Rheumatology International (2019) 39:1389–1396

https://doi.org/10.1007/s00296-019-04341-5
Rheumatology
INTERNATIONAL

OBSERVATIONAL RESEARCH

Core stability and balance in patients with ankylosing spondylitis

Yasemin Acar1 · Nursen Ilçin2 · Barış Gürpinar2 · Gerçek Can3

Received: 19 March 2019 / Accepted: 4 June 2019 / Published online: 12 June 2019
© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
The main purpose of this study was to compare core stability and balance between ankylosing spondylitis (AS) patients
and healthy controls. AS patients diagnosed according to the Modified New York criteria and healthy age- and sex-matched
controls were included in the study. Clinical status of AS patients was assessed using Bath AS Disease Activity Index
(BASDAI), Bath AS Functional Index (BASFI), Bath AS Spinal Mobility Index (BASMI). For evaluation of core stability,
static and dynamic core endurance and hip strength were assessed. Trunk flexor and extensor endurance, lateral side bridge
tests for static core endurance; modified sit-up test for dynamic core endurance were used. Hip strength was measured with
a hand-held dynamometer. Biodex Balance System was used to assess static and dynamic balance. Bilateral standing static
and dynamic postural stability, single leg standing postural stability and limits of stability test results were recorded. 64 AS
patients (40 male, 24 female) and 64 healthy controls (39 male, 25 female) were assessed. Static and dynamic core endurance
test results, hip abductor strength were significantly higher in control group than AS group (p < 0.05). Static postural stability
and left leg postural stability test results were significantly better in control group than AS group (p < 0.05). Overall, forward,
backward, and right, limits of stability test results were significantly higher in control group (p < 0.05). The results of our
study demonstrate that AS has negative effects on core stability and balance. It would be beneficial to add core stability and
balance training to AS patients’ rehabilitation program.

Keywords Spondylitis · Ankylosing · Postural balance · Spine · Abdominal muscles · Back muscles

Introduction structural and functional impairments and a decrease in the

quality of life [1].
Ankylosing spondylitis (AS) is a common inflammatory Characteristic symptoms of ankylosing spondylitis
rheumatic disease that affects the axial skeleton; causing are spinal stiffness and loss of spinal mobility, which are
characteristic inflammatory back pain, which can lead to explained by spinal inflammation, structural damage, or both
[2]. In advanced phases of this disease, flexibility decreases,
and the typical kyphotic posture occurs. This postural mala-
* Yasemin Acar lignment causes difficulties in maintaining the optimal body
fzt.yasemin@hotmail.com position [3]. Poor posture, decreased range of movement,
Nursen Ilçin and pain are commonly associated with balance impairment.
nrsozdemir@gmail.com It has been reported that AS patients have poorer balance
Barış Gürpinar than normal subjects [4, 5].
eski‑baris@hotmail.com Balance is closely related to core stability as it controls
Gerçek Can the trunk in response to disturbances generated by the move-
gercekcancantuna@gmail.com ment of the limbs, or other perturbations [6]. According to
1
Physical Therapy and Rehabilitation Department, Graduate
Panjabi, spinal stability involves three subsystems: pas-
School of Health Sciences, Dokuz Eylül University, Izmir, sive, active, and neural [7]. Vertebrae, facet articulations,
Turkey intervertebral discs, spinal ligaments, and joint capsules
2
School of Physical Therapy and Rehabilitation, Dokuz Eylül form the passive musculoskeletal subsystem. The active
University, Izmir, Turkey musculoskeletal subsystem consists of the muscles and ten-
3
Division of Rheumatology, Department of Internal Medicine, dons surrounding the spinal column. The neural subsystem
School of Medicine, Dokuz Eylül University, Izmir, Turkey

