Physiotherapy and rehabilitation in ankylosing spondylitis: Is it still the mainstay of management in the era of biologics?

Ankylosing spondylitis is a systemic inflammatory disease characterized by involvement of sacroiliac joints, spine and entheses. In the last two decades a lot of progress has been made both in the diagnosis and management of axial spondyloarthritis, including nonradiographic axial spondyloarthritis. Nonsteroidal anti-inflammatory drugs and TNF inhibitors reduce pain and improve quality of life in most patients. However, the radiologic progression seems to continue, probably due to the interacting pathways of inflammation and bone turnover. Despite pharmacological advances, nonpharmacological therapies including rehabilitation, exercise, spa or balneotherapy, and occupational therapy are still an integral part of the management of patients with ankylosing spondylitis. Although the duration and intensity of nonpharmacological therapies are not conclusive and the compliance for these therapies is low, effective pharmacological therapies seem to motivate and improve the compliance of the patients. Furthermore, the combination of pharmacological and nonpharmacological therapies seems to be feasible and have synergistic effects.