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Efficacy and safety of mind-body exercise for patients with axial spondyloarthritis: a systematic review and meta-analysis

Journal of Orthopaedic Surgery and Research volume 19, Article number: 586 (2024) Cite this article

Abstract

Objective

To evaluate the efficacy and safety of mind-body exercise (MBE) interventions, including Tai Chi, Yoga, Pilates, and Qigong, in patients with axial spondyloarthritis (axSpA), a systematic review and meta-analysis was conducted.

Methods

Eight electronic databases were searched from their inception to May 2024. RevMan 5.4 and Stata 16.0 software were used for statistical analysis. Outcome measures included Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Visual Analog Scale (VAS), Bath Ankylosing Spondylitis Metrology Index (BASMI), Ankylosing Spondylitis Quality of Life (ASQoL) Scale, and adverse events. The methodological quality of the included studies was evaluated using the Cochrane risk of bias (RoB) tool (2.0). The certainty of evidence for each outcome was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

Results

Of the 330 studies retrieved, 15 studies satisfied the criteria for meta-analysis. Compared with the controls, MBE interventions significantly improved physical function (measured by BASFI, MD = -0.76, 95% CI: -1.01 to -0.50, P < 0.00001), disease activity (measured by BASDAI, MD = -0.76, 95% CI: -0.94 to -0.57, P < 0.00001), pain intensity (measured by VAS, MD = -0.89, 95% CI: -1.21 to -0.57, P < 0.00001), spinal mobility (measured by BASMI, MD = -0.44, 95% CI: -0.70 to -0.19, P = 0.0006), and quality of life (measured by ASQoL, MD = -2.14, 95% CI: -3.54 to -0.75, P = 0.003). Subgroup analyses revealed that Tai Chi appeared to demonstrate a more pronounced effect on pain reduction when compared to Qigong (test for subgroup difference: P = 0.005). The quality of evidence for these outcomes was estimated as moderate to low. Additionally, no serious adverse events related to MBE were identified among the included studies.

Conclusions

Overall, MBE may be a promising non-pharmacological treatment to improve physical function, disease activity, pain intensity, spinal mobility, and quality of life in patients with axSpA. To enhance the certainty of the evidence, additional rigorous studies are needed to verify these findings.

Introduction

Axial spondyloarthritis (axSpA) is a chronic rheumatic inflammatory condition primarily affecting the axial skeleton, particularly the spine and sacroiliac joints [1]. The disease spectrum of axSpA encompasses non-radiographic axSpA (nr-axSpA) and radiographic axSpA (r-axSpA), with the latter also known as ankylosing spondylitis (AS). In general, the clinical characteristics and burden of disease are similar between these two subgroups of axSpA [2]. As the disease progresses, patients with axSpA often experience inflammatory low back pain, spinal stiffness, and restricted spinal mobility, which may progress to axial skeletal ankylosis, ultimately resulting in functional impairment and decreased quality of life [3].

The 2022 update of the Assessment of Spondyloarthritis International Society/European League Against Rheumatism (ASAS/EULAR) recommended that the optimal management of patients with axSpA requires a combination of pharmacological and non-pharmacological treatment modalities [4]. Non-steroidal anti-inflammatory drugs (NSAIDs), the first choice pharmacological treatment, have been confirmed to be efficacious in treating axSpA. Nevertheless, due to the possibility of gastrointestinal, cardiovascular, and renal adverse events, a large proportion of patients are unable to tolerate this therapy for longer periods [5]. Besides, targeted immunomodulatory therapies have been approved for treating axSpA, including tumor necrosis factor (TNF) inhibitors, antibodies targeting IL-17 A, and Janus kinase inhibitors, which also provide alternative therapeutic options for axSpA patients [6]. However, long-term safety data for these biological therapies are generally limited. And they may be associated with an increased risk of infections, injection site reactions, and potential malignancies [7,8,9]. There is a clear need for more research to standardize and optimize the pharmacological treatment for axSpA.