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involves various force and motion transducers, located in lig-
aments, tendons and muscles, and the neural control centers.
Panjabi suggested that these three subsystems are closely
related to each other and one system could compensate
for the deficits in another one. Tissue damage, insufficient
muscle strength or endurance, or poor muscle control could
result in instability [8]. The term “core”, also known as the
lumbopelvic-hip complex, could be described as a muscular
box with abdominals in the front, paraspinals, and gluteals
in the back, the diaphragm as the roof, and the pelvic floor
and hip girdle musculature as the bottom [9]. The systemic,
inflammatory nature of AS, chronic pain, inflammatory
cytokines, changes in the bone and ligaments of the spine
may affect passive and active subsystems of core stability.
However, to our knowledge, there is no study evaluating the
core stability of AS patients.
The main purpose of this study was to examine core sta-
bility and balance in AS patients compared with healthy con-
trols and to determine if there is any disruption in the core
stability and balance in AS patients. The second purpose was
to investigate relationships between disease-specific indices
and core stability and balance in AS patients.
Methods
Study design
The cross-sectional comparative study was carried out at
Dokuz Eylül University in Turkey, between 2017 and 2018.
The Ethics Committee of Dokuz Eylül University approved
the study (Decision number: 2017/05-20, dated 16.03.2017).
A signed informed consent form was obtained from all par-
ticipants included in the study.
Participants
AS patients diagnosed according to modified New York cri-
teria [10] who were under regular follow-up in Dokuz Eylül
University-Rheumatology Clinic between 18 and 65 years
of age, were included in the study. For the control group,
healthy age and sex matched and volunteer participants were
recruited from the community. Participants were excluded
if they have met any of the following criteria: the presence
of peripheral enthesitis, orthopedic disorders, cardiovascu-
lar disorders, neurological disorders, visual and auditory
deficits, history of surgery for spine or lower limb, failure
to complete the test.
Assessments
Demographic and physical characteristics (age, height,
weight, body mass index) were recorded. Participants were
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Rheumatology International (2019) 39:1389–1396
asked ‘‘Do you exercise regularly 3 or more days a week for
at least 30 min a day?’’. If the answer was ‘‘Yes’’, the type
of exercise was recorded.
Disease‑specific indices
Bath Ankylosing Spondylitis Disease Activity Index (BAS-
DAI) [11] and Ankylosing Spondylitis Disease Activ-
ity Score C (ASDAS C) [12] were used to assess disease
activity. Functional capacity was assessed using the Bath
Ankylosing Spondylitis Functional Index (BASFI). This
self-assessment instrument consists of eight specific ques-
tions regarding function in AS and two questions reflecting
the patient’s ability to cope with everyday life [13]. Bath
Ankylosing Spondylitis Spinal Metrology Index (BASMI)
was used to measure spinal mobility. The BASMI was first
published in 1994 as a 2-point scale [14], was adapted to a
10-point scale a year later [15]. In our study, 10-point scale
BASMI was used.
Core stability assessment
Although there is no consensus on the definition and meas-
urement of core stability, several tests and measurements are
available that claim to measure and assess components of
core stability. Suggested core stability components include
strength, endurance, flexibility, motor control, and function
[16]. In our study, endurance and strength were evaluated.
Endurance tests
Trunk flexor endurance test, trunk extensor endurance test,
and bilateral side bridge tests were used to evaluate static
core endurance; the protocols were introduced by McGill
et al. [17].
For trunk flexor endurance test, participants lean on a
support which kept the trunk at 60° flexion. Both the knees
and hips were flexed to 90°, arms crossed over the chest with
the hands placed on the opposite shoulder and feet were
fixed. The support of the trunk was then removed, and the
participant remained in this position for as long as possi-
ble. The test ended when the participant was no longer able
to hold the position [16]. The position holding time was
recorded in seconds.
The extensor endurance test was conducted when the
participant lay on the examining table in the prone position
with the upper edge of the iliac crests aligned with the edge
of the table. The lower body was fixed to the table by two
straps, located around the knees and ankles. With the arms
folded across the chest, the participant was asked to maintain
the upper body in a horizontal position. The time during
which the participant could hold this position was recorded
in seconds [18].
Rheumatology International (2019) 39:1389–1396
The lateral side bridge tests were performed in the side-
lying position on the mat. The subject’s knees were extended
with the top foot placed in front of the lower foot. The sub-
ject supported their weight only on their lower elbow and
