Physical activity and physical fitness in adults with Ankylosing Spondylitis
Citation:
Tom O'Dwyer, 'Physical activity and physical fitness in adults with Ankylosing Spondylitis', [thesis], Trinity College (Dublin, Ireland). School of Medicine. Discipline of Physiotherapy, 2016, pp.425Download Item:
Abstract:
International guidelines for the management of individuals with ankylosing spondylitis (AS) recommend a combination of pharmacological and non-pharmacological treatment modalities. While education, exercise and physiotherapy are core components of the latter, guidance in this area is vague. Furthermore, despite the numerous health risks associated with physical inactivity, there is no specific mention of physical activity (PA) in the guidelines. PA has seldom been investigated among this cohort, and has never been objectively measured in an Irish context. Health-related physical fitness, the set of attributes relating to the ability to perform PA, has not been comprehensively studied in AS cohorts. In an effort to expand the limited evidence base in this field, the overall aim of this thesis was to explore PA and physical fitness levels among adults with AS. In pursuing this aim, two systematic reviews of the existing literature and four original studies were completed. Systematic Review 1 - the first review of PA in individuals with AS - aimed to establish the PA levels of this cohort, within the wider context of spondyloarthritis and the general population. Nine studies met the inclusion criteria; the available evidence suggested that PA levels may be lower among adults with AS than the general population. However, cautious interpretation of findings was needed as only two trials compared objectively measured PA data. The heterogeneity of outcome measures, participant characteristics, disease parameters and medication usage prevented firm conclusions being drawn. Higher disease activity was associated with lower self-reported PA levels, although causality could not be established.
In addition to being an important constituent of PA, exercise is a key component of the management of individuals with AS. Systematic Review 2 was the first review to systematically appraise and synthesise trials examining the effects of exercise interventions in adults with AS. The existing evidence suggested that, compared to no intervention, therapeutic exercises are beneficial, and improve physical function, disease activity, pain and stiffness, cardiorespiratory function, spinal mobility and chest expansion. The most effective exercise protocol remained unclear. Supervised group exercises yielded better outcomes than unsupervised home exercise for quality of life. Incorporating aerobic exercise to flexibility programmes improved cardiorespiratory outcomes, but not cardiovascular risk factors. In light of the low adherence to PA guidelines among individuals with AS observed in
Systematic Review 1, the large cross-sectional Study 1 was conducted to explore (1) awareness of, (2) knowledge of, and (3) compliance with, PA guidelines among adults with rheumatic conditions. Awareness of PA guidelines was low (17.6%), and knowledge of the recommendations was largely inaccurate (82.6%). Despite the role of PA in health promotion and in the management of rheumatic conditions, adherence to PA recommendations was low (27%); ~30% reported no weekly PA. Level of education, perceived benefits and barriers to exercise, and awareness and self-report knowledge of PA guidelines were identified as factors associated with PA behaviour. The cross-sectional controlled Study 2 was conducted to objectively establish the PA profile of individuals with AS in Ireland. Compared to matched population controls, Irish adults with AS engaged in significantly less health-enhancing PA, and spent significantly less time performing vigorous-intensity PA. Less than half of the AS cohort met national PA guidelines. This finding highlighted the necessity to (1) explore PA behaviour in adults with AS, and (2) to investigate strategies to increase PA participation. The second objective of Study 2 was to profile the physical fitness of individuals with AS. The results of this comprehensive physical fitness assessment suggested that adults with AS had significantly lower cardiorespiratory fitness, flexibility, muscular strength and endurance, and increased body fat. Within the AS cohort, lower fitness outcomes were associated with higher functional limitations. The qualitative descriptive Study 3 explored attitudes towards PA and exercise from the perspective of adults with AS. Analysis of their unique insight revealed four themes relating to PA: (1) benefits, (2) barriers, (3) motivation, and (4) strategies and enablers. Perceived benefits of PA and exercise included amelioration of symptoms, improvements in general health, and enhancement of quality of life. Awareness of these benefits appeared insufficient to motivate individuals with AS to exercise. Sub-themes of barriers to PA included lack of resources, negative attitudes to exercise, misinformation, and condition-related factors. Many perceived barriers to PA may be considered modifiable. A number of factors influenced individual motivation to exercise, including both intrinsic and extrinsic factors. Individually-tailored interventions, collaboratively developed by the individual and the HCPs, were proposed as strategies for effective PA and exercise prescription. The fourth and final study of this thesis was conceptualised in response to the findings of the systematic reviews and preceding studies. The insights gained were integrated into creating, for the first time, a Brief Intervention targeting PA behaviour in adults with AS. The resultant randomised controlled trial - the INPACT-AS trial- was safely implemented, and resulted in significant positive effects on health-enhancing PA behaviour. The increased PA was sustained over a three-month follow-up; 70% of individuals receiving the intervention met PA recommendations. The intervention also significantly improved spinal mobility and quality of life. This individually tailored approach to PA behaviour change is a new component to the non-pharmacological management of individuals with AS.
International guidelines for the management of individuals with ankylosing spondylitis (AS) recommend a combination of pharmacological and non-pharmacological treatment modalities. While education, exercise and physiotherapy are core components of the latter, guidance in this area is vague. Furthermore, despite the numerous health risks associated with physical inactivity, there is no specific mention of physical activity (PA) in the guidelines. PA has seldom been investigated among this cohort, and has never been objectively measured in an Irish context. Health-related physical fitness, the set of attributes relating to the ability to perform PA, has not been comprehensively studied in AS cohorts. In an effort to expand the limited evidence base in this field, the overall aim of this thesis was to explore PA and physical fitness levels among adults with AS. In pursuing this aim, two systematic reviews of the existing literature and four original studies were completed. Systematic Review 1 - the first review of PA in individuals with AS - aimed to establish the PA levels of this cohort, within the wider context of spondyloarthritis and the general population. Nine studies met the inclusion criteria; the available evidence suggested that PA levels may be lower among adults with AS than the general population. However, cautious interpretation of findings was needed as only two trials compared objectively measured PA data. The heterogeneity of outcome measures, participant characteristics, disease parameters and medication usage prevented firm conclusions being drawn. Higher disease activity was associated with lower self-reported PA levels, although causality could not be established.
In addition to being an important constituent of PA, exercise is a key component of the management of individuals with AS. Systematic Review 2 was the first review to systematically appraise and synthesise trials examining the effects of exercise interventions in adults with AS. The existing evidence suggested that, compared to no intervention, therapeutic exercises are beneficial, and improve physical function, disease activity, pain and stiffness, cardiorespiratory function, spinal mobility and chest expansion. The most effective exercise protocol remained unclear. Supervised group exercises yielded better outcomes than unsupervised home exercise for quality of life. Incorporating aerobic exercise to flexibility programmes improved cardiorespiratory outcomes, but not cardiovascular risk factors. In light of the low adherence to PA guidelines among individuals with AS observed in
Systematic Review 1, the large cross-sectional Study 1 was conducted to explore (1) awareness of, (2) knowledge of, and (3) compliance with, PA guidelines among adults with rheumatic conditions. Awareness of PA guidelines was low (17.6%), and knowledge of the recommendations was largely inaccurate (82.6%). Despite the role of PA in health promotion and in the management of rheumatic conditions, adherence to PA recommendations was low (27%); ~30% reported no weekly PA. Level of education, perceived benefits and barriers to exercise, and awareness and self-report knowledge of PA guidelines were identified as factors associated with PA behaviour. The cross-sectional controlled Study 2 was conducted to objectively establish the PA profile of individuals with AS in Ireland. Compared to matched population controls, Irish adults with AS engaged in significantly less health-enhancing PA, and spent significantly less time performing vigorous-intensity PA. Less than half of the AS cohort met national PA guidelines. This finding highlighted the necessity to (1) explore PA behaviour in adults with AS, and (2) to investigate strategies to increase PA participation. The second objective of Study 2 was to profile the physical fitness of individuals with AS. The results of this comprehensive physical fitness assessment suggested that adults with AS had significantly lower cardiorespiratory fitness, flexibility, muscular strength and endurance, and increased body fat. Within the AS cohort, lower fitness outcomes were associated with higher functional limitations. The qualitative descriptive Study 3 explored attitudes towards PA and exercise from the perspective of adults with AS. Analysis of their unique insight revealed four themes relating to PA: (1) benefits, (2) barriers, (3) motivation, and (4) strategies and enablers. Perceived benefits of PA and exercise included amelioration of symptoms, improvements in general health, and enhancement of quality of life. Awareness of these benefits appeared insufficient to motivate individuals with AS to exercise. Sub-themes of barriers to PA included lack of resources, negative attitudes to exercise, misinformation, and condition-related factors. Many perceived barriers to PA may be considered modifiable. A number of factors influenced individual motivation to exercise, including both intrinsic and extrinsic factors. Individually-tailored interventions, collaboratively developed by the individual and the HCPs, were proposed as strategies for effective PA and exercise prescription. The fourth and final study of this thesis was conceptualised in response to the findings of the systematic reviews and preceding studies. The insights gained were integrated into creating, for the first time, a Brief Intervention targeting PA behaviour in adults with AS. The resultant randomised controlled trial - the INPACT-AS trial- was safely implemented, and resulted in significant positive effects on health-enhancing PA behaviour. The increased PA was sustained over a three-month follow-up; 70% of individuals receiving the intervention met PA recommendations. The intervention also significantly improved spinal mobility and quality of life. This individually tailored approach to PA behaviour change is a new component to the non-pharmacological management of individuals with AS.
Author: O'Dwyer, Tom
Advisor:
Wilson, FionaQualification name:
Doctor of Philosophy (Ph.D.)Publisher:
Trinity College (Dublin, Ireland). School of Medicine. Discipline of PhysiotherapyNote:
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Physiotherapy, Ph.D., Ph.D. Trinity College DublinMetadata
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