Evidence-based medicine is the “science of following evidence” and refers to “the careful, accurate and judicious application of the best currently available research, combined with the personal expertise and years of clinical experience of clinical staff, and the consideration of patient values and desires, to develop the perfect combination of patient care measures.” Evidence is the cornerstone of evidence-based medicine, and the essence of evidence-based medicine is to follow the evidence. It requires a combination of applying the best current evidence based on the individual expertise and years of clinical experience of the clinical provider and the values and desires of the patient that we fully consider when developing a treatment plan. The core of evidence-based medicine is the application of the best evidence to clinical practice. Gu Zhifeng, Department of Rheumatology and Immunology, Affiliated Hospital of Nantong University
Ankylosing spondylitis (AS) is a systemic inflammatory disease characterized by involvement of the spine and sacroiliac joints. It manifests clinically as inflammatory low back pain, stiffness and limitation of motion, and some patients may have peripheral arthritis, hip involvement, tendinopathy, ophthalmopathy and other extra-articular manifestations. The disease occurs in young men aged 15-30 years, with a prevalence of about 0.3% in China, and about 1/3 of patients may present with a poor prognosis [1]. A Norwegian study showed that patients with AS had the disease for an average of 15.6 years and needed to stop working, especially in women, those with low education, uveitis, bamboo-like spine and co-morbidities. In recent years, the prognosis of AS has been greatly improved with the intensive research on AS, especially with the use of biological agents. However, we must be soberly aware that non-pharmacological treatment, especially exercise therapy, is by no means less important than pharmacological treatment. The ASAS recommends that the standard treatment of AS should be a combination of exercise therapy and pharmacotherapy. It is very important to educate patients and their families about the disease, to persuade patients to perform physical function exercises cautiously and without interruption, and to take necessary physical therapy to improve patients’ prognosis, improve quality of life, and enhance their physical, psychological, and social adaptation [1-2]. There are few studies on exercise therapy for AS, and the current studies suffer from small sample size and lack of long-term effect observation.
In this paper, we review the recent research progress of exercise therapy for AS from the perspective of evidence-based medicine.
1 Home exercise
Studies have shown that home exercise can have a positive impact on pain, morning stiffness, function, mood, and quality of life in patients with AS, and it has become the preferred form of exercise because it is not limited by time, is economical, and is convenient. Home exercise can be a combination of recreational exercise and back training, both of which can relieve pain and stiffness, but back exercises can improve patients’ somatic function [3]. Different types of exercises should be chosen for home exercise depending on the duration of the disease. For example, patients with disease duration greater than 15 years should adhere to back exercises instead of choosing recreational exercises, due to the fact that back exercises can reduce pain and improve function. Back exercises are effective in moving specific soft tissues and joints, thus providing more effective relief of AS symptoms due to structural causes and inflammation. However, for patients with less than 15 years of disease, recreational exercise can also reduce severe pain and stiffness. The ideal home exercise also requires attention to the frequency and duration of exercise [3]. Current evidence suggests that sustained exercise is more important for slowing the progression of disability than the intensity of exercise; moderate intensity exercise (2 – 4 hours/week) is more beneficial than no exercise and high intensity exercise (>10 hours/week) in terms of functional status and disease activity [3-4]. In addition, it was found that daily and back exercise for at least 30 min five times per week significantly improved pain, morning stiffness, and HAQ scores in patients. A large-sample, randomized controlled study showed that a 6-month period of home exercise with video and written education significantly improved patients’ self-confidence, increased self-perceived joint flexibility, and improved patients’ functional score index (BASFI), but had no effect on patients’ disease activity index (BASDAI) [5]. Another small sample, randomized controlled study showed that educated home exercise significantly improved patients’ finger-to-ground distance and functional scores after 4 months; this effect was maintained, although not increased, in a subsequent 8-month follow-up observation [6]. Another study found that an 8-week, 20-minute home exercise program significantly improved spinal and large joint flexibility, functional indices, pain, and depression scores over patients without any intervention [7]. A small cross-sectional study found that regular exercise for patients significantly reduced pain and improved quality of life [8].The optimal home exercise for AS patients should be 30 min at least five times per week.Therefore, given the cost-effectiveness, home exercise should be the preferred modality of exercise therapy for AS.
