Exercise for ankylosing spondylitis: An evidence-based consensus statement

Non-pharmacological interventions for patients with axial spondyloarthritis: a meta-analysis

Background

Non-pharmacological interventions (NPIs) are recommended in current international clinical practice guidelines for the management of axial spondyloarthritis (axSpA) as a complementary therapy.

Objectives

To assess the comparative impact of different NPIs on the clinical outcomes of patients with axSpA.

Design

Network meta-analysis and traditional meta-analysis of randomized controlled trials (RCTs).

Data sources and methods

We searched systematically PubMed, EMBASE, the Cochrane Library, Web of Science, and Chinese Biological Medical Database up to May 2023, and included these RCTs of patients with axSpA receiving the managements of NPIs. The risk of bias of individual RCT was assessed through a modified version of the Cochrane Risk of Bias Tool. Bayesian random-effects network meta-analysis and traditional meta-analysis were performed to calculate the mean difference.

Results

A total of 51 RCTs involving 3457 patients with axSpA were included in this study. Both supervised combined exercises and neuromuscular training showed a significant reduction in disease activity (Bath Ankylosing Spondylitis Disease Activity Index (BASDAI): 1.13 lower, 1.17 lower, respectively), physical function (Bath Ankylosing Spondylitis Functional Index (BASFI): 1.0 lower, 0.88 lower, respectively), and spinal mobility (Bath Ankylosing Spondylitis Metrology Index (BASMI): 0.7 lower, 1.35 lower, respectively), compared to standard care. Both supervised combined exercises and neuromuscular training also presented more significant improvement than conventional exercises in disease activity (BASDAI: 0.91 lower, 0.95 lower, respectively), physical function (BASFI: 0.67 lower, 0.56 lower, respectively), and spinal mobility (BASMI: 0.18 lower, 0.82 lower, respectively). A traditional meta-analysis demonstrated that supervised combined exercise and neuromuscular training could significantly reduce BASDAI, BASFI, and BASMI scores when compared to unsupervised exercise or standard care. Aerobic exercise, supervised combined exercise, and conventional exercise could significantly reduce pain scores, compared to standard care.

Conclusion

Compared to either standard care or conventional exercises, supervised combined exercises and neuromuscular training were more beneficial for ameliorating disease activity, physical function, and spinal mobility in patients with axSpA. The choice of exercise modalities may depend on patient values and preferences.

Trial registration

PROSPRO: CRD42021251219.

State-of-the-Art Review on the Treatment of Axial Spondyloarthritis

The term axial spondyloarthritis (axSpA) encompasses patients with both radiographic (r-axSpA) and non-radiographic (nr-axSpA) forms of the disease. These are two entities within the same family that share many genetic and pathogenic factors, but they also have significant differences. For example, the male-to-female ratio is 2:1 in r-axSpA and 1:1 in nr-axSpA. Additionally, the prevalence of the HLA-B27 gene is notably higher in r-axSpA. Early diagnosis remains an unmet need, with magnetic resonance imaging (MRI) being the most important tool for diagnosis and disease monitoring. Early detection is crucial, as it allows for timely treatment, increasing the chances of preventing new bone formation and long-term structural bone damage. Various cytokines, such as tumor necrosis factor (TNF)-α and interleukin-17, play active roles in the disease's pathogenesis, although the exact mechanisms of interaction are not yet fully understood. Clarifying these mechanisms will be key to developing new classification criteria, screening methods, and more personalized, targeted therapies. Non-steroidal anti-inflammatory drugs (NSAIDs), TNF inhibitors, interleukin-17 blockers, and, more recently, Janus kinase (JAK) inhibitors, are the most effective treatments for both radiographic and non-radiographic axial spondyloarthritis.

Optomechanical Analysis of Gait in Patients with Ankylosing Spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease associated with alterations in posture and gait. The aim of this study was to assess the gait of AS patients using pedobarography and a markerless motion capture system. This is the first study of this population to combine these two methods. Twelve AS patients and twelve healthy controls were enrolled in this study. An instrumented gait analysis of both groups was performed using pedobarography and Microsoft Kinect v2. The AS group was significantly older than the controls (p < 0.05). The AS group showed a significantly lower relative pressure distribution in the front-right quadrant (p = 0.01) and a significantly higher relative pressure distribution in the rear-right quadrant (p = 0.05) on the static pedobarography. The AS group also had a higher peak force in the midfoot on the dynamic pedobarography (p < 0.05). The AS group had a significantly shorter stride length (p = 0.01). No significant differences between the groups were found in their hip flexion/extension and adduction/abduction, knee flexion, or ankle dorsiflexion/plantarflexion angles. This study shows significant alterations in the pedobarographic and spatiotemporal, but not in the kinematic, gait parameters of AS patients. These alterations represent a feature of AS and not antalgic adjustments. Rehabilitation programs for AS patients could be tailored according to the results of an instrumented gait analysis and should include balance and gait exercises.

Ankylosing spondylitis and kinesiophobia

Background

Ankylosing spondylitis (AS) is a chronic rheumatic disease that predominantly affects the axial skeleton, causing pain and functional impairment. Kinesiophobia, or fear of movement, is common in patients with chronic pain conditions and can significantly hinder treatment outcomes. This study aims to assess the level of kinesiophobia in AS patients and explore its relationship with demographic characteristics, disease duration, pain intensity, disease activity, and functional impairment.

Methods

This single-center study included 35 AS patients from July 2021 to July 2023. Patient demographics, disease duration, disease activity (BASDAI (Bath Ankylosing Spondylitis Disease Activity Index)), functionality (BASFI (Bath Ankylosing Spondylitis Functional Index)), pain intensity (VAS (Visual Analog Scale)), and kinesiophobia (TSK (Tampa Scale of Kinesiophobia)) were recorded and analyzed. Patients were categorized into low and high kinesiophobia groups based on TSK scores.

Results

Of the 35 AS patients, 15 (42.86%) had high kinesiophobia levels (TSK ≥37). Patients with high kinesiophobia had significantly higher BASDAI, BASFI, and VAS scores (p < 0.001) compared to those with low kinesiophobia. No significant relationship was found between kinesiophobia and age, gender, or disease duration (p > 0.05).

Conclusion

High levels of kinesiophobia in AS patients are associated with increased pain, disease activity, and functional impairment. Early interventions targeting kinesiophobia could improve treatment outcomes and patient functionality.

Synchronous and asynchronous remote core stability exercises in patients with axial spondyloarthritis: a randomized-controlled clinical trial

BACKGROUND

Exercise is a key component of axial spondyloarthritis (axSpA) management. As telerehabilitation has become a viable solution for delivering remote care, the effectiveness of core stability exercises via this method remains under-researched.

AIM

To compare the effects of telerehabilitation-based synchronous versus asynchronous core stability exercises on core muscle endurance, spinal mobility, disease activity, physical function, and quality of life in patients with axSpA.

METHODS

Forty-four patients with axSpA were randomly assigned to a synchronous exercise group (n = 22, 14 females) performing real-time exercises supervised by a physiotherapist, or an asynchronous group (n = 22, 10 females) following pre-recorded exercise videos. Core endurance tests, Bath Ankylosing Spondylitis Disease Activity (BASDAI), Bath Ankylosing Spondylitis Functional (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Ankylosing Spondylitis Quality of Life Scale (ASQoL), and functional mobility tests (timed-up-and-go and chair stand tests) were used to assess outcomes. Perceived change was evaluated at post-treatment using the 5-point Global Rating of Change (GRoC) scale.

RESULTS

The synchronous group demonstrated greater changes in core endurance, BASMI, BASDAI, ASQoL, BASFI, and functional mobility tests (p < 0.05) compared to asynchronous group. Asynchronous group displayed improvement only in core endurance, ASQoL, chair stand test, and some BASMI parameters (p < 0.05). Notably, 100% of participants in the synchronous group reported their condition as improved, compared to 50% in the asynchronous group shown by GRoC.

CONCLUSION

Supervised core stability exercises delivered by using a synchronous telerehabilitation program may provide better outcomes compared to unsupervised video-based exercise program.

TRIAL REGISTRATION

This study is prospectively registered at Clinicaltrials.gov (NCT06000072).

Sleep disorders in rheumatoid arthritis, axial spondyloarthritis and psoriatic arthritis

Sleep disorders are relatively common among patients with inflammatory arthritis (IA) and have a substantial impact on their quality of life. Although patients frequently recognize poor sleep as an important component of their disease, dyssomnias remain often underdiagnosed and untreated in routine clinical practice. This narrative review examines the prevalence, mechanism, risk factors and management of dyssomnias in rheumatoid arthritis (RA), axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA). Relevant articles were retrieved from PUBMED, Scopus and DOAJ. The pathomechanism of sleep disorders in IA is multifactorial and partially differs in RA, axSpA and PsA, however, comparative studies are lacking. Various factors affecting sleep quality, including disease activity, pain, mood disorders, fatigue and female gender, have been examined, but their interplay complicates establishing clear causal relationships. The bidirectional link between sleep quality and rheumatic disease activity highlights the complexity of this issue and demonstrates the importance of holistic management of rheumatic patients. Both pharmacological (e.g., hypnotics, NSAIDs, antidepressants, cannabidiol) and non-pharmacological (e.g., psychotherapy, physical activity) interventions for improving sleep were analyzed. Additionally, questionnaires currently used for assessing sleep were discussed. This review aims to provide a comprehensive overview of sleep disorders across the three most common types of IA, emphasizing the need to develop reliable and patient-friendly tools for everyday clinical practice and further comparative research.

