autoimmune diseases affecting the pelvic region and the spine are prevalent in men1 , even young2 athletes , especially ankylosing spondylitis ( as)3 . owing to the evolutionary nature of this chronic and disabling disease , modern and 
 internationally recognized , expert consensus documents include physical therapy among the 
 nonpharmacological and nonsurgical therapeutic strategies for the treatment of as . physical therapy for as includes patient education , self - management techniques , exercise 
 therapy , physical modalities , assistive devices , and balneotherapy4 , both individually and in groups5 .
physical therapy , especially exercise therapy , has been demonstrated as a treatment with 
 the highest level of evidence6,7,8,9 . however , the protocols are not defined and there is no evidence for 
 the possibilities of other forms of physical therapy .
in fact , the 2008 cochrane review emphasizes the need to improve the evidence on issues 
 such as different hands - on techniques , as well as specific education and information 
 programs .
moreover , the importance of providing an accurate description of the content , 
 dose , application , and adherence to the interventions is yet to be realized6 .
recent reviews confirmed the results found 
 by the cochrane review and have provided more evidence ; however , they have not fully 
 answered the many questions on this topic7,8,9 .
the latest results support a multimodal approach , including educational sessions supervised 
 by a physiotherapist followed by the maintenance of home - based treatment7 .
the outcomes of the interventions show a high level of evidence on better physical function 
 and a low level of evidence on pain relief and improved stiffness , spinal mobility , and 
 cardiorespiratory function .
spa 
 therapy followed by group physical therapy is better than group physical therapy alone , and 
 the effect of balneotherapy on pain is equal to that of nonsteroidal anti - inflammatory 
 drugs9 .
therefore , the objective of this case study is to describe a physical therapy approach 
 applied in a young athlete with as , and thus open new possibilities for physical therapy in 
 this pathology .
a 22-year - old man was referred to our physical therapy research unit on september 2013 
 because of the diagnosis of as based on symptoms and a positive expression of human 
 leukocyte antigen b27 .
he experienced bilateral sacroiliac and lumbar pain , especially in 
 the right side , as well as inguinal pain , on the cranial area of the triangle of scarpa , for 
 2  years .
the pain was triggered after trauma in the pelvic region that was sustained during 
 a game of football , a sport the patient practiced intensively .
the gammagraphy showed increased bilateral uptake in the sacroiliac region , especially in 
 the right side , and in the anterior superior iliac spine region .
he had limited active movement10 of the 
 lumbar spine in the frontal and sagittal planes ( table 
 1table 1.active range of movementreference values*september 12 , 2013june 16 , 2014october 30 , 2014january 21 , 2015may 28 , 2015lumbar flexion angle403040406060lumbar extension angle302030304040lumbar right lateral flexion angle20301825252828lumbar left lateral flexion angle20301822222525thoraco - lumbar right rotation angle15202235353838thoraco - lumbar left rotation angle15202230303838 degrees . *
madrid : editorial mdica 
 panamericana , 2008 at the time of the first physical therapy consultation , therapy with adalimumab ( the human 
 monoclonal antibody directed against tumor necrosis factor ) was proposed ; if there are no 
 changes in 6 months , physical therapy will be applied owing to the poor response to 
 anti - inflammatory medication in the past .
the physiotherapy research 
 unit , university of zaragoza , authorized the study , which complied with the ethical 
 requirements of the declaration of helsinki ( 1975 , revised 1983 ) .
the physical therapy evaluation revealed the following findings :  pain : night and morning lumbar - pelvic pain , and pain after prolonged sitting and standing 
 ( > 5  min ) , with a score of up to 9 in the 10-cm pain visual analogue scale ( pain vas )  inspection : spinal sagittal alignment and thoracic expansion : normal  joint biomechanics : more movement than normal in the right sacroiliac joint ; less 
 movement than normal in the lumbar spine , specifically in the thoracic12lumbar1 ( th12l1 ) , 
 lumbar1lumbar2 ( l1l2 ) , lumbar2lumbar3 ( l2l3 ) , and lumbar3lumbar4 ( l3l4 ) segments  muscular disorders : active trigger points in the next muscles : gluteus maximus , gluteus 
 medius , piriformis , tensor fasciae latae , rectus femoris , iliolumbar , quadratus lumborum , 
 and iliopsoas the objectives of physical therapy treatment were as follows : to relieve pain , normalize 
 joint mobility , increase muscle flexibility , regulate muscle contraction , return to normal 
 functionality in daily activities , and allow return to competitive sport ( football ) . the physical therapy protocol consisted of manual therapy administered by the 
 physiotherapist and autonomous general procedures .
the manual therapy administered by the physiotherapist consisted of orthopedic manual 
 therapy joint mobilizations . in this case , different degrees of tension were used in the 
 tissue during joint mobilization , described in the terminology proposed by kaltenborn as 
 grades i , ii , and iii11 .
grade i or 
  loosening  movement is a small traction force that produces no resistance in the tissue . 

