Effectiveness of Exercise Programs in Ankylosing Spondylitis: A Meta-Analysis of Randomized Controlled Trials

The effects of Pilates training on respiratory muscle strength in patients with ankylosing spondylitis

BACKGROUND

Reduction in flexibility and mobility are important factors that lead to impairments in quality of life, reduction of exercise tolerance, and a decreased pulmonary capacity with the progression of Ankylosing Spondylitis (AS).

AIM

The purpose of this study was to investigate the effects of Pilates exercises on mobility, quality of life, and respiratory muscle strength in patients with AS.

METHODS

Forty patients with AS were randomly divided into two groups as Pilates group and the control group. The Pilates group performed Pilates exercises in supervised group sessions and the control group performed conventional exercises at home three days a week for eight weeks. The main outcome measure was respiratory muscle strength. Secondary outcome measures were forced vital capacity (FVC), forced expiratory volume in one second (FEV1) FEV1/FVC ratio, chest expansion, Bath indices (BASDAI, BASMI), Ankylosing Spondylitis Quality of Life Questionnaire (ASQoL) and six-minute walk test (6MWT). All participants were assessed by a blind assessor at baseline and the end of eight weeks.

RESULTS

Thirty-six AS patients (n = 19 in the Pilates group, n = 17 in the control group) completed the study. Respiratory muscle strength, FEV1/FVC, chest expansion, BASDAI, BASMI, ASQoL, and 6MWT significantly improved at the 8th week (p < .05) in the Pilates group, while inspiratory muscle strength, FEV1/FVC, chest expansion, and 6MWT showed significant improvements in the control group at 8th week compared to baseline (p < .05). No significant between-group differences were observed when the change over time values were compared (Δ).

CONCLUSION

Both Pilates and home exercises seem to be effective for improving respiratory parameters and functional status in patients with AS. Pilates exercises without using any equipment and additional exercises is found to be useful for improving respiratory functions and disease-related symptoms.

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.

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).

Pain and Inflammation as Mediators of Tofacitinib Treatment Effect on Fatigue in Patients with Ankylosing Spondylitis: A Mediation Analysis

INTRODUCTION

Tofacitinib is an oral Janus kinase inhibitor for treatment of ankylosing spondylitis (AS). Using mediation modelling, we describe interrelationships between fatigue, pain, morning stiffness, C-reactive protein (CRP) and tofacitinib treatment in patients with AS.

METHODS

Data from phase 2 (NCT01786668)/phase 3 (NCT03502616) studies of patients receiving tofacitinib 5 mg twice daily (BID) or placebo were used. Initial models included treatment as the independent binary variable (tofacitinib 5 mg BID versus placebo); fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue [FACIT-F; model A] or Bath AS Disease Activity Index [BASDAI] Q1 [model B]) as the dependent variable; and pain (total back pain/nocturnal spinal pain [model A] or pain measured by BASDAI Q2/3 [model B]), morning stiffness (BASDAI Q5/6) and CRP as mediator variables.

RESULTS

Pooled data from 370/371 patients were included in models A/B. Initial models demonstrated that tofacitinib treatment affects fatigue mainly indirectly via pain and morning stiffness. As a result, initial models were respecified to exclude direct treatment effect and the indirect effect via CRP. For respecified model A, 44.0% of the indirect effect of tofacitinib treatment on fatigue was mediated via back pain/morning stiffness, 40.0% via morning stiffness alone and 16.0% via back pain alone (all P < 0.05). For respecified model B, 80.8% of the indirect effect of tofacitinib treatment on fatigue was mediated via pain/morning stiffness and 19.2% via pain alone (both P < 0.05).

CONCLUSIONS

In tofacitinib-treated patients with AS, improvements in fatigue were collectively mediated through combined treatment effects on morning stiffness and pain.

Tele-yoga in the management of ankylosing spondylitis amidst COVID pandemic: A prospective randomized controlled trial

PURPOSE

Ankylosing spondylitis (AS) signficantly affect day to day activities contributing to signficant disability. Patients with AS often report to have psychological problems and poor quality of life (QoL). This study investigates the effect of a three-month tele-yogic intervention on disease activity, functional index, inflammatory markers, quality of life and mental health measures in patients with AS.

METHODS

One hundred and twenty AS patients were assigned to either the yoga intervention group (YG) or the control group (CG). The YG (n = 57) received a 60-min structured yoga module online for 3 months in addition to standard medical care. The CG participants (n = 52) received only standard care during the same period. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Ankylosing Spondylitis-Quality of Life (ASQOL) and psychological and inflammatory biomarkers were assessed at baseline and after three months.

RESULTS

YG showed significant improvement in BASDAI (p = 0.001), anxiety (p = 0.0004), and depression (p = 0.001) at three months compared to baseline. The CG showed no significant change in similar outcome measures. At three months, the intervention resulted in a significant improvement in BASDI (-0.79; 95% CI (-1.3, to -0.29); p = 0.0021), BASFI (-0.86, 95% CI (-1.59, to -0.14); p = 0.0193), anxiety (-0.42, 95% CI (-0.84 to -0.01), p = 0.0468), and AS-QoL (-3.37; 95% CI (-5.21 to 1.53); p = 0.0004) compared to the CG.

CONCLUSIONS

The present study suggests that yoga helps improve pain, functional index, and mental health in patients with AS. Tele-yoga intervention is feasible and effective in treating AS.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Role of ferroptosis-associated genes in ankylosing spondylitis and immune cell infiltration

Ankylosing spondylitis (AS) is a chronic progressive autoimmune disease with insidious onset, high rates of disability among patients, unknown pathogenesis, and no effective treatment. Ferroptosis is a novel type of regulated cell death that is associated with various cancers and diseases. However, its relation to AS is not clear. In the present study, we identified two potential therapeutic targets for AS based on genes associated with ferroptosis and explored their association with immune cells and immune cell infiltration (ICI). We studied gene expression profiles of two cohorts of patients with AS (GSE25101 and GSE41038) derived from the gene expression omnibus database, and ferroptosis-associated genes (FRGs) were obtained from the FerrDb database. LASSO regression analysis was performed to build predictive models for AS based on FRGs, and the ferroptosis level in each sample was assessed via single-sample gene set enrichment analysis. Weighted gene co-expression network and protein-protein interaction network analyses were performed for screening; two key genes, DDIT3 and HSPB1, were identified in patients with AS. The relationship between key genes and ICI levels was assessed using the CIBERSORT algorithm, followed by gene ontology and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analyses. Finally, DDIT3 and HSPB1 were identified as diagnostic markers and potential therapeutic targets for AS. DDIT3 was highly positively correlated with the infiltration levels of various immune cells, while HSPB1 was negatively correlated with the infiltration levels of several different types of immune cells. In conclusion, DDIT3 and HSPB1 may induce ferroptosis in the cells of patients with AS via changes in the inflammatory response in the immune microenvironment, and these genes could serve as molecular targets for AS therapy.

