types of moderate exercise modalities on alleviating AS-related symptoms, including Pilates, Mckenzie, Heckscher, and. Global Posture Re-education [19-21].
LTH December 2017
Effects of Traditional Chinese Mind-Body Exercise on Disease Activity, Spinal Mobility, and Quality Of Life in Patients with Ankylosing Spondylitis 1
Liye Zou, 2 Yongsheng Cui, 3 Ting Li, 3 Minhua Lu, 4 Chaoyi Wang and 5 Huiru Wang,
1
Department of Sports Science and Physical Education, The Chinese University of Hong Kong, Hong Kong, China,
2
National Health-Qigong Association, General Administration of Sport of China, Beijing, China,
3
Department of Rheumatology at the Renji Hospital, Shanghai Jiaotong University, Shanghai, China,
4
Department of Physical Education, Jilin University, China
5
Department of Physical Education, Shanghai Jiao Tong University, ShangHai, China.
Abstract Aim: The purpose of this present study was to investigate the effects of traditional Chinese mind-body exercise (TCMD) on disease-specific symptoms and quality of life in people with ankylosing spondylitis (AS). Materials and methods: A quasi-experimental study was conducted in which forty eligible AS patients were arranged into either an experimental group or control group. The TCMD intervention program involved an instructor-led 75-minute session plus home-based daily practice for 12 weeks, whereas AS patients in the control group kept their original lifestyle. Disease activity and spinal mobility as the main disease-related symptoms were measured using BASDAI and BASMI, respectively. Quality of life was measured using SF-36 to evaluate the over well-being of AS patients. The testing took place one week before and after the TCMD program. We used multiple mixed ANOVAs to evaluate the effects of TCMD on disease activity, and spinal mobility, and quality of life in AS patients. Results: After the 12-week intervention period, TCMD effectively alleviated disease activity and spinal mobility and improving quality of life (p < 0.05 for all), whereas AS patients in the control group showed a slight deterioration in the outcome measures. No adverse event was reported during the intervention period, suggesting that TCMD is a safe, feasible method in assisting symptomatic management in AS patients. Conclusion: TCMD is a safe exercise therapy and has the potential to be integrated with mainstream treatments for symptomatic management of AS. Keyword: Ankylosing spondylitis, exercise, symptoms.
Corresponding author: Department of Physical Education, Shanghai Jiao Tong University, Shang Hai, China.
Zou et al. Introduction Ankylosing spondylitis (AS) is one of the most commonly occurring inflammatory diseases that primarily affects the axial skeleton and peripheral joints. Specifically, the progressive inflammation tends to cause some vertebrae of human spine to be fused, which potentially leads to limitation in spinal mobility in AS patients [1]. According to Khan [1], these morphological changes in AS patients are associated with musculoskeletal pain and stiffness, and bony ankyloses. Such complications are highly associated with reduced quality of life in AS patients, which is usually considered as the leading cause of disability or loss in productivity in people living with AS [2-5]. In particular, these disease-specific symptoms present in the second or third decade of life, but they may last a lifetime [6]. The estimated number of AS patients in Asia was 4.98 million [7], which may drive researchers to explore the potential mechanism on this type of disease for more than 40 years. Unfortunately, the etiology of AS remains unclear, suggesting that no evidence-based cure is applied for AS patients [8-10]. Pharmacological treatment for alleviating AS-related symptoms are often used, including non-steroidal anti-inflammatory drugs, tumor necrosis factor inhibitors, and infliximab [11-13]. To maximize the beneficial effects, complementary and alternative methods (e.g., physiotherapy, physical therapy, and balneotherapy) are incorporated into the mainstream drug treatment in assisting symptomatic management of AS [14-16]. Some of researchers have recently have proposed that exercise as a non-pharmacological lifestyle therapy has anti-inflammatory properties, which could slow down the progression of chronic diseases [17, 18]. A growing body of literature emerges to examine the effects of different types of moderate exercise modalities on alleviating AS-related symptoms, including Pilates, Mckenzie, Heckscher, and Global Posture Re-education [19-21]. The positive results following these exercise modalities are found in these previous studies [19-21]. Traditional Chinese mind-body exercises (TCMD) (Tai-Chi, Baduanjin, Five Animal, Daoyin Shu, and Ma Wang Dui Daoyin) have become more popular in the globe [22-24], Characterized by an integration of slow movements, breathing control, and meditative mind [25, 26]. Previous studies indicated that TCMD could effectively alleviate symptoms in people with knee Osteoarthritis [27, 28] and fibromyalgia [29-31]. In particular, a well-known research team recently used a randomized controlled trial to examine the effects of TCMD versus physical therapy in 204 individuals with knee osteoarthritis [32]. The findings of this study indicated that TCMD is as effective as physical therapy in the treatment of knee osteoarthritis [32]. Although TCMD is shown to have positive effects on alleviating symptoms in individuals with these rheumatic diseases, previous literature was limited regarding TCMD for Ankylosing Spondylitis as the most common of the rheumatic diseases that specifically affect the spine. Therefore, researchers in the present study attempted to examine the effects of TCMD on AS-related symptoms. Methods Study Design To examine the effects of TCMD in people with AS, a quasi-experimental study was designed in which AS patients who were interested in a 12-week TCMD program was considered as an experimental group and the remaining AS patients was arranged into a control group. The purpose and procedure of the study involved was approved by Institutional Review Board of the University (2014-019) prior to this research project started. This research project was also registered on the Chinese Clinical Trial Registry (ChiCTR-TQR-14004860). The authors abided by the fidelity of the study protocol, including data collection, management, analysis, and interpretation of the manuscript. Study Participants A billboard explaining the study procedure and purpose of this TMCD intervention was placed in the Department of Rheumatology in a hospital of Southeast of China, to recruit AS patients for this present study. Potential study participants were contacted via WeChat and underwent a screening administered by a rheumatologist according to the inclusion criteria.
