Rheumatol Int (2014) 34:367372

DOI 10.1007/s00296-013-2869-y

SHORT COMMUNICATION

Effects of Pilates, McKenzie and Heckscher training on disease

activity, spinal motility and pulmonary function in patients
with ankylosing spondylitis: a randomized controlled trial
Mihaela Oana Ros u Ionut T opa Rodica Chirieac
Codrina Ancuta

Received: 6 April 2013 / Accepted: 10 September 2013 / Published online: 26 September 2013
 Springer-Verlag Berlin Heidelberg 2013

Abstract The optimal management of ankylosis spondylitis (AS) involves a combination of nonpharmacologic and
pharmacologic treatment aiming to maximize health-related
quality of life. The primary objective of our study was to
demonstrate the benefits of an original multimodal exercise
program combining Pilates, McKenzie and Heckscher
techniques on pulmonary function in patients with AS, while
secondary objectives were to demonstrate the benefits of the
same program on function and disease activity. This is a
randomized controlled study on ninety-six consecutive
patients with AS (axial disease subset), assigned on a 1:1
rationale into two groups based on their participation in the
Pilates, McKenzie and Heckscher (group I) or in the classical
kinetic program (group II). The exercise program consisted
of 50-min sessions performed 3 times weekly for 48 weeks.
Standard assessments were done at week 0 and 48 and
included pain, modified Schober test (mST) and fingerfloor
distance (FFD), chest expansion (CE) and vital capacity
(VC), as well as disease activity Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), functional Bath
Ankylosing Spondylitis Functional Index (BASFI) and
metrology index Bath Ankylosing Spondylitis Metrology
Index (BASMI). Groups were comparable at baseline; we
demonstrated significant improvement between baseline and
after 48 weeks of regular kinetic training for all AS-related

M. O. Ros u
R. Chirieac
C. Ancuta (&)

University of Medicine and Pharmacy Grigore T. Popa,
Iasi, Romania
e-mail: alexia02ro@yahoo.com
I. T opa
Clinical Emergency Hospital Sfantu Ioan, Iasi, Romania
R. Chirieac
C. Ancuta
Clinical Rehabilitation Hospital, Iasi, Romania

parameters in both groups. However, significant improvement was found in pain, lumbar spine motility (mST, FFD),
BASFI, BASDAI and BASMI in AS performing the specific
multimodal exercise program at the end of study
(p = 0.001). Although there were significant improvements
in CE in both groups as compared to baseline (group I,
p = 0.001; group II, p = 0.002), this parameter increased
significantly only in group I (p = 0.001). VC measurements
were not significantly changed at the end of the study (group
I, p = 0.127; group II, p = 0.997), but we found significant
differences within groups (p = 0.011). A multimodal
training combining Pilates, McKenzie and Heckscher exercises performed regularly should be included in the routine
management of patients with AS for better control of function, disease activity and pulmonary function.
Keywords Ankylosing spondylitis
Pilates

McKenzie method
Heckscher method

Introduction
Ankylosing spondylitis (AS) is a chronic systemic
inflammatory disease that affects mainly the axial skeleton
and causes significant pain and disability [1]. While the
pathophysiology of AS is still not well understood, interactions between HLA-B27 and T cell response, including
the release of TNF-alpha, are widely involved in driving
initial inflammation as well as late ossification [1, 2].
Extra-articular manifestations can often occur, restrictive
respiratory dysfunction being commonly reported in a
significant proportion of patients [1, 3, 4].
The optimal management requires a combination of
nonpharmacologic and pharmacologic treatment modalities
aiming to maximize long-term health-related quality of life