Difficult-to-Treat Axial Spondyloarthritis: A New Challenge

Axial spondyloarthritis is a common form of chronic inflammatory rheumatic disease in adults, the treatment of which is based on non-pharmacological elements on the one hand, and pharmacological options on the other, such as non-steroidal anti-inflammatory drugs in the first line, followed by biological or targeted synthetic treatments. The therapeutic objective is remission or a low level of disease activity; if this objective is not achieved, the treatment is rotated or changed. Multiple changes is one factor illustrating the inability to achieve disease control and may lead to the notion of a difficult-to-treat disease (D2T). This requires a consensual definition including, beyond the number or therapeutic changes, the assessment of all the dimensions of the disease (objective signs of inflammation, residual pain, degenerative changes, psychosocial context). Recognising D2T patients will enable us to identify a particular population and the factors associated with this condition. When faced with a D2T disease, we need to analyse the causes of treatment failure and take into account the different components of the disease and the patient. In the absence of any prospect of new therapeutic targets in the short term for this disease, patient management may involve intensification of non-pharmacological means and evaluation of new therapeutic strategies such as combinations of targeted treatments.

Dual Diagnosis: Unraveling Ankylosing Spondylitis in a Cancer Patient

There have been several recent studies that indicate that patients with rheumatological diseases are at a higher risk of developing malignant neoplasms than the general population. This clinical case presents a patient with ankylosing spondylitis, a rare autoimmune disease in women, in addition to breast cancer. The close relationship between rheumatology and malignancy highlights the challenges in terms of diagnosis, treatment, and prevention, making this case highly relevant. Furthermore, this case also highlights the positive effect of chemotherapy drugs used in the treatment of breast cancer on the autoimmune disease. Therefore, further research in this area is necessary to gain a better understanding of the complex interplay between rheumatology and malignancy.

Treatment strategies for Spondyloarthritis: Implementation of precision medicine - Or "one size fits all" concept?

Spondyloarthritis (SpA) is a term to describe a group of chronic inflammatory rheumatic diseases, which have common pathophysiological, genetic, and clinical features. Under the umbrella term SpA, two main groups are subsumed: axial SpA (radiographic axSpA and non-radiographic axSpA) and peripheral SpA (with the leading representative being psoriatic arthritis (PsA) but also arthritis associated with inflammatory bowel disease (IBD), reactive arthritis, and undifferentiated pSpA). The key clinical symptom in axSpA is chronic back pain, typically with inflammatory characteristics, which starts in early adulthood, while the leading clinical manifestations of peripheral SpA (pSpA) are arthritis, enthesitis, and/or dactylitis. Furthermore, extra-musculoskeletal manifestations (EMMs) (acute anterior uveitis, psoriasis, and IBD) can accompany axial or peripheral symptoms. All these factors need to be taken into account when making treatment decisions in SpA patients. Despite the major advances in the treatment landscape over the past two decades with the introduction of biological disease-modifying anti-rheumatic drugs (bDMARDs) and most recently targeted synthetic DMARDs (tsDMARDs), a relevant proportion of patients still does not achieve the desired state of remission (=absence of disease activity). With this implementation of new treatment modalities, clinicians now have more choices to make in the treatment algorithms. However, despite generalized treatment recommendations, all factors need to be carefully considered when deciding on the optimal treatment strategy for an individual patient in clinical practice, aiming at an important first step towards personalized treatment strategies in SpA. In this narrative review, we focus on the efficacy of approved and emerging treatment options in axSpA and PsA as the main representative of pSpA and discuss their selective effect on the different manifestations associated with SpA to provide guidance on drivers of treatment decisions in specific situations.

Validity and reliability of the Turkish version of Exercise Benefits/ Barriers Scale: Perceived exercise benefits and barriers of patients with different axial spondyloarthritis subtypes

Objectives

The aim of this study was to translate the Exercise Benefits/Barriers Scale (EBBS) into Turkish and investigate the perceptions of Turkish-speaking patients with different axial spondyloarthritis (axSpA) subtypes regarding exercise benefits and barriers.

Patients and methods

This validation study was conducted between June 2018 and December 2021. Patients with axSpA were consecutively assessed regarding physical (age, sex and body mass index) and disease-related characteristics (disease activity, spinal mobility, functional status, quality of life, health status, emotional status, and kinesiophobia). Eligible participants were asked to complete the EBSS and other outcome measurements during their initial visits. EBBS was readministered 7 to 14 days later.

Results

One hundred forty-eight patients (89 males, 59 females; mean age: 44.3±11.8 years; range, 19 to 65 years) were included in the study. Of the patients, 108 had radiographic axSpA, and 40 had nonradiographic axSpA. EBBS-Barriers and EBBS-Benefits subscales demonstrated adequate internal consistency (Cronbach's alphas of 0.82 and 0.95, respectively) and test-retest reliability (intraclass correlation coefficients of 0.837 and 0.807, respectively). No significant differences were observed between axSpA subtypes regarding EBBS-Barriers (p=0.12) and EBBS-Benefits (p=0.10) subscales. Significant relationships were detected between kinesiophobia and EBBS-Barriers scores (r=-0.424, p<0.01), as well as EBBS-Benefits scores (r=-0.344, p<0.01) for all patients. EBBS-Benefits scores were correlated to health status (r=-0.412, p=0.08) and quality of life (r=-0.394, p=0.01) in patients with nonradiographic axSpA.

Conclusion

According to our results, the Turkish EBBS is a valid and reliable tool for patients with axSpA. Perceptions of the patients with axSpA regarding exercise barriers and benefits do not differ according to the disease subtype. It appears that kinesiophobia may be an important parameter regarding exercise perception in axSpA.

Swimming exercise alleviates pathological bone features in curdlan-injected SKG mice by inducing irisin expression

This study assessed the therapeutic potential of swimming exercise in the curdlan-injected SKG mouse model and investigated the modulatory effects of irisin on inflammation. Curdlan-injected SKG were randomly assigned to either a home-cage group or a swimming group for 6 weeks. Changes in clinical arthritis scores and ankle thickness were measured weekly. Post-swimming program, mice were anesthetized for collection of vastus lateralis muscle and blood, which was followed by histological analysis, micro-CT imaging of the ankle joints, and the measurement of pro-inflammatory cytokines and irisin levels. Additionally, curdlan-injected SKG mice were intravenously injected with recombinant irisin protein and observed. Finally, serum levels of irisin in healthy control and ankylosing spondylitis (AS) patient groups were measured by ELISA. The swimming group of curdlan-injected SKG mice exhibited significant improvements in arthritis and enthesitis compared to the home-cage group. In particular, micro-CT and histological analyses revealed a notable reduction in pathological bone features in the swimming group compared to the home-cage group. Muscle endurance was also enhanced in the swimming group compared to the home-cage group, as determined by the wire-hanging test. Intriguingly, irisin levels not only were statistically increased in the swimming group but, also, TNF-α, IL-1β, and IL-6 levels were decreased. Additionally, injection of irisin protein slightly attenuated both arthritis and enthesitis in curdlan-injected SKG mice. Meanwhile, irisin serum levels were declined in AS patients. Overall, we found that swimming exercise attenuated pathological bone features in an AS animal model, potentially mediated by increased irisin serum levels with associated anti-inflammatory effects.

Preliminary Studies on Changes in Static Plantar Pressure and Stabilometry in Patients with Ankylosing Spondylitis Undergoing an Exercise Program

Background/Objectives: Studies have reported that patients suffering from ankylosing spondylitis (AS) have decreased postural stability in comparison to healthy subjects. Our study aims to compare static plantar pressure and stabilometry parameters in AS patients who performed an 8-week exercise program (spine motion and flexibility exercises; stretching of hamstring, erector spine, and shoulder muscles; control abdominal and diaphragm breathing exercises and chest expansion exercises), in three different testing conditions (eyes open, eyes closed, and head retroflexed). Methods: Plantar pressure (the loading of the first and fifth metatarsal heads (MT1, MT5) and calcaneus) and stabilometry (CoP path length, 90% confidence ellipse area, and maximum CoP speed) were recorded in 28 AS patients (age 56.64 ± 10.3 years; body mass index 29.4 ± 4.9 kg/m2) at the beginning of rehabilitation and after 8 weeks. At first evaluation, there were significant differences (p < 0.05) for the foot loading sites (MT1, MT5, and calcaneus), both for the right and left feet, when comparing eyes open with the other two testing situations. Results: After rehabilitation, significant differences were recorded between eyes-open and head-retroflexed conditions for MT1 (p = 0.03 for right; p = 0.004 for left) and calcaneus (p = 0.014 for right; p = 0.011 for left). A significantly higher CoP path length was registered in both initial and final assessments when tested with eyes closed. The maximum CoP speed had increased values at both evaluations when tested with head retroflexed. Conclusions: The CoP path length decreased after the physical exercise program, with a better postural stability after rehabilitation.

Living with axial spondyloarthritis: a cross-sectional survey of patient knowledge and perceptions

Diagnosis and effective treatment of axial spondyloarthritis (AxSpA) are often delayed due to inadequate awareness and poor patient-physician communication. Some AxSpA patients fail to maintain an active lifestyle by exercising regularly, further worsening their disease management. The evolving concept of patient-centred care necessitates better understanding of patient awareness and their needs. We aimed to survey AxSpA patients to reflect on healthcare planning and management perspectives. Our self-administered questionnaire focused on perceptions of AxSpA diagnosis and management, particularly exploring issues of physical activity and active lifestyle. Satisfaction with AxSpA medical care and its accessibility, diagnostic delays, patient-physician communication, and support for disease management were also explored. This offline survey was arranged at the Department of Rheumatology, Immunology, and Internal Medicine of Jagiellonian University Medical College and Krakow University Hospital. We surveyed patients with AxSpA attending outpatient clinics between December 1st, 2023 and April 22nd, 2024. The questionnaire included questions on types of physical activities, barriers to exercising, satisfaction with medical care, patient-physician interactions, diagnostic delays, and use of teleconsultations. A total of 117 patients with AxSpA were enrolled (mean age 41.62 years). The majority (n = 93, 79.5%) were employed. There was a male predominance (69, 59%). The average diagnostic delay was 5.5 years. Notably, 104 (88.9%) responders perceived physical activity as a factor influencing their disease course. However, only 32 (27.35%) managed to exercise regularly (≥ 30 min, 2-3 times a week). The majority (70, 59.83%) were irregularly engaged in some form of physical activity, with 15 (12.8%) not exercising at all, and nearly half (48%) reported at least one barrier to maintaining a physically active lifestyle. Pain (32, 27.35%), fatigue (27, 23.08%), lack of motivation (17, 14.53%), and lack of time (12, 10.26%) were noted as barriers to exercising. The respondents preferred to exercise at home. The survey identified critical areas where patient dissatisfaction or uncertainty were notably prevalent: 38 (32.5%) were uncertain and 35 (30%) were dissatisfied with rehabilitation access. For spa therapy, 63 (53.85%) reported uncertainty and 23 (19.7%) expressed dissatisfaction. Only 48 (41%) were treated by a rehabilitation specialist last year. Only 23% of AxSpA patients took part in teleconsultations last year, and 65% preferred in-person visits. While AxSpA patients recognize the importance of physical activity, significant barriers exist to engaging them regularly in exercising. Addressing these barriers through personalized, motivational, and educational strategies could improve patient outcomes. Improving patient satisfaction with healthcare services, particularly in areas of rehabilitation and physician-patient communication, is crucial for improving the overall care of AxSpA patients.

