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Ankylosing Spondylitis and Cryotherapy Treatment

Updated: Aug 29, 2021

Whole Body Cryotherapy for Ankylosing Spondylitis (Bekhterev’s Disease) Application, Effects, and Suggested Treatment Regimens

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Based on theoretical knowledge, clinical studies and experience the indication list for whole body cryotherapy has been increasingly justified and expanded over the last years (7) to include a variety of health disorders. The terminology has also been adjusted to distinguish between talking about healthy subjects (cryostimulation) versus patients (cryotherapy). Some of the medical conditions for which whole body cryotherapy has been adequately proven include inflammatory rheumatic diseases (rheumatoid arthritis and ankylosing spondylitis), degenerative rheumatic diseases (osteoarthritis) and chronic pains of various causes. Based on the available evidence, German Statutory Pension Insurance, for example, has listed whole body cryotherapy in its “Classification of therapies used for medical rehabilitation” with the indications of “Inflammatory joint diseases and pain syndromes” for functional improvement and to reduce inflammatory activity and pain. WBC has now become a steady component of ankylosing spondylitis treatment. Nevertheless, regardless of the available proof of benefits, it must be noted that one needs a medical license to give any medical advice or, moreover, to prescribe a treatment. For this reason, all cryocenters that do not have the credentials to practice medicine must stress that whole body cryotherapy is an option that must be considered in every individual case by a doctor.

WHAT IS ANKYLOSING SPONDYLITIS Just like rheumatoid arthritis, ankylosing spondylitis (AS, also known as Bekhterev’s disease) is an autoimmune chronic inflammatory rheumatic disease. While rheumatoid arthritis is extremely common, ankylosing spondylitis is a comparatively rare form of arthritis. It causes swelling between the vertebrae, the disks that make up our spine, and in the joints between the spine and pelvis, resulting in pain and stiffness. Severe cases can leave the spine hunched. The name of the condition is made of two words - "ankylosis" means abnormal stiffening and immobility of a joint due to fusion of the bones or other hard tissue and "spondylitis" stands for inflammation in the vertebrae.

Ankylosing spondylitis is a progressing lifelong disease that usually starts in the lower back but can spread up to the neck and damage joints in other parts of the body.

Symptoms include stiffness in the lower back and hips, back and joint pain, neck pain, fatigue, and gradual hunching of the spine. Ankylosing spondylitis can result in compression fractures. Other possible complications include heart problems and eye inflammation.

Development of AS often begins in teens and young adulthood, in men more often than in women. About 80% of cases present themselves before the person turns 30, and 95% by age 45.

Researchers believe that the condition is genetic, as most people with AS have a gene that makes a protein called HLA-B27. Doctors think this particular protein tells the immune system to attack some common bacteria in the body and sets off AS symptoms.

There is no known cure to date, but progression of ankylosing spondylitis can be controlled by keeping the back strong and the inflammation low through medication, exercise, and various therapies, including WBC.

THE SIZE OF THE PROBLEM Estimates have shown that ankylosing spondylitis affects up to 1.4 percent of the general population hundreds of thousands of people in the US alone. Although far behind its “closest relative” rheumatoid arthritis, the condition is less rare than often thought and can be misdiagnosed.

THE RISK FACTORS AND THEIR MANAGEMENT Although predisposition to ankylosing spondylitis seems to be genetic and cannot be effectively prevented, there are numerous ways to lessen the related joint damage, including: - Avoiding alcohol to help keep bones strong. - Getting plenty of Calcium and Vitamin D — the building blocks of bone. - Staying physically active to prevent stiffness. - Wearing good footwear to help prevent deformation, pain, and falls. - Practicing good posture while sitting or standing. - Avoiding smoking to reduce the risk of calcification in ligaments of the spine - Practicing Pilates to promote proper postural alignment, core strength, and muscle balance. - Getting good sleep to lower inflammation. - Using hot and cold applications for better blood circulation and inflammation control. - Communicating with the doctor to monitor the condition.

THE IMPORTANCE OF TREATMENT The symptoms can be mild or moderate and remain unchanged for a long period of time, but they are likely to intensify with age. Ankylosing spondylitis is a progressing illness. The goal of treatment is therefore to achieve a decrease in disease intensity and to halt or delay its progression. Unlike local therapies, whole body cryotherapy has the advantage of systemically influencing the body and suppressing several disease factors (pains and inflammation) for extended periods of time.

