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

Is sarcopenia a real concern in ankylosing spondylitis? A systematic literature review

PURPOSE

Sarcopenia is a condition defined as loss of muscle mass and strength, associated with poor functional performance and disability. Sarcopenia can be exacerbated or worsened in presence of inflammation, sedentary lifestyle and cytokine imbalance, thus it frequently occurs in people affected by rheumatic diseases. This systematic literature review aims to explore the association between sarcopenia and spondyloarthritis (SpA) and its most frequent manifestation, i.e. ankylosing spondylitis (AS).

METHODS

The Scopus, PubMed, and Web of Science databases were searched for articles on muscle mass, muscle strength and axial SpA, from any date to November 2023. Only studies written in English were considered. The methodological quality of the studies included in the review was evaluated using the Newcastle-Ottawa Scales for observational studies and for case-control studies.

RESULTS

190 papers were retrieved from the searches, 14 of which met the inclusion criteria. Rather than diagnosis of sarcopenia, pre-sarcopenia or probable sarcopenia were frequent in people with AS, with a great reduction especially of muscle strength. The pre-sarcopenia status appears to be related to high AS disease activity, suggesting that chronic inflammation resulting in pain, less movement and decreased physical activity could play a role in the muscle heath of AS patients.

CONCLUSIONS

Our review confirms the existence of an association between AS and loss of muscle strength-likely sarcopenia-already at a young age. Preventive and early strategies should be adopted to ensure successful aging for individuals with AS.

The efficacy of tofacitinib combined with bDMARDs in the treatment of ankylosing spondylitis patients with inadequate response to bDMARDs: a retrospective study

INTRODUCTION

Ankylosing spondylitis(AS) is a chronic inflammatory rheumatic disease primarily affecting the spine and sacroiliac joints. While biologic disease-modifying antirheumatic drugs(bDMARDs) and targeted synthetic DMARDs(tsDMARDs) are popular treatments for AS, there is limited research on their combined use. This study examined a cohort of AS patients who demonstrated inadequate response to bDMARDs and subsequently initiated combination therapy with tofacitinib in conjunction with bDMARDs, assessing both the efficacy and safety profile of this therapeutic approach.

METHODS

In this study, we retrospectively collected the electronic medical records (EMR) of 15 adult patients with AS who were admitted to the Fourth Affiliated Hospital Zhejiang University School of Medicine between January 2018 and June 2022. All patients had received at least one bDMARD treatment for more than three months and still exhibited moderate to high disease activity. Tofacitinib 5 mg bid was added to their original biological treatment. Treatment was continued for a minimum of 12 weeks following the initiation of combination therapy. Changes in ASDAS-CRP and BASDAI scores at week 12 were collected and analyzed from baseline, while changes in C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) at weeks 4, 8, and 12 were also collected and analyzed.

RESULTS

After 12 weeks of treatment, the overall ASDAS-CRP score decreased significantly from a baseline of 3.82 ± 1.47 (2.83 ~ 4.99) to 1.47 ± 0.48 (0.75 ~ 2.44), with remission achieved by 7 patients (46.7%) and low disease activity achieved by 5 patients (33.3%). The overall BASDAI score also showed significant improvement, decreasing from a baseline of 5.11 ± 1.42 (3.25 ~ 7 0.75) to 1.28 ± 0.70(0.20 ~ 2.55). Additionally, both ESR and CRP levels decreased significantly during the course of treatment without any reported adverse events leading to discontinuation.

CONCLUSION

To a certain extent, our findings provide some evidence supporting the efficacy and safety of the combination of bDMARD and JAK inhibitor tofacitinib in AS patients with inadequate response to bDMARD monotherapy. It effectively controls disease activity while maintaining a relatively low and manageable incidence of adverse events. Further prospective randomized controlled trials with large sample sizes are anticipated to provide evidence-based medical support.

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.