Analysis of physical activity in psoriatic arthritis: relationship with clinical and analytical parameters and comorbidity-description of the sedentary patient

Objective

This study aimed to relate physical activity and a sedentary lifestyle to clinical, biological, functional, and comorbid parameters in a cohort of patients with psoriatic arthritis (PsA).

Methods

A cross-sectional study was conducted with 232 PsA patients. Physical activity and sedentary lifestyle were obtained using the International Physical Activity Questionnaire (IPAQ) questionnaire. The demographic, clinical, and biological variables measured were age, time since PsA diagnosis, smoking, type of treatment used, clinical form, presence of enthesitis, dactylitis (present or past), fatigue, tumor necrosis factor (TNF)-alpha, and interleukin 6 (IL-6). Activity and functionality were measured using the Disease Activity Index for Psoriatic Arthritis (DAPSA) and Health Assessment Questionnaire (HAQ) in peripheral forms, while the Ankylosing Spondylitis Disease Activity Score (ASDAS-PCR) and Bath Ankylosing Spondylitis Functional Index (BASFI) were measured in axial forms. Disease impact was assessed using the Psoriatic Arthritis Impact of Disease (PsAID) questionnaire. Alongside comorbidities, obesity, anxiety, depression [Hospital Anxiety and Depression Scale (HADS)], and sleep quality [Insomnia Severity Index (ISI)] were assessed.

Results

The mean age was 54.6 (SD: 11.4) years, with 54.3% being male. A total of 25.6% of patients were sedentary. Physical activity and sedentary lifestyle were inversely correlated with fatigue, activity, functionality, and disease impact. Within comorbidities, they correlated with anxiety, depression, and insomnia. In addition, physical activity was inversely correlated with obesity. In linear regression analysis, physical activity was found to be related to body mass index (BMI) with a ß coefficient of -0.1 (p < 0.04; 95%CI: -194.1--4.5), and an R2 value of 0.11. In logistic regression analysis, a sedentary lifestyle was found to be related to pain, with an odds ratio (OR) of 1.5 (p < 0.001; 95%CI:1.1-1.8) and an R2 Nagelkerke value of 0.36.

Conclusion

A quarter of the patients were sedentary. Lack of physical activity correlated with worse parameters of clinical activity, functionality, disease impact, and the presence of comorbidities.

Effectiveness of exercise intervention in relieving symptoms of ankylosing spondylitis: A network meta-analysis

BACKGROUND

Ankylosing spondylitis(AS) is a chronic inflammatory rheumatic disease that leads to a reduced quality of life. Exercise appears to be one of the promising modes of intervention. The aim of this study was to review the available evidence and compare the effectiveness of different exercises in relieving symptoms of AS.

METHODS

We searched the Pubmed, WOS, EMbase, CNKI, Cochrane Library, and Scopus databases. The search has spanned from the creation of the database until September 15, 2023. We extracted the first author, year of article publication, sample information, intervention, duration of intervention, and outcome indicators from the literature that met the inclusion criteria. The Cochrane Risk Assessment Tool was used to assess the risk of bias for included studies. I² was used to judge the consistency of the included studies. Egger's test and Begg's test were used to judge whether there was significant publication bias. Forest plots were used to compare intervention effects and SUCRA was provided to rank the effects of the interventions. This study has been registered in PROSPERO(No. CRD42024518522).

RESULTS

After screening, 10 papers matched the inclusion criteria for this study, and the total sample size of the 10 papers was 623. Upon analysis, the papers included in this study did not have significant publication bias (Begg's Test P = 0.210) and had good consistency (P>0.05). The direct comparisons showed that Running, Pilates, Stretching, Yoga, and Tai Chi were more effective interventions than traditional therapies. The effect sizes, confidence intervals, and number of studies for each intervention are shown below: Running [MD -1.90 (95% CI -3.14,-0.66) n = 1], Pilates [MD -1.70 (95% CI -2.90,-0.51) n = 1], Stretching [MD -1.54 (95% CI -2.21,-0.88) n = 4], Yoga [MD -1.24 (95% CI -2.18,-0.30) n = 1], Tai Chi [MD -0.78 (95% CI -1.44,-0.12) n = 2], Exergame[MD -0.80 (95% CI -1.99,0.39) n = 1], Swiss balls[MD -1.07 (95% CI -2.58,0.44) n = 1]. The indirect comparisons showed that the range of effect sizes for each sport intervention intersected the null line. Based on cumulative probability, the order of effectiveness of different exercises in relieving AS symptoms is Running, Pilates, Stretching, Yoga, Tai Chi, Exergame, and Swiss ball.

CONCLUSION

Running, Pilates, Stretching, Yoga, and Tai Chi provided significant relief from AS symptoms. Exergame and Swiss ball were not statistically significant in relieving AS symptoms. There were no significant differences in the effectiveness of different exercise interventions in relieving AS symptoms. Running may have the most beneficial effect on alleviating AS symptoms.

Comparison of Yoga with exercise in ankylosing spondylitis on mobility and functional capacity

AIM

To compare the effects of Yoga with traditional exercise on the mobility and functional capacity of individuals with ankylosing spondylitis (AS).

METHODS

The participants of the study were recruited at the rheumatology department, adhering to the study's inclusion and exclusion criteria. Participants were randomized into two groups (Group A - Yoga, and Group B - exercise).The candidates participated in an 8-week intervention consisting of 3 weekly sessions of either Yoga or Exercise intervention. Outcomes were collected at pre-treatment, at 8 weeks, and at 12 weeks.

RESULTS

The within-group comparison showed an improvement in all outcome measures with p < .05 between post-treatment and the follow-up. In the yoga group, there was an improvement in the measures of BASMI (p = .001), BASFI (p = .005), PSQI (p = .021), CE (p = .053) and NPRS (p = .001). Similarly, in the exercise group, there was an improvement in BASMI (p = .002), BASFI (p = .003), PSQI (p = .010), CE (p = .004) and NPRS (p = .001). In the between group comparison at post-treatment, there were no statistically significant differences in BASMI (yoga = 3.0 ± 1.50, exercise = 2.3 ± 1.38), PSQI (yoga = 5.3 ± 1.50, exercise = 4.9 ± 1.17) and NPRS (yoga = 1.3 ± 2.22, exercise = 0.4 ± 0.50) CE (yoga = 4.0 ± 1.18, exercise = 3.4 ± 0.96), BASFI (yoga = 1.8 ± 2.14, exercise = 2.1 ± 1.87).

CONCLUSION

The results demonstrated a statistically significant improvement in within-group scores of mobility, functional capacity, sleep quality and pain in AS patients of both intervention programs but there were no significant differences between the groups.

Do physical therapists follow evidence-based practices for treatment of inflammatory arthritis? Results from an online survey

BACKGROUND

Physical therapists (PTs) should know how to best treat patients with inflammatory arthritis.

OBJECTIVE

To document interventions chosen by PTs for patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS) and whether choices follow evidence-based practice.

METHODS

Licensed musculoskeletal PTs in Quebec, Canada responded to an online survey. Descriptive statistics illustrated proportions for each treatment choice and inferential statistics explored associations with demographic and practice-related factors.

RESULTS

There were 298 PTs who responded to the survey. For both RA and AS respectively, most common interventions were mobility exercises (91.0%; 98.3%) and patient education (90.1%; 92.8%). For both cases, slightly >60% selected strengthening exercises. Passive forms of therapy were chosen by 36% of PTs for RA and 58% for AS. Aerobic exercise was rarely selected. PTs working in the public sector were less likely to use manual therapy for both RA (Odds Ratio (OR) 0.43, 95% confidence interval (CI) 0.22,0.86) and AS (OR 0.46, 95% CI 0.22,0.97).

CONCLUSIONS

Most PTs chose mobility exercises and patient education, representing evidence-based approaches. Despite current recommendations, strengthening and especially aerobic exercises were not used as much. There is a need to increase awareness regarding the benefits of strengthening and aerobic exercise for these patients.

Bone metabolism and inflammatory biomarkers in radiographic and non-radiographic axial spondyloarthritis patients: a comprehensive evaluation

Introduction

Axial spondyloarthritis (axSpA) is a heterogeneous disease that can be represented by radiographic axSpA (r-axSpA) and non-radiographic axSpA (nr-axSpA). This study aimed to evaluate the relationship between the markers of inflammation and bone turnover in r-axSpA patients and nr-axSpA patients.

Methods

A cross-sectional study included 29 r-axSpA patients, 10 nr-axSpA patients, and 20 controls matched for age and sex. Plasma markers related to bone remodeling such as human procollagen type 1 N-terminal propeptide (P1NP), sclerostin, tartrate-resistant acid phosphatase 5b (TRACP5b), receptor activator of nuclear factor kappa B ligand (RANKL), and osteoprotegerin (OPG) were measured by an ELISA kit. A panel of 92 inflammatory molecules was analyzed by proximity extension assay.