The effect of Aqua Stretching exercises and Pilates on pain, function and spine posture in patients with ankylosing spondylitis: a randomized controlled trial

Background

Aqua Pilates and Aqua Stretch exercises are different and new methods for the rehabilitation of musculoskeletal disorders. This study aimed to compare the effectiveness of Aqua Stretch and Aqua Pilates interventions in the treatment of pain, function, and posture of the spine in ankylosing spondylitis (AS) patients.

Methods

Forty patients participated in this study who were randomly allocated into Aqua Stretch, aqua Pilates, and control. The experimental groups received four 60-min training sessions each week for six weeks. However, the control group had only its routine drug treatment (NSAIDs & Anti TNF). Pain with Visual Analog Scale (VAS), function with Bath Ankylosing Spondylitis Functional Index (BASFI) and 40-m walking test (MWT), quality of life with ankylosing spondylitis quality of life (ASQoL), and posture of the spine with the Spinal Mouse were evaluated. Evaluations were performed before and after the interventions. Repeated measure ANOVA was employed to determine the main and interaction effects.

Results

Aqua Stretch and Aqua Pilates had a significant effect on pain (Aqua-Pilates: P = 0.0001; Aqua-Stretch: P = 0.0001), BASFI (Aqua-Pilates: P = 0.01; Aqua-Stretch: P = 0.02), 40-MWT (Aqua-Pilates: P = 0.006; Aqua-Stretch: P = 0.0001) and ASQoL (Aqua-Pilates: P = 0.01; Aqua-Stretch: P = 0.001), spinal range of motion (ROM) (Aqua-Pilates: P = 0.0001; Aqua-Stretch: P = 0.0001) at a similar ratio. However, the control group did not present any improvement in these factors (P > 0.05). Moreover, the minimal clinically important difference (MCID) revealed that the Aqua Stretch group performed better than the Aqua Pilates group in terms of VAS, ASQOL, and 40-MWT factors.

Conclusions

Aqua Stretch and Aqua Pilates had statistically the same effect on improving pain, function, quality of life, and spinal ROM, while MCID results revealed that the Aqua Stretch group performed better than the Aqua Pilates in terms of VAS-ASQOL-40-MWT.

Trial registration It is notable that local ethics committee approval was obtained (IR.KUMS.REC.1399.1137), and the study was registered in Iranian Registry of Clinical Trials (IRCT; IRCT20190426043377N3; registered on 22/05/2021, https://fa.irct.ir/user/trial/56058/view) and patient recruitments were started on 06/07/2021.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Trial Registration

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

International Registered Report Identifier (IRRID)

RR2-10.2196/23359

Causal Relationships Between Total Physical Activity and Ankylosing Spondylitis: A Mendelian Randomization Study

Background

Currently, there is little literature about the association between physical activity (PA) and the risk of ankylosing spondylitis (AS). The present study aimed to understand the causal relationships between PA and AS.

Methods

We performed two-sample Mendelian randomization (MR) using publicly released genome-wide association studies summary statistics to estimate the causal associations of PA with AS risk. The inverse variance weighted (IVW) method was utilized as primary MR analysis. Furthermore, sensitivity, pleiotropy, and heterogeneity analyses were then conducted to assess the robustness of the findings of the present study.

Results

Results of the IVW analysis suggested a protective relationship between accelerometer-based PA and AS (average acceleration, odds ratio [OR] = 0.9995, 95% CI, 0.9988–0.9999, P = 0.014). On the contrary, there was no causal relationship between accelerometer-based PA (acceleration fraction >425 mg; OR = 0.9981, 95% CI = 0.9936–1.0026, P = 0.402) and AS. Furthermore, there was no significant relationship between self-reported vigorous PA and AS (OR = 1.0005, 95% CI = 0.9875–1.0136, P = 0.943), or even between self-reported moderate-to-vigorous PA and AS (OR = 1.0000, 95% CI, 0.9947–1.0052; P = 0.990).

Conclusions

The use of genetic approach in the present study revealed that total physical activity (TPA) has a protective relationship with AS risk. Furthermore, it was evident that vigorous PA or moderate-to-vigorous physical levels are not causally associated with AS. Therefore, the present study evidently supports the hypothesis that enhancing TPA rather than PA intensity is an effective prevention strategy for AS.

T2 mapping and fat quantification of lumbar paraspinal muscle in ankylosing spondylitis: a case control study

BACKGROUND

To compare changes in the composition of paraspinal muscles of patients with ankylosing spondylitis (AS) and matched healthy controls using T2 mapping and T2 IDEAL and correlate the quantitative magnetic resonance imaging (qMRI) results with clinical assessments of AS patients.

METHOD

In total, 37 AS patients and 37 healthy controls were enrolled in the case control study. T2 mapping with and without fat saturation and IDEAL imaging were used to assess the multifidus (MF) and erector spinae (ES) at the levels of L3/L4 and L4/L5 for all subjects. Mean T2_non-fatsat, T2_fat, T2_fatsat, cross-sectional area (CSA), and fat fraction (FF) were compared between AS and healthy controls. Correlations of qMRI results with clinical assessments were analyzed in AS.

RESULTS

Significantly elevated mean T2_non-fatsat values and the FF of the MF and ES at both levels were observed in AS and compared to the controls (p < 0.05). The mean T2_fatsat values of ES and MF were significantly higher only at the level of L3/L4 in AS compared to healthy controls (p < 0.05). A loss of muscle CSA compatible with atrophy was present in MF and ES at both levels in AS compared to the controls (p < 0.05). Weak to moderate positive correlations were found between FF and age and disease duration in AS (r = 0.318-0.415, p < 0.05). However, such positive correlation was not observed between FF and disease duration after adjusting for age (p > 0.05).

CONCLUSIONS

Our findings indicate that using a combination of IDEAL and T2 mapping may provide deeper insights into the pathophysiological degeneration of paraspinal muscles in AS.

miR‑148a‑3p facilitates osteogenic differentiation of fibroblasts in ankylosing spondylitis by activating the Wnt pathway and targeting DKK1

Ankylosing spondylitis (AS) is a chronic inflammatory form of arthritis. MicroRNAs (miRNAs) have been identified to serve as therapeutic targets in various inflammatory diseases. The aim of the present study was to determine the functional mechanism of miR-148a-3p on AS. Specimens were collected from AS patients and non-AS patients. Fibroblasts were delivered with the aid of miR-148a-3p inhibitor. Cell staining was performed to observe the morphological changes, calcified nodules, and mineralization degree. The binding sites of miR-148a-3p and DKK1 were predicted on the Starbase website and subsequently verified by means of dual-luciferase reporter assay. AS fibroblasts with silenced miR-148a-3p were transfected with si-DKK1. Levels of RUNX2 and Osteocalcin, DKK1 and Wnt1 protein and phosphorylation level of β-catenin were detected by means of western blot analysis. Results of the present study denoted that AS upregulated miR-148a-3p in fibroblasts to exacerbate osteogenic differentiation, resulting in increased calcified nodules and mineralization degree. Silencing miR-148a-3p could reverse the upregulation of RUNX2 and Osteocalcin in AS fibroblasts and reduce the calcified nodules and mineralization degree. miR-148a-3p targeted DKK1. DKK1 knockdown averted the effect of silencing miR-148a-3p in AS fibroblasts. In addition, silencing miR-148a-3p reversed the upregulation of Wnt1 and β-catenin proteins in AS fibroblasts. To conclude, miR-148a-3p exacerbated the osteogenic differentiation of AS fibroblasts by inhibiting DKK1 expression and activating the Wnt pathway.

