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Exercise therapy for patients with diffuse idiopathic skeletal hyperostosis

Article  in  Clinical Rheumatology · February 2008

DOI: 10.1007/s10067-007-0693-z · Source: PubMed

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Clin Rheumatol (2008) 27:207–210
DOI 10.1007/s10067-007-0693-z

ORIGINAL ARTICLE

Exercise therapy for patients with diffuse idiopathic

skeletal hyperostosis
Adeeba Al-Herz & Jan Paul Snip &
Bruce Clark & John M. Esdaile

Received: 15 June 2007 / Accepted: 22 June 2007 / Published online: 21 September 2007
# Clinical Rheumatology 2007

Abstract We evaluated the effect of exercise therapy on back
pain, spinal range of motion (ROM), and disability in persons
with diffuse idiopathic skeletal hyperostosis (DISH). Persons
with symptomatic DISH received a daily exercise program for
24 weeks consisting of mobility, stretching, and strengthening
exercises for the cervical, thoracic, and lumbar spine. It
included 14 supervised sessions over 8 weeks. Outcomes
included visual analogue scales (VAS) for pain, stiffness, and
fatigue, 13 spinal measurements, the neck pain and disability
scale, the Quebec back pain disability scale, the Bath
Spondylitis Functional Index, and the MACTAR patient
preference scale. Assessments were made at baseline, 8 weeks,
and 24 weeks. Fifteen of 17 completed the study. Comparing
week 24 with baseline, Schober’s test improved significantly
(p=0.02), and VAS stiffness and left finger-to-floor test
demonstrated a trend to improvement (p=0.07 each). The
physical measures, which were expected to improve with the
exercise program, all moved in the direction expected, but
had p values>0.10. At 24 weeks, eight (53.3%) participants
rated their status as improved, three (20%) as unchanged,
and four (27%) were unsure about the benefit. The exercise
program designed for DISH and tested in this study led to
small improvements in physical measures which achieved
significance only for lumbosacral flexion.

Keywords Diffuse idiopathic skeletal hyperostosis .

