Exercise Therapy Can Reduce Symptoms, Disease Activity in Axial Spondyloarthritis

Exercise therapy can be effective in mitigating symptoms and improving disease control in patients with axial spondyloarthritis (axSpA), according to a systematic review, meta-analysis, and meta-regression published in Archives of Physical Medicine and Rehabilitation.¹

“Studies have shown that exercise therapy has a favorable therapeutic effect on arthritis and improves health-related quality of life in patients with axSpA,” the authors wrote. “Compared to the higher potential side effects and less selectivity of pharmacological therapies, exercise therapy may be a more appropriate treatment strategy for patients with axSpA.”

The new study analyzed high-quality randomized controlled trials to explore whether exercise therapy is effective for patients with axial spondyloarthritis. | Image credit: Justlight - stock.adobe.com

Exercise therapy, including activities such as aerobic exercise, strength training, flexibility, and balance exercises, is often recommended for patients with a range of chronic conditions.² For those with arthritis, exercise may help reduce joint pain and can facilitate muscle growth around joints, which may reduce stiffness.

Axial spondyloarthritis, a type of inflammatory arthritis that causes back pain, stiffness, swelling, and joint tenderness, has no cure but can be managed with medications and other strategies to minimize the symptom burden for patients.¹ The range of medications available for axSpA has expanded in recent years, although traditional nonsteroidal anti-inflammatory drugs are the recommended first-line medication for most patients.

“Despite the multiple advantages of exercise therapy, there is still some controversy about its effectiveness and safety for axSpA,” the authors wrote. “Some studies have concluded that exercise does not intentionally affect a patient's disease activity, physical function, and biological parameters. In contrast, others have concluded that exercise therapy improves patients' conditions.”

Previous analyses have included small numbers of studies, with some studies showing highly heterogenous results, the authors noted. The new study analyzed high-quality randomized controlled trials (RCTs) to explore whether exercise therapy is effective for patients with axSpA, as well as the impacts of variables such as exercise duration, frequency, and total cycle time on exercise efficacy in this patient population.

The investigators searched PubMed (via Medline), the Cochrane Library, Embase, Web of Science, Scopus, and SPORTDiscus from database inceptions through March 2024 and included 20 RCTs in the comprehensive meta-analysis. The trials included 1670 participants, 852 of whom received exercise intervention and 818 who comprised a control group. Exercise interventions ranged from 6 to 24 weeks and from 2 to 7 interventions each week.

Main outcomes of interest were ankylosing spondylitis (AS) disease activity scores (ASDAS), Bath AS metrology index (BASMI) scores, Bath AS disease activity index (BASDAI) scores, Bath AS functional index (BASFI) scores, 6-minute walking test (6MWT) distance, chest expansion capacity, peak oxygen consumption, pain, fatigue, C-reactive protein (CRP) measurements, and erythrocyte sedimentation rate (ESR).

Of the included studies, 6 were considered at a low risk of bias, 7 were considered to have some concerns, and 5 were considered to be at a high risk of bias. However, most of the studies had a low risk of bias in terms of selecting the reported result and in missing outcome data. Overall, 3 studies were considered to have some concerns about randomization, and this was mainly due to not describing the process of random hiding and allocation in detail.

In the exercise group, patients showed significantly improved BASFI, BASMI, BASDAI, and ASDAS scores, with weighted mean differences of –0.49, –0.49, –0.78, and –0.44, respectively. There were also significant improvements in the 6MWT and peak oxygen consumption, with weighted mean differences of 27.64 and 3.16, in the exercise group. Pain and fatigue were also significantly lower in the exercise group, with standard mean differences of –0.47 and –0.49, respectively. Chest expansion, CRP, and ESR outcomes were not significantly different between the exercise and control groups.

The analysis also found that female patients may be more likely to benefit from exercise therapy, and limiting exercise sessions to 60 minutes when possible is recommended, the authors noted.

The study was limited by a small number of RCTs meeting inclusion criteria, which limited the power of the analyses conducted. Some studies also had quality concerns, and some outcomes had high heterogeneity. Still, the authors noted that the positive impact of exercise therapy in the study was significant.

“Our findings support previous recommendations from [the European Alliance of Associations for Rheumatology] and the American College of Rheumatology, which emphasize the interest of exercise in reducing functional disability in AS,” the authors wrote. “Nowadays, exercise therapy is widely used in many disease areas, such as diabetes, stroke, dementia, cancer, and more. Now we are confident in extending the application of exercise therapy to axSpA.”

References

1. Zhang M, Liang Z, Tian L, Han Y, Su Z, Liu T. Effects of exercise therapy in axial spondyloarthritis: a systematic review, meta-analysis and meta-regression of randomized trials. Arch Phys Med Rehabil. Published online June 26, 2024. doi:10.1016/j.apmr.2024.06.005

2. Exercise and chronic disease: get the facts. Mayo Clinic. January 14, 2023. Accessed July 8, 2024. https://www.mayoclinic.org/healthy-lifestyle/fitness/in-depth/exercise-and-chronic-disease/art-20046049