2021 clinical practice guideline for the early detection, diagnosis, treatment, and monitoring of patients with axial spondyloarthritis. Colombian Association of Rheumatology

BACKGROUND

Axial Spondyloarthritis is a rheumatic condition affecting young patients with social and occupational consequences. Diagnosis delay is associated with functional impairment and impact on quality of life, requiring a multidisciplinary approach.

OBJECTIVE

To develop a set of recommendations based on the best available evidence for early detection, diagnosis, treatment and monitoring adult patients with axial spondyloarthritis.

METHODS

A working group was established, questions were developed, outcomes were graded, and a systematic search for evidence was conducted. A multidisciplinary panel of members was established (including patient representatives), minimizing bias in relation to conflicts of interest. The GRADE approach "Grading of Recommendations Assessment, Development and Evaluation" was used to assess the quality of the evidence as well as the direction and strength of recommendations. In total, 11 recommendations with regard to diagnosis (n = 2), pharmacological treatment (n = 6), non-pharmacological treatment (n = 2) and monitoring (n = 1) are presented.

RESULTS

Sacroiliac joint radiography as the first diagnostic method, and the use of disease activity scales for patient monitoring (ASDAS or BASDAI), are recommended. Nonsteroidal anti-inflammatory drugs are the first treatment option; in case of intolerance or residual pain, acetaminophen or opioids are recommended. In patients with axial involvement, it is recommended not to use conventional disease-modifying antirheumatic drugs or systemic or local glucocorticoids. In patients with failure to non-steroidal anti-inflammatory drugs, anti-TNF or anti-IL17A is recommended. In those patients presenting with anti-TNF failure, starting an anti-IL17A is recommended. Exercise, physical and occupational therapy are recommended as part of treatment. It is recommended not to use unconventional therapies as the only treatment option.

CONCLUSIONS

This set of recommendations provides an updated guide on the diagnosis, treatment and monitoring of patients with axial spondyloarthritis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The effect of exercise training programs with aerobic components on C-reactive protein, erythrocyte sedimentation rate and self-assessed disease activity in people with ankylosing spondylitis: A systematic review and meta-analysis

AIM

To examine the effect of exercise training programs with aerobic components on C-reactive protein, erythrocyte sedimentation rate and self-assessed disease activity in people with ankylosing spondylitis compared to non-aerobic rehabilitation.

METHODS

A systematic review was undertaken of PubMED, Cochrane Library, Embase and Web of Science databases. Articles evaluating the effect of exercise training programs with aerobic components on C-reactive protein, erythrocyte sedimentation rate or Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) in adults (>17 years) with ankylosing spondylitis were included. Control groups were defined as non-aerobic rehabilitation, including usual care or physiotherapy.

RESULTS

Thirteen articles met inclusion criteria for qualitative and meta-analysis, involving 366 participants undertaking exercise and 361 controls. Exercise programs included modalities such as running, aerobic walking and swimming, and were between 3 weeks and 3 months in duration. Exercise programs significantly reduced C-reactive protein (weighted mean difference [WMD]: -1.09; 95% CI: -2.08 to -0.10; P = .03; n = 5) and BASDAI (WMD: -0.78; 95% CI: -0.98 to -0.58; P < .001; n = 13) compared to non-aerobic rehabilitation. BASDAI subgroup analysis revealed greater improvements compared to usual care than structured physiotherapy. Exercise programs did not reduce erythrocyte sedimentation rate (WMD: 0.16; 95% CI: -2.15 to 2.47; P = .89; n = 4).

CONCLUSION

Exercise training programs with aerobic components reduced C-reactive protein and improved self-assessed disease activity in people with ankylosing spondylitis. Further research is required to investigate the effects of differing aerobic exercise modes, intensities and durations.

How does Spinal Mobility Affect Balance and Postural Control in Patients with Ankylosing Spondylitis? A Cross-Sectional Study

Purpose Alterations in spinal mobility lead to impaired postural control and balance, an increased risk of falls and a decrease in quality of life. The purposes of this study were to investigate the relationship between spinal mobility, postural control and balance and to compare spinal mobility and balance with a view to disease severity in patients with ankylosing spondylitis (AS).

Methods 137 patients with AS were divided into 2 groups by tragus-to-wall distance (TWD): (Group I=mild AS, n=51), (Group II=moderate AS, n=86). Balance was assessed with the Single-Leg Balance Test, the Timed Up and Go Test (TUG) and the Berg Balance Scale (BBS). Spinal mobility was measured by BASMI Index [TWD, cervical rotation (CR), Modified Schober Test (MST), lumbar lateral flexion (LLF), intermalleolar distance (IMD) and thoracic expansion (TE)] and was compared between the groups. The association with balance was investigated.

Results Spinal mobility and BBS scores in Group II were worse than in Group I (p<0.05). Static balance and TUG of the groups were similar (p>0.05). Dynamic balance was weakly correlated with MST, LLF and IMM and moderately correlated with CR, TE and BASMI. Static balance was weakly correlated with spinal mobility (p<0.05). There was no correlation between TWD and any balance domains (p>0.05).

Conclusions In patients with AS, spinal mobility and dynamic balance worsen as the disease progresses, whereas static balance does not change. Such changes in mobility and balance can negatively affect patients’ participation in daily life and increase their risk of falls. Therefore, detailed evaluation of balance, balance training and fall prevention approaches need to be implemented in the rehabilitation programs of patients with AS.

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

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

The Future of Axial Spondyloarthritis Rehabilitation: Lessons Learned From COVID-19

Supervised physical therapy and rehabilitation are vital for effective long-term management of axial spondyloarthritis (SpA). However, the unprecedented year of 2020 and the COVID-19 pandemic has prompted a drastic change in health care provision across all disease areas. In this review, we summarize changes that have been introduced to support rehabilitation in axial SpA during the pandemic and considerations for the future of axial SpA rehabilitation in the wake of COVID-19. We have witnessed the launch of online virtual physical therapy and education, in addition to an emphasis on remote monitoring. We have been propelled into a new era of digital service provision; not only providing a temporary stop-gap in treatment for some patients, but in the future, potentially allowing for a wider reach and provision of care and resilience of vital services. Unique collaboration between patients, health care professionals, and researchers will be key to fostering relationships and trust and facilitating wider evaluation and implementation of digital services at each stage in a patient's journey, which is imperative for relieving pressure from health care providers. Despite the potential of such digital interventions, it is important to highlight the maintained critical need for face-to-face services, particularly for vulnerable patients or during diagnosis or a flare of symptoms. It is also vital that we remain vigilant regarding digital exclusion to avoid further widening of existing health inequalities. Optimization of digital infrastructure, staff skills, and digital education alongside promoting accessibility and engagement and building trust among communities will be vital as we enter this new age of blended in-person and digital service provision.

Treat-to-target in axial spondyloarthritis - what about physical function and activity?