123

368

throughout control of inflammation and prevention of

structural damage progression. Moreover, ASAS/EULAR
recommendations emphasize the role of education, physical exercise, physical therapy and rehabilitation tailored to
individual patient in reducing the overall burden of the
disease [1, 2].
Although there is an agreement on the benefits of
exercises in AS, the ideal kinetic approach is still open. On
the other hand, several methods, including Pilates,
McKenzie and Heckscher, are known to be effective in
patients with chronic low back pain [510], mainly in
decreasing functional impairment and increasing quality of
life. Their utility in patients with AS was recently
addressed, particularly for Pilates, with encouraging
response [1113].
Pilates is a well-known formula of physical exercises
based on the mindbody relaxation, focusing on the controlled movement, posture and breathing [14]. It was suggested as an efficient therapeutic method for patients with
musculoskeletal disorders of the spine, including AS,
providing positive results on pain and spine mobility and
enhancing abdominal as well as back muscles [5, 6, 11, 12,
14].
Robin McKenzie developed a much more experienced
method, comprising the assessment, diagnosis and treatment for the spine and extremities pathology. Also called
the Mechanical Diagnosis and Therapy (MDT), the
McKenzie method encourages self-treatment as the best
way to achieve a lasting improvement in back and neck
pain [710]. As this method is directed to the erector
muscles of the back, a potential benefit could be described
in AS patients characterized by severe impairment of
lumbar flexion. Further, Skikic [8] and Clare [9] realized a
systematic revision of McKenzie efficacy on pain and
physical function of the spine.
Heckscher method could be included in the correction
at maximum possible of all the disharmonies of the
mobilized structure and of the mobilizing forces, no matter
the other objectives. This is a Danish method, made up of
correcting exercises for all the segments involved in the
breathing act, for the correction of the breathing pathophysiological conditions, targeting mainly the neck and
lumbar muscles reflecting the posture of the head and hips,
as well as the diaphragm and breathing muscles [15].
We choose to combine exercises from three kinetic
methods as each of them addresses in another way the
functional impairment described in AS: Heckscher method
is directed mainly to upper back and arms, Pilates to dorsal
spine, truck and breathing control, while McKenzie is
mainly involved in lumbar spine and pelvis rehabilitation,
starting from the corrected posture in lordosis.
The primary endpoint of our study was to demonstrate
the benefits of an original multimodal exercise program

123

Rheumatol Int (2014) 34:367372

combining Pilates, McKenzie and Heckscher techniques on

pulmonary function in patients with AS, while secondary
endpoints were to demonstrate the benefits of the same
program on function and disease activity.

Materials and methods

Subjects
A total of ninety-six consecutive patients (seventy-nine
men) from a single center in northeastern Romania fulfilling the 1988 modified New York diagnostic criteria for
AS, with an axial disease subset, were enrolled in an openlabel randomized controlled study and assigned (on a
rationale of 1:1) into two groups based on their further
involvement in different kinetic programs.
Half of cases were provided a combined Pilates,
McKenzie and Heckscher training (group I), while the
others were included in a classic kinetic program (group II
or control group).
Patients with either peripheral or mixed AS, those with
total ankylosis of the spine, as well as patients with abnormal
high ESR ([30 mm/hour) and C-reactive protein level ([2
times the upper normal limit) were excluded from the study.
Exercise protocol
Group I: The multimodal exercise program proposed for
patients included in group I was divided into three periods
as follows:

Pilates method: 20 min of breathing exercises (20

exercises, each one repeated 2 times), exercises for
abdominal muscle (20 exercises, each one repeated 2
times), buttock muscles (20 exercises, each one
repeated 2 times), paravertebral muscle (20 exercises,
each one repeated 2 times), superficial trunk muscles
(20 exercises, each one repeated 2 times), pelvic flexors
in neutral position (20 exercises, each one repeated 2
times), progressive stretching of trunk, arms and leg
muscles (20 exercises, each one repeated 2 times).
Heckscher method: 20 min of aerobic exercises aiming
to correct posture of neck and head (20 exercises, each
one repeated 2 times), shoulders (20 exercises, each one
repeated 2 times), upper and/or lower back (20
exercises, each one repeated 2 times), pelvis (20
exercises, each one repeated 2 times), as well as
exercises aiming to tonify the diaphragm and respiratory muscles (20 exercises, each one repeated 2 times)
McKenzie method: 10 min of aerobic exercises for
lower back (each one repeated for 4 times) and
abdominal muscles (each one repeated for 4 times).