Results

R-axSpA patients had decreased plasma levels of P1NP, a marker of bone formation, compared to controls. In addition, r-axSpA patients exhibited decreased plasma levels of sclerostin, an anti-anabolic bone hormone, which would not explain the co-existence of decreased plasma P1NP concentration; however, sclerostin levels could also be influenced by inflammatory processes. Plasma markers of osteoclast activity were similar in all groups. Regarding inflammation-related molecules, nr-axSpA patients showed increased levels of serum interleukin 13 (IL13) as compared with both r-axSpA patients and controls, which may participate in the prevention of inflammation. On the other hand, r-axSpA patients had higher levels of pro-inflammatory molecules compared to controls (i.e., IL6, Oncostatin M, and TNF receptor superfamily member 9). Correlation analysis showed that sclerostin was inversely associated with IL6 and Oncostatin M among others.

Conclusion

Altogether, different inflammatory profiles may play a role in the development of the skeletal features in axSpA patients particularly related to decreased bone formation. The relationship between sclerostin and inflammation and the protective actions of IL13 could be of relevance in the axSpA pathology, which is a topic for further investigation.

Global trends and research status in ankylosing spondylitis clinical trials: a bibliometric analysis of the last 20 years

BACKGROUND

Ankylosing spondylitis (AS) is a rheumatic and autoimmune disease associated with a chronic inflammatory response, mainly characterized by pain, stiffness, or limited mobility of the spine and sacroiliac joints. Severe symptoms can lead to joint deformity, destruction, and even lifelong disability, causing a serious burden on families and society as a whole. A large number of clinical studies have been published on AS over the past 20 years. This study aimed to summarize the current research status and global trends relating to AS clinical trials through a bibliometric analysis.

METHODS

The Web of Science Core Collection database was searched for publications related to AS clinical trials published between January 2003 and June 2023. Bibliometric analysis and web visualization were performed using CiteSpace, VOSviewer, and a bibliometric online analysis platform (https://bibliometric.com), which included the number of publications, citations, countries, institutions, journals, authors, references, and keywords.

RESULTS

1,212 articles published in 201 journals from 65 countries were included in this study. The number of publications related to AS clinical trials is increasing annually. The United States and the Free University of Berlin, the countries and institutions, respectively, that have published the most articles on AS, have made outstanding contributions to this field. The author with the most published papers and co-citations over the period covered by the study was Desiree Van Der Heijde. The journal with the most published and cited articles was Annals of the Rheumatic Diseases. The keywords: "double-blind," "rheumatoid arthritis," "efficacy," "placebo-controlled trial," "infliximab," "etanercept," "psoriatic arthritis" and "therapy" represent the current research hotspots regarding AS.

DISCUSSION

This is the first study to perform a bibliometric analysis and visualization of AS clinical trial publications, providing a reliable research focus and direction for clinicians. Future studies in the field of AS clinical trials should focus on placebo-controlled trials of targeted therapeutic drugs.

Global trends and research status in ankylosing spondylitis clinical trials: a bibliometric analysis of the last 20 years

BACKGROUND

Ankylosing spondylitis (AS) is a rheumatic and autoimmune disease associated with a chronic inflammatory response, mainly characterized by pain, stiffness, or limited mobility of the spine and sacroiliac joints. Severe symptoms can lead to joint deformity, destruction, and even lifelong disability, causing a serious burden on families and society as a whole. A large number of clinical studies have been published on AS over the past 20 years. This study aimed to summarize the current research status and global trends relating to AS clinical trials through a bibliometric analysis.

METHODS

The Web of Science Core Collection database was searched for publications related to AS clinical trials published between January 2003 and June 2023. Bibliometric analysis and web visualization were performed using CiteSpace, VOSviewer, and a bibliometric online analysis platform (https://bibliometric.com), which included the number of publications, citations, countries, institutions, journals, authors, references, and keywords.

RESULTS

1,212 articles published in 201 journals from 65 countries were included in this study. The number of publications related to AS clinical trials is increasing annually. The United States and the Free University of Berlin, the countries and institutions, respectively, that have published the most articles on AS, have made outstanding contributions to this field. The author with the most published papers and co-citations over the period covered by the study was Desiree Van Der Heijde. The journal with the most published and cited articles was Annals of the Rheumatic Diseases. The keywords: "double-blind," "rheumatoid arthritis," "efficacy," "placebo-controlled trial," "infliximab," "etanercept," "psoriatic arthritis" and "therapy" represent the current research hotspots regarding AS.

DISCUSSION

This is the first study to perform a bibliometric analysis and visualization of AS clinical trial publications, providing a reliable research focus and direction for clinicians. Future studies in the field of AS clinical trials should focus on placebo-controlled trials of targeted therapeutic drugs.

The effect of a six-week Aqua Pilates and Aqua Stretch intervention on pain, function, and quality of life in patients affected by ankylosing spondylitis: A rater-blind randomized controlled trial

BACKGROUND

There has been a dearth of research into the benefits of water-based workouts for ankylosing spondylitis (AS) patients.

OBJECTIVE

This study aimed to compare the effect of Aqua Stretch and Aqua Pilates in improving quality of life (QOL), function, and pain in AS patients.

METHODS

This study was conducted on 40 patients, who were randomly assigned to the Aqua Pilates, Aqua Stretch, and control groups. The experimental groups attended interventions for six-week. QOL, pain intensity, function, and fatigue were measured before and after treatments.

RESULTS

Except for the chest expanding, all variables in the Aqua Stretch group changed significantly after six weeks (p< 0.05). QOL (p= 0.002), 6MWT (p= 0.016), and Schober flexion (p= 0.011) showed changes, while BASDAI (p= 0.0001), VAS (p= 0.0001), fatigue (p= 0.0001), and Schober extension (p= 0.028) showed significant decreases. Except for chest expansion and Schober extension, which did not alter significantly after six-week of Aqua Pilates (p> 0.05), all other variables did. There was an increasing trend in 6MWT and Schober flexion (p= 0.021) and a decreasing trend in BASDAI (p= 0.002), VAS (p= 0.0001) and fatigue (p= 0.002). Except for QOL (p= 0.016), no statistically significant differences were found between the groups.

CONCLUSION

All variables had a significant change after six-week Aqua Stretch, except for the chest expanding. Chest expanding and Schober extension were the variables which had no significant change after six-week Aqua Pilates. With the exception of QOL, no statistically significant differences were found between the groups. Aqua Stretch had the greatest effect on the VAS, as measured by the minimum clinically relevant differences (MCID). Moreover, in Aqua Stretch alone, there was a notable impact on fatigue, QOL, and the BASDAI.

Effectiveness of Physiotherapy Exercises on Pain, Range of Motion, and Quality of Life in Patients With Ankylosing Spondylitis: A Case Report

Ankylosing spondylitis (AS) is an inflammatory disease that affects the entire body. Immune cells positive for human leukocyte antigen B27 are thought to be involved in the pathophysiology. AS is caused by inflammation of the spinal joints, leading to stiffness and reduced spinal movement. This case study describes a 38-year-old man who suffered from hip problems and back pain that worsened over eight years. This study investigates how well physiotherapy exercises can help patients with AS manage their pain, increase their range of motion, and improve their overall quality of life. It examines the effects of a structured physiotherapy intervention on pain levels, functional mobility, and general well-being in a particular group of patients. Quantitative measures are used in the assessment to assess changes in pain intensity, range of motion, and quality of life. These measures offer important new information about the potential advantages of physiotherapy as a supplemental treatment for AS. The results add to the increasing amount of data demonstrating the role of physiotherapy exercises as an additional therapeutic approach for people with AS.

Online physiotherapy for people with axial spondyloarthritis: quantitative and qualitative data from a cohort study

Life-long exercise is essential in axial spondyloarthritis (axSpA) management; however, long-term adherence is challenging. Online exercise programmes are an alternative to face-to-face physiotherapy. (1) To measure adherence to a 12-month, individualised, online physiotherapy programme for people with axSpA, and investigate the effects on disease activity, spinal mobility, work ability, quality of life and function. (2) To investigate associations between programme adherence and outcomes. (3) To explore participants' views of the programme and factors affecting adherence. Participants were 'non-exercisers' recruited from rheumatology outpatient services. Adherence was measured using online diary entries. Outcomes included the BATH indices, health status (EQ5D), Ankylosing Spondylitis Quality of Life (ASQOL), exercise capacity (6MWT), Work, Productivity and Activity Impairment in AS (WPAI), Exercise Attitude Questionnaire (EAQ) and Exercise Motivations Inventory-2 (EMI-2) at baseline, 6 and 12 months. Interviews determined views on the intervention and factors affecting adherence. Fifty participants were recruited. Over the 52-week intervention, adherence (five times/week) ranged from 19% (± 30%) to 44% (± 35%). Significant improvements were found in disease activity (BASDAI), spinal mobility (BASMI), 6MWT, AsQoL and EQ5D-VAS at 6 and 12 months. There were no associations between adherence and baseline variables or demographics. Interviews suggested support from others, routine, and feeling the benefit positively affected adherence. Conversely, lack of motivation, life events and symptoms negatively affected adherence. A 12-month online physiotherapy programme significantly improved symptoms in people with axSpA who were not regular exercisers. Adherence reduced over the intervention period. Online exercise programmes may benefit people with axSpA; however, strategies to improve adherence are required.

Triple jump for the optimal management of psoriatic arthritis: diet, sleep and exercise - a review

Psoriatic arthritis (PsA) is a complex, multiform and chronic inflammatory disease characterised by the association of arthritis and psoriasis combined with other related conditions and comorbidities. Treatment of PsA has rapidly evolved by the introduction of new biological drugs and small molecules which allow to achieve disease remission or low disease activity in most of the patients. However, unmet treatment needs still persist for those patients with persistent disease activity or symptoms, impaired function, reduced quality of life or comorbidities. In this context, non-pharmacological approaches, including diet modifications, an adequate sleep quality and physical activity could provide additional benefits. In recent years, diet modifications, improvement of sleep quality and physical activity became an area of interest for researchers and some studies showed how a holistic non-pharmacological approach may ameliorate the quality of life of patients with PsA.The aim of this manuscript was to review the current evidence on the intriguing link and potential effects of diet, sleep and exercise in PsA patients. In particular, we reviewed the literature focusing on the possible benefits of a holistic approach to PsA patients considering lifestyle modifications.

