title: Tumour necrosis factor alpha inhibitor therapy and rehabilitation for the treatment of ankylosing spondylitis: a systematic review.
abstract: OBJECTIVE
  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.
authors.affiliation: Department of Medicine and Health Sciences, School of Medicine, University of Molise, via F. De Sanctis, Campobasso 86100, Italy. Electronic address: enniolubrano@hotmail.com.
authors.forename: Ennio
authors.initials: E
authors.lastname: Lubrano
authors.affiliation: Rheumatology Unit, Department of Internal Medicine and Medicine Specialties, Sapienza University of Rome, Rome, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Spadaro
authors.affiliation: U.O. of Rheumatology, A.O.U. Polyclinic-Vittorio Emanuele, Catania, Italy.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Amato
authors.affiliation: Rheumatology Unit, Hospital S.Giovanni di Dio, Florence, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Benucci
authors.affiliation: Rheumatology and Clinical Immunology Unit, Spedali Civili Hospital, Brescia, Italy.
authors.forename: Ilaria
authors.initials: I
authors.lastname: Cavazzana
authors.affiliation: Rheumatology, Allergology and Clinical Immunology Unit, Medicina dei Sistemi Department, University of Rome Tor Vergata, Rome, Italy.
authors.forename: Maria Sole
authors.initials: MS
authors.lastname: Chimenti
authors.affiliation: Section of Rheumatology, Department of Clinical and Experimental Medicine, Sant׳Anna University Hospital, Ferrara, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Ciancio
authors.affiliation: Department of General Medicine, Ospedali Riuniti-University of Foggia, Foggia, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: D Alessandro
authors.affiliation: Rheumatology Clinic, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy.
authors.forename: Rossella De
authors.initials: R
authors.lastname: Angelis
authors.affiliation: Rheumatology Unit, Sant׳Anna e San Sebastiano Hospital, Caserta, Italy.
authors.forename: Salvatore
authors.initials: S
authors.lastname: Lupoli
authors.affiliation: Rheumatology Unit, Fornaroli Hospital, Magenta, Italy.
authors.forename: Alfredo Maria
authors.initials: AM
authors.lastname: Lurati
authors.affiliation: Rheumatology Unit, Internal Medicine Department, Mauro Scarlato Hospital, Scafati, Italy.
authors.forename: Caterina
authors.initials: C
authors.lastname: Naclerio
authors.affiliation: Rheumatology Unit, Department of General Medicine and Medical Specialties, Cardarelli Hospital, Naples, Italy.
authors.forename: Romualdo
authors.initials: R
authors.lastname: Russo
authors.affiliation: Internal Medicine Unit, Outpatient Clinic of Rheumatology, ASL Taranto "Valle d׳Itria" Hospital, Martina Franca (TA), Italy.
authors.forename: Angelo
authors.initials: A
authors.lastname: Semeraro
authors.affiliation: Outpatient Unit of Rheumatology, Internal Medicine Clinic, Trieste, Italy.
authors.forename: Paola
authors.initials: P
authors.lastname: Tomietto
authors.affiliation: Geriatrics Unit, Outpatient Clinic of Rheumatology, Ospedale "Di Summa-Perrino", Brindisi, Italy.
authors.forename: Carmelo
authors.initials: C
authors.lastname: Zuccaro
authors.affiliation: Geriatric Rheumatology Unit, "Sant׳Antonio" Hospital, Padua, Italy.
authors.forename: Gabriele
authors.initials: G
authors.lastname: De Marco
mesh_terms: D018501:Antirheumatic Agents / Q000627:therapeutic use; D003131:Combined Modality Therapy; D005081:Exercise Therapy; D006801:Humans; D013167:Spondylitis, Ankylosing / Q000188:drug therapy* / Q000534:rehabilitation; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*
chemical_list: D018501:Antirheumatic Agents; D014409:Tumor Necrosis Factor-alpha
keywords: Ankylosing spondylitis; Biologic; Exercise; Rehabilitation; Systematic review