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Zou et al. Before we collected basic demographic information (gender, age, education level, height, and weight) in 40 eligible patients with AS, each individual participant needed to complete a consent form. Outcome Assessment Baseline and post-intervention tests occurred one week before and after the 12-week intervention program, respectively. Testing was administered by the two physician assistants who were blinded to the study purpose. The outcome measures to be assessed included disease activity (Bath Ankylosing Spondylitis Index, BASDAI), spinal mobility (Bath Ankylosing Spondylitis Metrology Index, BASMI), and quality of life (Short form Health Survey, SF-36). The instruction and scoring relating to these tests are specifically described below. BASDAI with test-retest reliability ranging from .92 to .94 and convergent validity of .70 that was used to measure disease activity [33, 34]. The BASDAI is comprised of six AS symptoms-related questions (fatigue, spinal pain, joint pain/swelling, areas of localized tenderness, morning stiffness duration and severity), with a 10-cm line (one being no problem and 10 being the most severe symptom) [35]. As Questions 5 and 6 are both associated with morning stiffness, therefore, the mean score from the two questions was first calculated and then added to the score of the other four questions. The final average value between zero and ten was obtained by dividing the total scores (zero to fifty) by five, with higher BASDAI scores indicating more severe symptoms [35]. BASMI with test-retest reliability ranging from .87 to .91 and criteria validity of .92 that was used to measure spinal mobility [36]. The BASMI consisted of five indexes (lateral lumbar flexion, tragus-to-wall distance, modified Schober, maximal inter malleolar distance, and cervical rotation) (more detail about measurement instruction and scoring system can be retrieved from http://nass.co.uk/silo/files/basmi-pdf.pdf). The score (0-to-2) for each item was used to calculate the sum scores ranging from 0 to 10 for the spinal mobility [37]. Quality of life (QOL) is a multidimensional construct that is usually utilized to subjectively evaluate both positive and negative aspects of life, involving physical, mental, and social domains [38]. The Medical Outcomes Study of 36-item Short-Form Health Survey (SF-36) as a valid (structural validity = .786) and reliable (split-reliability = .778) assessment tool was used to evaluate the health status in AS patients at the baseline and week 12 [39]. The SF-36 involves eight domains: physical functioning, role limitations due to physical health, role limitations due to emotional problems, energy/fatigue, emotional well-being, social functioning, pain, general health [40-42]. The total scores were computed, ranging from 0 to 100, with higher scores indicating greater better health status [43]. Inclusion Criteria Patients are considered eligible if they were: (1) diagnosed with AS according to the Modified Criteria of New York [44], (2) classified as Stage I or II of AS based on Steinbroker Functional disability Criteria [Stage I – patients are able to perform all the usual duties without handicaps, Stage II, patients are capable of carrying out normal activities regardless of handicap of discomfort or limited motion of one of the joints] [45], (3)18 years of age or above, (4) were not currently participating in any other instructor-led exercise intervention, (5) were able to read the questionnaire. Patients were excluded from the study if they: (1) have had comorbid conditions (e.g., serious infections, cardiopulmonary, gastrointestinal, neurological, or endocrine diseases) that limit or affect their physical function, (2) had actively been participating in exercises for three months or longer before and during the study, (3) had been taking AS educational classes for the last three months. Intervention AS patients in the experimental group had one 75-minute TCMD (Mai Wang Dui Health-Qigong) session weekly for 12-weeks, taught by a certified instructor. The instructor-led practice involved 8-minute warmup and 7-minute cool-down exercises, respectively, and 60-minutes for TCMD. During the first two sessions, the instructor had taught technique of each movement along with appropriate demonstrations and ensure that each AS patient were familiar with the TCMD form. The TCMD form included 15 basic movements (including beginning and ending) associated with deep breathing, chest 1587
Zou et al. expansion, trunk rotation and bending, hip extension and flexion, flying bird movements, opening and closing the hands, and
waving
hands
in
the
clouds
(a
video
displaying
TCMD
form
can
be
watched
through
https://www.youtube.com/watch?v=9-hdzHPto9Y). Additionally, daily home-based practice was encouraged during the intervention period. A WeChat group was created to monitor the home-based TCMD practice in which AS patients needed to report their practice (only one time in the TCMD form). AS patients in control group maintained their original lifestyle during the intervention period. Adherence to Program Before the beginning of the TCMD program, all patients were encouraged to adhere to exercise for 12-weeks. The instructor was responsible for taking attendance before each session and then reporting to the researchers. If anyone was absent from weekly session, the instructor had contacted the AS patient and requested to make the session up if possible. All sessions were managed by the instructor and he was responsible for contacting the patients and coordinating the sessions. AS patients were considered a withdrawal if they: (a) wanted to discontinue participating in the TCMD program, (b) were not able to complete post-assessment, and (c) missed more than six sessions during the intervention period. AS patients who withdrew from the study had a short interview via WeChat to determine the cause of discontinuing the study. Adverse Event Adverse event was monitored using the weekly report form through the entire intervention period. Such events included, but were not limited to a single fall episode, deterioration of AS symptoms, or hospitalization required. If AS patients had any aforementioned adverse events, they were immediately notified to discontinue the TCMD intervention program and saw their private doctors. However, AS patients who experienced muscle-related soreness, pain, or discomfort three days after TCMD training were not considered as the adverse events. Statistical Analysis Multiple separate mixed ANOVAs were performed to examine: 1) if the significant improvement on outcome measures between baseline and Week 12 in both TCMD and control groups, 2) whether AS patients who had completed TCMD program showed significantly better scores on outcome measures than those in the control group. To determine statistical significance, we set a two-tailed p value of less than 0.05 as a cut-off. Between-group differences with 95% confidence intervals were used to demonstrate the results of the study. Results Baseline Characteristics Based on the inclusion criteria, 17 participants were excluded for the following reasons: (1) 9 participants were diagnosed with Stage III of AS according to the Steinbrocker Functional classification, (2) 8 participants had been or were currently enrolled in other supervised exercise programs for more than three months. Because three in the TCMD (after the baseline assessment, they withdrew from the intervention program) and one in the control group (one missed post-assessment) were not considered, the final number of 36 AS patients were included for data analysis. The flowchart displaying the process of screening, assessment, and intervention is presented in Figure 1. During the entire intervention period, no adverse event was reported. Demographic information of participants between TCMD and control groups is presented in Table 1.
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Figure 1: Flowchart showing recruitment and experimental implementation of study. Table 1: Demographic information of participants between TCQG and control groups Demographic TCQG (n = 17) Control (n = 19) Mean ± SD N (%) Mean ± SD N (%) Functional Disability .888 Stage I 12 (71%) 13 (68.4%) Stage II 5 (29%) 6 (31.6%) Age 36.12 ±10.4 36.16 ± 11.33 .991 Gender .535 Male 9 (52.9%) 12 (63%) Female 8 (47.1%) 7 (37%) BMI 2 (11.8%) 2 (10.5%) .797 Underweight Normal weight 5 (29.4%) 6 (31.6%) Overweight 7 (41.2%) 9 (47.4%) Obesity 3 (17.6%) 2 (10.5%) Educational level .953 high school 3 (17.6%) 4 (21.1%) Bachelor degree or above 14 (82.4%) 15 (78.9.7%) Note. Underweight = less than 18, Normal weight = 18.5 – 24.99, Overweight = 25 – 28, Obesity = 28 – 32 III.2 the effect of TCMD on outcome measures A significant interaction between group and test in the BASDAI scores [Wilk’ λ= .676, F (1, 34) = 16.33, p = .000, η2 =.32] was observed (Figure 2). Specifically, the results of the significant interaction indicate that TCMD had a higher mean score on the baseline but a lower mean score at Week 12 when compared to the control group. A follow-up simple effect test was then performed to determine the interaction between group and test. The results of the follow-up test indicate that no significant differences were observed between the TCMD and control groups in the BASDAI score at both the baseline (p = 0.177) and Week 12 (p = 0.651). With regard to within-group comparison, study results indicate that AS patients who had received TCMD at Week 12 (M = 2.33, SD = 1.51) showed significantly lower BASDAI score (p = 0.000) in comparison to the baseline (M = 3.03, SD = 1.73). However, for the control group, no significant change from Week 12 (M = 2.58, SD = 1.74) to baseline (M = 2.28, SD =1.52) was not found in the BASDAI score (p = 0.089). 1589
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Figure 2: Mean changes in Disease Activity from baseline to 12-week between TCMD and control group. A significant interaction between group and test in the BASMI scores [Wilk’ λ= .395, F (1, 34) = 52.06, p = .000, η2 =.61] was observed (Figure 3). Specifically, the results of the significant interaction indicate that TCMD had a higher mean score at baseline but a lower mean score at Week 12 as compared to those in the control group. A follow-up simple effect test was then performed to determine the interaction between group and test. The results of the follow-up test indicate that no significant differences were observed between the TCMD and control groups in the BASMI score at both baseline (p = 0.171) and Week 12 (p = 0.417). With regard to within-group comparison, study results indicate that participants who had received TCMD at baseline (M = 2.28, SD = 1.63) showed significantly lower BASDAI score (p = 0.000) when comparing to Week 12 (M = 3.25, SD = 2.10). However, it was not observed that AS patients who maintained their original lifestyle at Week 12 (M= 2.66, SD = 1.32) showed significant change in the BASDAI score (p = 0.12) when compared to the baseline (M = 2.48, SD = 1.06).
Figure 3: Mean changes in Spinal Mobility from baseline to 12-week between TCMD and control groups. A significant interaction between group and test in the SF-36 [Wilk’ λ= .869, F (1, 34) = 162.62, p = .03, η2 =.13] was observed (Figure 4). Specifically, the results of the significant interaction indicate that TCMD had a higher mean score at baseline and Week 12, as compared to those in the control group. A follow-up simple effect test was then performed to determine the interaction between group and test. The results of the follow-up test revealed that no significant differences were observed between the TCMD and control groups in the SF-36 score at both baseline (p = 0.97) and Week 12 (p = 0.36). For within-group comparison, study results indicate that AS patients who had received TCMD at Week 12 (M = 66.06, SD = 23.50) showed significantly higher QOL scores (p = 0.014) when comparing to baseline (M = 61.04, SD = 17.40).