Although pharmacological interventions play an important role in axSpA management, non-pharmacological strategies, especially regular exercises, are equally critical for improving the physical function and quality of life of the patients [3, 6]. Due to joint stiffness and decreased muscle strength of the whole body, patients with axSpA often have a significant reduction in motor ability [10,11,12]. Thus, it is advisable to perform slow, gentle, and low to moderate-intensity exercises. Mind-body exercise (MBE), known as a low-cost, low-impact multimodal exercise category, may be a suitable exercise method for people with axSpA [13]. MBE interventions primarily include Tai Chi, Yoga, Pilates, and Qigong, aiming to focus on the interplay between the body (physical movements), mind (mindfulness meditation), and breathing. Through focused concentration, controlled movement, and regulated breathing, MBE interventions can heighten bodily awareness, promote relaxation, and enhance mind-body coordination [14]. Moreover, MBE is simple to learn and perform, does not require expensive equipment, and allows practice in various locations [15]. According to the National Health Interview Survey, MBE was considered one of the most favored complementary health methods among adults in the United States [16]. The beneficial effects of MBE on human health have been extensively studied. Several systematic reviews and meta-analyses have explored the positive effects of MBE on chronic musculoskeletal pain, rheumatoid arthritis, Parkinson’s disease, cardiopulmonary dyspnea, mental health issues, and sleep disorders [17,18,19,20,21]. In addition, recent studies have indicated that MBE can significantly improve functional capacity, reduce disease activity, and enhance the quality of life among patients with axSpA; however, no systematic review has investigated this topic [22,23,24,25,26,27,28,29,30,31,32,33,34,35,36].

For these reasons, a meta-analysis is justified as well as needed to examine the efficacy of MBE interventions in patients with axSpA. Therefore, we conducted the first systematic review and meta-analysis to comprehensively summarize the available evidence on the efficacy and safety of four major MBE interventions, including Tai Chi, Yoga, Pilates, and Qigong, in the management of axSpA. This study focuses on evaluating the impact of MBE interventions on physical function, disease activity, pain intensity, spinal mobility, and quality of life in patients with axSpA, to provide evidence-based clinical recommendations.

Method

Protocol and registration

This study was presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and recommendations, as shown in Supplementary files (Table S1). The meta-analysis was registered in the International Prospective Register of Systematic Review (PROSPERO), with reference number CRD42023429949.

Search strategy

An extensive search of the literature was conducted in PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), Chinese Scientific Journals Database (VIP), China Biomedical Literature Service System (SinoMed), and Wanfang databases, without language or country restrictions. Searches of these databases were performed from their respective inception through to May 30, 2024. The search strategy combined the MeSH terms and other related keywords, including “mind body exercise”, “mind body therapy”, “Tai Chi”, “Tai Ji”, “Tai Ji Quan”, ‘Tai Chi Chuan”, “Yoga”, “Pilates”, “Qigong”, “Wuqinxi”, “Yijinjing”, “Liuzijue”, “ankylosing spondylitis”, “AxSpA”, “spondylitis”, “spondyloarthritis”, “axial spondyloarthritis”, “axial spondylarthritis”, “Bechterew’s Disease”, “Marie-Struempell Disease”, “Rheumatoid Spondylitis”, “Spondylarthritis Ankylopoietica ”. Further details of the complete search strategy can be found in Supplementary files (Table S2). Besides, we manually screened the reference lists of included articles for additional eligible studies.

Selection criteria

The PICOS approach (Patients, Intervention, Comparison, Outcomes, and Study design) was used to formulate eligibility criteria as follows:

Participants: adults (≥ 18 years) diagnosed with axSpA (both radiographic and non-radiographic) according to any recognized criteria, including the 2009 Assessment of Spondyloarthritis International Society (ASAS) criteria and the 1984 modified New York criteria [37, 38].

Intervention: the intervention group received four major MBE interventions, including Tai Chi, Yoga, Pilates, or Qigong (Baduanjin, Yijinjing, Wuqinxi, et al.).

Comparison: the control group received usual care, drug therapy, other exercises, or no treatment.

Outcomes: outcomes included data on physical function measured by Bath Ankylosing Spondylitis Functional Index (BASFI), disease activity measured by Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), pain intensity measured by Visual Analog Scale (VAS), spinal mobility measured by Bath Ankylosing Spondylitis Metrology Index (BASMI), quality of life measured by Ankylosing Spondylitis Quality of Life (ASQoL) Scale, and reports of any adverse events. Study design: randomized clinical trials (RCTs).

The following exclusion criteria were adopted:

(1) studies including patients with other neurological or coexistent systemic disease other than axSpA; (2) studies without full text or available outcomes; (3) non-English or non-Chinese research; (4) duplicate publications; and (5) reviews, case reports, conference abstracts, or letters.

