Rheumatology Advance Access originally published online on May 21, 2008
Rheumatology 2008 47(7):1100-1101; doi:10.1093/rheumatology/ken191
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LETTERS TO THE EDITOR |
Physical therapy in anti-TNF treated patients with ankylosing spondylitis
Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK
Correspondence to: S. Dubey, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK. E-mail: s.dubey{at}nhs.net
SIR, AS is a chronic inflammatory condition of the spine most commonly affecting the axial skeleton. Physical therapy has a well-defined role in the management of this condition. A Cochrane review on the role of physiotherapy interventions in AS concluded that physical therapy (physiotherapy, home exercises, spa therapy) was beneficial; although it was not clear as to which treatment protocol should be recommended [1]. Similar conclusions were drawn in the review of AS for the ASAS/EULAR management recommendations [2, 3]. In patients with OA, studies have shown that a significant majority of patients were not fully compliant with exercise regimes [4]. No studies reporting real-life data for physical therapy in AS have been published. In the National Health Service in United Kingdom, most patients undergo education and supervised exercise programme at diagnosis or flare, but are expected to continue with unsupervised physical therapy for continuing benefit.
In patients with AS on treatment with anti-TNF agents, we sought to ascertain details of physical therapy regimes and its perceived benefit; and explore motivation levels for physical therapy.
We could not find any suitable instruments in literature for this study. Hence, we devised a one-page anonymous questionnaire on the basis of the Cochrane review. This was piloted on six patients, their feedback obtained and combined with feedback from research nurse, physiotherapist and Consultant Rheumatologist (all with an interest in AS). Content validation was thus performed; the modified questionnaire was then distributed by nurse practitioners either at the time of patients’ attendance for infliximab infusion or for clinic visits. All 40 patients at our centre who fulfilled the inclusion criteria were included. This was a cross-sectional survey, and was conducted between March and July 2006. Results were analysed using Microsoft Excel and SPSS version 14.0.
We obtained 32 responses, a response rate of 80%. Twenty-six responders are males with six females, and mean duration of AS was 16.34 yrs (2–40 yrs). Mean age was 45.21 yrs (26–64 yrs); 17 patients were on infliximab, eight were on etanercept and two on adalimumab. The most common form of exercise was walking (21) followed by swimming (7). The mean time spent weekly on physical therapy was 133.61 min compared with 67.97 min prior to anti-TNF treatment. Out of 32 responders, 31 did more exercise now than prior to anti-TNF treatment. Patients perceived mild to moderate benefit from physical therapy in terms of fitness, function, maintenance of posture, stiffness and long-term outcome (Fig. 1). The internal consistency of this scale using Cronbach's-
was 0.6.
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On a 10-point scale, motivation levels for physical therapy had significantly increased to 6.32 compared with 3.78 pre-anti-TNF treatment (Wilcoxon signed-ranks test, P = 0.000). Qualitative data suggest that physical therapy is perceived as a useful adjunct to anti-TNF treatment.
Physical therapy has an accepted role in the management of AS; however, patients are expected to develop personalized physical therapy regimes for continuing benefit. This study clearly suggests that patients are spending time on physical therapy, and this had increased since commencing anti-TNF treatment. Literature appears to be mixed in terms of benefits in symptoms of AS, with studies suggesting no benefit in pain [1], no benefit in pain, stiffness or physical function [5] and two trials suggesting modest improvement in function [6, 7]. This leads us to hypothesize that this group of patients experience greater benefit than patients not on anti-TNF treatment. There is some support for this hypothesis with another study reporting synergistic effect between anti-TNF treatment and intensive in-patient rehabilitation [8]. Further studies are needed to investigate this. The limitations of this study are small sample size, lack of construct validity testing and study design due to which reliability issues remain with the retrospective data.
Motivation levels for physical therapy have not been studied previously in AS. The improvement in motivation levels is interesting, and may be partly attributable to increased functional ability, as these patients represent increased disease severity. No data exist for assessing how other forms of treatment have altered motivation levels for physical therapy.
Patients with AS treated with anti-TNF agents appear to be exercising more than prior to anti-TNF treatment, and they feel that physical therapy helps stiffness, function and overall outcome. Their motivation levels for physical therapy have improved significantly with anti-TNF treatment.
Disclosure statement: K.G. has been a speaker and advisory board member for Wyeth, Abbott and Schering-Plough Ltd. Their department is in receipt of research funding from Wyeth, Abbott and Schering-Plough. All other authors has declared no conflicts of interest.
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