Exercise blogs

Physiotherapy evidence-base and experience of using the Peanut-Shaped Gym Ball with people living with rheumatological conditions, including Axial SpA

Promoting regular exercise is an important part of supporting people living with rheumatological conditions including axial Spondyloarthritis (axial SpA), a chronic inflammatory disease that predominantly affects the spine .

Working as a rheumatology specialist physiotherapist I support people living with both mechanical and inflammatory low back pain (LBP). I have always held the belief that increasing one’s "core muscles" can be important in reducing postural problems and low back pain. The spinal and abdominal muscles help maintain one’s neutral posture and the five components of core stability (strength, endurance, flexibility, motor control and function). Both abdominals and spinal extensor muscle groups need to work equally to increase the core strength and spinal extensors’ endurance have been thought to help reduce stress at the spine and hence improve efficiency in all physical activities.

The therapy cohort commonly uses Swiss or round shaped Gym balls to improve one’s balance and core strength. Gym ball work by forcing the body to balance against the ball's instability, leading to greater muscle activation. In my experience of using such supportive devices, patients relax and self-exercise easier. Unlike the spherical-shaped Swiss ball, PeaNut shaped (PNS) gym balls offer a slightly more supportive rehabilitation environment. PNS Gym balls are ideal for various therapeutic uses in both children and adults (including the antenatal cohort). The shape offers greater stability and control by limiting movements experienced to just the one axis (forward and backward), Ideal for anyone who requires lateral stability. They are adaptable and offer extra support during exercises improving one’s flexibility, strength, balance, coordination, posture, and mobility. They are extensively used for therapeutic activities including, yoga, Pilates, Taichi, pregnancy and dance. They can be used both in and outdoors. Some PNS balls are manufactured with tactile nodules for massaging purposes, users have reported they are effective in relaxing upper trapezius and scalenus (the most common to get stressed muscle groups).

Research Background Lumbar stabilization exercises sat on a ball iare reported to be effective for alleviating LBP and could produce a higher rate of increase of bone mineral density compared with lumbar stabilization exercises done on the floor (Yoon et al 2013). Recently Liam et al in 2023, identified joint mobilization, breathing works alongside gym ball assisted exercises improved respiratory pattern abnormalities and joint position sense in persons with chronic LBP. Progressive muscle strengthening exercising with assistance of a Swiss ball was demonstrated to be effective in reducing disease activity, improving overall muscle strength, walking performance and great customer satisfaction in patients with Axial SpA. Future studies of longer duration should be attempted to finalise the effectiveness of the Swiss gym balls.

There is limited research surrounding the use of the PNS ball in musculoskeletal physiotherapy. Most of the research done on the PNS balls were aimed in its use during labour. In 2016, clinicians have proved PNS balls compared to Swiss balls were easy tools to measure, assess and improvise trunk extensor’s endurance amongst healthy subjects. Though PNS gym balls efficiency needs to be further evaluated amongst people with inflammatory conditions, one cannot avoid that they are easy to use supportive tools that clinicians can incorporate in testing and in clinical progression training.

PNS Gym ball at our NLAG NHS Trust

People diagnosed with Rheumatology conditions including axial SpA can struggle to lie/ stretch down regularly for both resting and exercising lower limbs and trunk. Regular gym balls supported resting positions and allowed easier movements of the lower limb/trunk only if the patients can flex their hip/. knee joints beyond > 60 degrees. Introducing PNS gym balls made a significant difference. Only 45 degrees of hip flexion was required to place their legs (compared to the 60-90 degrees required with the Swiss gym balls) and the ridge between the double ball shaped balls worked out as a great supportive platform for both the knee joints and lower limbs.

For the last decade, I have observed the PNS gym balls eased and enabled my patients with rheumatological conditions (who struggle with symptoms with pain /stiffness and fatigue) to exercise easier. The gentle rocking and bouncing of the ball can help regulate ones’ nervous system and promote relaxation and focus. Additionally due to being offloaded, positioned in a flattened lumbar lordosis (posterior pelvic tilted) position, patients with LBP and lower limb related pains can relax and work gradually to regaining the full range of pelvic tilts. Patients instantly report how ‘easier’ it feels using the PNS ball and how the weight of the lower limb been lifted off, reducing the soft tissue strain, thereby reducing further LBP, and associated hip joint pains.