Data management and selection procedure

EndNote X9 software was used to manage the literature and exclude duplicates. Two authors independently screened the titles and abstracts of each potentially eligible study based on predefined inclusion and exclusion criteria. Subsequently, the full texts of the remaining studies were then assessed for their eligibility for inclusion in this review. In cases of disagreement, it will be resolved through discussion or in consultation with a third author.

Data extraction

Relevant data were abstracted by two independent reviewers from the eligible studies using a customized Microsoft Excel spreadsheet. The following information was considered: study characteristics (first author, publication year, study location, and language), participant information (sample size, average age, and disease duration), intervention design (intervention methods, exercise frequency, intervention duration, and instructor), and outcome indicators (BASFI, BASDAI, VAS, BASMI, ASQoL, and adverse events).

Quality assessment

The methodological quality of included studies was assessed by two independent authors, using the Cochrane Risk of Bias 2 tool (RoB 2.0) [39]. Each eligible trials were considered as “high risk”, “low risk”, or “some concerns” on the following domains: D1 (bias arising from the randomization process), D2 (bias due to deviations from intended intervention), D3 (bias due to missing outcome data), D4 (bias in the measurement of the outcome), and D5 (bias in the selection of the reported result). Any discrepancies were resolved by discussion or negotiation with a third reviewer.

The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was employed to evaluate the quality of evidence for the outcomes in the meta-analysis [40]. This tool includes five domains, including study design, risk of bias, inconsistency, indirectness, imprecision, publication bias, participant size, and other considerations. According to GRADE, the quality of evidence was graded as the following four levels: very low, low, moderate, and high.

Statistical analysis

The RevMan software version 5.4 and Stata 16 software were used for meta-analysis and bias analysis. To assess heterogeneity between studies, the Chi-square (Q) and I-square tests (I2) were calculated. Generally, the study heterogeneity was categorized as low, moderate, and high, referring to I2 values of 25%, 50%, and 75%, respectively. For inclusion in the meta-analysis, effect sizes were expressed as mean difference (MD) or standardized mean difference (SMD) with 95% confidence intervals (CIs). If I2 < 50%, a fixed-effect model was used to pool the data, otherwise, a random-effect model was selected. In addition, for outcomes with a sufficient number of included studies, subgroup analyses were performed to assess the impact of different exercise types (Tai Chi; Yoga; Pilates; and Qigong), exercise frequencies (low: 2 times/week; moderate: 3 times/week; and high: ≥ 4 times/week), and length of intervention (short: ≤ 12 weeks; long: > 12weeks) on patients with axSpA. A sensitivity analysis was carried out to assess the robustness of our results by excluding individual studies each time. If the number of trials included in the meta-analysis was more than 10, the publication bias was evaluated using funnel plots and Egger’s test by Stata 16.0 software. A p-value of less than 0.05 was defined as statistically significant in all data analyses.

Results

Study selection

In the initial screening, we identified 330 records from eight electronic databases. After excluding 87 duplicates, two authors reviewed the titles, abstracts, and full text of the remaining 243 studies. A total of 228 studies were excluded for the following reasons: reviews (28), protocol (9), conference (13), trial registry records (13), irrelevant themes (38), improper interventions (116), non-RCT design (8), improper outcomes (1), and no available outcome indicators (2). Finally, 15 studies [22,23,24,25,26,27,28,29,30,31,32,33,34,35,36] involving 855 participants met the inclusion criteria and were included in the meta-analysis. The detailed retrieval process is presented in the PRISMA flow chart (Fig. 1).

Fig. 1
figure 1

Flow diagram of study selection

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Study characteristics

A total of 15 eligible studies were included in this review, with 10 reported in English and 5 in Chinese. The abbreviations and definitions of interventions relevant to the included studies are listed in Table 1. The study characteristics are shown in Table 2. Six of these studies were conducted in Turkey [22,23,24,25, 27, 30], one in India [26], one in South Korea [29], and seven in China [28, 31,32,33,34,35,36]. The 15 studies were published between 2008 [29] and 2023 [22, 24, 26, 30, 35], with sample size varying from 26 [22] to 109 [26]. The disease duration of 855 subjects ranged from 2.9 to 13.93 years. Among the 15 included studies, 5 studies [27, 29, 32, 33, 36] used Tai Chi as the main intervention, 2 studies [26, 30] involved Yoga, 4 studies [22,23,24,25] applied Pilates, and 4 studies employed Qigong [28, 31, 34, 35]. The duration of single sessions ranged from 15 to 60 min, and the total duration of the intervention ranged from 8 weeks to 6 months. The control group involved interventions such as usual care, home-based exercise, conventional exercises, conventional medical therapy, or no treatment. In addition, most interventions were instructed by physical therapists, certified trainers, professionals, or rheumatologists, but few reported information about their qualifications.

Table 1 Abbreviations and definition of intervention arms
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Table 2 Characteristics of the included studies
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Quality Appraisal

The RoB2 tool was used to evaluate the risk of bias in the included RCTs, and the Shiny app (https://mcguinlu.shinyapps.io/robvis/) was used to create ROB graphs (Fig. 2). In the randomization process, 11 studies [23,24,25,26,27,28,29,30, 33,34,35] confirmed randomization, but only 3 studies [26, 28, 32] reported the details of concealed allocation. Six studies [22, 26, 28, 30, 32, 34] were considered as low risk in this domain, and the remaining research was evaluated as having some concerns. In the domains of deviations from intended interventions and measurement of outcomes, details of blinding implementation were reported in 4 studies [23, 26, 28, 29]; one study [25] did not blind evaluators, while the remaining studies did not provide explicit information. Since all included studies reported their methods of statistical analysis, we rated them as low risk. However, 8 studies [23,24,25,26,27,28,29,30] were judged as having some concerns regarding addressing missing outcome data. For those unregistered studies [23, 24, 29, 31,32,33,34,35,36], we were unable to assess whether there was consistency between their reported results and any prior planning, so they were evaluated as having some concerns in the selection of the reported result.

Fig. 2
figure 2

Assessment of risk of bias of randomized trials with RoB-2

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Meta-analysis results

Effects of MBE on physical function

Twelve RCTs reported physical function as an outcome measure and the assessment scale was BASFI [22,23,24, 26,27,28, 30,31,32,33,34, 36]. The studies were classified based on different forms of MBE interventions, including Tai Chi with 4 studies, Qigong with 3 studies, Yoga with 2 studies, and Pilates with 3 studies. Due to the presence of heterogeneity (I2 = 56%), a random-effect model was used. Overall, compared with the control group, the MBE group had a positive effect on improving physical function (MD = -0.76, 95% CI: -1.01 to -0.50, P < 0.00001) (Fig. 3). Additionally, the results of subgroup analysis based on different exercise forms indicated that compared to the control group, Tai Chi (MD = -0.58, 95% CI: -0.90 to -0.25, P = 0.0005), Qigong (MD = -0.74, 95% CI: -1.40 to -0.08, P = 0.03), Yoga (MD = -0.92, 95% CI: -1.40 to -0.44, P = 0.0002), and Pilates (MD = -1.16 95% CI: -1.96 to -0.36, P = 0.005) significantly improved the physical function in patients with axSpA. However, no significant subgroup differences were found between the four types of MBE (P = 0.46).

Fig. 3
figure 3

The forest plot of BASFI score

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In subgroups analyses based on different exercise frequencies and intervention durations, no significant subgroup differences were found (all interactions P > 0.05). The results of the subgroup analyses were consistent with the overall findings, except for the low-frequency exercise subgroup, which did not show a statistically significant difference compared to the control group (Suppl. Fig. S1 and Fig. S2).

Effects of MBE on disease activity

Thirteen RCTs [22,23,24,25,26,27,28,29,30, 32, 33, 35, 36] used BASDAI as an evaluation index to evaluate the effect of MBE on disease activity. A fixed-effect model was employed due to low heterogeneity between studies (I2 = 46%). The result of the meta-analysis showed that the MBE group was more effective in reducing disease activity compared to the control group (MD = -0.76, 95% CI: -0.94 to -0.57, P < 0.00001) (Fig. 4). Furthermore, the results of subgroup analysis based on different exercise forms revealed that compared to the control group, Tai Chi (MD = -0.84, 95% CI: -1.13 to -0.55, P < 0.00001), Qigong (MD = -0.46, 95% CI: -0.88 to -0.05, P = 0.03), Yoga (MD = -0.91, 95% CI: -1.32 to -0.50, P < 0.0001), and Pilates (MD = -0.72 95% CI: -1.12 to -0.33, P = 0.0004) significantly reduced the disease activity in patients with axSpA.

Fig. 4
figure 4

The forest plot of BASDAI score

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Besides, there were no significant subgroup differences among varied exercise frequencies and exercise durations (all interactions P > 0.05). The subgroups’ results were consistent with the overall results (Suppl. Fig. S3 and Fig. S4).

Effects of MBE on pain intensity

Five RCTs [31, 33,34,35,36] explored the beneficial effects of MBE on pain intensity using VAS. Due to the presence of heterogeneity (I2 = 58%), a random-effect model was applied. Compared with the control group, the MBE group significantly reduced pain intensity (MD = -0.89, 95% CI: -1.21 to -0.57, P < 0.00001) (Fig. 5). Two of these 5 studies involved Tai Chi intervention, and the remaining three studies involved Qigong intervention. In subgroup analysis, we found that the interaction effects varied significantly across different types of MBE interventions (P = 0.005). Practicing Tai Chi (Exercise for ≤ 12 weeks, MD = -1.54, 95% CI -2.08 to -1.00, P < 0.00001) demonstrated a more pronounced effect on pain reduction compared to practicing Qigong (Exercise for > 12 weeks, MD = -0.71, 95% CI -0.91 to -0.51, P <0.00001 shown in Fig. 5 and Supple. Fig. S5).

Fig. 5
figure 5

The forest plot of VAS score

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Effects of MBE on spinal mobility

Eight RCTs [22,23,24,25, 27, 28, 30, 32] used spinal mobility as an outcome measure, which was assessed by BASMI. The pooled results using a fixed-effect model showed that the MBE group could significantly improve spinal mobility compared to the control group (MD = -0.44, 95% CI: -0.70 to -0.19, P = 0.0006) (Fig. 6).

Fig. 6
figure 6

The forest plot of BASMI score

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Effects of MBE on quality of life

The ASQoL score was used to measure quality of life in patients with axSpA in 6 studies [22,23,24,25,26,27]. Due to the presence of heterogeneity (I2 = 50%), a random-effect model was used. Compared with the control group, the MBE group was more effective in improving quality of life (MD = -2.14, 95% CI: -3.54 to -0.75, P = 0.003) (Fig. 7).

Fig. 7
figure 7

The forest plot of ASQoL score

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Adverse events

Seven studies investigated adverse events [26,27,28,29, 32,33,34]. Only 2 studies [32, 34] observed mild stomach and abdominal pain. All other studies [26,27,28,29, 32] reported no serious adverse effects associated with MBE. Details are summarized in Supplementary files (Table S3).

Sensitivity analysis and publication bias assessment

Sensitivity analysis was used to evaluate the impact of each study on the combined results of the meta-analysis. The results indicated that, after systematically excluding individual studies and performing reanalysis, the point estimates consistently fell within the 95% confidence interval of the original effect size. Taken together, the pooled effect of these four MBE interventions on improving BASFI, BASDAI, VAS, BASMI, and ASQoL scores was stable and reliable.

In this study, we only performed the publication bias assessment for results with more than 10 studies (i.e., BASFI score and BASDAI score). The funnel plots of these two outcome indicators were approximately symmetric, indicating no obvious publication bias (Figs. 8 and 9). In addition, the results of Egger’s test further confirmed no indication of publication bias for the BASFI score (P = 0.642) and BASDAI score (P = 0.361).

Fig. 8
figure 8

The funnel plots of BASFI score

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Fig. 9
figure 9

The funnel plots of BASDAI score

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Quality of the evidence

Based on the GRADE approach, the certainty of evidence for seven outcome indicators was assessed (Table 3). The results indicated moderate-quality evidence for BASFI score, BASDAI score, and BASMI score. Besides, low-quality evidence was identified for the VAS score and ASQoL score. Inconsistency and imprecision were the main reasons for downgrading the level of evidence in this study.

Table 3 The overall quality of evidence assessment
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Discussion

In this systematic review and meta-analysis, we provide a comprehensive analysis of the efficacy and safety of four major MBE interventions, including Tai Chi, Yoga, Pilates, and Qigong, in managing axSpA. A total of 15 trials from 4 countries were included, revealing that these MBE interventions have a positive impact on physical function, disease activity, pain intensity, spine mobility, and quality of life in patients with axSpA. These findings were consistent with several previous studies [41,42,43]. Moreover, these four MBE interventions are considered safer movements due to the few reports of minor adverse events. The quality of evidence was judged as moderate for most outcome measures, meaning that these findings could inform potential clinical practice guidelines. Nevertheless, researchers should still be encouraged to focus on the effects of MBE on the physical and mental health of axSpA patients and to conduct more rigorous RCTs to enhance the reliability of our findings.