368

throughout control of inflammation and prevention of

structural damage progression. Moreover, ASAS/EULAR
recommendations emphasize the role of education, physical exercise, physical therapy and rehabilitation tailored to
individual patient in reducing the overall burden of the
disease [1, 2].
Although there is an agreement on the benefits of
exercises in AS, the ideal kinetic approach is still open. On
the other hand, several methods, including Pilates,
McKenzie and Heckscher, are known to be effective in
patients with chronic low back pain [510], mainly in
decreasing functional impairment and increasing quality of
life. Their utility in patients with AS was recently
addressed, particularly for Pilates, with encouraging
response [1113].
Pilates is a well-known formula of physical exercises
based on the mindbody relaxation, focusing on the controlled movement, posture and breathing [14]. It was suggested as an efficient therapeutic method for patients with
musculoskeletal disorders of the spine, including AS,
providing positive results on pain and spine mobility and
enhancing abdominal as well as back muscles [5, 6, 11, 12,
14].
Robin McKenzie developed a much more experienced
method, comprising the assessment, diagnosis and treatment for the spine and extremities pathology. Also called
the Mechanical Diagnosis and Therapy (MDT), the
McKenzie method encourages self-treatment as the best
way to achieve a lasting improvement in back and neck
pain [710]. As this method is directed to the erector
muscles of the back, a potential benefit could be described
in AS patients characterized by severe impairment of
lumbar flexion. Further, Skikic [8] and Clare [9] realized a
systematic revision of McKenzie efficacy on pain and
physical function of the spine.
Heckscher method could be included in the correction
at maximum possible of all the disharmonies of the
mobilized structure and of the mobilizing forces, no matter
the other objectives. This is a Danish method, made up of
correcting exercises for all the segments involved in the
breathing act, for the correction of the breathing pathophysiological conditions, targeting mainly the neck and
lumbar muscles reflecting the posture of the head and hips,
as well as the diaphragm and breathing muscles [15].
We choose to combine exercises from three kinetic
methods as each of them addresses in another way the
functional impairment described in AS: Heckscher method
is directed mainly to upper back and arms, Pilates to dorsal
spine, truck and breathing control, while McKenzie is
mainly involved in lumbar spine and pelvis rehabilitation,
starting from the corrected posture in lordosis.
The primary endpoint of our study was to demonstrate
the benefits of an original multimodal exercise program

123

Rheumatol Int (2014) 34:367372

combining Pilates, McKenzie and Heckscher techniques on

pulmonary function in patients with AS, while secondary
endpoints were to demonstrate the benefits of the same
program on function and disease activity.

Materials and methods

Subjects
A total of ninety-six consecutive patients (seventy-nine
men) from a single center in northeastern Romania fulfilling the 1988 modified New York diagnostic criteria for
AS, with an axial disease subset, were enrolled in an openlabel randomized controlled study and assigned (on a
rationale of 1:1) into two groups based on their further
involvement in different kinetic programs.
Half of cases were provided a combined Pilates,
McKenzie and Heckscher training (group I), while the
others were included in a classic kinetic program (group II
or control group).
Patients with either peripheral or mixed AS, those with
total ankylosis of the spine, as well as patients with abnormal
high ESR ([30 mm/hour) and C-reactive protein level ([2
times the upper normal limit) were excluded from the study.
Exercise protocol
Group I: The multimodal exercise program proposed for
patients included in group I was divided into three periods
as follows:

Pilates method: 20 min of breathing exercises (20

exercises, each one repeated 2 times), exercises for
abdominal muscle (20 exercises, each one repeated 2
times), buttock muscles (20 exercises, each one
repeated 2 times), paravertebral muscle (20 exercises,
each one repeated 2 times), superficial trunk muscles
(20 exercises, each one repeated 2 times), pelvic flexors
in neutral position (20 exercises, each one repeated 2
times), progressive stretching of trunk, arms and leg
muscles (20 exercises, each one repeated 2 times).
Heckscher method: 20 min of aerobic exercises aiming
to correct posture of neck and head (20 exercises, each
one repeated 2 times), shoulders (20 exercises, each one
repeated 2 times), upper and/or lower back (20
exercises, each one repeated 2 times), pelvis (20
exercises, each one repeated 2 times), as well as
exercises aiming to tonify the diaphragm and respiratory muscles (20 exercises, each one repeated 2 times)
McKenzie method: 10 min of aerobic exercises for
lower back (each one repeated for 4 times) and
abdominal muscles (each one repeated for 4 times).

