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Treat-to-target in axial spondyloarthritis — what about physical function and activity?

Abstract

In patients with axial spondyloarthritis (axSpA), pain, functional and structural impairments, reduced mobility and potential deformity of the axial skeleton are the most prominent health concerns. Limitations in physical function and spinal mobility are caused by both inflammation and structural damage, and therefore restrictions to physical function must be monitored throughout a patient’s life. Consequently, the assessment of physical function is recommended as a key domain in the Assessment of Spondyloarthritis International Society–OMERACT Core Outcome Set. However, in comparison with disease activity, physical function seems to be a relatively neglected target of intervention in patients with axSpA, even though physical function is a major contributor to costs and disability in this disease. This Review aims to reacquaint rheumatologists with the targets for physical function, physical activity and performance by giving guidance on determinants of physical function and how physical function can be examined in patients with axSpA.

Key points

  • Impairments in physical function are among the most prominent health concerns in patients with axial spondyloarthritis (axSpA); their assessment is a key domain in the ASAS–OMERACT Core Outcome Set.

  • The WHO International Classification of Functioning, Disability and Health is the most sophisticated classification system to capture the entire spectrum of functioning and health.

  • Physical function can be assessed using self-report tools for physical function and physical activity, objective measurements of spinal mobility and performance-based tests.

  • Physical function in patients with axSpA is influenced by inflammation and structural damage, as well as by comorbidities, mental health and various contextual factors.

  • Although a combination of pharmacological and non-pharmacological therapy is recommended for the management of axSpA, interventions to improve or maintain function is a relatively neglected target for patients with axSpA.

  • Interventions to improve physical function include strategies to enhance physical activity on a regular basis and physiotherapy interventions, often in combination with pharmacological treatments.

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Fig. 1: The biopsychosocial model of function in axial spondyloarthritis.
Fig. 2: Factors that affect physical function in axial spondyloarthritis.

References

  1. 1.

    Braun, J. & Sieper, J. Ankylosing spondylitis. Lancet 369, 1379–1390 (2007).

    PubMed  Article  PubMed Central  Google Scholar 

  2. 2.

    Sieper, J. & Poddubnyy, D. Axial spondyloarthritis. Lancet 390, 73–84 (2017).

    PubMed  Article  PubMed Central  Google Scholar 

  3. 3.

    Kiltz, U. & van der Heijde, D. Health-related quality of life in patients with rheumatoid arthritis and in patients with ankylosing spondylitis. Clin. Exp. Rheumatol. 27, S108–S111 (2009).

    CAS  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Kiltz, U., Kiefer, D. & Boonen, A. (Health-related) quality of life as an outcome in studies of axial spondyloarthritis. Rheumatic Dis. Clin. North. Am. 46, 379–393 (2020).

    Article  Google Scholar 

  5. 5.

    Boel, A. et al. Do patients with axial spondyloarthritis with radiographic sacroiliitis fulfil both the modified New York criteria and the ASAS axial spondyloarthritis criteria? Results from eight cohorts. Ann. Rheum. Dis. 78, 1545–1549 (2019).

    PubMed  Article  PubMed Central  Google Scholar 

  6. 6.

    van der Heijde, D. et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann. Rheum. Dis. 76, 978–991 (2017).

    PubMed  Article  PubMed Central  Google Scholar 

  7. 7.

    Smolen, J. S. et al. Treating axial spondyloarthritis and peripheral spondyloarthritis, especially psoriatic arthritis, to target: 2017 update of recommendations by an international task force. Ann. Rheum. Dis. 77, 3–17 (2018).

    PubMed  Article  PubMed Central  Google Scholar 

  8. 8.

    Rudwaleit, M., Listing, J., Brandt, J., Braun, J. & Sieper, J. Prediction of a major clinical response (BASDAI 50) to tumour necrosis factor α blockers in ankylosing spondylitis. Ann. Rheum. Dis. 63, 665–670 (2004).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  9. 9.

    Ramiro, S. et al. Higher disease activity leads to more structural damage in the spine in ankylosing spondylitis: 12-year longitudinal data from the OASIS cohort. Ann. Rheum. Dis. 73, 1455–1461 (2014).

    PubMed  Article  PubMed Central  Google Scholar 

  10. 10.

    Machado, P. et al. Both structural damage and inflammation of the spine contribute to impairment of spinal mobility in patients with ankylosing spondylitis. Ann. Rheum. Dis. 69, 1465–1470 (2010).

    PubMed  Article  PubMed Central  Google Scholar 

  11. 11.

