Regular physical activity preserves the lung function in patients with ankylosing spondylitis without previous lung alterations

Abstracts

A espondilite anquilosante é uma doença inflamatória que influencia de maneira restritiva a mecânica respiratória por meio do acometimento das articulações da coluna, bem como das alterações posturais decorrentes desse processo como o aumento da cifose torácica. OBJETIVO: O objetivo deste estudo foi avaliar a alteração pulmonar dos pacientes portadores de espondilite anquilosante e relacioná-la à atividade física, verificando a influência na capacidade respiratória. MÉTODOS:Foram recrutados para este estudo 104 pacientes. Apenas 15 preenchiam os critérios de inclusão e exclusão, sendo divididos em dois grupos: grupo I, composto por indivíduos sedentários, e o grupo II, composto por pacientes que praticam uma atividade física regular moderada. RESULTADOS:Os dois grupos não diferiram em relação à média da idade (49,6 ± 11,6 versus 43,3 ± 13,2 anos, p = 0,19), peso (70,9 ± 9,7 versus 74,1 ± 12,1 kg, p = 0,30) e a altura (164,6 ± 3,5 versus 167,6 ± 6,9 cm, p = 0,16). Entretanto, o tempo médio de doença foi significantemente maior no grupo I comparado ao grupo de ativos (20,1 ± 6,9 vs. 9,6 ± 3,4, p = 0,004). Como tema de interesse, observou-se que o volume minuto foi significativamente maior no grupo ativo que no inativo (4,83 ± 1,07 versus 6,1 ± 1,25, p = 0,035). Por outro lado, isso não foi demonstrado em relação à frequência respiratória (14,57 ± 1,76 versus 16,25 ± 3,53 ipm, p = 0,15), ao volume corrente (0,402 ± 0,07 versus 0,342 ± 0,10 L, p = 0,13), bem como às medidas de pressão PI máx (84,29 ± 24,99 versus 93,13 ± 16,76 cmH2O), p = 0,24) e PE máx (102,2 ± 29,26 versus 105 ± 17,32 cmH2O, p = 0,42). CONCLUSÃO:Este estudo pareceu demonstrar que os volumes pulmonares são mantidos em pacientes com espondilite anquilosante que realizam atividade física regular.

espondilite anquilosante; espondiloartropatia; função pulmonar; atividade física; exercício físico

ORIGINAL ARTICLE

^IPhysiotherapist. Division of Rheumatology and Physiotherapy, Physical Therapy Course, Universidade Cidade de São Paulo (UNICID)

^IIProfessor of Physical Therapy at the Rheumatology/ Physiotherapy Division at Universidade Cidade de São Paulo (UNICID)

^IIICollaborating Lecturer of Rheumatology at the University of São Paulo (USP) Medical School and referring physician at the Rheumatology Division at Hospital das Clínicas, University of São Paulo Medical School

^IVDivision of Rheumatology Service at Hospital das Clínicas, University of São Paulo Medical School

Correspondence to

ABSTRACT

Ankylosing spondylitis is an inflammatory condition which causes restriction in the lung function due to column joint alterations leading to postural dysfunction and thoracic ciphosis.

OBJECTIVE: The objective of this study was to evaluate the lung function in patients with ankylosing spondylitis and to associate this parameter with physical activity.

METHODS:104 patients were selected and only 15 fulfilled inclusion and exclusion criteria. They were divided in two groups: group I composed by sedentary patients, and group II with patients that has a regular physical activity. Demographic features, parameters of cervical, dorsal and lumbar column mobility were collected. Measurements of minute volume, respiratory rate, maximum inspiratory and expiratory pressures and quality of life (HAQ-S) were also evaluated.