Rheumatol Int (2014) 34:367372

Group II: The multimodal exercise program proposed

for patients included in group II was adapted from the
program proposed by Inge et al. [16] and was divided into
three periods as follows:

Warm-up: 10 min of step-aerobic exercises (each

motion repeated 10 times) plus 5 min of stretching
exercises.
Main period: 20 min of step-aerobic exercises (each
motion repeated 10 times).
Cooldown: 10 min of pulmonary exercises plus 5 min
of stretching exercises.

Both groups were informed about the exercises that

would be helpful for their illness.
A trained kinetotherapist provided instruction and
guided the initial training under the supervision of a
treating rheumatologist; however, the kinetotherapist was
blinded to physiological measures. After the learning
module assisted in the outpatient rheumatology department for 12 weeks, kinetotherapy was performed individually at home comprising the same program organized
in sessions of 50 min, 3 times weekly, during a period of
48 weeks.
Patients in both groups were informed about the exercises that would be helpful for their illness; however, they
were not aware of the group they were in. Patients were
asked to complete each attended session of exercises using
the study journal provided at baseline and to return the
journal at the end of the study. Only the subjects attending
the kinetic program on a regular basis were accepted for the
final evaluation.

369
Table 1 Demographics, AS-related parameters and breathing function in group I and group II at baseline
Parameter

Week 0
Group I
(n = 48)

Group II
(n = 48)

Gender (male/female)

39/9

40/8

0.789

Age (years)

25.33 (3.77)

24.98 (3.83)

0.649

Disease durationa
(years)

5.81 (3.02)

5.35 (3.11)

0.466

NSAIDs (%)

52.1

54.2

0.838

Drugs biologics (%)

20.8

18.8

0.798

Pain (VAS)

36.46 (10.42)

34.79 (12.03)

0.470

mSTa (cm)

2.71 (0.76)

2.83 (0.77)

0.428

FFDa (cm)

-18.94 (8.29)

-18.77 (8.58)

0.923

CEa (cm)

3.94 (0.79)

3.86 (0.78)

0.651

VCa (%)
BASDAIa

99.50 (7.21)
5.41 (1.95)

101.80 (11.46)
5.29 (1.96)

0.243
0.758

BASFIa

3.56 (1.83)

3.42 (1.94)

0.718

BASMIa

3.73 (0.45)

3.3 (0.45)

1.000

Mean (SD)

Data analysis
The statistical analysis was conducted using the SPSS
statistical package, version 13.00. Descriptive statistics
were used for the means and standard deviations, while
Students t and Chi-squared tests were applied for the
comparison of groups. Spearmans rank test was used to
define the intensities of statistical relations, and also their
sense. The level of significance was accepted as p \ 005.

Measurements
Results
Standard assessments were performed at week 0 and 48
and included the following parameters: pain rated on a
visual analogue scale (VAS) from 0 to 100 mm (0
meaning no pain and 100 unbearable pain) [1];
spine mobility evaluated by the modified Schober test
(mST), finger-to-floor distance (FFD) and Bath Ankylosing
Spondylitis Metrology Index (BASMI) [1]; function
defined as Bath Ankylosing Spondylitis Functional Index
(BASFI) [1]; disease activity as Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) [1]; while
breathing capacity based on chest expansion (CE) and vital
capacity (VC \ 75 %) determined by spirometry.
Conventional nonsteroidal anti-inflammatory drugs
(NSAIDs) and biologics were allowed in all cases if
reported at baseline.
The study was approved by the local ethic committee,
and written informed consent was obtained before the
study from all patients.