feet while lifting their hips off the mat. Upper arm crossed
over the chest with hand placed on the opposite shoulder.
The test ended when the side-lying position was lost, and the
position-holding time was recorded in seconds [17].
Sit-up test was used to assess dynamic endurance. The
subject was positioned supine with knees flexed and feet
secured. The arms were crossed on the chest with the hands
on the opposite shoulders. To complete a full sit-up, the
participant’s scapulae touched the mat in the lying position,
and the elbows touched the thighs while sitting. The number
of correctly executed sit-ups within 60 s was recorded [16].
Strength tests
Isometric hip strength was measured with a hand-held
dynamometer (Lafayette Manual Muscle Tester, Model
01,163, Lafayette Instrument Company, Lafayette, IN, USA).
The hand-held dynamometer has been shown to be reliable
in assessing hip muscle strength [19]. Participants were
seated with hip and knee at 90° flexion and a dynamom-
eter was placed on 5 cm proximal of the medial malleolus
for hip external rotation strength. The participants pushed
maximally against the hand-held dynamometer for 4–5 s.
For hip extension strength measurement, the dynamometer
was placed 5 cm above the popliteal crease, and the subject
was in the prone position with the hip in the neutral posi-
tion. To measure hip abduction strength, the dynamometer
was applied to the lateral side of the distal femur while the
subject was in the supine position with hip in the neutral
position [20]. Measurements for each muscle group were
repeated 3 times bilaterally, and the highest measurement
for each pair of trials was noted. When compensation
was observed the test was terminated, and the patient was
instructed to avoid compensatory maneuvers [21].
Balance assessment
Balance was assessed by using Biodex Balance System SD
(Biodex, Inc, Shirley, NY) which is an instrument designed
to measure and train the postural stability on a static or
unstable surfaced. BBS uses a circular platform that is free
to move in the anterior–posterior and medial–lateral axes
simultaneously. The stability of the platform can be var-
ied by adjusting the level of resistance given by the springs
under the platform [22].
In our study we used 4 different test; bilateral stance static
postural stability test (level 12, stable platform), bilateral
stance dynamic postural stability test (level 4, unstable
platform), single leg stance postural stability test (stable
1391
platform) and limits of stability test. Measurement of pos-
tural stability involves the overall stability index (OSI), the
anteroposterior stability index (APSI) and the mediolateral
stability index (MLSI). The high score in these indexes
indicates poor balance. Limits of stability test examines an
individual’s ability to control the center of gravity within
the base of support. This test is a good indicator of dynamic
control. Overall, forward, backward, right and left limits of
stability results given in percentage were recorded. All bal-
ance tests were performed with eyes open and barefoot. Each
test was applied in 3 trials with 10 s rest intervals.
Statistical analysis
Sample size was calculated using G*Power (version 3.0.10)
for medium effect size (d = 0.5), 95% confidence interval and
80% power. For each group, 64 subjects were planned to be
included in the study.
Statistical analyses were performed using SPSS (Statisti-
cal Package for Social Sciences), version 24. Data normality
was tested using the Kolmogrov-Smirnov test. Descriptive
data were presented using means, standard deviations for
normally distiributed variables and medians, interquartile
range (IQR) for non-normally distrubuted variables. The
independent sample t test was used to compare normally dis-
tributed variables and the Mann–Whitney U test was used to
compare non-normally distributed variables between groups.
Categorical variables were compared using the Chi square
test. Spearman’s correlation analysis was used for investigat-
ing the relationship between disease-specific indices, core
stability results, and Biodex balance test results. Strength
of correlation was interpreted as “very high” (r > 0.90),
“high” (r = 0.70–0.90), “moderate” (r = 0.50–0.70), “low”
(r = 0.30–0.50), and “negligible” (r = 0.00–0.30) [23]. P
values less than 0.05 were considered to be statistically
significant.
Results
128 subjects (64 AS patients, 64 healthy controls) completed
the study. The demographic and anthropometric features of
AS patients and healthy controls are presented in Table 1.
There was no significant difference between the groups
(p > 0.05) (Table 1). Twenty-two subjects in the AS group
and nineteen subjects in the control group reported regular
exercise. There was no significant difference between the
groups in terms of the number of people exercising regularly
(p = 0.570). The types of exercise are presented in Table 1.
In AS group median disease duration was 9.0 (3.2–16.0)
years, median ASDAS C was 2.0 (1.4–2.8), median CRP
level was 5.0 (1.8–10.8) mg/L. Median BASDAI, BASFI,
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Table 1  Characteristics of AS group (n = 64) Control group (n = 64) p value