grade ii or  tightening  takes up the slack in the tissue and then tightens it , producing 
 little resistance .
grade iii or  stretching  is applied after the slack and the tissues 
 become taut , producing rapidly increased resistance .
grade i mobilizations relieve pain ; grade ii mobilizations relieve pain and relax 
 periarticular muscle spam ; and grade iii mobilizations applied over a sufficient period can 
 safely stretch tissues crossing the joint11 .
the following were applied : - gliding mobilization techniques : grade i  ii in the sacroiliac joints11 - gliding mobilization techniques : grades i , ii , and iii , in flexion11 and in extension11 of the segments th12l1 , l1l2 , l2l3 , and l3l4 - dry needling in trigger points12 of 
 the gluteus maximus , gluteus medius , piriformis , tensor fasciae latae , rectus femoris , 
 iliolumbar , quadratus lumborum , and iliopsoas each session lasted around an hour and a half .
manual therapy was implemented once a week the first 4.5 months , and one session every 3 
 weeks in the next 4.5 months , from september 12 , 2013 to june 16 , 2014 .
this 1  year follow - up included three manual therapy and 
 evaluation sessions .
since september 25 , 2013 , autonomous general procedures were added to the protocol . 

exercise was performed for 3 days / week , with a duration of 1  h for each session , including 
 aerobic training on the treadmill , strength training , and stretching exercises . 

strengthening exercises trained especially the trunk for the correct positioning of the 
 lumbar spine13 .
stretching exercises14 targeted the rectus femoris , piriformis , 
 gluteus maximus , gluteus medius , and quadratus lumborum .
also since the above - mentioned date , the patient started 1 day / week of dry sauna , lasting 
 for 10  min , particularly after physical activity to promote recovery . since november 13 , 2013 , the patient continued with a 3 days / week physical activity program 
 with higher quality and intensity .
the strength training involved both the members and the 
 trunk , and increased intensity .
2013june 16 , 2014october 30 , 2014january 21 , 2015may 28 , 2015pain vas93 120101inspectionnormalnormalnormalnormalnormaljoint biomechanicshypermobility in the right sacroiliac joint , 
 hypomobility in the lumbar spinenormalnormalnormalnormalmuscular disordersactive trigger pointsno active trigger pointsno active trigger pointsno active trigger pointsno active trigger pointsfunctionality in daily activitiesno more than 5 min in a sitting or standing 
 positionnormalnormalnormalnormalcompetitive sporting activitiesno competitive sporting activities4560 minutes / week football game6075 minutes / week football game75 minutes / week football game90 minutes / week football game which present the physical therapy evaluation at the onset ( september 12 , 
 2013 ) , 9 months later ( june 16 , 2014 ) , and at the three follow - up sessions . in june 2014 ,
virtual disappearance of pain , return of normal active mobility , return of 
 full functionality , and absence of active trigger points were achieved . during the follow up 
 period ,
his participation was increased until he 
 was allowed to play through an entire match from january to may .
despite the evidence about the effectiveness of physical therapy in as , a physical therapy 
 intervention protocol has not yet been established .
our patient received a treatment protocol including manual therapy administered by the 
 physiotherapist , indoor and outdoor training , aerobic exercise , stretching and strengthening 
 therapeutic exercises , and thermotherapy , broadly in line with those of previous 
 studies15 , 16 .
orthopedic manual therapy joint mobilizations have been effective in this case , as seen 
 with other manual therapy techniques17,18,19 . 

