Physical activity in axial spondyloarthritis – what should we be telling our patients?

Posted on by bjsm

Authors: Kaley Ainsworth and Raj Amarnani

This blog explores the evidence based physical activity guidelines and resources available for patients with axial spondyloarthritis

Introduction

The importance and benefits of exercise in patients with chronic disease, in particular axial spondyloarthritis (AxSpA), is evident within existing literature. The inclusion of exercise programmes within the management of patients with AxSpA has the potential to:

  • Reduce disease symptoms, such as pain, fatigue and stiffness (1)
  • Reduce disease activity (2)
  • Improve disease outcomes (3)

Moving Medicine is an initiative with the aim to improve physical activity conversations across healthcare as well as supporting physical activity delivery to patients (4). Specifically, in 2018, an “inflammatory rheumatic diseases” scoping review was produced. We updated this review in 2022 to include further findings with regards to the effects of physical activity on AxSpA as well as looking at motivators, facilitators and barriers for patients and healthcare professionals towards exercise programmes (5). Barriers towards exercise programmes for patients included lack of time, fatigue, pain and economic concern.

Axial Spondyloarthritis

AxSpA is a chronic inflammatory arthritis that mainly affects joints of the chest, spine and pelvis with the most common symptoms being back pain and joint stiffness (6). AxSpA can also affect other parts of the body such as the eyes, heart, skin and bowel (7). AxSpA can have a variety of negative effects on patients including pain and fatigue which can restrict activities of daily living and reduce quality of life (8). In our Moving Medicine scoping review, there was good quality evidence that physical activity has a number of benefits in patients with AxSpA. This included improvement in function and activities of daily living, reduced disease activity and fatigue (9-11). There was also some low-quality evidence that physical activity can improve sleep, mood, pain and stiffness (12,13). Importantly, no harm from physical activity was found in any of the identified research.

Physical activity and exercise

The information in the following two paragraphs summarised from a recent narrative review (5). 

AxSpA poses unique challenges in managing physical activity due to its impact on the axial skeleton. From our evidence, we believe that a pragmatic exercise program tailored to patients with AxSpA should prioritise flexibility, strength, and cardiovascular fitness while mitigating the risk of exacerbating symptoms. Patients should engage in a combination of low-impact aerobic exercises such as swimming, cycling, or brisk walking to improve cardiovascular health without imposing excessive strain on the spine and sacroiliac joints. Flexibility exercises, including yoga and pilates, can enhance range of motion and alleviate stiffness commonly associated with AxSpA. However, caution may need to be exercised to avoid hyperextension or high-impact movements that may strain the spine, exacerbate inflammation, and potentially worsen symptoms. Although the evidence in the literature has not found harms with this explicitly, a patient centred pragmatic approach ought to be taken if the patient desires to take part in such exercises. 

Alongside this, resistance training focusing on core stability and muscle strength is integral to the exercise regimen for axSpA patients. Targeting muscles around the spine and pelvis through exercises like planks, bridges, and modified squats can enhance spinal support and reduce the risk of injury. It is imperative to emphasise proper form and technique to prevent overloading vulnerable joints while gradually increasing resistance and intensity over time. By adhering to a tailored exercise program that balances cardiovascular fitness, flexibility, and strength training while avoiding provocative movements, patients with AxSpA can optimise their physical function and quality of life

Conclusion

Exercise programmes and physical activity have an important role in the management of patients with AxSpA. In order for patients with AxSpA to benefit fully from the positive effects of exercise, this requires a balance of motivation from the patient as well as support from healthcare professionals. Moving Medicine provides guidance for healthcare professionals with the aim of encouraging patients to become more physically active. In order to address particular barriers towards exercise programmes from patients, structured programmes formed between both the patient and healthcare professional have the potential to be beneficial in encouraging physical activity. These would be individualised to the patient and would enable progress to be monitored and the exercise programme adjusted accordingly. Further research is required to fully understand the extent to which physical activity can have a positive effect on disease symptoms, activity and outcomes. This could include looking at disease activity on laboratory tests as well as through radiology and imaging. 