In patients with axial spondyloarthritis (axSpA), pain, functional and structural impairments, reduced mobility and potential deformity of the axial skeleton are the most prominent health concerns. Limitations in physical function and spinal mobility are caused by both inflammation and structural damage, and therefore restrictions to physical function must be monitored throughout a patient's life. Consequently, the assessment of physical function is recommended as a key domain in the Assessment of Spondyloarthritis International Society-OMERACT Core Outcome Set. However, in comparison with disease activity, physical function seems to be a relatively neglected target of intervention in patients with axSpA, even though physical function is a major contributor to costs and disability in this disease. This Review aims to reacquaint rheumatologists with the targets for physical function, physical activity and performance by giving guidance on determinants of physical function and how physical function can be examined in patients with axSpA.

Effectiveness of self-management interventions in inflammatory arthritis: a systematic review informing the 2021 EULAR recommendations for the implementation of self-management strategies in patients with inflammatory arthritis

Objective

To perform a systematic review (SR) on the effectiveness of self-management interventions, in order to inform the European League Against Rheumatism Recommendations for its implementation in patients with inflammatory arthritis (IA).

Methods

The SR was conducted according to the Cochrane Handbook and included adults (≥18 years) with IA. The search strategy was run in Medline through PubMed, Embase, Cochrane Library, CINAHL Plus with Full Text, and PEDro. The assessment of risk of bias, data extraction and synthesis were performed by two reviewers independently. A narrative Summary of Findings was provided according to the Grading of Recommendations, Assessment, Development and Evaluation.

Results

From a total 1577 references, 57 were selected for a full-text review, and 32 studies fulfilled the inclusion criteria (19 randomised controlled trials (RCTs) and 13 SRs). The most studied self-management components were specific interactive disease education in ten RCTs, problem solving in nine RCTs, cognitive–behavioural therapy in eight RCTs, goal setting in six RCTs, patient education in five RCTs and response training in two RCTs. The most studied interventions were multicomponent or single exercise/physical activity in six SRs, psychosocial interventions in five SRs and education in two SRs. Overall, all these specific components and interventions of self-management have beneficial effects on IAs-related outcomes.

Conclusions

The findings confirm the beneficial effect of the self-management interventions in IA and the importance of their implementation. Further research should focus on the understanding that self-management is a complex intervention to allow the isolation of the effectiveness of its different components.

2021 EULAR recommendations for the implementation of self-management strategies in patients with inflammatory arthritis

Background

An important but often insufficient aspect of care in people with inflammatory arthritis (IA) is empowering patients to acquire a good understanding of their disease and building their ability to deal effectively with the practical, physical and psychological impacts of it. Self-management skills can be helpful in this regard.

Objectives

To develop recommendations for the implementation of self-management strategies in IA.

Methods

A multidisciplinary taskforce of 18 members from 11 European countries was convened. A systematic review and other supportive information (survey of healthcare professionals (HCPs) and patient organisations) were used to formulate the recommendations.

Results

Three overarching principles and nine recommendations were formulated. These focused on empowering patients to become active partners of the team and to take a more proactive role. The importance of patient education and key self-management interventions such as problem solving, goal setting and cognitive behavioural therapy were highlighted. Role of patient organisations and HCPs in promoting and signposting patients to available resources has been highlighted through the promotion of physical activity, lifestyle advice, support with mental health aspects and ability to remain at work. Digital healthcare is essential in supporting and optimising self-management and the HCPs need to be aware of available resources to signpost patients.

Conclusion

These recommendations support the inclusion of self-management advice and resources in the routine management of people with IA and aim to empower and support patients and encourage a more holistic, patient-centred approach to care which could result in improved patient experience of care and outcomes.

Psoriatic arthritis and physical activity: a systematic review

INTRODUCTION

The positive effects of physical activity in both rheumatoid arthritis and ankylosing spondylitis have been proven, but no clear data is yet published regarding psoriatic arthritis (PsA). The aims of this study were (i) to assess the level of physical activity (PA) in these patients and (ii) to review the effects of PA on articular disease, extra articular symptoms, and overall well-being.

METHODS

The research strategy was performed on Pubmed, Cochrane, PEDro databases using the following keywords: "psoriatic arthritis AND physical activity" without restriction. The PRISMA methodology was used to select and analyze articles. We searched for all studies published online and in English before January 2021.

RESULTS

A total of 319 studies were retrieved by our search but only 13 could be included. Two reports showed that 17 and 68% of patients reported practicing regularly physical activity. Exercise improved the BASDAI (Bath Ankylosing Spondylitis Disease Activity Index), the general symptoms (pain and fatigue), and the quality of life. Muscle strength and some of cardiovascular comorbidities were also improved. While the studies concerning the risk of enthesitis or flare induced by physical activity are conflicting, recent clinical trials did not mention any adverse event. Finally, rehabilitation programs were associated with a reduction mainly of pain and fatigue.

CONCLUSION

Studies show clear beneficial effects of exercise in PsA on disease activity, on well-being, and on comorbidities, and they seem to outweigh the risk of enthesitis induced by mechanical stress. Further investigations are necessary to confirm these results and to precise the modalities of exercise. Key Points • Psoriatic arthritis patients have a sedentary lifestyle • Physical activity has beneficial effects on disease activity, well-being and reduced some cardiovascular risk factor in psoriatic arthritis • Risk of enthesitis and flares is low with exercise in psoriatic arthritis.

Effects of traditional qigong exercise on ankylosing spondylitis: a protocol for systematic reviews and meta-analysis

INTRODUCTION

Ankylosing spondylitis (AS) is a recurrent autoimmune disease that is associated with a high disability rate, which has a profound negative impact on daily life. It has been clinically reported that traditional qigong exercise has certain therapeutic advantages in treating AS; however, this postulation is not evidence-based. Therefore, this study will aim at systematically appraising the validity and safety of traditional qigong exercise in treating AS.

METHODS AND ANALYSIS

We searched the English (PubMed, Embase, Web of Science and the Cochrane Library) and Chinese databases (China National Knowledge Infrastructure, Wan fang, VIP and Chinese biomedical database) for relevant information. Additionally, the Baidu Academic and Google Academic databases were manually searched to mine relevant information. Randomised controlled clinical trials of traditional qigong exercise in treating AS were searched from the establishment of the database to September 2020. Quality articles were extracted and independently evaluated by two researchers before inclusion in this study. Meta-analysis of the included articles was performed using the RevMan V.5.3 software.

ETHICS AND DISSEMINATION

This study will not involve primary data collection, and formal ethics approval will, therefore, not be required. We aim to publish this systematic review in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

CRD42020207057.

Efficacy of home-based physical activity interventions in patients with autoimmune rheumatic diseases: A systematic review and meta-analysis

INTRODUCTION

Physical activity (PA) has been receiving increasing interest in recent years as an adjuvant therapy for autoimmune rheumatic disease (ARDs), but there is scarce information about the efficacy of home-based PA for patients with ARDs.

OBJECTIVE

To perform a systematic review and meta-analysis on the efficacy of home-based physical activity (PA) interventions in improving health-related quality of life, functional capacity, pain, and disease activity in patients with ARDs.