A. Al-Herz Exercise therapy . Treatment
Division of Rheumatology, Kuwait University, Al-Amiri Hospital,
P.O. Box 4077, Kuwait 13041, Kuwait
e-mail: adeebaalherz@yahoo.com
Introduction
J. P. Snip
Treloar Physiotherapy Clinic, Diffuse idiopathic skeletal hyperostosis (DISH) is a com-
Vancouver BC, Canada
mon disorder in the middle aged and elderly. It is
B. Clark : J. M. Esdaile (*) characterized by flowing ossification of the anterior longitu-
Arthritis Research Centre of Canada, dinal ligament of the spine leading to bony ankylosis [1], as
895 W 10th Ave, well as ossification of the entheses and bony spurs in the
Vancouver BC V5Z 1L7, Canada
e-mail: jesdaile@arthritisresearch.ca
peripheral skeleton [2]. While many persons with DISH are
asymptomatic, those with symptoms have complaints and
J. M. Esdaile findings that are distinctive from other spinal disorders [3]
Division of Rheumatology, University of British Columbia, and from osteoarthritis [4] and that can cause significant pain
Vancouver BC, Canada
and disability.
J. M. Esdaile The treatment of DISH is anecdotal. Nonsteroidal anti-
University of Queensland, inflammatory drugs (NSAIDs) or low-dose radiation ther-
Brisbane, Australia apy can reduce heterotopic bone formation after hip
J. M. Esdaile
arthroplasty, a condition sometimes linked to DISH. In
Canadian Arthritis Network, 1976, Utsinger et al. [5] reported symptomatic benefit from
Vancouver, Canada mild analgesics or local heat. Chiropractic and acupuncture
208
were reported helpful in two cases [6, 7]. Local corticoste-
roid or lidocaine injections, massage therapy, and therapeu-
tic ultrasound have been tried to ease pain and increase
spinal flexibility. No treatment has been suggested as
altering the natural history of DISH.
Many physicians refer their patients for physical therapy.
However, exercise therapy has not been studied for DISH.
We have conducted a pilot study to explore the potential
effect of exercise on pain, range of motion (ROM), and
function in persons with DISH.
Materials and methods
Study subjects Individuals with symptomatic spinal DISH
were recruited from local rheumatologists. To be included,
individuals had to: (1) fulfill the criteria of Resnick [1]; (2)
have either back pain, back stiffness, or both; and (3)
provide informed consent. They were excluded if: (1) they
had a condition that would prevent them from performing
regular exercise; (2) they had a major concomitant inflam-
matory rheumatic disease; and (3) they had had back
surgery during the previous 3 months or had any surgery
planned for the ensuing 6 months.
Study visits Study subjects attended Treloar Physiotherapy
Clinic for 14 visits over 8 weeks. At each session, the
participant received 1 h of supervised exercise instruction
from JPS. The participants were instructed to perform the
same exercises on the days when they did not attend the
clinic. After 8 weeks of supervised therapy, the study
subjects were required to continue the same exercise
program for 16 more weeks on a daily basis and were not
permitted to start a new exercise program.
Treatment program The physical therapy protocol con-
sisted of three parts: strengthening, mobility, and stretching
exercises. The strengthening exercises included the pelvic
pinch combined with alternate single knee raise, abdominal
curl (upper abdominals), quadriceps strengthening over roll,
gluteus medius bent knee lift (hip abductor strengthening),
hip abductor straight leg raise (side lying), and buttock raise
(hip extensor strengthening). The mobility exercises in-
cluded single knee to chest, double knee to chest, bilateral
knee rolls (crook lying), lateral knee rolls variation with
foot crossed over contralateral thigh (crook lying), cervical
rotation, cervical side flexion with arm raised over head,
chin tuck (lying and standing against the wall), thoracic
rotation using chair support, cat back, elevation on to
elbows then hands and pushing head and shoulders
upwards in a prone position, and side flexion with arm
over head. The stretching exercises included hamstring
stretch and seated low backstretch.
Clin Rheumatol (2008) 27:207–210
Painkillers including acetaminophen, with or without
codeine, and NSAIDs were maintained at a fixed dose
throughout the study.
Outcome assessments Participants were assessed at base-
line, after 8 weeks and at 24 weeks. At each assessment
visit, they were assessed with five 100-mm visual analogue
scales (VAS), four disability scales, and 13 spinal measure-
ments. The VAS included two scales for pain (Overall, how
do you describe your neck pain this week? And, Overall,
how do you describe your mid-back and low back pain this
week?), one for fatigue (Overall, how do you describe your
general fatigue this week?), and two for stiffness (How
would you describe the overall level of morning stiffness
you have had from the time you wake up? And, How long
does your morning stiffness last from the time you wake
up?). They were all scaled from 0 to 100 mm, 0 being none
and 100 being extreme, except for the duration of stiffness
VAS which was scaled from 0 to 120 min. The disability
scales were the neck pain and disability scale [8] and the
Quebec back pain disability scale [9] (both scored 0 to 100
with 100 the worst), the Bath Ankylosing Spondylitis
Functional Index (BASFI) [10] (scored 0 to 10 with 10 the
worst), and the modified MACTAR patient preference
disability scale [11], a self-assessed questionnaire in which
the patient chooses activities that are affected by his or her
pain and rates them according to their importance. Cervical
range of motion (ROM) included right and left lateral
flexion, right and left rotation, and tragus to wall distance
[12]. The thoracolumbar ROM included chest expansion
[13], right and left axial rotation, Moll and Wright’s
modified Schober test [14], and right and left fingertip-
to-floor distance [15]. Upper and lower abdominal strength
measures were assessed. At 24 weeks, subjects were asked,
“In general, do you think you have benefited from this
program, and if so, how do you think it helped you?”
Analysis The data were analyzed using SPSS version 10.0. To
compare the change from baseline to 24 week for the outcome
measures, Student’s paired t test was used. Significance was
determined using a two-tailed test and p<0.05 was consid-
ered significant.
Ethical approval The protocol and the consent form were
approved by the University of British Columbia Ethics
Committee.
Results
Seventeen patients fulfilling the inclusion criteria agreed to
participate in the study and 15 completed the study. One
Clin Rheumatol (2008) 27:207–210 209

Table 1 Baseline characteristics of the 15 participants were taking acetaminophen (two with codeine) and eight
Characteristics Values were taking NSAIDs.
The participants had moderate neck and back pain and
Male gender, number (%) 12 (80) stiffness and moderate disability (Table 2). The exercise
Mean age, years (range) 67 (51–86) program was designed to improve spinal ROM. The mod-
College education or higher, 5/15 (33)
ified Schober test showed significant improvement (p=0.02)
number (%)
and there was a trend to statistical significance for the left
Duration of DISH symptoms, 12.2 (1.5–25)
years (range) finger-to-floor distance (p=0.07), as well as a nonspinal
Time since diagnosis, years (range) 1.6 (0.1–10) ROM variable, the VAS stiffness severity scale (p=0.07).
Benefit from previous treatments The other physical measures variables all improved (Table 2)
NSAIDs, number (%) 8/12 (67) although the improvements were small. In the interests of
Acetaminophen, number (%) 7/11 (64) space, Table 2 provides the results from only the left-sided
Physiotherapy, number (%) 5/9 (56) physical measures. Those on the right were similar and the
Massage therapy, number (%) 4/9 (44)
results are available from the authors. The VAS back pain
Heat, number (%) 3/7 (43)
Chiropractic, number (%) 3/7 (43)
scale improved but the VAS neck pain scale did not. The
Acupuncture, number (%) 1/4 (25) changes in the disability scales were modest.
Ice packs, number (%) 1/2 (50) At the end of the study, eight participants (53%) rated
their status as improved and stated that they felt they had
increased their spinal flexibility. Six of the eight also stated
they had had a reduction in back pain. Three participants
(20%) felt they were unchanged and four (27%) were
discontinued the program because of worsening back pain unsure about the benefit.
and the other developed an unrelated gastrointestinal
disease that prevented her from continuing. The demo-
graphic features and previous treatments for the 15 patients Discussion
are outlined in Table 1. Eight participants were retired, four
had a full-time job, and two were receiving disability Physical therapy has not been studied previously in DISH.
payments because of back pain. At baseline, six participants The program resembles one that might have been used for

