High intensity exercise for 3 months reduces disease activity in axial spondyloarthritis (axSpA): a multicentre randomised trial of 100 patients

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.

One-year effectiveness of long-term exercise therapy in people with axial spondyloarthritis and severe functional limitations

OBJECTIVE

To evaluate the effectiveness of long-term, personalized, supervised exercise therapy on functional ability compared with usual care in people with axial spondyloarthritis (axSpA) and severe functional limitations.

METHODS

Participants were randomly 1:1 assigned to the intervention [maximal 64 sessions, with 14 additional optional sessions of supervised active exercise therapy (e.g. aerobic and muscle strengthening) with individualized goal-setting, education and self-management regarding physical activity] or usual care (care determined by clinician(s) and participants themselves). Primary endpoint was the change in the Patient-Specific Complaints activity ranked 1 [PSC1 (0-10)] at 52 weeks. Secondary endpoints were the PSC activities ranked 2 and 3, the Bath Ankylosing Spondylitis Functional Index, 6-min walk test, Patient Reported Outcome Measurement Information System-Physical Function-10 and the Short Form-36 Physical and Mental Component Summary Score (SF-36 PCS and MCS). Statistical comparisons comprised independent student t-tests and linear mixed models, based on intention-to-treat.

RESULTS

214 participants [49% female, age 52 (s.d. 12) years], were randomized to the intervention (n = 110) or usual care (n = 104) group. In the intervention group 93% started treatment, using on average 40.5 sessions (s.d. 15.1). At 52 weeks, the difference in change in PSC1 between groups favoured the intervention group [mean difference (95% CI); -1.8 (-2.4 to -1.2)]. Additionally, all secondary outcomes, except the SF-36 MSC, showed significantly greater improvements in the intervention group with effect sizes ranging from 0.4 to 0.7.

CONCLUSION

Long-term, supervised exercise therapy proved more effective than usual care in improving functional disability and physical quality of life in people with axSpA and severe functional limitations.

TRIAL REGISTRATION

Netherlands Trial Register NL8238, included in the International Clinical Trial Registry Platform (ICTRP) (https://trialsearch.who.int/Trial2.aspx?TrialID=NL8238).

Clinical Validation and Outcome Measures From Bend Ease: A Novel, Sensor-Based Digital Measurement Tool for Assessing At-Home Morning Stiffness and Spinal Range of Motion in Axial Spondyloarthritis

INTRODUCTION

To evaluate the accuracy, reliability, and usability of Bend Ease, a novel smartphone-based digital health technology (DHT), which objectively self-measures spinal range of motion (SRoM) and remotely assesses morning stiffness.

METHODS

This phase 1 study involved healthy volunteers (HV) and patients with axial spondyloarthritis (axSpA). Participants used Bend Ease by placing a phone against their chest during a forward-flexion bend, and the application collected and processed accelerometry data to measure bend angle in both clinical and at-home settings. Bend Ease measurements were compared to the video-based method (gold standard) and functional ability questionnaires.

RESULTS

The study included 30 HV and 30 patients with axSpA. Bend Ease accurately measured forward-flexion bend angles, demonstrating strong correlation (r = 0.74) and concordance (ρc = 0.71) with measurement by video. Impaired bending for patients with axSpA relative to HV was most pronounced upon waking (65.3° versus 88.3°, P < 0.001), with increasing bend angle improvements observed for patients with axSpA at later time points (71.0° and 75.8° at 30 min and 1 h after waking, respectively). Waking bend angle correlated with self-reported morning stiffness and functional ability scores. A minimum clinically important difference in bend angle of 14 degrees was established for patients with axSpA, providing a benchmark for improvement. Bend Ease demonstrated robust test-retest reliability, and participants reported high usability.

CONCLUSIONS

Bend Ease is an accurate, reliable, and user-friendly tool for assessing SRoM. As the first DHT to objectively evaluate morning stiffness upon waking, Bend Ease provides valuable assessments of spinal mobility when it is most impaired.

The history of ankylosing spondylitis/axial spondyloarthritis - what is the driving force of new knowledge?

The history of (axial) spondyloarthritis has started several centuries ago. Since the end of the 19th century major achievements have been made. This historical review tries to show how closely the advances in clinical medicine in rheumatology have been related to advances made in basic sciences.

Effects of aquatic high-intensity interval training on aerobic capacity in adults with rheumatic and musculoskeletal diseases: the AquaHigh randomised controlled trial

OBJECTIVES

To examine the effects of 12 weeks aquatic high-intensity interval training (AHIIT) compared with aquatic moderate-intensity continuous training (AMICT) on aerobic capacity and lower limb functional strength in adults with rheumatic and musculoskeletal diseases (RMDs).

DESIGN

An assessor-blinded randomised controlled trial.

SETTING

Community-based setting.

PARTICIPANTS

89 participants (91% female, mean age 62 (SD 13) years) with RMDs were randomly allocated to AHIIT (n=44) or AMICT (n=45).

INTERVENTIONS

Both groups participated in group-based peer-led exercise programmes two times per week for 12 weeks. The AHIIT group included four intervals of 4 min at high intensity (Borg scale 14-18). The AMICT group maintained moderate continuous intensity level (Borg scale 12-13).

MAIN OUTCOME MEASURES

Peak aerobic capacity (VO2peak) was estimated by time to exhaustion and lower limb functional strength with the 30-second sit-to-stand test (30sSTS) at baseline, 3 months and 6 months. A linear mixed model for repeated measures estimated the mean difference with 95% CI in VO2peak and 30sSTS.

RESULTS

Mean exercise intensity was Borg scale 15 (SD 2) and 13 (SD 2) in the AHIIT and AMICT, respectively. Mean improvement in VO2peak in AHIIT was 1.9 mL∙kg-1∙min-1 (95% CI 0.045 to 3.77) compared with AMICT after 12 weeks (p<0.05). There was no statistically significant difference between groups in VO2peak after 6 months or in 30sSTS at either 3 or 6 months (p>0.05). No adverse events during exercise were reported.

CONCLUSIONS

AHIIT demonstrated significant improvements in aerobic capacity after 12 weeks, and the intervention was well tolerated with no adverse events reported. However, there was no maintenance of aerobic capacity at 6 months.

TRIAL REGISTRATION NUMBER

NCT05209802.

Personalized physical activity recommendations for people with axial spondyloarthritis using wearable activity tracker data: an exploratory study

OBJECTIVE

Benefits of physical activity (PA) on sleep in people with axial SpondyloArthritis (axSpA) are largely unknown. Our aim is to explore the relationships between PA and sleep on both a group level and an individual level using Wearable Activity Trackers (WATs) and machine learning.

METHODS

A sample of 64 axSpA participants received a WAT to monitor their PA and sleep. Participants with more than 30 days data of PA and sleep duration were included in the analyses. Spearman's correlation and the machine learning technique Subgroup Discovery were used to determine relationships between PA during the three prior days and light and deep sleep duration.

RESULTS

Number of daily steps (n = 64) was (median (first quartile (Q1) - third quartile (Q3) )) 4026 (1915 - 6549), total sleep (daily light and deep sleep) duration of the participants was 7 h 29 min (6 h 41 min - 8 h 8 min). Nearly 30% (n = 18) of the participants were eligible for inclusion in analyses (> 30 days of data). No significant relationships between prior PA and sleep were obtained on a group level. On an individual level, for 8 of the 18 included participants, significant relationships (p < 0.05) could be identified between PA during the three prior days and daily sleep duration. These significant relationships differed from participant to participant with a varying qualification of PA (number of steps, intensity level PA) and relevant time window (previous one, two or three days).

CONCLUSION

Significant relationships between PA and daily sleep duration could be obtained on an individual level with details of the significant relationships varying between participants.

REGISTRATION NUMBER

Netherlands Trial Register NL8238, included in the International Clinical Trial Registry Platform (ICTRP) ( https://trialsearch.who.int/Trial2.aspx?TrialID=NL8238 ).

Prevalence and associations of kinesiophobia with patient reported outcomes and mobility measures in axial spondyloarthritis

OBJECTIVE

To investigate prevalence and associations of kinesiophobia on patients with axSpA, and its relation to global functioning and health, disease activity, function, spinal mobility and physical activity in comparison to healthy controls (HC).

METHODS

Cross-sectional, observational study in which consecutive axSpA patients with axSpA (n=100) and 20 healthy controls (HC) were examined by the Tampa scale of kinesiophobia (TSK), and the Fear avoidance belief questionnaire (FABQ). Patient reported outcomes and objective assessments of disease activity physical function, global health and functioning as well as the BASMI, the AS physical performance index (ASPI), the Short Physical Performance Battery (SPPB) and Epionics SPINE (ES) measurements, including range of motion (RoM) and kinematics (RoK) were collected.

