Effects of a multimodal exercise program for people with ankylosing spondylitis.

Ankylosing spondylitis (AS) is a chronic, systemic, rheumatic disease that is a prototype of seronegative spondyloarthopathies characterized by inflammation, especially at the spinal column. The disease affects the joints of the spinal and peripheral joints such as the shoulder, hip, knee, and ankle. The thoracic vertebrae are affected, and inflammation of the costovertebral, costosternal, and manubriosternal joints causes pulmonary restriction and thoracic pain. (1-3) The vertebrae become ankylotic, leading to limitation of spinal mobility. From the beginning of the early stage of the disease, inflammation of the spinal and extraspinal joints and enthesis frequently lead to limitation of spinal and joint mobility. As a result, people with AS demonstrate inspiratory muscle fatigue during exercise and limited capacity of maximal oxygen. (4,5) These restrictions lead to decreased daily activity and to decreased quality of life in people with AS. (6-8)

A growing body of research reveals that exercise is as crucial as drug treatment in the management of AS. (6,9,10) For example, Dougados et al (2) reported that physical therapy and exercise are necessary adjuncts to pharmacotherapy. Similarly, Karatepe et al (11) found that Bath Ankylosing Spondylitis Functional Index and Dougados Functional Index scores and Bath Ankylosing Spondylitis Metrology Index and Bath Ankylosing Spondylitis Disease Activity Index values showed significant improvements in patients with AS who exercised at home, and this group of patients stopped using nonsteroidal anti-inflammatory drugs. Sturm et al (12) reported that moderate-intensity exercise training with elements of step aerobics can achieve significant and clinically relevant increases in physical work capacity (PWC) in patients with severe chronic heart failure based on dilated cardiomyopathy. Other researchers (13,14) have suggested that physical exercise can be a remedy for restrictions in PWC, spinal and joint mobility, and pulmonary function. Some exercise studies (13-14) have examined the effects of interventions targeted at a specific impairment.

This focused approach to rehabilitation limits the potentional gains. The application of a multimodal approach to intervention may lessen reductions and lead to even greater improvements in functional performance. Thus, the aim of our study was to examine the effects of a multimodal exercise program (including aerobic, stretching, and pulmonary exercises) on AS-associated restrictions.

Materials and Methods

Subjects

Out of 35 patients with AS who were referred by their physician for treatment in the Department of Physical Medicine and Rehabilitation of Cukurova University, 30 patients were recruited for, and consented to participate in, the study. Because communication could not be established with 5 patients, these patients were excluded from this study. The remaining 30 patients were diagnosed according to the modified New York criteria for diagnosing AS (15) by a physician who specialized in physical medicine and rehabilitation. The patients were classified as having stage I or stage II AS based on Steinbrocker Function Criteria (stage I--patient performs all usual activities without handicaps; stage II--functional capacity adequate to conduct normal activities despite handicap or discomfort or limited mobility of 1 or more joints). (16-19) The 30 subjects with AS were randomly divided into 2 groups: an exercise group (15 subjects [6 female, 9 male]; 13 subjects with stage I AS and 2 subjects with stage II AS) and a control group (15 subjects [6 female, 9 male]; 13 subjects with stage I AS and 2 subjects with stage II AS). The subjects' age, height, weight, and duration of disease were recorded. There was no significant difference in these values between the groups (Tab. 1). Both groups were informed about the exercises that would be helpful for their illness. However, only the subjects in the exercise group received supervised exercise training. All subjects were examined by the same physician regularly (once a month), and all subjects were taking nonsteroidal anti-inflammatory drugs and sulfasalazine (2 g daily). After physical examination, pulmonary, PWC, and joint mobility parameters of AS disease were measured. Subjects in the exercise group performed the multimodal exercise program, which lasted 3 months (3 days per week, 50 minutes per session). A doctorally trained exercise instructor from the Department of Physical Therapy, Cukurova University, who had 10 years of experience provided instruction and guided the training under constant supervision of the physician who diagnosed the subjects. The exercise instructor was blinded to physiologic measures.