    Maxwell, L. J. et al. TNF-alpha inhibitors for ankylosing spondylitis. Cochrane Database Syst Rev. 4, CD005468 (2015).

    Google Scholar 

  12. 12.

    Poddubnyy, D. et al. Physical function and spinal mobility remain stable despite radiographic spinal progression in patients with ankylosing spondylitis treated with TNF-α inhibitors for up to 10 years. J. Rheumatol. 43, 2142–2148 (2016).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  13. 13.

    Fongen, C. et al. Frequency of impaired spinal mobility in patients with chronic back pain compared to patients with early axial spondyloarthritis. J. Rheumatol. 45, 1643–1650 (2018).

    PubMed  Article  PubMed Central  Google Scholar 

  14. 14.

    Haibel, H. et al. Health care and disease burden in persons with axial spondyloarthritis in Germany [German]. Z. Rheumatol. 78, 865–874 (2019).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  15. 15.

    Kiltz, U., Ahomaa, E., Bühring, B., Baraliakos, X. & Braun, J. Clinically relevant deficits in simple performance tests of patients with axial spondyloarthritis (axSpA) – only collecting questionnaires is insufficient [abstract]. Arthritis Rheumatol. 71, 1820 (2019).

    Google Scholar 

  16. 16.

    Ward, M. M. Functional disability predicts total costs in patients with ankylosing spondylitis. Arthritis Rheum. 46, 223–231 (2002).

    PubMed  Article  PubMed Central  Google Scholar 

  17. 17.

    Boonen, A. et al. Direct costs of ankylosing spondylitis and its determinants: an analysis among three European countries. Ann. Rheum. Dis. 62, 732–740 (2003).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  18. 18.

    Landewe, R., Dougados, M., Mielants, H., van der Tempel, H. & van der Heijde, D. Physical function in ankylosing spondylitis is independently determined by both disease activity and radiographic damage of the spine. Ann. Rheum. Dis. 68, 863–867 (2009).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  19. 19.

    Chui, E. T. F. et al. MRI inflammation of facet and costovertebral joints is associated with restricted spinal mobility and worsened functional status. Rheumatology 59, 2591–2602 (2020).

    PubMed  Article  PubMed Central  Google Scholar 

  20. 20.

    Bochkova, A. G., Levshakova, A. V., Bunchuk, N. V. & Braun, J. Spinal inflammation lesions as detected by magnetic resonance imaging in patients with early ankylosing spondylitis are more often observed in posterior structures of the spine. Rheumatology 49, 749–755 (2010).

    PubMed  Article  PubMed Central  Google Scholar 

  21. 21.

    Dias J. M. in Encyclopedia of Quality of Life and Well-Being Research (ed Michalos A. C.) (Springer, 2014).

  22. 22.

    Montero-Odasso, M. et al. Gait velocity as a single predictor of adverse events in healthy seniors aged 75 years and older. J. Gerontol. A Biol. Sci. Med. Sci. 60, 1304–1309 (2005).

    PubMed  Article  PubMed Central  Google Scholar 

  23. 23.

    World Health Organization. International classification of functioning disability and health. who.int https://www.who.int/classifications/international-classification-of-functioning-disability-and-health (2021).

  24. 24.

    Peeters, G., Dobson, A. J., Deeg, D. J. & Brown, W. J. A life-course perspective on physical functioning in women. Bull. World Health Organ. 91, 661–670 (2013).

    PubMed  PubMed Central  Article  Google Scholar 

  25. 25.

    Rausch Osthoff, A. K. et al. 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Ann. Rheum. Dis. 77, 1251–1260 (2018).

    PubMed  Article  PubMed Central  Google Scholar 

  26. 26.

    Fanning, J. et al. Relationships between profiles of physical activity and major mobility disability in the LIFE study. J. Am. Geriatrics Soc. 68, 1476–1483 (2020).

    Article  Google Scholar 

  27. 27.

    van Weely, S. F. et al. Moving instead of asking? Performance-based tests and BASFI-questionnaire measure different aspects of physical function in ankylosing spondylitis. Arthritis Res. Ther. 14, R52 (2012).

    PubMed  PubMed Central  Article  Google Scholar 

  28. 28.

    Yuksel Karsli, T. et al. Comparison of physical activity levels among different sub-types of axial spondyloarthritis patients and healthy controls. Mod. Rheumatol. https://doi.org/10.1080/14397595.2021.1891676 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Boonen, A. et al. Aspects relevant for functioning in patients with ankylosing spondylitis according to the health professionals: a Delphi study with the ICF as reference. Rheumatology 48, 997–1002 (2009).

