Exercise Adherence in patients with Ankylosing Spondylitis

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Introduction

Exercise adherence has been a significant problem for the clinician to tackle for many years. Various psychosocial factors and exercise behaviour theories are believed to be the reasons behind poor exercise adherence. This is particularly important for patients with Ankylosing Spondylitis (AS). The reason for that is because there is no known cure for AS at the moment [1]. The treatment for AS mainly consists of drug therapy (usually nonsteroidal anti-inflammatory drugs), and regular performance of an exercise regimen designed by physiotherapists to improve or maintain mobility and posture [2]. Exercise therapy has been consistently supported by current evidence to be a beneficial ameliorative, instead of curative, treatment for patients with AS and it is recommended by the NICE guideline as a vital component in the management of patients with AS [3]. As a result, exercise treatment has to be maintained for the remainder of the patient's life and long term exercise adherence is crucial.

Quality of life in patients with AS

Exercise and quality of life are closely linked together. Studies have shown that exercise therapy is able to improve the quality of life in patients with long term illness [4]. Moreover, another study has shown that monitoring adherence and tailored exercise regimen to induce changes in cardiovascular fitness and body composition can improve the quality of life and self-efficacy [5]. Therefore, exercise adherence and quality of life in patients with AS are closely linked and should be explored.

A recent US-based survey (AS Life Impact survey) on the quality of life in patients with AS was published in 2019 [6].

  • The overall mean score for the Evaluation of Ankylosing Spondylitis Quality of Life (EASi-QoL) questionnaire is 28.9 (medium impact).
  • Female patients are more likely to report a high impact of AS than male in all the domains (physical, emotional, social and discomfort domains) of the questionnaire. (p< 0.05)
    • Various aspects of daily living being affected include:
      • Lifting a child or heavy object (P<0.0001)
      • Standing for 30 mins (P=0.0128)
      • Feeling tired or lacking in energy (P=0.0004)
      • Interference with sleep (P=0.0081)
      • Worried about the future (P<0.0001)
      • Lacked drive or motivation (P=0.0364)
      • The ability to concentrate (P=0.0057)
      • Prevented them from being physically active (P=0.0092)
      • Travel by car or public transport (P=0.0019)
      • Interference with work (P=0.0268)
  • The authors concluded there is a need to identify and ameliorate the impaired QoL aspects to improve outcomes of AS, especially in the female patient population.

Ankylosing Spondylitis can have a considerable impact on the patient's quality of life. Exercise therapy is shown to be a beneficial treatment and the adherence to a tailored exercise program can potentially improve the patient's qualify of life. Hence, the barriers and facilitators to exercise adherence will be explored.

Exercise Adherence in patients with AS

Measurement of Adherence

According to the systematic review done by McDonald et al. in 2019[7], the level of adherence to prescribed exercise in patients with Spondyloarthritis was focused. The following ways of measuring adherence was reported in 9 studies:

  • Six studies measured adherence with patient-reported home exercise diaries. Four of these studies also reported the minutes of exercise per week.
  • One study asked participants to tick a box to record that the prescribed exercises had been completed and one study provided no details.
  • In the remaining two studies, participants were asked to retrospectively record their adherence at different time periods in a questionnaire, including whether they had completed their exercises the previous day, the frequency and volume of exercises in 1 week, and how often the exercises had been completed over the past year.

Supervised exercise session

  • Supervised exercise therapy is suggested to have clinically relevant benefits compared with non‐supervised regimens by the previous study.[8]
  • It is not possible to quantify whether benefits from supervised exercise are due to the change in setting or environment, or the consequential support for motivation. However, Nierdemann et al.[9] reported 75% of sessions completed to three times per week supervised over 12 weeks which indicates a high exercise class adherence.
  • Supervised exercise therapy has a moderate level of evidence of increasing physical activity level (PAL), which indicates to increase in exercise adherence.[10]
  • Patients with AS under supervised exercise therapy also spend significantly longer on their home exercise program compared to those who do not undertake supervised exercise therapy (mean duration 1.9 versus 1.2 h per week p < 0.05).[7]

Home Exercise Program (HEP)

