In a first phase, we distributed a survey sent by e-mail utilizing an online platform of the 106 professionals who are members of the SpA working group of the Spanish Society of Rheumatology (GRESSER), the results of which have been published.12

To learn the opinion and evaluation of the patients, we considered that the most adequate technique was to form focus groups. For the recruitment of the participants we contacted with the Spanish Coordinator of Spondylitis and the Spanish League of Rheumatology. The results of these groups have also been published.11

The results of the survey and of the focus groups were presented in 2 discussion groups. To the first group, we invited specialists in exercise, physical activity and sports and physiotherapists, who were familiar to the scientific committee, who, in turn, invited others (snowball sampling). In all, 9 individuals were invited (see the description in Table 1). In the meeting, we established the discussion forum and the bases for the most technical recommendations were determined (report of the meeting is available upon request). The second group was attended by rheumatologists selected from the participants of the GRESSER group due to their interest in the subject, and they were explained the preceding material. In this second group, we discussed the recommendations provided by the first group and determined the bases for the overall recommendations for indication, follow-up and their adaptation to the rheumatology services.

The preliminary recommendations were voted in a first Delphi round to establish the level of agreement with the proposals. The level of agreement was expressed by voting according to a Likert scale from 1 (totally in disagreement) to 5 (totally in agreement). This was defined if the mean in the two groups and overall mean was over 4 and the standard deviation did not exceed 1. The recommendations with a level of agreement of less than 4 were rewritten, taking into account any comments received, and were voted on in a second Delphi round. It was possible to include new recommendation between the two Delphi rounds, which were voted on in the second round.

Before they know all of the complications of the disease, the patients want information on what they can do to improve.11 It must be stressed that exercise is a fundamental pillar of the treatment and these individuals should be informed of the benefits it produces.

Attitude and the level of knowledge of the rheumatologist are essential for the prescription of exercise. If rheumatologists feel that what they prescribe is convenient, because they are familiar with it, it is probable that they devote more time to the office and perform an adequate follow-up.15 Patients confide in verbal and written information provided by their specialists. Thus, it is necessary to design strategies to be employed in the office to provide positive information.16 For example, we allude to a number of studies that have demonstrated the benefit of the combined effect of drug therapy plus exercises devised specifically for SpA versus drug therapy or exercise alone.10,17–20

On the other hand, the patient must be given realistic information, with the specification that, like certain drugs, exercise requires perseverance and time in order to begin to have an effect. This message is important to prevent dropouts for not complying for this reason. In initial phases, it is preferable to give only positive messages to incite the patients to exercise, for the purpose of converting it into a routine.

It is essential to make the message clear that exercise is necessary in all the phases of SpA, given that the general advantages are maintained throughout the disease. However, for an optimal efficacy of the exercise program, it is indispensable to consider the phase of the disease, its activity and progression.10 In the opinion of the experts, an early introduction of the indications following the diagnosis might favor a greater implication and adherence to exercise.

In the initial stages—patients with less severe mobility limitation and functional impact—the recommendation for physical activity is that advised by the American College of Sports Medicine for healthy adults (Tables 2 and 3).13 According to this recommendation, an adult between 18 and 64 years of age should spend a minimum of 150min a week in moderate aerobic physical activity, or a minimum of 75min a week in vigorous aerobic activity or, again, an equivalent combination of moderate and vigorous activity; all this should be distributed over a period of 3–5 days.

In intermediate phases (patients with limited mobility and functional impact), the progression of exercise should be stressed from the start, with the prevention of exceeding the limit in which it will no longer be beneficial; in this respect, professional help from a specialist in physical exercise can be suggested. In this phase, a combination of adapted aerobic exercise and one of the programs for stretching-strengthening that have shown to be effective in clinical trials should be recommended.21-23

In advanced phases (in patients who are found to have ankylosis), aerobic exercise should continue, avoiding overexertion and working on flexibility. Simple exercises can be added that make it possible to strengthen the major muscle groups (vertebral, diaphragm, abdominal, etc.23,24). Forced stretching and maintained postures do not appear to be effective and rheumatologists should advise against them.