RESULTS: Both groups were similar regarding mean age (49.6 ± 1.6 vs. 43.3 ± 13.2 years, p = 0.19), weight (70.9 ± 9.7 vs. 74.1 ± 12.1 kg, p = 0.30) and height (164.6 ± 3.5 vs. 167.6 ± 6.9 cm, p = 0.16). However, the mean disease duration was significantly higher in the group I compared to the active group (20.1 ± 6.9 vs. 9.6 ± 3.4 years, p = 0.004). Interestingly, a significantly higher minute volume was observed in the active group than inactive one (4.83 ± 1.07 vs. 6.1 ± 1.25 L/min, p = 0.035). On the other hand, no differences were found regarding respiratory rate (14.57 ± 1.76 vs. 16.25 ± 3.53 ipm, p = 0.15), tidal volume (0.402 ± 0.07 vs. 0.342 ± 0.10 L, p = 0.13), as well as maximum inspiratory pressure (84.29 ± 24.99 vs. 93.13 ± 16.76 cmH₂O), p = 0.24) and maximum expiratory pressure (102.2 ± 29.26 vs. 105 ± 17.32 cmH₂O, p = 0.42). ),

CONCLUSION: This study seems to show that respiratory volumes are maintained stable in patients with ankylosing spondylitis that are under regular physical activity.

Keywords: ankylosing spondylitis, spondyloarthropathy, lung function, physical training, physical activity.

INTRODUCTION

Ankylosing spondylitis (AS) is a progressive chronic inflammatory disease, with unknown etiology that affects, especially, sacroiliac joints and spine leading to loss of mobility.¹ The pulmonary function tests in AS have revealed a high prevalence of restrictive defect, characterized by a low forced vital capacity. Rigidity of the thorax occurs in AS with bony ankylosis of the thoracic vertebrae, costovertebral, costotransverse, sternoclavicular and sternomanubrial joints leading to a predominant diaphragmatic breathing.^2,3

The importance of studying the respiratory system in these patients is related to the necessity of a minimum of respiratory capacity suitable for performing daily activities.^3-5

Considering that there is no definitive treatment for AS and the main goals are to educate and make patient aware of his/her participation in an exercise program so that he/she can keep a functional posture and also maintain movements, this research is a transversal study aiming at comparing patients with AS and verifying the effect of moderate regular physical activity in these patients' respiratory capacity.^4-8

PATIENTS AND METHODS

Patients: From August to November, 2001, 104 patients with ankylosing spondylitis that had been followed up at the Seronegative Spondyloarthropathy Unit at the Rheumatology Department of Hospital das Clínicas of University of São Paulo Medical School (FMUSP) were selected for this protocol accordingly to New York ⁹ criteria.

Inclusion criteria were: Patients diagnosed by international criteria of ankylosing spondylitis⁹ whose ages were equal or higher than 18 years old who had this disease for more than five years. Additionally, patients who have been practicing on a regular basis any type of physical training (running, swimming, cycling or treadmill) at least twice a week and for a minimum of thirty minutes were included.

Exclusion criteria were other conditions that could influence pulmonary function tests, such as: Previous history or physical examination suggesting cardiac or pulmonary diseases, smoking habits, congenital kyphoscoliosis, history of previous thoracotomy; or even patients with other associated seronegative arthropathy.

Materials: All patients underwent a through physical examination: pulmonary auscultation, respiratory rate, expansibility and chest symmetry through physical exam.¹⁰ Each patient signed an informed consent and answered a protocol of functional capacity - HAQ modified for ankylosing spondylitis (HAQ-S), from 0 to 3 (0 for total independence and 3 for severe functional disability), and a specific protocol for possible respiratory changes.¹¹

In order to measure positive and negative maximum pulmonary pressure, a "Ger-Ar" brand compound gauge was used to evaluate respiratory muscle strength, as there is a change in lung function due to chest movement limitation resulting from thorax and spinal rigidity, and it cannot be evaluated by spirometry. In order to get minute volume and tidal volume, an "Ohmeda" respirometer was used. A 3-cm long and 1-cm width adapted mouthpiece was connected to both devices in order to avoid air escaping from the patient's mouth.^12,13

Clinical assessments: The following tests were performed: chest expansion, finger-to-floor distance, occipital wall distance and Schober test using measuring tape.¹⁴