    PubMed  Article  PubMed Central  Google Scholar 

  30. 30.

    Boonen, A. et al. ASAS/WHO ICF Core Sets for ankylosing spondylitis (AS): how to classify the impact of AS on functioning and health. Ann. Rheum. Dis. 69, 102–107 (2010).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  31. 31.

    Kiltz, U. et al. Measurement properties of the ASAS Health Index: results of a global study in patients with axial and peripheral spondyloarthritis. Ann. Rheum. Dis. 77, 1311–1317 (2018).

    PubMed  Article  PubMed Central  Google Scholar 

  32. 32.

    Kiltz, U. et al. Development of a health index in patients with ankylosing spondylitis (ASAS HI): final result of a global initiative based on the ICF guided by ASAS. Ann. Rheum. Dis. 74, 830–835 (2015).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  33. 33.

    van der Heijde, D. et al. Preliminary core sets for endpoints in ankylosing spondylitis. Assessments in Ankylosing Spondylitis Working Group. J. Rheumatol. 24, 2225–2229 (1997).

    PubMed  PubMed Central  Google Scholar 

  34. 34.

    Zochling, J., Braun, J. & van der Heijde, D. Assessments in ankylosing spondylitis. Best. Pract. Res. Clin. Rheumatol. 20, 521–537 (2006).

    PubMed  Article  PubMed Central  Google Scholar 

  35. 35.

    Calin, A. et al. A new approach to defining functional ability in ankylosing spondylitis: the development of the Bath Ankylosing Spondylitis Functional Index. J. Rheumatol. 21, 2281–2285 (1994).

    CAS  PubMed  PubMed Central  Google Scholar 

  36. 36.

    Prince, S. A. et al. A comparison of direct versus self-report measures for assessing physical activity in adults: a systematic review. Int. J. Behav. Nutr. Phys. Act. 5, 56 (2008).

    PubMed  PubMed Central  Article  Google Scholar 

  37. 37.

    van Genderen, S. et al. Physical functioning in patients with ankylosing spondylitis: comparing approaches of experienced ability with self-reported and objectively measured physical activity. J. Clin. Rheumatol. 20, 133–137 (2014).

    PubMed  Article  PubMed Central  Google Scholar 

  38. 38.

    Perrotta, F. M., Lories, R. & Lubrano, E. To move or not to move: the paradoxical effect of physical exercise in axial spondyloarthritis. RMD Open 7, e001480 (2021).

    PubMed  PubMed Central  Article  Google Scholar 

  39. 39.

    Doward, L. C. et al. Development of the ASQoL: a quality of life instrument specific to ankylosing spondylitis. Ann. Rheum. Dis. 62, 20–26 (2003).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  40. 40.

    Haywood, K. L., Garratt, A. M., Jordan, K., Dziedzic, K. & Dawes, P. T. Disease-specific, patient-assessed measures of health outcome in ankylosing spondylitis: reliability, validity and responsiveness. Rheumatology 41, 1295–1302 (2002).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  41. 41.

    Doward, L. C. et al. Translation and validation of non-English versions of the Ankylosing Spondylitis Quality of Life (ASQOL) questionnaire. Health Qual. Life Outcomes 5, 7 (2007).

    PubMed  PubMed Central  Article  Google Scholar 

  42. 42.

    Duruoz, M. T. et al. Translation and validation of the Turkish version of the Ankylosing Spondylitis Quality of Life (ASQOL) questionnaire. Rheumatol. Int. 33, 2717–2722 (2013).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  43. 43.

    Kiltz, U., van der Heijde, D., Boonen, A. & Braun, J. The ASAS Health Index (ASAS HI) – a new tool to assess the health status of patients with spondyloarthritis. Clin. Exp. Rheumatol. 32, S105–S108 (2014).

    Google Scholar 

  44. 44.

    Kiltz, U., Wendling, D. & Braun, J. ASAS Health Index: The “all in one” for spondyloarthritis evaluation? J. Rheumatol. 47, 1457–1460 (2020).

    PubMed  Article  PubMed Central  Google Scholar 

  45. 45.

    Kiltz, U. et al. Including contextual factors in the development of a self report questionnaire: the case of environmental factors in the ASAS Health Index [abstract]. Ann. Rheum. Dis. 72, A776 (2013).

    Article  CAS  Google Scholar 

  46. 46.