  • HEP is efficient in improving the functional capacity, mobility, pain and reduction in fatigue. Because of these advantages, HEP is generally advised for the management program in AS in addition to medical treatments.[11]
  • HEP is reported to have high exercise adherence. There are two studies that measured adherence to AS patients with HEP only.
    • Fernandez-de-las-Penas et al.[12] reported 95% adherence to a once-weekly HEP for 1 year.
    • Chimenti et al.[13] reported an overall 76% adherence to prescribed exercises during a 12 week, twice-weekly HEP.
  • There is a strong level of evidence that show HEP with proper self-monitoring measures such as keeping an activity diary, tracking activity in a calendar, or recording activity on a website etc, can enhance the PAL of AS patients.[10]

HEP following an educational program

  • The study found that exercise after receiving a patient education program can lead to an increase in exercise adherence (number of patients completing exercises and frequency) of HEP. However, the number and frequency of exercises significantly decreased in a rather short period (at 6 months).[7]
  • However, educational support patients have been shown to have an increase in adherence to drug therapy.[14]

Barriers to adherence

  • Pain- Pain levels during exercise in musculoskeletal patients presented strong evidence as a barrier to adherence in a systematic review. [15]
  • Stiffness
  • Fatigue- Fatigue was perceived as an important barrier for being physically active for patients with AS. [16]
  • Disability - Studies suggest that an association between reduced physical function and decreased participation in physical activity. [17]
  • Quality of sleep - It has a negative effect on all aspects of a patient’s life: physically, psychologically, and socially. [18]
  • Perceived barriers - eg Exercising costs too much, time is taken off from family responsibilities, places to exercises are too far away.
  • Poor therapeutic relationship - the nature of the disease itself, being unpredictable, incurable and difficult to diagnose, may influence the experience of people with AS in their contact with healthcare providers, who can offer little in the way of treatment [2].
  • Low self-efficacy - patients with AS learn to accept the reality and may lower their expectation of personal control over health because AS is unpredictable and incurable [2].

Facilitators to adherence

  • Appropriate medication -  A qualitative study showed that, in addition to reduced symptoms, the use of TNF inhibitors also improved patients’ motivation and ability to exercise. [19]
  • Adapted physical activity - Evident showed that adapted physical activity was feasible and meaningful for patients with complex rheumatic disease. [20]
  • Disease stability - This is an important facilitator, underlining the importance of adequate symptom and disease control.
  • Time
  • Motivation

Recommendations to improve adherence

A recent study has combined literature reviews with theories on exercise behaviour and the perspective of important stakeholders of two ecological levels (individual patients and therapists) to identify the effective intervention components required to optimise (determinants of) exercise behaviour of people with axSpA. It was found that, by incorporating these components in an intervention, the likelihood and magnitude of sustainable change in exercise behaviour of people with AS shall increase.[21]

The three components should be included in an intervention:

  1. Behaviour change guidance, including individualised education, motivational interviewing, goal setting, action planning, monitoring and feedback.
  2. Training for therapists on how to tailor and practice an exercise program and provide behaviour change guidance.
  3. Encouragement to exercise in a group.

Group therapy

According to a study that investigated the psychosocial factors of AS patients in 1992 [2], the authors found out that:

  • Group exercise and education session can increase satisfaction due to receiving support from fellow group members
  • Exercise group can exert both social facilitative and social persuasion effect on their members in terms of adherence to exercise programs.
  • Group encourage the dissemination of information and also act as a forum for the exchange of information between group mates and medical professionals.

