Evcik

Received: 15 January 2014 / Accepted: 28 February 2014 / Published online: 14 March 2014
Springer-Verlag Berlin Heidelberg 2014

Abstract Ankylosing spondylitis (AS) is a chronic systemic inflammatory disease that affects mainly the axial
skeleton and causes significant pain and disability. Aquatic
(water-based) exercise may have a beneficial effect in various musculoskeletal conditions. The aim of this study was
to compare the effectiveness of aquatic exercise interventions with land-based exercises (home-based exercise)
in the treatment of AS. Patients with AS were randomly
assigned to receive either home-based exercise or aquatic
exercise treatment protocol. Home-based exercise program
was demonstrated by a physiotherapist on one occasion and
then, exercise manual booklet was given to all patients in
this group. Aquatic exercise program consisted of 20 sessions, 5 per week for 4weeks in a swimming pool at
3233C. All the patients in both groups were assessed for
pain, spinal mobility, disease activity, disability, and quality
of life. Evaluations were performed before treatment (week
0) and after treatment (week 4 and week 12). The baseline
and mean values of the percentage changes calculated for
both groups were compared using independent sample

t test. Paired t test was used for comparison of pre- and

posttreatment values within groups. A total of 69 patients
with AS were included in this study. We observed significant improvements for all parameters [pain score (VAS)
visual analog scale, lumbar flexion/extension, modified
Schober test, chest expansion, bath AS functional index,
bath AS metrology index, bath AS disease activity index,
and short form-36 (SF-36)] in both groups after treatment
at week 4 and week 12 (p<0.05). Comparison of the percentage changes of parameters both at week 4 and week 12
relative to pretreatment values showed that improvement
in VAS (p<0.001) and bodily pain (p<0.001), general
health (p<0.001), vitality (p<0.001), social functioning
(p<0.001), role limitations due to emotional problems
(p<0.001), and general mental health (p<0.001) subparts of SF-36 were better in aquatic exercise group. It is
concluded that a water-based exercises produced better
improvement in pain score and quality of life of the patients
with AS compared with home-based exercise.
Keywords Aquatic exercise Home-based exercise
Ankylosing spondylitis

U.Dundar(*) O.Solak H.Toktas V.Kavuncu

Department ofPhysical Medicine andRehabilitation,
Faculty ofMedicine, Kocatepe University, 03200Afyon, Turkey
e-mail: umitftr@yahoo.com
U.S.Demirdal
Department ofPhysical Medicine andRehabilitation,
Faculty ofMedicine, Katip Celebi University, Izmir, Turkey
V.Subasi
Department ofPhysical Medicine andRehabilitation,
Medical Park Tarsus Hospital, Mersin, Turkey
D.Evcik
Department ofPhysical Medicine andRehabilitation,
Haymana Vocational School, Ankara University, Ankara, Turkey

Introduction
Ankylosing spondylitis (AS) is a chronic systemic inflammatory disease that affects mainly the axial skeleton and
causes significant pain and disability [1]. AS may lead to
structural impairment and loss of important dynamic functions, resulting in problems with daily activities [2, 3].
Inflammatory back pain is characterized by improvement of
symptoms with exercise and no improvement or worsening
with rest. The treatment guidelines therefore recommend
exercise as an important part of the disease management [4].

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The optimal management of AS requires a combination

of non-pharmacologic and pharmacologic treatment modalities aiming to maximize long-term health-related quality
of life throughout control of inflammation and prevention
of structural damage progression. Moreover, assessment of
spondyloarthritis international society (ASAS)/European
league against rheumatism (EULAR) recommendations
emphasizes the role of education, physical exercise, physical therapy, and rehabilitation tailored to individual patient
in reducing the overall burden of the disease [14].
There are many difficulties for AS patients exercising on
land. Land-based exercises may not attract patients interest
and this may cause discontinuation of exercise. However,
aquatic (water-based) exercise is a popular treatment for
many patients with musculoskeletal conditions [5]. Aquatic
exercises are exercises that are performed in the water.
Movement in water is often less painful than the same
movement on land. Water offers natural resistance, which
helps to strengthen the muscles. The effects of water resistance, for instance drag forces, may increase energy expenditure and decrease mechanical loads on lower extremity joints [6]. The buoyancy of water reduces pressure on
the bones, joints, and muscles facilitating movement, and
may block nociception by acting on thermal receptors and
mechanoreceptors, thus influencing spinal segmental mechanisms [7]. These findings suggest the potential benefits of
aquatic exercise for people with AS; however, only a few
published studies have examined the effects of swimming
or spa therapy on people with AS. As we know, there has
not been any study that investigates the effectiveness of
aquatic exercise in the patients with AS yet.
The primary aim of this study was to compare the effectiveness of aquatic exercise interventions with home-based
exercise in the treatment of AS. The secondary aim of the
present study was to clinically assess the effects of waterbased exercise therapy on functional capacity, disease
activity, spinal mobility, and quality of life in AS patients.