    Akgul, O. et al. Clinical performance of ASAS Health Index in patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis: real-world evidence from Multicenter Nationwide Registry. Rheumatol. Int. 40, 1793–1801 (2020).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  47. 47.

    Haywood, K. L., Garratt, A. M., Dziedzic, K. & Dawes, P. T. Generic measures of health-related quality of life in ankylosing spondylitis: reliability, validity and responsiveness. Rheumatology 41, 1380–1387 (2002).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  48. 48.

    Ware, J. E. Jr. & Sherbourne, C. D. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med. Care 30, 473–483 (1992).

    PubMed  Article  PubMed Central  Google Scholar 

  49. 49.

    Ware, J. E. Jr., Keller, S. D., Hatoum, H. T. & Kong, S. X. The SF-36 Arthritis-Specific Health Index (ASHI): I. Development and cross-validation of scoring algorithms. Med. Care 37, MS40–MS50 (1999).

    PubMed  Article  PubMed Central  Google Scholar 

  50. 50.

    Boonen, A. et al. Rapid and sustained improvement in health-related quality of life and utility for 72 weeks in patients with ankylosing spondylitis receiving etanercept. J. Rheumatol. 35, 662–667 (2008).

    CAS  PubMed  PubMed Central  Google Scholar 

  51. 51.

    Davis, J. C. Jr. et al. Health-related quality of life outcomes in patients with active ankylosing spondylitis treated with adalimumab: results from a randomized controlled study. Arthritis Rheum. 57, 1050–1057 (2007).

    PubMed  Article  PubMed Central  Google Scholar 

  52. 52.

    van Poppel, M. N., Chinapaw, M. J., Mokkink, L. B., van Mechelen, W. & Terwee, C. B. Physical activity questionnaires for adults: a systematic review of measurement properties. Sports Med. 40, 565–600 (2010).

    PubMed  Article  PubMed Central  Google Scholar 

  53. 53.

    Craig, C. L. et al. International physical activity questionnaire: 12-country reliability and validity. Med. Sci. Sports Exerc. 35, 1381–1395 (2003).

    PubMed  Article  Google Scholar 

  54. 54.

    Wendel-Vos, G. C., Schuit, A. J., Saris, W. H. & Kromhout, D. Reproducibility and relative validity of the Short Questionnaire to Assess Health-Enhancing Physical Activity. J. Clin. Epidemiol. 56, 1163–1169 (2003).

    PubMed  Article  PubMed Central  Google Scholar 

  55. 55.

    Ainsworth, B. E. et al. Compendium of physical activities: an update of activity codes and MET intensities. Med. Sci. Sports Exerc. 32, S498–S504 (2000).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  56. 56.

    Arends, S. et al. Daily physical activity in ankylosing spondylitis: validity and reliability of the IPAQ and SQUASH and the relation with clinical assessments. Arthritis Res. Ther. 15, R99 (2013).

    PubMed  PubMed Central  Article  Google Scholar 

  57. 57.

    van Genderen, S. et al. Accelerometer quantification of physical activity and activity patterns in patients with ankylosing spondylitis and population controls. J. Rheumatol. 42, 2369–2375 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  58. 58.

    Jenkinson, T. R. et al. Defining spinal mobility in ankylosing spondylitis (AS). The Bath AS Metrology Index. J. Rheumatol. 21, 1694–1698 (1994).

    CAS  PubMed  PubMed Central  Google Scholar 

  59. 59.

    van der Heijde, D. et al. Comparison of three methods for calculating the Bath Ankylosing Spondylitis Metrology Index in a randomized placebo-controlled study. Arthritis Care Res. 64, 1919–1922 (2012).

    Article  Google Scholar 

  60. 60.

    van der Heijde, D. et al. Efficacy and safety of infliximab in patients with ankylosing spondylitis: results of a randomized, placebo-controlled trial (ASSERT). Arthritis Rheum. 52, 582–591 (2005).

    PubMed  Article  CAS  PubMed Central  Google Scholar 

  61. 61.

    Marques, M. L. et al. Measuring spinal mobility in early axial spondyloarthritis: does it matter? Rheumatology 58, 1597–1606 (2019).

    PubMed  Article  PubMed Central  Google Scholar 

  62. 62.

    Ramiro, S. et al. Hierarchy of impairment of spinal mobility measures in ankylosing spondylitis: twelve-year data. Arthritis Care Res. 67, 1571–1577 (2015).

    Article  Google Scholar 

  63. 63.

