The use of exercise for the management of individuals with Ankylosing Spondylitis (AS)

AS ROM and flexibility section

A recent retrospective study, observed that a significant number of patients with AS had visited centres for alternative therapies, suggesting that they are not satisfied with the current conventional approach of AS management (Singh et al., 2021). Due to the broad impact of Ankylosing Spondylitis on various lifestyle factors, including pain and particularly quality of life, combined with the absence of a universally effective intervention, innovation in AS treatment is necessary. Recently, there has been a focus on alternative methods beyond generic exercise programmes and medication.

In this section, the focus of treatment will be exercise that aims to improve ROM and flexibility in those with AS and identify the outcomes of its implementation.

The first intervention which has been highlighted recently as being efficacious in the outcome measures associated with AS is Yoga.

A 2023 study by Singh et al. focused on tele-yoga’s impact on AS patients amidst the covid pandemic. From the study of one hundred and twenty AS patients who were assigned to either the yoga intervention group (YG) or the control group (CG), they identified that the three-month Tele-Yoga-Yoga intervention improved disease activity and quality of life in patients with ankylosing spondylitis compared with the control group. This positive trend associated with Yoga in AS is consistent in the broader literature. Singh et al. (2021) also observed a 37.5% improvement in the sit-and- reach test of AS patients after nine days of integrated approach to yoga therapy intervention. This test examines the shortening of hamstrings and lumbar hyperextension, and with AS patients commonly reporting stiffness and pain of the lower back and are prone to have fractures and ligamentous injuries in the lumbosacral region of the spine. They concluded that the yoga intervention had an improvement in the flexibility and the functional status of patients (Singh et al., 2021).However, the retrospective design, small sample size, no randomisation, and no objective parameters in the study limits the external validity of the study but the results gathered still hold significsnt clinical relevance.

Another study by Singh et al. (2022) focusing on patient perception of their condition found that the percentage of responses suggesting a high efficacy of Yoga was 85% (17/20). When analysed separately, the percentage of participants claiming pain reduction and improvement in their spinal flexibility with a yoga practice was 100% and 96%, respectively (Singh et al., 2022). The researchers concluded that ‘The results of the pilot study suggested that the yoga module is feasible, acceptable, and easy to practice for AS patients. We recommend the yoga module to AS patients (Singh et al., 2022). Albeit these studies had relatively small sample sizes, which may reduce how generalisable and valid these conclusions are, their benefits, as identified by AS patients, provide promise for this intervention. However, more extensive comprehensive studies comparing this intervention with a control group are required to solidify these findings and allow Yoga to be globally prescribed to AS patients.

Another intervention which is subject to a substantial base of research in AS is Pilates. Pilates has been determined in the literature as an effective and safe method for improving physical capacity in AS patients (Altan et al., 2011).

With AS, a set of key outcome measures are used to determine the extent of the condition. These measures are Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Chest expansion and fingertip-to-floor (FTF) test distance. In a yearlong study looking at the effects that Pilates has on these measures from baseline, the researchers found that 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%) (Rodríguez-López et al., 2019). Roşu et al. (2013) also identified a significant improvement in chest expansion, clinical and functional AS-related parameters in patients performing Pilates-based exercise.

A final intervention which has enhancing flexibility and ROM at the forefront of its purpose is Tai Chi. For treating AS patients, Tai Chi has been widely advised for inclusion in rehabilitation programs due to it being a safe alternative type of exercise to reduce disease activity, improve spinal mobility and quality of life in patients with AS (Cetin et al., 2020). Another study identified that compared with standard exercise therapy, “Tai Chi spinal exercise” has an ideal effect in patients with Axial Spondyloarthritis (ax-SpA), which can more effectively relieve patient’s low back pain and improve spinal motor function, with shorter training time and better compliance (Ma et al., 2020). This data shows that Tai Chi has beneficial outcomes in ax-SpA. With ax-SpA being the precursor to AS, it outlines the significant role interventions like Tai Chi can have in the preventative care of AS.

