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

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.

AS ROM and Flexibility for Psychological Outcomes

Yoga for patients with Ankylosing Spondylitis The 2023 study performed by Singh et al identified positive and significant improvements in Ankylosing Spondylitis disease activity and functional capacity from tele-yoga compared to ‘standard medical care’, which consisted of prescribed medication and physiotherapy management. However, not only did Singh et al discover the positive trends in biological outcome measures, but improvements in psychological outcome measures were also observed following the three-month tele yoga programme. The AS-Quality of life tool evidenced significant increases within the tele-yoga group, effectively demonstrating the self-efficacy benefits that a yoga can have on an individual with AS (Singh et al., 2023). The patient health questionnaire-4, used as a secondary outcome measure, included components assessing anxiety and depression levels (Singh et al., 2023), which are symptoms that Ma et al discovered that AS patients are at higher risk of experiencing (Ma et al., 2022). Both the control group and yoga group within Singh et al’s study identified reductions in levels of anxiety and depression following intervention; however, the yoga group experienced significantly greater reductions that the control group, demonstrating the key emotional benefits of consistent exercise to manage one’s health conditions. External validity of the study should however be considered, due to the yoga being performed remotely, and not within a group setting, raising the question of whether the yoga would have the same benefits within a group and face-to-face setting (Singh et al., 2023). The significance of the yoga-group’s results throughout the study may appear exaggerated due to the contrasting interventions received between the two groups, with remote physiotherapy intervention and bi monthly check-ups received for the control groups (Singh et al., 2023).

Tai Chi for patients with Ankylosing Spondylitis Previous literature supports the use of Tai Chi, an ancient Chinese exercise focusing on relaxation techniques, to improve disease activity and flexibility within a population with Ankylosing Spondylitis (Lee et al., 2008). This study performed by Lee et al involved 40 patients with AS to a Tai Chi group, receiving 60 minutes of home-based Tai Chi twice weekly for eight weeks, and a control group, receiving no intervention. A lack of change in outcome measures such as the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and finger to floor distance (FFD) was identified, emphasising the importance of a form of intervention within the management of AS (Lee et al., 2008). Another outcome measure used within Lee et al’s study was the Centre for Epidemiological Studies Depression Scale (CES-D), aiming to measure the participants depressive symptomatology. The Tai Chi group demonstrated a score of -5.86 post-intervention, whilst the control group recorded a score of -2.12, a statistically significant difference. However, the small intervention period, sample size and limited disclosed information regarding the randomisation process limits the external validity of the study, as well as the study being dated back to 2008 (Lee et al., 2008).

Pilates for patients with Ankylosing Spondylitis As previously discussed, Altan et al deemed Pilates as an appropriate form of exercise for AS patients to improve physical functioning. The study used 55 participants with AS diagnoses, as per the Modified New York Criteria, exposing 30 participants to an hour Pilates exercise programme three times weekly for 12 weeks (Altan et al., 2012). The other 25 participants received usual care in the means of exercise advice and their current medication (Altan et al., 2012). Improvements deemed significant were identified over 24 weeks within the Pilates group in functional capacity, but little increase was observed within the Ankylosing Spondylitis Quality of Life questionnaire, with no significant difference between the usual care or Pilates group (Altan et al., 2012). This demonstrates the physiological benefits that Pilates may have on an AS population, but how there may be alternative treatment modalities that more positively affect the psychological factors to health within an AS population (Altan et al., 2012). However, this study was performed in 2012, more than 10 years ago, in which time Pilates may have developed as a treatment method for physiological and psychological outcomes within AS patients. This study also may have benefited from a longer period of intervention, as well as a larger sample size, limiting the risk of external validity and bias’ (Altan et al., 2012).

