All three
authors show relevant medical background and inform the reader very
clearly the concept of their research through the title. Most of the
references used by the authors were from 1990’s. Few of them
were much older, the oldest taken from 1956 but this suggests relevant
material of importance could be retrievable from the available research.
This could also make us debate, whether or not much relevant research
was done after1956. Most of the references were quantitative research
studies/trials done in relation with Ankylosing spondylitis (AS).
The abstract
is more than 250 words, clearly illustrates the study undertaken and
explains the research purpose, methods and outcome.
The introduction
explains how AS was managed in the early 1900’s and explores
the effects of exercises and how they made an affect in health status
of the patients with AS.
These
authors have chosen to have convenient sampling in this prospective
longitudinal study involving 220 patients diagnosed with AS, chosen
from clinical settings medical centres, local rheumatologists and
the community by advertisement. Their inclusion criteria were the
patients should be 18 years old, be able to read English and diagnosed
AS by the modified New York criteria. They have excluded patients
with irritable bowel syndrome, but not included any reason for it.
Outcome
measures chosen were physical examination at the study entry and through
mailed questionnaire at entry of study and 6/12 later. Questionnaires
included questions on health status including functional disability,
pain severity and stiffness severity, exercise habits and medications
use. Patients were followed up from study entry to death or withdrawal
from the study (from 1992 to March 31st 1999).
Patients
were classified as they reported how much they exercised. They were
classified as high exercisers if they reported exercising 150 minutes
per week on 80% or more (n=44) in their questionnaires, n=55 low exercises
if they reported exercising 60 minutes per week on 80% or less in
their questionnaires, all others were classified as intermediate (n=126)
exercises.
Statistical analysis was done in two ways:
1) Exercise minutes per week (number of days per week of back exercise)
against change in pain severity (measured by 15 cm visual analogue
scale) changes in stiffness severity (measured by 15 cm visual analogue
scale) and health assessment questionnaires disability index for 6
months periods.
2) Difference in rate of progression of patients functional disability
between patients who reported constantly high levels of exercise over
time and these who reported consistently low levels of exercises over
time.
They also assessed the results analysed in 2 subgroups of patients
those who had AS for 15 years or less (n=100) and those who had AS
for more than 15 years at study entry (n= 120).
Study
results revealed that unsupervised recreational exercise improved
pain and stiffness, back exercise (if performed 1 to 4 days per week)
improves pain and function in patients with AS, though these effects
differed with the duration of AS (Among patients who had A.S more
than 15 years, HAQ Disability Index improved by 0.045 points ( On
a scale of 0-3:P=.001) whereas in patients who had A.S less than 15
years, there was no significant association found between the frequency
of back exercises and the HAQ Disability Index.
On the
whole authors had statistical evidence that patients who performed
30 minutes per day of recommended exercises (aerobic, jogging, brisk
walking, swimming, weight lifting, cycling, team sport and others)
and back exercise at least 5 days per week, had their health status
improved when they measured through the task of ADL in 8 areas (dressing,
arising, eating, walking, hygiene reacting, gripping, errands and
chores).
Evaluation:
AS is
a chronic inflammatory rheumatic disease and due to the consequences
of the disease, physiotherapy is considered to be an important part
of overall management of AS. Effects of physiotherapy in AS patients
has been assessed by many researchers (Dagfinrud et al 1996, Van-der-Esch-Martin
et al 2004, Aneloy-Yildiz et al 2003, and Sundstrom- Bjorn et al 2002).
Aneloy-Yildiz et al (2003) found that group exercises in hospital
was proved to be effective than home based exercise, whereas Dagfinrud
et al (2004) proved that a home based exercise programme is better
than no intervention.
This
study proves to be good advantage and has statistical evidence that
back exercises performed 1-4 days per week and recreational exercises
30 minutes per day done at home would improve AS patients’ activities
of daily living (ADL). These definitely would give the confidence
and teach patients self responsibility and motivation to do back exercises
unsupervised at home as a part of self management. The authors used
HAQ Disability Index questionnaires for outcome measures. Even though
questionnaires type of data collection could lead to subjective type
of results which are of poorer validity, HAQ Disability Index questionnaire
chosen by the author had been proven for its reliability and validity
and could have eased critical comments.
The authors could have randomised the samples which are the most recommended
source (Cormack 2001 and Bowling 2002). This could have been helped
in generalising the results. The ethics approval is not mentioned;
even though the study participants were already participants in another
longitudinal study. Patient consent was not documented either. As
the study was an investigational type, some of the methods used could
be confusing for the reader and needs re-reading to understand the
methodology. This could be overruled as it is clearly understand that
the authors had taken increased steps to study the effectiveness of
unsupervised exercises, which had not been extensively studied before.
The authors
had proved that in patients with AS for 15 year or less, recreational
exercises decreased the severity of pain and stiffness whereas in
patients with AS for 15 years or more, consistent back exercises improved
pain and function. The authors place the reason on the physiological
nature of the condition AS, that in early AS, patients who could present
with less spinal fusion would be able to exercise more vigorously
and derive analgesics benefit through the physiological effects of
exercises. Frequency of back exercises also helped with late AS patients
where symptoms may be due to both mechanical as well as inflammatory
process. This definitely shows the patients, already long term diagnosed
AS the need to continue self exercising the back even more so than
the newly diagnosed AS patients. So generally back exercises have
indeed been proven to have more advantages in maintaining function
in patients’ with AS.
The large
sample and long term follow up for a medium 4.5 years were advantages
of this study. If the effects of each particular type of exercise
could have been explored in depth and the re-testing the physical
examination could have identified more strong outcomes of the study.
The cardiovascular fitness, lung function, weight control and osteoporosis
aspect were not studied to find the overall benefits of exercises
which is very much required in AS patient group.
Nevertheless
this is a good piece of research which had 2 specific goals and the
research questions had been answered. This I would recommend for every
AS patient to read and understand more about the benefits of exercise.
This also answers all the patients’ questions of “are
home exercises as helpful as supervised exercises in hospital?”
I especially liked the final verdict that the doctors should prescribe
AS patients with at least 30minutes per day, especially encourage
back exercise at least 5/week as an important part of treatment. If
this could be done in practice, it would help to get patients even
better motivation and cooperation thereby help in reducing deformities
in patients with AS.
PHI
Website
The Patient-assessed Health Instruments (PHI) website is designed
to inform the selection of patient-assessed health instruments through
the provision of a bibliographic database, selection criteria, published
reports and relevant links.
For more
info go to... http://phi.uhce.ox.ac.uk
Bath
Indices
Outcome Measures for use with Ankylosing Spondylitis Patients.
Start
here... The Bath Indices Cover & Index