All ninety-nine patients included in the study were eligible

for the final analysis as all have attended on a regular basis
the kinetic program at home.
No statistically significant differences were demonstrated at baseline between groups, including demographics, clinical and functional AS-related parameters, as well
as treatment options (NSAIDs and biological agents) and
pulmonary function (Table 1). We included in our study
mainly young adults, with mild functional impairment as
reflected by mild mean values for the spinal range of
motions (mST, FFT), BASFI and BASMI, as well as mild
impairment of the physiologic measurements of pulmonary
function (CE, VC).
We demonstrated significant improvement between
baseline and after 48 weeks of regular kinetic training for
all AS-related parameters in both groups. However, for the
comparison of the groups, significant improvement was

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Rheumatol Int (2014) 34:367372

Group I
(n = 48)

Group II
(n = 48)

NSAIDs (%)

14.6

52.1

0.0002

Drugs biologics (%)

Paina (VAS)
p (revaluation vs
pretreatment)
mSTa (cm)
p (revaluation vs
pretreatment)
FFDa (cm)
p (revaluation vs
pretreatment)
CEa (cm)

14.6
13.54 (7.85)
0.001

18.8
21.04 (8.81)
0.001

0.784
0.001

4.56 (0.56)
0.001

3.48 (0.74)
0.002

0.001

BASFI (r = -0.739, p = 0.000) (Table 2). It seems that

correction of chest expansion within the 48-week multimodal exercises combining Pilates, McKenzie and Heckscher relates not only on the improvement in pain, disease
activity, function and metrology index, but also on the
increase in lumbar spine flexibility as defined by mST
(r = 0.599, p = 0.000) and FFD (r = 0.520, p = 0.000).
Surprisingly, vital capacity did not correlate with any of
the AS parameters, irrespective of the kinetic training
performed, meaning there is no relation between vital
capacity and pain, disease activity and function, flexion of
the lumbar spine as well as metrology index.

-4.81 (6.15)
0.001

-12.63 (5.89)
0.002

0.001

Discussion

Table 2 AS-related parameters and breathing function in group I and

group II after 48-week treatment
Parameter

Week 48

5.88 (0.50)

4.39 (0.77)

0.001

p (revaluation vs
pretreatment)
VCa (%)
p (revaluation vs
pretreatment)
BASDAIa
p (revaluation vs
pretreatment)
BASFIa
p (revaluation vs
pretreatment)
BASMIa

0.001

0.002

105.63 (6.94)
0.124

101.31 (9.24)
0.997

0.011

2.10 (0.82)
0.001

4.13 (1.66)
0.002

0.001

1.50 (1.11)
0.001

2.76 (1.56)
0.041

0.001

1.19 (0.84)

3.02 (0.44)

0.001

p (revaluation vs
pretreatment)

0.001

0.004

Mean (SD)

p values indicate statistical significance

found in pain, lumbar spine motility (mST, FFD), BASFI,

BASDAI and BASMI in subjects with AS performing the
specific multimodal exercise program at the end of the
study (p = 0.001). Data are shown in Table 2.
Tables 1 and 2 show that there were significant
improvements only in chest expansion in both groups as
compared to baseline (group I, p = 0.001; group II,
p = 0.002). Furthermore, at the end of the exercise program, CE increased significantly only in patients who
participated in our original kinetic program (p = 0.001).
Although the vital capacity measurements were not
significantly changed at the end of the study (group I,
p = 0.127; group II, p = 0.997), there were significant
differences within groups (p = 0.011).
We have further identified significant correlations
between chest expansion and clinical as well as AS functional variables only in the specific exercise group: spinal
pain (r = -0.360, p = 0.012), BASMI (r = -0.437,
p = 0.002), BASDAI (r = -0.744, p = 0.000) and