Common ankylosing spondylitis symptoms include back pain, joint pain and swelling, stiffness, decreased range of motion, and fatigue. In severe ankylosing spondylitis, new bone forms as part of the body's attempt to heal. This new bone gradually bridges the gap between vertebrae and eventually fuses sections of vertebrae. Those parts of the spine become stiff and inflexible, result in inability to do daily activities and an increased risk of falls and fractures. Fusion can also stiffen the rib cage and restrict the lung capacity and function. Complications may also include: - Eye inflammation (uveitis) which is one of the most common complications of ankylosing spondylitis. Symptoms include rapid onset eye pain, sensitivity to light, and blurred vision. - Heart problems. Ankylosing spondylitis can cause inflammation of aorta, enlarging it to the point of distorting the shape of the aortic valve in the heart and impairing its function. To prevent progression of the disease, treatment must begin in as early stages as possible. THE ROLE OF CRYOTHERAPYCRYOTHERAPY PROTOCOLS FOR ARTHRITIS As far as whole body cryotherapy is concerned, the therapeutic procedure for ankylosing spondylitis does not differ from rheumatoid arthritis treatment. With consistency one can usually achieve recession of the inflammation, relief and/or elimination of the pain, a reduction in medication intake, and an improvement in joint mobility. It has been demonstrated by multiple studies that whole body cryotherapy at -110° C does result in decrease of pro-inflammatory cytokines and other inflammatory immune cells and increase in anti-inflammatory cytokines and immune cells, thus having a positive effect on inflammation. On the other hand, research of whole body cryotherapy effects on ankylosing spondylitis by Agata Stanek and colleagues1,2,3,4 resulted in conclusions that WBC decreased pain intensity, improved spine mobility parameters, reduced oxidative stress, and helped prevent atherosclerosis in AS patients. Two indexes, BASDAI and BASFI*, were assessed comparing a group of people who did whole body cryotherapy followed by kinesiotherapy for 10 straight days to a group that only did kinesiotherapy (2).

* BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) is a validated diagnostic test used to determine the effectiveness of a therapy for the treatment of ankylosing spondylitis.

BASFI (Bath Ankylosing Spondylitis Functional Index) is a self-administering questionnaire that evaluates, on a visual analogue scale, functional limitation in patients with ankylosing spondylitis. Both indexes are named for the city in England where it was developed. BASDAI in the whole body cryotherapy group improved by 40% as opposed to a 15% improvement in the “kinesiotherapy only” group. BASFI changed by 30% and 16%, respectively. Relief can last for up to 2 months following the course of 10-20 cryotherapy sessions. In some cases, improvement for half a year has been reported. Cryotherapy -> reduced inflammation. Cryotherapy -> reduced pain and improved range of motion-> -> better exercise -> reduced cardiovascular risks and improved overall quality of life. The pain relief becomes more sustainable with increasing duration of serial treatment. It is important to remember, though, that whole body cryotherapy is an adjuvant physical therapy. Best results are always achieved following a holistic, complex approach. WBC is not a substitute for other proven therapies, even if it has reportedly resulted in prolonged periods of symptom relief and reduction in drug consumption in some cases.

CRYOTHERAPY PROTOCOLS FOR ARTHRITIS Due to similarities between rheumatoid arthritis and ankylosing spondylitis in nature and in symptoms, the same protocols of min 10 to 20 consecutive WBC sessions are recommended, depending on the severity of pain, the person’s response to cold and access to treatment. The below treatment protocols have been recommended by Dr. Alan Christianson, NMD, one of the first adopters of whole-body cryotherapy in the UnitedStates. In each case, the treatment protocol shall be coordinated with the doctor for additional recommendation and professional oversight of the patient’s reaction and progress.

Treatment protocol A for those with longer history of the disease and higher average pain scores: - Pain scores of 6 or over. - Those with pain over multiple locations. - Duration of symptoms greater than 2 years. Minimum number of treatments: 20. Recommended frequency of treatments: five days per week (weekdays). Duration of treatments: 4-5 weeks.