We have been using this PNS ball with axial SpA patients in the earlier pain/stiff days to encourage with the aim of trying to recruit lower trunk and hip/knee joint flexibility, strength, and core stability. The comfortable and easier exercising enabled patients to feel pain less, encouraging them to buy their own gym balls and start self-managing and working through progressions / regressions as per their pain levels. Over the time, patients wean off the ball support and work on their Axial SpA specific home exercise programme. They are happy to self-manage their flare up days using the PNS ball as required.

Patients with axial SpA in NASS group have always reported positive feedback to me:

· Forgot my LBP, I would not mind lying down now.

· Wow, I love this position, it is easier to rest.

· That feels so nice, the weight of my legs has been taken off.’

· I can move my Hip/Knee joints can move without any discomfort.

· Brilliant calm therapy, able to breathe deep with less pain.

Two of our Grimsby Town NASS group members, Sue C, Sue B have used the PNS balls for few years and offered to convey their positive experience with picture illustrations.

Conclusion:

· Improved Outcome measures – active range of movement, muscle power, balance and coordination and pain relief, VAS pain/stiffness/fatigue scores, EQ-5D-5L,

· Improved Patient engagement, compliance, and satisfaction with therapy

· Thousands of patients with rheumatological conditions and several local Grimsby Town NASS group members have bought their own PNS gym ball – because it supports to exercise easier during painful/stiff days. So, they engaged, self-managed symptoms better, progressed easier with further strengthening programme under therapists’ guidance.

· Future trials should evaluate PNS balls efficiency in patient diagnosed with axial SpA.

Susi

References

Yoon, J.S., Lee, J.H. and Kim, J.S., 2013. The effect of Swiss ball stabilization exercise on pain and bone mineral density of patients with chronic low back pain. Journal of physical therapy science, 25(8), pp.953-956.

Chalana Duarte de Sena Fragaet al (2024) Use of a peanut ball, positioning and pelvic mobility in parturient women shortens labour and improves maternal satisfaction with childbirth: a randomised trial. Journal of Physiotherapy 2024 Apr;70(2):134-141.

Nuno Pina Gonçalves et al (2019) The effects of physical exercise on axial Spondyloarthritis - a systematic review ARP Rheumatol 2023 Aug 27.

Patel, G. and Deshpande, V., 2019. Effectiveness of Swiss ball Exercises and Mini Stability ball Exercises on core Strength, Endurance and Dynamic balance in Mechanical Low back Pain. SCOPUS IJPHRD CITATION SCORE, 10(5), p.70.

Lim, C.G., 2020. Comparison of the effects of joint mobilization, gym ball exercises, and breathing exercises on breathing pattern disorders and joint position sense in persons with chronic low back pain. Physical Therapy Rehabilitation Science, 9(1), pp.25-35.

Beate Carriere(1999).The ‘Swiss Ball': An effective tool in physiotherapy for patients, families and physiotherapists, Physiotherapy Volume 85, Issue 10, October 1999, Pages 552- 561

Marcelo Cardoso de Souza et al (2017), Swiss ball exercises improve muscle strength and walking performance in ankylosing spondylitis: a randomized controlled trial Revista Brasileira de Reumatologia (English Edition)Volume 57, Issue 1, January–February 2017, Pages 45-55

Tarek M. El-Gohary et al (2016): Using the Swiss ball versus peanut ball to assess the back extensors endurance among healthy collegiate physical therapy students at Taibah University International Journal of Therapies & Rehabilitation Research, January 2016

Alice Goodman (2013): Exercise Improves Outcomes in Ankylosing Spondylitis Medscape Thursday, November 21, 2024

High Intensity Exercise – Does it Have a Place in the Management of Axial Spondyloarthropathy?