Baduanjin Qigong for patients with Ankylosing Spondylitis Baduanjin Qigong is a traditional chine medicine that takes the form of exercise (Xie et al., 2018). It dates back to over a thousand years ago, uses principles of Yin-Yang, whilst being a meditative movement prioritising exercising the body and the mind (Xie et al., 2019). Baduanjin Qigong consists of eight varying movements, performed in a slow and controlled manner (Xie et al., 2019). It targets balance, stretching the spine and limbs and increasing muscle strength (Xie et al., 2019). Xie et al performed a randomised controlled trial in 2019, exploring the benefits of Baduanjin Qigong exercise within the symptomology of AS, over a 12-week intervention period. The study used a total of 60 patients, diagnosed with AS using the modified New York criteria, who were randomly assigned to the exercise group or no intervention group (Xie et al., 2019). Following the 12-week intervention, the overall BASDAI score was not significantly lower than the group that received no treatment, as well as the BASFI, used as a secondary outcome measures. Fatigue and the intensity and duration of morning stiffness were however significantly reduced post-intervention, compared to the control group, which are components of the BASDAI. Fatigue plays an important part within symptomology with AS, and is a recognised important symptom within an AS population, with patient strategies often provided to help manage one’s condition (Missaoui and Revel, 2006). Fatigue has a significant effect on quality of life, and should be considered within the management of AS (Missaoui and Revel, 2006), which demonstrates the positive effects of Baduanjin Qigong on psychological factors and quality of life, due to the reductions in fatigue, despite not significantly improving disease activity scores (Xie et al., 2019). However, the results from this study may not be repeatable due to the limited use of Baduanjin Qigong within the UK, which opens the door for other management strategies that are more easily accessible within the UK, like Yoga, Pilates and Tai Chi. The study also did not use a secondary follow-up period, which questions the validity and longevity of the results (Xie et al., 2019).

Conclusion Research surrounding Yoga, Tai Chi, Pilates and Baduanjin Qigong have all demonstrated positive health trends in regard to improving health and biological-related outcome measures with Ankylosing Spondylitis (Singh et al., 2023) (Lee et al., 2008) (Altan et al., 2012) (Xie et al., 2019). However, all exercise modalities have varying levels of positive effects on the AS populations psychological health. Yoga saw significant improvements within levels of anxiety and depression in AS populations (Singh et al., 2023), Tai Chi prompted a significant reduction of depressive symptomology within AS patients (Lee et al., 2008), but Baduanjin Qigong and Pilates observed marginal increases within fatigue, an indirect measure of psychological health anyway, and quality of life respectively, which were not deemed significant (Altan et al., 2012) (Xie et al., 2019). Yoga and Tai Chi are best advised for improvement within psychological outcome measures in AS populations, but the research used to determine this did include levels of bias and external validity, limiting its application to the AS population.

The use of exercise to manage social factors in AS:

Management of ankylosing spondylitis can be challenging, as in many cases patients with AS are still working, due to the early age of onset of the disease (Regnaux et al., 2019). A longitudinal observational study found that AS correlated with reduced work productivity and employment, causing increased absenteeism and work disability. (Boonen et al., 2010) The impact of AS also has a significant financial burden for healthcare systems and society. (Boonen et al., 2010). This can have a knock-on effect on all aspects of an individual's life, and depression has been shown to correlate with employment and absenteeism. (Healey et al., 2010) Therefore, an intervention is needed to mitigate the social burden that AS has on individuals, and promote continuation of work, and overall quality of life.

Social support is vital during the management of AS. Research has shown that as individuals social support decreases, there is an increase in loneliness and depression scores (Öksüz et al., 2018). Therefore, interventions aiming to limit absence from work may help to improve the psychosocial aspects of an individual's life and improve adherence to exercise. All factors mentioned will provide a holistic approach to the patient’s care.

