The World Health Organization considers physical inactivity to be a risk factor for mortality and, thus, recommends an active role for health professionals in promoting exercise.1

In spondyloarthritides (SpA), not only has exercise been shown to relieve symptoms of disease and improve functional capacity and quality of life, it could prevent the development of deformities. The importance of exercise in these processes has led to the inclusion of specific recommendations for performing physical activity in different consensus statements on the management of SpA issued by international organizations.2–6

The response to exercise is determined by a number of components (frequency, intensity and duration), but also depends on the patient's adherence to, or compliance with, the prescribed program.7–12 The results of a Cochrane review show that exercise programs in ankylosing spondylitis (AS) fail to comply with the current recommendations, that the measurement of the efficacy is inadequate and that adherence is evaluated in few cases.13 Although compliance varies depending on the definition and the means used to measure it, some studies report it to be around 50% in AS.14

Poor adherence to exercise regimens by patients is multidimensional. In addition to their low expectations, little motivation and limited understanding of the exercises, other possible factors are the pain they experience and their lack of time, aspects that should be taken into account when prescribing any program.15,16 Patient compliance can also be affected by the difficulties faced by the physiotherapists themselves, who need to resolve the confrontation between accepted patient care standards and those that each professional judges to constitute best clinical practice. Thus, the main problems stemming from this lack of agreement is the professional's freedom and the need to individualize physiotherapy.17

In contrast to the approach to disease prevention in healthy young individuals, the range of options for the therapeutic management of physical activity in patients with chronic diseases may be limited. When prescribing exercise, physicians should be familiar with the physiological mechanisms and the underlying principles that enable an exercise regimen to act on the organism, as well as with the barriers that impede patients from carrying it out. On the other hand, the adaptation of the exercise program should be based on the patient's physical status and on establishing, together with the patient, the program of goals to achieve. Despite the available evidence,5,10,12,18 rheumatologists are not trained in techniques related to physical activity and sports.19,20 Their recommendations to patients concerning the need to exercise are usually general, without a prescription based on clear guidelines; rather they are substantiated by their own experience. Thus, it is important to record and analyze the opinions of rheumatologists regarding exercise in general and programs specific for SpA in order to improve the prescription of individualized programs and promote adherence to them.

The objective of this report is to know the opinions, perceptions and assumptions of Spanish rheumatologists, experts in SpA, concerning the role of exercise in diseases of this type and in other rheumatic diseases. The results of this study will make it possible to define criteria for the prescription of adequate exercise programs in patients with SpA and to develop effective prescribing strategies.

The survey was completed by a total of 44 rheumatologists (Table 1), with a slight predominance of women (51%), a mean age of 47±6 years, an average of 20 years of professional practice and an average of 20 new patients and 54 patients already in treatment per week. The majority of the responders were associate physicians (77%) and their personal experience with exercise was good (78%); they devoted more than 3h a week to aerobic exercise (27%) or to strength or resistance training (56%). These findings are shown in detail in Banexo Appendix A (available online).

Exercise Prescription in Routine Clinical Practice

Despite the fact that the surveyed rheumatologists calculated that more than 86% of their patients needed to perform physical exercise (Fig. 1), the rate of exercise prescription was moderate, with 23% of the patients being referred for rehabilitation and 17% for physical therapy (Fig. 2). The rheumatologists reported having good access to rehabilitation providers (7/10), moderate access to physiotherapists (4/10) and practically no access to other physical activity or sports specialists (1/10) (Fig. 3).

Fig. 1.

Recommendations to rheumatologists concerning exercise performance.

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Fig. 2.

Referral of patients to exercise specialists.

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Fig. 3.

Degree of access to different specialists (scored on a scale of 0 to 10).

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The majority considered that the referral of a patient to the rehabilitation service for a demonstration of how exercise should be performed is the best format for recommending exercise—better than brochures, the Internet, videos or a demonstration on the part of the rheumatologist.

On the other hand, 93% of the rheumatologists considered that they could recommend exercise programs to their patients, although only 68% believed themselves to be qualified to suggest particular exercises and a little over 60% devoted a specific part of their patients’ visits to aspects related to exercise. Finally, the educational material on physical activity available in the rheumatologist's office consisted basically of informative brochures (90%) and, to a lesser extent, websites (52%) and videos (23%).

In this study, we analyze the opinions of and approaches to exercise in patients with rheumatic and musculoskeletal disease offered by a group of Spanish rheumatologists, experts in SpA.