ankylosing spondylitis and (X ± SD) (X ± SD)
control group
Age (years, X + SD) 39.9 ± 8.8 38.1 ± 9.7 0.251a
Weight (kg, X + SD) 77.0 ± 13.5 74.73 ± 12.67 0.322a
Height (m, X + SD) 1.7 ± 0.1 1.7 ± 0.1 0.979a
BMI (kg/m2, X + SD) 26.5 ± 3.8 25.7 ± 3.4 0.196a
Gender, male/female 40/24 39/25 0.856b
Smoking (yes/no) 22/42 23/41 0.853b
Regular exercise (n)
Yes/no 22/42 19/45 0.570b
Type of exercise
Swimming (n) 7 1
Fitness (n) 5 6
Walking (n) 5 5
Pilates (n) 2 2
Running (n) 2 4
Cycling (n) 1 –
Tenis (n) - 1

AS ankylosing spondylitis, X mean, SD standard deviation, BMI body mass index, n number of subject
a
Independent sample t test, bChi–square test

Table 2  Endurance test results AS group (n = 64) Control group (n = 64) p

Median (P25–P75) Median (P25–P75)

Trunk flexor endurance (s) 34.1 (20.0–53.5) 56.5 (40.9–82.5) < 0.001
Trunk extensor endurance (s) 43.3 (22.1–69.7) 86.0 (71.2–106.6) < 0.001
Right side bridge (s) 40.7 (23.1–59.9) 61.0 (43.5–84.3) < 0.001
Left side bridge (s) 40.0 (25.7–58.9) 61.5 (45.2–82.2) < 0.001
Sit-up test 17.5 (7.0–26.7) 24.0 (15.2–30.0) 0.004

AS ankylosing spondylitis, P25 percentile 25, P75 percentile 75

Mann–Whitney U test

and BASMI scores were 2.1 (1.0–3.9), 1.1 (0.3–2.7), and Table 3  Isometric hip strength results
2.1 (1.1–3.4), respectively. AS group (n = 64) Control p
(X ± SD) group
(n = 64)
Core stability results (X ± SD)

Endurance test results Hip extension (R) 29.9 ± 5.5 31.5 ± 3.5 0.052
Hip extension (L) 30.4 ± 5.8 31.7 ± 3.6 0.159
Static and dynamic endurance test results are given in Hip abduction (R) 23.7 ± 4.7 25.7 ± 4.0 0.015
Table 2. Static and dynamic endurance test results were sig- Hip abduction (L) 23.8 ± 4.2 25.9 ± 4.2 0.005
nificantly higher in control group than AS group (p < 0.05). Hip external rotation (R) 17.3 ± 3.9 17.8 ± 3.8 0.487
Ten of the AS patients could not perform the sit-up test Hip external rotation (L) 17.0 ± 4.0 17.7 ± 4.0 0.354
while only one person in the control group could not. AS ankylosing spondylitis, R right, L left, X mean, SD standart devia-
tion
Independent sample t test
Isometric hip strength results

When we compared the isometric hip strength results of the right and left hip isometric abductor strength were higher in
AS group with the control group, it was seen that the mean the control group (p < 0.05) (Table 3).

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Balance results Table 5  Correlation analysis