Group based exercise for patient with ankylosing spondylitis:

A meta-analysis by Lane et al., (2022) investigated the effectiveness of group and home-based exercise on the psychological status of individuals with AS. Group-based exercise was superior to home-based exercise for improving depression, anxiety, and mental health outcomes. The component of supervision was the key difference between groups, however adherence to the home-based exercise plan may have been questioned, as depression has been identified as a risk factor for exercise non-adherence in individuals with spondyloarthritis (McDonald et al., 2019). Furthermore, individuals participating in group exercise were supervised by physiotherapists and psychiatrists, which may have exposed individuals to a greater level of management education. Despite the positive outcomes of this study, the long-term effects are unclear. This meta-analysis provides evidence that group exercise may be of benefit in the early phases of AS, to improve exercise adherence, and provide patients with an insight of the effects of exercise for their condition. This may improve outcomes in the long-term management of AS, however, further research is needed to understand which individuals would benefit from this intervention.

Combining home and workplace exercise for patients with ankylosing spondylitis:

A study was conducted by Lim and Cho, (2021), who aimed to investigate the effects of combining a home and workplace exercise programme, on physical function, depression and work-related disability in AS patients. 52 patients were included and split between 3 groups. One group combined home-and-workplace exercise, one group just included home-exercise, and the other was a control group. A combination of stretching and muscle strengthening exercise, walking, deep breathing exercises and workout videos were used in the home-and-workplace combined exercise plan. The combined exercise programme showed significant improvements in spinal mobility, pulmonary function, and significantly lower absenteeism and work-related disability, than the other groups. Due to AS patients having a three times higher risk of work-related disability due to physical dysfunction and structural changes (Lim and Cho, 2021), this study provides a potential intervention to lower this risk, and the social burden of the disease. However, for some patients the environment may be too overwhelming, or their occupation may not be appropriate for this type of intervention. A quasi-experimental study was used; therefore, variables were not controlled which may affect the reliability of results. There is currently minimal research combining home-and-workplace exercise, particularly in AS, and the long-term effects are unclear. However, progressively combining exercise with work may empower patients to correlate the improved physical function with attending their occupation and improved work-related outcomes.

ESCAPE PAIN exercise group:

In the UK, there is a national group exercise rehabilitation programme for individuals with arthritic pain. The programme “ESCAPE PAIN” is used to educate, perform exercise, and provide management techniques for individuals with pain. One of the programmes focuses on back pain, and a pilot study found that ESPACE-pain for backs significantly improves outcomes in musculoskeletal health, function, and mental wellbeing for individuals with lower back pain, whilst remaining in line with NICE guidelines (ESCAPE-pain for backs: An evaluation of a 12-month pilot, 2020). Whilst this exercise group isn’t specific for ankylosing spondylitis, the implications for practice and effectiveness of outcomes provide a structured programme to educate individuals on the importance of exercise, whilst implementing the biopsychosocial approach. This also limits the financial burden on the NHS and society as less staff will be required to manage the group. Despite the benefits of ESCAPE pain, it has yet to be fully implemented in every trust in the UK. Physiotherapists should determine which patients may be appropriate for the exercise group, as this can massively impact a patient's physical, psychological, and social health.

Support groups:

The Spondylitis Association of America provides an online support group for individuals with Ankylosing spondylitis. This provides individuals with a sense of community, whilst also being able to discuss management techniques, and share stories that others may relate to. This can empower patients to come together who have experienced similar experiences, and to feel less isolated within their condition. Conversations with individuals who have had positive outcomes can improve adherence and allow patients to gain an insight into their potential.

There is very limited research investigating the use of support groups for Ankylosing Spondylitis. However, a study conducted by Barlow, et al, (1993) found that individuals with AS, who were involved in a self-help group, had an increased frequency of exercise, greater satisfaction with available support, and a greater health locus of control. Physical improvements were also found over a 6-month period (Barlow, et al, 1993). Whilst this study is old, this provides evidence that individuals can experience an improved locus of control, empowering patients with AS to exercise more, and improve adhere to exercise. This can be identified by the secondary physiological improvements in patients in the self-help group.

With the growing rates of technology, this is an area that needs to be utilised. Patients will have the availability of constant support, which is of great importance when managing a long-term condition. Outcomes have shown to improve social and physiological markers in patients with AS, therefore further research is needed to validate the use of self-help groups in patients with AS. This will reduce the financial burden on the NHS and health care systems, whilst improving overall outcomes for patients.

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