Exercise Protocol

The multimodal exercise program (Tab. 2) was divided into 3 periods:

1. Warm-up: 10 minutes of step exercises (each motion repeated 10 times) + 5 minutes of stretching exercises.

2. Main period: 20 minutes of step exercises (each motion repeated 10 times).

3. Cool-down: 10 minutes of pulmonary exercises + 5 minutes of stretching exercises.

Aerobic exercises. The prescribed intensity of aerobic exercise training was calculated for the main period using the Karvonen formula 20:

220 - patient age

= estimated maximum heart rate (HRMx)

HRMx - mean resting heart rate (MRHR) = (C)

The subjects' personal target zones then were calculated:

(C) x .50 = (D), (D + MRHR) x 0.5 = limit number (C) x .60 = (E), (E + MRHR) x 0.6 = limit number

A metronome (Wittner mechanics metronome *) and the Borg Scale, a measure of perceived exertion, (21) were used to support the Karvonen formula. The metronome was adjusted for indicating the exact tempo of movement to the subjects. The subjects in the exercise group measured their heart rate (HR) (HR per minute = HR within 15 seconds x 4) during the exercise program. (22,23) Because some negative effects of cardiac training associated with training intensity have been reported, (24) we used low-intensity training to avoid any possible cardiac complications that might emerge during the exercise program in our study. In addition to the rating of perceived exertion of the exercise program, the Borg Scale was used to rate exercise intensity (21) at the end of the warm-up and main periods of the exercise program. The 8 step motions (march, tap up-tap down, V step, step touch, turn step, grapevine, grapevine with knee up, and grapevine with leg curl) that were selected were applied easily to both the warm-up and main periods of the exercise program by the subjects in the exercise group. Table 3 shows descriptions of the step aerobic exercises for the exercise group. (25)

Stretching exercises. (26) The subjects performed 14 stretching exercises during the warm-up and cool-down periods: forward and backward head stretch (Fig. 1), sideways head stretch (Fig. 2), chest and shoulders stretch (Fig. 3), deltoid muscle stretch (Fig. 4), triceps muscle stretch (Fig. 5), overhead stretch (Fig. 6), lateral trunk muscle stretch (Fig. 7), arched back stretch (Fig. 8), leg extensor and pelvic flexor stretch (Fig. 9), spinal twist stretch (Fig. 10), paravertebral muscle stretch (Fig. 11), loosen-up stretch (Fig. 12), upper back prayer (Fig. 13), and double knee-to-chest stretch (Fig. 14). Pulmonary exercises also were used during the cool-down period.

[FIGURES 1-14 OMITTED]

Pulmonary exercises. (27) To increase chest expansion, the following pulmonary exercises were applied: (1) twice the normal rate of inspiration through the nose and expiration through the mouth, (2) normal expiration through the nose and normal expiration through the mouth, (3) respiration through the chest and abdomen, and (4) deep breathing and then expiration through the mouth slowly. Resistance exercises for the inspiratory pulmonary muscles were performed while each subject pressed on the chest with his or her hand and breathed strongly. Measurements

The [PWC.sub.170] test (28) was used in the estimation of maximal oxygen intake on a bicycle ergometer (Monark 814 ([dagger])). Spinal mobility was measured by inclinometer (Saunders digital inclinometer ([double dagger])) with the subjects in an erect posture and in trunk flexion. For the inclinometric measurements, the curve angle method was used. (29) Measurements were done in 3 different regions: (1) gross hip flexion (sacral midpoint [L5-S1]) (A point), (2) gross lumbar flexion (T12-L1) (B point), and (3) gross thoracic flexion (C7-T1) (C point). The following instructions were given by physician to the subjects during the inclinometric measurements.

Once the inclinometer had stabilized on a flat place and had been zeroed, each subject achieved maximal trunk flexion and the measurement (in degrees) at the A point was recorded. After the inclinometer was set at zero at the A point, it was placed to record the reading (in degrees) at the B point. Finally, after the inclinometer was set at zero at the B point, it was placed to record the reading (in degrees) at the C point. The Saunders digital inclinometer is a portable handheld inclinometer designed to measure posture and mobility of the spine. (30)

We used chest expansion, defined as the difference in chest circumference at maximal inspiration and expiration at the level of the fourth intercostal space, as a clinical measure of spinal mobility. We measured occiput-to-wall distance, which is the distance between the occiput and the wall while the person stands with heels and back against a wall and tries to place the occiput against the wall with the chin horizontal. Finger-to-floor distance was assessed by measuring the distance between the fingertips and the floor at maximal flexion of the spine and pelvis while the knees were kept in extension. Chin-to-chest distance was measured by marking the distance between the chin and the jugulum (jugular notch) in maximal flexion of the cervical spine. We used the Modified Schober Flexion Test (MSFT) to measure the increase in the distance between 2 skin marks on the first sacral spinous process (S1) and 10 cm above S1 after maximal forward bending. (31,32) A measuring tape was used in all these measurements. Each measurement was made 3 times by the same physician and exercise instructor.