    Martin-Ponce, E. et al. Prognostic value of physical function tests: hand grip strength and six-minute walking test in elderly hospitalized patients. Sci. Rep. 4, 7530 (2014).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  64. 64.

    Studenski, S. et al. Gait speed and survival in older adults. JAMA 305, 50–58 (2011).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  65. 65.

    Guralnik, J. M. et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J. Gerontol. 49, M85–M94 (1994).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  66. 66.

    Ohrnberger, J., Fichera, E. & Sutton, M. The relationship between physical and mental health: a mediation analysis. Soc. Sci. Med. 195, 42–49 (2017).

    PubMed  Article  PubMed Central  Google Scholar 

  67. 67.

    Pavasini, R. et al. Short Physical Performance Battery and all-cause mortality: systematic review and meta-analysis. BMC Med. 14, 215 (2016).

    PubMed  PubMed Central  Article  Google Scholar 

  68. 68.

    Alfaro-Acha, A., Al Snih, S., Raji, M. A., Markides, K. S. & Ottenbacher, K. J. Does 8-foot walk time predict cognitive decline in older Mexicans Americans? J. Am. Geriatr. Soc. 55, 245–251 (2007).

    PubMed  Article  PubMed Central  Google Scholar 

  69. 69.

    Mahoney, F. I. & Barthel, D. W. Functional evaluation: The Barthel Index. Md. State Med. J. 14, 61–65 (1965).

    CAS  PubMed  PubMed Central  Google Scholar 

  70. 70.

    Lawton, M. P. & Brody, E. M. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 9, 179–186 (1969).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  71. 71.

    Ostir, G. V., Markides, K. S., Black, S. A. & Goodwin, J. S. Lower body functioning as a predictor of subsequent disability among older Mexican Americans. J. Gerontol. A. Biol. Sci. Med. Sci. 53, M491–M495 (1998).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  72. 72.

    Cesari, M. et al. Prognostic value of usual gait speed in well-functioning older people–results from the Health, Aging and Body Composition Study. J. Am. Geriatr. Soc. 53, 1675–1680 (2005).

    PubMed  Article  PubMed Central  Google Scholar 

  73. 73.

    Laukkanen, P., Heikkinen, E. & Kauppinen, M. Muscle strength and mobility as predictors of survival in 75-84-year-old people. Age Ageing 24, 468–473 (1995).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  74. 74.

    van Weely, S. F. et al. Objective evaluation of physical functioning after tumor necrosis factor inhibitory therapy in patients with ankylosing spondylitis: a selection of 3 feasible performance-based tests. J. Rheumatol. 42, 623–629 (2015).

    PubMed  Article  CAS  PubMed Central  Google Scholar 

  75. 75.

    van Weely, S. F. et al. What do we miss? ASAS non-responders on anti-TNF therapy show improvement in performance-based physical function. Rheumatology 52, 1884–1889 (2013).

    PubMed  Article  CAS  PubMed Central  Google Scholar 

  76. 76.

    van Bentum, R. E. et al. The Ankylosing Spondylitis Physical Performance Index: reliability and feasibility of an objective test for physical functioning. J. Rheumatol. 47, 1475–1482 (2020).

    PubMed  Article  PubMed Central  Google Scholar 

  77. 77.

    Fongen, C. et al. Responsiveness and interpretability of 2 measures of physical function in patients with spondyloarthritis. Phys. Ther. 100, 728–738 (2020).

    PubMed  Article  PubMed Central  Google Scholar 

  78. 78.

    Rausch, A. K. et al. Reliability of an adapted core strength endurance test battery in individuals with axial spondylarthritis. Clin. Rheumatol. 40, 1353–1360 (2020).

    PubMed  PubMed Central  Article  Google Scholar 

  79. 79.

    Creemers, M. C. et al. Assessment of outcome in ankylosing spondylitis: an extended radiographic scoring system. Ann. Rheum. Dis. 64, 127–129 (2005).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  80. 80.

    Poddubnyy, D. et al. Functional relevance of radiographic spinal progression in axial spondyloarthritis: results from the GErman SPondyloarthritis Inception Cohort. Rheumatology 57, 703–711 (2018).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  81. 81.

    Protopopov, M. et al. Relevance of structural damage in the sacroiliac joints for the functional status and spinal mobility in patients with axial spondyloarthritis: results from the German Spondyloarthritis Inception Cohort. Arthritis Res. Ther. 19, 240 (2017).

    PubMed  PubMed Central  Article  Google Scholar 

  82. 82.