METHODS

Searches were performed in PubMed, Web of Science, Scopus, Cochrane, CINAHL database and Sport Discus. Trials were considered eligible if they included a home-based physical activity intervention. The population included adults with autoimmune rheumatic diseases (e.g., rheumatoid arthritis, systemic lupus erythematosus, idiopathic inflammatory myopathies, systemic sclerosis and ankylosing spondylitis), comparisons included non-physical activity control or centre-based interventions (i.e., interventions performed on a specialized exercise centre) and the outcomes were quality of life, pain, functional capacity, disease activity and inflammation.

RESULTS

Home-based physical activity improved quality of life (p<0.01; g = 0.69; IC95%, 0.61 to 1.07) and functional capacity (p = 0.04; g = - 0.51; IC95%, -0.86; -0.16), and reduced disease activity (p = 0.03; g = - 0.60; IC95%, -1.16; -0.04) and pain (p = 0.01; g = -1.62; IC95%, -2.94 to -0.31) compared to the non-physical activity control condition. Additionally, home-based physical activity interventions were as effective as centre-based interventions for all investigated outcomes.

CONCLUSION

Home-based PA is an efficacious strategy to improve disease control and aleviate symptoms in ARD.

Potential Role of Yoga in the Management of Ankylosing Spondylitis: A Retrospective Study

BACKGROUND

Ankylosing spondylitis (AS) is a chronic autoimmune inflammatory spondyloarthropathy with unclear pathogenesis. The inflammatory pain in AS leads to restricted spinal mobility and significant disability. Yoga is a nonpharmacological intervention that has positive effects on various musculoskeletal-related problems. However, its role in AS is unknown.

OBJECTIVE

The present retrospective study assessed the efficacy of a two-week residential yoga intervention on spinal flexibility among AS patients.

METHODS

The records for 24 male AS patients within the age range 30 to 50 years (average age 38.3 ± 10.5 years) who underwent a two-week residential yoga retreat between 2015 and 2020 were obtained from a yoga center located in South India. Yoga intervention consisted of yoga postures, breathing practices, meditation, a healthy diet, and devotional sessions. Pre and Post data of the sit-and-reach test, blood pressure, heart rate, and symptom score were analyzed using Statistical Package for Social Sciences (SPSS).

RESULTS

Compared to the baseline, the post scores of the sit-and-reach test, systolic blood pressure and heart rate were found to be significantly (P < .05) lower. The symptom score and analgesic medication score also showed significant improvement after two-weeks compared to the baseline.

CONCLUSION

This retrospective study indicates the positive impact of on and analgesic use among AS patients. However, additional studies using robust research designs are warranted.

Recommendations of the Mexican College of Rheumatology for the Management of Spondyloarthritis

OBJECTIVES

To update the recommendations for the management of patients with Spondyloarthritis (SpA) in the Mexican population, and identify which variables could influence patient management.

MATERIAL AND METHODS

A group of 15 experts in SpA translated, analyzed and modified the recommendations of the Mexican College of Rheumatology (CMR) and the International Society for the Assessment of Spondyloarthritis (ASAS)/European League Against Rheumatism (EULAR) 2016 group through a systematic review of the literature by two external reviewers during the period from 2015 to 2018 using the grade of recommendation, Oxford levels of evidence, percentage of concordance (Delphi).

RESULTS

Compared to previous recommendations, there were no significant changes from the year 2015. However, we modified the five fundamental principles and reduced the number of recommendations to ten by incorporating the first item in the text and combining five recommendations into two and adding a further recommendation. We confirmed the tendency to use glucocorticoids for patients with inflammatory activity and scarce access to biologicals. We identified the sociodemographic and clinical characteristics of patients with SpA and their influence on the application of the recommendations.

CONCLUSIONS

The ten recommendations of the CMR and the analysis of the characteristics of the Mexican patients with SpA focussed on step therapy, including pharmacological and non-pharmacological therapies, in a spectrum from easily accessible to high-tech substances available to a small percentage of the population.

Positive effects of a four-week rehabilitation spa program on quality of life in patients with ankylosing spondylitis

This is an open uncontrolled study about the positive effects of a four-week rehabilitation spa program on the quality of life of 74 patients with ankylosing spondylitis. We assessed the following health status parameters on admission and discharge from the Institute Igalo, Montenegro: BASFI, BASDAI, ASDAS-CRP, ASAS 20 improvement criteria and SF-36 questionnaire. It was a "test-retest study". All the patients had six days of spa physical therapy per week during the four-week rehabilitation program, which made 24 therapy days in total. Therapy sets included the exercise program in gym and pool with mineral water, breathing exercises, massage therapy, balneotherapy (mud packs of baths, mineral and pearl baths, underwater massages), electrotherapy, sonotherapy, as well as thalassotherapy. Physiotherapy was prescribed by physician individually according to general health status and eventual contraindications. In all the observed parameters, statistical analysis showed that there was a highly significant improvement (p < 0.01). After four weeks of spa rehabilitation, ASAS 20 improvement index was achieved in 74.3% of patients with ankylosing spondylitis. Conclusions were that four weeks of complex spa physical therapy program in Institute Igalo led to a significant improvement of assessed parameters of disease activity, functional status and in domains of quality of life.

Consensus Recommendations for the Diagnosis and Management of X-Linked Hypophosphatemia in Belgium

X-linked hypophosphatemia (XLH) is the most common genetic form of hypophosphatemic rickets and osteomalacia. In this disease, mutations in the PHEX gene lead to elevated levels of the hormone fibroblast growth factor 23 (FGF23), resulting in renal phosphate wasting and impaired skeletal and dental mineralization. Recently, international guidelines for the diagnosis and treatment of this condition have been published. However, more specific recommendations are needed to provide guidance at the national level, considering resource availability and health economic aspects. A national multidisciplinary group of Belgian experts convened to discuss translation of international best available evidence into locally feasible consensus recommendations. Patients with XLH may present to a wide array of primary, secondary and tertiary care physicians, among whom awareness of the disease should be raised. XLH has a very broad differential-diagnosis for which clinical features, biochemical and genetic testing in centers of expertise are recommended. Optimal care requires a multidisciplinary approach, guided by an expert in metabolic bone diseases and involving (according to the individual patient's needs) pediatric and adult medical specialties and paramedical caregivers, including but not limited to general practitioners, dentists, radiologists and orthopedic surgeons. In children with severe or refractory symptoms, FGF23 inhibition using burosumab may provide superior outcomes compared to conventional medical therapy with phosphate supplements and active vitamin D analogues. Burosumab has also demonstrated promising results in adults on certain clinical outcomes such as pseudofractures. In summary, this work outlines recommendations for clinicians and policymakers, with a vision for improving the diagnostic and therapeutic landscape for XLH patients in Belgium.

