An Exploration of the Impact of anti-Tumour Necrosis Factor Alpha

Medication on the Exercise Behaviour of Patients with Ankylosing

Spondylitis

Dr Jenny Stockdale Grad Dip Phys, MSc, PhD 22nd November 2014

Ankylosing Spondylitis

Painful and progressive inflammatory disease

Affects the spine and sacroiliac joints(van der Heijde et al 2009)

Progression leads to fusion of the spine, ↓ mobility and ↓ function(Davis et al 2008)

Ankylosing Spondylitis

Ankylosing spondylitis

3:1 male to female ratio

Average age of onset 24 years(NASS 2011)

Direct and indirect socioeconomic costs(Boonen et al 2001)

Direct and indirect costs to patient and healthcare system (van der Heijde 2009)

Management

Exercise – home based (Karapolat et al 2007) - group based (Wang et al 2009)

Medication – NSAID’s anti-TNFα (NICE 2008) – Etanercept Adalimumab Golimumab

Background

Why undertake this specific study?

Objectives

To develop an understanding of the impact of anti-TNFα medication on AS patients engagement in exercise behaviour.

To develop an understanding of the perceptions of patients with AS about their engagement in exercise behaviour

To explore the factors influencing the choice of the exercise activities in which AS patients engage

To reflect if changes are required in physiotherapy practice with regards to the treatment of AS patients overall.

Literature search

Prior to the study commencing – 6 quantitative studies:Lubrano et al. (2006)(n=19) - ↑ function and QoL with etanercept

and exercise programmeDubey et al. (2008) (n=40) - ↑ motivation and time on exerciseColina et al. (2009) (n=60) - ↑ function and QoL with etanercept

and spa treatmentCiprian et al. (2013) (n=30) - ↑ function, pain and QoL with TNF

and spa treatmentSo et al. (2012) (n=46) - ↑ function and pulmonary function with

TNF and incentive spirometer exerciseYigit et al. (2013) (n=40) - ↑ function, fatigue, QoL and mood with

TNF and home-based exercise programme

Methodology

Qualitative research

Hermeneutic phenomenology

Research design – longitudinal study – cross sectional study

Method

Longitudinal study (4 participants) – 3 semi-structured interviews (pre anti-TNFα, 3 months and 6 months post anti-TNFα with completed exercise diaries)

Cross sectional study (20 participants, 1-10 years on medication) – one semi-structured interview

Method

Semi-structured interviews

Digitally recorded and transcribed

Longitudinal study – thematic network analysis

Cross sectional study – thematic network analysis (Attride-Stirling 2001)

Global Themes

Exercise Behaviour

Pain and Anxiety

Quality of life

Demographics

24 participants: 21 male 3 femaleAge range: 24 – 75 yearsDisease duration: 1 – 36 yearsEmployment: 18 employed 2 unemployed 4 retired

Results – Exercise behaviour

Enthusiasm and keenness for sports

‘I was always into sport’ – Christian

(Daily) ‘weights for an hour and a half…jogging four miles…boxing fifteen rounds…go training for rugby, football, cricket, athletics…training like a professional athlete’ - Trevor

Results – Exercise behaviour

Inconsistency and inability to do exercises

‘The exercises just didn’t happen I just couldn’t do them’ – Sheila

‘…being active was the last thing on my mind…I tried to, the pain would always succeed’ - George

Results – Exercise behaviour

Anticipation of the impact on exercise behaviour

‘…I am not one to let the medicine do its work, you have got to do your part in it as well so all part of the physical side of it is me, you know and I will do it.’ – Chris

‘Yes I am putting a lot of hope in this medication working.’ - David

Results – Exercise behaviour

Incentives and elation of being able to exercise

‘I never have to think about ‘oh can I do this because of the AS?’’ - Ann

‘…it is about the psychological and physiological benefits…sense of achievement…looking good and feeling good’ - Patrick

Results – Exercise behaviour

Variations in undertaking physiotherapy exercise programmes

(The exercises) ‘always difficult to do. I still did them… not on a regular basis, some days…I couldn’t even go to work (so the exercises were) just a complete no, no’ – Eric

‘average three times a week now…I just forget that I have anything wrong…since the TNF my life has changed’ - Karl

Results – Pain and Anxiety

Hindrances of problematic joints

‘My problem started with my knees so my knees were just getting worse and worse with pain and stuff’ - George

‘I was restricted really in everything that I did’ - Ann

Results – Pain and Anxiety

Relentless daily pain

‘I had real, real bad pains in my hips. I remember it, it was horrible.’ - Christian

‘… it is kind of a constant grind as if it got to the point where there was no kind of let up it was kind of it is in a cycle…’ - Mark

Results- Pain and Anxiety

Presence of pain despite anti-TNFα medication

‘I know that within the day that I have to have painkillers the pain is pretty bad but at least I am out and doing things and I am more than happy to take on the pain because the exercise and the stretching are allowing me to do something…’ - Trevor

‘there is an element of pain that I suffer’ - George

Results – Pain and Anxiety

Underlying fears for the future pre anti-TNFα medication

‘you might be having to use a wheelchair’ – Eric

‘I thought my life had ended’ - Sheila

Results – Pain and Anxiety

Underlying fears for the future post anti-TNFα medication

‘I feel you are right on the limit of what is going to work and not’s what going to work’ – Brian

‘I had to miss a month and it scared me actually. Scary because it made me realise how dependent I was on it. It is not in my control as much as I like to think.’ - Christian

Results – Quality of Life

Impact on the quality of life

‘It destroyed my life’ – Owen

‘you kind of think I have another 40/50 years ahead and it is kind of getting progressively worse so it is kind of quite you know mentally you start to think you know is this really it?’ - Mark