It is recommended that the prescription initially include few and simple exercises in all the phases. This will favor adherence of patients who exercise very little, given that the complexity of a therapeutic intervention reduces adherence and programs with a limited number of simple exercises will have greater probabilities of being maintained over time.25

Regarding the type of physical activity, the experts recommend adapting the frequency, intensity, duration and type of exercise to the preferences of the patient, as well as the results of the physical examination, the aims and lifestyle of each. The international guidelines on physical activity can be utilized, although they will require adaptation. Traditionally, exercises indicated in patients with SpA were for the maintenance of spinal and thoracic mobility, but it has been seen that aerobic exercise should be included in the prescription for these individuals. The performance of cardiorespiratory exercises and those involving muscle strength have demonstrated their efficacy in the prevention of cardiovascular diseases in SpA because of the reduction of classical risk factors and improvement in aortic elasticity,25–27 in addition to increasing the flexibility of these patients.8,9,28

The exercises should be adjusted to the severity of the disease, the short- and long-term objectives, the needs and expectations of the patient and even his or her resources.18 The inadequacy of exercise, either due to its elevated intensity or because its progressivity is limited, is a barrier for the patients who exercise. Thus, it is necessary to adapt physical exercise to the patient who has seen improvement with adherence, which facilitates training.10,22

The exercise programs most widely utilized focus on the improvement of flexibility, thoracic expansion and strengthening of the extensor musculature. They include exercises of the major muscle groups, especially the vertebral and pelvic muscles of the posterior plane.29 There are certain cases in which the recommendations include overall exercises that can also be functional, such as squatting, getting up from a chair, etc. Another alternative involves overall flexibility that consists of stretching at the level of the back and of the lower and upper extremities.30

In initial phases, exercises involving the spine do not provide a significant improvement; whereas aerobic exercise leads to less pain and stiffness. Sveaas et al.26 found that engaging in high-intensity exercise improved the Bath Ankylosing Spondylitis Disease Activity Index score, acting as a complement to drug intervention. If the patient already has ankylosis, aerobic exercises and those designed for strengthening should be recommended, avoiding forced stretching and high-impact exercises as they can be hazardous.21,31

The exercise guidelines can include a component of postural education. Patients in whom postural education is indicated improve in terms of morning stiffness, spinal mobility, thoracic expansion and quality of life.22,23 Sports that promote a good posture and stretching of the torso, such as hiking, swimming, cross-country skiing, tennis, badminton, archery, Nordic walking and volleyball, are especially recommendable.4

With respect to the format, supervised exercise programs seem to be more effective than unsupervised models. This may be the result of an increased adherence or because these exercises have a greater control in terms of intensity and duration.1,8,24,28,32,33 Working in groups is recommended as a good option to facilitate adherence and lower the costs, although it reduces the individuality of the exercise1,2,34 and, as the patients point out, the individual barriers to a given activity must be taken into account.11

When there is pain, it cannot be ignored, and it is necessary to avoid any exercise that significantly increases it. During a flare, or when there is pain or inflammation, the range of mobility should be restricted to “unpainful” limits, and there should be a close supervision of exercise to avoid complications.29 Nevertheless, immobilization should be avoided, even in periods of pain, since physical activity helps to relieve the pain, improves spinal mobility and the overall assessment of the patient.9,35 It is necessary to avoid exercise focused on a painful region unless there is a clear objective. For example, exercise involving cervical flexibility would not be indicated in a patient with pain in that region, but with no limitation affecting mobility. It is useful to have variants of certain types of exercise for patients with given characteristics (advanced age, an evident limitation of mobility).36

It is advisable to have some type of supervision, for example, sending e-mails to the patient and carrying out follow-up especially in the initial phases of the process. An adequate way to make patients engage in exercise programs as part of their custom could be the use of motivating messages, or the routine introduction of phrases promoting physical activity. There must be sufficient follow-up and feedback, in an individual manner, to achieve the confidence and proficiency with the performance of physical exercise and to be informed of the necessities of changing the prescription. All of the patient's follow-up visits must include questions on the type and dose of exercise, and the patient should be asked to maintain it or even increase it. Although it would be unusual, the patient may be engaging in more exercise than would be reasonable. In these cases, it is important to detect this fact and modulate it.

The authors declare that no experiments were performed on humans or animals for this study.

The authors declare that they have followed the protocols of their work center on the publication of patient data.

The authors declare that no patient data appear in this article.