Methods
This randomized, prospective, controlled, single blind
study was conducted in physical medicine and rehabilitation department of Kocatepe University, faculty of medicine between January 2011July 2013. The patients,
fulfilling the 1988 modified New York criteria for AS,
were enrolled in the study and assigned to two groups. In
addition to their demographic characteristics [age, gender, weight, height, body mass index (BMI)], the patients
were also questioned for occupation, main symptoms,
time of diagnosis, and drug usage (NSAID, disease-modifying antirheumatic drugs including biologics). Exclusion criteria were the presence of prosthesis, hypertension,

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Rheumatol Int (2014) 34:15051511

cardiovascular disease, chronic obstructive pulmonary disease, and exercising regularly for previous 3months.
Patients were randomly assigned to two treatment groups
(randomization was allocated by using numbered envelopes
method). Aquatic therapy group (group I, n=35) participated under the supervision of a physiotherapist during
the therapy program. Aquatic exercise program consisted
of 20 sessions, 5 per week for 4weeks in a swimming
pool at 3233C. Each session was conducted in groups of
89 patients and lasted 60min. The program started with
15min of poolside exercises including warming up, active
range of motion (ROM), and stretching. Poolside exercises
were followed with 40min of aquatic exercises in the pool
including warming up (such as walking forwards and backwards in the pool); aerobic exercises (such as jumping,
jogging); active ROM of the joints of the all extremities
and stretching of neck, trunk and all extremities; strengthening (such as hip adduction and abduction, knee flexion
and extension); straight posture, respiratory exercises, and
relaxation (such as lying supine). The program ended with
cooling-down (such as slow walking and squatting) for
5min.
Group II (n =34) received a home-based exercise
(land-based exercise) program for 4weeks, performing
each exercise once a day with 1520 repetitions lasting
for 60min. Exercise program including muscle relaxation
(such as deep breathing, stretching, and relaxing of different muscle groups in the body, lying supine) for 10min;
flexibility exercises for cervical, thoracic, and lumbar spine
(such as bringing chin to the chest, looking up to the ceiling, thoracic flexion and extension, lumbar flexion and
extension) ROM exercises of hip joints, stretching exercises for the major muscle groups (such as stretching exercises for shoulder muscles, abdominal muscles, erector
spine, hamstring, quadriceps, hip flexors, and stretching of
neck, trunk and all extremities) for 30min; straight posture,
respiratory exercises, and muscular strengthening (such as
strengthening of muscle groups of upper and lower limbs
and isometric exercise of the superficial trunk muscles) for
20min were practically demonstrated by a physiotherapist
on one occasion and then a training and exercise manual
booklet was given to all patients in group II. Telephone follow-up was used as a means of increasing patients adherence to home-based exercise program. These calls were
made every week by one of the investigators after the demonstration of exercise until the end of home-based exercise
program (week 4). The same investigator asked following
questions; did you perform exercises everyday for 60min?
was there any difficulty while doing exercises? If investigator were not satisfied from answers, patient was called to
the hospital for one more time demonstration of exercises.
The patients were assessed for pain, spinal mobility,
disease activity, disability, and quality of life. Evaluations

Rheumatol Int (2014) 34:15051511

were performed before treatment (week 0) and after treatment (week 4 and week 12). Before treatment, one of the
physicians evaluated the clinical assessment parameters.
Posttreatment outcome measures were assessed by another
physician, and all of them were blinded to the treatments.
Only the physiotherapist who did not join the study was
aware of the therapy. The spinal mobility was assessed by
modified Schober test [8] and measurement of active ROM
(lumbar flexion/extension) using an inclinometer and a
goniometer. Pain was evaluated using the 010cm visual
analog scale (VAS). Chest expansion was measured. Bath
AS functional index (BASFI) [9], Bath AS metrology index
(BASMI) [10], Bath AS disease activity index (BASDAI)
[11], and SF-36 [12] scales were filled. The patients were
not allowed to change the dosage of their regular medication or begin a new medication.
Informed consent was obtained before the examination,
and approval for the study was granted by the local ethical
committee of the university.
Statistical analysis
All parametric results were expressed as means and standard deviations for each group. A level of significance of
p<0.05 (2-tailed) was accepted for this study. KolmogorovSmirnov test showed that variables were normally
distributed. The baseline and the mean values of the percentage changes calculated for both groups were compared
by using the independent sample t test. The paired t test
was used for comparison of pre- and posttreatment values
within groups. The Chi-square test was used for comparison of categoric variables. All analyses were performed
using the SPSS for Windows 13.0 software program.