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Zou et al. However, it was not observed that AS patients who maintained their original lifestyle at Week 12 (M= 59.83, SD = 16.48) showed a significant change in the SF-36 score (p = 0.585) when compared to the baseline (M = 60.84, SD = 16.61).
Figure 4: Mean changes in Quality of Life from baseline to 12-week between TCMD and control group. Table 6: Descriptive Statistics on the baseline and 12-week for both the traditional Chinese Qigong exercises (TCQG) and control group. Outcome measure Disease Activity Baseline 12-week Mean diff. P value Spinal Mobility baseline 12-week Mean diff. P value Quality of Life baseline 12-week Mean diff. P value Mean diff. = baseline – 12-week: 1) for
TCQG (n = 17) M ± SD
Control group (n = 19) M ± SD
3.03 ± 1.73 2.33 ± 1.51 - 0.7 0.00
2.28 ± 1.52 2.58 ±1.74) 0.3 .089
3.25 ± 2.10 2.28 ± 1.63 -0.97 0.00
2.48 ± 1.06 2.66 ± 1.13 0.18 0.12
61.04 ± 17.4 60.84 ±16.6 66.06 ± 23.5 59.83 ± 16.48 5.02 -1.01 0.014 0.59 disease activity and spinal mobility, a negative value indicates improvement, and
vice versa, 2) for functional flexibility, a positive value indicates improvement, and vice versa. Discussion The purpose of this study was to examine the effects of TCMD on disease activity, spinal mobility, and quality of life in AS patients. The study findings suggest that the 12-week TCMD effectively alleviated AS-related symptoms (disease activity and spinal mobility) and improved QOL, whereas these disease-specific symptoms slightly deteriorated in the control group, which ultimately led to reduced QOL. No adverse event throughout the entire intervention period was reported, which is indicative of the safety of TCMD. The 12-week TCMD has been shown to have therapeutic effects in reducing the level of disability (disease activity) that AS patients are experiencing. More importantly, the TCMD showed a decrease of 23.10% in the level of disability, which is close to the value (22.5%) of the minimum clinically important difference for the BASDAI [47]. Thus, it is worth emphasizing that the TCCM is clinically meaningful for AS patients in alleviating the level of disability. The study findings of the present study are supported by previous studies, suggesting that other types of exercise modalities (Pilates, McKenzie technique, Global Posture Reeducation method) effectively alleviated AS-related pain, fatigue, and stiffness [47-50]. The potential mechanism underlying the effects of TCMD on pain relief may be related to the gate control theory. According to Melzack and Wall [51], the gate control theory suggests that the passage 1591
Zou et al. of the discomforts (pain) can be attenuated or eliminated by any simultaneously emerging input in the A Beta-nerve fiber. The painful information is typically transmitted from the peripheral receptors to the central nerve system through the dorsal horn containing C nerve fiber and A Beta-nerve fiber: (1) if a person touched a sharp or hot object, pain is perceived when more C nerve fibers or only C nerve fibers are stimulated, because C-fiber stimulation inactivates the inhibitory neurons so that projection neuron is not inhibited from sending pain signals to the brain, (2) the degree of pain sensation has become weaker when more A Beta-nerve fibers are stimulated due to the A Beta-nerve fiber stimulation activates the inhibitory neuron preventing projection neuron from sending pain signals to the brain In general, if one touches a hot stove, the discomfort or pain perception occurs in peripheral pain receptors, which then relay it to the dorsal horn of the spinal cord via C nerve fibers and subsequently travel upwards to the central nerve system so that the pain is perceived. If we rubbed or massaged the affected area, more A Beta-nerve fiber are stimulated, which can weaken the degree of the uncomfortable impulses or pain sensation. Exercise itself is like rubbing or massaging, which has the same function as stimulating A Beta nerve fiber [52, 53]. Mind-body exercises are low-to-moderate intensity exercise modality that can potentially activate the larger afferent nerve fiber, which may be reasonably beneficial for pain relief in AS patients. As mentioned previously [22-26], mind-body exercises have concentrated on integrating physical training with spiritual practice (e.g., mental focus, breathing technique, self-awareness, musculoskeletal stretching, and relaxation). The spiritual practice may also help with pain management in this population because breathing technique, mental focus, and self-awareness require practitioners to have an empty, meditative mind, instead of focusing on the pain itself. For example, when you are competing in a sport, you often ignore pain produced by even severe injury. If we can get the brain think of anything else though the spiritual practice (mental focus, meditative mind, breathing technique), pain is not perceived. The relevant literature supporting the importance of cognitive factor for pain management is associated with these clinical trials investigating the effects of drug versus placebo on alleviating pain in patients with different disease conditions [54]. For example, patients who received placebo demonstrated less pain perception as compared to those in a drug group