RESULTS

AxSpA patients showed higher TSK (25.5±6.8 vs. 14.0±5.1) and FABQ scores (40.1±22 vs. 3.1±6.9) compared to HC, all P≤0.001. Categorical analyses of kinesiophobia levels revealed that patients with higher levels performed significantly worse in ASPI and SPPB tasks, and they also showed impairments in BASMI and ES measures. TSK and FABQ scores correlated with ASAS HI (r=0.45 and r=0.52) and BASFI (r=0.38 and r=0.44), but not with ASPI, SPPB and RoK. Weak correlations were found for BASMI (r=0.24 and r=0.38) and BASDAI (both r=0.35).

CONCLUSION

Kinesiophobia seems to be a clinically relevant problem of axSpA patients, since the mobility of patients with moderate to high TSK and FABQ scores was much more impaired in this study. Of interest, the level of kinesiophobia showed stronger correlations with physical function, global functioning and health than with mobility and PA.

Axial Spondyloarthritis: A Review

Importance

Axial spondyloarthritis is an immune-mediated inflammatory condition involving the sacroiliac joints, spine, and peripheral joints. It affects approximately 1% of adults in the US and is associated with impaired physical function and reduced quality of life.

Observations

Inflammatory chronic back pain characterized by gradual onset starting before age 45 years, prolonged morning stiffness, improvement with exercise, and lack of improvement with rest is the most common symptom of axial spondyloarthritis and affects more than 80% of patients. Patients with axial spondyloarthritis may also have inflammatory arthritis in large peripheral joints (most commonly knees) in an oligoarticular, asymmetric fashion; inflammation at tendon insertions (enthesitis); inflammatory eye disease (uveitis); psoriasis; and inflammatory bowel disease. The pathogenesis of axial spondyloarthritis may involve genetic predisposition, gut microbial dysbiosis, and entheseal trauma, with immune cell infiltration of the sacroiliac joints and entheseal insertion areas in the spine. There are currently no diagnostic criteria for axial spondyloarthritis. The diagnosis, often delayed 6 to 8 years after symptom onset, is based on history (ie, inflammatory back pain [sensitivity, 74%-81%; specificity, 25%-44%]), laboratory findings (human leukocyte antigen B27-positive [sensitivity, 50%; specificity, 90%] and elevated C-reactive protein level [sensitivity, 35%; specificity, 91%]), and imaging findings consisting of sacroiliitis on plain radiography (sensitivity, 66%; specificity, 68%) or magnetic resonance imaging (sensitivity, 78%; specificity, 88%). First-line treatments are physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs). However, less than 25% of patients achieve complete symptom control with NSAIDs. Approximately 75% of patients require biologic drugs (tumor necrosis factor inhibitors [anti-TNF agents], interleukin 17 inhibitors [anti-IL-17 agents]) or targeted synthetic disease-modifying antirheumatic agents (Janus kinase [JAK] inhibitors) to reduce symptoms, prevent structural damage, and improve quality of life. Clinical trials reported that anti-TNF agents significantly improved ASAS20 (measure of pain, function, and inflammation) in 58% to 64% of patients compared with 19% to 38% for placebo. Similar outcomes were attained with anti-IL-17 agents (48%-61%, vs 18%-29% with placebo) and JAK inhibitors (52%-56%, vs 26%-29% with placebo). Anti-TNF agents, anti-IL-17 agents, and JAK inhibitors have been associated with reduced radiographic progression of axial spondyloarthritis.

Conclusions

Axial spondyloarthritis predominantly affects the sacroiliac joints and spine but is also associated with extraskeletal manifestations such as uveitis, psoriasis, and inflammatory bowel disease. Physical therapy and NSAIDs are first-line treatments, but most patients require therapy with biologics (anti-TNF or anti-IL-17 agents) or JAK inhibitors to achieve improvement in signs and symptoms, inflammation control, and reduced progression of structural damage.

[German translation and linguistic validation of the modified short questionnaire to assess health-enhancing physical activity (mSQUASH) for patients with axial spondyloarthritis (axSpA)]

BACKGROUND

Patients with axial spondyloarthritis (axSpA) often experience chronic pain and inflammation, resulting in physical impairments, reduced mobility and decreased physical activity. The modified short questionnaire to assess health-enhancing physical activity (mSQUASH) was developed to assess daily physical activity in patients with axSpA.

OBJECTIVE

To translate, cross-culturally adapt and linguistically validate the original mSQUASH into German for patients with axSpA.

METHODS

The original mSQUASH was translated from Dutch into German using a multistep process (Beaton method) with forward-backward translations into German by bilingual Dutch-German lay people and experts. Any remaining discrepancies were resolved by a scientific committee, resulting in a prefinal German version. Field testing with cognitive debriefing interviews with patients with axSpA from diverse backgrounds led to a final German version.

RESULTS

Minor discrepancies, primarily related to formalities, semantic errors and syntax were found during translations. These were addressed, resulting in slight wording modifications. The prefinal German version was validated through cognitive debriefing by 10 patients with axSpA, confirming its linguistic validity and equivalence to the Dutch version.

CONCLUSION

Overall, this study confirmed the final German mSQUASH as a comprehensive measurement instrument for daily physical activity. It can now be used as a patient-reported outcome by German patients with axSpA. This can enable cross-linguistic comparisons and expanding its utility across language barriers.

Ankylosing spondylitis: From pathogenesis to therapy

Ankylosing spondylitis (AS) is an autoimmune rheumatic disease that primarily affects the axial joints, with its etiology complex and still not fully understood. The unknown pathogenesis of AS limits the development of treatment strategies, so keeping up-to-date with the current research on AS can help in searching for potential therapeutic targets. In addition to the classic HLA-B27 genetic susceptibility and Th17-related inflammatory signals, increasing research is focusing on the influence of autoantigen-centered autoimmune responses and bone stromal cells on the onset of AS. Autoantigens derived from gut microbiota and preferential TCR both exacerbate the autoimmune response in patients with AS. Furthermore, dysregulated bone metabolism also promotes pathological new bone formation in AS. Current treatments approved for AS almost focus on the management of inflammation with inconsistent treatment results due to the heterogeneity of patients. In this review, we systematically summarized various pathogenesis and management of AS, meanwhile discussed the underlying risk factors and potential therapeutic targets.

Long-term association between physical activity and global functioning in patients with axial spondyloarthritis: results of a two-year prospective study

OBJECTIVES

To assess the longitudinal association between physical activity and global functioning in patients with axial spondyloarthritis (axSpA), and to identify the subtype of physical activity that is longitudinally related to global functioning.

METHOD

Physical activity was measured using Global Physical Activity Questionnaire. Global functioning was assessed using the Assessment of SpondyloArthritis international Society Health Index (ASAS HI). The amount and subtype (work, transport, and recreation) of physical activity, disease activity, and ASAS HI were assessed at baseline, and at 1 and 2 year follow-up. Physical activity levels were categorized as low, moderate, or high. The longitudinal association between physical activity and ASAS HI scores was analysed using a generalized estimating equation.

RESULTS

The study evaluated 160 patients. Univariate analysis identified physical activity at moderate level and higher, Ankylosing Spondylitis Disease Activity Score (ASDAS), and syndesmophyte number as being longitudinally associated with ASAS HI over 2 years. Multivariate analysis identified physical activity at moderate level and higher as being longitudinally associated with ASAS HI. Physical activity above moderate levels was associated independently with good global functioning. In the analysis stratified by radiographic axSpA and non-radiographic axSpA, a positive association between physical activity and global functioning was observed in both groups. Only recreational activity, but not work- and transport-related activity, showed an independent longitudinal relationship with the ASAS HI score.

CONCLUSIONS

Physical activity at moderate level and higher was associated independently with global functioning in axSpA. Therefore, patients should maintain physical activity above moderate levels to preserve global function.

High-intensity interval training improves cardiovascular and physical health in patients with rheumatoid arthritis: a multicentre randomised controlled trial

OBJECTIVES

Patients with rheumatoid arthritis (RA) have substantially elevated risk for cardiovascular diseases, and low cardiorespiratory fitness (VO2max) is a major mediator. The aim of this assessor-blinded, two-armed multicentre randomised controlled trial was to evaluate the effects of high-intensity interval training (HIIT) and strength exercise on cardiovascular health, physical fitness and overall health in patients with RA.

METHODS

In total, 87 patients (86% female; aged 20-60 years) were randomly assigned to an intervention group (IG) or a control group (CG). The IG performed HIIT and strength exercise for 12 weeks. The CG was instructed to be physically active on a moderately intensive level, ≥150 min/week. Primary outcome was change in VO2max. Secondary outcomes were changes in anthropometry measures, muscle strength, overall health (Visual Analogue Scale (VAS)-Global), Patient Global Impression of Change (PGIC), pain and disease activity (Disease Activity Score in 28 joints (DAS28)).