As time increases, patients’ enthusiasm to adhere to exercise decreases. Studies have shown that younger patients with a short duration of disease and little disability spend significantly less time exercising at home than older patients with a longer duration of disease and more functional loss [9]. A lot of research work has been done in China and abroad on how to improve motivation and compliance of patients to home exercise. hidding A et al [10] showed that home exercise combined with weekly group exercise was more effective than home exercise alone after 9 months. patients who still adhered to weekly group exercise and home exercise after 9 months had a significantly higher functional index than those who withdrew from group exercise. bakker et al [11] also showed that group exercise was more effective than home exercise alone, but group exercise cost $531/year, which only 75% were willing to pay. Therefore community and hospital provision of similar group exercise can improve patient compliance. We must also enhance patient exercise monitoring and patient education during home exercise to educate patients about appropriate exercise, recreational activities, posture, and improved exercise self-efficacy. kragg et al [6] showed that education during home exercise significantly improved patients’ fingertip distance and functional status. Helliwell et al [12] showed that patients with AS can benefit from home exercise as much as those with different disease activity levels. One study showed that patients with disease duration greater than or less than 5 years could benefit from 6 weeks of home exercise [13-14]. Studies have shown that routine home exercise during the first ten years after disease diagnosis can significantly improve patient function, and this study suggests the importance of exercise early in the disease course [14].
2 Water bath and tai chi therapy
Studies have shown that water baths and Tai Chi therapy play a very important role in the non-exercise treatment of AS. A large sample of 40-week, randomized controlled studies showed that combining home exercise and medication with 3 weeks of SPA therapy significantly improved patients’ BASFI scores [15]. A study also showed that a 3-month SPA combined with exercise therapy significantly improved patients’ functional status [16]. However, the high cost of SPA limits its dissemination in AS patients. The same results showed that hydrotherapy combined with exercise therapy significantly improved the functional status of patients compared to exercise therapy alone. A study showed that hydrotherapy combined with home exercise improved neck flexibility, pain, and stiffness in patients in the short term. Hydrotherapy for 30 minutes daily for 3 weeks significantly improved patients’ BASDAI scores [17]. Swimming also significantly improved patients’ fingertip distance and patients’ functional status [18]. Studies have shown that 8 weeks of Tai Chi exercise significantly reduced disease mobility and improved patient flexibility compared to controls. Tai Chi exercise can reduce AS-related symptoms such as joint pain by improving the cardiovascular system, increasing muscle strength, reducing body weight, and increasing joint flexibility, the mechanisms of which need to be further investigated [19].
3 Formal physiotherapy
Formal physiotherapy has a positive effect on posture, flexibility, function and mood of AS patients. Physical therapy and assistive devices can be given by rehabilitation therapists according to the patient’s functional status and disease activity. A large sample, randomized controlled study found that home exercise based physiotherapy guided by a physiotherapist for 9 months significantly improved spinal mobility and overall patient perception [20]. Another small-sample, randomized, single-blind clinical study showed that weekly physiotherapist-guided flexibility and stretching exercises over a 4-month period were significantly better than traditional physiotherapy. The program was beneficial in improving flexibility, increasing muscle strength and lung capacity in the patient’s cervical, thoracic and lumbar spine. The results showed that the program significantly improved ear-wall distance and lumbar scoliosis and BASFI and BASMI [21]. Subsequent follow-up for 1 year found that adherence to at least 3 monthly sessions consistently improved BASFI and BASMI. another small sample, short-term randomized study found that 6 weeks of rigorous rehabilitation significantly improved BASFI and depression status over home exercise [22]. Daily passive stretching of the hip for 3 weeks significantly improved hip range of motion, and continued exercise for 6 months was even more effective [23]. Recent programs on exercise therapy for patients with AS have emerged one after another. The global posture re-education (GPR) method is a specific treatment program that aims to maintain correct posture. The method is designed to strengthen 4 specific groups of muscle groups. After 4 months of intervention, both the GPR group and the conventional group benefited significantly compared to baseline. And the GFR group benefited more than the conventional group. After one year both groups switched to home exercise and the study found that patients had diminished function, but the GPR group had less diminished function than the conventional group [20].