Results
A total of 69 patients (58 male and 11 female) were
enrolled in the study. All patients completed the study. No
side effects were observed during the study. There were
no statistically significant differences in the demographic
features and pretreatment evaluation parameters of the
patients. The demographic properties of the patients and
pretreatment evaluation parameters are given in Table1.
In aquatic exercise group, seven patients received
only NSAID, 12 patients used NSAID+sulfasalazine,
and 11 patients received biologic agent treatment regularly, while five patients did not use regular medication.
In land-based exercise group, eight patients received only
NSAID, 11 patients used NSAID+sulfasalazine, and 12
patients received biologic agent treatment regularly, while
three patients did not use regular medication. Distribution
of the patients according to medications did not show a

1507
Table1Demographic features and pretreatment values (Mean
standard deviation) for evaluation parameters of the groups
Group 1 (n: 35)
(aquatic exercise)
Age (year)
42.311.3
Weight (kg)
87.515.9
Height (cm)
171.921.2
BMI
29.62.4
Gender (F/M)
5/30
Disease duration
13.712.5
(year)
Lumbar flexion ()
66.715.4
Lumbar extension () 16.54.4
Modified Schober
2.91.9
(cm)
Chest expansion (cm) 3.31.6
Pain (VAS)
5.12.6
BASFI
3.52.9
BASMI
5.32.7
BASDAI
3.91.9
SF-36, PF
65.224.6
SF-36, RL
61.726.8
SF-36, BP
55.327.4
SF-36, GH
58.519.7
SF-36, V
53.617.6
SF-36, SF
68.531.6
SF-36, RLEP
60.528.8
SF-36, GMH

70.318.2

Group 2 (n: 34)

(land-based exercise)

43.111.7
86.317.2
170.322.1
29.72.7
6/29
14.112.2

>0.05
>0.05
>0.05
>0.05
>0.05
>0.05

69.517.8
17.16.9
3.12.1

>0.05
>0.05
>0.05

3.21.8
4.92.8
3.62.8
5.23.1
4.02.3
63.426.2
59.529.5
56.119.8
56.721.1
54.524.9
65.827.4
58.924.6

>0.05
>0.05
>0.05
>0.05
>0.05
>0.05
>0.05
>0.05
>0.05
>0.05
>0.05
>0.05

71.925.1

>0.05

VAS Visual Analog Scale, BASFI Bath Ankylosing Spondylitis Functional Index, BASMI Bath Ankylosing Spondylitis Metrology Index,
BASDAI Bath Ankylosing Spondylitis Disease Activity Index, SF-36
short form 36 health survey, PF physical function, RL role limitations due to physical functioning, BP bodily pain, GH general health,
V vitality, SF social functioning, RLEP role limitations due to emotional problems, and GMH general mental health

significant difference between the groups (p>0.05). The

occupation of the patients were as follows; 8 office workers, 7 sales/marketing personnels, 2 heavy work workers,
2 unemployed, 4 full time homemakers, 5 part time workers, 9 farmers in aquatic exercise group and 9 office workers, 6 sales/marketing personnels, 3 heavy work workers, 3
unemployed, 3 full time homemakers, 4 part time workers,
6 farmers in home-based exercise group. Distribution of the
patients according to occupation did not show a significant
difference between the groups (p>0.05).
Main symptoms were pain and stiffness in the lower
back and buttocks in 25 patients in aquatic exercise group
and 26 patients in home-based exercise group.
Week 4 and week 12 results showed significant improvement for all parameters in both groups (p<0.05) (Tables2,
3). However, comparison of the percentage changes of

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Rheumatol Int (2014) 34:15051511

Table2The results (Meanstandard deviation) and statistical comparisons of the pretreatment (week 0), and posttreatment (weeks 4 and 12)
evaluation parameters in group 1 (aquatic exercise group)
n: 35