RESULTS

There was a significant mean group difference of change on VO2max (3.71 mL/kg/min; 95% CI 2.16, 5.25) in favour of the IG. Significant mean group differences of change were also seen for O2-pulse (1.38; 95% CI 0.85 to 1.91), waist circumference (-2.6; 95% CI -5.09 to -0.18), 1-minute sit-to-stand (5.0; 95% CI 3.35 to 6.72), handgrip strength (28.5; 95% CI 3.80 to 52.8), overall health (-14.7; 95% CI -23.8 to -5.50) and PGIC (p<0.0001) in favour of the IG. No significant mean group differences of change were found for pain (-4.0; 95% CI -13.07 to 5.06), DAS28 (-0.25; 95% CI -0.60 to 0.10) and erythrocyte sedimentation rate (-0.64; 95% CI -3.23 to 1.90).

CONCLUSION

Supervised HIIT and strength exercise improved cardiovascular health, physical fitness and overall health without a deterioration in pain and disease activity and should be considered in patients with well-controlled RA.

TRIAL REGISTRATION NUMBER

NCT05768165.

Technology supported High Intensity Training in chronic non-specific low back pain (the Techno-HIT trial): study protocol of a randomised controlled trial

Chronic low back pain (CLBP) is one of the most common chronic musculoskeletal disorders worldwide. Guidelines recommend exercise therapy (ET) in CLBP management, but more research is needed to investigate specific ET modalities and their underlying mechanisms. The primary goal of this study is to evaluate the short-term and long-term effectiveness of a time-contingent individualised high-intensity training (HIT) protocol on disability compared with a time-contingent moderate-intensity training (MIT) as used in usual care, in persons with severely disabling CLBP. Additionally, the effectiveness on central effects, the added value of prolonged training at home and technology support, and the cost-effectiveness are evaluated. In this randomised controlled trial, CLBP patients will be randomly divided into three groups of 56 participants. Group 1, 'TechnoHIT', receives HIT with technology-support in the home-phase. Group 2, 'HIT', receives HIT without technology support. Group 3, 'MIT', receives MIT, reflecting training intensity as used in usual care. The primary outcome is patient-reported disability, measured by the Modified Oswestry Disability Index. Secondary outcomes include quantitative sensory testing, psychosocial factors, broad physical fitness, quality of life, cost-effectiveness, adherence and usability of technology. Trial registration number NCT06491121.

Complementary App-Based Yoga Home Exercise Therapy for Patients With Axial Spondyloarthritis: Usability Study

BACKGROUND

Axial spondyloarthritis (AS) is a chronic inflammatory rheumatic disease characterized by potentially disabling inflammation of the spine and adjacent joints. Regular exercise is a cornerstone of treatment. However, patients with AS currently have little support. YogiTherapy (MaD Lab) is an app developed to support patients with AS by providing instructions for yoga-based home exercise therapy.

OBJECTIVE

This study aimed to evaluate the usability and acceptance of the newly designed YogiTherapy app for patients with AS.

METHODS

Patients completed the User Version of the Mobile Application Rating Scale (uMARS) and net promoter score (NPS) questionnaires after the app introduction. Wilcoxon Mann-Whitney rank sum test, chi-square test for count data, and correlation analysis were conducted to examine the usability of the app, acceptance, and patient characteristics.

RESULTS

A total of 65 patients with AS (33, 51% female; age: mean 43.3, SD 13.6 years) were included in the study from May 2022 to June 2023. Subsequently, the data were analyzed. Usability was rated moderate, with a mean uMARS of 3.35 (SD 0.47) points on a scale from 0 to 5. The highest-rated uMARS dimension was information (mean 3.88, SD 0.63), followed by functionality (mean 3.84, SD 0.87). Females reported a significantly higher uMARS total score than males (mean 3.47, SD 0.48 vs mean 3.23, SD 0.45; P=.03, Vargha and Delaney A [VDA] 0.66, 95% CI 0.53-0.77). The mean average of the NPS was 6.23 (SD 2.64) points (on a scale from 0 to 10), based on 43% (26/65 nonpromoters, 42% (25/65) indifferent, and 15% (9/65) promoters. A total of 7% (5/65) of those surveyed did not answer the question. When applying the NPS formula, the result is -26%. The NPS showed a positive correlation with the usage of mobile apps (r=0.39; P=.02). uMARS functionality was significantly higher rated by patients younger than 41 years (mean 4.17, SD 0.55 vs mean 3.54, SD 1; P<.001; VDA 0.69, 95% CI 0.56-0.80). Patients considering mobile apps as useful reported higher uMARS (r=0.38, P=.02). The uMARS app quality mean score was correlated with the frequency of using apps (r=-0.21, P<.001).

CONCLUSIONS

The results revealed moderate acceptance and usability ratings, prompting further app improvement. Significant differences were observed between age and gender. Our results emphasize the need for further improvements in YogiTherapy.

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.

High-quality research on physical therapy in psoriatic arthritis is needed: a systematic review

Objectives

Although physical therapy is recommended as part of the non-pharmacological management of patients with psoriatic arthritis (PsA), the evidence is still unclear. Therefore, this study aimed to systematically review and appraise the quality of research on physical therapy in the management of patients with PsA.

Methods

In June 2024, a systematic literature search using four different databases (Medline, Embase, Web of Science and the Cochrane Library) was performed to include interventional and observational studies examining physical therapy in patients with PsA (PROSPERO ID 255501). A risk of bias assessment was conducted. Due to the wide variety of interventions and outcomes, a narrative synthesis was used.

Results

Of 9442 abstracts, 15 papers examining physical therapy uptake in clinical practice (N = 2) and different physical therapy interventions (N = 13) were included: cardiorespiratory exercises (N = 5), resistance exercises (N = 2), therapeutic modalities (N = 4) and mixed rehabilitation programs (N = 2). A low risk of bias was scored in only one RCT assessing cardiorespiratory exercises. The well-tolerated 11-week high-intensity interval training resulted in a long-term increase in peak oxygen uptake and a short-term decrease in truncal fat percentage in patients with low disease activity. Resistance training in patients with active disease did not increase muscle strength, but improved functional capacity, disease activity, pain and general health after the intervention. Evidence for other modalities was inconclusive.

Conclusion

High-quality evidence on physical therapy in PsA was scarce. Cardiorespiratory and resistance exercises demonstrated promising results to positively influence cardiometabolic risk as well as disease-related outcomes. Future research on physical therapy in PsA with adequate methodological quality is needed.

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.

Presentation of the first international research network to foster high-quality clinical trials testing non-pharmacological interventions (TRACTION network)

Clinical trials are essential for evaluating the efficacy and safety of new treatments and health interventions. However, while pharmacological trials are well-established, non-pharmacological trials face unique challenges related to their complexity and difficulties such as recruitment, retention, intervention standardisation, selection of outcome measures and blinding of clinicians, participants and data collectors. This communication paper describes the objectives, implementation steps and bylaws of the 'Trials foR heAlth Care inTerventIONs' Network (TRACTION), established by an international multiprofessional task force of experts to foster high-quality non-pharmacological research, ultimately improving patient care and healthcare outcomes.The TRACTION research network will provide information and resources through a collaborative hub for researchers, health professionals, patient research partners and stakeholders in diverse biomedical and healthcare areas, connecting people with different levels of expertise but with the same interests (eg, to evaluate the effect of non-pharmacological interventions, recruiting participants). This open network will support researchers in optimising trial design, participant recruitment, data management and analysis, and disseminating and implementing trial results.The network will also facilitate specialisation training and provide educational materials and mentoring.

Higher levels of physical activity are associated with less evasive coping, better physical function and quality of life in patients with axial spondyloarthritis

OBJECTIVE

To evaluate daily physical activity (PA) in relation to psychosocial factors, such as anxiety, depression and different types of coping strategies, as well as patient- and disease-related factors in patients with axial spondyloarthritis (axSpA).

METHODS

Consecutive outpatients from the Groningen Leeuwarden AxSpA (GLAS) cohort completed the modified Short Questionnaire to assess health-enhancing PA (mSQUASH), Hospital Anxiety and Depression Scale (HADS) and Coping with Rheumatic Stressors (CORS) questionnaires, as well as standardized patient- and disease-related assessments. Univariable and multivariable linear regression analyses and comparison of lowest and highest PA tertiles were performed to explore associations between the HADS, CORS, patient- and disease-related factors and PA.

RESULTS

In total, 84 axSpA patients were included; 60% male, mean age 49 (SD ±14) years, median symptom duration 20 (25th-75th percentiles: 12-31) years, mean ASDAS 2.1 (±1.0). Higher PA levels were significantly associated with better scores on patient-reported disease activity (BASDAI), physical function (BASFI) and quality of life (ASQoL). Furthermore, higher levels of PA were associated with less impact of axSpA on wellbeing and lower HADS depression scores. In the multivariable linear regression model, less use of the coping strategy 'decreasing activities' (β: -376.4; p 0.003) and lower BMI (β:-235.5; p: 0.030) were independently associated with higher level of PA. Comparison of patients from the lowest and highest PA tertiles showed results similar to those found in the regression analyses.