The effects of supervision on the outcomes of exercise training in patients with ankylosing spondylitis: A single-blind randomized controlled trial

AIM

Exercise training is crucial for managing ankylosing spondylitis. We evaluated the effects of exercise with different levels of supervision on clinical outcomes in patients with ankylosing spondylitis.

METHODS

We performed a single-blind randomized controlled trial in a university outpatient clinic. Overall, 45 (31 men) patients with ankylosing spondylitis were randomly allocated to 3 groups. The mean (SD) for age and disease duration were 39.3 (9.3) and 8.4 (7.8) years. The primary outcome was chest expansion in cm, and the secondary outcomes were the index scores of 5 standard questionnaires. For each participant, adalimumab 40 mg/0.8 mL/2 wk was injected and a 3-session exercise program per week for 1 month was prescribed. Controls received a pamphlet on the exercise program. Another group received the pamphlet and underwent a 2-hour training session. The supervised group received the pamphlet, and the 2-hour training, and completed the program by attending each exercise session in the clinic.

RESULTS

Within-group analysis showed significant improvement in chest expansion (P = 0.016) and all subjective or objective questionnaire scores (all P < 0.001) for the full-supervised group. Between-group analysis implied best outcomes for chest expansion (P = 0.046), Ankylosing Spondylitis Disease Activity Score (P < 0.001), Bath Disease Activity (P = 0.010), and Metrology (P = 0.002) Indices for ankylosing spondylitis. The group with 2-hour training experienced an improvement in some indices, and the control group did not show significant changes in the outcomes.

CONCLUSION

We recommend the prescription of a supervised training program instead of in-home exercises for patients with ankylosing spondylitis.

Comparison of the effects of aerobic training alone versus aerobic training combined with clinical Pilates exercises on the functional and psychosocial status of patients with ankylosing spondylitis: A randomized controlled trial

To compare the effects of aerobic training versus aerobic training combined with clinical Pilates exercises (CPE) on the functional and psychosocial status of patients with ankylosing spondylitis (AS). Twenty-eight patients with ankylosing spondylitis (AS) were randomized into 2 groups. Group 1 (n = 14) performed both aerobic training and CPE, whereas group 2 (n = 14) performed aerobic training alone. Functional status of the patients was assessed using the Bath Ankylosing Mobility Index (BASMI), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), back scratch test (BST), single leg stance test, functional reach test, a dynamometer, chair sit and stand test, and 6-minute walk test (6MWT), and the psychosocial status of the patients was assessed using the Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire, the Multidimensional Assessment of Fatigue (MAF), Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety Depression Scale (HADS), and Tampa Scale of Kinesiophobia (TSK). Both training programs were conducted for 8 weeks, and then, the assessments were repeated. A statistically significant improvement was observed in the BASMI (p = .001), BASDAI (p = .001), BASFI (p = .002), BST (right, p = .05; left, p = .025), functional reach test (p = .013), back muscle strength (p = .033), 6MWT (p = .011), ASQoL (p < .001), MAF (p = .01), and PSQI (p = .013) scores in group 1. A significant difference was observed in the BASDAI (p = .028), chair sit and stand test (p = .022), 6MWT (p = .04), and ASQoL (p = .04) scores in group 2. CPE in addition to aerobic training was more effective in improving the functional and psychosocial status of the patients with AS.

2021 EULAR recommendations regarding lifestyle behaviours and work participation to prevent progression of rheumatic and musculoskeletal diseases

OBJECTIVES

A European League Against Rheumatism taskforce was convened to review the literature and develop recommendations on lifestyle behaviours for rheumatic and musculoskeletal diseases (RMDs).

METHODS

Six lifestyle exposures (exercise, diet, weight, alcohol, smoking, work participation) and seven RMDs (osteoarthritis, rheumatoid arthritis, axial spondyloarthritis, psoriatic arthritis, systemic lupus erythematosus, systemic sclerosis, gout) were considered. The taskforce included health professionals in rheumatology, geriatricians, epidemiologists, public health experts, people with RMDs and exposure domain experts. Systematic reviews were conducted to gather available evidence, from which recommendations were developed.

RESULTS

Five overarching principles and 18 specific recommendations were defined based on available evidence. The overarching principles define the importance of a healthy lifestyle, how lifestyle modifications should be implemented, and their role in relation to medical treatments. Exercise recommendations highlight the safety and benefits of exercise on pain and disability, particularly among people with osteoarthritis and axial spondyloarthritis. The diet recommendations emphasise the importance of a healthy, balanced diet for people with RMDs. People with RMDs and health professionals should work together to achieve and maintain a healthy weight. Small amounts of alcohol are unlikely to negatively affect the outcomes of people with RMDs, although people with rheumatoid arthritis and gout may be at risk of flares after moderate alcohol consumption. Smokers should be supported to quit. Work participation may have benefits on RMD outcomes and should be discussed in consultations.

CONCLUSIONS

These recommendations cover a range of lifestyle behaviours and can guide shared decision making between people with RMDs and health professionals when developing and monitoring treatment plans.

Implementing enhancements in supervised group exercise for people with axial spondyloarthritis: a hybrid effectiveness-implementation study

OBJECTIVES

The content of supervised group exercise (SGE) for axial spondyloarthritis (axSpA) has hardly changed in recent decades, despite new evidence-based insights to improve SGE quality. This pilot implementation study evaluated the effects and feasibility of enhancements in axSpA-specific SGE in four regions in the Netherlands.

METHOD

The implemented enhancements included: more high-intensity aerobic exercise; exercise personalization with periodic assessments; and patient education on home exercise. The implementation strategy included a one-day supervisor training course and telephone support. To evaluate effects, aerobic capacity [Six-Minute Walk Test (6MWT)], physical functioning [Ankylosing Spondylitis Performance-based Improvement (ASPI); improved/not improved], health status [Assessment of SpondyloArthritis international Society Health Index (ASAS HI) questionnaire], and home exercise engagement [Short QUestionnaire to ASsess Health-enhancing physical activity (SQUASH)] were assessed at baseline and after one year in 60 participants. Changes were analysed with the Wilcoxon signed-rank test. To evaluate feasibility, a survey of participants and semi-structured interviews with four SGE supervisors assessed uptake and satisfaction with the enhancements.

RESULTS

Aerobic capacity increased significantly and 35% of participants improved functioning, whereas health status and home exercise engagement did not change. The participants' survey and supervisors' interviews showed that high-intensity aerobic exercise was implemented successfully, exercise personalization and periodic assessments were implemented partially, and patient education was not implemented at all. Most participants were satisfied with the changes.

CONCLUSIONS

After this pilot implementation, SGE enhancements were only partially implemented. Nevertheless, aerobic capacity improved significantly and satisfaction with accomplished changes was high. Nationwide implementation would require adaptations to improve feasibility.

The effectiveness of hippotherapy simulation exercises for muscle strength, disease activity and quality of life in sedentary adults with ankylosing spondylitis

INTRODUCTION/OBJECTIVE

Newly created systems called hippotherapy simulators (HS) mimic the primitive movements of a live horse. As they are new systems, research examining their usefulness has been well received. The aim of this study is to research the effects of HS on disease activity, quality of life and muscle strength in patients with ankylosing spondylitis (AS).

METHODS

In a prospective, assessor-blinded, block-randomized trial, 48 AS patients were randomly assigned in a 1:1 ratio to receive either HS or conventional home (CH) exercise therapy. All Participants received 48 sessions, that is 4 sessions a week for 12 consecutive weeks. The primary outcome measures included the quadriceps muscle strength, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI) and Ankylosing Spondylitis Quality of Life Scale (ASQoL).

RESULTS

Both groups demonstrated significant improvement in BASDAI, BASFI, BASMI, ASQoL and muscle strength scores compared to the baseline (p < 0.05). BASDAI, BASFI and BASMI scores decreased significantly in the HS group compared to the CH group at week 12 (p=.005, p=.003, p=.045, respectively), but there was no significant difference between the groups in terms of ASQoL and muscle strength scores at week 12 (p=.245, p=.212, respectively).

CONCLUSIONS

The results of this clinical trial of HS exercises for AS patients indicate a positive effect on disease activity, quality of life and muscle strength. Therefore, horse-riding simulator exercises can be used as an alternative method for the management of individuals with AS.

The effectiveness of group and home-based exercise on psychological status in people with ankylosing spondylitis: A systematic review and meta-analysis

INTRODUCTION

Ankylosing spondylitis (AS) is an inflammatory rheumatic disease in which the physical impact has been evaluated; however, the psychological consequences are less well explored. The primary aim of this review was to determine the effectiveness of group versus home-based exercises on psychological status of patients with AS.

METHODS

Six databases were searched until January 2020. Eligible studies were randomised controlled trials including group or home-based exercise interventions. Risk of bias (RoB) was evaluated using the Cochrane RoB 2.0 tool. Relative percentage difference (RPD) between groups and effect sizes were presented as standardised mean differences (SMDs) with 95% confidence intervals (CI).

RESULTS

Five studies met the inclusion criteria (n = 240), outcomes of interest were depression, anxiety and mental health. Three studies were low-risk RoB, one study was high-risk RoB and one study there was 'some concerns' of bias. Group-based exercise was more effective than home-based exercise for improving depression at 6-week (RPD 18%) and 3-month (RPD 42%), anxiety (RPD 17%) and mental health (RPD 20%). Home-based exercise was more effective than control interventions for improving depression (RPD 33%). A meta-analysis demonstrated group-based exercises compared to home exercises, improved depression (SMD: -0.54; 95% CI: [-0.89; -0.18]; p = 0.003) and physical function (SMD: -0.49; 95% CI: [-0.84; -0.14]; p = 0.006).

CONCLUSION

Supervised group-based demonstrated improvements in depression, anxiety and mental health compared to home-based exercise. Individualised home-based exercise is more effective than no intervention for improving depression in people with AS.