Baseline (week 0)

Week 4

Week 12

P (baseline-week 4)

P (baselineweek 12)

Lumbar flexion ()
Lumbar extension ()
Modified Schober (cm)
Chest expansion (cm)
Pain (VAS)
BASFI
BASMI
BASDAI
SF-36, PF
SF-36, RL
SF-36, BP
SF-36, GH
SF-36, V
SF-36, SF
SF-36, RLEP

66.715.4
16.54.4
2.91.9
3.31.6
5.12.6
3.52.9
5.32.7
3.91.9
65.224.6
61.726.8
55.327.4
58.519.7
53.617.6
68.531.6
60.528.8

73.817.6
20.25.1
3.72.1
3.91.8
2.62.5
2.52.2
4.02.4
2.61.5
80.826.8
77.729.3
78.629.9
77.421.3
74.825.3
89.532.1
80.431.1

74.218.3
20.35.4
3.72.4
3.81.9
2.52.6
2.62.4
4.12.6
2.71.7
81.325.3
78.527.5
79.228.3
77.923.5
73.526.7
88.630.5
79.527.9

<0.001
<0.001
0.001
0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

<0.001
<0.001
0.001
0.001
<0.001
0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

SF-36, GMH

70.318.2

89.423.7

87.825.7

<0.001

<0.001

VAS Visual Snalog Scale, BASFI Bath Ankylosing Spondylitis Functional Index, BASMI Bath Ankylosing Spondylitis Metrology Index, BASDAI Bath Ankylosing Spondylitis Disease Activity Index, SF-36 short form 36 health survey, PF physical function, RL role limitations due to
physical functioning, BP bodily pain, GH general health, V vitality, SF social functioning, RLEP role limitations due to emotional problems, and
GMH general mental health

Table3The results (meanstandard deviation) and statistical comparisons of the pretreatment (week 0), and posttreatment (weeks 4 and 12)
evaluation parameters in group 2 (land-based exercise group)
n: 34

Baseline (week 0)

Week 4

Week 12

P (baseline-week 4)

P (baselineweek 12)

Lumbar flexion ()
Lumbar extension ()
Modified Schober (cm)
Chest expansion (cm)
Pain (VAS)
BASFI
BASMI
BASDAI
SF-36, PF
SF-36, RL
SF-36, BP
SF-36, GH
SF-36, V
SF-36, SF
SF-36, RLEP

69.517.8
17.16.9
3.12.1
3.21.8
4.92.8
3.62.8
5.23.1
4.02.3
63.426.2
59.529.5
56.119.8
56.721.1
54.524.9
65.827.4
58.924.6

74.921.2
20.57.8
3.82.4
3.82.1
3.32.3
2.52.2
3.92.8
2.82.1
76.424.9
71.226.3
66.521.3
65.225.6
65.726.1
74.228.3
67.527.3

74.523.1
20.48.1
3.72.2
3.82.4
3.42.5
2.62.3
4.02.7
2.82.5
77.525.8
71.627.1
67.324.1
66.724.3
67.221.9
73.826.7
69.228.1

<0.001
<0.001
0.001
0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
0.001
0.001
<0.001
0.002
0.002

<0.001
<0.001
0.001
0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
0.001
0.001
<0.001
0.001
0.001

SF-36, GMH

71.925.1

82.423.8

81.524.5

<0.001

<0.001

VAS Visual Analog Scale, BASFI Bath Ankylosing Spondylitis Functional Index, BASMI Bath Ankylosing Spondylitis Metrology Index, BASDAI Bath Ankylosing Spondylitis Disease Activity Index, SF-36 short form 36 health survey, PF physical function, RL role limitations due to
physical functioning, BP bodily pain, GH general health, V vitality, SF social functioning, RLEP role limitations due to emotional problems, and
GMH general mental health

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Rheumatol Int (2014) 34:15051511

1509

Table4Comparison of the two groups on the basis of the posttreatment (both week 4 and week 12) percentage changes and difference scores
relative to pretreatment (week 0) values
Week 4
group 1