As we emerge from the pandemic sport has taken on a renewed importance in our lives. From the coming together during the Euro’s and the Olympics, to being able to play sport again with our friends it has helped to lift people’s spirits. So imagine, when your world revolves around sport, being told you have Axial Spondyloarthropathy (axial SpA). In my twenty plus years working in Rheumatology, it still makes me sad to meet people living with axial SpA who have given up on the sport they love as they believe it could make their condition worse.

We all know about the importance of exercise in the management of axial SpA; but do we always think about exercise in its broadest context? Yes, we know those people living with axial SpA that we work with need flexibility exercises, but do we always consider high intensity exercise? There is no greater motivational tool to exercise than doing something you are passionate about; but for many living with axial SpA the fear of making their condition worse makes them turn their backs on sport.

As Physiotherapists we have a vital role in educating and ensuring people living with axial SpA are able to live their lives to the full. With the advancements in the treatment of axial SpA it need not be a life-changing condition. Phil Mickleson’s recent win at the PGA golf championships despite having psoriatic arthritis shines a beacon of hope for all those people who have given up on sport because they have an inflammatory condition.

A recent study in the British Journal of Sports medicine helps support the message that sport is safe. Halvorsen Sveaas et al. (2020) investigated the effectiveness of high intensity exercise on disease activity in people living with axial SpA. A group of 100 participants aged between 18-70 years with an average Bath Ankylosing Disease Activity Index (BASDAI) of > 3.5 were randomly assigned to either an exercise group or a no intervention control group. The primary outcome measures used were the Ankylosing Disease Activity Score (ASDAS) and the BASDAI.

Over a 3 month period, the participants in the exercise group carried out cardiorespiratory exercises 3 days a week. Two days supervised running or walking on a treadmill/cycle ergometer and 1 day unsupervised walking, running or cycling at a fitness centre. Two days a week they carried out supervised strength training; this included squats, leg press, deadlifts, rows to chest, bench press, shoulder press, pull downs and sit ups. The strength training was individually adapted.

The exercise group were shown to have a 23% difference in the ASDAS when compared to the control group and there was a 24% difference in the BASDAI compared to the control group. As well as the reduction in disease activity there was also a significant improvement in their V02max.

These findings are important in reassuring people living with with axial SpA that they can continue with high intensity exercise, not just as a means of maintaining cardiovascular fitness but being able to continue to enjoy sport alongside their friends and family. Brophy et al. (2013) reported that intrinsic motivation, freely choosing to exercise because it is pleasurable and fun, is associated to the greatest effect on exercise levels and benefit to function. It is therefore important that when we are educating people living with axial SpA about exercise, that we discuss what they enjoy doing, and in creating a tailor made programme for that patient we include this. Hopefully, in doing so we will see better adherence with exercise and enhance all the benefits that go along with that.
???????

There are still very few studies that look at the effects of high intensity exercise in axial SpA. There is a need for further research in this field whilst there is still the misconception that high intensity exercise will cause a flare up of axial SpA. Working to dispel this myth would be a big step forward in improving the outlook for many people living with axial SpA by ensuring they do not abandon their sporting activities and all the physical and mental improvements that they bring.

Halvorsen Sveaas S et al. (2020) High Intensity Exercise for 3 Months Reduces Disease Activity in Axial Spondyloarthritis: A Multicentre Randomised Trial of 100 Patients. British J Sports Medicine 54 (5) 292-297

Brophy S et al. (2013) The Effect of Physical Activity and Motivation on Function in Ankylosing Spondylitis. Seminars in Arthritis and Rheumatism 42 (6) 619 - 626