the results of a recent study showed that spinal mobility impairment in as is determined by 
 irreversible spinal damage in later disease , and by spinal inflammation in early 
 disease20 . in this case , the stress on 
 the tissue graduated along the mobilization , and thus our treatment was more specific to 
 stage of the joint disease in as .
large tensions were avoided in the most inflammatory and 
 painful phase of the joint , and grade iii mobilizations were applied when symptoms of 
 inflammation subsided , to prevent loss of joint mobility . adapting the force applied to the 
 periarticular tissue state
no previous studies have described the use of different levels of tension in the tissue , 
 along the mobilization , depending on the stage of the joint disease .
the state of myofascial pain associated with active myofascial trigger points was regulated 
 with the dry needling technique .
there is no previous scientific evidence for the 
 effectiveness of this technique in as .
one study stated that needle therapy combined with 
 spinal massage has a significant therapeutic effect for treatment of as at the active 
 stage21 ; however , the method used in 
 the needle therapy was not the same as that used in dry needling .
some evidence supports the 
 use of dry needling in nonspecific low back pain , because it appears to be useful in 
 combination with other therapies22 . in 
 this study ,
dry needling was very effective for the normalization of pain and muscle 
 contraction , which may have facilitated the muscle function recovery and may have decreased 
 biomechanical stress .
jacques et al . identified increased tension in the enthesis as one of 
 the factors favoring the development of enthesitis and subsequent arthritis and 
 osteoproliferation .
the enthesis was defined as a unique site , juxtaposing the synovium , 
 tendon , and bone , and causing immense mechanical forces .
therefore , to reduce the tension in 
 the enthesis , normalizing muscle function can be one of the mechanisms23 that support the effectiveness of dry needling in this 
 pathology .
the exercise therapy applied in our patient improved his functional capabilities , which 
 resulted in his suitable readaptation to daily living , even allowing him to return to 
 intense sports such as football .
the literature has previously shown that exercise is very 
 useful in counteracting the deleterious effects of as24 , and that including aerobic exercise is safe and effective7 .
the main objective of exercise is to preserve the range of movement in joints25 and thoracic expansion26 , and thus avoid progressive positional and 
 functional impairment .
in addition , the beneficial effects of exercise on as may also be 
 related to the anti - inflammatory and immunomodulatory effects of regular moderate 
 exercise27 , owing to potential 
 underlying mechanisms such as reduction in visceral fat mass28 , increased production and release of myokines , regulation of 
 monocyte and macrophage functioning , and increase in the number of circulating t regulatory 
 cells . the results of a previous study showed that the use of infrared sauna had clinically 
 relevant effects during treatment in as patients without enhancing disease activity29 .
in this study , the patient benefitted 
 from traditional , not infrared , sauna ; however , the effect of mild whole - body hyperthermia 
 may have been positive by activating similar mechanisms to those implemented by other 
 thermal treatments such as infrared sauna29 or balneotherapy7 , 30 , which have higher scientific evidence . 

the mechanisms of the favorable influence of mild whole - body hyperthermia are not completely 
 understood ; however , this treatment modality may have anti - inflammatory effects31 . in the study by tarner et al.31 ,
mild whole - body hyperthermia resulted in 
 a reduction of the cytokines tumor necrosis factor ( tnf)- , interleukin ( il)-1 , and il-6 by 
 4050% .
thus , this modality of hyperthermia may result in heat - induced changes of the 
 proinflammatory cytokine network , and cytokine dysregulation ( particularly tnf- and il-23 ) 
 has been identified as one of the immune pathways associated with as pathogenesis32 .
improvements in joint function and muscle function allows a recovery of the active mobility 
 compatible with normal lumbar range of movement10 , which , together with the disappearance of pain , establish that as 
 has entered a period of remission . the results obtained after the treatment and follow - up periods indicated that the 
 prescribed autonomous general procedures should be continued in our patient .
in addition , he 
 must receive manual therapy based on the protocol presented in this study , every 3 or 4 
 months , or when symptoms of pain or morning stiffness become aggravated .
the early stage of as , and the young age , good overall condition , and cooperative attitude 
 of the patient have led to positive outcomes .
future clinical trials should increase the 
 level of evidence on the use of this physical therapy approach . in conclusion ,
our patient showed a favorable response to physical therapy , mediated by its 
 anti - inflammatory and biomechanical effects , which promoted remission of the disease . 

because of the chronic nature of as , regular exercise and sauna sessions and periodic manual 
 therapy should be continued to keep the asymptomatic state .
 [ purpose ] ankylosing spondylitis is prevalent in men . 
 modern and expert consensus 
 documents include physical therapy among the strategies for the treatment of ankylosing 
 spondylitis . 
 this study aimed to describe the physical therapy approach in an athlete with 
 ankylosing spondylitis . 
 [ subject and methods ] the patient , refractory to treatment with 
 anti - inflammatory medication , showed pelvic and lumbar pain and joint , muscle , and 
 functional disorders , which were treated with orthopedic joint mobilization , dry needling , 
 exercise , and whole - body hyperthermia . [ results ] 
 after the treatment , pain relief , normal 
 joint mobility , improved muscle function , and return to activities of daily living and 
 competitive sporting activities were recorded . 
 [ conclusion ] the literature provides 
 evidence for the use of joint mobilization techniques ; however , no previous studies have 
 used the same techniques and methods . 
 there is no previous evidence for the use of dry 
 needling in this pathology . 
 exercise therapy has a higher level of evidence , and 
 guidelines with scientific support were followed . 
 this research confirms the effectiveness 
 of hyperthermia for arthritis . 
 the early stage of ankylosing spondylitis , and the young 
 age , good overall condition , and cooperative attitude of the patient led to positive 
 outcomes . in conclusion , a favorable response that promoted the remission of the disease 
 was observed . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION