The effectiveness of intensive group exercise on patients with ankylosing spondylitis

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1 Clinical Rehabilitation 2003; 17: The effectiveness of intensive group exercise on patients with ankylosing spondylitis Yildiz Analay Istanbul University, Cerrahpasa Faculty of Medicine, Department of Orthopedics, Emel Ozcan, Ayse Karan, Demirhan Diracoglu and Resa Aydin Istanbul University, Istanbul Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Istanbul, Turkey Received 11th October 2002; returned for revisions 23rd December 2002; revised manuscript accepted 24th March Objective: To compare, in patients with ankylosing spondylitis (AS), the effectiveness on pain, functional and psychological status of an intensive group exercise programme under the supervision of a physiotherapist and a home physiotherapy programme. Design: Fifty-one patients with AS were randomly allocated into study and control groups. The study was designed as a prospective, double-blind study. Setting: Outpatient department, Istanbul Medical Faculty. Subjects: Patients who consulted with complaints of pain, morning stiffness and restricted range of movement with a con rmed diagnosis of ankylosing spondylitis. Interventions: Before exercise, both groups were given an education programme about AS. For group I patients an intensive exercise programme was organized under the supervision of a physiotherapist for six weeks. Group II patients had to practise exercises individually at home. Main outcome measures: Both groups were evaluated and compared for pain, functional and psychological status before treatment, at the end of treatment and three months after treatment using a visual analogue scale (VAS) for pain, Beck Depression Scale and Bath Ankylosing Spondylitis Functional Index (BASFI). Results: Six patients withdrew, four from group I. Results from the remaining 45 showed more positive changes in the patients undertaking group exercise at six weeks and three months after treatment. Values showed a statistical signi cant difference in favour of group I. Conclusion: Group exercise in hospital may be more effective than home-based exercises at reducing impairment associated with ankylosing spondylitis. Address for correspondence: Ayse Karan, Istanbul University, Istanbul Faculty of Medicine, Physical Medicine and Rehabilitation, 34390, Capa, Istanbul, Turkey. makifkaran@ihlas.net.tr Arnold / cr658oa

2 632 Y Analay et al. Introduction Ankylosing spondylitis (AS) is a chronic and systemic disease that is characterized by in ammation and pain in many joints, primarily in the spine, and may result in disability. Its aetiology is still not known. 1 4 The purpose of the therapy is to reduce pain and morning stiffness, to prevent deformity and to maintain correct posture, physical condition and psychosocial health. Exercises are considered as basic therapy to increase the functional capacity and to prevent the development of deformity. They are also bene cial in augmenting coordination, joint motion, exibility, muscular strength and endurance and cardiovascular capacity. 5 Training and intensive exercise programmes for the rehabilitation of patients with ankylosing spondylitis are not currently used in Turkey. Therefore, this study was performed to determine and compare the effectiveness of group and individualized physical therapies in patients with early ankylosing spondylitis. Methods The study involved 51 ankylosing spondylitis patients according to Amor criteria 1 aged years and able to participate in exercise groups. We did not include those with systemic organic involvement, severe deformities or limited hip and knee joints motion preventing regular cycling. Those treated by physiotherapy in the last three months or practising regular exercise or sport and those receiving disease-modifying drugs were also excluded. In the study the physician making the diagnosis of AS and the physician making the pre- and post exercise assessments of the patient were different people and a different physiotherapist gave the exercises. The assessing doctor was blind to the patient s group allocation. The therapist was blind the patients clinical evaluations. The 51 patients were randomly allocated by sealed envelopes on a 1:1 basis to one of two groups. Six patients withdrew from the study due to dif culties in transportation and getting permission from work, so that the study was completed with 45 patients (Figure 1). Group I patients were included in a physical therapy programme supervised by a physiotherapist and patients of group II were given a home physiotherapy programme. All patients had a 1-hour training programme at entry, giving information about spondylarthropathies and the purpose of physical exercises. 4,6 The intensive exercise programme was delivered to 4 5 subjects for six weeks (three days a week and 50 minutes a day) under the supervision of a physiotherapist. The exercise programme included stretching, mobilization and strengthening exercises for lower, upper extremities and back muscles, aerobic exercises on a static bicycle, postural and respiratory exercises. After maintaining an appropriate posture by rst stretching the hip exor muscles and pectoral muscles, primarily the hip and back extensor muscles and both of the two upper and two lower extremity muscles were strengthened. Exercises were performed without resistance then, according to individual tolerance, according to the De Lateur method. 7 A static bicycle was used for the aerobic exercises. The patients pedalled the bicycle three days a week for a shorter period initially (15 minutes) and later this period was increased to 30 minutes. At the beginning and end, the patients cycled without any resistance; the purpose was to achieve good adaptation to exercise and to minimize postexercise tiredness. 8,9 The patients were told to stop the exercises in case of tiredness and/or pain. All of the patients were taught the exercises proposed to group I but control group II patients were asked to practise these exercises at home individually for six weeks (three days a week), and were called by phone every week. The patients from both groups were clinically evaluated before treatment, after treatment and three months after treatment by the same physician. Pain at rest and during activity were evaluated with a visual analogue scale (VAS) 10 and duration of morning stiffness by questionnaire. 11 The following measurements were done; chest expansion 12 ; tragus-to-wall distance 13 ; modi ed lumbar Schober 11 and ngertip-to- oor distance 12 ; and intermalleolar distance. 14. General physical condition level was evaluated with the Astrand test,