The multichannel exercise program included aerobic exercise and spirometry. Studies have shown that inspiratory muscle fatigue in AS patients limits the decrease in maximum lung capacity, the rise in residual air volume, and the decrease in compensatory inspiratory volume leading to a decrease in daily activity capacity and quality of life. Moderate-intensity aerobic exercise combined with conventional therapy can significantly improve spinal flexibility, work capacity, and chest expansion. The program consisted of three phases: 10 min of warm-up exercises (pacing and stretching), 20 min of pacing exercises to further aerobic capacity, and 10 min of chest expansion exercises to improve lung capacity. Although the program did not find an improvement in patient function, the study found a recovery from the program compared to conventional treatment [24]. A multichannel exercise program of 50 min three times a week for 3 months significantly improved thoracic expansion, modified Schober score, occipital wall distance, spinal mobility, and work capacity [25].
4 Inpatient rehabilitation
Inpatient rehabilitation may be necessary for some patients with AS who have significant disease, activity, stiffness and pain that severely affect quality of life. Despite the advent of biologics, the number of patients involved has decreased significantly. Studies have shown that inpatient rehabilitation is beneficial in terms of disease mobility, function, and overall sensation [26]. Studies have shown significant improvements in finger ground distance, thoracic expansion, thoracolumbar and shoulder mobility in AS patients with different levels of mobility. A preliminary study showed that etanercept combined with inpatient rehabilitation was significantly more effective than rehabilitation alone [27].
In summary, home exercise programs are the most convenient and cost-effective, and therefore should be the exercise of choice for patients with AS. The key to the success of a home exercise program is long-term adherence, not the intensity of the exercise. Weekly group exercise and long-term adherence by the patient, combined with SPA, hydrotherapy, swimming, chest expansion exercises, GFR exercises, and formal rehabilitation are more beneficial to the patient. Active participation of health care professionals and the community can improve the quality of survival of patients.
References.
1. Zochling J, van der Heijde D, Burgos-Vargas R, et al. ASAS/EULAR recommendations for the management of ankylosing spondylitis [J]. BMJ , 2006, 65: 442-52.
2. Dagfinrud H, Halvorsen S, Vøllestad NK, et al. Exercise programs in trials for patients with ankylosing spondylitis: do they really have the potential for effectiveness? for effectiveness? [J], Arthritis Care Res (Hoboken). 2011 , 63: 597-603.
3. Uhrin Z, Kuzis S, Ward MM . Exercise and changes in health status in patients with ankylosing spondylitis[J]. Arch Intern Med, 2000, 160: 2969-75.
4. Santos H, Brophy S, Calin A Exercise in ankylosing spondylitis: how much is optimum?
5. Sweeney S, Taylor G, Calin A. The effect of a home based exercise intervention package on outcome in ankylosing spondylitis: a randomized controlled trial[J]. J Rheumatol , 2002, 29: 763-766.
6. Kraag G, Stokes B, Groh J, et al. The effects of comprehensive home physiotherapy and supervision on patients with ankylosing spondylitis: a randomized controlled trial[J]. J Rheumatol, 1990, 17: 228-233.
7. Kraag G, Stokes B, Groh J, et al. The effects of comprehensive home physiotherapy and supervision on patients with ankylosing spondylitis: an 8- month follow-up[J]. J Rheumatol, 1994, 21: 261-263.
8. Lim HJ, Moon YI, Lee MS. Effects of home-based daily exercise therapy on joint mobility, daily activity, pain, and depression in patients with ankylosing spondylitis[J]. Rheumatol Int, 2005, 25: 225-229.