The chest expansion was measured around, during maximum inspiration and maximum expiration, and the difference between these two measures (cm) was recorded. Normal values were those higher or equal to 2.5cm of difference. Finger-to-floor distance measures were also taken, considering the distance of the third finger to the floor (cm).¹⁴

Occipital wall distance measure was taken with patient's heels leaning on the wall and the body straight without bending the knees (cm). Normal value is zero, that is, occipital should touch the wall. For Schober's test, posterior superior iliac spines are palpated and a line between them is delineated. With the individual standing with straight body, a measure 10 cm over this line is marked. Ask the patient to lean the body forward and measure the distance between these two points (cm). Normal values were those whose distance between these two points were higher or equal to 5 cm.¹⁵

Each measure was taken three times without interruption and then an average was calculated.

Minute volume (MV) is the volume of air which can be inhaled or exhaled from a person's lungs in one minute (L/min). This measure was taken asking the patient to breathe in and out normally for one minute. This device read the average of all expirations during this minute (MV= TVx RR).¹⁶

Tidal volume (TV) is the lung volume representing the normal volume of air displaced between normal inhalation and exhalation when extra effort is not applied (~ 500 mL) and it is obtained dividing by the number of breaths the patient take in this minute, which is the respiratory rate (TV= MV/ RR).¹⁶

Maximum inspiration pressure was obtained requesting a maximum inspiration started from the deepest expiration, that is, from a residual volume. The unit is cmH2O; maximum expiration pressure was measured from a deep inspiration, that is, the volume of air contained in the lungs at the end of maximum inspiration, total lung capacity.¹⁶

In statistical analysis, t-test was used to compare both groups. When p < 0.05, it was considered significant.

RESULTS

Out of 104 patients selected, only 15 could take part of this study according to exclusion criteria. Many of them were smokers, cardiac disease patients, pneumopathy patients or presented associate arthropathies. These 15 patients were divided into two groups: Sedentary group (I) (n = 8) and active group (II) (n = 7), consisting of regular physical training practitioners.

Patient's group I (sedentary) and group II (active) were similar regarding mean age (49.6 ± 11.6 versus 43.3 ± 13.2 years, respectively, p = 0.19). These groups were also similar regarding anthropometric variables, such as weight (70.9 ± 9.7 versus 74.1 ± 12.1 years, p = 0.30) and height (164.6 ± 3.5 versus 167.6 ± 6.9 cm, p = 0.16). However, the mean disease duration was significantly higher in group I compared to the active group (20.1 ± 6.9 versus 9.6 ± 3.4, p = 0.004) (Table 1).

Regarding variables related to disease damage in axial skeleton, both groups did not present significant differences in none of the studied variables. The Schober's test (3.0 ± 1.79 versus 2.38 ± 1.56 cm, p = 0.23), middle finger-to-floor distance (31.23 ± 11.2 versus 27.13 ± 8.21 cm, p = 0.23), occipital wall distance (8.36 ± 7.38 versus 8.88 ± 7.46 cm, p = 0.45), and, finally, chest expansion (2.36 ± 1.06 versus 3.19 ± 1.32, p = 0.12) were comparable in both groups, respectively (Table 2). Functional capacity, measured by HAQ-S, was also similar in both groups: 0.96 ± 0.45 versus 1.05 ± 0.51, respectively, p = 0.37 (Table 2).

Concerning the scope of this paper, pulmonary mechanical measures, the active patient group presented, significantly, a higher minute volume when compared to the sedentary group (4.83 ± 1.07 versus 6.1 ± 1.25, p = 0.035). On the other hand, no differences were found regarding respiratory rate (14.57 ± 1.76 versus 16.25 ± 3.53 ipm, p = 0.15), tidal volume (0.402 ± 0.07 versus 0.342 ± 0.10 years, p = 0.13), as well as maximum inspiratory pressure (84.29 ± 24.99 versus 93.13 ± 16.76 cmH₂O, p = 0.24) and maximum expiratory pressure (102.2 ± 29.26 versus 105 ± 17.32 cmH₂O, p = 0.42) (Table 3).