Clinical bottom line

  • Limited evidence on the level of adherence in SpA patients
  • Findings suggested that patients do not fully adhere to the exercise program or attend a supervised exercise session.
  • Psychosocial factors, such as fatigue and quality of sleep, have been shown to be the major barriers to adherence, while appropriate medication and a tailored exercise program can improve exercise adherence.
  • Physiotherapists should look out for these psychosocial factors (yellow flags) during the assessment while utilising these facilitators to promote exercise adherence.
  • Physiotherapists should incorporate the three recommended components into a group exercise program which can encourage and motivate patients to remain physically active.
  • Patient's quality of life can be improved by having better adherence to an exercise program.
  1. NHS UK, 2019. Ankylosing spondylitis - Treatment [WWW Document]. nhs.uk. URL https://www.nhs.uk/conditions/ankylosing-spondylitis/treatment/ (accessed 5.24.20).
  2. 2.0 2.1 2.2 2.3 Barlow, J.H., Macey, S.J., Struthers, G., 1992. Psychosocial factors and self-help in ankylosing spondylitis patients. Clin Rheumatol 11, 220–225. https://doi.org/10.1007/BF02207961
  3. Millner, J.R., Barron, J.S., Beinke, K.M., Butterworth, R.H., Chasle, B.E., Dutton, L.J., Lewington, M.A., Lim, E.GS., Morley, T.B., O’Reilly, J.E., Pickering, K.A., Winzenberg, T., Zochling, J., 2016. Exercise for ankylosing spondylitis: An evidence-based consensus statement. Seminars in Arthritis and Rheumatism 45, 411–427. https://doi.org/10.1016/j.semarthrit.2015.08.003
  4. Hacker, E., 2009. Exercise and Quality of Life: Strengthening the Connections. Clin J Oncol Nurs 13, 31–39. https://doi.org/10.1188/09.CJON.31-39
  5. Imayama, I., Alfano, C.M., Mason, C.E., Wang, C., Xiao, L., Duggan, C., Campbell, K.L., Foster-Schubert, K.E., McTiernan, A., 2013. Exercise adherence, cardiopulmonary fitness and anthropometric changes improve exercise self-efficacy and health-related quality of life. J Phys Act Health 10, 676–689.
  6. Rosenbaum, J.T., Pisenti, L., Park, Y., Howard, R.A., 2019. Insight into the Quality of Life of Patients with Ankylosing Spondylitis: Real-World Data from a US-Based Life Impact Survey. Rheumatol Ther 6, 353–367. https://doi.org/10.1007/s40744-019-0160-8
  7. 7.0 7.1 7.2 McDonald, M., Siebert, S., Coulter, E., McDonald, D. and Paul, L., 2019. Level of adherence to prescribed exercise in spondyloarthritis and factors affecting this adherence: a systematic review. Rheumatology International, 39(2), pp.187-201.
  8. Fokkenrood, H., Bendermacher, B., Lauret, G., Willigendael, E., Prins, M. and Teijink, J., 2013. Supervised exercise therapy versus non-supervised exercise therapy for intermittent claudication. Cochrane Database of Systematic Reviews,.
  9. Niedermann K, Sidelnikov E, Muggli C, et al. 2013. Effect of cardiovascular training on fitness and perceived disease activity in people with ankylosing spondylitis. Arthritis Care Res (Hoboken);65:1844–1852. doi: 10.1002/acr.22062.
  10. 10.0 10.1 Millner, J., Barron, J., Beinke, K., Butterworth, R., Chasle, B., Dutton, L., Lewington, M., Lim, E., Morley, T., O’Reilly, J., Pickering, K., Winzenberg, T. and Zochling, J., 2016. Exercise for ankylosing spondylitis: An evidence-based consensus statement. Seminars in Arthritis and Rheumatism, 45(4), pp.411-427.
  11. Durmus, D., Alayli, G., Cil, E. and Canturk, F., 2008. Effects of a home-based exercise program on quality of life, fatigue, and depression in patients with ankylosing spondylitis. Rheumatology International, 29(6), pp.673-677.
  12. Fernandez-de-Las-Penas C, Alonso-Blanco C, Alguacil-Diego IM, Miangolarra-Page JC, 2006. One-year follow-up of two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil.;85:559–567. doi: 10.1097/01.phm.0000223358.25983.df.
  13. Chimenti MS, Triggianese P, Conigliaro P, Santoro M, Lucchetti R, Perricone R, 2014. Self-reported adherence to a home-based exercise program among patients affected by psoriatic arthritis with minimal disease activity. Drug Dev Res. 75:S57S59.
  14. Shillington, A., Ganjuli, A. and Clewell, J., 2016. The impact of patient support programs on adherence, clinical, humanistic, and economic patient outcomes: a targeted systematic review. Patient Preference and Adherence, p.711.
  15. Argent, R., Daly, A. and Caulfield, B., 2018. Patient Involvement With Home-Based Exercise Programs: Can Connected Health Interventions Influence Adherence?. JMIR mHealth and uHealth, 6(3), p.e47.
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  19. Stockdale J, Selfe J, Roddam H (2014). An exploration of the impact of anti-TNFα medication on exercise behaviour in patients with ankylosing spondylitis. Musculoskeletal Care 12: 150–9.
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  21. Hilberdink, B., van der Giesen, F., Vliet Vlieland, T., Nijkamp, M. and van Weely, S., 2020. How to optimize exercise behavior in axial spondyloarthritis? Results of an intervention mapping study. Patient Education and Counseling, 103(5), pp.952-959.