Comparative efficacy of different exercise interventions in patients with ankylosing spondylitis: a systematic review and network meta-analysis

Abstract

Background. Exercise interventions have been widely used as an adjunct treatment for ankylosing spondylitis (AS), effectively reducing pain, improving function, and enhancing quality of life. However, the effectiveness of different types of exercise remains unclear. This study aims to systematically compare the effects of various exercise interventions on clinical outcomes in AS patients using a network meta-analysis (NMA) to determine the optimal exercise regimen. Methods. A comprehensive search was conducted across six databases to identify studies evaluating the impact of exercise interventions on AS. The primary outcomes analyzed were the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), and Ankylosing Spondylitis Quality of Life (ASQoL). A network meta-analysis was performed using the frequentist approach in STATA 18.0, and effect publication bias was analyzed using Review Manager 5.4. Results. Forty-eight studies involving 3,140 participants, published between 2002 and 2024, were included. Compared with the control group, all exercise interventions showed varying degrees of improvement in BASDAI, BASFI, BASMI, and ASQoL scores. For BASDAI, Aquatic Stretching Exercise (ASE) (−1.42, 95% CI [−2.51 to −0.33]), Land Aerobic Exercise (LAE) (−0.94, 95% CI [−1.41 to −0.47]), and Land Stretching Exercise (LSE) (−0.49, 95% CI [−0.94 to −0.04]) provided significant symptom relief, with ASE ranking highest (surface under the cumulative ranking curve (SUCRA) = 85.5). For BASFI, significant improvements were observed with Aquatic Aerobic Exercise (AAE) (−0.90, 95% CI [−1.50 to −0.29]), ASE (−1.74, 95% CI [−2.45 to −1.04]), LAE (−0.74, 95% CI [−1.05 to −0.43]), LSE (−0.54, 95% CI [−0.81 to −0.27]), and Muscle Exercise (ME) (−0.48, 95% CI [−0.83 to −0.13]), with ASE having the highest SUCRA ranking (99.6). For BASMI, ASE (−1.06, 95% CI [−2.10 to −0.02]), LAE (−0.51, 95% CI [−1.01 to −0.01]), and the China Health Campaign (CHC) (−1.15, 95% CI [−2.18 to −0.13]) showed significant improvements, with CHC ranking the highest (SUCRA = 78.7). For ASQoL, ASE (−3.67, 95% CI [−6.17 to −1.18]) and LAE (−2.64, 95% CI [−4.50 to −0.79]) were statistically significant, with ASE achieving the highest ranking (SUCRA = 88.4). Conclusion. This NMA systematically evaluated the effectiveness of different exercise interventions on clinical outcomes in AS patients. All exercise modalities provided varying degrees of benefit compared to the control group. ASE showed the most significant improvements in BASDAI, BASFI, and ASQoL, suggesting it is the superior intervention. Additionally, CHC showed the greatest potential for improving BASMI. ASE is the most effective exercise modality for symptom relief, functional improvement, and quality-of-life enhancement, and should be further promoted in clinical practice. Registration PROSPERO (No. CRD42025639115).