CONCLUSION

In this cohort of axSpA patients, higher levels of daily PA were associated with better patient-reported outcomes and lower depression scores. Additionally, the passive coping strategy "decreasing activities" and lifestyle factor BMI were independently associated with PA. Besides anti-inflammatory treatment, coping strategies and lifestyle should be taken into account in the management of individual axSpA patients. Incorporating these aspects into patient education could increase patient awareness and self-efficacy. In the future, longitudinal studies are needed to better understand the complex relationship between patient-, disease- and psychosocial factors associated with daily PA.

Exercise as an anti-inflammatory Therapy in Axial Spondyloarthritis Therapeutic Intervention (EXTASI) study: a randomized controlled trial

Objectives

Axial SpA (axSpA) is a chronic inflammatory disease, yet despite known anti-inflammatory effects of exercise, the effect of exercise on inflammatory immune cell populations and associated inflammatory profiles in axSpA is unknown. This randomized controlled trial investigated the effect of 12 weeks of walking on symptom severity, cardiometabolic health, inflammatory biomarkers and immune cell populations.

Methods

Twenty people (60% male) living with axSpA who were on a stable dose of NSAIDs participated. Participants were randomly assigned to control or exercise (30 min of walking five times per week). Participants were invited back every 4 weeks for assessment.

Results

There was a 0% dropout rate and no adverse events in the exercise group, showing walking exercise was well tolerated. Home-based walking for 12 weeks lowered the proportion of pro-inflammatory monocytes, whereas they increased in the control group. Changes were associated with lower IL-6 and CRP concentrations, lower spinal pain and lower systolic blood pressure in the exercise group, whereas these markers increased in the control group. Reductions in IL-6 and pro-inflammatory monocytes with exercise were independent of lower body fat percentage.

Conclusions

Supplementing NSAID therapy with walking exercise can improve inflammatory immune profiles in people with axSpA, coinciding with reductions in spinal pain. Importantly, the exercise was well tolerated, suggesting walking exercise can be used as an adjuvant anti-inflammatory therapy for NSAID treatments. This should now be explored in people living with axSpA who have had high enough disease activity to necessitate the prescription of biologic or synthetic DMARD treatments.

Trial registration

ClinicalTrials.gov (http://clinicaltrials.gov), NCT04368494.

The anti-inflammatory effects of exercise on autoimmune diseases: A 20-year systematic review

BACKGROUND

The anti-inflammatory effect of exercise may be an underlying factor in improving several autoimmune diseases. The aim of this systematic review was to examine the evidence on the role of exercise training in mitigating inflammation in adolescents and adults with autoimmune disease.

METHODS

PubMed, Web of Science, and Embase databases were systematically reviewed for related studies published between January 1, 2003, and August 31, 2023. All randomized and non-randomized controlled trials of exercise interventions with autoimmune disease study participants that evaluated inflammation-related biomarkers were included. The quality of evidence was assessed using the Tool for the assEssment of Study qualiTy and reporting in EXercise scale and Cochrane bias risk tool.

RESULTS

A total of 14,565 records were identified. After screening the titles, abstracts, and full texts, 87 were eligible for the systematic review. These studies were conducted in 25 different countries and included a total of 2779 participants (patients with autoimmune disease, in exercise or control groups). Overall, the evidence suggests that inflammation-related markers such as C-reactive protein, interleukin 6, and tumor necrosis factor α were reduced by regular exercise interventions. Regular exercise interventions combined with multiple exercise modes were associated with greater benefits.

CONCLUSION

Regular exercise training by patients with autoimmune disease exerts an anti-inflammatory influence. This systematic review provides support for the promotion and development of clinical exercise intervention programs for patients with autoimmune disease. Most patients with autoimmune disease can safely adopt moderate exercise training protocols, but changes in inflammation biomarkers will be modest at best. Acute exercise interventions are ineffective or even modestly but transiently pro-inflammatory.

Can we achieve pain stratification in musculoskeletal conditions? Implications for clinical practice

In the last few years there has been an increased appreciation that pain perception in rheumatic and musculoskeletal diseases (RMDs) has several mechanisms which include nociceptive, inflammatory, nociplastic and neuropathic components. Studies in specific patient groups have also demonstrated that the pain experienced by people with specific diagnoses can present with distinctive components over time. For example, the pain observed in rheumatoid arthritis has been widely accepted to be caused by the activation of nociceptors, potentiated by the release of inflammatory mediators, including prostaglandins, leukotrienes and cytokine networks in the joint environment. However, people with RA may also experience nociplastic and neuropathic pain components, particularly when treatments with disease modifying anti-rheumatic drugs (DMARDs) have been implemented and are insufficient to control pain symptoms. In other RMDs, the concept of pain sensitisation or nociplastic pain in driving ongoing pain symptoms e.g. osteoarthritis and fibromyalgia, is becoming increasingly recognised. In this review, we explore the hypothesis that pain has distinct modalities based on clinical, pathophysiological, imaging and genetic factors. The concept of pain stratification in RMD is explored and implications for future management are also discussed.

Reduced sleep quality is highly prevalent and associated with physical function and cardiorespiratory fitness in patients with axial spondyloarthritis: a cross-sectional study

OBJECTIVES

To assess sleep quality, and its associations with physical function, cardiorespiratory fitness, and spinal mobility, in axial spondyloarthritis (axSpA) patients.

METHOD

Baseline data from the Exercise for Spondyloarthritis trial were used. Assessments included [Pittsburgh Sleep Quality Index (PSQI), 0-21, 21 = worst], performance-based physical function [Ankylosing Spondylitis Performance Index (ASPI), seconds, higher = worse], patient-reported physical function [Bath Ankylosing Spondylitis Functional Index (BASFI), 0-10, 10 = worst], cardiorespiratory fitness [peak oxygen uptake (V O2peak), mL/kg/min, lower = worse], and spinal mobility [Bath Ankylosing Spondylitis Metrology Index (BASMI), 0-10, 10 = worst]. Associations were examined in separate models using multiple linear regression.

RESULTS

Ninety-nine patients with axSpA were included, 53% female, mean age 46 years, and 72% with high disease activity (ASDAS-C-reactive protein ≥ 2.1), of whom 84 (85%) had reduced sleep quality. Sleep disturbance was most frequently reported (65%), followed by poor subjective sleep quality (53%), daytime dysfunction (41%), and increased sleep latency (41%). Positive associations were observed between PSQI and ASPI [β = 0.10, 95% confidence interval (CI) 0.01, 0.19] and PSQI and BASFI (β = 0.85, 95% CI 0.51, 1.20), and there was an inverse association between PSQI and V O2peak (β = -0.14, 95% CI -0.27, -0.01), adjusted for age and sex. There was no association between PSQI and BASMI.

CONCLUSION

Reduced sleep quality was common in axSpA patients with moderate to high disease activity. Better sleep quality was associated with better physical function and higher cardiorespiratory fitness. There was no association between sleep quality and spinal mobility.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02356874.

Impact of daily physical therapy over 2 weeks on spinal mobility including objective electronic measurements and function in patients with axial spondyloarthritis

Background

Patients with axial spondyloarthritis (axSpA) are often compromised by impaired function and mobility. The standardized 2-week inpatient program 'multimodal rheumatologic complex treatment' (MRCT) was designed for patients with axSpA. The Epionics SPINE (ES) is an objective tool validated to assess mobility.

Objective

To investigate the impact of MRCT on physical function and mobility including range of motion (RoM) and kinematics (RoK).

Design

Single-center interventional, observational trial.

Methods

Patients with axSpA presenting with high disease activity and impaired physical function were consecutively recruited to undergo MRCT. Assessments performed before (V1) and after (V2) the intervention included Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis functional index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), the ankylosing spondylitis physical performance index (ASPI), the Short Physical Performance Battery (SPPB), and ES measurements.

Results

At baseline, the 80 patients included had: BASDAI 5.5 ± 1.5, BASFI 5.6 ± 2.0, BASMI 4.2 ± 1.8, SPPB 13.8 ± 1.8, and ASPI 37.3 ± 18.1 s. Clinically relevant improvements between V1 versus V2 were noted for BASFI, BASMI, and all other assessments (p < 0.001), and also for ES measures of RoK (all p < 0.003) and RoM (all p < 0.04), while a positive trend was seen for flexion and extension (RoM). There was no significant effect of changes in medication (all p > 0.05).

Conclusion

The 2-weeks MRCT was associated with definite improvements of function and mobility. Importantly, the effect of this extensive physical activity was confirmed by using the ES as an objective tool to assess spinal mobility. The ES demonstrated for the first time that the RoK of spinal mobility can significantly improve related to an exercise intervention.

Trial registration

Ethical Committee: Ruhr-Universität (reference-number: 19-6735-BR).

