NIHR Signal Exercise improves symptoms and function for people with ankylosing spondylitis

Published on 21 November 2017

People with ankylosing spondylitis showed improvement in their symptoms and their ability to perform day-to-day tasks when they did more exercise. Symptom and function scores improved by almost one point on a 10-point scale after 3 to 12 weeks of exercise.

Ankylosing spondylitis is a type of arthritis which mainly affects the spine, causing pain, stiffness and progressive fusion of the spine. There have been recent advances in pharmacological treatment, and it was uncertain whether exercise along with modern drug treatment has useful benefits.

This review pooled the results of eight trials comparing different types of exercise with education or no exercise. People’s symptoms and ability to perform daily activities improved regardless of whether they were receiving new drug treatments.

The functional improvements shown in this research and the potential to prolong independence and working life for the most severely affected might also be another important reason to maintain activity.

Share your views on the research.

Why was this study needed?

Ankylosing spondylitis affects around 200,000 people in the UK, mostly starting before the age of 45. People with ankylosing spondylitis may have difficulty with everyday activities and with work. There is no cure, but there are some approaches to manage symptoms including medication, physiotherapy, exercise and sometimes surgery.

Although exercise has long been recommended for people with ankylosing spondylitis, few studies have properly tested how effective exercise is. Meanwhile, drug treatments have changed a lot in recent years, with new drugs which suppress the immune system (called anti-TNFs) being introduced. It is unclear whether these new therapies have altered the benefit of carrying out exercise.

This study looked at a range of exercise programmes, and also examined whether exercise had a lesser or greater benefit in studies which included people receiving anti-TNF drugs.

What did this study do?

This systematic review identified eight randomised controlled trials evaluating exercise in 331 people with ankylosing spondylitis. All participants were diagnosed according to one of two sets of standard criteria (Assessment of SpondyloArthritis international Society or modified New York criteria) though disease duration and severity varied.

Interventions included home-based exercise, swimming and Pilates compared with usual care, education or physical therapy in one study. Programmes lasted from 3 to 12 weeks.

Studies provided data on two validated 10-point outcome scales: the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) for measuring symptoms, and the Functional Index (BASFI) to look at day-to-day activities.

Four of the eight studies came from Turkey, two Norway, one Spain and one Italy. All took place after 2005. Studies were pooled in meta-analysis regardless of intervention type.

What did it find?

  • Exercise improved symptoms on the BASDAI scale. Exercise groups scored on average 0.90 points lower than control groups (95% confidence interval [CI] -1.52 to -0.27) in a meta-analysis of all eight studies. This result is a weighted mean difference (WMD) which takes greater account of larger studies. There was considerable difference in results (heterogeneity) between individual studies.
  • Exercise also improved day-to-day function on the BASFI scale (WMD -0.72, 95% CI -1.03 to -0.40) with no heterogeneity between the eight studies for this outcome.
  • Exercise gave apparently greater benefit when limited to the four studies that included people who received anti-TNF therapies. Symptoms improved by WMD -1.37 (95% CI -1.90 to -0.84) on the BASDAI, and daily activities by WMD -0.81 (95% CI -1.25 to -0.38) on the BASFI. Findings were similar across all four studies.

What does current guidance say on this issue?

NICE produced recent guidelines (2017) on the management of spondyloarthritis, which includes ankylosing spondylitis and other inflammatory arthritis such as psoriatic arthritis.

NICE recommends that people with spondyloarthritis affecting the spine should be referred to a specialist physiotherapist to start an individualised, structured exercise programme. This should include deep breathing and aerobic exercise, stretching, strengthening and postural exercises, spinal extension and a range of motion exercises for the spine.

Exercise and stretching are also emphasised as a component of self-care during disease flare-ups.

What are the implications?

The findings show that exercise gives measurable improvements in symptoms and physical function scores in people with ankylosing spondylitis.

The results broadly support NICE guidelines that exercise should be a core component of care in people with ankylosing spondylitis.

It would be nice to know more about how this exercise should be carried out, for example, at home or in a supervised group. By analysing all types of exercise programme together, it is not possible to tell if some types of exercise are more effective than others.

Citation and Funding

Pécourneau, V, Degboé, Y, Barnetche, T, et al. Effectiveness of exercise programs in ankylosing spondylitis: a meta-analysis of randomized controlled trials. Arch Phys Med Rehabil. 2017. [Epub ahead of print].

This study did not report any funding.

Bibliography

NHS Choices. Ankylosing spondylitis. London: Department of Health; updated 2016.

NICE. Spondyloarthritis in over 16s: diagnosis and management. NG65. London: National Institute for Health and Care Excellence; 2017.

Why was this study needed?

Ankylosing spondylitis affects around 200,000 people in the UK, mostly starting before the age of 45. People with ankylosing spondylitis may have difficulty with everyday activities and with work. There is no cure, but there are some approaches to manage symptoms including medication, physiotherapy, exercise and sometimes surgery.

Although exercise has long been recommended for people with ankylosing spondylitis, few studies have properly tested how effective exercise is. Meanwhile, drug treatments have changed a lot in recent years, with new drugs which suppress the immune system (called anti-TNFs) being introduced. It is unclear whether these new therapies have altered the benefit of carrying out exercise.

This study looked at a range of exercise programmes, and also examined whether exercise had a lesser or greater benefit in studies which included people receiving anti-TNF drugs.