Results – Quality of Life

Regaining independence, worthiness and a sense of normality

‘Yes well it is absolutely wonderful it is you know I feel like it is a gift really you know. …I have won the lottery’ – Karl

‘I feel ten years, fifteen years younger. It has just been fantastic…’ - Chris

Results – Quality of Life

Overwhelming exhaustion

‘I had no quality of life really I was just exhausted and I couldn’t do anything.’ – Sheila

‘by 8, 9 o’clock I am absolutely dead’ - Trevor

Results – Quality of Life

Occupational traits

‘I have done a range of jobs really from the manual to the managerial’ – Patrick

‘I can actually get to positive flexi hours and I can manage my hours at work’ - Nick

Discussion

Anti-TNFα medication reduces symptoms and improves the ability to exercise

Anti-TNFα medication improves motivation to exercise

Incentives to exercise Physiotherapy exercises should be taught at

diagnosis Regular reviews of the condition

Conclusion

Long term evidence of the effects of anti-TNFα medication on exercise behaviour

Evidence that AS patients on anti-TNFα medication can maintain an exercise regime and physical activities over a number of years

An insight into the motivation and incentives for a regular exercise regime whilst taking anti-TNFα medication

Evidence that a holistic understanding of the condition is required by physiotherapists so AS patients can be treated effectively with an exercise programme.

References

Attride-Stirling, J. (2001) Thematic networks: an analytical tool for qualitative research. Qualitative Research. Volume 1 No. 385 pp 385- 405

Boonen, A. Chorus, A. Miedema, H. van der Heijde, D. van der Tempel, H. van der Linden, S.(2001) Employment, work disability and work days lost in patients with ankylosing spondylitis: a cross sectional study of Dutch patients. Annals of Rheumatic Diseases. Volume 60 Issue 4 pp 352-358

Ciprian, L. Nigro, A.L. Rizzo, M. Gava, A. Ramonda, R. Punzi, L. Cozzi, F. (2013) The effects of combined spa therapy and rehabilitation on patients with ankylosing spondylitis being treated with TNF inhibitors. Rheumatology International. Volume 33 Issue 1 pp 241-245

Colina, M. Ciancio, G. Garavini, R. Conti, M. Trotta, F. Govoni, M. (2009) Combination treatment with etanercept and an intensive spa rehabilitation program in active ankylosing spondylitis. International Journal of Immunopathology and Pharmacology. Volume 22 Issue 4 pp 1125 – 9

.

References

Davis Jr. J.C. van der Heijde, D.M. Braun, J. Dougados, M. Clegg, D.O. Kivitz, A.J. Fleischmann, R.M. Inman, R.D. Ni, L. Lin, S-L. Tsuji, W.H. (2008) Efficacy and safety of up to 192 weeks of etanercept therapy in patients with ankylosing spondylitis. Annals of the Rheumatic Diseases. Volume 67 Issue 3 pp 346-352

Dubey, S.G. Leeder, J. Gaffney, K. (2008) Physical therapy in anti-TNF treated patients with ankylosing spondylitis. Rheumatology. Volume 47 Issue 7 pp 1100-1101

Karapolat, H. Akkoc, Y. Sari, I. Eyigor, S. Akar, S. Kirazli, Y. Akkoc, N. (2007) Comparison of group-based exercise versus home-based exercise in patients with ankylosing spondylitis: effects on Bath Ankylosing Spondylitis Indices, quality of life and depression. Clinical Rheumatology Volume 27 Issue 6 pp 695–700

Lubrano, E. D'Angelo, S. Parsons, W.J. Serino, F. Tommaso Tanzillo, A. Olivieri, I. Pappone, N. (2006) Effects of a Combination Treatment of an Intensive Rehabilitation Program and Etanercept in Patients with Ankylosing Spondylitis: A Pilot Study Journal of Rheumatology. Volume 33 Issue 10 pp 2029-2034

National Ankylosing Spondylitis Society (NASS) (2011) Ankylosing Spondylitis (AS) Guidebook – answers and practical advice http://www.nass.co.uk/about-as

References

National Institute for Health and Clinical Excellence (NICE) (2008) Adalimumab, Etanercept and Infliximab for Ankylosing Spondylitis. http://www.nice.org.uk

So, M.W. Heo, H.M. Koo, B.S. Kim, Y.G. Lee, C.K. Yoo, B. (2012) Efficacy of incentive spirometer exercise on pulmonary functions of patients with ankylosing spondylitis stabilized by tumor necrosis factor inhibitor therapy. Journal of Rheumatology. Volume 39 Issue 9 pp1854-1858

van der Heijde, D. Schiff, M.H. Sieper, J. Kivitz, A.J. Wong, R.L. Kupper, H. Dijkmans, B.A.C. Mease, P.J. Davis Jr,J.C. for the ATLAS Study Group (2009) Adalimumab effectiveness for the treatment of ankylosing spondylitis is maintained for up to 2 years: long-term results from the ATLAS trial. The Annals of Rheumatic Diseases. Volume 68 Issue 11 pp 922–929

Wang, C.Y. Chiang, P.Y. Lee, H.S. Wei, J. (2009) The effectiveness of exercise therapy for ankylosing spondylitis: a review. International Journal of Rheumatic Diseases Volume 12 Issue 3 pp 207–210

References

Yigit, S. Saliha, Z. Demir, E. Hatun Aytac, D. (2013) Home-based exercise therapy in ankylosing spondylitis: short-term prospective study in patients receiving tumor necrosis factor alpha inhibitors. Rheumatology International. Volume 33 Issue 1 pp 71 - 77