    Machado, P. et al. A stratified model for health outcomes in ankylosing spondylitis. Ann. Rheum. Dis. 70, 1758–1764 (2011).

    PubMed  Article  PubMed Central  Google Scholar 

  83. 83.

    Carvalho, P. D., Ruyssen-Witrand, A., Fonseca, J., Marreiros, A. & Machado, P. M. Determining factors related to impaired spinal and hip mobility in patients with axial spondyloarthritis: longitudinal results from the DESIR cohort. RMD Open 6, e001356 (2020).

    PubMed  PubMed Central  Article  Google Scholar 

  84. 84.

    Nikiphorou, E. et al. Association of comorbidities in spondyloarthritis with poor function, work disability, and quality of life: results from the Assessment of SpondyloArthritis International Society Comorbidities in Spondyloarthritis Study. Arthritis Care Res. 70, 1257–1262 (2018).

    CAS  Article  Google Scholar 

  85. 85.

    England, B. R., Sayles, H., Mikuls, T. R., Johnson, D. S. & Michaud, K. Validation of the rheumatic disease comorbidity index. Arthritis Care Res. 67, 865–872 (2015).

    Article  Google Scholar 

  86. 86.

    EuroQol Group. EuroQol–a new facility for the measurement of health-related quality of life. Health Policy 16, 199–208 (1990).

    Article  Google Scholar 

  87. 87.

    Reilly, M. C., Gooch, K. L., Wong, R. L., Kupper, H. & van der Heijde, D. Validity, reliability and responsiveness of the Work Productivity and Activity Impairment Questionnaire in ankylosing spondylitis. Rheumatology 49, 812–819 (2010).

    PubMed  Article  PubMed Central  Google Scholar 

  88. 88.

    Redeker, I. et al. The prevalence and impact of comorbidities on patients with axial spondyloarthritis: results from a nationwide population-based study. Arthritis Res. Ther. 22, 210 (2020).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  89. 89.

    Maas, F. et al. Obesity is common in axial spondyloarthritis and is associated with poor clinical outcome. J. Rheumatol. 43, 383–387 (2016).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  90. 90.

    Fernandez-Carballido, C. et al. Impact of comorbidity on physical function in patients with ankylosing spondylitis and psoriatic arthritis attending rheumatology clinics. Results from a cross-sectional study. Arthritis Care Res. 72, 822–828 (2020).

    CAS  Article  Google Scholar 

  91. 91.

    Ward, M. M. Predictors of the progression of functional disability in patients with ankylosing spondylitis. J. Rheumatol. 29, 1420–1425 (2002).

    PubMed  PubMed Central  Google Scholar 

  92. 92.

    Ward, M. M., Weisman, M. H., Davis, J. C. Jr. & Reveille, J. D. Risk factors for functional limitations in patients with long-standing ankylosing spondylitis. Arthritis Rheum. 53, 710–717 (2005).

    PubMed  PubMed Central  Article  Google Scholar 

  93. 93.

    Brophy, S. et al. The effect of physical activity and motivation on function in ankylosing spondylitis: a cohort study. Semin. Arthritis Rheum. 42, 619–626 (2013).

    PubMed  PubMed Central  Article  Google Scholar 

  94. 94.

    Zhang, L., Wu, Y., Liu, S. & Zhu, W. Prevalence of depression in ankylosing spondylitis: a systematic review and meta-analysis. Psychiatry Investig. 16, 565–574 (2019).

    PubMed  PubMed Central  Article  Google Scholar 

  95. 95.

    Zhao, S. S. et al. Prevalence and impact of comorbidities in axial spondyloarthritis: systematic review and meta-analysis. Rheumatology 59, iv47–iv57 (2020).

    PubMed  PubMed Central  Article  Google Scholar 

  96. 96.

    Li, Y., Zhang, S., Zhu, J., Du, X. & Huang, F. Sleep disturbances are associated with increased pain, disease activity, depression, and anxiety in ankylosing spondylitis: a case-control study. Arthritis Res. Ther. 14, R215 (2012).

    PubMed  PubMed Central  Article  Google Scholar 

  97. 97.

    Meesters, J. J. et al. The risk for depression in patients with ankylosing spondylitis: a population-based cohort study. Arthritis Res. Ther. 16, 418 (2014).

    PubMed  PubMed Central  Article  Google Scholar 

  98. 98.

    Katz, S. & Akpom, C. A. 12. Index of ADL. Med. Care 14, 116–118 (1976).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  99. 99.