BASDAI BASFI BASMI
Biodex Balance System test results are shown in Table 4.
We found that static postural stability OSI, APSI and MLSI Trunk flexor endurance − 0.028 − 0.117 − 0.215
were significantly better in control group than AS group Trunk extensor endurance − 0.296* − 0.344** − 0.592**
(p = 0.020, 0.001, 0.011 respectively). There was no statis- Right side bridge − 0.265* − 0.307* − 0.184
tically significant difference between AS and control group’s Left side bridge − 0.256* − 0.362** − 0.269*
OA, AP, and ML stability indices at level 4. Left leg OA, Sit-up test − 0.216 − 0.261* − 0.431**
AP, and ML postural stability indices in the control group Static postural stability (OSI) − 0.011 − 0.017 − 0.036
were significantly better than AS group (p < 0.05). Overall, Dynamic postural stability (OSI) 0.115 0.288* 0.131
forward, backward and right, limits of stability test results Right leg postural stability (OSI) 0.185 0.305* 0.052
were significantly higher in the control group (p < 0.05). Left leg postural stability (OSI) 0.125 0.190 − 0.019
Limits of stability (overall) 0.083 0.054 − 0.148
Correlation analysis Values represent Spearman’s rho
BASDAI Bath Ankylosing Spondylitis Disease Activity Index, BASFI
Correlation analysis was performed between the disease- Bath Ankylosing Spondylitis Functional Index, BASMI Bath Anky-
specific indices and core endurance test results, balance test losing Spondylitis Spinal Metrology Index, OSI overall stability index
results. The results of the correlation analysis are presented *p < 0.05
in Table 5. There was a negative weak correlation between **p < 0.01
the BASFI score and the trunk extensor endurance test
(rs= − 0.344, p = 0.005), right side bridge test (rs = − 0.307,
p = 0.014), and left side bridge test (rs = − 0.362, p = 0.003).
A negative weak correlation between the BASMI score and
Table 4  Biodex Balance System test results sit-up test (rs = − 0.431, p < 0.01), and a negative moderate
correlation between the BASMI score and the trunk exten-
AS group Control group p
(n = 64) (n = 64) sor endurance test (rs = − 0.592, p < 0.01) was found. When
the correlation between the disease-specific indices and the
Static postural s­ tabilitya balance test results was examined, there was only a positive
OSI 0.3 (0.2–0.5) 0.3 (0.2–0.4) 0.020 weak correlation between the BASFI score and the right leg
APSI 0.2 (0.2–0.3) 0.2 (0.2–0.3) 0.001 postural stability OSI (rs = 0.305, p = 0.014).
MLSI 0.1 (0.1–0.2) 0.1 (0.1–0.1) 0.011
Dynamic postural s­ tabilitya
OSI 1.5 (1.3–2.1) 1.5 (1.1–1.19) 0.216 Discussion
APSI 1.0 (0.8–1.5) 1.0 (0.7–1.2) 0.053
MLSI 0.9 (0.8–1.2) 0.9 (0.7–1.2) 0.501 AS is a chronic systemic disease which damages bone and
Right leg postural ­stabilitya soft tissue around spinal colon leads to postural changes. It
OSI 0.8 (0.7–1.1) 0.8 (0.7–0.9) 0.176 is a known fact that these changes restrict patients’ range
APSI 0.5 (0.4–0.7) 0.5 (0.4–0.6) 0.171 of movements. Studies have been showing that there are
MLSI 0.4 (0.4–0.6) 0.5 (0.4–0.5) 0.498 many other primary and secondary symptoms of AS. To our
Left leg postural s­ tabilitya knowledge core stability is not analyzed previously and our
OSI 0.8 (0.7–1.1) 0.7 (0.6–0.9) 0.006 study revealed that core stability and balance are negatively
APSI 0.5 (0.4–0.7) 0.5 (0.4–0.6) 0.012 affected in AS patients compared to healthy subjects.
MLSI 0.5 (0.4–0.6) 0.4 (0.3–0.5) 0.038 In order to evaluate core stability, we used core endurance
Limits of s­ tabilityb and hip strength tests. The results of this study demonstrated
Overall (%) 52.0 ± 9.9 58.9 ± 11.7 < 0.01 that AS patients had decreased static and dynamic endur-
Forward (%) 64.7 ± 16.6 70.9 ± 14.5 0.027 ance compared to healthy subjects. Similarly, isometric hip
Backward (%) 53.3 ± 16.7 62.6 ± 19.1 0.004 abduction strength in AS patients was significantly lower
Right (%) 56.7 ± 16.8 62.4 ± 15.2 0.046 than healthy group. Static core endurance scores even in the
Left (%) 64.8 ± 14.9 67.7 ± 16.2 0.290 healthy subjects were found lower than the related literature.
AS ankylosing spondylitis, OSI Overall Stability Index, APSI Anter- There is no study investigating the Turkish normative values
oposterior Stability Index, MLSI Mediolateral Stability Index of static endurance, therefore, it is difficult to discuss the
a
Median (25th–75th percentile) amount of change yet. However, there was a considerable
b
Mean ± standart deviation difference between AS and healthy subjects.

