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.

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.

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.

ALTAN, L., KORKMAZ, N., DIZDAR, M. & YURTKURAN, M. 2012. Effect of Pilates training on people with ankylosing spondylitis. Rheumatology International, 32, 2093-2099.

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.

LEE, E.-N., KIM, Y.-H., CHUNG, W. T. & LEE, M. S. 2008. Tai chi for disease activity and flexibility in patients with ankylosing spondylitis—a controlled clinical trial. Evidence-Based Complementary and Alternative Medicine, 5, 457-462.

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].

MA, T., GENG, Y. & LI, P. 2022. Depression in patients with ankylosing spondylitis. Rheumatology & Autoimmunity, 2, 69-75.

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.

MISSAOUI, B. & REVEL, M. Fatigue in ankylosing spondylitis. Annales de réadaptation et de médecine physique, 2006. Elsevier, 389-391.

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.

XIE, Y., GUO, F., LU, Y., GUO, Y., WEI, G., LU, L., JI, W. & QIAN, X. 2019. A 12-week Baduanjin Qigong exercise improves symptoms of ankylosing spondylitis: a randomized controlled trial. Complementary therapies in clinical practice, 36, 113-119.