Role of Exercise in the Management of Axial Spondyloarthritis

Introduction

Axial spondyloarthritis (axSpA) is a long-lasting inflammatory rheumatic disease that mostly impacts the spine and sacroiliac joints. People with axial spondyloarthritis experience chronic back pain (often with stiffness), physical limitations, fatigue, and decreased overall quality of life. They also have an elevated risk of cardiovascular diseases, where inflammation and traditional risk factors contribute to this elevated risk. To effectively manage axSpA, a combination of pharmacological and nonpharmacological treatments is recommended. Traditionally, flexibility exercises have been emphasized to improve and maintain mobility, while aerobic exercises have not received as much focus. However, studies have shown that aerobic exercise effectively improves physical function, reduces stiffness, and enhances cardiovascular health in patients with axSpA.

What Is Axial Spondyloarthritis?

A chronic inflammatory condition called axial spondyloarthritis (axSpA) primarily affects the axial skeleton, which includes the spine and sacroiliac joints. It is a subtype of spondyloarthritis, which is a group of inflammatory conditions that affect the joints and entheses (the places where ligaments and tendons attach to bones). It includes patients with both radiographic (ankylosing spondyloarthritis) and non-radiographic sacroiliitis. Inflammation in the sacroiliac joints (a joint where the spine attaches to the pelvis), and in the joints between the vertebrae of the spine are the hallmarks of axial spondyloarthritis.

What Are the Advantages of Exercise for Managing Axial Spondyloarthritis?

The advantages of exercises for managing axial spondyloarthritis are:

1. Reduces Pain: Exercising on a regular basis can aid in easing axSpA-related pain and discomfort. Endorphins, the body's natural painkillers, are released when one exercises, and they can help one feel better and reduce pain. Exercise can also increase blood flow to afflicted areas, lowering inflammation and pain levels.

2. Improved Flexibility: Axial spondyloarthritis may lead to stiffness and restricted range of movement in both the spine and joints. Stretching and range-of-motion exercises can improve flexibility, helping to maintain joint function and reduce pain. Improved flexibility can also enhance overall mobility and make daily activities more manageable.

3. Strengthening of Muscles: Weak muscles can worsen axSpA symptoms, leading to increased stress on the joints. Exercise routines that target the core, back, and supporting muscles can help stabilize the spine and reduce the risk of injury. Strengthening exercises can enhance muscle support and alleviate strain on affected areas.

4. Posture and Balance: AxSpA can negatively impact posture and balance due to inflammation in the spine. Specific exercises that focus on balance and core stability assist in enhancing posture and reducing the risk of falls. Better posture contributes to overall mobility and a reduced risk of injuries related to compromised balance.

5. Psychological Well-being: Living with a chronic condition like axSpA can cause emotional stress, anxiety, and depression. Exercise has been shown to have positive effects on mental health, promoting the release of neurotransmitters like serotonin and dopamine that elevate mood and reduce stress. Participating in physical activity with others can also provide social support and a sense of community, further benefiting mental well-being.

6. Cardiovascular Health: Regular aerobic exercises, such as walking, swimming, and stationary cycling, improve cardiovascular fitness. Maintaining good cardiovascular health is essential for overall well-being, especially for individuals with chronic conditions like axSpA.

7. Weight Management: Exercise can aid in weight management, which is crucial for individuals with axSpA. Sustaining a healthy weight reduces stress on the joints and can help manage inflammation, leading to improved symptom control.

8. Bone Health: Weight-bearing exercises, such as walking and resistance training, promote bone health. It also lessens the risk of osteoporosis, a condition that may be more prevalent in people with axSpA.

9. Enhanced Sleep - Engaging in exercise can be physically tiring, leading to improved sleep quality and waking up feeling refreshed.

10. Social Engagement: Participating in group exercise classes or engaging in physical activities with others can provide social interaction and support, which can contribute to a positive outlook and overall well-being.

What Are the Different Exercises for Axial Spondyloarthritis Management?

There exist four major categories of exercises advised for the management of axial spondyloarthritis, which are listed below:

1. Range of Motion or Stretching Exercises: These exercises involve moving the muscles and joints through their full range of motion without using weights. They help improve flexibility, reduce stiffness, swelling, and pain, and minimize joint fusion risk. Range of motion exercises are often used as warm-up exercises before engaging in sports activities. These exercises are crucial in spondyloarthritis because people tend to limit movement around inflamed joints due to pain, swelling, and stiffness. However, lack of movement can lead to loss of mobility and increase the risk of joint fusion. Doing stretching exercises daily for all stiff or potentially stiff joints is recommended. Some beneficial stretches include:

   1. Neck Stretches: Gentle neck stretches can help alleviate tension and stiffness in the cervical spine.

   2. Spinal Rotation Stretches: Controlled twisting movements can improve flexibility in the spine.

   3. Hip and Hamstring Stretches: Stretching the hips and hamstrings can ease the strain on the lower back.

2. Aerobic or Cardiovascular Exercises: Aerobic exercise involves engaging in activities for a prolonged duration that promotes increased blood flow to the heart. This type of exercise is beneficial for improving heart and lung function, as well as overall health. Research indicates that individuals with spondyloarthritis who incorporate aerobic exercise into their routine experience enhanced breathing function, endurance, mood, and reduced disease activity, pain, and fatigue compared to those who do not exercise. Current recommendations suggest performing aerobic exercise between three to five times per week, totaling 75 to 150 minutes per week. Low-impact aerobic activities are gentle on the joints and provide cardiovascular benefits without putting undue stress on the spine and affected joints. Recommended exercises include:

   1. Walking: Regular walking is a simple and effective means of enhancing general health and cardiovascular fitness.

   2. Swimming: Exercising in the water helps reduce the impact on joints while providing resistance to strengthen muscles.

   3. Stationary Cycling: Cycling on a stationary bike allows for low-impact cardio exercise without straining the back.

3. Strengthening Exercises: These exercises involve using muscles to move against resistance or weight. They aim to enhance the performance of muscles, enabling more efficient and safe movement and supporting good posture. In spondyloarthritis, some of the most crucial muscles to strengthen are the ‘core muscles,’ which include the abdominal and back muscles that act like a ‘corset’ to support the spine. Strengthening the core muscles has been proven to reduce stress on the spine, thus minimizing back pain. Often, individuals experiencing back pain due to spondyloarthritis may adjust their posture to alleviate discomfort. However, these postural changes can lead to stiffness and weakness in muscles and joints, resulting in increased pain. Therefore, focusing on ‘core strengthening’ is essential for managing back pain in spondyloarthritis. For optimal results, strengthening exercises should be performed two to four times per week.

4. Balance Exercises: The primary goal of balance exercises is to enhance both still and moving stability. These exercises hold particular significance for individuals who are less physically active and as we age. Engaging in balance exercises can significantly reduce the risk of falling, which is particularly crucial for individuals with lower bone density, as they are more vulnerable to fractures in the event of a fall. For optimal outcomes, it is recommended to perform balance exercises three to five times per week.

Conclusion

When it comes to exercise for individuals with axial SpA, the key focus lies in improving or preserving various aspects. These include enhancing the range of movement in joints, maintaining proper posture control, strengthening muscles, promoting muscle length and flexibility, optimizing lung capacity, improving balance, and enhancing cardiovascular fitness. It is essential to emphasize the importance of regularity, consistency, and long-term commitment in any chosen exercise regimen. By adhering to these principles, individuals can maximize the benefits and effectively manage their condition.