Sue

June 2021 BSR eLearning - spotlight on Axial SpA

After a period of failing to produce our monthly blog, June is our month to gradually introduce this back into your learning schedules. Please do bear with us as we get things back together for what will hopefully soon be a monthly blog released on the first Monday of each month...back to our usual routine for July.
Our aims at AStretch remain to share best practise and promote best care for people living with Axial SpA. Of course, we don't do this alone, and this month we wanted to spotlight one of the organisations we work closely with, namely the British Society for Rheumatology (BSR). The BSR is the national society for rheumatology and has recently amalgamated its medical and health professional sections as well as its paediatric arms into one combined Society. This has been a great move for physiotherapy and for health professions as a whole as we get more closely associated with all members of the team that look after those living with rheumatological diagnoses. One of the aims of the BSR at the moment is to invest and develop its eLearning platform. This has led to a recent implementation of a Digital Learning Board which is meant to act in the same way as an editorial board would do for a more traditional paper journal based output. One of our members of the AStretch committee was fortunate enough to be recruited to this Digital Learning Board and therefore we at AStretch have a voice and strong representation at this level. Amongst other benefits, this has led to the allocation of the month of June for the BSR eLearning to be more focused on physiotherapists (and other allied health professionals) and to offer content around the management of those living with axial SpA. Not all physiotherapists working in rheumatology are members of the British Society of Rheumatology, and for that reason the membership team at the BSR did offer free access to all interested physiotherapists to the June eLearning content, more than 40 physiotherapists took up this offer (offer finished 5th July 2021)

Here is a screenshot of the menu of learning activities you'll see on accessing the BSR eLearning content for this June month of focus on axial SpA and we do hope you'll find it useful. It includes an eLearning case study written by Will Gregory. There's an expert webinar on axial SpA delivered by Professor Karl Gaffney. We've got a new podcast recorded specifically for the eLearning where two members of the 2017 NICE SpA guidelines development group (Dr. Carol McCrum and Dr. Nicola Goodson) discuss how the guideline was written and its current application in 2021. We also have free access to a journal article on the Early Inflammatory Back Pain service that Becky Adshead runs at Barts, ten years of experience and an exemplar service. And finally, there is a webinar on investigation interpretation thinking about bloods and their role in diagnosing back pain as well as potential differential diagnosis including red flag issues.

This is a great development that the BSR are investing in eLearning and are clearly committed to physiotherapists and also to axial SpA. We are really keen that as many people as possible can access the June learning and hence this slight hijack of the AStretch blog to spread the word far and wide. We will be back to usual educational, informative and evidence-based blog content next month so please do lookout for the new blog dropping Tuesday 6th of July.

Will

Five Reasons People with Axial SpA might not do Physio Exercises and What Might Help….

February 2020: As February starts, if you are anything like me, the New Year’s resolutions that we made on the 1st of January start waning. My brand new trainers have had a few outings, but far less than I had hoped. Starting an exercise programme is hard, and keeping it going is even harder.
Physiotherapists who work with people with Axial Spondyloarthritis (axial SpA) prescribe exercises that improve spinal mobility, cardiovascular health, function and quality of life. Although evidence suggests that the exercises improve clinical outcomes, people with axial SpA don’t always manage to start their exercises, many (like me) struggle to do it as often as prescribed and some can stop all together. Here are five common reasons why people struggle to complete their exercises and some hints of where we can help……

1. Time.

Sounds simple. Time is the most commonly reported barrier to exercising. Time pressures come from work, family obligations and study; with these often prioritised before time for exercise. It has been suggested that lack of time actually represents lack of motivation, but a recent study found that those who report lack of time as a barrier to exercise actually had less free time than those who didn’t report lack of time as a barrier. What might help? Try including a support network, such as family, into the exercise programme and incorporate exercises into the working day.

2. Concurrent medical problems.

People with axial SpA often have other health problems, such as mental health problems, hypertension and osteoporosis. Following multiple medical regimes can overload people. What might help? Tailoring exercises regimes to the individual, keeping them simple, enjoyable and varied. Again, include any support networks such as family, friends, work colleagues or health care professionals.