Effect of high-intensity interval training in physiotherapy primary care for patients with inflammatory arthritis: the ExeHeart randomised controlled trial

OBJECTIVES

To assess the effect of high-intensity interval training (HIIT) delivered in physiotherapy primary care on the primary outcome of cardiorespiratory fitness (CRF) in patients with inflammatory arthritis (IA). Additionally, to explore the effects of HIIT on secondary outcomes, including cardiovascular disease (CVD) risk factors and disease activity.

METHODS

Single-blinded randomised controlled trial with 60 patients randomly assigned to either a control group receiving usual care or an exercise group receiving usual care and 12 weeks of individualised HIIT at 90%-95% peak heart rate. Outcomes were assessed at baseline, 3 months and 6 months post baseline and included CRF measured as peak oxygen uptake (VO2peak), classic CVD risk factors, disease activity, anthropometry and patient-reported physical activity, pain, fatigue, disease impact and exercise beliefs and self-efficacy.

RESULTS

Intention-to-treat analysis demonstrated a significant between-group difference in VO2peak at 3 months (2.5 mL/kg/min, 95% CI 0.9 to 4.0) and 6 months (2.6 mL/kg/min, 95% CI 0.8 to 4.3) in favour of the exercise group. A beneficial change in self-reported physical activity in favour of the exercise group was observed at 3 and 6 months. The HIIT intervention was well-tolerated with minimal adverse events and no apparent impact on disease activity. Differences in secondary outcomes related to CVD risk factors, disease impact, pain, fatigue and exercise beliefs and self-efficacy were generally small and non-significant.

CONCLUSION

After 12 weeks of supervised HIIT delivered in physiotherapy primary care, patients with IA demonstrated a favourable improvement in CRF, with sustained effects at 6-month follow-up.

TRIAL REGISTRATION NUMBER

NCT04922840.

Clinically relevant differences in spinal mobility related to daytime performance in patients with axial spondyloarthritis

OBJECTIVE

Patients with axial spondyloarthritis (axSpA) suffer from clinical symptoms like morning stiffness and back pain. Mobility of patients with axSpA is often impaired. The aim of this study is to compare the performance of patients with axSpA regarding mobility measures including performance-based tests and objective electronic assessments with the Epionics SPINE device (ES) at different times of the day compared with healthy controls (HC).

METHODS

Observational trial, consecutive inpatients with axSpA (n=100) and 20 HCs were examined in the morning (V1: before 10:00 am) and in the afternoon (V2: after 02:00 pm) by the Bath Ankylosing Spondylitis Metrology Index (BASMI), the AS physical performance index (ASPI), the Short Physical Performance Battery (SPPB) and ES measurements, including range of motion (RoM) and range of kinematics (RoK).

RESULTS

The assessments of patients with axSpA performed in the morning clearly differed from those in the afternoon, especially regarding performance-based tests. Significant improvements were seen for BASMI (4.0±3.8 to 3.8±1.9; p<0.001), ASPI (36.2±18.3 to 28.8±11.9 s; p<0.001), SPPB (10.1±1.5 to 10.7±1.4 points; p<0.001) and for ES measures of speed (RoK; p<0.018) but not for RoM, except for lateral flexion (13.3±7.4 to 14.7±8.2°; p=0.002). This time of assessment-related variability was not observed in HC.

CONCLUSION

The spinal mobility of patients with axSpA was worse in the morning but significantly improved in the afternoon. This was captured best by performance-based measures and was not seen in HC. The diurnal variation of mobility has implications for clinical studies, suggesting that the time of assessments needs to be standardised.

Quality of reporting and nature of harms in clinical trials on supervised exercise in patients with rheumatoid arthritis or axial spondyloarthritis

To describe the quality of reporting and the nature of reported harms in clinical studies on the effectiveness of supervised exercises in patients with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA). We performed a systematic review, searching eight databases up to February 2023. Randomized controlled trials (RCTs) evaluating supervised exercises in adults with RA or axSpA were considered eligible. Data on harms were extracted according to the CONSORT Harms 2022 Checklist. Among others, it was recorded if harms were prespecified or non-prespecified. Moreover, the nature of reported harms was listed. Forty RCTs were included for RA and 25 for axSpA, of which 29 (73%) and 13 (52%) reported information on harms. In 13 (33%) RCTs in RA and four (16%) in axSpA, the collection of harms outcomes was described in the methods section. Prespecified outcomes were reported by eight (RA) and two (axSpA) RCTs. Non-specified harms outcomes were reported by six (RA) and four (axSpA) RCTs. Prespecified harms outcomes included measures of pain, disease activity, inflammation, and structural joint changes. The nature of non-prespecified harms outcomes varied largely, with pain being most common. A considerable proportion of trials on supervised exercise in RA or axSpA does not or inadequately report harms outcomes. Pain was the most commonly reported prespecified or non-specified harm. For a considerate interpretation of the balance between benefits and harms of supervised exercise in RA or axSpA, use of the CONSORT Harms 2022 Checklist for the design, conduct and reporting of trials is advocated.

Follow-Up of Patients With Axial Spondyloarthritis in Specialist Health Care With Remote Monitoring and Self-Monitoring Compared With Regular Face-to-Face Follow-Up Visits (the ReMonit Study): Protocol for a Randomized, Controlled Open-Label Noninferiority Trial

BACKGROUND

Patients with chronic inflammatory joint diseases such as axial spondyloarthritis have traditionally received regular follow-up in specialist health care to maintain low disease activity. The follow-up has been organized as prescheduled face-to-face visits, which are time-consuming for both patients and health care professionals. Technology has enabled the remote monitoring of disease activity, allowing patients to self-monitor their disease and contact health care professionals when needed. Remote monitoring or self-monitoring may provide a more personalized follow-up, but there is limited research on how these follow-up strategies perform in maintaining low disease activity, patient satisfaction, safety, and cost-effectiveness.

OBJECTIVE

The Remote Monitoring in Axial Spondyloarthritis (ReMonit) study aimed to assess the effectiveness of digital remote monitoring and self-monitoring in maintaining low disease activity in patients with axial spondyloarthritis.

METHODS

The ReMonit study is a 3-armed, single-site, randomized, controlled, open-label noninferiority trial including patients with axial spondyloarthritis with low disease activity (Ankylosing Spondylitis Disease Activity Score <2.1) and on stable treatment with a tumor necrosis factor inhibitor. Participants were randomized 1:1:1 to arm A (usual care, face-to-face visits every sixth month), arm B (remote monitoring, monthly digital registration of patient-reported outcomes), or arm C (patient-initiated care, self-monitoring, no planned visits during the study period). The primary end point was disease activity measured with the Ankylosing Spondylitis Disease Activity Score, evaluated at 6, 12, and 18 months. We aimed to include 240 patients, 80 in each arm. Secondary end points included other measures of disease activity, patient satisfaction, safety, and cost-effectiveness.

RESULTS

The project is funded by the South-Eastern Norway Regional Health Authority and Centre for the treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Norway. Enrollment started in September 2021 and was completed with 242 patients by June 2022. The data collection will be completed in December 2023.

CONCLUSIONS

To our knowledge, this trial will be among the first to evaluate the effectiveness, safety, and cost-effectiveness of remote digital monitoring and self-monitoring of patients with axial spondyloarthritis compared with usual care. Hence, the ReMonit study will contribute important knowledge to personalized follow-up strategies for patients with axial spondyloarthritis. These results may also be relevant for other patient groups with inflammatory joint diseases.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05031767; hpps://www.clinicaltrials.gov/study/NCT05031767.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52872.

Effectiveness of functional training versus resistance exercise in patients with psoriatic arthritis: randomized controlled trial

OBJECTIVE

This study aims to evaluate the effect of functional versus resistance exercise training on the functional capacity and quality of life of psoriatic arthritis patients.

METHODS

Forty-one psoriatic arthritis patients (18 to 65 years old) were randomized into two groups: functional training group and resistance exercise group. The functional training group underwent functional exercises with elastic band and the functional training group underwent machine resistance exercise twice a week for 12 weeks. Outcome measures were: The Bath Ankylosing Spondylitis Functional Index (BASFI) and Health Assessment Questionnaire for the Spondyloarthropathies (HAQ-S) for functional capacity and functional status, one-repetition maximum test for muscle strength, the Short Form 36 health survey questionnaire (SF-36) for quality of life, and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Disease Activity Score 28 (DAS-28) for disease activity. Analyzes were performed by a blinded evaluator at baseline (T0), six (T6) and twelve (T12) weeks after the beginning of the exercise.

RESULTS

At baseline, the groups were homogeneous in the clinical and demographic characteristics. There was a statistical intra-group improvement for both groups in the BASFI, BASDAI, HAQ-s, and DAS-28. In the quality-of-life assessment, both groups showed statistical intra-group improvements for all domains except the "emotional aspect" domain in the resistance exercise group. In the muscle strength, there was a statistical improvement for all exercises in both groups, except for the "alternate biceps (bilateral)" exercise.

