Ankylosing Spondylitis and Exercise

Ankylosing Spondylitis (AS) affects up to two percent of the Australian population, where the prevalence of this condition is more common in men than women (3:1). The onset of AS ranges from early 20s to 45 years of age and has a detrimental lifetime impact on the individual (Brown, 2009).  AS is a form of chronic systemic inflammatory disease that mainly affects the axial skeleton. Individuals that are diagnosed with AS report, pain,  stiffness and a significantly reduced mobility of affected joint(s) (Millner et al., 2016). These changes in axial mobility impair postural control, creates a kyphotic posture, increases the patients risk of falling, reduces pulmonary function, and increases their risk of CVD (Berdal, Halvorsen, van der Heijde, Mowe, & Dagfinrud, 2012; Millner et al., 2016; Vergara, O’Shea, Inman, & Gage, 2012).

The studies

Multiple studies (Gyurcsik, 2012; Millner et al., 2016; Vergara et al., 2012 Atlan ,2011) concluded that standing postural control is significantly altered in those diagnosed with AS and  trunk stability and core muscle recruitment is impaired.  Further research conducted by Mathieu, Gossec, Dougados, & Soubrier (2011) and Masiero et al., (2011) reported those with AS who engaged in 20-minutes of light aerobic exercise (walking, swimming and cycling) in conjunction with daily spinal mobility exercises have a reduced pain and improved function.   It is suggested that a supervised exercise program is undertaken  two-times per week for three-months, which consists of postural education, spinal mobility exercise and stretches can decrease pain intensity and spine stiffness for AS sufferers  (Gyurcsik et al., 2012).

Exercise Physiology and AS

Exercise has been proven (and well known) to play an important part in the management of AS in conjunction with appropriate anti-inflammatory medication.  Exercise physiology is essential in facilitating and empowering patients diagnosed with AS to provide education, improving mobility, fitness and functional posture. Additionally, playing a role in preventing the rapid onset and management of structural deformities.

The aim of a tailored exercise program is to help alleviate patient’s symptoms through improving spinal mobility, educating and teaching correct posture, improving postural stabilisation and breathing techniques, retrain poor muscular recruitment caused by changes in the disease state.  Consistency seems to be key with AS management, performing a few exercises every day will help alleviate pain.

Due to the progression of the disease, balance and core stability exercise should be undertaken 2-3 x p.wk-1 under supervision to manage pain, improve spinal stability and decrease risk of a fall.  Reported further by Millner et al., (2016) that exercise prescription that is delivered one-on-one is paramount in ensuring that appropriate exercise is prescribed for patients to manage their disease state.

The following table outline appropriate exercise routine for AS patient:

Exercise to assist with AS

(Important: These are suggested exercises to help manage symptoms of AS, and may not be suitable for everyone. For personalised exercises please contact your local PACE Exercise clinic.)

Exercise 1. Controlled breathing with spinal alignment.
This exercise assist with posture and rib movement to optimise breathing capacity. If lying flat on the floor is to uncomfortable place a pillow under the head.

Instructions: Lie on your back with knees bent in, neutral spine. Place hands on ribs and deeply breath, expanding ribs. Repeat 15 times.

Exercise 2. Seated posture

Sit up tall on a chair or swiss ball with chest wide, chin in and thumbs pointing away from your body. Hold for 60seconds as comfortable. Repeat through the day.

This is great to wake up the core and upper back muscles which support the spine

Exercise 3. 4 point core stability

This exercise improves core stability by engaging Transverse Abdominus and Multifidus muscle which support the vertebrae.

Instructions:  Assume 4 point position with hands underneath shoulders and knees under hips.  In neutral spine position lightly draw up pelvic floor muscles, and lightly belly button to spine.  Breathe for 20- 60 sec, perform daily.

Exercise 4. Spinal extensions

This exercise help position the spine in extension, reversing the natural progression of AS.

Instructions: Lie on your tummy and slowly raise up into your elbows. Breath and try to open up your chest and lengthen the upper back.  Hold and breath for 5 breaths, lower. Repeat 2-5 times.

Exercise 5. Lumbar flexion with thoracic mobilisation

This exercise helps mobilise the spine and thoracic area, which can become stiff with AS.

Instructions: Kneel, and place hands on a roller, raised object or chair. Slowly lower your bottom towards your heels. Breath relaxing into the stretch 3- 5 times. Relax and repeat 2-5 times.

Exercise 6. Total spine stretch

Lying on you back is onethe best way to realign your spine and reduce tension and assisting with kyphotic posture AS develops.

Instructions: Simply just lie on your back in a comfortable position and breath. Place a towel under your head if required to help support the head. Hold for 1-3 minutes. Repeat daily.

REFERENCES

Altan, L., Korkmaz, N., Dizdar, M., & Yurtkuran, M. (2011). Effect of Pilates training on people with ankylosing spondylitis. Rheumatology International, pp. 1–7. https://doi.org/10.1007/s00296-011-1932-9

Berdal, G., Halvorsen, S., van der Heijde, D., Mowe, M., & Dagfinrud, H. (2012). Restrictive pulmonary function is more prevalent in patients with ankylosing spondylitis than in matched population controls and is associated with impaired spinal mobility: a comparative study. Arthritis Res Ther, 14(1), R19. https://doi.org/10.1186/ar3699

Brown , M. (2009). How to Treat: Ankylosing Spondylitis and The Spondyloarthropathies. Australian Doctor 25-32. Retrieved from https://www.australiandoctor.com.au/cmspages/getfile.aspx?guid=ddf8099c-41a4-4467-af84-4cbb8b24aaf5

Gyurcsik, Z. N., András, A., Bodnár, N., Szekanecz, Z., & Szántó, S. (2012). Improvement in pain intensity, spine stiffness, and mobility during a controlled individualized physiotherapy program in ankylosing spondylitis. Rheumatology International, 32(12), 3931–3936. https://doi.org/10.1007/s00296-011-2325-9

Masiero, S., Bonaldo, L., Pigatto, M., Lo Nigro, A., Ramonda, R., & Punzi, L. (2011). Rehabilitation treatment in patients with ankylosing spondylitis stabilized with tumor necrosis factor inhibitor therapy: a randomized controlled trial. The Journal of Rheumatology, 38(7), 1335–1342. https://doi.org/10.3899/jrheum.100987

Mathieu, S., Gossec, L., Dougados, M., & Soubrier, M. (2011). Cardiovascular profile in ankylosing spondylitis: A systematic review and meta-analysis. Arthritis Care & Research, 63(4), 557–563. https://doi.org/10.1002/acr.20364

Millner, J. R., Barron, J. S., Beinke, K. M., Butterworth, R. H., Chasle, B. E., Dutton, L. J., … Zochling, J. (2016). Exercise for ankylosing spondylitis: An evidence-based consensus statement. Seminars in Arthritis and Rheumatism, 45(4), 411–427. https://doi.org/10.1016/j.semarthrit.2015.08.003

Vergara, M. E., O’Shea, F. D., Inman, R. D., & Gage, W. H. (2012). Postural control is altered in patients with ankylosing spondylitis. Clinical Biomechanics (Bristol, Avon), 27(4), 334–40. https://doi.org/10.1016/j.clinbiomech.2011.10.016