These findings further support the narrative that exercise such as Pilates, Tai Chi and Yoga, which focus on flexibility, balance and strength in tandem, have extensive clinical relevance and are worthy of greater research. The current studies of these interventions have yielded results that show not only physical benefits but also improvements in the psychosomatic element of the condition, and thus far, they have been highlighted as ‘less popular activities’ in the AS demographic (Brophy et al., 2013). With this significant evidence base, it raises the question as to whether these interventions should be promoted and implemented more in the care of those with AS than they are at present.

References

Altan, L., Korkmaz, N., Dizdar, M. and Yurtkuran, M. (2011). Effect of Pilates training on people with ankylosing spondylitis. Rheumatology International, 32(7), pp.2093–2099. doi:https://doi.org/10.1007/s00296-011-1932-9.

Brophy, S., Davies, H., Dennis, M.S., Cooksey, R., Husain, M.J., Irvine, E. and Siebert, S. (2013). Fatigue in Ankylosing Spondylitis: Treatment Should Focus on Pain Management. Seminars in Arthritis and Rheumatism, 42(4), pp.361–367. doi:https://doi.org/10.1016/j.semarthrit.2012.06.002.

Cetin, S., Calik, B., Ayan, A. and Kabul, E. (2020). The effectiveness of 10-Tai Chi movements in patients with ankylosing spondylitis receiving anti-tumor necrosis factor α therapy: A randomized controlled trial. European Journal of Integrative Medicine, [online] 39, p.101208. doi:https://doi.org/10.1016/j.eujim.2020.101208.

Ma, C., Qu, K., Wen, B., Zhang, Q., Gu, W., Liu, X., Shao, P., Shi, Y. and Wang, B. (2020). Clinical effect of ‘Tai Chi spinal exercise’ on spinal motor function in patients with axial spondyloarthritis. Int J Clin Exp Med, [online] 13(2), pp.673–681. Available at: https://e-century.us/files/ijcem/13/2/ijcem0103082.pdf [Accessed 18 May 2023].

Masiero, S., Poli, P., Bonaldo, L., Pigatto, M., Ramonda, R., Lubrano, E., Punzi, L. and Maffulli, N. (2013). Supervised training and home-based rehabilitation in patients with stabilized ankylosing spondylitis on TNF inhibitor treatment: a controlled clinical trial with a 12-month follow-up. Clinical Rehabilitation, 28(6), pp.562–572. doi:https://doi.org/10.1177/0269215513512214.

Rodríguez-López, E.S., Garnacho-Garnacho, V.E., Guodemar-Pérez, J., García-Fernández, P. and Ruiz-López, M. (2019). One Year of Pilates Training for Ankylosing Spondylitis: A Pilot Study. The Journal of Alternative and Complementary Medicine, 25(10), pp.1054–1061. doi:https://doi.org/10.1089/acm.2018.0405.

Roşu, M.O., Ţopa, I., Chirieac, R. and Ancuta, C. (2013). Effects of Pilates, McKenzie and Heckscher training on disease activity, spinal motility and pulmonary function in patients with ankylosing spondylitis: a randomized controlled trial. Rheumatology International, 34(3), pp.367–372. doi:https://doi.org/10.1007/s00296-013-2869-y.

Singh, J., Metri, K., Tekur, P., Mohanty, S., Jha, M., Singh, A. and Raghuram, N. (2022). Designing, validation, and feasibility of a yoga module for patients with ankylosing spondylitis. Journal of Ayurveda and Integrative Medicine, 13(1), p.100479. doi:https://doi.org/10.1016/j.jaim.2021.06.019.

Singh, J., Metri, K., Tekur, P., Mohanty, S., Singh, A. and Raghuram, N. (2023). Tele-yoga in the management of ankylosing spondylitis amidst COVID pandemic: A prospective randomized controlled trial. Complementary Therapies in Clinical Practice, [online] 50, p.101672. doi:https://doi.org/10.1016/j.ctcp.2022.101672.