CONCLUSION

Functional training and resistance exercise are similarly effective in improving functional capacity, functional status, disease activity, general quality of life, and muscle strength in patients with psoriatic arthritis.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04304326. Registered 11 March 2020, https://clinicaltrials.gov/ct2/show/NCT04304326?term=NCT04304326&draw=2&rank=1 .

Impact of different types of exercise programs on ankylosing spondylitis: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis of controlled studies aimed to assess the efficacy of different types of exercise programs (EP) on ankylosing spondylitis (AS) activity, function and mobility.

METHODS

We searched PubMed/Medline, Cochrane Library and Embase databases for reports of controlled trials of patients with AS published up to May 2022. The studies were classified by intervention into categories defined by the 4 exercise domains established by the American College of Sports Medicine and then adopted by the European League Against Rheumatism: aerobic, muscle strength, flexibility, neuromotor performance.

RESULTS

We found a moderate effect of EP as a whole on BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) (-0.60, 95% CI -0.95, -0.25, p < 0.001), BASFI (Functional) (-0.63, 95% CI -0.84, -0.42, p < 0.0001) and BASMI (Metrology) (-0.52, 95% CI -0.88, -0.15, p < 0.01). The effect of "flexibility + muscle strength" EP was large for BASMI, moderate for BASDAI and BASFI. The effect of "flexibility + muscle strength + aerobic" EP was large for BASFI, moderate for BASDAI.

CONCLUSIONS

EP, regardless of the specific type of exercise, have a moderate effect on AS activity, function and mobility. EP including flexibility and muscle strength exercises may have a large effect, especially for mobility. Programs including aerobic exercise showed significant efficacy for function.IMPLICATIONS FOR REHABILITATIONIn ankylosing spondylitis (AS), any exercise program (EP), regardless of the type of exercises involved, showed a moderate effect on disease activity, function and spinal mobility.In AS, EP combining flexibility and strength exercises showed the largest effect on spinal mobility and should be encouraged.In AS, EP combining flexibility, muscle strength and aerobic exercises may be particularly effective on patient function.

Translation and cross-cultural adaptation of the mSQUASH into Spanish

BACKGROUND

There is a lack of outcome measures for the assessment of physical activity in patients with axial spondyloarthritis (axSpA). For this matter, the modified Short QUestionnaire to Assess Health (mSQUASH) was developed and validated, originally in Dutch.

OBJECTIVE

To translate and cross-culturally adapt the mSQUASH into Spanish and to evaluate the equivalence of the translated version in patients with axSpA.

METHODS

The mSQUASH was translated following forward-backward procedure according to the protocol of Beaton. Two bi-lingual translators produced independent forward translations of the mSQUASH into Spanish, and the versions were harmonized in a consensual version. Another translator back translated the synthesized version into Dutch. A scientific committee reached consensus on discrepancies and developed a pre-final version of the questionnaire. The field test with cognitive debriefing involved 10 patients with axSpA with different gender, age, disease duration, educational level and working status.

RESULTS

The translation process of the mSQUASH was completed without major issues. The first translation needed several iterations due to small discrepancies in the wording. Back-translation was performed without difficulties, and the scientific committee agreed upon a final version of the questionnaire. Cognitive debriefing showed the Spanish questionnaire to be clear, relevant, understandable and comprehensive. The preliminary version was accepted with minor modifications.

CONCLUSIONS

The resulting Spanish version of the mSQUASH showed good linguistic and face validity according to the field test, revealing potential for use in clinical practice and research. In order to conclude the cross-cultural adaptation of the mSQUASH into Spanish, the next step is the assessment of psychometric properties of the Spanish version.

The effectiveness of exercise and physical activity programs on fatigue and sleep in people with arthritis - A systematic review with meta-analysis

This systematic review aimed to systematically investigate the literature on the effectiveness of exercise and physical activity programs on fatigue and sleep in people with arthritis. For that, seven databases were searched for relevant randomized controlled trials. After the searches, 36 studies investigating 2281 participants were included. Risk of bias assessments were done by two independent reviewers using the Cochrane Risk of Bias tool 2. Random-effects meta-analyses were performed, and the Grading of Recommendations Assessment, Development and Evaluation framework was used to judge the certainty of evidence. The evidence on benefits of exercise and physical activity programs on fatigue and sleep parameters in people with osteoarthritis and psoriatic arthritis was either lacking or inconclusive. There was very low to low certainty evidence for a slight benefit of exercise and physical activity programs on fatigue at short-term in people with ankylosing spondylitis and rheumatoid arthritis. However, the evidence was very uncertain for the medium- and long-term as well as for any sleep parameters. The results indicate that exercise and physical activity programs may offer some benefits on fatigue for people with arthritis in the short-term, although the best type of exercise remains uncertain. The available evidence on improvements in sleep was insufficient to draw strong conclusions.

Changes of inflammation in patients with psoriatic arthritis after high intensity interval training assessed by ultrasound and MRI, a randomized controlled trial

BACKGROUND

In psoriatic arthritis (PsA) there is a theoretical risk of increased disease activity related to strenuous physical activity, including exercise. We evaluated the effect of high intensity interval training (HIIT) on objective measures of inflammation in PsA assessed by ultrasound (US) of peripheral joints and entheses, and by bone marrow edema (BME) on MRI of the sacroiliac joints (SIJ) and spine.

METHODS

We randomly assigned 67 PsA patients to an intervention group that performed structured HIIT for 11 weeks, or to a control group instructed not to change their physical exercise habits. Outcome measures included US evaluation of the total cohort and MRI in a subgroup of 41; both assessed at 3 months. We calculated the proportions with an increased US B-mode and power-doppler (PD) signal of joints and entheses and Spondyloarthritis-Research-Consortium-of-Canada (SPARCC)-BME score of the SIJ and spine for both groups.

RESULTS

Proportions with an increased US B-mode score of the joints were 32% and 28% in HIIT and control groups, respectively. Corresponding proportions of PD scores of the joints were 7% and 10% and PD scores of entheses were 32% and 31%. The proportions with increased MRI BME of the SIJ were 6% in the HIIT group and 10% in the control group. Corresponding proportions were 6% and 5% for the MRI BME of the spine.

CONCLUSION

In PsA patients with a low to moderate disease activity, there was no clear evidence of objectively measured increased inflammation after HIIT, as evaluated by US and MRI.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02995460 (16/12/2016).

Patients' awareness towards physical activity in the treatment of axial spondyloarthritis

INTRODUCTION

The course of axial spondyloarthritis (axSpA) is often characterized by impairments in physical function and mobility. Regular physical activity (PA) is a cornerstone of axSpA management. Recent European League Against Rheumatism (EULAR) recommendations for PA have stressed the importance of their implementation.

OBJECTIVE

Cohort study to investigate the awareness on and individual implementation of axSpA patients towards PA.

METHODS

Patients with axSpA and impaired physical function (Bath AS Functional Index [BASFI] score≥2.0) were recruited consecutively. All patients underwent a clinical examination including assessments of disease activity, physical function, mobility and global functioning. Patients also had to fill out structured questionnaires on knowledge, awareness and individual attitudes to PA.

RESULTS

Out of a total of 100 patients enrolled, 96 were included. Most respondents (n=82, 85.4%) were aware that PA has significant health benefits for patients with axSpA. Even though less than half of the patients (n=44, 42.7%) were aware that actual EULAR recommendations do exist, 45 patients (46.9%) did already fulfill these in terms of frequency/week. The majority of patients (n=61, 67.7%) had been informed about the benefits of PA by their physician, and physiotherapy had often been prescribed (n=61, 63.3%). Many patients (n=51, 53.1%) reported to perform individual exercise programs, and some (n=22, 22.9) supervised PA.

CONCLUSION

Even though the majority of axSpA patients are not aware of the recent EULAR recommendations for PA, many understand and agree that PA is beneficial for their health status. Health care providers should concentrate on the patients who are not active and do not know about the benefits of PA.

Treatment overview of axial spondyloarthritis in 2023

The treatment of patients with axial spondyloarthritis (axSpA) is characterized by non-pharmacological and pharmacological treatment options. It may depend on the type and extent of musculoskeletal and extramusculoskeletal manifestations. Recent data on non-pharmacological treatment options, such as physical activity, physiotherapy, and modification of lifestyle factors, are summarized in this review. Moreover, we have provided an overview on non-steroidal anti-inflammatory drugs and the ever-expanding number of biological and targeted synthetic disease-modifying antirheumatic drugs (bDMARDs and tsDMARDs, respectively). In addition to data on efficacy and safety, the review also encompasses data on switching/cycling, tapering, and treatment selection for specific patient subgroups to optimize treatment outcomes.

Advances in pharmacotherapies for axial spondyloarthritis

INTRODUCTION

Axial spondyloarthritis (axSpA) refers to an inflammatory rheumatic disease that mainly affects the axial skeleton and leads to progressive radiographic changes of the sacroiliac joints and spine. axSpA is currently subdivided into the radiographic (r-axSpA) and non-radiographic (nr-axSpA) form. Both forms are associated with musculoskeletal pain, restriction of spinal mobility, specific extra-musculoskeletal manifestations, and overall, altered quality of life. The therapeutic management of axSpA is currently well standardized.