9. Falkenbach A. Disability motivates patients with ankylosing spondylitis for more frequent physical exercise[J]. Arch Phys Med Rehabil, 2003, 84: 382-3.
10. Hidding A, van der Linden S, Boers M, et al. Is group physical therapy superior to individualized therapy in ankylosing spondylitis? controlled trial[J]. Arthritis Care Res , 1993, 6:117-125.
11. Bakker C, Hidding A, van der Linden S, et al. Cost effectiveness of group physical therapy compared to individualized therapy for ankylosing A randomized controlled trial[J]. J Rheumatol, 1994, 21: 264-8.
12. Helliwell PS, Abbott CA, Chamberliain MA. A radomised trial of three different physiotherapy regimes in ankylosing spondylitis[J]. Physiotherapy, 1996, 82: 85-90.
13. Carette S, Graham D, Little H, et al. The natural disease course of ankylosing spondylitis[J]. Arthritis Rheum, 1983, 33: 1060-6.
14. Gran JT, Skomsvoll JF. The outcome of ankylosing spondylitis: a study of 100 patients[J]. Br J Rheumatol , 1997, 36: 766-71.
15. van Tubergen A, Landewe R, van der Heijde D, et al. Combined spa-exercise therapy is effective in patients with ankylosing spondylitis: a randomized controlled trial[J]. Arthritis Care Res, 2001, 45: 430-8.
16. Helliwell PS, Abbott CA, Chamberlain MA. A randomised trial of three different physiotherapy regimes in ankylosing spondylitis[J]. Physiotherapy, 1996, 82: 85-90.
17. Atlan L, Bingol U, Aslan M, Yurtkuran M. The effect of balneotherapy on patients with ankylosing spondylitis[J]. Scand J Rheumatol, 2006, 35: 283-9.
18. Karapolat H, Eyigor S, Zoghi M, et al. Are swimming or aerobic exercise better than conventional exercise in ankylosing spondylitis patients? randomized controlled study[J]. Eur J Phys Rehabil Med. 2009, 45: 449-57
19. Lee EN, Kim YH, Chung WT, et al. Tai chi for disease activity and flexibility in patients with ankylosing spondylitis-a controlled clinical trial[J]. Evid Based Complement Alternat, 2008, 5: 457-62.
20. Fernandez-de-Las-Penas C, Alonso-Blanco C, Morales-Cabezas M, et al. Two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial[J]. Am J Phys Med Rehabil, 2005, 84:407-419.
21. Fernandez-de-Las-Penas C, Alonso-Blanco C, Alguacil-Diego IM,et al. One-year follow-up of two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial[J]. Am J Phys Med Rehabil , 2006, 85: 559-567.
22. Analay Y, Ozcan E, Karan A, et al. The effectiveness of intensive group exercise on patients with ankylosing spondylitis[J]. Clin Rehabil 2003, 17: 631-636.
23. Bulstrode SJ, Barefoot J, Harrison RA, et al. The role of passive stretching in the treatment of ankylosing spondylitis[J]. Br J Rheumatol , 1987, 26:40-42.
24. Ince G, Sarpel T, Durgun B, et al. Effects of a multimodal exercise program for people with ankylosing spondylitis[J]. Phys Ther, 2006, 86: 924-35.
25. Altan L, Bingol U, Aslan M, et al. The effect of balneotherapy on patients with ankylosing spondylitis[J]. Scand J Rheumatol, 2006, 35: 283-289.
26. Band DA, Jones SD, Kennedy LG, et al. Which patients with ankylosing spondylitis derive most benefit from an inpatient management program? J Rheumatol, 1997, 24: 2381-2384.
27. Heikkila S, Viitanen JV, Kautiainen H, et al. Sensitivity to change of mobility tests; effect of short term intensive physiotherapy and exercise on spinal, hip, and shoulder measurements in spondyloarthropathy[J]. J Rheumatol , 2000, 27:1251-1256.