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During trunk extensor endurance test high fatigue rate
was shown in the multifidus muscle due to the high activ-
ity level of the multifidus muscle [24]. The systemic and
inflammatory nature of AS, chronic pain, inflammatory
cytokines and changes in the bones/ligaments of the spinal
column may affect the paravertebral muscles. Similarly atro-
phy in the multifidus and erector spinal muscles was shown
in AS patients [25]. Atrophy of paravertebral muscles may
cause a decrease in strength and endurance of trunk exten-
sor muscles. Another factor affecting extensor endurance
may be spinal mobility. Alaranta et al. [26] reported that
spinal mobility and static extensor endurance were related
in AS patients. Similarly, we found a moderate relationship
between extensor endurance and spinal mobility in our study.
Transversus abdominis (TrA), external oblique (EO),
internal oblique (IO) muscles are active during the lat-
eral side bridge test [27, 28]. Our study showed that static
endurance of these muscles was affected negatively in AS
patients. Atrophy may be considered as the reason for lower
endurance scores however the thickness of these muscles
was found similar in AS patients and healthy subjects in
another study [29]. On the other hand in the same study, it
was reported that AS patients with higher physical activity
level had significantly thicker muscles. Literature does not
have sufficient evidence on TrA, EO, IO muscle thickness
and its relation with static endurance in AS patients so more
studies are needed to understand the reason of lower endur-
ance level in AS patients.
Dynamic core endurance was evaluated with a modified
sit-up test. Modified sit up test results were higher in the
control group. Only one subject in the control group had
difficulty in performing the test while 10 AS patients failed
to perform the test. We also concluded that a modified sit-up
test was associated with spinal mobility. This relationship
between spinal mobility and core endurance tests indicates
that when spinal mobility is reduced, core endurance may
be decreased or vice versa. The deterioration of the neutral
position of the spine in ankylosing spondylitis may impair
the stabilization synergy between the core muscles. We think
there is a need for further studies evaluating core stability
in AS patients.
Since hip muscle strength is an important component
of core stability, we evaluated the isometric hip extension,
abduction and external rotation strength in our study. We
found that only the hip abduction strength was significantly
lower in AS patients compared to healthy subjects. When
we examined the literature, we could not reach another study
evaluating hip strength in AS patients.
It was reported during the Sorenson test fatigue occurred
not only in the paraspinal muscles but also in the hip exten-
sor muscles, and their fatigue was closely related to endur-
ance times [30]. Because the gluteus maximus is coupled
with the paraspinal muscles via the thoracolumbar fascia,
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Rheumatology International (2019) 39:1389–1396
the loads that occur during this test are shared between the
paraspinal muscles and the hip extensors. However, it was
reported that isometric hip strength measures, particularly
external rotation, are predictors of back and lower extremity
injury in the athletic population [31]. Strengthening of hip
muscles may improve core endurance in AS patients.
Balance in AS is a growing debate. The first study in
this field was conducted by Murray et al. [32] compared
postural sway of AS patients and healthy controls and found
that AS patients had poor balance in eyes open and closed
positions. In another study that force platform was used in
the evaluation of postural control was reported that postural
control was altered particularly in the frontal plane in AS
patients [33]. Similar to results of these studies we found
that, static postural stability in AS patients impaired not
only in frontal planes but also in the sagittal planes. On the
other hand, Adam et al. tested thirty patients with AS and
20 healthy subjects by using the Tetrax Interactive Balance
System. Unlike our results, they found no significant differ-
ence between AS patients and healthy subjects in terms of
general stability index in static position with open eyes. It
was reported that this result may be due to compensation
related to increased thoracic kyphosis or higher number of
female patients in this study [34].
Dynamic postural stability test results were similar in
both groups. Likewise Aydoğ et al. evaluated dynamic pos-
tural stability using the Biodex Stability System and indi-
cated that AS did not have a negative effect on dynamic pos-
tural balance. According to these authors, postural stability
in AS patients can be compensated by other unaffected joints
[35]. Different from our results Durmuş et al. concluded that
there was a decrease in dynamic balance in AS patients.
They also found that impaired balance was associated with
increased kyphosis during the course of the disease [36].