AREAS COVERED

We reviewed available literature (by using PubMed search) on non-pharmacological and pharmacological treatment options that may be used in axSpA, including r-axSpA and nr-axSpA, as well as the role of non-steroidal anti-inflammatory drugs (NSAIDs), biological agents including TNFalpha (TNFi) and IL-17 (IL-17i) inhibitors. New treatment options such as Janus kinase inhibitors are also reviewed.

EXPERT OPINION

NSAIDs remain the mainstay of initial therapy, and subsequently, biological agents (TNFi and IL-17i) may be envisaged. Four TNFi are licensed for the treatment of both r-axSpA and nr-axSpA, while IL-17i are approved in each indication. The choice between a TNFi and an IL-17i is mainly guided by the presence of extra-articular manifestations. JAKi were more recently introduced for the treatment of r-axSpA, but their use is restricted to specific patients with a safe cardiovascular profile.

Efficacy of non-pharmacological interventions: a systematic review informing the 2023 EULAR recommendations for the management of fatigue in people with inflammatory rheumatic and musculoskeletal diseases

OBJECTIVE

To identify the best evidence on the efficacy of non-pharmacological interventions in reducing fatigue in people with inflammatory rheumatic and musculoskeletal diseases (I-RMDs) and to summarise their safety in the identified studies to inform European Alliance of Associations for Rheumatology recommendations for the management of fatigue in people with I-RMDs.

METHODS

Systematic review of randomised controlled trials (RCTs) including adults with I-RMDs conducted according to the Cochrane Handbook. Search strategy ran in Medline, Embase, Cochrane Library, CINAHL Complete, PEDro, OTseeker and PsycINFO. Assessment of risk of bias, data extraction and synthesis were performed by two reviewers independently. Data were pooled in meta-analyses.

RESULTS

From a total of 4150 records, 454 were selected for full-text review, 82 fulfilled the inclusion criteria and 55 RCTs were included in meta-analyses. Physical activity or exercise was efficacious in reducing fatigue in rheumatoid arthritis (RA) (standardised mean differences (SMD)=-0.23, 95% CI=-0.37 to -0.1), systemic lupus erythematosus (SLE) (SMD=-0.54, 95% CI=-1.07 to -0.01) and spondyloarthritis (SMD=-0.94, 95% CI=-1.23 to -0.66); reduction of fatigue was not significant in Sjögren's syndrome (SMD=-0.83, 95% CI=-2.13 to 0.47) and systemic sclerosis (SMD=-0.66, 95% CI=-1.33 to 0.02). Psychoeducational interventions were efficacious in reducing fatigue in RA (SMD=-0.32, 95% CI=-0.48 to -0.16), but not in SLE (SMD=-0.19, 95% CI=-0.46 to 0.09). Follow-up models in consultations (SMD=-0.05, 95% CI=-0.29 to 0.20) and multicomponent interventions (SMD=-0.20, 95% CI=-0.53 to 0.14) did not show significant reductions of fatigue in RA. The results of RCTs not included in the meta-analysis suggest that several other non-pharmacological interventions may provide a reduction of fatigue, with reassuring safety results.

CONCLUSIONS

Physica activity or exercise and psychoeducational interventions are efficacious and safe for managing fatigue in people with I-RMDs.

High-Intensity Training for Knee Osteoarthritis: A Narrative Review

Knee osteoarthritis (OA) is the most common joint disease worldwide. Exercise therapy has been identified as a first-line treatment option in patients suffering from knee OA. High-intensity training (HIT) is an innovative exercise modality with potential in improving various disease-related outcomes. The purpose of this review is to explore the impact of HIT on knee OA symptoms and physical functioning. A comprehensive search of scientific electronic databases was conducted to identify articles on the effects of HIT on knee OA. Thirteen studies were included in this review. Ten compared the effects of HIT with those of low-intensity training, moderate-intensity continuous training, or a control group. Three evaluated the effects of HIT alone. Eight reported a decrease in knee OA symptoms (especially pain), and eight reported an increase in physical functioning. HIT was shown to improve knee OA symptoms and physical functioning, but also aerobic capacity, muscle strength, and quality of life with minimal or no adverse events. However, compared with other exercise modalities, no clear superiority of HIT was found. HIT is a promising exercise strategy in patients with knee OA; nonetheless, the actual quality of evidence remains very low, and more high-quality studies are needed to confirm these promising outcomes.

Ultrasonography of heel entheses in axial spondyloarthritis patients: frequency and assessment of associated factors

PURPOSE

Foot entheses involvement is a common manifestation of spondyloarthritis. The superiority of ultrasonography examination in foot entheses damages detection has been reported. We aimed to compare the ultrasonography findings of foot entheses between spondyloarthritis patients. and healthy controls and to identify factors associated with enthesitic heel involvement.

METHODS

We conducted a cross-sectional study including 37 patients with axial spondyloarthritis (G1) and 37 healthy subjects matched by age and gender (G0). The following pro-inflammatory cytokines were measured: Interleukin (IL-)1, IL-6, IL-17, and IL-23. A blind ultrasonography of foot entheses was performed to examine calcaneal tendon (CT) and plantar fascia (PF).

RESULTS

The mean age was 44.62 ± 12.31 years. Non-steroidal anti-inflammatory drugs were taken in 92% of patients. Clinical heel enthesopathy was noted in 10 patients (27%) of G1. No participant has enthesitic pain in G0. Ultrasonography changes in CT and PF were more frequent in G1 than G0 (p = 0.001 and p = 10-3, respectively). In the PF, tendon thickening was significantly higher in G1 than G0 (p = 0.03). Power Doppler in both enthesitic sites was exclusively observed in G1 (p = 10-3). Regarding associated factors, CT enthesophytes were less frequent in patients taking non-steroidal anti-inflammatory drugs continuously or having regular physical activity. PF structural damages were associated with higher erythrocyte sedimentation rate (p = 0.02), higher IL-23 level (p = 0.01), and higher disease activity (p = 0.04).

CONCLUSION

Ultrasonography lesions of heel entheses were frequent in spondyloarthritis. Disease activity and inflammatory markers were higher in patients with heel enthesitis. Non-steroidal anti-inflammatory drugs intake and regular physical activity may prevent enthesophytes' occurrence.

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.

[Translation of the 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis and linguistic validation in German-speaking countries with healthcare professionals]

BACKGROUND

Regular physical activity is beneficial for people with rheumatic diseases and one of the cornerstones in its management. Based on the international recommendations of the World Health Organization for the general population, the "2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis" provide evidence-based recommendations on the prescription, performance, and implementation of physical activity exercises in this population for the first time.

AIM

Translation of the 2018 EULAR recommendations into German and linguistic validation in Germany, Austria and Switzerland.

METHODS

A professional translation of the EULAR recommendations into the German language was performed and revised by German-speaking experts from all three countries. The translation was validated by healthcare professionals consisting of rheumatologists, occupational therapists, physiotherapists, nurses, and medical assistants in a field test. In each of the three countries, eight structured interviews were conducted on comprehensibility, wording, completeness, and feasibility. The experts then discussed changes until consensus was reached and indicated the level of agreement with the final translation.

RESULTS

The translation of the EULAR recommendations was substantially revised. Based on the results of the cognitive test, formulations were adapted in order to increase comprehensibility. The level of agreement between 10 (SD 0.0) and 8.9 (SD 1.5) was very high.

DISCUSSION

The final German version of the EULAR recommendations is comprehensible and accepted across all three German-speaking countries. It can help to improve the structure and clarity of the handling of physical activity and promote physical activity for healthcare providers and patients.

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.

Efficacy and safety of non-pharmacological and non-biological interventions: a systematic literature review informing the 2022 update of the ASAS/EULAR recommendations for the management of axial spondyloarthritis

OBJECTIVE

To update the evidence of non-biological treatments for axial spondyloarthritis (axSpA), as a basis for the 2022 Assessment of SpondyloArthritis international Society-European Alliance of Associations for Rheumatology (ASAS-EULAR) recommendations for the management of axSpA.

METHODS

A systematic literature review (2016-2021) on efficacy and safety of non-pharmacological and non-biological pharmacological treatments was performed, up to 1 January 2022. The research question was formulated according to the PICO format: Population: adult patients with r-axSpA and nr-axSpA; Intervention: non-pharmacological and non-biological pharmacological treatments; Comparator: active comparator or placebo; Outcomes: all relevant efficacy and safety outcomes. Type of studies included were: randomised controlled trials (RCTs), observational studies (for efficacy of non-pharmacological treatments, and safety), qualitative studies. Cohen's effect size (ES) was calculated for non-pharmacological and risk ratio (RR) for pharmacological treatments.