    Radloff, L. S. The use of the Center for Epidemiologic Studies Depression Scale in adolescents and young adults. J. Youth Adolesc. 20, 149–166 (1991).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  100. 100.

    World Health Organization. WHO publishes new guidelines to measure health. who.int https://www.who.int/news/item/15-11-2001-who-publishes-new-guidelines-to-measure-health (2001).

  101. 101.

    Houses of the Oireachtas. Disability Act 2005. oireachtas.ie https://www.oireachtas.ie/en/bills/bill/2004/39/ (2005).

  102. 102.

    Burgstahler, S. Universal design: process, principles, and applications. Washington.edu (2015).

  103. 103.

    Niedermann, K., Nast, I., Ciurea, A., Vliet Vlieland, T. & van Bodegom-Vos, L. Barriers and facilitators of vigorous cardiorespiratory training in axial spondyloarthritis: surveys among patients, physiotherapists, rheumatologists. Arthritis Care Res. 71, 839–851 (2019).

    Article  Google Scholar 

  104. 104.

    Fongen, C., Sveaas, S. H. & Dagfinrud, H. Barriers and facilitators for being physically active in patients with ankylosing spondylitis: a cross-sectional comparative study. Musculoskelet. Care 13, 76–83 (2015).

    Article  Google Scholar 

  105. 105.

    Curbelo, R. J., Loza, E., de Yebenes, M. J. & Carmona, L. Databases and registers: useful tools for research, no studies. Rheumatol. Int. 34, 447–452 (2014).

    PubMed  Article  PubMed Central  Google Scholar 

  106. 106.

    Niedermann, K. et al. Effect of cardiovascular training on fitness and perceived disease activity in people with ankylosing spondylitis. Arthritis Care Res. 65, 1844–1852 (2013).

    Article  Google Scholar 

  107. 107.

    Ding, D. et al. Physical activity guidelines 2020: comprehensive and inclusive recommendations to activate populations. Lancet 396, 1780–1782 (2020).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  108. 108.

    Haglund, E. et al. Differences in physical activity patterns in patients with spondylarthritis. Arthritis Care Res. 64, 1886–1894 (2012).

    Article  Google Scholar 

  109. 109.

    Dagfinrud, H., Kvien, T. K. & Hagen, K. B. Physiotherapy interventions for ankylosing spondylitis. Cochrane Database Syst Rev. 1, CD002822 (2008).

    Google Scholar 

  110. 110.

    Liang, H. et al. The comparative efficacy of supervised- versus home-based exercise programs in patients with ankylosing spondylitis: a meta-analysis. Medicine 99, e19229 (2020).

    PubMed  PubMed Central  Article  Google Scholar 

  111. 111.

    Dagfinrud, H. et al. Exercise programs in trials for patients with ankylosing spondylitis: do they really have the potential for effectiveness? Arthritis Care Res. 63, 597–603 (2011).

    Article  Google Scholar 

  112. 112.

    Regnaux, J. P. et al. Exercise programmes for ankylosing spondylitis. Cochrane Database Syst. Rev. 10, CD011321 (2019).

    PubMed  PubMed Central  Google Scholar 

  113. 113.

    Pecourneau, V. et al. Effectiveness of exercise programs in ankylosing spondylitis: a meta-analysis of randomized controlled trials. Arch. Phys. Med. Rehabil. 99, 383–389.e1 (2018).

    PubMed  Article  PubMed Central  Google Scholar 

  114. 114.

    Escalas, C., Dalichampt, M., Dougados, M. & Poiraudeau, S. Evaluation of physiotherapy in a prospective cohort of early axial spondyloarthritis. Data from the DESIR cohort. Joint Bone Spine 83, 185–190 (2016).

    PubMed  Article  PubMed Central  Google Scholar 

  115. 115.

    Paul, L. et al. Web-based physiotherapy for people with axial spondyloarthritis (WEBPASS) – a study protocol. BMC Musculoskelet. Disord. 17, 360 (2016).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  116. 116.

    Lubrano, E. et al. Effects of a combination treatment of an intensive rehabilitation program and etanercept in patients with ankylosing spondylitis: a pilot study. J. Rheumatol. 33, 2029–2034 (2006).

    PubMed  PubMed Central  Google Scholar 

  117. 117.

    Dubey, S. G., Leeder, J. & Gaffney, K. Physical therapy in anti-TNF treated patients with ankylosing spondylitis. Rheumatology 47, 1100–1101 (2008).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  118. 118.