Treatment protocol B for those with more recent onset ankylosing spondylitis and lower average pain scores: - Pain scores of 5 or under. - Pain mainly in single location. - Duration of symptoms less than 2 years. Minimum number of treatments: 10. Best frequency of treatments: five days per week (weekdays). Duration of treatments: 2-3 weeks. The pain scores can be assessed using a subjective pain scale like this:

OTHER CONSIDERATIONS FOR MORE NOTICEABLE RESULTS All inflammatory conditions are heavily influenced by insufficient exercise and poor nutrition and lifestyle choices. For best results, approach to controlling and reducing symptoms of ankylosing spondylitis must be complex and include medication, physical therapy and

adjunct treatments like whole body cryotherapy, movement, diet, and other life-style adjustments. Leaving any particular nutrition- or other health-related advice to professionals, a cryotherapy center may at least raise awareness of the importance of proper nutrition and healthy lifestyle with the clients. According to and, one with ankylosing spondylitis should consider a gluten-free diet, as gluten-containing grains contribute to inflammation. Other inflammatory foods include: - Foods rich in sugar, salt, and sodium. - Vegetable oils. - Red meat. - Dairy. - Starchy foods. - Alcohol. The anti-inflammatory diet should be rich in: - Unprocessed vegetables and fruit. - Omega-3 fatty acids. - Foods naturally rich in calcium, like leafy greens. - Herbs and spices. - Vitamin D.

Other proven strategies include:

- Staying active is one of the keys to managing AS. It is suggested to make time to exercise every day, even a few minutes at a time. Due to low impact, working out in water is particularly beneficial to people with ankylosing spondylitis. - Keeping a healthy weight to put less stress on the back and joints. - Quitting smoking. Smokers’ AS symptoms tend to increasingly worsen as they get older. - Managing stress with things like massage, yoga, meditation, and counseling. - While at home or not having access to physical therapy and treatments like WBC, applying heat to stiff joints and tight muscles, and using cold on the inflamed areas.

SOURCES 1. Agata Stanek, Aleksander Sieroń,Grzegorz Cieślar, Beata Matyszkiewicz, Irena Rozmus-Kuczia. The impact of whole-body cryotherapy on parameters of spinal mobility in patients with ankylosing spondylitis. Ortopedia, traumotologia, rehabilitacja 2005. 2. Agata Stanek, Armand Cholewka, Jolanta Gadula, Zofia Drzazga, Aleksander Sieron, Karolina Sieron-Stoltny. Can Whole-Body Cryotherapy with Subsequent Kinesiotherapy Procedures in Closed Type Cryogenic Chamber Improve BASDAI, BASFI, and Some Spine Mobility Parameters and Decrease Pain Intensity in Patients with Ankylosing Spondylitis? BioMed Research International 2015. 3. Agata Stanek, Armand Cholewka, Tomasz Wielkoszyński, Ewa Romuk, Aleksander Sieroń. Whole-Body Cryotherapy Decreases the Levels of Inflammatory, Oxidative Stress, and Atherosclerosis Plaque Markers in Male Patients with Active-Phase Ankylosing Spondylitis in the Absence of Classical Cardiovascular Risk Factors. Randomized Controlled Trial. Mediators of inflammation 2018. 4. Agata Stanek, Armand Cholewka, Tomasz Wielkoszyński, Ewa Romuk, Aleksander Sieroń. Decreased Oxidative Stress in Male Patients with Active Phase Ankylosing Spondylitis Who Underwent Whole-Body Cryotherapy in Closed Cryochamber. Oxidative medicine and cellular longevity 2018 5. Mateusz Wojciech Romanowski, Anna Straburzyńska-Lupa. Is the whole- body cryotherapy a beneficial supplement to exercise therapy for patients with ankylosing spondylitis? Journal of back and musculoskeletal rehabilitation 2020 6. Bouzigon R, Grappe F, Ravier G, Dugue B. Whole- and partial-body cryostimulation/cryotherapy: Current. technologies and practical applications. Journal of Thermal Biology 2016 7. Prof. Dr. sc. Med. Winfried Papenfuß.Power from the Cold. Whole body cryotherapy at -110° C, a short-lasting physical therapy with a long-lasting

effect. 5th, revised and expanded edition January 2016, ISBN 978-3-938912- 08-9

8. Anna Lubkowska, Zbigniew Szyguła, Dariusz Chlubek, Giuseppe Banfi. The effect of prolonged whole-body cryostimulation treatment with different amounts of sessions on chosen pro- and anti-inflammatory cytokines levels. Scandinavian Journal of Clinical and Laboratory Investigation 2011

9. “WBC Protocols Pain” by Dr. Alan Christianson, NMD, for Millennium Ice 2013

Disclaimer: This article is a summary of available publications and some well- known practices that have proven to be effective in reducing inflammation and managing symptoms of ankylosing spondylitis. At the same time, every condition is different, and the result depends on many factors. By no means should this document serve as a success guarantee or as a replacement for medical advice.

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