after the intervention period. From the cognitive perspective, the phenomenon is probably attributed to that patients in the placebo had the same expectation for pain relief as those in the experimental group did. In addition to spinal and joint pain, AS patients also experience fatigue and stiffness as other two components of the disease activity [35]. Fatigue is defined as a subjective perception of physical or mental energy deficiency while carrying activities of daily life [55]. Increase muscle tone in AS patients resulted in stiffness, which can make it hard to carry out voluntary movements such as manipulative skills and walking [56]. The findings suggest that TCMD effectively alleviated fatigue and stiffness in AS patients, which is consistent with previous studies investigating the effects of home- or supervised-based exercise (including components of breathing technique, chest expansion, range of motion and muscular stretching) on fatigue and stiffness [48, 57]. Ma Wangdui Health-Qigong is a moderate-intensity exercise that has an emphasis on a combination of physical (e.g., joint range of motion stretching and relaxation) and spiritual elements (e.g., self-awareness, breathing technique, mental focus) to slowly and gently move the internal vital energy throughout the body, which may reduce muscle stiffness and change the perception of musculoskeletal fatigue in AS patients [25, 26]. Change in physical structures in AS patients are not reversible, consequently leading to limited spinal mobility [58]. To evaluate the impact of TCMD on spinal mobility, researchers utilized a combined instrument, called the BASMI consisting of tragus-to-wall, lumbar flexion (modified Schober test), cervical rotation, lumbar side flexion, and inter malleolar distance. AS patients in the TCMD group showed significantly better flexibility performance at both baseline and Week 12 as compared to those in the control group. It is worth noting that the significant difference was observed at baseline. A randomized controlled trial in future studies can be used, which may potentially eliminate this imbalance baseline. After the 12-week intervention period, the difference between the two groups at Week 12 has become more apparent, which can best be explained by the within-group comparison: AS patients receiving the 12-week TCMD intervention showed an improvement in spinal mobility, whereas the control group slightly deteriorated. The encouraging findings of the present study are in line with previous studies focusing on the influence of individual or multimodal exercise programs (Pilates, Mckenzie, Heckscher) containing stretching, respiratory, mobilization, 1592
Zou et al. and strengthening components [47, 49, 59-61]. Improvement in spinal mobility in the TCMD group may be due to the positive effects of the 12-week TCMD on promoting the joint range of motion (ROM), including shoulder joint, sacroiliac joint, and knee joint. The increased ROM after the 12-week TCMD may be explained by the feature of 12 main movements from TCMD (Ma Wang Dui Health-Qigong). For example, Movement 3 (Fu Yu) and Movement 9 (Yang Fei) require practitioners to flex their lumbar spine to left and right side, which is best reflected by Lumbar Side Flexion as one of the five measuring components of the BASMI. In the meanwhile, when practitioners are performing lumbar spine flexion, they also need to rotate their necks. Such neck rotation may result in the improvement in the cervical rotation test. In addition, Movement 5 (Niao Shen) involves a forward bending with fingertips touching feet, which is relatively equivalent to both the Modified Schober test, is probably the main reason why flexibility-related performance improved after the 12-week TCMD program. Such improvements in the five individual tests directly may contribute to a better overall performance in spinal mobility. Physical and psychological symptoms of AS seriously reduce the QOL in AS patients [62-64]. The Short Form-36 questionnaire as a generic QOL instrument was used to determine whether TCMC was effective in improving QOL in AS patients. AS patients receiving the 12-week TCMD intervention showed an improvement in QOL, whereas reduced QOL was found in the control group from baseline to Week 12. The study findings suggest that TCMD is effective in improving QOL in AS patients. However, AS patients in the control kept their original life experienced normal deterioration of symptoms. Because of a small number of experimental studies in a recently published systematic review, study findings indicated that the therapeutic effect of exercise as a treatment for AS patients still remain unclear, specifically for mitigating symptoms [65]. When compared to the systematic review, the findings of the present study are encouraging, which adds to the current body of research literature reflecting the therapeutic effect of exercise-based intervention on improving QOL [47, 48, 60, 66, 67]. As mentioned previously, multiple domains of QOL are affected by AS-related clinical manifestations [68-70]. Fortunately, improvements in disease activity and spinal mobility were found in the present study, which may reasonably contribute to better QOL perception in AS patients of the TCMD training group. Although the present study