First of all, we consider it striking that, although according to the responders to the survey, a very large percentage of their patients would benefit from exercise, as reported in the medical literature,21,22 the rate of referral to specialists in physical exercise and sports is not very high. This may be due to a number of factors, including the perception that the recommendations and explanations concerning exercise given during consultations are sufficient, or the search for greater autonomy on the part of the patients. However, we cannot rule out other possibilities, for example, the effects in some centers of a waiting list for access to rehabilitation, or the nonexistence of protocols that clearly indicate which patients should be referred to a specialist and when, or the lack of specific training of rheumatologists in this aspect.

With respect to the different formats for recommending exercise (including brochures and videos), the majority are considered to be relatively useful, although the demonstration on the part of a rehabilitation provider is thought to be the most effective approach. There is evidence of the efficacy of different methods of recommending exercise, although its quality is moderate,23 it usually focuses only on the short-to-medium term and does not always reflect other aspects that can play a role, such as the duration of patient visits, the extent to which the Internet is used, etc.

All the rheumatologists coincide in that, depending on the underlying disease, exercises of one type or another should be recommended, as is pointed out by different organizations.4,24–26 In this block of questions, there is a notable variability in the descriptions of the beneficial effects of stretching exercises and strength training. To this we should add the finding that a high percentage of responders do not consider themselves competent enough to recommend specific exercises. All this may indicate the need to attain a greater understanding of the bases and benefits of exercise. Similar results have been reported by others in settings like ours.27

On the other hand, in rheumatic diseases, there is a majority opinion with regard to the need to reduce the intensity of exercise when acute inflammation develops, but that bedrest is not required. There are data that coincide with the published evidence and the recommendations issued to date in this respect.12,24

In relation to the findings specific for SpA, the majority of those surveyed stress the beneficial role that exercise can play in multiple symptoms and signs of the disease, such as spinal and joint mobility, fatigue, stiffness, self-care and sleep. Likewise, the majority of the responders do not consider exercise to have a relevant role in the inflammation and structural damage that these patients develop. A systematic review of the literature on the effects of different exercise modalities on AS points out that it can have a moderate to good efficacy in different aspects of the disease, especially mobility and function, but also in activity as measured by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). However, it is important to stress that the studies on which these affirmations are based are small, and that the results are not always statistically significant, a circumstance that limits the validity of the conclusions.12 Another recent systematic review also demonstrates that exercise may have a beneficial effect on inflammation in AS, although it also concludes that, as yet, its effect on other types of SpA is unknown.28

Continuing with the discussion of the disease activity in SpA, there is no general agreement as to whether exercise can trigger a flare of the disease; two thirds of those surveyed reject this idea. To date, the data in the literature have been unable to demonstrate the existence of an association between exercise and the onset of flares.29,30 Likewise, there is no agreement as to whether or not exercise can delay the initiation of treatment, a question that remains unresolved in the literature. One aspect in which all the responders coincide is in the need to recommend exercise to patients with SpA, regardless of the disease course. In relation to other nonpharmacological measures, the level of recommendation of spinal manipulation is very low, a circumstance that coincides with the majority of the current guidelines and consensus statements.4,30 In an intermediate point, we find physical means and balneotherapy. Finally, in the early stages, aerobic exercises, strength training and stretching are those most widely recommended, whereas exercises aimed at improving respiratory function, occupational therapy and postural exercises are reserved for patients with more advanced disease. The approach employed is very similar to those proposed in the Spanish guidelines.

On the other hand, these findings should be interpreted with caution. One of the major limitations of the present study is the fact that the survey was sent to a small number of rheumatologists who belong to a SpA working group. Although these professionals can treat patients with rheumatic diseases of all types, their experience in SpA may mean, at least a priori, that they have a greater knowledge of the study subject than the general population of rheumatologists in Spain. Then again, the low percentage of participation on the part of the rheumatologists invited may have some effect on the results. Nevertheless, there were no differences between the responders and the nonresponders in terms of sex or the Spanish autonomous communities in which they lived, there being no other data on which to base a comparison between the two groups. Finally, the lack of information on the recommendation of specific exercise programs or evaluation of the degree of compliance with them may contribute to the apparent contradiction between the widespread knowledge of the beneficial effects of exercise and the low rate of referral of patients to the specialists in that area.

In conclusion, although there is general agreement on the beneficial effects of exercise in rheumatic diseases, including SpA, a greater understanding of these effects and the design of protocols for exercise regimens are needed.

The authors declare they have no conflicts of interest involving any of the laboratories that could be related to the objective of this manuscript either directly or indirectly (agencies, scientific societies or publishing companies), or through institutional (governmental) agencies, foundations or private entities.