    Meier, F. M., Muller-Ladner, U. & Lange, U. Efficacy of intensive physiotherapy in combination with low-dose etanercept in active spondyloarthritis: a monocentric pilot study. J. Rheumatol. 41, 1897–1898 (2014).

    PubMed  Article  PubMed Central  Google Scholar 

  119. 119.

    Lubrano, E. et al. Tumour necrosis factor alpha inhibitor therapy and rehabilitation for the treatment of ankylosing spondylitis: a systematic review. Semin. Arthritis Rheum. 44, 542–550 (2015).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  120. 120.

    Liang, H. et al. Concurrent intervention with exercises and stabilized tumor necrosis factor inhibitor therapy reduced the disease activity in patients with ankylosing spondylitis: a meta-analysis. Medicine 94, e2254 (2015).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  121. 121.

    Halvorsen, S. et al. Physical fitness in patients with ankylosing spondylitis: comparison with population controls. Phys. Ther. 92, 298–309 (2012).

    PubMed  Article  PubMed Central  Google Scholar 

  122. 122.

    Eriksson, J. K., Jacobsson, L., Bengtsson, K. & Askling, J. Is ankylosing spondylitis a risk factor for cardiovascular disease, and how do these risks compare with those in rheumatoid arthritis? Ann. Rheum. Dis. 76, 364–370 (2017).

    PubMed  Article  PubMed Central  Google Scholar 

  123. 123.

    Haroon, N. N., Paterson, J. M., Li, P., Inman, R. D. & Haroon, N. Patients with ankylosing spondylitis have increased cardiovascular and cerebrovascular mortality: a population-based study. Ann. Intern. Med. 163, 409–416 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  124. 124.

    Verhoeven, F. et al. Aerobic exercise for axial spondyloarthritis – its effects on disease activity and function as compared to standard physiotherapy: a systematic review and meta-analysis. Int. J. Rheum. Dis. 22, 234–241 (2019).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  125. 125.

    Sveaas, S. H. et al. High-intensity exercise improves fatigue, sleep, and mood in patients with axial spondyloarthritis: secondary analysis of a randomized controlled trial. Phys. Ther. 100, 1323–1332 (2020).

    PubMed  PubMed Central  Article  Google Scholar 

  126. 126.

    Sveaas, S. H. et al. High intensity exercise for 3 months reduces disease activity in axial spondyloarthritis (axSpA): a multicentre randomised trial of 100 patients. Br. J. Sports Med. 54, 292–297 (2020).

    PubMed  Article  PubMed Central  Google Scholar 

  127. 127.

    Bilberg, A., Sveaas, S. H., Dagfinrud, H. & Mannerkorpi, K. How do patients with axial spondyloarthritis experience high-intensity exercise? ACR Open Rheumatol. 2, 207–213 (2020).

    PubMed  PubMed Central  Article  Google Scholar 

  128. 128.

    Sveaas, S. H. et al. Longterm effect on leisure time physical activity level in individuals with axial spondyloarthritis: secondary analysis of a randomized controlled trial. J. Rheumatol. 47, 1189–1197 (2020).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  129. 129.

    Buijze, G. A. et al. An add-on training program involving breathing exercises, cold exposure, and meditation attenuates inflammation and disease activity in axial spondyloarthritis – a proof of concept trial. PLoS ONE 14, e02257490225749 (2019).

    Article  CAS  Google Scholar 

  130. 130.

    Kiltz, U. et al. Development of ASAS quality standards to improve the quality of health and care services for patients with axial spondyloarthritis. Ann. Rheum. Dis. 79, 193–201 (2020).

    PubMed  Article  PubMed Central  Google Scholar 

  131. 131.

    Regel, A. et al. Efficacy and safety of non-pharmacological and non-biological pharmacological treatment: a systematic literature review informing the 2016 update of the ASAS/EULAR recommendations for the management of axial spondyloarthritis. RMD Open 3, e000397 (2017).

    PubMed  PubMed Central  Article  Google Scholar 

  132. 132.

    Zangi, H. A. et al. EULAR recommendations for patient education for people with inflammatory arthritis. Ann. Rheum. Dis. 74, 954–962 (2015).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  133. 133.

    Agca, R. et al. EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Ann. Rheum. Dis. 76, 17–28 (2017).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

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Braun, J., Baraliakos, X. & Kiltz, U. Treat-to-target in axial spondyloarthritis — what about physical function and activity?. Nat Rev Rheumatol 17, 565–576 (2021). https://doi.org/10.1038/s41584-021-00656-5

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