findings are supportive of the therapeutic effect of TCMD training for the level of disease, spinal mobility, and quality of life, several notable limitations should be acknowledged in the present study. Firstly, a small sample (N = 36) may be a reason why mean differences in the BASDAI, BASMI, and QOL between the TCMD and control groups were unable to be detected. The small sample size also makes it difficult to definitively generalize the results to this special population. Secondly, the sample of the present study is limited to AS patients with Stage I and II, the results, therefore, are not appropriate to be generalized into AS patients with Stage III and IV of functional disability classification. Thirdly, even if the therapeutic effects were found in the present study, AS patients of the TCMD group were not blinded to this intervention and therefore possibly have high expectation of the therapeutic effect of TCMD, which could inflate the responses. Conclusion TCMD (Ma Wang Dui Health-Qigong) is effective in alleviating AS-related symptoms (level of disability, spinal mobility) and improving quality of life in people with ankylosing spondylitis. Give the therapeutic effect of Mawangdui Health Qigong exercise for AS patients, health professionals should incorporate Mawangdui Qigong exercise into a rehabilitation program for symptomatic management of AS. Researchers in the future studies should also utilize randomized controlled trials with a large sample size to further examine whether a long-term effect of Mawangdui Health-Qigong exercise exists in AS patients with all levels of functional disability. Acknowledges We must thank all AS patients who voluntarily participated in this research project. Without his permission and assistance, this project could never be done. Author Contribution 1593
Zou et al. Liye Zou and Huiru Wang contributed to the conception and design of this research project. Liye Zou and Huiru Wang were responsible for the method section. All authors had contributed to manuscript writing and edition. Conflicts of Interest The authors declare no conflict of interest References Khan, M.A. Update on spondyloarthropathies. Ann Intern Med. 2002, 136, 896-907. Barlow, J.H., Wright, C.C., Williams, B., Keat, A. Work disability among people with ankylosing spondylitis. Arthritis Care Res. 2001, 45, 424-429. Shen, B., Zhang, A., Liu, J., Da, Z., Xu, X., Liu, H, Li, L., Gu, Z. Body image disturbance and quality of life in Chinese patients with ankylosing spondylitis. Psychology and Psychotherapy: Theory, Research and Practice. 2014, 87, 324-337. Vesović-Potić, V., Mustur, D., Stanisavljević, D., Ille, T., Ille, M. Relationship between spinal mobility measures and quality of life in patients with ankylosing spondylitis. Rheumatol Int. 2009, 29, 879-884. Zink, A., Braun, J., Listing, J., Wollenhaupt, J. Disability and handicap in rheumatoid arthritis and ankylosing spondylitis--results from the German rheumatological database. German Collaborative Arthritis Centers. J Rheumatol. 2000, 27, 613-622. Zochling, J., van der Heijde, D., Dougados, M., Braun, J. Current evidence for the management of ankylosing spondylitis: a systematic literature review for the ASAS/EULAR management recommendations in ankylosing spondylitis. Ann Rheum Dis. 2006, 65, 423-432. Dean, L.E., Jones, G.T., MacDonald, A.G., Downham, C., Sturrock, R.D., Macfarlane, G.J. Global prevalence of ankylosing spondylitis. Rheumatology. 2014, 53, 650-657. Braun, J., Brandt, J., Listing, J., Zink, A., Alten, R., Golder, W., Gromnica-lhle, E., Kellner, H., Krause, A., Schneider, M., Sörensen, H. Treatment of active ankylosing spondylitis with infliximab: a randomised controlled multicentre trial. The Lancet. 2002, 359, 1187-1193. Kim, T.H., Uhm, W.S., Inman, R.D. Pathogenesis of ankylosing spondylitis and reactive arthritis. Curr Opin Rheumatol. 2005, 17, 400-405. Sieper, J., Braun, J., Rudwaleit, M., Boonen, A., Zink, A. Ankylosing spondylitis: an overview. Ann Rheum Dis. 2002, 61, 8-18. Boulos, P., Dougados, M., MacLeod, S. M., Hunsche, E. Pharmacological treatment of ankylosing spondylitis. Drugs. 2005, 65, 2111-2127. Gorman, J.D., Sack, K.E., Davis Jr, J.C. Treatment of ankylosing spondylitis by inhibition of tumor necrosis factor α. N Engl J Med. 2002, 346, 1349-1356. Wanders, A., Heijde, D. V. D., Landewé, R., Béhier, J. M., Calin, A., Olivieri, I., Zeidler, H., Dougados, M. Nonsteroidal antiinflammatory drugs reduce radiographic progression in patients with ankylosing spondylitis: a randomized clinical trial. Arthritis & Rheumatism. 2005, 52, 1756-1765. Chatfield, S.M., Dharmage, S.C., Boers, A., Martin, B.J., Buchanan, R.R., Maksymowych, W.P., Schachna, L. Complementary and alternative medicines in ankylosing spondylitis: a cross-sectional study. Clin Rheumatol. 2009, 28, 213-217. Van Tubergen, A., Boonen, A., Landewé, R., Mölken, R.V., Van Der Heijde, D., Hidding, A., Van Der Linden, S. Cost effectiveness of combined spa–exercise therapy in ankylosing spondylitis: A randomized controlled trial. Arthritis Care Res. 2002, 47, 459-467. Zochling, J. Measures of symptoms and disease status in ankylosing spondylitis: Ankylosing Spondylitis Disease Activity 1594