RESULTS

Of 107 publications included, 63 addressed non-pharmacological interventions, including education (n=8) and exercise (n=20). The ES for education on disease activity, function, mobility was small to moderate (eg. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), ES: 0.06-0.59). Exercise had moderate to high ES on these outcomes (eg.

BASDAI, ES

0.14-1.43). Six RCTs on targeted synthetic disease-modifying antirheumatic drugs (DMARDs) showed efficacy of tofacitinib, upadacitinib and filgotinib (phase 2 only) in r-axSpA (range RR vs placebo for ASAS20: 1.91-3.10), while apremilast and nilotinib were not efficacious. Studies on conventional synthetic DMARDs (n=3), non-steroidal anti-inflammatory drugs (NSAIDs, n=8) and other drugs (n=12) did not provide new evidence on efficacy/safety (efficacy of NSAIDs confirmed; limited efficacy of short-term glucocorticoids in one RCT).

CONCLUSIONS

Education, exercise and NSAIDs confirmed to be efficacious in axSpA. JAKi were proved efficacious in r-axSpA.

Understanding beliefs related to physical activity in people living with axial Spondyloarthritis: a theory-informed qualitative study

Background

People living with axial Spondyloarthrtis (axSpA) have an increased risk of cardiovascular diseases, which can be reduced by regular physical activity (PA) and its subset of cardiorespiratory training (CRT). To fulfil their crucial role in PA promotion, physiotherapists and other health professionals need to understand the beliefs that people living with axSpA possess concerning general PA and CRT. The aim of this study is to explore these behavioural, normative and control beliefs.

Methods

A qualitative descriptive design approach was chosen. Five semi-structured focus group interviews with 24 individuals living with axSpA were performed. Data was analysed using structured thematic qualitative content analysis.

Results

People with axSpA possessed multifaceted behavioural, normative and control beliefs concerning general PA and CRT. Behavioural beliefs revealed a positive attitude towards general PA, with participants mentioning numerous physical, psychological, and social benefits and only few risks. However, the conceptual difference between general PA and CRT, and the relevance of CRT, was unclear to some participants. Normative beliefs were expressed as the beliefs of significant others that influenced their motivation to comply with such beliefs, e.g. spouses, other people living with axSpA, rheumatologists. Regarding control beliefs, general PA and CRT were both mentioned as effective self-management strategies to control the disease. From experience, a high level of self-discipline, as well as technology, were shown to be useful.

Conclusions

General PA is understood to be an important self-management strategy for people with axSpA and most participants build general PA into their daily routines. They believe that general PA beneficially impacts personal health and wellbeing. However, some participants are unaware of the difference between general PA and CRT and the important impact that this difference could have on their health. The consequences of CRT promotion for people living with axSpA should be the subject of further research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-022-00270-2.

High-Intensity Interval Training (HIIT) on Biological and Body Composition Variables in Patients with Musculoskeletal Disorders: A Systematic Review and Meta-Analysis

In order to assess the impact of high-intensity interval training (HIIT) on biological and body composition variables in patients with musculoskeletal disorders (MSKD), a systematic search on PubMed (Medline), CENTRAL, CINAHL, Web of Science, SPORTDiscus, and Scopus was conducted. Standardized mean differences (SMD) and 95% confidence intervals were calculated and pooled in a meta-analysis using the random-effects model. The effectiveness of HIIT on waist circumference, muscle mass, resting heart rate, resting systolic and diastolic blood pressure, C-reactive protein, body weight, and body fat were determined. GRADE, risk of bias 2, and PEDro scales were employed. HIIT compared to no intervention, minimal intervention, or usual care did not show significant results in its favor on any of the variables studied, except for the resting heart rate when compared with no intervention (SMD = -0.33; 95% CI: -0.63, -0.04; heterogeneity Q value: 0.14; p = 0.93; I² = 0%). In addition, HIIT also does not seem to be more effective than moderate-intensity continuous training. Based on the results, it seems that HIIT has almost no significant effects on biological and body composition variables, except for resting heart rate, in patients with MSKD.

Effects of High-Intensity Interval Training (HIIT) on Patients with Musculoskeletal Disorders: A Systematic Review and Meta-Analysis with a Meta-Regression and Mapping Report

The aim was to assess the impact of high-intensity interval training (HIIT) on patients with musculoskeletal disorders. We conducted a search of Medline, Embase, PEDro, and Google Scholar. We conducted a meta-analysis to determine the effectiveness of HIIT on pain intensity, maximal oxygen consumption (VO2 max), disability, and quality of life (QoL). We employed the GRADE and PEDro scales to rate the quality, certainty, and applicability of the evidence. Results showed significant differences in pain intensity, with a moderate clinical-effect (SMD = -0.73; 95% CI: -1.40--0.06), and in VO2 max, with a moderate clinical-effect (SMD = 0.69; 95% CI: 0.42-0.97). However, the meta-analysis showed no statistically significant results for disability (SMD = -0.34; 95% CI: -0.92-0.24) and QoL (SMD = 0.40; 95% CI: -0.80-1.60). We compared HIIT against other exercise models for reducing pain intensity and increasing VO2 max. The meta-analysis showed no significant differences in favour of HIIT. Meta-regression analysis revealed that pain intensity scores were negatively associated with VO2 max (R2 = 82.99%, p = 0.003). There is low-moderate evidence that the HIIT intervention for patients with musculoskeletal disorders can reduce pain intensity and increase VO2 max but has no effect on disability and QoL. Results also showed that HIIT was not superior to other exercise models in reducing pain intensity and increasing VO2 max.

Lifestyle modification and inflammation in people with axial spondyloarthropathy-A scoping review

INTRODUCTION

People with axial spondyloarthritis (AS) have an inflammatory profile, increasing the risk of hypertension, type 2 diabetes, obesity, and dyslipidaemia. Consequently, AS is linked with co-morbidities such as cardiovascular disease (CVD). Physical inactivity, diet, smoking, alcohol consumption, and obesity influence inflammation, but knowledge of the interaction between these with inflammation, disease activity, and CVD risk in AS is dominated by cross-sectional research.

METHODS

A review of the literature was conducted between July 2020 and December 2021. The focus of the scoping review is to summarise longitudinal and randomised control trials in humans to investigate how tracking or modifying lifestyle influences inflammation and disease burden in patients with AS.

KEY MESSAGES

(1) Lifestyle modifications, especially increased physical activity (PA), exercise, and smoking cessation, are critical in managing AS. (2) Smoking is negatively associated with patient reported outcome measures with AS, plus pharmaceutical treatment adherence, but links with structural radiographic progression are inconclusive. (3) Paucity of data warrant structured studies measuring inflammatory cytokine responses to lifestyle modification in AS.

CONCLUSION

Increased PA, exercise, and smoking cessation should be supported at every given opportunity to improve health outcomes in patients with AS. The link between smoking and radiographic progression needs further investigation. Studies investigating the longitudinal effect of body weight, alcohol, and psychosocial factors on disease activity and physical function in patients with AS are needed. Given the link between inflammation and AS, future studies should also incorporate markers of chronic inflammation beyond the standard C-reactive protein and erythrocyte sedimentation rate measurements.

Changes in ultrasound imaging of joints, entheses, bursae and tendons 24 and 48 h after adjusted weight training

Background:

Joint effusion and enthesitis are common ultrasound findings in rheumatic diseases such as rheumatoid arthritis or spondyloarthritis. However, changes of joints and entheses were not only observed in patients but also in physically active individuals and athletes.

Objectives:

The purpose of this study was to evaluate joint, entheseal, bursal and tendon musculoskeletal ultrasound (MSUS) findings in large and medium joints of young healthy individuals after completing a standardised weight training.

Design:

This is a prospective cohort study.

Methods:

MSUS examinations of large- and medium-sized joints, and related entheseal sites, bursae and tendons were performed on young healthy individuals (ages 18–30 years). Before, 24 and 48 h after completing 1 h of standardised weight exercise, the subjects were evaluated by MSUS. The development of the MSUS findings and associated effects were examined using generalised linear mixed effects models.

Results:

In total, 51 healthy individuals (52.9% female) with a mean age of 23.7 (±2.5) years were enrolled. The results showed an increase in the number of individuals with at least one joint effusion from 37 (72.5%) before the weight training to 48 (94.1%) after 48 h. Entheses with pathologies were observed in 14 participants (27.5%) at baseline, increasing to 29 participants (56.9%) 48 h after the weight training. Biceps tendon sheath effusion was detected in 9 individuals (17.6%) prior to training, rising to 22 individuals (43.1%) after 48 h. A significant increase in the number of joints with effusion and abnormal entheses within 48 h after the weight training was indicated by the generalised linear mixed effects models.

Conclusion:

Within 48 h after the weight training session, a significant increase in the prevalence of joint effusion in large and medium joints and the prevalence of abnormal entheses was observed. As a result, when performing and interpreting an MSUS examination, the patient’s physical activities should be taken into account.