What did this study do?

This systematic review identified eight randomised controlled trials evaluating exercise in 331 people with ankylosing spondylitis. All participants were diagnosed according to one of two sets of standard criteria (Assessment of SpondyloArthritis international Society or modified New York criteria) though disease duration and severity varied.

Interventions included home-based exercise, swimming and Pilates compared with usual care, education or physical therapy in one study. Programmes lasted from 3 to 12 weeks.

Studies provided data on two validated 10-point outcome scales: the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) for measuring symptoms, and the Functional Index (BASFI) to look at day-to-day activities.

Four of the eight studies came from Turkey, two Norway, one Spain and one Italy. All took place after 2005. Studies were pooled in meta-analysis regardless of intervention type.

What did it find?

  • Exercise improved symptoms on the BASDAI scale. Exercise groups scored on average 0.90 points lower than control groups (95% confidence interval [CI] -1.52 to -0.27) in a meta-analysis of all eight studies. This result is a weighted mean difference (WMD) which takes greater account of larger studies. There was considerable difference in results (heterogeneity) between individual studies.
  • Exercise also improved day-to-day function on the BASFI scale (WMD -0.72, 95% CI -1.03 to -0.40) with no heterogeneity between the eight studies for this outcome.
  • Exercise gave apparently greater benefit when limited to the four studies that included people who received anti-TNF therapies. Symptoms improved by WMD -1.37 (95% CI -1.90 to -0.84) on the BASDAI, and daily activities by WMD -0.81 (95% CI -1.25 to -0.38) on the BASFI. Findings were similar across all four studies.

What does current guidance say on this issue?

NICE produced recent guidelines (2017) on the management of spondyloarthritis, which includes ankylosing spondylitis and other inflammatory arthritis such as psoriatic arthritis.

NICE recommends that people with spondyloarthritis affecting the spine should be referred to a specialist physiotherapist to start an individualised, structured exercise programme. This should include deep breathing and aerobic exercise, stretching, strengthening and postural exercises, spinal extension and a range of motion exercises for the spine.

Exercise and stretching are also emphasised as a component of self-care during disease flare-ups.

What are the implications?

The findings show that exercise gives measurable improvements in symptoms and physical function scores in people with ankylosing spondylitis.

The results broadly support NICE guidelines that exercise should be a core component of care in people with ankylosing spondylitis.

It would be nice to know more about how this exercise should be carried out, for example, at home or in a supervised group. By analysing all types of exercise programme together, it is not possible to tell if some types of exercise are more effective than others.

Citation and Funding

Pécourneau, V, Degboé, Y, Barnetche, T, et al. Effectiveness of exercise programs in ankylosing spondylitis: a meta-analysis of randomized controlled trials. Arch Phys Med Rehabil. 2017. [Epub ahead of print].

This study did not report any funding.

Bibliography

NHS Choices. Ankylosing spondylitis. London: Department of Health; updated 2016.

NICE. Spondyloarthritis in over 16s: diagnosis and management. NG65. London: National Institute for Health and Care Excellence; 2017.

Effectiveness of exercise programs in ankylosing spondylitis: A meta-analysis of randomized controlled trials

Published on 2 September 2017

Pecourneau, V.,Degboe, Y.,Barnetche, T.,Cantagrel, A.,Constantin, A.,Ruyssen-Witrand, A.

Arch Phys Med Rehabil , 2017

OBJECTIVE: To assess the effectiveness of exercise programs on disease activity and function in ankylosing spondylitis (AS) by a systematic review and meta-analysis of randomized controlled trials (RCTs). DATA SOURCES: Medline via PubMed and Cochrane Library. STUDY SELECTION: Reports of RCTs examining the effectiveness of exercise programs for AS published up to May 2017. DATA EXTRACTION: Outcomes were evolution of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Functional Index (BASFI) after the completion of exercise programs. Modalities of exercise were compared and the use of biologic therapy was reported. DATA SYNTHESIS: After screening 190 abstracts, we selected 26 reports for detailed evaluation and finally investigated 8 trials that assessed a home-based exercise program (2/8), swimming (1/8), Pilates training (1/8) or supervised exercises (4/8), for 331 AS patients. Four trials included patients receiving anti-TNF therapy. All trials except one showed a decrease in BASDAI and BASFI, with exercise. The weighted mean difference (95% confidence interval) was -0.90 (-1.52, -0.27) (I2=69%, p=0.005) for the BASDAI and -0.72 (-1.03, -0.40) (I2= 0%, p<0.00001) for the BASFI in favor of exercise programs. CONCLUSIONS: Despite the small number of patients and the heterogeneity of exercise programs in the RCTs included in this meta-analysis, its results support the potential of exercise programs to improve disease activity and body function in AS.

Expert commentary

Yet again we see that physical activity reduces symptoms and improves health – in this case for people with painful, stiff spines due to ankylosing spondylitis. Yet we lack good systems to support people with long-term conditions, many of whom live with pain, to become physically active and thus enjoy the benefits.

This is partly about behaviour change, but also about access and affordability – public health systems happily pay for drugs that reduce symptoms (with possible side effects), but won’t cover the cost of, for example, a yoga class, or swimming pool membership (with endless added benefits). Time to rethink this?

Dr Benjamin Ellis, Senior Clinical Policy Advisor, Arthritis Research UK