A computerized spirometer (Spiromet 250 ([section])) was used to measure vital capacity (VC), which is a reliable index in evaluation of volumetric pulmonary function, (33,34) Vital capacity testing was performed for all subjects by the same physiologist in the exercise physiology laboratory.

The spirometer was calibrated by using its own calibration injector every week. All subjects were instructed to rest for 15 minutes prior to the VC testing. Subjects wore a noseclip to prevent air from escaping through the nose. Each subject assumed a standing position, and a mouthpiece, which was attached to a hose connected to the machine, was placed in the subject's mouth. The subject then was asked to breathe in as deeply as possible and to blow into the machine as completely as he or she could. The VC test was performed 3 times, and then the best value was accepted and recorded. The physiologist was blinded to group assignment.

The chronometer was used to record HR during the [PWC.sub.170] test. Heights and weights were measured with a scale, which was calibrated before each measurement.

All of the subjects regularly attended the exercise program. The subjects were asked to rate their perceived exertion during the training exercises, after both the warm-up and main periods, using the Borg Scale.

Data Analysis

All analyses were conducted using the SPSS statistical package, version 10.0. ([parallel]) Descriptive statistics were used for the means and standard deviations. The Student t test (2-tailed) and paired-samples t test were used for the comparison of groups. The level of significance was accepted as P<.05.

Results

The results of this study showed that there were significant differences in the clinical measurements (chin-to-chest distance, occiput-to-wall distance, and MSFT), inclinometric measurements (at the A point [erect position] and C point [flexion]), and in the physiologic measurements (in [PWC.sub.170] and in VC). A comparison of mean values for the spinal range of motion of the exercise and control groups is shown in Table 4.

Significant improvement was found between the beginning and end values of the exercise group for chest expansion (P=-.04) and finger-to-floor distance (P=.003). There were significant increases in chin-to-chest distance (P=.03) and occiput-to-wall distance (P=.02) in the control group. For the comparison of the groups, there were no significant differences in the baseline values, but significant improvements were found in chest expansion, chin-to-chest distance, occiput-to-wall distance, and MSFT in the exercise group at the end of the exercise program.

Table 5 shows that there were significant improvements in inclinometric measurements, such as at the A point (erect position) (P=.03) and C point (flexion) (P=.001). For the group comparison, there were no significant differences in the baseline values, but significant improvements were found for the C point (P=.001) at the end of the exercise program. Although the [PWC.sub.170] test measurements significantly decreased in the control group at the end of 3 months (P=.002), they significantly increased in the exercise group (P=.001) (Tab. 6).

At the end of exercise program, VC was decreased in the control group (P=-.004). In the exercise group, VC was unchanged. A comparison of VC values between the exercise and control groups is presented in Table 7. There were no significant differences in the baseline values for both groups; however, significant increases in VC were observed in the exercise group (P=.02) at the end of the exercise program.

Discussion and Conclusion

The findings of this study showed that there were significant improvements in clinical measurements (chest expansion, chin-to-chest distance, occiput-to-wall distance, and MSFT), in inclinometric measurements (at the A point [erect position] and C point [flexion]), and in physiologic measurements (in [PWC.sub.170] and VC values) in patients with AS who participated in a multimodal exercise program. The significant differences between and within groups for chest expansion showed that there were significant improvements. The spinal mobility tests showed no statistically significant changes. In a study by Wordsworth et al, (9) 11 patients who were given a low dosage of corticotrophin and 10 patients who were given a placebo received postural mobilization exercises for 2 months. The results revealed that functional improvements (in measurements of finger-to-floor distance and wall-to-tragus distance) resulted from the regular exercises. Radiological findings also supported the improvements in lumbar spinal movements. However, there was no improvement in neck movements. Their study also showed that there were no significant differences between the group with the medication and the group with the placebo. The study by Wordsworth et al (9) emphasized that exercise plays as important a role as the traditional drug treatments for AS. In our study, the increases in chin-to-chest distance and occiput-to-wall distance in the control group indicated that exercise is the most important factor for the improvement in spinal mobility, and this finding is in line with that of Wordsworth et al. (9) The other spinal movement tests in our study did not indicate that there were any significant changes.