Cardiovascular Disease in Spondyloarthritides

The spondyloarthritides are a group of chronic systemic inflammatory joint diseases, the main types being ankylosing spondylitis (AS) and psoriatic arthritis (PsA). Evidence accumulating during the last decades suggests that patients with AS or PsA carry an increased risk for cardiovascular disease and cardiovascular death. This risk appears to be mediated by systemic inflammation over and above classical cardiovascular risk factors. The excess cardiovascular risk in those patients has been formally acknowledged by scientific organizations, which have called physicians' attention to the matter. The application by Rheumatologists of new effective anti-rheumatic treatments and treat-to-target strategies seems to benefit patients from a cardiovascular point of view, as well. However, more data are needed in order to verify whether anti-rheumatic treatments do have an effect on cardiovascular risk and whether there are differences among them in this regard. Most importantly, a higher level of awareness of the cardiovascular risk is needed among patients and healthcare providers, better tools to recognize at-risk patients and, ultimately, commitment to address in parallel both the musculoskeletal and the cardiovascular aspect of the disease.

Effects of exercise programmes on pain, disease activity and function in ankylosing spondylitis: A meta-analysis of randomized controlled trials

BACKGROUND

To evaluate the effects of exercise programmes on pain, function and disease activity in patients with ankylosing spondylitis (AS).

MATERIALS AND METHODS

We searched PubMed, Embase, CNKI and Wanfang from inception to February 2020. Randomized controlled trials comparing exercises with nonexercise interventions in AS patients were applied. Studies that assessed the visual analogue scale (VAS) pain score, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Functional Index (BASFI), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were included. Outcomes of home-based exercise intervention were also reported independently.

RESULTS

Ten studies met the inclusion criteria in all, including 534 patients (278 exercise, 256 control). Compared with the nonexercise group, exercise group had statistically significant improvements in pain (weighted mean difference [WMD]: -1.02 [95% CI: -1.50 to -0.55]) (I² : 31%, P <.0001), BASDAI (WMD: -0.85 [95% CI: -1.09 to -0.61]) (I² : 20%, P <.00001), and BASFI (WMD: -0.66 [95% CI: -0.95 to -0.38]) (I² : 0%, P <.00001), but not in CRP and ESR. What's more, home-based exercise programmes had positive impacts on BASFI, BASDAI and pain.

CONCLUSIONS

For patients with AS, exercise programmes improve pain, function and disease activity. To confirm the results, more well-designed randomized controlled trials with large number of patients are required.

Therapeutic exercises and rehabilitation in axial spondyloarthropathy: Balancing benefits with unique challenges in the Asia-Pacific countries

The burden of axial spondyloarthropathy (axSpA) in the Asia-Pacific region is substantial. The management of axSpA has been revolutionized with the advent of biological therapy where the disease activity, functional disability and negative psychological affect can be mitigated to a great extent. On the other hand, exercise remains an essential component of the treatment of axSpA at all stages, which is often discounted or underused. This is compounded by a gap in demand and supply between increasing number patients with axSpA and paucity of trained specialists and rehabilitation personnel in the Asia-Pacific countries. The acceptability and uptake of therapeutic exercise is strikingly poor in this region because of multiple factors such as lack of awareness among health professionals and the general population, poor healthcare infrastructure, lack of resources and limited accessibility to rehabilitation services. Health authorities and professional bodies in these countries need to work in tandem to expand healthcare facilities, encourage training opportunities and promote safe and effective exercise interventions which is accessible to the general population and individuals with axSpA. Adequate patient education, optimum control of disease activity and strict adherence to therapeutic exercise is essential to predict the best clinical outcome. In this narrative review we have appraised the impact of therapeutic exercise in this era of biological therapies in axSpA and have explored the challenges of rehabilitation services in the Asia-Pacific countries. Overall, the available quality of evidence is mixed, acknowledging the beneficial role of exercise and optimum usage and protocols pertaining to axSpA specific exercises and therefore further research is warranted.

Organisation and content of supervised group exercise for people with axial spondyloarthritis in The Netherlands

Supervised group exercise (SGE) is recommended for people with axial spondyloarthritis (axSpA). Recent literature suggests that its contents and dosage must probably be revised. As a first step towards renewal, this study examined the current SGE organisation and content for people with axSpA in The Netherlands. A pen-and-paper survey was sent to the boards of the 82 local patient associations affiliated with the Dutch Arthritis Society in 2016. One member of each board was asked to complete questions on the nature and organisation of SGE and one of the supervising therapists to complete questions on the SGE supervision and contents. The questionnaire was returned by representatives of 67/82 (82%) local patient associations, of which 17 (25%) provided axSpA-specific SGE (16/17 SGE programmes with both land-based exercise and hydrotherapy and 1/17 with only hydrotherapy). These involved in total 56 groups with 684 participants and 59 supervisors, of whom 54 were physical therapists and 21 had had postgraduate education on rheumatic and musculoskeletal diseases (RMDs). Besides mobility and strengthening exercises and sports (17/17), most programmes included aerobic exercise (10/17), but rarely with heart rate monitoring (1/17), patient education (8/17), periodic assessments (2/17), or exercise personalisation (1/17). In the Netherlands, a quarter of local patient associations organised axSpA-specific SGE, mostly containing land-based exercises combined with sports and hydrotherapy. Most supervisors lacked postgraduate education on RMDs and most programmes lacked intensity monitoring, patient education, periodic assessments, and personalisation, which are needed for optimising exercise programmes according to current scientific insights.

Effectiveness of Global Postural Reeducation in Ankylosing Spondylitis: A Systematic Review and Meta-Analysis

The aim of this study was to determine the role of global postural reeducation for people with ankylosing spondylitis. We compared the effects of treatments on pain, dysfunction (using the Bath Ankylosing Spondylitis Disease Activity Index and Bath Ankylosing Spondylitis Functional Index), range of motion, and chest expansion in a specific population aged over 18 years old with ankylosing spondylitis. We performed a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statements. The search was conducted using the PubMed, Physiotherapy Database (PEDro), Scientific Electronic Library Online (SciELO), and Web of Science (WoS) databases. Clinical trials and systematic reviews/meta-analysis were reviewed. Results: 154 studies were found. Finally, four were included. Conclusions: global postural reeducation is beneficial for ankylosing spondylitis, but no more so than other conventional treatments, except for spinal mobility, where Global Postural Reeducation demonstrated an advantage.

Supervised Group Exercise in Axial Spondyloarthritis: Patients' Satisfaction and Perspective on Evidence-Based Enhancements

OBJECTIVE

Supervised group exercise (SGE) has been proven effective in patients with axial spondyloarthritis (SpA), but its contents and dosage do not always comply with current scientific insight. This aim of this study was to describe axial SpA patients' satisfaction with current SGE and perspective on potential evidence-based SGE enhancements.

METHODS

Patients with axial SpA who participated in SGE in 4 regions in The Netherlands (n = 118) completed a cross-sectional survey on their satisfaction with features of their current SGE (8 questions scored on a 3-point Likert scale; 1 overall grade, scored according to an 11-point scale) and their perspective on the introduction of appropriately dosed cardiorespiratory and strengthening exercise, monitoring of exercise intensity, periodic reassessments, patient education, and supervision by physical therapists with specific expertise (4 dichotomous questions and one 5-point Likert scale).