Stretching Training Rehabilitation Has Potential to Alleviate Ankylosing Spondylitis in Mice by Inactivating the Wnt/β-Catenin Pathway

Ankylosing spondylitis (AS) is a chronic inflammatory disease characterized by invasion of the joints of the central axis that involves soft tissues and joints surrounding the spine. Stretching training rehabilitation (STR) has been widely applied for the treatment of AS. The Wnt/β-catenin signalling pathway is closely related to AS. In this study, we aimed to explore the potential molecular mechanisms underlying the protective effect of STR on AS both in vitro and in vivo. Male DBA/1 mice were employed to establish an AS animal model. Hematoxylin-eosin staining showed that STR reversed pathological damages in bone tissues and the total antioxidant capacity of AS mice and increased the antioxidant capacity by upregulating superoxide dismutase and malondialdehyde expression in DBA/1 mice. The MTT, RT-qPCR, and Western blotting results further indicated that STR improved the survival rate of cells by downregulating the expression of target genes in the Wnt/β-catenin pathway and by inhibiting cell inflammation and apoptosis. In conclusion, our findings indicated that STR treatment might be an effective therapeutical strategy for AS.

Wearables for Measuring the Physical Activity and Sedentary Behavior of Patients With Axial Spondyloarthritis: Systematic Review

BACKGROUND

Axial spondyloarthritis (axSpA) is an inflammatory rheumatic disease associated with chronic back pain and restricted mobility and physical function. Increasing physical activity is a viable strategy for improving the health and quality of life of patients with axSpA. Thus, quantifying physical activity and sedentary behavior in this population is relevant to clinical outcomes and disease management. However, to the best of our knowledge, no systematic review to date has identified and synthesized the available evidence on the use of wearable devices to objectively measure the physical activity or sedentary behavior of patients with axSpA.

OBJECTIVE

This study aimed to review the literature on the use of wearable activity trackers as outcome measures for physical activity and sedentary behavior in patients with axSpA.

METHODS

PubMed, PEDro, and Cochrane electronic databases were searched in July 2021 for relevant original articles, with no limits on publication dates. Studies were included if they were original articles, targeted adults with a diagnosis of axSpA, and reported wearable device-measured physical activity or sedentary behavior among patients with axSpA. Data regarding the study's characteristics, the sample description, the methods used for measuring physical activity and sedentary behavior (eg, wearable devices, assessment methods, and outcomes), and the main results of the physical activity and sedentary behavior assessments were extracted.

RESULTS

A total of 31 studies were initially identified; 13 (13/31, 42%) met the inclusion criteria, including 819 patients with axSpA. All the studies used accelerometer-based wearable devices to assess physical activity. Of the 13 studies, 4 (4/31, 31%) studies also reported outcomes related to sedentary behavior. Wearable devices were secured on the wrists (3/13 studies, 23%), lower back (3/13, 23%), right hip (3/13, 23%), waist (2/13, 15%), anterior thigh (1/13, 8%), or right arm (1/13, 8%). The methods for reporting physical activity and sedentary behavior were heterogeneous. Approximately 77% (10/13) of studies had a monitoring period of 1 week, including weekend days.

CONCLUSIONS

To date, few studies have used wearable devices to quantify the physical activity and sedentary behavior of patients with axSpA. The methodologies and results were heterogeneous, and none of these studies assessed the psychometric properties of these wearables in this specific population. Further investigation in this direction is needed before using wearable device-measured physical activity and sedentary behavior as outcome measures in intervention studies in patients with axSpA.

TRIAL REGISTRATION

PROSPERO CRD42020182398; https://tinyurl.com/ec22jzkt.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/23359.

Effects of physical exercise and body weight on disease-specific outcomes of people with rheumatic and musculoskeletal diseases (RMDs): systematic reviews and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A European League Against Rheumatism (EULAR) taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). This paper reviews the literature on the effects of physical exercise and body weight on disease-specific outcomes of people with RMDs.

METHODS

Three systematic reviews were conducted to summarise evidence related to exercise and weight in seven RMDs: osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis, systemic sclerosis and gout. Systematic reviews and original studies were included if they assessed exercise or weight in one of the above RMDs, and reported results regarding disease-specific outcomes (eg, pain, function, joint damage). Systematic reviews were only included if published between 2013-2018. Search strategies were implemented in the Medline, Embase, Cochrane Library of systematic reviews and CENTRAL databases.

RESULTS

236 articles on exercise and 181 articles on weight were included. Exercise interventions resulted in improvements in outcomes such as pain and function across all the RMDs, although the size of the effect varied by RMD and intervention. Disease activity was not influenced by exercise, other than in axSpA. Increased body weight was associated with worse outcomes for the majority of RMDs and outcomes assessed. In general, study quality was moderate for the literature on exercise and body weight in RMDs, although there was large heterogeneity between studies.

CONCLUSION

The current literature supports recommending exercise and the maintenance of a healthy body weight for people with RMDs.

Home-based rehabilitation in patients over 60 with stabilized ankylosing spondylitis during the COVID-19 pandemic

BACKGROUND

COVID-19 has become a significant healthcare issue, particularly challenging for patients with ankylosing spondylitis (AS), because immune-related diseases and their treatments could adversely affect the susceptibility to or severity of a viral infection.

OBJECTIVE

This study is conducted to present an exercise rehabilitation program that patients older than 60 years with AS can do at home during the COVID-19 pandemic.

METHODS

Three Delphi surveys were conducted to reach a consensus on home-based rehabilitation programs. This study recruited ten experts and performed three Delphi rounds for a month.

RESULTS

The expert panel suggested that home-based rehabilitation for the patients should be carried out with a clear rehabilitation goal. Their final recommendations are to institute a program aimed to ease symptoms, such as pain and stiffness; encourage patients to consult with experts regularly to ensure that they perform exercise rehabilitation properly at home; add fast walking and stretching to the rehabilitation program; and see if indoor cycling, Pilates, or yoga could be appropriate.

CONCLUSIONS

This study suggests that patients with AS over 60 should repeat low-intensity exercises, such as stretching, for an hour a day, four to six times a week during the COVID-19 pandemic.

Qualitative interview study exploring the patient experience of living with axial spondyloarthritis and fatigue: difficult, demanding and draining

OBJECTIVE

To explore patients' lived experiences of axial spondyloarthritis (axSpA) and fatigue.

DESIGN

Interpretative phenomenological analysis (lived experience) was used as the study design. Analysis drew together codes with similar meaning to create superordinate and subordinate themes.

SETTING

Rheumatology departments in three National Health Service Foundation Trusts in the north, midlands and south of England.

PARTICIPANTS

A purposive sample of seventeen axSpA patients were recruited. The age range was 22-72 years (median age 46), nine were male and eight, female.

RESULTS

A central concept of achieving balance was identified as the active process of integrating axSpA symptoms and fatigue into daily life, working with and not against their condition to lead a fulfilled life. This was conveyed through three superordinate themes: struggling to find energy, engaging in everyday life and persevering through difficulties. Struggling to find energy was the challenge of retaining enough stamina to do things in daily life. Engaging in everyday life highlighted dedication to being active and organised, learning through experience and acceptance of a changed way of being. Persevering through difficulties identified the physical and emotional effort required to keep moving forward and the importance of feeling supported.

CONCLUSION

Achieving balance through finding energy, engaging and persevering everyday was fundamental to having the best possible life. The experience of energy emerged as a distinct but related component of fatigue. However, while energy could be maintained or replenished, fatigue was more difficult to overcome and required greater effort. Energy may be a useful indicator of an individual's current state and ability to sustain activities that supports their well-being, such as exercise. Awareness of the elements of achieving balance in axSpA may enable patients and clinicians to work together to tailor treatments to individual patient need.

Adherence, Efficacy, and Safety of Wearable Technology-Assisted Combined Home-Based Exercise in Chinese Patients With Ankylosing Spondylitis: Randomized Pilot Controlled Clinical Trial

Background

Clinical practice guidelines recommend that exercise is essential in the self-management of ankylosing spondylitis (AS). Attending supervised interventions requiring periodic medical center visits can be difficult and patients may decline participation, whereas effective home-based exercise interventions that do not require regular medical center visits are likely to be more accessible for AS patients.

Objective

The goal of the research was to investigate the adherence, efficacy, and safety of a wearable technology–assisted combined home-based exercise program in AS.

Methods

This was a 16-week investigator-initiated, assessor-blinded, randomized, pilot controlled trial conducted at Chinese People’s Liberation Army General Hospital. We enrolled patients with AS who had no regular exercise habits and had been stable in drug treatment for the preceding month. Patients were randomly assigned (1:1) using a computer algorithm. An exercise program consisting of moderate-intensity aerobic exercise and functional exercise was given to the patients in the intervention group. The exercise intensity was controlled by a Mio FUSE Heart Rate Monitor wristband, which uses photoplethysmography to measure heart rate. Patients in the control group received usual care. The primary outcome was the difference in the Ankylosing Spondylitis Disease Activity Score (ASDAS). The secondary outcomes were patient global assessment (PGA), physician global assessment (PhGA), total pain, nocturnal pain, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), BAS Functional Index (BASFI), BAS Metrology Index (BASMI), Spondyloarthritis International Society Health Index (ASAS HI), 36-item Short Form Survey (SF-36), maximal oxygen uptake (VO₂) max, body composition, range of motion of joints, and muscle endurance tests. Retention rate, adherence rate, barriers to being active, and adverse events were also assessed.

Results

A total of 77 patients were screened, of whom 55 (71%) patients were enrolled; 2% (1/55) withdrew without treatment after randomization. Patients were assigned to the intervention (n=26) or control group (n=28). The median adherence rate of the prescribed exercise protocol was 84.2% (IQR 48.7%-97.9%). For the primary outcome, between-group difference of ASDAS was significant, favoring the intervention (–0.2, 95% CI –0.4 to 0.02, P=.03). For the secondary outcomes, significant between-group differences at 16 weeks were detected in PGA, PhGA, total pain, BASDAI, BASDAI-fatigue, BASDAI–spinal pain, BASDAI–morning stiffness intensity, BASFI, and BASMI. Moreover, the frequency of difficulty in ASAS HI-motivation at 16 weeks was less in the intervention group (P=.03). Between-group difference for change from baseline were also detected in VO₂ max, SF-36, back extensor endurance test, and the range of motion of cervical lateral flexion at 16 weeks. Lack of time, energy, and willpower were the most distinct barriers to being active. Incidences of adverse events were similar between groups (P=.11).

