With all the current therapies for ankylosing spondylitis (AS)—anti-inflammatory medications, biologics, dietary modifications, and even surgery in some cases— the consensus among most is that exercise is one of the most consistently beneficial treatments for symptom relief and optimal management. In fact, seven years ago at the Spondylitis Association of America’s Atlanta Spondylitis Educational Seminar, one specialist called exercise the “granddaddy” of all therapies for AS—the one clinicians repeatedly come back to because of its time-tested effectiveness.
What has been lacking, however, are specific recommendations for exercise type and dosage for those with AS. What is required for maximum benefit? And what exactly should clinicians prescribe to their patients with AS? Now, an evidence-based consensus statement on exercise, developed by a group of Australian clinicians, helps answer these questions by providing practical recommendations to “guide sustainable exercise prescription for individuals with AS.” Published in the February 2016 issue of the journal Seminars in Arthritis and Rheumatism, the authors offer 10 clinically useful recommendations that can be used by health professionals in crafting an exercise program for their AS patients, and as a self-management strategy for individuals living with the condition.
To reach a consensus on their recommendations, the authors (comprised of 11 physical therapists—all members of an Australian AS special interest group—and a rheumatologist with expertise in guideline development and research methodology) started by independently submitting up to 10 questions deemed of significant importance, which were grouped into topics. They then conducted a literature review and analysis on each topic, combining information from published studies with the group’s collective opinion to drive the development of the recommendations.
The resulting guidelines, called “Exercise for ankylosing spondylitis: An evidence-based consensus statement” focus on the core areas related to exercise and AS: assessment, monitoring, safety, disease management, AS-specific exercise, physical activity, dosage, adherence, and setting. The authors believe that these recommendations will help “guide exercise prescription and ensure that people with AS get the best possible results for the time they invest in their AS exercises.”
Assessment, monitoring, and safety are crucial components of any effective exercise program, whether for a healthy individual or for someone with an acute or chronic medical condition. These elements go hand in hand to enable clinicians to prescribe an appropriate, beneficial, and individualized exercise regimen given a patient’s specific conditions, evaluate the program’s effectiveness at relieving or improving symptoms, alter the activities within the program as the patient’s condition changes, and determine if specific exercises are safe and thus unlikely to cause additional harm to the patient.
Pre-program assessment is crucial in order to determine what type and amount of exercise is most beneficial and what precautions need to be built into the exercise program to prevent potential injury. The recommendations call for exercise prescription only after an analysis of an individual’s musculoskeletal and psychosocial factors, both of which may impact effectiveness of and adherence to the regimen. In addition, thorough AS-specific measures, such as axial (spine, hip, and shoulder) mobility and chest expansion (which may be compromised in some) must be assessed and monitored at least annually, so that the usefulness of the program can be evaluated and changed as necessary.
An important part of monitoring an exercise program is being mindful of potential complications and challenges that may arise as a result of adverse events associated with such physical activity, as well as those already existent within the individual. For AS this includes potential axial and peripheral joint injuries, cardiovascular and pulmonary issues, osteoporosis, movement restrictions, and impaired balance, among others. While most exercises are safe for the majority of AS patients, the increased potential for exercise-related injury is present for any patient with AS, warn the Australian researchers.
The guidelines say, for example, that high-impact activities, such as contact sports—think football, hockey, rugby—and martial arts, may be contraindicated for patients with severe AS. Likewise, exercises that greatly challenge balance and postural stability should be assessed on a case-by-case basis to ensure their safety for the participant.
The authors stress that clinicians must consider the physical changes that may occur in their patients as a result of AS progression—the amount of ankylosis, balance and mobility changes, and susceptibility to cardiorespiratory issues—when designing an exercise program.
Whether exercise affects AS at a systemic, anti-inflammatory level or more locally at the entheses (the connective tissue between tendons or ligaments and bones,) remains unknown. The researchers did not find sufficient evidence on whether the benefits of exercise for AS patients were systemic or local. They did, however, identify two studies that demonstrated a highly beneficial effect when therapy with TNF inhibitor medications is combined with an AS-specific exercise regimen, compared to TNF inhibitor use alone. The recommendations state that TNF inhibitor therapy “can be a ‘window of opportunity’ to optimize mobility and physical fitness,” and that individuals on TNF inhibitors should continue their regular exercise program.