RESULTS

Most patients were satisfied with the current total intensity (84 of 112 patients [75%]), duration (93 of 111 patients [84%]), and load (89 of 117 patients [76%]) of the program and the proportion of mobility (102 of 114 patients [90%]), strengthening (90 of 115 patients [78%]), and cardiorespiratory exercise (82 of 114 patients [72%]). The median overall grade of the program was a 7 (interquartile range 7-8). Most patients agreed with the implementation of more frequent (home) exercise (73 of 117 patients [62%]), heart-rate monitoring (97 of 117 patients [83%]), and annual reassessments (97 of 118 patients [82%]), whereas 50% agreed with the introduction of patient education (37 of 74 patients). The majority found supervision by therapists specializing in axial SpA to be of high importance (105 of 118 patients [89%]).

CONCLUSION

The majority of SGE participants with axial SpA were satisfied with current SGE but also agreed with enhancements in line with scientific evidence. Current satisfaction levels indicate that a planned implementation strategy, including education and addressing potential barriers and facilitators for the uptake of enhancements, is warranted.

How to optimize exercise behavior in axial spondyloarthritis? Results of an intervention mapping study

OBJECTIVE

Many individuals with axial spondyloarthritis (axSpA) do not engage in adequate exercise, despite its proven health benefits. This study aimed to identify the intervention components needed to optimize exercise behavior in people with axSpA.

METHODS

The first three steps of the Intervention Mapping protocol were used: 1) needs assessment; 2) identification of axSpA-specific exercise barriers and facilitators (´determinants'); 3) selection of effective intervention components addressing potentially modifiable determinants. All three steps included scoping reviews and semi-structured interviews with patients (n = 2) and physical therapists (n = 2).

RESULTS

The scoping reviews included 28, 23 and 15 papers, respectively. Step 1 showed that only one third of axSpA patients exercise regularly, demonstrating especially a lack of strengthening and cardiorespiratory exercises. Based on eight determinants identified in Step 2, 10 intervention components were selected in Step 3: education, motivational interviewing, goal setting, action planning, monitoring, feedback, tailoring, guided practice, therapists' training and group exercise encouragement.

CONCLUSION

Using the Intervention Mapping method, 10 intervention components for optimizing exercise behavior in people with axSpA were identified and an intervention with behavior change guidance and a training for health professionals is proposed.

PRACTICE IMPLICATIONS

This study provides a foundation for the development of an axSpA-specific exercise intervention.

How Do Patients With Axial Spondyloarthritis Experience High-Intensity Exercise?

Objective

In a few studies, high‐intensity exercise has displayed beneficial effects on cardiovascular health among patients with rheumatic diseases, yet the high‐intensity exercise mode is still not fully accepted among health care professionals. The aim of this study was to investigate experiences of high‐intensity exercise among patients with axial spondyloarthritis.

Methods

Fourteen respondents who had participated in a high‐intensity exercise program for 12 weeks were included in this qualitative study with individual semistructured, in‐depth interviews. The respondents’ median age was 53, ranging from 23 to 63 years old, and both men and women of different ethnicities were represented. Interviews were analyzed by qualitative content analysis, including both manifest content and interpretations of underlying latent meaning.

Results

The analysis resulted in five categories describing the respondents’ experiences with high‐intensity exercise: 1) high‐intensity exercise as a challenge for both body and mind, 2) increased faith in one's own body, 3) changed attitude toward exercise, 4) taking charge of one's own health by challenging the disease, and 5) exercise in a social context.

Conclusion

Supervised high‐intensity interval exercise was perceived as challenging for both body and mind but was also described as a positive experience, with rapid bodily effects that strengthened respondents’ faith in their own bodies. The new experience seemed to have changed the respondents’ attitude and motivation for exercise and made them start taking charge of their health by challenging the disease. Exercise in a social context, under professional leadership, enhanced exercise self‐efficacy and helped the respondents to adhere to the exercise program.

The comparative efficacy of supervised- versus home-based exercise programs in patients with ankylosing spondylitis: A meta-analysis

OBJECTIVES

The aim of this meta-analysis is to investigate the comparative efficacy between supervised- and home-based programs in patients with ankylosing spondylitis (AS).

METHOD

A systematic search in PubMed, Web of Science, EMBASE, and the Cochrane Library was electronically performed by 2 independent investigators in order to capture all potential studies comparing supervised- with home-based in patients with AS from inception to April 2018. After extracted essential information, apprised risk of bias, statistical analysis was performed with Review Manager (RevMan) software (version 5.3.0). The protocol was registered at PROSPERO platform with an identifier of CRD42018097046.

RESULTS

A total of 7 studies comprising 271 patients were included finally. Meta-analyses showed that, compared to home-based program, supervised-based program was associated with reduced bath ankylosing spondylitis metrology index (BASMI) scores (mean difference [MD], -0.45; 95% confidence interval [CI], -0.73, -0.17), bath ankylosing spondylitis disease activity index (BASDAI) scores (MD, -0.48; 95% CI, -0.88, -0.08), and bath ankylosing spondylitis functional index (BASFI) scores (MD, -0.78; 95% CI, -1.19, -0.37). However, depression scores (standard mean difference, -0.22; 95% CI, -0.58, 0.14) between the 2 groups showed no significant defference.

CONCLUSIONS

Both supervised- and home-based programs can benefit to reduce BASMI, BASDAI, and BASFI scores in AS patients. However, short-term, supervised exercise program may be more effective than home-based exercises at decreasing disease activity with AS.

Relationship between sleep quality and physical activity level in patients with ankylosing spondylitis

Introduction: Aim of this study was to investigate whether there is a relationship between exercise level and sleep quality in AS patients.Method: In our study, 150 AS patients and 80 healthy controls were included. Physical activity levels of both groups were evaluated using International Physical Activity Questionnaire (IPAQ-s) short form. Sleep quality of the participants was evaluated using Pittsburgh Sleep Quality Index (PSQI). Disease activity and functional status were measured by Bath AS Disease Activity Index and Bath AS Functional Index.Results: Subjective sleep quality, habitual sleep efficiency, sleep disturbance and Total PSQI scores were significantly higher in the patient group compared to healthy participants. The IPAQ score was found to be significantly lower in the patient group. Sleep disturbance, one of the components of PSQI, was found to be significantly higher in patients with low IPAQ score.Conclusions: Sleep disorders were found to be higher in AS patients than normal population and physical activity levels of AS patients were lower than normal population. In addition, Sleep disturbance was found to be high in patients with low physical activity. Therefore, it should be remembered that one of the causes of sleep disorders in AS patients may be related to low physical activity.

New Insights in Physical Therapy and Rehabilitation in Axial Spondyloarthritis: A Review

Axial spondyloarthritis (axSpA) is a chronic and inflammatory rheumatic disease characterized by pain, structural and functional impairments, and reduced mobility and potential deformity of the axial skeleton. Treatment of axSpA includes pharmacological and non-pharmacological therapy. However, in the biologic era, unmet needs still remain for patients intolerant to or non-responders to biologic drugs and despite the development of new treatments, physical therapy and rehabilitation are of crucial importance in the management of axSpA patients. The aim of this manuscript is to review the current evidence on the assessment, physical therapy, and rehabilitation in axSpA patients.

