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

Exercise Therapy Research in Ankylosing Spondylitis-Induced Back Pain: A Bibliometric Study (2004-2023)

BACKGROUND Ankylosing spondylitis (AS), a chronic inflammatory disease predominantly causing back pain, affects up to 0.5% of the global population, more commonly in males. Frequently undiagnosed in early stages, AS is often associated with comorbid depression and anxiety, imposing significant healthcare burdens. Despite available pharmaceutical treatments, exercise therapy (ET) has emerged as an effective, side-effect-free alternative, particularly for managing AS-induced back pain. This study aims to explore the research trends in ET for treating AS back pain from 2004-2023. MATERIAL AND METHODS A comprehensive analysis of 437 articles, sourced from the Science Citation Index-Expanded within the Web of Science Core Collection, was conducted using CiteSpace 6.2.R5. This study spanned from 2004 to October 15, 2023, examining publications, authors, institutions, and keywords to assess keyword co-occurrences, temporal progressions, and citation bursts. RESULTS Research interest in ET for AS began escalating around 2008 and has since shown steady growth. The USA emerged as a significant contributor, with Van der Heijde, Desiree, and RUDWALEIT M being notable authors. Key institutions include Assistance Publique Hopitaux Paris and UDICE-French Research Universities, with ANN RHEUM DIS being the most influential journal. The field's evolution is marked by interdisciplinary integration and branching into various sub-disciplines. CONCLUSIONS Exercise therapy for AS-induced back pain is a growing research area, necessitating further exploration in clinical management and rehabilitation strategies. The relationship between ET and osteoimmunological mechanisms remains a focal point for future research, with a trend towards personalized and interdisciplinary treatment approaches.

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.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Study about a New Standardized Method of Home-Based Exercise in Elderly People Aged 65 and Older to Improve Motor Abilities and Well-Being: Feasibility, Functional Abilities and Strength Improvements

BACKGROUND

To verify the effects in terms of feasibility, strength and functional abilities of a standardized exercise training method that is partially supported (home training), with the aim of improving motor abilities and well-being.

METHODS

A total of 67 participants underwent two sessions per week for 12 weeks for the program, based on 8 sequences with specific body part targets, with each sequence made up of 9 exercises.

OUTCOME MEASURES

Recording of training session data, Chair Test, Hand Grip Test, Timed Up-and-Go Test, Stork Balance Test, Sit-and-Reach Test, VAS, Perceived Physical Exertion.

RESULTS

In total, 97% of the sample were "adherent" (more than 70% of the prescribed treatments performed). The rate of adverse events was infrequent (only 8). Chair Test +31%, Hand Grip Test +6%, Timed Up-and-Go Test -17%, Stork Balance Test +65%, Sit-and-Reach Test +55%, VAS -34%, Perceived Physical Exertion -69%.

CONCLUSIONS

Home training has good feasibility (adherence, tolerability, safety) and cost-effectiveness ratio and improves both strength and functional abilities, which, in turns, helps to improve motor abilities and well-being.

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.

Peripheral vitamin D levels in ankylosing spondylitis: A systematic review and meta-analysis

Objectives

Previous studies showed conflicting results regarding peripheral vitamin D levels in ankylosing spondylitis (AS). We performed this systemic review and meta-analysis to explore whether vitamin D may influence AS process.

Methods

Articles published until March 2022 were searched in databases as follows: PubMed, Web of Science, and Google Scholar. The present study included cross-sectional and case-control studies regarding vitamin D levels in patients with AS. Studies were excluded according to the following exclusion criteria: (1) we excluded studies which did not provide sufficient information regarding the comparison of vitamin D levels in AS patients and healthy controls (HC). Vitamin D levels in the two group studies should be reported or could be calculated in included studies; (2) meta-analysis, reviews and case reports. STATA 12.0 software was used to make a meta-analysis. Standard mean differences (SMDs) and 95% confidence intervals (CIs) were computed as effect size.

Results

The present meta-analysis showed no significant difference in peripheral 1,25-dihydroxyvitamin D3 (1,25OHD) levels between AS and healthy controls (HCs) in Caucasians with a random effects model [SMD: −0.68, 95% CI (−1.90, 0.54)]. Patients with AS had lower peripheral 25-hydroxyvitamin D (25OHD) levels compared with HC with a random effects model [SMD: −0.45, 95% CI: (−0.70, −0.20)]. Patients with AS had higher peripheral C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels compared with HC in Caucasian population with random effects models [CRP: SMD: 1.08, 95% CI: (0.78, 1.37); ESR: SMD: 0.86, 95% CI: (0.39, 1.34)]. However, no significant difference in alkaline phosphatase (ALP), parathyroid hormone (PTH) or calcium levels were indicated between AS and HC in Caucasian with random effects models [ALP: SMD: 0.07, 95% CI: (−0.41, 0.55); PTH: SMD: −0.15, 95% CI: (−0.56, 0.26); calcium: SMD: −0.06, 95% CI: (−0.39, 0.26)].

Conclusion

In conclusion, the study showed an inverse association between 25OHD and AS, which suggests that vitamin D may have a protective effect on AS. ESR and C-reactive protein (CRP) are important biomarkers for AS.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Trial Registration

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

International Registered Report Identifier (IRRID)

RR2-10.2196/23359

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.

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.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Trial Registration

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

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.

Effect of Chronic Resistance Training on Circulating Irisin: Systematic Review and Meta-Analysis of Randomized Controlled Trials

Irisin seems to play an important role in several chronic diseases, however, the interactions between chronic training and irisin are still unclear. The purpose of this systematic review and meta-analysis was to examine the effect of chronic resistance training on circulating irisin in adults. Literature search was conducted in PubMed, Web of Science and EBSCOhost (Academic Search Complete) until December 2020. Randomized controlled trials researching irisin levels after a resistance training program for at least 8 weeks among an adult population were eligible. Other inclusion criteria comprised recruiting a control group and reporting circulating irisin through ELISA kits. Cohen's d effect size and subgroup analyses (95% confidence level) were calculated using a random effects analysis model. Data of the seven included studies comprising 282 individuals showed an increasing and non-significant tendency after a resistance training program (d = 0.58, 95% CI: -0.25 to 1.40, p = 0.17). Subgroup analyses showed significant increases for the older adults group (p < 0.001) and when training is demanding and progressive in terms of intensity (p = 0.03). Data suggest that resistance training programs seem to increase circulating irisin, especially in older adults and in demanding and progressive training programs. However, more studies should be conducted using robust measurement methods, such as mass spectrometry, to better understand the interaction between chronic resistance exercise and irisin.