3 Intensive group exercise in ankylosing spondylitis 633 Recruited 51 patients with ankylosing spondylitis Group therapy as hospital outpatients (n =27) Randomized Given exercise programme to undertake at home (n =24) Losses: 4 3 Unable to get permission to miss work 1 transport problems Losses: 2 2 Transport problems Outcome data 23 patients Outcome data 22 patients Figure 1 Flow diagram for the study. which is an indirect method. 15 The Beck Depression Scale was used for depression measurement. 16 The Bath Ankylosing Spondylitis Functional Index (BASFI) was used for functional status. 2,6,17 19 Results The average (SD) age of the group I was 37.6 ± 11.3 while that of the control group was 34.3 ± 7.9 (years). Of the people in the group I, 3 were female and 20 male. Of the people in the group II, 4 were female and 18 male. The average weights of group I and group II were 69.8 ± 9.6 and 71.1 ± 10.4 kg respectively. The average heights of the group members were ± 5.8 and ± 7.0 cm respectively. There was no statistically signi cant difference between the groups. In both groups, before treatment, after treatment and three months after treatment mean rest and during activity pain VAS, duration of morning stiffness (minutes), chest expansion (cm), tragus-to-wall distance (cm), modi ed lumbar Schober and ngertip-to- oor distance (cm), intermalleolar distance (cm), mean VO 2max values (ml/min/kg) obtained by Astrand test were measured. There was no statistically signi cant difference

4 634 Y Analay et al. before treatment in all parameters except modi- ed lumbar Schober evaluated between groups (p >0.05) (Table 1). In group I, statistical signi cant improvements were observed in all parameters except pain and these results were still present at three months after treatment (p > 0.05). In group II, no statistically signi cant difference in aftertreatment and three months after-treatment values compared with before-treatment values were observed. The decrease in Astrand test was not statistically signi cant (p > 0.05). Before treatment Beck and BASFI scores showed no statistically signi cant difference between both groups (p > 0.05) (Table 1). In group I, while there was a statistical signi cant difference toward well-being in after-treatment Beck and BASFI scores (p < 0.05), the well-being in Beck scores disappeared during three months after treatment (p > 0.05). Group II showed no statistically signi cant difference towards wellbeing for these parameters (p > 0.05). Relating to BASFI and Beck scores, the comparison of aftertreatment and three months after-treatment values between both groups showed a statistically signi cant difference in favour of group I (p < 0.05) (Table 1). In both groups, the comparison of after-treatment and three months after-treatment values showed a statistically signi cant difference in all parameters except pain (p < 0.05) (Table 1). Pain was not in uenced by therapy programmes but most of the functional, physical tness and psychological measurements improved. Discussion Many studies showed the effectiveness of exercises on AS treatment. The exercises are effective particularly on joint exibility and functional capacity. 4,20,21 Although the effectiveness of individualized exercise is proven we aimed at investigating the effect of group exercise on clinical parameters. There are some important limitations affecting this study. First, the drop-out rate primarily affected the exercise group. Second, only a selected group of patients entered the study. The majority of the patients were young, male patients, and the great majority were employed. Third, it was very dif cult to motivate the patients for regular exercise. We attribute the lack of further withdrawals from exercise to the convincing explanation of the importance of exercise in the initial training programme and to the good communication established between the patient and the physiotherapist during exercise. In this study, the pain levels in patients remain constant in both groups; exercise does not improve or worsen the pain level. In a similar study by Kraag et al., the pain didn t show any decrease 4 but ngertip-to- oor distance decreased and functional capacity increased in the patients allocated to the training and physiotherapy groups. Jenkinson et al. used tragus-to-wall distance, chest expansion and intermalleolar distance for mobility evaluation in patients with AS. 23 In our study, chest expansion increased and tragus wall distance decreased. Russell et al. practised an intensive physiotherapy with patients with AS for three weeks and reported that chest expansions of patients increased, while ngertip-to- oor and tragus wall distances decreased. 22 Kraag et al. compared the effectiveness of a group exercise programme lasting for four months and home therapy. They stated that there was a signi cant decrease in ngertip-to- oor distance in the study group, but no signi cant difference in pains, occiput-to-wall distances and morning stiffness duration between the groups. 24 Hidding et al. compared the effectiveness of group and individualized therapies and reported that group therapy had more positive impacts on global health and functions, but did not cause a signi cant difference in spinal mobility. 25 Clinical messages Group exercise improves function in patients with ankylosing spondylitis more than undertaking exercises alone at home. Many people nd it dif cult to succeed with group exercises because of social factors. The long-term effectiveness of group exercise programmes must be evaluated in prospective controlled studies.

