Long-term exercise program improves physical function in axial SpA beyond ‘usual care’
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Key takeaways:
- Long-term, supervised exercise improved functional disability and physical quality of life in axial SpA with severe functional limitations.
- Such programs “should be considered” in this population, the researchers wrote.
A long-term, supervised exercise program for patients with axial spondyloarthritis and severe functional limitations improved functional disability and physical quality of life vs. usual care, according to data published in Rheumatology.
“Due to an unfavorable course of the disease, people with [axial SpA (axSpA)] and severe functional limitations may gain substantial benefits from exercise therapy, provided that it is tailored to the complexity of their individual impairments and functional limitations,” Maria A.T. van Wissen, of the department of orthopedics, rehabilitation and physical therapy at Leiden University Medical Center, in the Netherlands, and colleagues wrote. “Recent guidelines on the management of axSpA underscore the importance of tailored approaches to personalized care.
“Earlier research has shown that a tailored exercise intervention for people with rheumatoid arthritis and severe functional limitations, for elderly people with mobility problems and people with knee osteoarthritis and multimorbidity were feasible and effective with respect to physical functioning and pain,” they added. “However, the efficacy of such a comprehensive, personalized approach in people with axSpA and severe functional limitations remains to be established.”
To assess the impacts of long-term, personalized and supervised exercise in axial SpA, van Wissen and colleagues conducted a randomized, assessor-blinded, parallel-group study. The researchers recruited 214 adults (mean age, 52 years) diagnosed with axial SpA and “self-perceived limitations in basic daily activities,” and randomly assigned them in a 1:1 ratio to participate in the exercise program (n = 110) or receive usual care (n = 104).
The intervention group began the program with an assessment and collaborative goal-setting, then involved aerobics, muscle strengthening and functional, neuromotor and flexibility exercises, which physical therapists tailored for each patient. Meanwhile, the group assigned to usual care “received care determined by their clinician(s) and themselves, including regular physical therapy through physician or self-referral, without specific encouragement or discouragement,” the researchers wrote.
The researchers assessed participants using the Patient-Specific Complaints (PSC) Numeric Rating Scale, where each patient’s “three most limited activities” were ranked in difficulty from zero to 10. The primary endpoint was the change in difficulty for each participant’s most limited activity at 52 weeks.
According to the researchers, 93% of the intervention group started the program and participated in an average of 40.5 sessions. The 52-week change in the top ranked PSC item was greater in the intervention group compared with usual care (mean difference, –1.8; 95% CI, –2.4 to –1.2).
The intervention group also demonstrated “significantly greater improvements” across secondary outcomes, such as the second- and third-ranked PSC items, PROMIS Physical Function score, and the Short Form-36 physical component — but not the mental component, the researchers wrote.
“To our knowledge this is the first study on the effectiveness of a supervised exercise program for people with axSpA and severe functional limitations,” van Wissen and colleagues wrote. “We demonstrated that long-term, personalized, supervised exercise therapy was more effective with respect to functional ability and quality of life than usual care over 52weeks of treatment. Further research is needed to explore the long-term outcomes, and assess its cost-effectiveness and applicability of this approach in the management of other rheumatic diseases with potential complex consequences.”
Perspective
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David A. McLain, MD, MACR, FACP, FRCP
We have long recognized the benefits of exercise in axial spondyloarthritis, including enhancing balance, flexibility, strength, posture and bone density. It has also been touted to improve cardiovascular health and breathing capacity, lower blood pressure and reduce weight. The present study shows the benefit of exercise in long-term axial SpA with functional disabilities.
However, a previous French review of 14 randomized controlled trials, with more than 1,500 participants, regarding the benefits of exercise in ankylosing spondylitis contradicts these findings. Their review showed no clinically meaningful improvement with exercise for physical function, pain, patient global assessment (PGA) as measured by BASDAI, or fatigue from baseline. Spinal mobility did improve with exercise, but there was no clinically meaningful benefit associated with this improvement.
When compared to usual care — as the present study design does also — the researchers of the previous review found statistically significant improvements with exercise in physical function, pain, and PGA by BASDAI, but felt that these small improvements (–4%, –5% and –7%, respectively) were of no clinically meaningful benefit. Spinal mobility similarly showed no clinically significant benefit with exercise.
Depending on the cost of long-term, personalized exercise therapy for 52 weeks, a cost-benefit analysis will probably not show that this is cost effective based on their large review.
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