The Impact of Whole-Body Cryotherapy on Endothelium Parameters in Patients with Ankylosing Spondylitis

BACKGROUND

The aim of the study was to assess the effect of whole-body cryotherapy (WBC) with subsequent exercise training (WBC group) or exercise-only training (ET group) on endothelium inflammation parameters in patients with ankylosing spondylitis (AS).

METHODS

The WBC procedure lasted 3 min, and exercise training consisted of one 60 min session a day, which was the same in each group. The ET group was compared to the WBC group. Endothelium (high-sensitivity C-reactive protein (hsCRP), soluble P-Selectin, soluble vascular cell adhesion molecule-1 (sVCAM-1), neopterin), and oxidative stress (lipid hydroperoxide (LHP), protein sulfhydryl (PSH), lipofuscin, paraoxonase-1(PON-1), and albumin) parameters were estimated 1 day before and 1 day after the completion of the study.

RESULTS

A significant decrease in hsCRP, sP-Selectin, sVCAM-1, and neopterin concentrations was observed in the WBC group after the treatment. After the treatment, in both groups, LHP and lipofuscin levels and PON-1 activity decreased significantly. The observed drop in these parameters was higher in the WBC group compared to the ET group. Albumin concentration increased in the WBC group after treatment.

CONCLUSION

Procedures of WBC have a beneficial effect on endothelium parameters in AS patients; therefore, this method can be applied in the treatment of this group of patients.

The Role of Core Stability and Core Muscles in Ankylosing Spondylitis: A Review of Functional and Clinical Importance

Purpose: Physiotherapy and exercise training are one of the cornerstones in the treatment of patients with ankylosing spondylitis (AS). However, although the effects of exercise programs and their superiority over each other have still not been determined, research on this subject is continuing in the literature day by day. Due to the pathophysiology of AS, the spine is one of the most affected areas of the musculoskeletal system. Therefore, stabilization of the lumbopelvic region and the spine, which is the reference point for the core muscles, is important for the treatment and management of this disease. In this review, the involvement of core muscles and core stability in patients with AS and the literature on core training programs will be discussed.

Sustained improvements in EQ-5D utility scores and self-rated health status in patients with ankylosing spondylitis after spa treatment including low-dose radon - an analysis of prospective radon indication registry data

Background

Patients with ankylosing spondylitis (AS) have significantly lower quality of life (QoL) than the general population. Holistic interventions addressing QoL comprise spa- or balneotherapy including radon. These interventions have shown to be beneficial in reducing pain and improving QoL in AS-patients. We explored the association of spa-therapy including low-dose radon with QoL in AS-patients over an extended time period.

Methods

Registry data collected for the “Radon indication registry” in the Austrian Gastein valley comprising data on QoL (EuroQol EQ-5D) directly before the treatment (baseline), directly(t1), 3 (t2); 6(t3) and 9(t4) months after the treatment, age, sex and body mass index (BMI) were analysed. Linear regression models explored the association of measurement time with 1) EQ-5D-5L utilities and 2) EuroQol visual analogue scale (VAS) score. Alterations of 0.05 (utilities) and 5.00 (VAS) were considered clinically relevant.

Results

Two-hundred-ninety-one AS-patients were included in the analyses. Forty-four percent (n = 128) were women, the mean age was 52 (SD 10) and the average BMI was 26 (SD 4). Utilities (t1: 0.09 [0.07;0.11]; t2: 0.08 [0.06; 0.10]; t3: 0.06 [0.05;0.09]; t4: 0.04 [0.02;0.06]) and VAS (t1: 11.68 [9.38; 13.97]; t2: 12.20 [9.78; 14.61]; t3: 9.70 [7.24; 12.17]; t4: 6.11 [3.57; 8.65]) were significantly higher at all timepoints compared to baseline. Improvements were clinically relevant at all timepoints in case of the VAS and until 6 months after treatment for the utilities.

Conclusion

AS-patients who received spa therapy including radon show significantly and clinically relevant improvements in Qol until 6–9 months after treatment.

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.