Original articleOccupational therapy in ankylosing spondylitis: Short-term prospective study in patients treated with anti-TNF-alpha drugs
Introduction
Ankylosing spondylitis (AS) is a chronic, inflammatory and progressive disease [1], and the medical consequences, in terms of pain, reduced mobility, and deformity of the spine, are well known [2], [3], [4]. The disease process results in various degrees of impairment due to changes in the axial skeleton, stiffness, pain, and fatigue. This in turn may lead to activity limitation, such as difficulty in performing self-care activities, and reduced participation in work and leisure time activities [5].
Evidence-based recommendations for the management of ankylosing spondylitis (AS) as a combined effort of the ‘Assessment in AS’ (ASAS) international working group and the European League Against Rheumatism have been developed [6]. These recommendations stated that optimal management of AS requires a combination of non-pharmacological and pharmacological treatments. In fact exercise and non-steroidal anti-inflammatory drugs (NSAIDs) have been the mainstay of symptom control for decades, but the advent of anti tumor necrosis factor alpha (TNFα) treatment, such as infliximab, etanercept or adalimumab, is currently modifying the management of AS [7], [8], [9], [10], [11], [12], [13].
Nevertheless, non-pharmacological treatment of AS, including patient education and regular exercise, is recommended [6].
In particular, occupational therapy (OT), including both therapeutic and educational interventions, is widely provided for people with chronic musculoskeletal conditions. The aims are to improve their ability to perform daily occupations, facilitate successful adaptations in lifestyle, prevent losses of function and improve or maintain psychological status [14].
Treatment includes: assessment of functional (personal and domestic activities of daily living, work and leisure), physical, psychological, and social abilities and the patient's understanding of his disease. Individualized treatment programs are developed including arthritis education (individual and group), training of daily living activities, joint protection, fatigue management and exercise, splinting, assistive devices, work and leisure counselling, sexual advice, relaxation, and pain/stress management training when necessary. Interventions emphasize achieving empathetic rapport and providing counselling and support appropriate to the person's needs to explore the impact of disease on their lives and assist in adjusting lifestyle.
Although the combination treatment including rehabilitation and etanercept vs rehabilitation only seemed to improve function, disability, and quality of life in patients with active AS [15], there are no prior studies reporting the effects of combination treatment with anti-TNFα agents and OT.
The primary endpoint of this study was the evaluation of OT program on functional status, measured by Bath Ankylosing Spondylitis Functional Index (BASFI), of patients with AS during treatment with anti-TNFα agents. Secondary endpoints were the evaluation of disease, physical, and psychosocial status during the study.
Section snippets
Methods
We admitted to an open controlled study 27 patients with AS fulfilling the New York classification criteria [16] treated with TNFα blockers, including etanercept (25 mg twice/week) and infliximab (5 mg/kg at 6 weekly intervals), for at least 12 weeks. All patients reached maximal therapeutic benefit from the beginning of anti-TNFα therapy. No patients had received rehabilitative intervention for at least 24 weeks. No patient previously underwent occupational treatment. Those AS patients agreeing
Results
At baseline the main demographic and clinical features of AS patients of OT and control groups were similar (Table 1). The dosage of NSAIDs, DMARDs and anti-TNFα agents was stable starting from 12 weeks before the study. No patients took corticosteroids. Anti-TNFα treatment duration did not differ between OT (median/range = 24/4 – 37 months) and control groups (median/range = 22/4 – 41 months). The frequency and type of previous pharmacological (i.e. DMARDs, NSAIDs, corticosteroid) and
Discussion
ASAS/EULAR evidence-based recommendations for the management of AS stated that optimal management of this disease requires a combination of non-pharmacological and pharmacological treatments [6].
The group consensus pointed out that these approaches are complementary and both are of value in the initial and continuing treatment of patients with AS.
In fact systematic review of physiotherapy for AS showed [21] that exercise improved function in the short-term compared with no intervention.
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