The results of this study showed that AS patient had
diminished single leg stance postural stability. Interestingly
it was found that only left leg stance postural stability was
diminished. Gluteus medius is one of the most important
muscles in single leg stance as it prevents the contralateral
pelvis from “dropping”, maintains frontal plane position and
initiate transverse-plane rotation of the pelvis. Even though
the left and right gluteus medius strengths were lower in AS
patients only the left leg stance postural stability was found
impaired. More studies are needed to understand the reason
behind this result.
Limits of stability (LOS) is known as the maximum dis-
tance that an individual can intentionally move his center of
gravity in any direction without losing balance or taking a
step [37]. It was found that there was a significant difference
between the AS group and control group in all of the over-
all, anterior, posterior and right LOS results except the left
LOS results. Although the left LOS results were higher in
the control group than AS group, no statistically significant
Rheumatology International (2019) 39:1389–1396
difference was found between them. In the literature, we
could not find any other study evaluating the limits of stabil-
ity in AS patients. Functional reach test is considered as a
valid and reliable method for measuring limits of stability
[38]. Studies have reported that the functional reach test in
patients with AS is lower than in healthy subjects [3, 5].
When we examined whether there was a relation-
ship between disease-specific indices (BASDAI, BASFI,
BASMI) and balance in AS group, we concluded that only
positive weak correlation was found between BASFI and
right leg postural stability OSI. Similarly, some previous
studies have shown that there is no relationship between bal-
ance and BASDAI, total BASMI score. However, in these
studies, when the relationship between the subparameters of
BASMI and postural stability was investigated, the relation-
ship between tragus-wall distance and postural stability was
found [36, 39].
We think that conflicting results in studies evaluating bal-
ance in AS patients are derived from the different method-
devices used in. The lack of a specific scale that assessing
the balance of AS patients makes it difficult to reach a defi-
nite conclusion about the balance effect in AS.
Limitations
The study has some limitations. Although many different
tests have been used to assess core stability, there is no con-
sensus on the definition, components and assessment of core
stability. The hand-held dynamometer measurements can be
influenced by the strength of the examiner, in future studies,
it would be better to use the isokinetic device for assessment
of the hip strength. Another limitation of our study is that,
there is no standard protocol for the use of the Biodex Bal-
ance System.
Exercise has positive effects on core stability and balance.
Since there is no significant difference between the groups in
terms of the number of subjects who exercise regularly, we
think that it does not affect our results. However, the pres-
ence of regular exercise could have been another exclusion
criterion. There may be a relationship between radiographic
findings and core stability/balance in AS patients. Another
limitation of our study is that the radiographic findings were
not used.
Conclusion
In conclusion, the results of our study suggest that anky-
losing spondylitis has negative effects on core stability and
balance. To our knowledge, this is the first study evaluat-
ing core stability in AS patients. Literature suggests that
core stability is an important component of nearly all gross
motor activities. We believe that our study is important for
1395
the eliminating deficiencies in the literature and there is a
need for new studies evaluating core stability in AS patients.
In clinical practice balance problems in AS patients are not
common, but the presence of subclinical balance disorders
should be considered. It would be beneficial to add core
stability and balance exercises to the rehabilitation program
of AS patients.
Author contributions YA conducted the literature search for the back-
ground of the study, collected, analyzed and interpreted statistical data,
wrote the majority of the manuscript. NI contributed to the design
and implementation of the research, the analysis of the results and the
writing of the manuscript. BG and GC contributed to the design of the
study, the collection of data and the revision of the manuscript. All
authors read and approved the final manuscript.
Compliance with ethical standards
Conflict of interest The authors declare no conflicts of interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Human and animal rights statement All procedures performed in stud-
ies involving human participants were in accordance with the ethical
standards of the institutional and/or national research committee and
with the 1964 Helsinki Declaration and its later amendments or com-
parable ethical standards.
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