WEB-Based Physiotherapy for People With Axial Spondyloarthritis: A Cohort Study

Background and Rationale Axial spondyloarthritis (axial SpA) is an inflammatory arthritis characterised by inflammatory back pain and includes both ankylosing spondylitis (AS) and non-radiographic axial SpA. Axial SpA is associated with pain and stiffness in the spine and/or sacroiliac joints, reduced spinal mobility, fatigue, reduced physical activity, psychological consequences such as depression, and reduced function, work productivity and quality of life. Effective management in axial SpA requires a combination of pharmacological and non-pharmacological interventions. While there have been significant advances in pharmacological therapies, particularly with the introduction of TNF-inhibitors, there have been few advances in how physiotherapy and the non-pharmacological therapies are delivered. This is despite physiotherapy being recognised as the 'cornerstone' in the overall management of people with AS, in terms of both managing symptoms and maintaining function. Physiotherapy comprises of education and exercise programmes aimed at improving or maintaining spinal mobility, reducing spinal pain, increasing strength and stabilising or slowing down disability progression. Physiotherapy is required long-term and in combination with pharmacological therapies. A Cochrane Review in 2008 concluded that both home and supervised individual exercises were beneficial for people with AS, with group exercise more beneficial than home-based exercise. However, to be beneficial, exercise needs to be done at least five times per week, for at least 30 minutes per session and continued on a long-term basis. Patients with axial SpA are increasingly diagnosed and treated earlier, have reduced disease activity as a result of treatment with TNF-inhibitors and are more likely to be younger and in employment than was traditionally the case. For these reasons, patients find it difficult to attend and maintain regular traditional physiotherapy sessions, particularly in the long-term. Practically, then, exercise programmes must include some degree of home-based exercise since this level of exercise cannot be delivered on a long-term basis by the NHS or other services. Despite the requirement for regular physiotherapy, a recent NASS patient survey revealed that 60% of patients had not had physiotherapy in the previous 12 month period. There is therefore a need to find alternative service models which support and facilitate people with axial SpA to exercise regularly and on a long-term basis.

The Office of National Statistics reported that 86% of the adult population (aged over 16 years) in the UK had used the internet and 73% (36 million adults) used it on a daily basis. In addition, there are increasing numbers of people using the internet for health care information and resources. Thus the almost ubiquitous availability and use of the internet provides an ideal opportunity to deliver tailored, individualised, interactive exercise programmes for people with long-term conditions, including axial SpA. Web-based interventions are available 24 hours a day and thus the patient can choose the time and location in which they participate to suit their own personal circumstances. Physiotherapy-led, personalised web-based exercise therefore offers a potentially cost-effective mechanism to deliver this important long-term component in axial SpA and warrants evaluation.

Two groups based in the Netherlands have examined web-based interventions to increase physical activity in patients with rheumatoid arthritis (RA) and osteoarthritis (OA). Van Den Berg compared a 12 month individually targeted, physical intervention delivered online with 12 months of general online advice and education regarding physical activity in people with RA. In addition, the intervention group received regular emails from the physiotherapist and also attended group meetings every 3 months. The study demonstrated that the intervention was effective in increasing the proportion of participants achieving the national physical activity recommendations compared to the general training group. There was no difference however in function or quality of life and the authors noted that the website usage reduced over time. The study by Bossen et al (2013) investigated an internet delivered physical activity programme but in patients with hip and/or knee OA. The Join2move programme was a nine-week programme of nine modules to be completed by the participant. The results showed an increase in physical activity and time spent in moderate intensity physical activity but not significantly more so than a waiting list control. The study reported high attrition rates which were attributed mainly to the fully automated nature of the intervention and absence of human contact or support. Thus there is some evidence for the use of web-based interventions to increase physical activity in people with RA or OA however no previous studies have investigated axial SpA nor regular physiotherapy delivered via the internet.

We have developed a website in collaboration with patient groups and the Scottish Accessible Information Forum which is a platform for delivering individualised web-based physiotherapy (demonstration page: www.webbasedphysio.com (log in: testphysiopatient@gmail.com, password: password). We have evaluated the short term effectiveness of this approach (maximum of 12 weeks) in a number of patient groups. Kelders et al. (2012) reported that not all users continue to use web-based interventions in the desired way and that as usage reduces so does the effectiveness of the intervention. Since the evidence base suggests that people with axial SpA should exercise five days per week, it is important to evaluate the compliance/adherence to this web-based physiotherapy programme over a longer period.

Study Design Pilot cohort study