Zou et al. Score (ASDAS), Ankylosing Spondylitis Quality of Life Scale (ASQoL), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Global Score (BAS‐G), Bath Ankylosing Spondylitis Metrology Index (BASMI), Dougados Functional Index (DFI), and Health Assessment Questionnaire for the Spondylarthropathies (HAQ‐S). Arthritis Care Res. 2011, 63, 47-58. Pedersen, B.K., Saltin, B. Evidence for prescribing exercise as therapy in chronic disease. Scand J Med Sci Sports. 2006, 16, 3-63. Gleeson, M., Bishop, N.C., Stensel, D.J., Lindley, M.R., Mastana, S.S., Nimmo, M.A. The anti-inflammatory effects of exercise: mechanisms and implications for the prevention and treatment of disease. Nat Rev Immunol. 2011, 11, 607-615. Nolte, K., van Rensburg, D.C. The role of exercise in the rehabilitation of ankylosing spondylitis. International Sport Medicine Journal. 2001, 2, 1-12. Van den Berg, R., Baraliakos, X., Braun, J., van der Heijde, D. First update of the current evidence for the management of ankylosing spondylitis with non-pharmacological treatment and non-biologic drugs: A systematic literature review for the ASAS/EULAR management recommendations in ankylosing spondylitis. Rheumatology. 2012, 51, 1388-1396. Wang, C.Y., Chang, P.Y., Lee, H.S., Wei, J. C. The effectiveness of exercise therapy for ankylosing spondylitis: A review. Int J Rheum Dis. 2009, 12, 207-210. Zou, L., Wang, H., Xiao, Z., Fang, Q., Zhang, M., Li, T., Du, G., Liu, Y. Tai chi for health benefits in patients with multiple sclerosis: A systematic review. PloS one. 2017, 12, p.e0170212. Zou, L., SasaKi, J.E., Wang, H., Xiao, Z., Fang, Q., Zhang, M. A Systematic Review and Meta-Analysis Baduanjin Qigong for Health Benefits: Randomized Controlled Trials. Evid Based Complement Alternat Med, 2017. Zou, L., Wang, C., Chen, K., Shu, Y., Chen, X., Luo, L., Zhao, X. The Effect of Taichi Practice on Attenuating Bone Mineral Density Loss: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Int. J. Environ. Res. Public Health. 2017, 14, 1000. Zou, L., Wang, C., Tian, Z., Wang, H., Shu, Y. Effect of Yang-Style Tai Chi on Gait Parameters and Musculoskeletal Flexibility in Healthy Chinese Older Women. Sports. 2017, 5, 52. Lou, L., Zou, L., Fang, Q., Wang, H., Liu, Y., Tian, Z., Han, Y. Effect of Taichi softball on function-related outcomes in older adults: A randomized controlled trial. Ecam. 2017, Article ID 4585424 Song, R., Roberts, B.L., Lee, E.O., Lam, P., Bae, S.C. A randomized study of the effects of tai chi on muscle strength, bone mineral density, and fear of falling in women with osteoarthritis. J Altern Complement Med. 2010, 16, 227-233. Wang, C., Schmid, C.H., Hibberd, P.L., Kalish, R., Roubenoff, R., Rones, R., McAlindon, T. Tai Chi is effective in treating knee osteoarthritis: A randomized controlled trial. Arthritis Care Res. 2009, 61, 1545-1553. Wang, C., Schmid, C. H., Rones, R., Kalish, R., Yinh, J., Goldenberg, D.L., Lee, Y., Mc Alindon, T. A randomized trial of tai chi for fibromyalgia. N Engl J Med. 2010, 363, 743-754. Jones, K.D., Sherman, C.A., Mist, S.D., Carson, J.W., Bennett, R.M., Li, F. A randomized controlled trial of 8-form Tai chi improves symptoms and functional mobility in fibromyalgia patients. Clin Rheumatol. 2012, 31, 1205-1214. Sigl-Erkel, T., Wang, C., Schmid, C.H., Rones, R., Kalish, R., Yinh, J., Goldenberg, D.L., Lee, Y., Mc Alindon, T. A randomized trial of Tai Chi for fibromyalgia. Deutsche Zeitschrift fuer Akupunktur. 2010, 53, 40-41. Wang, C., Schmid, C.H., Iversen, M.D., Harvey, W.F., Fielding, R.A., Driban, J.B., Price, L.L., Wong, J.B., Reid, K.F., Rones, R., McAlindon, T. Comparative Effectiveness of Tai Chi Versus Physical Therapy for Knee Osteoarthritis: A Randomized Trial. Ann Intern Med. 2016. Park, H., Kim, S., Lee, J., Jun, J., Bae, S. The reliability and validity of a Korean translation of the BASDAI in Korean patients with ankylosing spondylitis. Value in Health. 2017, 11, 99-104. Wei, J., Wong, R., Huang, J., Yu, C., Chou, C., Jan, M., Tsay, G., Chou, M., Lee, H., Evaluation of internal consistency and re-test reliability of Bath ankylosing spondylitis indices in a large cohort of adult and juvenile spondylitis patients in 1595
Zou et al. Taiwan. Clin Rheumatol. 2007, 26, 1685-1691. Garrett, S., Jenkinson, T., Kennedy, L.G., Whitelock, H., Gaisford, P., Calin, A. A new approach to defining disease status in ankylosing spondylitis: the Bath Ankylosing Spondylitis Disease Activity Index. The Journal of rheumatology. 1994, 21, 2286-2291. Cao, X., Chen, L., Diao, Y., Tian, L., Liu, W., Jiang, X. Validity and Reliability of the Chinese Version of the Care Transition Measure. PLoS ONE. 2015, 10, e0127403. Jone, S., Porter, J., Garrett, S., Kenedy, L., Whitelock, H., Calin, A. A new scoring system for the Bath Ankylosing Spondylitis Metrology Index (BASMI). Journal of Rheumatology. 