In the protocol about possible signals of respiratory changes, 43.88% of the patients presented fatigue at medium efforts, and 21.9% at large efforts. Coughing was observed in 27.7% and dyspnea in 21.7% of the total patients studied (data not shown in tables).

DISCUSSION

The results showed that patients with ankylosing spondylitis who practice some regular physical activity present a preservation of their pulmonary function, measured by minute volume.¹⁴

Choosing patients who practiced such physical exercises was based on the study by Seçkin et al.,¹⁶ Santos et al.¹⁵ and Carbon et al.,¹² which concluded that these exercises are moderate and ideal for AS patients, because they maintain or improve quality of life, without influencing disease's activity. Maintenance findings on the quality of life in this paper reinforce these previous studies, although they are not significant.

In this paper, with exception of recent prosthesis, presence of prosthesis was not an exclusion criteria, in the beginning of the trial seven patients had prosthesis (one in the shoulder and six in the hip) and it was not a limiting factor for physical training, different from literature and existing studies. However, only one patient with prosthesis took part of this study, as the other patients were excluded due to new prostheses.

Strict exclusion criteria were used in this study, leading to an analysis of a homogeneous population and without higher external interference of cardiopulmonary function. We also highlight the exclusion of patients with smoking habits, because, according to Averns et al.,⁷ as smokers patients presented a clinical aggravation, both functional and radiological, and cigarette effects increase morbidity and mortality rates in these patients.

Disease duration is one of the factors that may influence the level of physical involvement of these patients. The longer the pathology extension, more restrictions are observed concerning mobility and functional capacity. According to Ward et al.,¹⁸ this factor is one of the main causes that increment the incapacity at work and, then, disability retirement. This factor may be a determinant factor of the best performance of active individuals in their current job. However, there was no statistically significant difference in clinical and functional parameters (Schober's test, finger-to-floor distance and occipital wall distance, chest expansion and HAQ) among the groups, reducing the relevance of the factor of disease duration in the findings of this study.

Band et al.¹¹ discuss that the age influences upon the treatment and conclude in their study that younger patients, women and those with shorter disease duration tend to respond better to physical therapy. In this study, there was no this confusing factor, because both groups presented similar ages.

Carbon et al.¹² and Uhrin et al.¹⁷ demonstrated that physical training promotes a beneficial effect in flexibility and wideness of spinal movement due to release of analgesic and anti-inflammatory effect mediators. Additionally, Uhrin et al.¹⁷ discussed in their paper that daily exercises without supervision did not show any relation with changes in pain, stiffness or quality of life, as we also demonstrated here in these two last variables.

Regarding the pulmonary mechanics, minute volume is statistically related to physical activity, that is, even with mechanical change established by this disease and generating chest rigidity, the volume of air that passes through airways every minute is better maintained in individuals who had practiced physical activity regularly.

Inspiration and expiration pressures were within normal limits, and they were not able to identify the group of patients with regular physical activity from sedentary patients. This finding is in accordance with the literature where AS is a restrictive pathology; therefore, changes in maximum expiration pressure are not expected.¹⁰

Hence, it was concluded that regular physical activity in ankylosing spondylitis patients allows maintenance of respiratory capacities and volumes, regardless low thoracic expansibility and spinal mobility restriction. Additionally, physical training provides a general welfare, keeping individual's functional capacity.