3. Symptoms.

Axial SpA manifestations include inflammatory back pain, arthritis of the lower limbs, dactylitis (‘sausage’- like digits), enthesitis at the heel or other sites, uveitis, inflammatory bowel disease and psoriasis. Individuals with axial SpA commonly complain of fatigue, stiffness, flares and pain. These symptoms are variable, but for a proportion of individuals with axial SpA these will be intense, frequent and disabling. Those with troublesome disease symptoms may be less likely to do their exercises. What might help? Exercise may help some symptoms – but not everyone might be aware of this, so education on this will help. Also, start exercise plans off slowly and build up, and set simple achievable goals. Refer onto other colleagues who might also be able to help with the symptoms.

4. Fear.

Some people are scared the exercises are going to do more harm than good, or that they are not doing them correctly. What might help? Practise the exercises with the individual, provide digital resources so the person can see the exercises, and educational resources to reassure the person.

5. Self-efficacy.

This is an individual’s belief in their ability to complete specific tasks, in this case the exercises. People with low self-efficacy typically stop the task if they encounter problems such as understanding the regime, being physically unfit, busy or tired. Those with high level of self-efficacy, do their best to improve skills and overcome the obstacles. What might help? Interventions such as education resources and support can improve self-efficacy and feedback to the individual on how they are doing. Again, provide support.

There are probably not just five, but more than a hundred and five reasons why people find it difficult to adhere to their prescribed exercise programmes. The World Health Organisation suggests adherence is determined by a complex interaction between healthcare, personal, socioeconomic, treatment and condition constructs. If an individual is struggling, exploring with the person their reasons for why they are finding it difficult and considering tailoring interventions are steps to improving adherence.

MT McDonald, Physiotherapist, Glasgow

Email mmd7@gcu.ac.uk

Bibliography
ANONIMO et al. (2003) Adherence to Long-term Therapies: Evidence for Action. World Health Organisation.
Reichert, F.F. et al. (2007) "The role of perceived personal barriers to engagement in leisure-time physical activity" American Journal of Public Health, 97(3), 515-519
DiMatteo MR, Lepper HS, Croghan TW. Depression Is a Risk Factor for Noncompliance With Medical Treatment: Meta-analysis of the Effects of Anxiety and Depression on Patient Adherence. Arch Intern Med. 2000;160(14):2101–2107.
O’Dwyer, T., McGowan, E., O’Shea, F., & Wilson, F. (2016). Physical Activity and Exercise: Perspectives of Adults With Ankylosing Spondylitis, Journal of Physical Activity and Health, 13(5), 504-513

Some further reading (and watching): AStretch supporting people with AxSpA over the lockdown period

These have been most unusual times and we have all been working differently. We are very lucky as a group of physiotherapists working with people with AxSpA to have the National Axial Spondyloarthritis Society encouraging and enabling us. These past few months we've worked with NASS on a handful of public-facing resources. And so, in lieu of any new material for this August blog, please find below some links to these resources. Whilst essentially recorded for people with AxSpA, we've had good feedback from a number of physiotherapists and other health care professions who have found them useful for their own learning.

In addition to the individual links below there is a summary page on the NASS website of what we at AStretch have done as well as ALL the other sessions NASS have hosted in the past few months, please do have a look here https://nass.co.uk/managing-my-as/my-as-my-life/ there is absolutely loads covered and a fantastic combination of blogs, videos and further reading.

Will

Emily: Motivation to Exercise

Mel: Telehealth to Empower Patients

Heather: Improving Balance & Reducing Falls

Louise: Using Rheumatology Expertise in an FCP Role

Will: Making the Most of Your Remote Consultation

Emily: 30-minute Stretch Routine

LOOKING FOR OUR OLDER BLOGS?

CLICK HERE for our blogs from the 2010s

About us

AStretch is a not for profit organisation; our main aim is to provide a co-ordinated approach to the planning and delivery of education and best practice. Also to support physiotherapists working with people who have Axial Spondyloarthritis (AxSpA) and Ankylosing Spondylitis (AS).

Navigation

Contact

Email us on astretch@astretch.co.uk for general enquiries

comms@astretch.co.uk to submit features for peer review and consideration for website inclusion

education@astretch.co.uk for enquiries related to our courses or conference.