The results of this meta-analysis showed that MBE had a beneficial effect on physical function in patients with axSpA. The BASFI was utilized to evaluate the impact of the disease on axSpA patient’s ability to perform physical and functional activities, primarily involving ten questions related to tasks such as standing, walking, and self-care [44]. Although the exact mechanism involved is not yet clear, it appears to be related to the favorable effects of MBE on the neurological and musculoskeletal systems of axSpA patients. First, MBE practices have been shown to activate regions of the lower brain and the cerebellum, facilitating the improvement of body awareness and coordination ability [45]. Besides, it has been reported that MBE can increase proprioceptive stimulation, improve neuromuscular control, and relieve muscle tone through the activation of neuroreceptors around the muscle spindle, joints, and ligaments [46, 47]. These improvements can prevent spinal overload, ensure optimal spinal alignment, and promote enhanced spinal mobility and function. Several studies examining the effects of MBE on chronic low back pain have also observed these benefits, aligning with our findings [48, 49]. Moreover, MBE practice can target core muscle groups around the abdomen, back, and pelvis, particularly the paravertebral muscles, multifidus muscles, and transversus abdominis muscles, which play an important role in maintaining normal functional movement of the spine in axSpA patients [24]. Through a regular MBE program, these core muscles, as well as the associated tendons, joints, ligaments, and peripheral nerves are strengthened and conditioned, thereby increasing muscle endurance, enhancing joint mobility, and improving spinal stability for axSpA patients [23, 30].

This study also revealed that MBE could significantly reduce disease activity in patients with axSpA. The BASDAI was applied to assess the severity of disease-specific symptoms, such as fatigue, morning stiffness, and spine and peripheral joint pain [44]. Although the pathogenesis of axSpA has not yet been fully understood, inflammation might play a crucial role in the disease activity of axSpA [2]. Studies have shown that inflammation of the spine, extraspinal joints, and enthesis can damage the structure of the axial skeleton, resulting in chronic back pain, spinal ankylosis, and functional impairments [50, 51]. Previous studies have indicated that MBE interventions, including Tai Chi and Yoga, have significant effects in reducing the levels of inflammation markers (e.g., IL-6, TNF-α, IL-1β, and endorphins) by suppressing hypothalamic-pituitary-adrenal axis hypersensitivity, decreasing sympathetic hyperactivity, and enhancing vagal activity [52,53,54]. This implies that MBE has shown promise in improving disease activity in patients with axSpA. Results of the included studies also reported the positive effects of MBE on pain symptoms, with three studies using Qigong and two studies using Tai Chi. The VAS was employed as the assessment tool, which allows patients to quantify their pain intensity on a continuous scale [55]. Studies have demonstrated that Tai Chi and Qigong have positive effects on improving pain sensitivity, muscular tension, and fatigue, and they have been used to manage different chronic pain conditions, such as lower back and neck pain, cancer-related pain, and rheumatic pain [13, 17, 18, 56]. The possible underlying mechanisms may be associated with their ability to regulate levels of pain-related hormones or neurotransmitters, including epinephrine, acetylcholine, gamma-aminobutyric acid, and endorphins, thereby exerting analgesic effects [47, 57]. In short, these findings further demonstrate that MBE can be used as a promising therapeutic strategy to improve disease activity and pain symptoms in patients with axSpA.

Furthermore, this meta-analysis supported that MBE might have a beneficial effect on spinal mobility and quality of life in patients with axSpA. The following scales were employed: BASMI, an index comprising 5 measures of spinal and hip mobility, and ASQoL, an 18-item questionnaire used to quantify the impact of axSpA on quality of life [58, 59]. Increased spinal mobility in axSpA patients is closely associated with the improvements in physical function as well as disease activity. Additionally, the improvement of quality of life by MBE may be attributed to a series of interconnected biological and psychological processes. Researchers have revealed that MBE can reduce symptoms of anxiety and depression by increasing the release of mood-regulating hormones like serotonin, norepinephrine, and endorphins, which provides beneficial effects on improving quality of life [60]. Moreover, mindfulness and relaxation techniques during MBE movements can effectively promote relaxation, decrease physiological arousal, and develop a sense of calm, happiness, and well-being [61, 62]. When participating in MBE practice, especially in community settings, it can promote social interaction and provide biopsychosocial support, positively affecting the overall well-being and quality of life of individuals [27]. Consistent with our findings, MBE was found to have a considerable impact on physical function, pain, anxiety, depression, and quality of life in several previous studies involving individuals with chronic musculoskeletal conditions [63,64,65]. Therefore, in light of our positive results, it may be beneficial to use MBE as an effective non-pharmacological therapy for axSpA patients in their treatment plans, and these findings should be further confirmed in future studies.