1995, 22, 1609. The WHOQOL Group. The World Health Organization Quality of Life Assessment (WHOQOL). Development and psychometric properties. Soc Sci Med. 1998, 46, 1569-1585. Zhang, Y., Qu, B., Lun, S., Wang, D., Guo, Y., Liu, J. Quality of Life of Medical Students in China: A Study Using the WHOQOL-BREF. PLoS ONE. 2012, 7, e49714. Bodur, H., Ataman, Ş., Rezvani, A., Buğdaycı, D.S., Çevik, R., Birtane, M., Akıncı, A., Altay, Z., Günaydın, R., Yener, M., Koçyiğit, H. Quality of life and related variables in patients with ankylosing spondylitis. Qual Life Res. 2011, 20, 543-549. Özdemir, O. Quality of life in patients with ankylosing spondylitis: relationships with spinal mobility, disease activity and functional status. Rheumatol Int. 2011, 31, 605-610. Rugiene, R., Kirdaitė, G., Gražuleviciūtė, E., Dadonienė, J., Venalis, A. The quality of life and functional ability in patients with ankylosing spondylitis. Acta Med Litu. 2008, 15, 99-103. Ware Jr., J.E., Sherbourne, C.D. The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Medical care. 1992, 473-483. Linden, S.V.D., Valkenburg, H.A., Cats, A. Evaluation of diagnostic criteria for ankylosing spondylitis. Arthritis and Rheumatism. 1984, 27, 361-368. Steinbrocker, O., Traeger, C.H., Batterman, R.C. Therapeutic criteria in rheumatoid arthritis. JAMA. 1949, 140, 659-62. Pavy, S., Brophy, S., Calin, A. Establishment of the minimum clinically important difference for the bath ankylosing spondylitis indices: a prospective study. The Journal of Rheumatology. 2005, 32, 80-85. Altan, L., Korkmaz, N., Dizdar, M., Yurtkuran, M. Effect of Pilates training on people with ankylosing spondylitis. Rheumatol Int. 2012, 32, 2093-2099. Durmus, D., Alayli, G., Cil, E., Canturk, F. Effects of a home-based exercise program on quality of life, fatigue, and depression in patients with ankylosing spondylitis. Rheumatol Int. 2009, 29, 673-677. Rosu, O.M., Ancuta, C. McKenzie training in patients with early stages of ankylosing spondylitis: results of a 24-week controlled study. Eur J Phys Rehabil Med. 2015, 51, 261-268. Sweeney. S., Taylor, G., Calin, A. The effect of a home-based exercise intervention package on outcome in ankylosing spondylitis: a randomized controlled trial. J Rheumatol, 2002, 29, 4, 763-766. Melzack, R., Wall, P. Pain mechanisms: A new theory. Survey of Anesthesiology. 1967, 11, 89-90 Bement, M.K.H., Sluka, K.A. Low-intensity exercise reverses chronic muscle pain in the rat in a naloxone-dependent manner. Arch. Phys. Med. Rehabil. 2005, 86, 1736–1740. Kanarek, R., Gerstein, A., Wildman, R., Mathes, W., D’Anci, K. Chronic Running-Wheel Activity Decreases Sensitivity to Morphine-Induced Analgesia in Male and Female Rats. Pharmacol Biochem Behav. 1998, 61, 19-27. Benedetti, F. Placebo effects: From the neurobiological paradigm to translational implication. Neuro. 2014, 84, 623-637. Missaoui, B., Revel, M. Fatigue in ankylosing spondylitis. In Annales De Réadaptation ET de Médecine Physique. 2006, 49, 389-391. Calin, A., Garret, S., Whitelock, H., Kennedy, L., O’ Hea, J., Mallorie, P., Jenkinson, T. A new approach to defining functional ability in ankylosing spondylitis: the development of the Bath Ankylosing Spondylitis Functional Index. J 1596
Zou et al. Rheumatol. 1994, 21, 2281-2285. Lim, H., Moon, Y., Lee, Effects of home-based daily exercise therapy on joint mobility, daily activity, pain, and depression in patients with ankylosing spondylitis. Rheumatol Int. 2005, 25, 225-229. Russel, A.S. Ankylosing spondylitis history. Rheumatology. 1994, 1, 23-1. Ince, G., Sarpel, T., Durgun, B., Erdogan, S. Effects of a multimodal exercise program for people with ankylosing spondylitis. Physical Therapy. 2006, 86, 924-935. Karapolat, H., Akkoc, Y., Sarı, İ., Eyigor, S., Akar, S., Kirazlı, Y., Akkoc, N. 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. Clin Rheumatol. 2008, 27, 695-700. Roşu, M.O., Topa, I., Chirieac, R., Ancuta, C. Effects of Pilates, McKenzie and Heckscher training on disease activity, spinal motility and pulmonary function in patients with ankylosing spondylitis: a randomized controlled trial. Rheumatol Int. 2014, 34, 367-372. Baysal, Ö., Durmuş, B., Ersoy, Y., Altay, Z., Şenel, K., Nas, K., Uğur, M., Kaya, A., Gür, A., Erdal, A., Ardıçoğlu, Ö. Relationship between psychological status and disease activity and quality of life in ankylosing spondylitis. Rheumatol Int. 2011, 31, 795-800. 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. 2012, 14, 215. Turan, Y., Duruöz, M.T., Cerrahoglu, L. Quality of life in patients with ankylosing spondylitis: a pilot study. Rheumatol Int. 2007, 27, 895-899. O’Dwyer, T., O’Shea, F., Wilson, F. Exercise therapy for spondyloarthritis: a systematic review. Rheumatol Int. 2014, 34, 7, 887-902. Aytekin, E., Caglar, N.S., Ozgonenel, L., Tutun, S., Demiryontar, D.Y., Demir, S.E. Home-based exercise therapy in patients with ankylosing spondylitis: effects on pain, mobility, disease activity, quality of life, and respiratory functions. Clin Rheumatol. 2012, 31, 91-97. Karapolat, H., Eyigor, S., Zoghi, M., Akkoc, Y., Kirazli, Y., Keser, G. Are swimming or aerobic exercise better than conventional exercise in ankylosing spondylitis patients? A randomized controlled study. Eur J Phys Rehabil Med. 2009, 45, 449-457. Özdemir, O. Quality of life in patients with ankylosing spondylitis: relationships with spinal mobility, disease activity and functional status. Rheumatol Int. 2011, 31, 605-610. Vesović-Potić, V., Mustur, D., Stanisavljević, D., Ille, T., Ille, M. Relationship between spinal mobility measures and quality of life in patients with ankylosing spondylitis. Rheumatol Int. 2009, 29, 879-884. Ward, M.M. Health related quality of life in ankylosing spondylitis: A survey of 175 patients. Arthritis Care Res. 1999, 12, 247-255.
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