123

The main outcome of our study was to evaluate the

benefits of an original kinetic program combining three
methods (Pilates, McKenzie and Heckscher) on pulmonary function in subjects with AS, while secondary outcomes were focused on the assessment of function and
disease activity.
We demonstrated a significant improvement in pulmonary function, spinal motility, disease activity and
function in patients with AS who participated in the multimodal exercise program at home. Although we found
significant differences between and within groups for chest
expansion, vital capacity did not improve significantly at
the end of the 48-week exercise period. However, significant differences between the control and specific exercise
group were reported.
Starting from the idea that asserts how the cob is the
thorax is [5], we grant a special emphasis to maintain the
mobility of the spine and joints involved in accurate
breathing (costosternal and costovertebral) as well as to
prevent the occurrence of restrictive ventilatory
dysfunction.
It is well known that ankylosis of the rib cage that is
classically described in advanced AS is driving restriction
of chest expansion and vital capacity [1, 3, 4]. Furthermore,
patients become significantly impaired in performing
physical effort, as the muscles commonly involved in the
breathing, such as intercostal muscles, become atrophic [1,
4, 6].
Pilates, McKenzie and Heckscher techniques are all
concerned about the correction of vertebral statics through
exercises that preserve body alignment along with spine
mobility, with relevance to correct breathing, delaying
impairment of pulmonary ventilation [58, 10, 15, 17].
Moreover, combining breathing exercises with exercises
aiming to either achieve or maintain the standard posture of
the spine expresses the key for preserving the breathing
compliance for subjects with AS [7, 15, 17].

Rheumatol Int (2014) 34:367372

It is largely accepted that these kinetic programs aim to

correct the static deformities throughout holding the flexion
of the spine in normal range, relaxing the neck, scapulohumeral and coxofemoral muscles (antalgic exercises),
stretching the girdle muscles, as well as the abdominal
muscles, superficial and profound back muscles, stabilizing
the pelvis muscles in a neutral position, controlling
breathing accompanied by controlled movements and
reeducating the diaphragmatic breathing [57, 15].
On the other hand, according to Fernandez-de-LasPenas et al. [18], not all the exercises are benefic for AS;
however, the global postural reeducation may advance
several AS parameters, especially BASFI, BASDAI, and
BASMI.
Therefore, a revision of the literature on the role of the
exercises in AS suggested that it is necessary to establish
standardized physical programs in such particular patient
population settings [2, 1921].
Based on all these reasons, we set ourselves to carry out
a study to apply standardization of therapeutic exercises in
order to train muscle involved in the pulmonary
ventilation.
We performed an interim analysis at 24 weeks [22],
emphasizing the role of Pilates, McKenzie and Heckscher
training fulfilled on a regular basis in the management of
the restrictive respiratory dysfunction in patients suffering
from AS. Additionally, we reported statistically significant
differences in all patients as compared to baseline, particularly for chest expansion (p = 0.000), BASMI
(p = 0.000) and BASDAI (p = 0.041) [21]; thus, our
hypothesis that a multimodal exercise program improves
physical function, disease activity and respiratory function
in AS was supported.
Our final results showed significant improvement not
only in pain, BASFI, BASDAI and BASMI (p \ 0.001),
but also in lumbar spine mobility (MST, FFD) and chest
expansion (p \ 0.001), as well as in vital capacity
(p = 0.011) after 48 weeks in subgroup I compared to
subgroup II.
The significant improvement of pain in group I can be
assigned to Pilates and McKenzie training, in accordance
with prior studies [8, 9, 11].
In addition, Altan et al. [11] also reported remarkable
improvement in pain, functional status BASFI at week 12
(p = 0.031) and 24 (p = 0.007), respectively, metrology
index BASMI (p = 0.005), disease activity BASDAI
(p = 0.036) and chest expansion (p = 0.002) in patients
with AS performing Pilates training.
We reported significant correlations between chest
expansion and the functional parameters and spine mobility
in patients from group I. Besides, Cerrahoglu et al. [4]
found out that the pulmonary function was significantly
correlated with different AS parameters, while G}uns ah

371

et al. [17] showed a negative correlation between disease

duration and forced vital capacity (r = -0.509; p = 0.03)
and the chest expansion (r = -0.502; p = 0.03). Also,
Gyurcsik et al. [23] demonstrated correlations between
pain, BASFI, MST, CE and the activity of the disease,
while Velocic-Potic [24] reported a significant correlation
between the disease duration and BASFI.
In conclusion, the present study proved that there was a
significant improvement in chest expansion, clinical and
functional AS-related parameters in patients performing
the original kinetic program for a 48-week period. Furthermore, we recommend that a complex training combining Pilates, McKenzie and Heckscher exercises should
be regularly used for the improvement of pain, spine
mobility and physical functioning, as well as pulmonary
function in patients with AS.
Conflict of interest
of interest.

The authors declare that they have no conflict

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