Viitanen et al (31) reported on 141 patients with AS who participated in a 3- to 4-week exercise program. Improvements in occiput-to-wall distance, finger-to-floor distance, VC, chest expansion, and chin-to-chest distance were observed in these patients. Their results also indicated that the duration of the sickness did not affect the results. Our study also gave support to these findings of the study by Viitanen et al. In addition, Hidding et al (35) showed that the short-term effects of supervised individual therapy on AS were slightly improved mobility, fitness, functioning, and global health. The results of another study by Hidding and colleagues (36) revealed that group physical therapy proved superior to individualized therapy in improving thoracolumbar mobility and fitness.

The comparison of the beginning and 3-month values for spinal movements in both groups showed no significant improvements in the exercise group. Our findings revealed: (1) increases in occiput-to-wall distance and chin-to-chest distance in the control group, (2) significant improvements in chest expansion and finger-to-floor distance in the exercise group, and (3) significant differences between the control and exercise groups in chest expansion, chin-to-chest distance, occiput-to-wall distance, and MSFF at the end of 3 months. Related studies have indicated the following findings. Viitanen et al (31) reported that, after an exercise program of 3 to 4 weeks, improvements were observed in patients' spinal movements, as indicated by MSFT results. However, Heikkila et al (10) reported that the MSFT is not enough for the evaluation of spinal elasticity. They suggested that finger-to-floor distance, chest expansion, thoracolumbar rotation, and lateral flexion also should be used. In our study, the MSFT revealed that there were no significant improvements in AS at the end of the 3-month exercise period. Thus, we assume that the MSFT was not sensitive enough to measure improvements. In addition, our results are in agreement with those obtained by Heikkila et al (10) in terms of inclinometer use for proper evaluation of spinal mobility.

The inclinometric measurements revealed significant differences between the beginning and 3-month exercise results at the A point (in erect position) and at the C point (in flexion) in the exercise group. Significant differences between the control and exercise groups also were found at the C point (in flexion) at the end of the 3-month exercise period. Although there did not seem to be any significant differences between groups at the beginning of our study, the findings of related studies of vertebral flexibility suggest that treatment methods including exercise and physical therapy may increase the quality of life and spinal mobility of people with AS. (37-41)

Related literature (6,7,42,43) emphasized that maximal oxygen consumption and exercise capacity decreased during the course of AS. Sturm et al (12) reported that moderate-intensity exercise training with elements of step aerobics could achieve a significant and clinically relevant increase in PWC in patients with severe chronic heart failure based on dilated cardiomyopathy. Comparison of the beginning [PWC.sub.170] test values between the control and exercise groups in our study did not show any significant differences. The exercise group, however, had significantly higher values than those of the control group at the end of 3 months (P<.001).

In this study, the beginning VC measurements of both groups showed no significant differences (P<.12), the measurements of exercise group were found to be significantly higher than those of the control group (P<.05) after 3 months. When the beginning and 3-month measurements for each group were evaluated, the mean values of the control group at the end of 3 months indicated a significant decrease (P<.001), whereas those of the exercise group indicated no significant changes (P<.72). Previous studies (42,44) have shown significant reductions in static pulmonary volume (related to chest wall restriction) and decreases in pulmonary volume in people with AS. Thus, it has been shown that limited chest expansion causes decreases in residual volume, VC, maximal respiratory flow rate, total pulmonary capacity, stroke volume, and cardiac output. (45-47)

Miller et al (48) examined the effects of chest-wall restriction on cardiorespiratory function at rest and during exercise in subjects who were healthy. They applied canvas straps around the subjects' thorax and abdomen so that VC was reduced approximately 38%. Our study supported the findings of the study by Miller et al. We found that the volume of VC decreased 7% and chest expansion was reduced 6% in the control group. Fisher et al (4) conducted a study to determine the relationship among restriction of chest expansion, limitation of lung function, and PWC or exercise tolerance in 33 patients with AS. The results of their study suggested that patients who performed a modest amount of exercise regularly could maintain a satisfactory PWC despite very restricted spinal and chest wall mobility. They recommended that patients with AS should be encouraged to maintain cardiorespiratory fitness as well as spinal mobility. Our study showed that multimodal exercises enhance the quality of life of patients with AS. However, we suggest that pyschometric testing should be done to determine patient satisfaction. A limitation of our study is that data were not available on reliability and validity for each instrument used in the study.