Conclusions

Our pilot study suggests that this technology-assisted combined home-based exercise program can improve the clinical outcomes of patients with AS who have no exercise habit, with good adherence and safety profile.

Trial Registration

Chinese Clinical Trial Registry ChiCTR1900024244; http://www.chictr.org.cn/showproj.aspx?proj=40176

2022 French Society for Rheumatology (SFR) recommendations on the everyday management of patients with spondyloarthritis, including psoriatic arthritis

OBJECTIVE

Update the French Society for Rheumatology (SFR) recommendations on the everyday management of patients with spondyloarthritis, including psoriatic arthritis.

METHODS

Following standardized procedures, a systematic literature review was done by four supervised rheumatology residents based on questions defined by a task force of 16 attending rheumatologists. The findings were reviewed during three working meetings that culminated in each recommendation receiving a grade and the level of agreement among experts being determined.

RESULTS

Five general principles and 15 recommendations were developed. They take into account pharmacological and non-pharmacological measures along with treatment methods based on the dominant phenotype present (axial, articular, enthesitis/dactylitis) and the extra-articular manifestations (psoriasis, inflammatory bowel disease, uveitis). NSAIDs are the first-line pharmacological treatment in the various presentations. Conventional synthetic disease modifying antirheumatic drugs (csDMARDs) are not indicated in the axial and isolated entheseal forms. If the response to conventional treatment is not adequate, targeted therapies (biologics, synthetics) should be considered; the indications depend on the clinical phenotype and presence of extra-articular manifestations.

CONCLUSION

This update incorporates recent data (published since the prior update in 2018) and the predominant clinical phenotype concept. It aims to help physicians with the everyday management of patients affected by spondyloarthritis, including psoriatic arthritis.

Effectiveness of Physiotherapy in Patients with Ankylosing Spondylitis: A Systematic Review and Meta-Analysis

This study aimed to evaluate the safety and effectiveness of non-pharmacological interventions supervised by a physiotherapist in patients with Ankylosing Spondylitis, PROSPERO Protocol number CRD42020209453. Five databases (PubMed, PEDro, Scopus, Web of Science Core, and EMBASE) and reference lists with relevant articles were searched. Randomised controlled trials (RCTs) on the effectiveness of non-pharmacological interventions supervised by a physiotherapist were compared with usual care or home-based exercise programmes. Two investigators independently screened eligible studies. A total of 12 RCTs satisfied eligible criteria. The risk of bias ranged between medium and high. The meta-analysis results indicated that between supervised physiotherapy and usual care, the former was significantly associated with improvement in disease activity (standardised mean difference = -0.37, 95% CI, -0.64; -0.11; p < 0.001, I² = 71.25%, n = 629), and functional capacity (standardised mean difference = -0.36, 95% CI, -0.61; -0.12, p < 0.05; n = 629). No statistically significant differences emerged when interventions were compared with home-based exercise programmes. Supervised physiotherapy is more effective than usual care in improving disease activity, functional capacity, and pain in patients with ankylosing spondylitis. No significant improvements emerged when supervised physiotherapy and home-based exercise programmes were compared. Further investigation and RCTs with larger samples are needed.

Association of Core Muscle Endurance Times With Balance, Fatigue, Physical Activity Level, and Kyphosis Angle in Patients With Ankylosing Spondylitis

BACKGROUND/OBJECTIVE

Core muscle endurance (CME), which is the ability of sustaining the activity of trunk muscles, has been shown to be lower in patients with ankylosing spondylitis (AS). The aim was to investigate the possible relationship between CME times and balance, fatigue, physical activity (PA) level, and thoracic kyphosis angle.

METHODS

Fifty-one patients with AS with a mean age of 41.0 years (interquartile range, 25/75 years; 29.0/51.0 years) were included in the study. Core muscle endurance times were assessed by using trunk extension, trunk flexion, and side bridge tests. Overall stability index, anteroposterior stability index, mediolateral stability index, and limits of stability were evaluated with the Biodex Balance System. Fatigue and PA levels were surveyed using Fatigue Severity Scale and International Physical Activity Questionnaire, respectively. Thoracic kyphosis angle was measured by using a digital inclinometer. Additionally, CME times were compared for "high-fatigue" versus "low-fatigue" and as "low PA" versus "moderate/high PA" groups. Spearman correlation coefficients and Mann-Whitney U test were used for statistical analysis.

RESULTS

Significant correlations were detected between overall stability index, anteroposterior stability index, Fatigue Severity Scale, International Physical Activity Questionnaire, and all CME tests (p < 0.05) and between mediolateral stability index and side bridge test (p < 0.05). Limits of stability correlated only with side bridge test (p < 0.05). Core muscle endurance significantly differed between high-fatigue and low-fatigue groups (p < 0.05), except trunk flexor test (p > 0.05). No significant differences were observed between low PA and moderate/high PA groups (p > 0.05), except side bridge test (p < 0.05).

CONCLUSIONS

Core muscle endurance times seem to be related to PA level, fatigue, and balance but not with thoracic kyphosis angle. Assessing CME in patients with AS might help in planning individualized exercise programs.

The comparison of effects of balneotherapy, water-based and land-based exercises on disease activity, symptoms, sleep quality, quality of life and serum sclerostin level in patients with ankylosing spondylitis: A prospective, randomized study

Objectives

This study aims to compare the effects of balneotherapy, water-based exercise (WBE), and land-based exercise (LBE) on disease activity, symptoms, sleep quality, quality of life, and serum sclerostin level (SSL) in patients with ankylosing spondylitis (AS).

Patients and methods

Between January 2019 and January 2020, a total of 60 patients (35 males, 25 females; mean age: 40.9±11.2 years; range, 18 to 55 years) who were diagnosed with AS were randomly divided into the balneotherapy (n=20), WBE (n=20), and LBE (n=20) groups (20 sessions of treatment in groups of five to six patients). The patients were evaluated before treatment and at 4 and 12 weeks using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Ankylosing Spondylitis Disease Activity Score-C-reactive protein (ASDAS-CRP), Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), Ankylosing Spondylitis Quality of Life (ASQoL) Scale, Fatigue Severity Scale (FSS), and Pittsburg Sleep Quality Index (PSQI), and SSL were measured.

Results

Statistically significant improvements in the BASDAI, BASFI, MASES, BASMI, ASQoL, FSS, and ASDAS-CRP scores were observed in all groups at 4 and 12 weeks of follow-up (p<0.05). A significant improvement in sleep latency was seen in the balneotherapy and WBE groups. Changes in SSL were not statistically significant in any group (p>0.05).

Conclusion

Balneotherapy, WBE, and LBE are effective in the treatment of AS, and the beneficial effects may last for at least 12 weeks.

[Apps in rheumatology : Is there a need for an app in therapy for axial spondyloarthritis?]

BACKGROUND

Digital health applications/apps (DiGA) are entering many medical disciplines and have the potential to revolutionize patient care. In rheumatology, the use for axial spondyloarthritis (axSpA) would be conceivable in the form of an exercise app. Therefore, a representative survey among axSpA patients was conducted to determine the need for an axSpA exercise app.

MATERIALS AND METHODS

An anonymous online survey among axSpA patients of the German Bechterew's Disease Association was conducted using a questionnaire; data were analysed using Excel, and GraphPad Prism.

RESULTS

Four hundred and thirty-five axSpA patients participated in the survey. Eighty-four percent of the participants responded that there is a need to develop an axSpA-specific exercise app, and the same proportion want to use it. Patients under 60 years, patients under 60 years on biologics or Janus kinase inhibitor therapy, and patients with frequent back pain reported a greater need than their respective control subgroups (p < 0.001 in each case).

CONCLUSION

The development of an exercise app for axSpA is considered necessary by a large proportion of the patients; younger and more intensively treated patients appear to have a greater need.

To move or not to move: the paradoxical effect of physical exercise in axial spondyloarthritis

In the last years, new researches focused on the role of biomechanical stress and microdamage in the pathogenesis of inflammatory arthritis and, in particular, in axial spondyloarthritis (axSpA). Animal models showed how entheseal stress and physical exercise could contribute to the development of inflammation and new bone formation at entheseal and articular sites, by activating innate immune system and the release of cytokines. Furthermore, clues of the involvement of biomechanical stress in the development of axSpA are present in clinical experiences. However, rehabilitation and exercise programmes are the cornerstone of treatment for axSpA, reducing disease activity and improving spinal function and quality of life. The concept of mechanical stress as a contributor to disease development and progression represents, potentially, a conceptual challenge for this approach. The aim of this review is to discuss the current evidence on the intriguing contribution of the biomechanical stress to the pathogenesis of inflammation and new bone formation and to evaluate and reflect on the role of exercise in the treatment and in the management of the disease, considering both the beneficial effects and its possible paradoxical action.

Evaluating Chinese Mobile Health Apps for Ankylosing Spondylitis Management: Systematic App Search

BACKGROUND

Patients with ankylosing spondylitis (AS), a chronic systematic inflammatory disease, require long-term treatment and management. Mobile health (mHealth) apps can deliver health services through mobile devices, facilitate long-term disease management, support patient-health care provider communication, and enable patients to engage in disease management. There are some apps targeted at patients with AS, but the feature and quality of these apps have not been systematically examined.

OBJECTIVE

The aim of this study was to identify existing, publicly available Chinese mHealth apps for AS management and to evaluate their features and quality.

METHODS

We systematically searched potential apps for AS management on the Apple and Huawei App Stores, using 4 search terms: ankylosing spondylitis, spondyloarthritis, rheumatic disease, and arthritis. Apps were included if they were in the Chinese language, targeted at patients with AS, could be downloaded and run on Android and/or iOS operating systems, and incorporated elements of disease management and/or patient education. We excluded apps that were not for patient use, not relevant to AS, or had not been updated since 2018. Apps that met the inclusion criteria were downloaded for final analysis. We formulated a list of app quality measures from and consistent with international guidelines for mHealth apps and AS management to evaluate the features and quality of the included app. The user version of the Mobile App Rating Scale (uMARS) was also used to rate the apps' quality.