Table 2 Outcome measures at baseline, end of treatment (8 weeks), and final visit (24 weeks)

Measure Baseline, 8 weeks, 24 weeks, 24 weeks, p value

mean (SD) mean (SD) mean (SD) baseline mean (SD)

Symptoms VAS-neck pain (0–100 mm) 38.7 (33.7) 29.33 (22.3) 39.7 (34.6) 1.1 (33.8) 0.91
VAS-back pain (0–100 mm) 54.8 (26.2) 42.1 (30.7) 43.7 (31.9) −11.1 (26.8) 0.13
VAS-fatigue (0–100 mm) 47.4 (23.7) 40.9 (25.7) 44.1 (26.3) −3.3 (29.8) 0.67
VAS-stiffness (0–100 mm) 59.9 (27.9) 47.5 (29.7) 51.7 (29.5) −8.1 (15.8) 0.07
Duration of stiffness (minutes) 55.5 (38.7) 45.6 (28.1) 59.3 (45.3) 3.8 (38.4) 0.70
Disability Neck pain and disability scale 34.3 (24.9) 27.0 (18.6) 33.9 (24.4) −0.36 (18.2) 0.94
scales (0–100)
Quebec back pain disability 42.7 (20.8) 39.8 (23.5) 42.3 (24.4) −0.40 (9.5) 0.87
scale (0–100)
BASFI (0–10) 5.1 (2.1) 4.2 (2.3) 4.6 (2.4) −0.46 (1.3) 0.18
MACTAR (15–45) 30.1 (2.3) 32.3 (5.5) 30.9 (3.9) 0.80 (4.6) 0.51
Physical Chest expansion (cm) 2.3 (1.2) 2.3 (1.3) 2.4 (1.4) 0.02 (1.2) 0.82
measures Left axial rotation (degrees) 16.3 (7.8) 17.1 (7.2) 18.8 (6.1) 2.5 (8.5) 0.27
Left cervical flexion (degrees) 17.1 (5.2) 18.1 (7.3) 19.3 (9.4) 2.2 (7.2) 0.26
Left cervical rotation (degrees) 51.7 (10.8) 56.9 (11.0) 55.3 (11.5) 3.6 (10.3) 0.20
Schober’s test (cm) 18.3 (1.3) 18.8 (0.94) 18.8 (1.4) 0.58 (0.81) 0.02
Left finger to floor (cm) 59.2 (6.1) 57.5 (5.9) 53.4 (12.1) −5.8 (11.4) 0.07
Tragus to wall (cm) 13.3 (2.8) 13.2 (2.9) 13.7 (3.3) 0.36 (1.5) 0.36
Lower abdominal strength 1.4 (1.1) 1.0 (0.0) 1.0 (0.0) −0.40 (1.1) 0.19
(grades = 1–6)
Upper abdominal strength 3.7 (0.59) 3.5 (0.74) 3.6 (0.83) −0.13 (0.52) 0.33
(grades = 1–4)
210
ankylosing spondylitis (AS) as for both DISH and AS
require mobility exercises to maintain mobility or to restore
lost range of motion. The strengthening of the spinal
extensor muscles needed to combat the tendency to a
stooped posture with AS was not included. The DISH
program did include exercises for strengthening the abdomi-
nals, the quadriceps and the hip abductors, and exercises for
hamstring stretching so it was quite comprehensive.
We hoped to demonstrate larger benefits with the
exercise program in the spinal ROM measures than were
seen. The Schober test did demonstrate significant im-
provement and there was a trend to improvement in the left
finger-to-floor distance (Table 2). The improvement in the
other spinal ROM measures was limited. Pain and stiffness
were expected to benefit less than spinal ROM. Chest
expansion for which no therapeutic component was
included in the exercise program was not expected to
improve. Nonetheless, eight of the 15 participants conclud-
ed that they had increased flexibility and six of the eight
stated they had reduced back pain. Neck pain was reduced
at the end of the treatment phase but returned to baseline by
24 weeks (Table 2). Low back pain was improved at 8 and
24 weeks but the improvement did not reach statistical
significance.
The limited improvement in the spinal ROM measures
may reflect the prolonged disease duration and the
underlying pathology—calcification and ossification of
spinal ligaments. While the participants had been diagnosed
for only an average of 1.6 years, they had been symptom-
atic for more than 12 years.
The lack of benefit may not mean that exercise is not
effective in DISH. It may have been the specific program that
was ineffective. However, the program was well tolerated.
Only one participant withdrew from the program because of
worsening of back pain. We conclude that the exercise
program tested in this pilot improved lumbosacral flexion
although the impact on other spinal measures was small.
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Clin Rheumatol (2008) 27:207–210
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