Ennio Lubrano1, Antonio Spadaro2, Giorgio Amato3, Maurizio Benucci4, Ilaria Cavazzana5, Maria Sole Chimenti6, Giovanni Ciancio7, Giuseppe D Alessandro8, Rossella De Angelis9, Salvatore Lupoli10, Alfredo Maria Lurati11, Caterina Naclerio12, Romualdo Russo13, Angelo Semeraro14, Paola Tomietto15, Carmelo Zuccaro16, Gabriele De Marco17. 1. Department of Medicine and Health Sciences, School of Medicine, University of Molise, via F. De Sanctis, Campobasso 86100, Italy. Electronic address: enniolubrano@hotmail.com. 2. Rheumatology Unit, Department of Internal Medicine and Medicine Specialties, Sapienza University of Rome, Rome, Italy. 3. U.O. of Rheumatology, A.O.U. Polyclinic-Vittorio Emanuele, Catania, Italy. 4. Rheumatology Unit, Hospital S.Giovanni di Dio, Florence, Italy. 5. Rheumatology and Clinical Immunology Unit, Spedali Civili Hospital, Brescia, Italy. 6. Rheumatology, Allergology and Clinical Immunology Unit, Medicina dei Sistemi Department, University of Rome Tor Vergata, Rome, Italy. 7. Section of Rheumatology, Department of Clinical and Experimental Medicine, Sant׳Anna University Hospital, Ferrara, Italy. 8. Department of General Medicine, Ospedali Riuniti-University of Foggia, Foggia, Italy. 9. Rheumatology Clinic, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy. 10. Rheumatology Unit, Sant׳Anna e San Sebastiano Hospital, Caserta, Italy. 11. Rheumatology Unit, Fornaroli Hospital, Magenta, Italy. 12. Rheumatology Unit, Internal Medicine Department, Mauro Scarlato Hospital, Scafati, Italy. 13. Rheumatology Unit, Department of General Medicine and Medical Specialties, Cardarelli Hospital, Naples, Italy. 14. Internal Medicine Unit, Outpatient Clinic of Rheumatology, ASL Taranto "Valle d׳Itria" Hospital, Martina Franca (TA), Italy. 15. Outpatient Unit of Rheumatology, Internal Medicine Clinic, Trieste, Italy. 16. Geriatrics Unit, Outpatient Clinic of Rheumatology, Ospedale "Di Summa-Perrino", Brindisi, Italy. 17. Geriatric Rheumatology Unit, "Sant׳Antonio" Hospital, Padua, Italy.
Abstract
OBJECTIVES: To systematically review the evidence for a synergistic effect of combining rehabilitation with biological anti-tumour necrosis factor (TNF) therapy in patients with ankylosing spondylitis (AS). METHODS: Data were analysed to identify the most effective rehabilitation programmes, the best endpoints for effectiveness, and patient subgroups most likely to benefit from combination therapy. Systematic MEDLINE and Embase searches were performed to identify studies evaluating rehabilitation programmes and biological therapy in patients with AS. Evidence was categorised by study type, and efficacy, adverse effects and other outcomes were summarised. RESULTS: Of the 75 studies identified, 13 investigated the combination of a rehabilitation programme with TNF inhibitor therapy, while the remainder studied rehabilitation with standard therapy (often not specified). Data from these few studies suggest that combined rehabilitation plus anti-TNF therapy is more effective in terms of symptom severity, disease activity, disability and quality-of-life indices versus biologic alone or rehabilitation with standard medical therapy, or, in non-comparative studies, compared with baseline. The most effective rehabilitation appears to be supervised or in-patient programmes with an educational component. Available data do not provide guidance on most appropriate endpoints or identify patients most likely to benefit from combination therapy. Combined, TNF inhibitor and rehabilitation therapy appear to have a synergistic effect, possibly due to increased adherence to exercise. Exercise regimes are more effective if supervised and include an education component. CONCLUSIONS: Further randomized, controlled trials comparing endpoints and investigating longer-term benefits of combining TNF inhibitors with rehabilitation in different AS subgroups are needed.
OBJECTIVES: To systematically review the evidence for a synergistic effect of combining rehabilitation with biological anti-tumour necrosis factor (TNF) therapy in patients with ankylosing spondylitis (AS). METHODS: Data were analysed to identify the most effective rehabilitation programmes, the best endpoints for effectiveness, and patient subgroups most likely to benefit from combination therapy. Systematic MEDLINE and Embase searches were performed to identify studies evaluating rehabilitation programmes and biological therapy in patients with AS. Evidence was categorised by study type, and efficacy, adverse effects and other outcomes were summarised. RESULTS: Of the 75 studies identified, 13 investigated the combination of a rehabilitation programme with TNF inhibitor therapy, while the remainder studied rehabilitation with standard therapy (often not specified). Data from these few studies suggest that combined rehabilitation plus anti-TNF therapy is more effective in terms of symptom severity, disease activity, disability and quality-of-life indices versus biologic alone or rehabilitation with standard medical therapy, or, in non-comparative studies, compared with baseline. The most effective rehabilitation appears to be supervised or in-patient programmes with an educational component. Available data do not provide guidance on most appropriate endpoints or identify patients most likely to benefit from combination therapy. Combined, TNF inhibitor and rehabilitation therapy appear to have a synergistic effect, possibly due to increased adherence to exercise. Exercise regimes are more effective if supervised and include an education component. CONCLUSIONS: Further randomized, controlled trials comparing endpoints and investigating longer-term benefits of combining TNF inhibitors with rehabilitation in different AS subgroups are needed.