Spondyloarthritis is an autoimmune disease characterized by backpain, stiffness in the spine and/or various other joints in the body and fatigue. It can also cause inflammation in other organs in the body. It is incurable but newly developed medication are effective in controlling the disease but costly and with side effects. In patients with chronic backpain, please do consider Spondyloarthritis. The diagram below can help us physiotherapists in decision making:
Exercise is an important component of disease management because those suffering from this disease will experience decline in their ability to carry out activities of daily living (ADL) due to pain, stiffness and fatigue. Regular exercise reduces disease activity and is already a known treatment that benefits these people. As a physiotherapist, I am constantly on the lookout for emerging research that shows the effectiveness of new exercise programs.
A newly published research paper done by a Scandinavian group has been recently brought to my attention because of its novelty: high-intensity exercise. This is the first published trial using high intensity exercise to treat patients with Spondyloarthritis. Initially, I thought it must be crazy to put these people through bootcamps and Bodypump classes like in fitness centres or gyms! Reading the paper, I realised that I was too naive to think so. High-intensity exercise doesn’t mean ‘bootcamp’ or ‘HIIT’, it’s exercise performed at a level that is considered to be in the ‘intensive zone’ for the particular person. It requires measuring one’s baseline and maximal fitness levels in order to derive one’s ‘intensive zone’.
For those unfamiliar with exercise intensity, this is an image taken from the World Health Organization (WHO) website:
This is the link to the paper published on BJSM.
How effective is high intensity exercise for people with spondyloarthritis?
The results of this paper is impressive. For the population of people age between 23-69, suffering from axial-spondyloarthritis (affecting the spine only), this is what you can expect if you participate in a 12-week program (3 times per week of high-intensity aerobic and strengthening):
- Intensity and duration of morning stiffness
- Aerobic capacity / fitness
- Waist circumference
Is this safe for people with spondyloarthritis?
From the paper, there has not been any reported significant adverse events in the 3-month follow-up. One patient reported chest pain and nausea during exercise and completed the exercise program at moderate-intensity after advice from a cardiologist; 2 patients reported persistent pain but completed the program. Patients involved in ‘high intensity exercise’ did 3 sessions per week: 2 sessions (aerobic and strengthening exercises) were supervised by a physiotherapist with experience in rheumatology while patients did 1 session (aerobic only) on their own.
If I am inactive, is high intensity exercise appropriate for me?
The disadvantage of high intensity exercise is that, compliance will be an issue. Usually, only highly motivated people stick to the whole program. It has been shown in this study that, 5/50 (10%) in the ‘high intensity exercise group’ dropped out of the study due to dissatisfaction with the exercises. Only 24% did not complete >80% of the prescribed exercise protocol. In many research trials, it is common to find drop-out rates up to 30%. Therefore it seems that high-intensity exercise is suitable for both the young and old. If one is inactive, this should not be a problem unless you really do not like to exercise. For this reason, I would advice you to begin with low intensity, gradually building up towards higher intensities for better results.
How much better is high intensity compared to low-moderate intensity exercise?
We don’t know.
This has not been explored in research before, as this paper only explored comparison between ‘high intensity exercise’ and ‘usual care’. However, it has already been established from previous research that ‘physical exercises’ has a beneficial effect over ‘no exercise’.
Can I implement high intensity exercise by myself from the start?
Yes and no.
Patients involved in this study underwent a baseline assessment of their fitness levels and were put through a standardised fitness test (modified treadmill Balke protocol). Unless you are trained and know how to perform the test by yourself, or have been through a similar type of test and know how to monitor the intensity of your exercise, it is advised to be supervised under someone experienced when you initiate such a program.
High intensity exercise should not be carried out by anyone. People who are older (>45 years old), with risks for heart conditions, for example high blood pressure, high cholesterol, obese, smoking, etc should not participate in high intensity exercise before consulting a medical professional. If there are any risks for adverse events when you exercise intensely, do not implement high intensity exercises before seeing a medical professional.
These patients are just research lab rats, the results cannot be generalised to all patients with axial spondyloarthritis.
In this predominantly middle-aged patient group (23-70 years old), subjects were recruited in the outpatient clinics and exercise sessions were carried out in the hospital or at fitness centres. This gives me the confidence to say that the program is feasible and can be carried out well in the outpatients setting.
High intensity exercise for people with axial-spondyloarthritis is safe, effective and is recommended to be prescribed to the right patients. Patients with the disease seek to be as ‘normal’ as they can be and by providing the best information and treatment program, we can give them hope. However, we recognise that high intensity exercise is not easy and it may be expected that drop-out rates to be higher than usual physiotherapy care.
Thank you for reading!
Sveaas SH, et al. High intensity exercise for 3 months reduces disease activity in axial spondyloarthritis (axSpA): a multicentre randomised trial of 100 patients. Br J Sports Med 2019;0:1–7. doi:10.1136/bjsports-2018-099943