In conclusion, an aerobic, stretching, and pulmonary exercise program for a 3-month period led to the improvement of spinal movements, VC volume, and PWC. Therefore, we conclude that the management program for patients with AS should include multimodal exercises. Further research is needed to determine whether the interruption of this exercise program for a long period affects the prognosis of patients with AS.

This article was received January 19, 2005, and was accepted January 31, 2006.

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* Wittner GmbH, PO Box 1464, D-88308 Isny, Germany (http://www.wittnergmbh.de).

([dagger]) Monark Exercise AB, Kroonsvag 1, S-7080 50 Vansbro, Sweden.

([double dagger]) The Saunders Group Inc, 4250 Norex Dr, Chaska, MN 55318-3047.

([section]) Spiromet, 1-6-15 Ikenohata, Taito-ku, Tokyo 110 Fukuda Sangyo, Japan.

([parallel]) SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

G Ince, PhD, is Doctor, Sport-Health Division, Department of Physical Education and Sport, Cukurova University, Adana, Turkey ([e-mail] or [e-mail]). Address all correspondence to Dr Ince at Cukurova Universitesi Beden Egitimi ve Spor Yuksekokulu, Balcali, Adana, Turkiye.

T Sarpel, MD, is Professor, Department of Physical Therapy and Rehabilitation, Medical Faculty, Cukurova University.

B Durgun, PhD, is Professor, Department of Anatomy, Medical Faculty, Cukurova University.

S Erdogan, MD, is Associate Professor, Department of Physiology, Medical Faculty, Cukurova University.

All authors provided writing, facilities/equipment, and consultation. Dr Ince provided data collection and analysis and clerical support. Dr Ince and Dr Sarpel provided fund procurement and institutional liaisons. Dr Sarpel and Dr Durgun provided concept/idea/research design and project management. Dr Sarpel provided subjects.

This study was supported by the Research Project Unit of Cukurova University, Adana, Turkey (Project No: SBE2002D12).

Table 1.
Characteristics of Subjects With Ankylosing Spondylitis

                          Age (y),               Height (cm),
Group                [bar.X] [+ or -] SD     [bar.X] [+ or -] SD

Exercise (n = 15)    33.67 [+ or -] 5.15     167.73 [+ or -] 7.91
Control (n = 15)     36.13 [+ or -] 7.20     166.87 [+ or -] 7.84
Total (N = 30)       34.90 [+ or -] 6.28      167.3 [+ or -] 7.75
P (a)                        .29                     .77

                            Body                   Disease
                        Weight (kg),            Duration (y),
Group                [bar.X] [+ or -] SD     [bar.X] [+ or -] SD

Exercise (n = 15)   70.267 [+ or -] 12.70     8.27 [+ or -] 5.71
Control (n = 15)    68.500 [+ or -] 9.22      9.79 [+ or -] 6.46
Total (N = 30)       69.38 [+ or -] 10.90     9.00 [+ or -] 6.02
P (a)                        .67                     .51

(a) Significant difference at P < .05.

Table 2.
Multimodal Exercise Program for Exercise Group of Subjects
With Ankylosing Spondylitis

Stretching Exercises

 1. Forward and backward head stretch
 2. Sideways head stretch
 3. Chest and shoulders stretch
 4. Deltoid muscle stretch
 5. Triceps muscle stretch
 6. Overhead stretch
 7. Lateral trunk muscle stretch
 8. Arched back stretch
 9. Leg extensor and pelvic flexor stretch
10. Spinal twist stretch
11. Paravertebral muscle stretch
12. Loosen-up stretch
13. Upper back prayer
14. Double knee-to-chest stretch

Aerobic Exercises

1. March
2. Tap up-tap down
3. V step
4. Step touch
5. Turn step
6. Grapevine
7. Grapevine with knee up
8. Grapevine with leg curl

Pulmonary Exercises

1. To increase chest expansion, the following pulmonary exercises
   were applied:
   a. Twice the normal rate of inspiration through the nose and
      expiration through the mouth
   b. Normal inspiration through the nose and normal expiration
      through the mouth
   c. Respiration through the chest and abdomen
   d. Deep breathing and then expiration through the mouth
      slowly

2. Resistance exercises for the inspiratory pulmonary muscles were
   performed while the subject pressed on the chest with his or her
   hand and breathed strongly.