Longterm Effect on Leisure Time Physical Activity Level in Individuals with Axial Spondyloarthritis: Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

To explore the longterm effect of a 3-month exercise program on leisure time physical activity level in individuals with axial spondyloarthritis (axSpA).

METHODS

A secondary analysis was performed on data from 100 individuals with axSpA who were included in a randomized controlled trial. The exercise group (EG) participated in a 3-month exercise program while the control group (CG) received no intervention. Physical activity during leisure time was measured with a questionnaire (physically active: ≥ 1 h/week with moderate/vigorous intensity physical activity). Disease activity was measured with the Ankylosing Spondylitis Disease Activity Scale (ASDAS; higher score = worst). Statistical analyses were performed on an intention-to-treat basis using chi-square tests, logistic regression, and mixed models.

RESULTS

At the 12-month followup, significantly more individuals in the EG than in the CG were physically active [29 (67%) vs 13 (30%), p < 0.001] and exercised 2-3 times/week [25 (58%) vs 15 (34%), p = 0.02], and fewer exercised at light intensity [3 (8%) vs 14 (44%), p = 0.002]. "Participation in the EG" (OR 6.7, 95% CI 2.4-18.6, p < 0.001) and "being physically active at baseline" (OR 4.7, 95% CI 1.4-15.8, p = 0.01) were the factors most associated with being physically active. There were no differences between the groups in ASDAS (p = 0.79).

CONCLUSION

A 3-month exercise program had a beneficial longterm effect on leisure time physical activity in individuals with axSpA, thus indicating a more beneficial health profile. Still, few individuals continued the intensive program, and there was no difference between the groups in disease activity after 12 months. (ClinicalTrials.gov: NCT02356874).

Factors associated with depressive symptoms in patients with ankylosing spondylitis in Northern Taiwan

Patients with ankylosing spondylitis (AS) experience impaired physical function and reduced quality of life, which puts this group at high risk for depression. Identifying factors associated with depressive symptoms could improve outcomes for this at-risk group. However, few studies have examined the relationship between demographic and clinical variables and depressive symptoms in patients with AS. This cross-sectional correlation study recruited patients with AS by convenience sampling from the division of immunology and rheumatology of a medical center in Northern Taiwan. Participants (N = 120) included 91 males and 29 females, age ≥ 20 years. Data were collected from chart reviews, and structural questionnaires, which included demographic information regarding employment status, history of falls, impact of AS on work; clinical information relative to AS was obtained from structural questionnaires: the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and functional index (BASFI), Numerical Rating Scale (NRS), Body Image Scale (BIS), and Beck Depression Inventory-II (BDI-II). Multiple regression analysis identified predictors of depression. The mean BDI-II score was 9.50 ± 8.30; 25% had scores indicating mild to severe depressive symptoms. Mean score on the BIS was 68.17 ± 16.14; 14.2% had fallen within the previous year; and 57.5% reported AS affected their work. Variables associated with depressive symptoms were work affected by AS (β = 0.14, p = .049), occurrence of a fall within the previous year (β = 0.14, p = .032), higher scores on the BASDAI (β = 0.21, p = .032), and lower body image (β = −0.38, p < .001). Clinical professionals should regularly assess patients with AS for depressive symptoms. Health care planning should provide instruction in fall prevention and control of disease activity, and strategies to improve body image, which could improve patients’ self-management capabilities and body image as well as mitigate depressive symptoms.

[Physical activity, exercise and nutrition in rheumatism : Adjuvant treatment options for inflammatory-rheumatic diseases]

BACKGROUND AND OBJECTIVES

The positive effects of physical activity, physical training and an adaptation of diet on health have been scientifically proven for many diseases. Focusing on inflammatory rheumatic diseases and their potential comorbidities, positive effects are assumed from these two adjuvant treatment opportunities, which are examined in more detail in this review.

MATERIAL AND METHODS

Based on a literature search, randomized controlled trials (RCTs), non-RCT studies, reviews and recommendations from professional societies were included.

RESULTS

Physical activity and training show positive effects on the disease itself and also on its comorbidities with existing certainty. In addition, the exercise and training recommendations of the American College of Sports Medicine (ACSM) and the American Heart Association (AHA) provide recommendations, which were adapted by the European League Against Rheumatism (EULAR) to control intensity, duration and training extent. Nutritional medical approaches also provide preventive and rehabilitative beneficial possibilities.

DISCUSSION

The increase of physical activity, regular physical training and the adaptation of diet should be a basic additive component of the treatment of inflammatory rheumatic diseases. In individual sub-aspects, the study situation is very heterogeneous and requires further research.

One Year of Pilates Training for Ankylosing Spondylitis: A Pilot Study

Objectives: This prospective long-term study examines the effects of a Pilates training intervention on spinal mobility, disease activity, and functional capacity in patients with ankylosing spondylitis (AS). Design: The study design was quasi experimental and single blind. Subjects: 11 subjects were recruited among patients undergoing followup of AS diagnosed according to modified New York criteria at the rheumatology clinic. Interventions: Over a 12-month period, 11 patients completed a training program consisting of two sessions per week of selected Pilates exercises. There was no control group. Outcome measures: The primary outcome variable was functional capacity measured using the Bath Ankylosing Spondylitis Functional Index (BASFI) questionnaire. Exploratory outcome measures were Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Metrology Index (BASMI), and chest expansion and fingertip-to-floor (FTF) test. Baseline and follow-up examinations were performed immediately before the intervention and during the course of treatment at 4, 8, and 12 months. Results: After the exercise intervention, improvements were observed in BASFI (77.51%), BASDAI (64.39%) and BASMI (58.95%) scores, FTF distance (71.92%), and chest expansion (88.74%). Conclusions: These findings suggest that Pilates training could be useful in AS patients and provide direction for larger controlled trials designed to determine the therapeutic benefits of Pilates in the management of these patients.

Exercise interventions for ankylosing spondylitis: a protocol for a Bayesian network meta-analysis

INTRODUCTION

Ankylosing spondylitis (AS) is a universal chronic inflammatory rheumatic disease which predominantly results in chronic back pain and stiffness. However, some patients suffering from AS do not react well to pharmacological interventions. Exercise intervention has been employed for the treatment of AS and works as a complementary part of the management of AS. However, the effect of different types of exercise interventions remains unclear. The purpose of this study is to determine the relative efficacy of different types of exercise interventions for individuals with AS using a Bayesian network meta-analysis.

METHODS AND ANALYSIS

We will conduct a systematic literature review of randomised controlled trials that compare different types of exercise interventions for individuals with AS. PubMed, EMBASE and the Cochrane Library will be searched up to February 2019. The primary outcomes are functional capacity, pain and disease activity. The risk of bias for individual studies will be evaluated according to the Cochrane Handbook. A Bayesian network meta-analysis will be performed to compare the efficacy of different types of exercise interventions. The quality of evidence will be assessed by the Grading of Recommendations, Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

Ethical approval and patient consent are not required as this study is a meta-analysis based on published studies. The results of this network meta-analysis will be submitted to a peer-reviewed journal for publication.

PROSPERO REGISTRATION NUMBER

CRD42019123099.