Week 4
group 2

Week
12 group1

Week
12 group 2

0.100.02
0.220.07
0.270.08
0.180.05
0.490.14
0.280.07
0.240.06
0.330.11
0.230.09

0.080.03
0.200.06
0.220.06
0.180.06
0.320.12
0.300.09
0.250.07
0.300.12
0.200.08

>0.05
>0.05
>0.05
>0.05
<0.001
>0.05
>0.05
>0.05
>0.05

0.110.03
0.230.07
0.270.09
0.150.06
0.500.17
0.250.09
0.220.07
0.300.10
0.240.08

0.070.04
0.190.08
0.190.11
0.180.08
0.300.16
0.270.13
0.230.09
0.300.12
0.220.09

>0.05
>0.05
>0.05
>0.05
<0.001
>0.05
>0.05
>0.05
>0.05

SF-36, RL
SF-36, BP
SF-36, GH
SF-36, V
SF-36, SF
SF-36, RLEP

0.250.07
0.420.15
0.320.09
0.390.13
0.300.11
0.320.15

0.190.09
0.180.06
0.150.05
0.200.11
0.120.11
0.140.09

>0.05
<0.001
<0.001
<0.001
<0.001
<0.001

0.270.11
0.430.21
0.330.12
0.370.12
0.290.14
0.310.13

0.200.08
0.200.11
0.170.6
0.230.13
0.120.09
0.170.11

>0.05
<0.001
<0.001
<0.001
<0.001
<0.001

SF-36, GMH

0.270.11

0.140.08

<0.001

0.240.15

0.130.09

<0.001

Lumbar flexion ()
Lumbar extension ()
Modified Schober (cm)
Chest expansion (cm)
Pain (VAS)
BASFI
BASMI
BASDAI
SF-36, PF

Bold values indicate statistically significant difference between groups

VAS Visual Analog Scale, BASFI Bath Ankylosing Spondylitis Functional Index, BASMI Bath Ankylosing Spondylitis Metrology Index, BASDAI Bath Ankylosing Spondylitis Disease Activity Index, SF-36 short form 36 health survey, PF physical function, RL role limitations due to
physical functioning, BP bodily pain, GH general health, V vitality, SF social functioning, RLEP role limitations due to emotional problems, and
GMH general mental health

parameters both at week 4 and week 12 relative to pretreatment values showed that improvement in pain VAS
score (p<0.001) and bodily pain (p<0.001), general
health (p<0.001), vitality (p<0.001), social functioning
(p<0.001), role limitations due to emotional problems
(p<0.001), and general mental health (p<0.001) subparts
of SF-36 were better in aquatic exercise group. Comparison
of the percentage changes of other parameters did not show
a significant difference between the two groups (p>0.05)
(Table4).

Discussion
Due to the typical disease characteristics, the main focus
for exercise prescription has traditionally been improvement or maintenance of spinal mobility in AS. A Cochrane
review including 11 randomized controlled trials (RCTs)
concluded that exercises have beneficial, effects on spinal
mobility, physical function, and patient global assessment
for patients with AS [13]. In a recent study, Dagfinrud
etal. [14] wanted to answer to following question; exercise programs for patients with AS, do they really have the
potential for effectiveness? They found that high-quality
studies of the effects of exercise for patients with AS are
warranted, but it is important that future studies provide

exercise programs that are planned in accordance with recommendations for developing physical fitness.
A recent review that investigated the effectiveness of
physiotherapy in AS showed that home-based exercises
have been recognized as an effective physiotherapy modality for AS with respect to pain reduction, spinal mobility,
function, and decreased disease activity. They also emphasized that although research in physiotherapy has grown
significantly over the past several years, the number of
studies published examining the effects of physiotherapy
interventions for AS remains small [15].
Spa therapy involves immersion in thermal water, the
use of mudpacks, and/or massage [16]. This physiotherapy
modality has been traditionally used in the treatment of AS,
with evidence to support its use in the improvement of spinal mobility, pain, and disease activity [17, 18]. Spa therapy is a passive therapy in thermal water; however, aquatic
exercise (hydrotherapy) is an active therapy in which
patient make active aerobic and strengthening exercise in a
therapeutical pool.
Swimming is often recommended for patients with AS.
However, there is only one known randomized controlled
study to examine the effects of swimming as an intervention for ankylosing spondylitis. This randomized control
study (n: 37) compared freestyle swimming (swimming for
30min, 3days per week for 6weeks and daily conventional