Table 3.
Descriptions of Step-Aerobic Exercises for Exercise Group
of Subjects With Ankylosing Spondylitis

Step-Aerobic Exercises       Description

1. March                     Walk in military manner or with regular
                               paces.

2. Tap up-tap down           Tap up and tap down on the floor. Step
                               forward on the floor with the lead
                               foot. Step forward and tap the floor
                               with your other foot. Step backward
                               with your other foot. Step backward
                               with your lead foot, with biceps
                               muscle curls (elbow should be at side
                               of the trunk with the palms of the
                               hand facing upward).  Bring the hands
                               toward the chest by flexing the elbow
                               and return them to the side of the
                               trunk.

3. V step                    Step forward on the floor with the left
                               foot with the shoulder breadth. At the
                               same time, adduct left upper extremity
                               by making fist of your hand. Repeat
                               this movement for the right side.
                               Bring the right foot next to other
                               side. Step backward on the floor with
                               the left foot. At the same time,
                               extend and rotate left upper
                               extremity backward. Repeat this
                               movement for the right side. Bring
                               the right foot next to other side.

4. Step touch                Tap up and tap down on the floor side
                               by side (left side-right side) with
                               arms in a U-position (flex your
                               forearm in front of your body). The
                               elbows are on the level of the
                               shoulders, and the palms are facing
                               each other. The hands are formed into
                               fists. Hands and forearms touch
                               lightly in the middle in front of
                               your body.

5. Turn step                 Step forward on the floor with the lead
                               foot. Bring other foot on the floor
                               as you turn. Step off with the lead
                               foot. Bring the other foot backward
                               next to the lead foot.

6. Grapevine                 Step to the side with the lead foot.
                               Bring the other foot slightly behind
                               and past the lead foot. Step to the
                               side with the lead foot. Bring the
                               other foot next to the lead foot with
                               overhead pull (with arms shoulder
                               level, pull the arms in toward the
                               thighs and then return them overhead).

7. Grapevine with knee up    Grapevine with knee up (left) at the
                               end of the grapevine (step with one
                               foot and lift the opposite knee) with
                               arm rotation (arms are overhead or at
                               level of shoulder). Rotate the arms
                               clockwise and then back to the
                               starting point.

8. Grapevine with leg curl   Grapevine with leg (hamstring muscle)
                               curl. Step with one foot and bring the
                               opposite heel toward your rear until
                               there is tension in the hamstring
                               muscle) and frontal pull (arms
                               shoulder level, pull the arms in
                               toward the body so fists rest on
                               thighs, then return them to the level
                               shoulder).

Table 4.
Comparison of Control and Exercise Groups of Subjects
With Ankylosing Spondylitis for Physical Examination Tests (a)

                                 Control Group

Physical                             After                  Within-
Examination   Baseline               3 Months               Group
Tests         (cm)                   (cm)                   P

CE             1.87 [+ or -] 0.94     1.77 [+ or -] 1.67    NS
CCD            3.68 [+ or -] 1.39     4.38 [+ or -] 1.63    .03
FFD           18.70 [+ or -] 14.46   18.07 [+ or -] 14.74   NS
OWD            5.83 [+ or -] 3.48     6.79 [+ or -] 3.27    .02
MSFT          12.91 [+ or -] 1.81    12.48 [+ or -] 1.77    NS

                                Exercise Group

Physical                             After
Examination   Baseline               3 Months
Tests         (cm)                   (cm)

CE             2.40 [+ or -] 1.38     3.23 [+ or -] 1.60
CCD            2.97 [+ or -] 1.51     2.50 [+ or -] 1.73
FFD           18.13 [+ or -] 16.16   14.67 [+ or -] 16.55
OWD            4.48 [+ or -] 3.21     4.23 [+ or -] 3.27
MSFT          13.63 [+ or -] 1.74    13.83 [+ or -] 1.62