REFERENCES

• ¹
  Yoshinari N, Bonfá E. Espondiloartropatias. In: Gonçalves, CR. Reumatologia para o clínico. São Paulo: Roca, 2000.
• ²
  West J. Fisiopatologia pulmonar moderna. 4 ed. São Paulo: Manole, 1996.
• ³
  Guyton A, Hall J. Ventilação pulmonar. In: Tratado de fisiologia médica. 9 ed. Rio de Janeiro: Guanabara Koogan, 1996.
• ⁴
  Turetschek K, Ebner W, Fleischmann D, Wunderbaldinger P, Erlacher L, Zontsich T, et al Early pulmonary involvement in ankylosing spondylitis: assessment with thin-section CT. Clin Radiol 2000;55(8):632-6.
• ⁵
  Robbins S, Cotran R, Kumar V, Collins T. Ossos, articulações e tumores de partes moles. In: Rosenberg, A. Patologia estrutural e funcional. 5 ed. Rio de Janeiro: Guanabara Koogan, 2000.
• ⁶
  Casserly I, Fenlon HM, Breatnach E, Sant SM. Lung findings on high-resolution computed tomography in idiopathic ankylosing spondylitis - correlation with clinical findings, pulmonary function testing and plain radiography. Br J Rheumatol 1997;36 (6): 677-82.
• ⁷
  Averns H, Oxtoby J, Taylor HG, Jones PW, Dziedzic K, Dawes PT. Smoking and outcome in ankylosing spondylitis. Scand J Rheumatol 1996;25(3):138-42.
• ⁸
  Carter R, Riantawan P, Banham SW, Sturrock RD. An investigation of factors limiting aerobic capacity in patients with ankylosing spondylitis. Respir Med 1999;93(10):700-8.
• ⁹
  Cury S,. Qualidade de vida e espondilite anquilosante: estudo piloto. Rev Bras Reumatol 1995;35:77-86.
• ¹⁰
  Guyton A, Hall J. Ventilação pulmonar. In: Tratado de fisiologia médica. 9 ed. Rio de Janeiro: Guanabara Koogan, 1996.
• ¹¹
  Band D, Jones SD, Kennedy LG, Garrett SL, Porter J, Gay L et al. Which patients with ankylosing spondylitis derive most benefit from an inpatient management program? J Rheumatol 1997;24(12):2381-4.
• ¹²
  Carbon R, Macey MG, McCarthy DA, Pereira FP, Perry JD, Wade AJ. The effect of 30 min cycle ergometry on ankylosing spondylitis. B J Rheumatol 1996;35(2):167-77.
• ¹³
  Fenlon H, Casserly I, Sant SM, Breatnach E. Plain radiographs and thoracic high-resolution CT in patients with ankylosing spondylitis. Am J Roentgenol 1997;168(4):1067-72.
• ¹⁴
  Heikkila S, Viitanen JV, Kautiainen H, Kauppi M. Sensitivity to change of mobility tests: effect of short term intensive physioterapy and exercise on spinal, hip and shoulder Measurements in spondyloarthropathy. J Rheumatol 2000;27(5):1251-5.
• ¹⁵
  Santos H, Brophy S, Calin A. Exercise in ankylosing spondylitis: how much is optimum? J Rheumatol 1998;25(11):2156-60.
• ¹⁶
  Seçkin U, Bölükbasi N, Gürsel G, Eröz S, Sepici V, Ekim N. Relationship between pulmonary function and exercise tolerance in patients with ankylosing spondylitis. Clin Exp Rheumatol 2000;18(4):503-6.
• ¹⁷
  Uhrin Z, Kuzis S, Ward MM. Exercise and changes health status in patients with ankylosing spondylitis. Arch Int Medicine 2000;160(19):2969-75.
• ¹⁸
  Ward M, Kuzis S: Risks factors for disability in patients with ankylosing spondilitis. J Rheumatol 2001;28(1):315-21.

Regular physical activity preserves the lung function in patients with ankylosing spondylitis without previous lung alterations

Karin M. Goya^I; Luciana T. Siqueira^I; Renata Alqualo Costa^II; Andréa Lopes Gallinaro^II; Celio Roberto Gonçalves^III; Jozélio Freire de Carvalho^IV

Publication Dates

• Publication in this collection
  07 Apr 2009
• Date of issue
  Apr 2009

History

• Received
  20 May 2008
• Accepted
  03 Nov 2008