5 Intensive group exercise in ankylosing spondylitis 635 Table 1 Mean (SD) scores in two groups at three times: before, at six weeks and at 12 weeks Group I Group II Before After 3 months Before After 3 months (n = 27) (n = 23) (n = 23) (n = 24) (n = 22) (n = 22) R pain VAS 3.82 ± ± ± ± ± ± 3.1 A pain VAS 4.47 ± ± ± ± ± ± 3.2 MS (min) ± ± ± ± ± ± CE (cm) 3.97 ± ± ± ± ± ± 2.39 TWD (cm) ± ± ± ± ± ± 3.87 MLS (cm) 4.38 ± ± ± ± ± ± 3.16 FFD (cm) ± ± ± ± ± ± IMD (cm) ± ± ± ± ± ± VO 2max ± ± ± ± ± ± (ml/min/kg) Beck score 5.52 ± ± ± ± ± ± 6.41 BASFI score ± ± ± ± ± ± Group I group therapy in hospital; Group II home exercises. BT, before treatment; AT, after treatment; R, rest; A, activity; VAS, visual analogue scale; MS, duration of morning stiffness; CE, chest expansion; TWD, tragus-to-wall distance; MLS, modi ed lumbar Schober; FFD, ngertip-to- oor distance; IMD, intermalleolar distance. Aerobic exercises raise VO 2max, an indicator of global body condition. 26 Bakker et al. compared the group physiotherapy supervised by a physiotherapist with home therapy. Group I also cycled an aerobic exercise, and was observed to have signi cantly increased aerobic capacity. 27 Similarly, the aerobic capacity of our patients evaluated indirectly with Astrand test increased in intensive exercise group, and did not change in the other group and, on the contrary, it tended to decrease. Carter et al. assessed that peripheric muscular strength was the most important factor in the aerobic capacity stability. 28 Barlow and Barefoot determined that patients gave up home therapies in the long term. Since regular exercises are important for muscular strength stability, irregular home exercises might have caused the decrease of aerobic capacity. 29 Santos et al. emphasized that regular exercises were important to obtain positive results in AS. 9 Calin et al. observed an obvious increase in the functional capacity evaluated with BASFI after an intensive physiotherapy for three weeks in patients with AS. 17 Band et al. reported a 25% decrease in BASFI scores after an intensive physiotherapy for two weeks. 2 Similarly, in our patients, BASFI scores signi cantly decreased in group I and did not change in group II. Our study is consistent with the above-mentioned studies relating to BASFI scores. The psychosocial status evaluated with Beck Depression Scale was seen to be affected by intensive therapy although mean scores were not much higher in our patients. Close relation with the patient and group therapy positively affect the psychosocial status, and this positive impact disappears when the group therapy is left. Barlow et al. stated that group therapy positively affected patients with respect to psychosocial factors. 30 The positive effects of group exercise may arise from the exercise itself, especially as it might encourage performance of recommended exercises, but it might also arise from the more general effects of meeting with other patients with similar problems. References 1 Amor B, Dougados M, Mijiyama M. Criteria of the classi cation of spondyloarthropathies. Rev Rheum Mal Osteoartic 1990; 57: Band DA, Jones SD, Kennedy LG et al. Which patients with ankylosing spondylitis derive most bene t from an inpatient management programme? J Rheumatol 1997; 24:

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