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land-based exercise), walking (walking for 30min, 3days

per week for 6weeks, and daily conventional land-based
exercise), and daily conventional land-based exercise alone
(control group). Significant improvements were observed
in pulmonary and exercise tolerance outcome measures in
the swimming and walking groups compared with the control. This study provides support for both swimming and
walking as an effective form of aerobic exercise intervention for AS patients [19]. However, swimming alone is not
a real aquatic exercise program, and we have not found any
study that investigates the effectiveness of aquatic exercise
in the patients with AS in literature.
In a recent review, Verhagen etal. [20] stated that exercises in water are very popular treatment for many patients
with musculoskeletal conditions, but especially in rheumatologic conditions. Based on the evidence found, they
conclude that aquatic therapy is probably effective at
short-term in patients with osteoarthritis, low back pain,
and fibromyalgia. They also stated that it remains unclear
whether aquatic exercises are more effective than other
active interventions such as land-based exercises; furthermore, there is a lack of evidence for specific doses and
timing of exercise programmes. Aquatic exercise involves
special exercises in a hydrotherapy pool, which is maintained at temperatures between 32 and 36C, supervised
by a physiotherapist. There is not a consensus about the
length of treatment but, usually recommended two to four
3060min sessions a week for 34weeks. Patients are
advised to continue with their exercise program once discharged [21]. In an another review, Kamioka etal. [22]
stated that aquatic exercise had small but statistically significant effects on pain relief and related outcome measures
of locomotor diseases (e.g., arthritis, rheumatoid diseases).
Previous several studies recommended land-based
exercises in treatment of AS [23, 24]. These trials provide
strong evidence that exercise is an important part of the disease management. However, aquatic therapy programs have
not been studied yet in AS. There is no standard guidelines
exist for aquatic exercises in AS, particularly regarding
number of sessions, duration, and frequency. In our study,
patients with AS performed an intensive program. Aquatic
exercise program consisted of 20 sessions, 5 per week,for
4weeks and each session lasted 60min. In our study, week
4 and week 12 results showed significant improvement for
all parameters in both groups. However, comparison of the
percentage changes of parameters both at week 4 and week
12 relative to pretreatment values showed that improvement in pain VAS score and bodily pain, general health,
vitality, social functioning, role limitations due to emotional problems, and general mental health subparts of SF36 were better in aquatic exercise group. One of the reason
of the better improvement in pain score and bodily pain,
general health, and social component scores of the SF-36

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Rheumatol Int (2014) 34:15051511

quality of life measure of the patients with AS in aquatic

exercise group may be due to an evidence showing that
hydrotherapy provides the optimal environment for patients
to exercise aerobically, and at higher intensities than would
be possible on land, owing to the reduction of joint loading
[25].
In a meta-analysis, Hayden etal. [26] stated that exercise therapy that consists of individually designed programs, including stretching or strengthening, and is delivered with supervision may improve pain and function better
than home-based exercise in chronic non-specific low back
pain. Also in an another study, Judith etal. [27] reported
that a hospital-based exercise rehabilitation program may
improve treadmill exercise performance more than a homebased program in the patients with peripheral arterial
occlusion disease. Our control group performed not really
land-based but home-based exercise, which has already
been proven to be less efficacious than any supervised exercise. Furthermore, despite the differences between groups,
the effect sizes are not very large, thus showing a not relevant clinical difference. It is reassuring that both aquatic
and home-based exercises are efficacious, that aquatic exercises have a slightly better effect, but also these small differences may be due to supervised sessions of the aquatic
exercise programs because supervision of exercises may
provide assurance of compliance, assurance of good technique, positive role of therapist reinforcement, and socializing of the patients. All of these factors are absent in homebased exercise. Also, a supervised land-based program may
produce similar effectiveness as aquatic exercise programs.
The main limitations of our study are the absence of the
lack of supervision in home-based exercise group, and low
number of patients included in this study.
We found potential benefits of aquatic exercise in a small
number of available 69 patients with AS, but more reliable
results may be obtained in the new future trials with larger
sample size and longer follow-up. Also, there is not a consensus about the frequency (number of sessions per week)
and optimal length of aquatic exercises in the patients with
musculoskeletal conditions. Further studies may establish
duration of pool programs, frequency and optimal length of
time.
As a result, it is concluded that a water-based exercises
produced better improvement in pain score VAS and bodily pain, general health, and social components of quality
of life of the patients with AS compared with home-based
exercise. Aquatic exercise may be considered as the initial
part of an exercise therapy program to get particularly disabled patients with AS. Further exercise interventions may
then continue on land.
Conflict of interest The authors have no conflict and interest to
disclose.

Rheumatol Int (2014) 34:15051511

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