Author information

Kaley Ainsworth
FY2 Foundation Doctor
South Tyneside and Sunderland NHS Foundation trust

Raj Amarnani
Sport and Exercise Medicine Specialist Registrar
Institute of Sport, Exercise and Health. University College London Hospitals NHS Foundation Trust.
@DrRajAmar

References:

  1. Sveaas SH;Bilberg A;Berg IJ;Provan SA;Rollefstad S;Semb AG;Hagen KB;Johansen MW;Pedersen E;Dagfinrud H; (no date) High intensity exercise for 3 months reduces disease activity in axial spondyloarthritis (axSpA): A multicentre randomised trial of 100 patients, British journal of sports medicine. Available at: https://pubmed.ncbi.nlm.nih.gov/30745314/ (Accessed: 30 June 2023). 
  2. Molto A, Gossec L, Poiraudeau S, Claudepierre P, Soubrier M, Fayet F, Wendling D, Gaudin P, Dernis E, Guis S, Pouplin S, Ruyssen-Witrand A, Chales G, Mariette X, Beauvais C, Combe B, Flipo RM, Richette P, Chary-Valckenaere I, Saraux A, Sibilia J, Schaeverbeke T, Dougados M. Evaluation of the impact of a nurse-led program of patient self-assessment and self-management in axial spondyloarthritis: results of a prospective, multicentre, randomized, controlled trial (COMEDSPA). Rheumatology (Oxford). 2021 Feb 1;60(2):888-895. doi: 10.1093/rheumatology/keaa480. PMID: 33063096.
  3. Perrotta, F.M., Lories, R. and Lubrano, E. (2021) To move or not to move: The paradoxical effect of physical exercise in axial spondyloarthritis, RMD Open. Available at: https://rmdopen.bmj.com/content/7/1/e001480 (Accessed: 30 June 2023). 
  4. Moving Medicine- About Us (2021) Moving Medicine. Available at: https://movingmedicine.ac.uk/about-us-2/about-us/ (Accessed: 30 June 2023).
  5. Mundell, A., Amarnani, R., Ainsworth, K. et al. The Effects of Exercise and Physical Activity in Inflammatory Rheumatic Diseases – a Narrative Review. J. of SCI. IN SPORT AND EXERCISE(2024). https://doi.org/10.1007/s42978-024-00303-x
  6. What is axial spa? (2023) National Axial Spondyloarthritis Society. Available at: https://nass.co.uk/about-as/what-is-as/ (Accessed: 30 June 2023). 
  7. Sieper J, Poddubnyy D. Axial spondyloarthritis. Lancet (London, England) [Internet]. 2017;390(10089):73–84. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28110981
  8. Axial spondyloarthritis and quality of life (2021a) AJMC. Available at: https://www.ajmc.com/view/axial-spondyloarthritis-and-quality-of-life (Accessed: 11 July 2023). 
  9. Sveaas SH, Bilberg A, Berg IJ, Provan SA, Rollefstad S, Semb AG, et al. High intensity exercise for 3 months reduces disease activity in axial spondyloarthritis (axSpA): a multicentre randomised trial of 100 patients. Br J Sports Med [Internet]. 2020 Mar;54(5):292–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/30745314
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  11. Basakci Calik B, Gur Kabul E, Taskın H, Telli Atalay O, Bas Aslan U, Tascı M, et al. The efficiency of inspiratory muscle training in patients with ankylosing spondylitis. Rheumatol Int [Internet]. 2018 Sep;38(9):1713–20. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29943207
  12. Regnaux J-P, Davergne T, Palazzo C, Roren A, Rannou F, Boutron I, et al. Exercise programmes for ankylosing spondylitis. Cochrane database Syst Rev [Internet]. 2019 Oct 2;10:CD011321. Available from: http://www.ncbi.nlm.nih.gov/pubmed/31578051
  13. Hu X, Chen J, Tang W, Chen W, Sang Y, Jia L. Effects of exercise programmes on pain, disease activity and function in ankylosing spondylitis: A meta‐analysis of randomized controlled trials. Eur J Clin Invest [Internet]. 2020 Dec 11;50(12). Available from: https://onlinelibrary.wiley.com/doi/10.1111/eci.13352

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