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.
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.
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.
Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre