|Year : 2019 | Volume
| Issue : 2 | Page : 67-70
A study to assess the improvement in physical function and spinal pain after a 3-month supervised rehabilitation program in patients with axial spondyloarthritis
Arupratan Ghosh1, Pankaj Kumar Mandal2
1 Department of Physical Medicine and Rehabilitation, NRS Medical College, Kolkata, West Bengal, India
2 Department of Physical Medicine and Rehabilitation, R.G. Kar Medical College, Kolkata, West Bengal, India
|Date of Submission||22-Nov-2018|
|Date of Decision||15-Apr-2019|
|Date of Acceptance||06-May-2019|
|Date of Web Publication||7-Aug-2019|
Dr. Arupratan Ghosh
CG-15, Sector-2, Salt Lake, Kolkata - 700 091, West Bengal
Source of Support: None, Conflict of Interest: None
Context: Axial spondyloarthritis (Ax-spA) is a disease for which there is hardly any treatment ensuring permanent cure. Hence, rehabilitation is the mainstay of management for improving the quality of life and sustaining socioeconomic productivity. A randomized controlled trial was done to assess the improvement in physical function and reduction in spinal pain after a supervised rehabilitation program (SRP). Aims: This study aims to assess the effect on physical function and spinal pain in patients with Ax-spA after a 3-month SRP. Settings and Design: A concurrent parallel randomized controlled trial was done at the Department of Physical Medicine and Rehabilitation, R. G. Kar Medical College, Kolkata, during June 2014 to July 2015 after approval from the institutional ethics committee. Subjects and Methods: A total of 63 participants (53 male, 10 female) with Ax-spA, aged 18–45 years, were randomly allocated into two groups. Participants of intervention group had undergone SRP and control group were put on home exercise program for 3 months. Physical function was measured by Bath Ankylosing Spondylitis Functional Index (BASFI) and spinal pain was measured by numerical rating score (NRS) at baseline and after 3 months. Statistical Analysis Used: The data were collected and compiled in Microsoft Office Excel 7 and analyzed with SPSS version 20. Results: After 3 months, BASFI improved significantly in both groups, whereas intergroup analysis showed a significant improvement (P < 0.001) in the intervention group compared to the control group. Spinal pain measured with NRS improved significantly in both groups, whereas intergroup analysis showed a significant improvement (P < 0.001) in the intervention group. Conclusions: Physical function and spinal pain improved significantly after SRP in patients with Ax-spA.
Keywords: Axial spondyloarthritis, Bath Ankylosing Spondylitis Functional Index, spinal pain, supervised rehabilitation program
|How to cite this article:|
Ghosh A, Mandal PK. A study to assess the improvement in physical function and spinal pain after a 3-month supervised rehabilitation program in patients with axial spondyloarthritis. Indian J Pain 2019;33:67-70
|How to cite this URL:|
Ghosh A, Mandal PK. A study to assess the improvement in physical function and spinal pain after a 3-month supervised rehabilitation program in patients with axial spondyloarthritis. Indian J Pain [serial online] 2019 [cited 2020 Jan 27];33:67-70. Available from: http://www.indianjpain.org/text.asp?2019/33/2/67/264083
| Introduction|| |
Axial spondyloarthritis (Ax-spA) is a heterogeneous group of chronic inflammatory disease involving mainly axial skeleton (especially spine and sacroiliac joints) progresses to predominantly spinal as well as peripheral joint deformities with restriction of range of motion. Ankylosing spondylitis is one of the prototypes of spondyloarthritis. Onset of spondyloarthritis generally occurs between second to fourth decade, which is the most important period for socioeconomic productivity. As of date, there is no definitive pharmacological management offering permanent cure for Ax-spA. (Of those pharmacological therapies which are used for control Ax-spA, Disease Modifying Anti Rheumatic Drugs (DMARDs) were not proven to be effective, whereas biologics are costly, having multiple adverse effects on different organs along with the increase in susceptibility to different infections, less acceptable to the patient population of developing countries like India.). Hence, restoration of physical function, disability limitation, and effective pain management is the felt need in this population for improving the quality of life and sustaining socioeconomic productivity. A systemic review by Cochrane musculoskeletal group suggested that an individual home-based or supervised exercise program is better than no intervention and supervised group physiotherapy is better than home exercise, not mentioning about the multidisciplinary rehabilitation approach. In reality, most of the studies were of different duration of intervention, lacks standardized exercise program and multidisciplinary institutional approach. Hence, this study was planned to assess the improvement of physical functions and spinal pain after a 3-month institutional supervised rehabilitation program (SRP) with all the necessary multidisciplinary components and least pharmacological interventions, as a cheap, accessible, acceptable, and effective management toward a better quality of life in patients with axial spondyloarthritis.
| Subjects and Methods|| |
A randomized controlled trial was done at the Department of Physical Medicine and Rehabilitation, R.G. Kar Medical College, Kolkata, during June 2014 to July 2015 after approval from the institutional ethics committee. A total of 63 participants (53 male, 10 female) diagnosed as Ax-spA by assessment of spondyloarthritis international society classification criteria, within the age group 18 years to 45 years, were included in the study with exclusion criteria of active noninflammatory spinal disease, Hip and Knee deformities, postsurgical history on axial skeleton or peripheral joints, hypertension, diabetes, psychiatric illness, heart diseases, equilibrium disturbances, or pregnancy. They were counseled about the study, relevance of rehabilitation, and explained about the chances of first allocation in the in the SRP (intervention) group or home exercise (control) group, followed by signing the informed consent form (in the language he or she is comfortable with). The participants were randomly allocated into two groups by serially numbered opaque-concealed envelope technique. A total of 32 participants were allocated in intervention group and 31 participants in control group. The participants of intervention group had undergone supervised multidisciplinary rehabilitation program including multimodal exercises for 3 months thrice weekly at the Department of Physical Medicine and Rehabilitation, R.G. Kar Medical College and Hospital; they also continue these exercises at home during rest of the days in week. Participants of control group were demonstrated multimodal home exercises for a period of initial 3 months [The interventions are summarized in [Table 1]a and [Table 1]b]
After 3 months, participants of control group were invited in SRP so that they should not be deprived. All the participants did not have any history of biologic therapy before and during study period. Short course of nonsteroidal anti-inflammatory drugs used not >2 times during the 3 months period of rehabilitation (as and when required).
Physical function was measured by Bath Ankylosing Spondylitis Functional Index (BASFI) and spinal pain was measured by Numerical Rating Score (NRS), at baseline and after 3 months in both groups. Of the ten questions that comprise the BASFI, the first 8 questions evaluate activities related to functional anatomical limitations due to the course of this inflammatory disease and the final 2 questions evaluate the patients' ability to cope with everyday life. A scale (with 0 being “easy” and 10 “impossible”) is used to answer the questions on the test. The mean of the ten scales gives the BASFI score a value between 0 and 10. The effects on spinal pain were measured by the subjective response in NRS (1–10) about spinal pain. The data collected from the two groups will be compiled in Microsoft Office Excel 7 and analyzed with SPSS (IBM Corporation, USA) software version 20 to obtain respective conclusions.
| Results|| |
The baseline data collected from dropouts (2 from intervention group and 1 from control group) were not included in analysis. Each group after dropout exclusion had 30 participants (male 25, female 5). Adherence to the SRP by other participants of intervention group was 66% or more. Data were collected at the time of entering the study (baseline) and end of the study (i.e., after 3 months) from both groups. Master chart was done in Microsoft office excel 7 and analyzed by SPSS version 20.
Variables were tested for normal distribution by Shapiro–Wilk test. Then, the relevant test of significance was selected. Discrete variables were analyzed by Chi-square tests. Continuous variables were analyzed by appropriate paired/unpaired t-test (for normally distributed variables) and nonparametric Mann–Whitney U-test (for skewed distributed variables) where P < 0.05 is taken as statistical significant change.
Baseline characteristics in both groups were similar [vide [Table 2]].
After 3 months, rehabilitation data from study variables in both groups were analyzed. The result of the postintervention outcome analysis is shown in [Table 3].
|Table 3: Effects of supervised rehabilitation program in respect of physical function (measured by Bath Ankylosing Spondylitis Functional Index) and spinal pain (measured by numerical rating score scale)|
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BASFI improved significantly in both groups from baseline to the end of study whereas intergroup analysis showed a significant improvement (P < 0.001) in the intervention group over the control group.
Spinal pain (P < 0.001) improved significantly at the end of the study in both intervention and control group from their baseline whereas intergroup analysis showed significantly higher improvement (P < 0.001) in intervention group compared to control group.
| Discussion|| |
SRP is a comprehensive rehabilitation program for patients with Ax-spA; it consists of group therapy sessions which start with patient education, lifestyle modification, postural control, joint protection, energy conservation techniques, along with the multimodal exercise program which consists of a total 50 min of aerobic, stretching, and pulmonary exercises to relieve pain, restoration of joint mobility, prevention and correction of deformities, increase chest expansion and vital capacity, and improve physical endurance. SRP also includes regular cognitive behavioral therapy sessions for improving pain coping skills. Thus, SRP promotes disability limitations as well as significantly promotes improvement in physical functions (BASFI) and reduction in chronic spinal pain.
In this study, physical function (BASFI) and spinal pain improved in intervention group (SRP) as well as in active control group (home exercise) after the end of 3 months. Whereas significant improvements achieved in BASFI (P < 0.001) and spinal pain (P < 0.001) in the intervention group compared to the active control group.
A similar duration study by Günay et al. reported a significant improvement in BASFI and spinal pain, with breathing and posture exercises, whereas a randomized controlled study by Sveaas et al. reported significant improvement in BASFI after a 12 weeks of high-intensity supervised endurance and strength exercise. However, studies on group physical therapy like randomized controlled trials by Hidding et al. and Analay et al. found no significant differences in physical function and spinal pain measured at the end of their studies. Another 4-month randomized controlled trial conducted by Fernández-de-Las-Peñas et al. on SRP with Global Posture Re-education reported significant improvement with BASFI without any significant improvement in pain parameters.
There were some studies on home-based exercise interventions which revealed mixed responses. A 6-month randomized controlled trial by Sweeney et al. reported no significant group difference for BASFI and small improvement in spinal pain. Whereas another 4-month randomized controlled trial by Kraag et al. failed to report any significant spinal pain reduction.
Studies on short-term in-patient rehabilitation in Ax-spA like Eppeland et al. shows significant improvement in BASFI after a 2-week program whereas Kjeken et al. registered no significant improvement in BASFI in supervised rehabilitation group after 3 weeks.
If we discuss about the different outcomes in those studies, reasons of most shortfalls were home exercise programs lack standardization, short-duration programs had inadequate efficacy, and programs with inadequate therapeutic components failed to combat disabilities in question.
Thus, it is evident that SRP s consisting of proper multimodal exercise with group therapy session added with multidisciplinary approach continuing for a minimum duration of 3 months can yield the required improvement in physical function as well as proper reduction of spinal pain components. The limitation of the study is adherence to the home exercises could not be monitored, and we have to rely on declaration of the patients. Changes in disease activities are also not mentioned here as we are focusing on physical functions and spinal pain situation for improvement in quality of life.
| Conclusions|| |
The 3-month SRP had made a significant improvement of physical function and spinal pain in patients with Ax-spA, thus improving the quality of life and sustaining socioeconomic productivity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]