              Exercise Group   Both Groups

Physical      Within-
Examination   Group            Between-Groups
Tests         P                P

CE            .04              .05
CCD            NS              .01
FFD           .003              NS
OWD            NS              .02
MSFT           NS              .02

(a) Values are mean [+ or -] SD. There were no significant differences
in the baseline values between groups. NS = not significant,
significant difference at P<.05. CE = chest expansion, CCD =
chin-to-chest distance, FFD = finger-to-floor distance, OWD =
occiput-to-wall distance, MSFT = Modified Schober Flexion Test.

Table 5.
Comparison of the Control and Exercise Groups of Subjects
With Ankylosing Spondylitis for Inclinometric Measurements
of Spinal Range of Motion (a)

Spinal Range       Control Group
of Motion                                                      Within-
Measured With      Baseline              After 3               Group
Inclinometer       ([degrees])           Months ([degrees])    P

A point
(erect position)   13.60 [+ or -] 8.69   12.47 [+ or -] 7.09    NS

A point (flexion)  74.67 [+ or -] 15.84  74.60 [+ or -] 15.81   NS

B point
(erect position)   12.40 [+ or -] 6.84   11.47 [+ or -] 6.65    NS

B point (flexion)   6.13 [+ or -] 3.54    5.60 [+ or -] 3.98    NS

C point
(erect position)   41.80 [+ or -] 15.38  40.93 [+ or -] 13.78   NS

C point (flexion)  75.87 [+ or -] 15.27  69.00 [+ or -] 14.74   NS

Spinal Range       Exercise Group
of Motion                                                      Within-
Measured With      Baseline              After 3               Group
Inclinometer       ([degrees])           Months ([degrees])    P

A point            15.40 [+ or -] 9.27   11.60 [+ or -] 7.39   .03
(erect position)

A point (flexion)  67.07 [+ or -] 17.80  68.00 [+ or -] 17.90   NS

B point             9.67 [+ or -] 6.83    9.07 [+ or -] 6.81    NS
(erect position)

B point (flexion)   5.47 [+ or -] 4.64    6.33 [+ or -] 4.86    NS

C point            35.00 [+ or -] 12.90  35.27 [+ or -] 13.80   NS
(erect position)

C point (flexion)  80.33 [+ or -] 10.77  87.60 [+ or -] 13.30  .001

Spinal Range       Both Groups
of Motion          Between-Groups
Measured With      P
Inclinometer

A point
(erect position)   NS

A point (flexion)  NS

B point
(erect position)   NS

B point (flexion)  NS
C point
(erect position)   NS

C point (flexion)  .001

(a) Values are mean [+ or -] SD. There were no significant
differences in the baseline values between groups. NS = not
significant, significant difference at P<.05.

Table 6.
Comparison of Mean Values for [PWC.sub.170] Test Between Control
and Exercise Groups of Subjects With Ankylosing Spondylitis (a)

Measurements       Control Group         Exercise Group
of [PWC.sub.170]   [PWC.sub.170] Test    [PWC.sub.170] Test
Tests              (W/kg),               (W/kg),
of Groups          [bar.X] [+ or -] SD   [bar.X] [+ or -] SD    P

Baseline           1.78 [+ or -] 0.62    1.57 [+ or -] 0.31     NS
After 3 mo         1.56 [+ or -] 0.60    2.25 [+ or -] 0.61    .004
P                  .002                  .001

(a) There were no significant differences in the baseline values
between groups. NS = not significant, significant difference at P<.05.

Table 7.
Comparison of Percentage of Predicted Values for Vital Capacity
(VC) Between Control and Exercise Groups of Subjects With
Ankylosing Spondylitis (a)

               Control Group          Exercise Group
Measurements   VC (% Predicted),      VC (% Presdicted),
of VC          [bar.X] [+ or -] SD    [bar.X] [+ or -] SD    P

Baseline       81.77 [+ or -] 11.30   88.53 [+ or -] 11.94    NS
After 3 mo     76.05 [+ or -] 14.60   89.29 [+ or -] 14.96   .02
P              .00                    NS

(a) There were no significant differences in the baseline
values between groups. NS = not significant, significant
difference at P<.05.