RESULTS

Of the 354 apps screened, 5 met the inclusion criteria and were included in our analysis. All apps were free, and most apps (4/5, 80%) had a privacy policy. Of the 5 apps, 1 (20%) involved medical professionals in the development process, 2 (40%) were developed by companies, and 2 (40%) were developed by medical institutions. All apps provided educational information about AS. Around half of the apps had functions like a basic information record (ie, users can input gender, age, disease history, etc) (n=3, 60%), patient-health care provider (and patient-patient) communication (n=2, 40%), symptom tracking (n=2, 40%), and information sharing (n=3, 60%). Only 1 (20%) app provided comprehensive functions that adhered to international guidelines for AS management and mHealth apps. The overall uMARS scores ranged from 2.7 to 4.2; only 1 app, with an overall uMARS score of 4.2, was considered as a high-quality app.

CONCLUSIONS

Most apps lacked comprehensive functions for AS management. One high-quality app provided comprehensive functions to help patients manage their conditions. This study assessed and summarized the features and quality of the apps but did not evaluate their efficacy. Future studies should evaluate the feasibility and efficacy of these apps. International guidelines and regulations for the design, development, validation, and implementation of mHealth apps are needed in the future. Meanwhile, health care providers, patients with AS, and app developers should collaborate to develop high-quality, evidence-based apps that take into account patients' needs and health care professionals' perspectives.

Tail suspension delays ectopic ossification in proteoglycan-induced ankylosing spondylitis in mice via miR-103/DKK1

Ankylosing spondylitis (AS), characterized by inflammatory lesions and osteophyte formation, is a common immune rheumatic disease affecting the sacroiliac and axial joints. A high-intensity mechanical load is known to accelerate the heterotopic ossification associated with enthesitis in AS. Thus, the present study explored whether decreased mechanical load could delay the heterotopic ossification in AS. First, 24-week-old female BALB/c mice were induced with proteoglycan (PG) to establish an AS model. The AS-induced pathological and bone morphological changes of the sacroiliac joint were confirmed by hematoxylin and eosin staining and microCT analysis, respectively. Subsequently, the mice were treated with interventions of different mechanical loads. Using reverse transcription-quantitative PCR, it was revealed that expression levels of the osteogenesis-related genes bone morphogenetic protein-2, runt-related transcription factor 2 and osteocalcin were significantly reduced in sacroiliac bone tissue after intervention with a reduced mechanical load. The level of mechanosensory microRNA (miR)-103 increased in response to reduced mechanical loads. Consistently, in groups with reduced mechanical load, proteins with mechanical functions, including ρ-associated coiled-coil-containing protein kinase 1 (ROCK1), phosphorylated (p)-Erk1/2 and β-catenin, were reduced compared with the PG control. A dual-luciferase assay verified that miR-103 binds to the 3'-untranslated region end of Rock1 mRNA, thus negatively regulating the activity of Rock1 and affecting pathological ossification during AS. However, immunohistochemical staining indicated that the expression of dickkopf Wnt signaling pathway inhibitor 1, an inhibitor of the Wnt/β-catenin pathway, was increased in sacroiliac tissues. The results indicated that tail suspension decreased the mechanical load, thus reducing the bone formation in AS mice. Furthermore, tail suspension could inhibit the activation of mechanical kinase ROCK1 and p-Erk1/2 in the MAPK signaling pathway by upregulating miR-103, thereby inhibiting the classical osteogenesis-related Wnt/β-catenin pathway in AS. In summary, the present study uncovered the ameliorative effect of suspension on AS and its therapeutic potential for AS.

Effects of a 6-month exercise programme on disease activity, physical and functional parameters in patients with ankylosing spondylitis: Randomised controlled trial

Background

Exercise forms an important component in the management of ankylosing spondylitis (AS). The objective of our study was to determine the effects of a 6-month swimming, land-based stretching, strengthening and breathing exercise intervention in AS patients.

Methods/design

A total of 29 (14 females, 15 males) patients diagnosed with AS according to the Modified New York Criteria participated in our study. Participants were randomly assigned to an exercise group (ASE) (16 participants) and a control group (ASC) (13 participants). Erythrocyte sedimentation rate and C-reactive protein (CRP); anthropometric measurements; pulmonary function; aerobic capacity; balance; Bath AS Metrology Index; Bath AS Disease Activity Index and the Bath AS Functional Index were assessed.

Discussion

Erythrocyte sedimentation rate and CRP did not change notably within or between the groups from pre- to post-intervention. The between group analyses of the physical assessments favoured the ASE with observable improvements in chest expansion (p = 0.002), forced expiration volume (p = 0.012), absolute (p = 0.017) and relative (p = 0.003) maximal oxygen consumption, absolute (p = 0.028) and relative (p = 0.001) physical work capacity. Within the ASE, there is statistical evidence of improvements in 11 of the 19 physical variables. Within the ASC, five of the physical variables deteriorated substantially (p between 0.004 and 0.037) and only balance overall stability on the right improved (p = 0.016). The three functional assessments in the ASE improved (p < 0.007) compared with the ASC post-intervention. A 6-month combined exercise programme may improve physical and functional capacity of AS patients.

Conclusion

A multimodal exercise intervention may be useful in the management of ankylosing spondylitis.

Clinical implications

An unsupervised well -explained exercise programme combining swimming, land-based strengthening and stretching exercises and breathing exercises may be an option for patients with ankylosing spondylitis.

Trial registration

Registration not undertaken at the time of writing.

Effectiveness and safety of Chinese herbal formula combined with western medicine for ankylosing spondylitis: A protocol for systematic review and meta-analysis

BACKGROUND

Ankylosing spondylitis (AS) is a chronic progressive inflammatory disease of the spine, which mainly invades the sacroiliac joint, spine, and large joints near the trunk, leading to fibrous and skeletal ankylosis and deformity, and can cause damage to the eyes, lung, cardiovascular, kidney and other organs. Chinese herbal formulas (CHF) is an important interventions of Traditional Chinese Medicine (TCM), and CHFs combined with western medicine are widely used in clinical practice to treat AS.

METHODS

Eight databases will be systematically retrieved from their inceptions to March 2021. Only randomized controlled trials (RCTs) of CHFs combined with western medicine for AS treatment will meet the inclusion criteria. The primary outcomes we focus on include clinical effectiveness rate, TCM syndrome score, TCM symptom score, Bath ankylosing spondylitis disease activity index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), chest expansion, nocturnal spinal pain, adverse reactions, erythrocyte sedimentation rate (ESR), and C protein response (CRP). The research screening, data extraction, and risk of bias assessment will be performed independently by 2 researchers, and divergence will be solved by a third researcher. Revman 5.3 software will be used for meta-analysis. The confidence of evidence will be graded using grading of recommendations assessment, development, and evaluation (GRADE) algorithm and methodological quality will be assessed adopting risk of bias in systematic reviews (ROBIS).

RESULTS

This systematic review (SR) will provide evidence-based medical evidence for AS therapy by CHF combined with western medicine and we will submit the findings of this SR for peer-review publication.

CONCLUSIONS

This SR will provide latest and updated summary proof for assessing the effectiveness and safety of CHF combined with western medicine for AS.

REGISTRATION NUMBER

INPLASY 202150089.

The mSQUASH; a valid, reliable and responsive questionnaire for daily physical activity in patients with axial spondyloarthritis

AIM

Adaptation of the Short QUestionnaire to Assess Health-enhancing physical activity (SQUASH) in order to improve measurement properties in axSpA patients.

METHODS

The original SQUASH was adapted using a qualitative stepwise approach with in-depth interviews including healthcare professionals and patients. Content validity was explored by comparing modified-SQUASH (mSQUASH) and original SQUASH. Next, mSQUASH was validated according to the OMERACT filter. International Physical Activity Questionnaire (IPAQ) was used as comparator and tri-axial accelerometer as gold standard for criterion validity and classification accuracy of intensity. Construct validity was assessed using Spearman correlations with clinical outcome assessments. For test-retest reliability, intra-class correlation coefficients (ICCs) were calculated. Responsiveness was assessed using standardized response mean (SRM), stratified by Anchor method.

RESULTS

The mSQUASH measured a systematically higher activity count and had less missing values (8% vs. 16%) then SQUASH. mSQUASH correlated better with accelerometer compared to IPAQ (ρ = 0.60 vs. ρ = 0.34). Accelerometer measured most activity in light intensity, whereas mSQUASH and IPAQ predominately measured moderate intensity. Correlations with ASDAS, BASDAI, BASFI and ASQoL were better for mSQUASH then IPAQ. Test-retest reliability was good in both questionnaires. In contrast to IPAQ, responsiveness was in correspondence with self-reported changes in physical activity for mSQUASH (SRM -0.84 for improvement and 0.88 for decrease). The average completion time of the mSQUASH was 7 minutes.

CONCLUSIONS

The development of the mSQUASH resulted in an easy applicable, valid, reliable and responsive questionnaire for the assessment of daily physical activity in axSpA patients, which can be used in research and daily clinical practice.

Value-Based Healthcare in Rheumatology: Axial Spondyloarthritis and Beyond

PURPOSE OF REVIEW

This review examines axial spondyloarthritis (axSpA) and the wider field of rheumatology through a value-based healthcare (VBHC) lens. VBHC is focused on ensuring patients receive high quality care to improve outcomes and reduce unnecessary costs.

RECENT FINDINGS

There are many opportunities to apply the principles of VBHC in axSpA. These include the appropriate utilization of diagnostic investigations, such as HLA-B27 and magnetic resonance imaging, assessing outcomes meaningful to patients, and optimizing care pathways. Multidisciplinary care may improve value, and reduced specialist review and medication tapering may be appropriate. Increasing the value of the care we provide to patients can occur across domains and directly and indirectly improves patient outcomes. Taking the time to integrate principles of VBHC into our practice will allow us to justifiably gain and maintain access to diagnostic and therapeutic advances for the benefit of all our patients.