Through their literature review, the authors found “consistent evidence” of the importance of spinal mobility exercises in the management of AS. Peripheral joint mobility exercises were also noted as important. While at this time they could not recommend specific *range of motion exercises over others, they stressed the importance of setting appropriate individual mobility goals based on assessment findings. For instance, in someone with early, or well-controlled AS, mobility goals may include restoring normal posture and full spinal range of motion. In others maintaining existing range of motion and posture may be the goal.
Note: Range of motion is simply how far joints can move in certain directions. Range of motion exercises are movements that take the joint through its full range of motion to help reduce stiffness, and maintain or improve the joint’s mobility.
In addition to maintaining or improving mobility, an effective AS exercise program should also include exercises to improve balance, coordination, muscle strength, cardiorespiratory (heart and lung) fitness, and functional fitness. The primary postural muscles that can benefit from stretching and strengthening exercises include those in the back, shoulder and chest, which can help prevent or limit kyphosis (excessive forward curving of the neck and spine.) Again, though specific exercises could not be recommended across the board, the authors noted the existence of preliminary evidence favoring a few modalities, including tai chi and modified Pilates. The authors stress that exercises that focus on biomechanical, or functional changes should be prescribed on a patient-by-patient basis, after assessing needs, limitations, and setting goals.
The evidence of the importance of physical activity on good health—for everyone—is abundant. The Centers for Disease Control and Prevention (CDC) says that adults should get 150 minutes of moderate-intensity exercise (such as light aerobics, brisk walking, or swimming) or 75 minutes of vigorous-intensity exercise such as jogging or running every week, plus two days or more of activities that strengthen the major muscle groups in the legs, back, hips, abdomen, chest, shoulders, and arms. “Regular physical activity should be encouraged to promote general health, well-being, and functional outcomes,” state the authors.
While the CDC guidelines above are intended for both AS and non-AS patients, some with AS may be advised to reduce or eliminate high-impact activities to reduce the risk of injury and of aggravating their symptoms. In addition, the authors found that low-impact activities that combine mobility, strengthening, and functional training, may be especially beneficial for those with AS.
Since a “one-size-fits-all” approach to exercise dosing is not possible, the guidelines call for exercise frequency, intensity, duration, and type to be tailored to each individual’s assessment findings and goals. Once the optimal level for mobility, posture, and stretching and strengthening exercises is achieved, a “maintenance” dose, rather than progression, is recommended. Consistency, the researchers say, is the most important factor. National physical activity guidelines for other types of exercise, like those proposed by the CDC, can be modified as needed.
An exercise program is only effective if an individual follows it. Adherence to such a program is crucial if any individual, with or without AS, is to benefit. The guidelines say that clinicians should assess adherence in order to “encourage motivation and promote ongoing self-management.” They do not, however, provide specific recommendations on how that should be done.
An exercise program can be implemented in a number of settings: in the home, in an outpatient clinic, at a spa, exercise facility, or gym, or even in an inpatient hospital setting. In order to enhance adherence and optimize positive outcomes, the authors recommend that patient preference be a priority in choosing where the exercise takes place. Supervision of the exercise often enhances its effectiveness, but is not necessary for compliance or success. AS-specific exercise in a group setting and warm water exercises were noted as beneficial additions to an individual’s regular exercise routine.
The consensus statement reviewed here is the first comprehensive set of exercise recommendations and guidelines developed for AS clinicians and patients. The researchers say their guidelines are “specific enough to be clinically useful, but flexible for adaptation” for other musculoskeletal conditions, including rheumatoid arthritis, osteoporosis, and osteoarthritis. And, while the framework was written by Australians primarily for Australians with AS, the recommendations are certainly applicable to AS patients throughout the world.
Clinicians have known for years that exercise is beneficial for people with AS and that when the right exercises are performed, patients are typically better able to manage their pain and other symptoms as well as improve their mobility and function. These new recommendations will help guide clinicians on the right type, frequency, and intensity of exercise for their patients with AS. We hope you put them to use!
Milner, J. et al. Exercise for ankylosing spondylitis: An evidence-based consensus statement. Seminars in Arthritis and Rheumatism (2016) Volume 45, Issue 4, 411 – 427.
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