Our meta-analysis also evaluated the impact of four different exercise forms, exercise frequency, and length of intervention on improving physical function, disease activity, and pain intensity, which could be clinically significant. Through subgroup analysis, we found that there were no significant differences among these subgroups in improving physical function or disease activity. Additionally, we observed that Tai Chi appeared to be more beneficial in reducing pain in axSpA patients compared to Qigong. However, due to insufficient research on the efficacy of Yoga and Pilates in pain reduction, we could not provide deeper insights into these MBE interventions for pain management. Importantly, the optimal types, duration, frequency, and intensity of exercise to maximize the benefits of MBE interventions for patients with axSpA remain undetermined. It is crucial to note that tailoring MBE interventions to the specific physical conditions and individual needs of patients is essential, which may further enhance the therapeutic efficacy, acceptance, and adherence. Therefore, future studies should expand sample sizes, employ rigorously designed methodologies, and consider individual patient contexts to contribute valuable evidence to support the application of MBE in managing axSpA.

This study has several strengths. First, this systemic review and meta-analysis may provide new insights into the use of non-pharmacologic interventions to improve axSpA by assessing the efficacy and safety of four major MBE interventions, including Tai Chi, Yoga, Pilates, and Qigong, in patients with axSpA. Besides, we developed a comprehensive search strategy, performed independent data extraction, and conducted detailed subgroup analyses, thereby increasing the credibility and precision of the findings. To ensure robust results, we also adopted meticulous sensitivity checks, and used funnel plots and the Egger’ test to assess potential publication bias. Finally, the ROB 2.0 tool and the GRADE approach were employed to evaluate the risk of bias and the quality of evidence, enhancing the validity and reliability of the conclusions.

Nevertheless, our meta-analysis has some limitations. First, the overall methodological quality of the included studies was suboptimal, and the results could be influenced by potential bias. Second, only 15 RCTs were included in this study. The relatively small sample size may affect the generalizability and stability of the results. Third, the long-term efficacy of MBE for axSpA remains to be observed, due to the lack of follow-up data in the included studies. Thus, we expect additional large-scale, well-conducted, and rigorous RCTs to further validate our findings. We also recommend that future researchers should prioritize trial registration, and strictly ensure the quality of clinical trial methodology to enhance the quality and credibility of their studies.

Conclusions

In conclusion, the results of our systematic review and meta-analysis highlight the positive role of MBE interventions, including Tai Chi, Yoga, Pilates, and Qigong, in improving both the physical and psychological functioning among patients with axSpA. Almost all of the evidence was of moderate quality, supporting the significant efficacy of MBE in the treatment of axSpA. Furthermore, practicing Tai Chi may be more beneficial in pain reduction than practicing Qigong. We hope that this study will encourage researchers to pay more attention to axSpA and conduct further studies to explore the appropriate MBE prescription (e.g. the most effective type, intensity, duration, and frequency of MBE in managing axSpA) for patients with axSpA, thereby enhancing the quality of life for this population.

Data availability

No datasets were generated or analysed during the current study.

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Funding

This work was supported by the Henan Province Science and Technology Research Project (grant number 242300420107), Henan Province Science and Technology Research Project (grant number 232102310466), Henan University of Chinese Medicine 2024 education and teaching reform research and practice projects (grant number 2024JX62), 2023 Henan Special Research Project of TCM on “Double First-Class” Construction (grant number HSRP-DFCTCM-2023-8-23), and 2023 Henan Special Research Project of TCM on “Double First-Class” Construction (grant number HSRP-DFCTCM-2023-1-21).

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  1. Rehabilitation Medicine College, Henan University of Chinese Medicine, 156 Jinshui East Road, Zhengzhou, Henan, China

    Jing Wang, Fangjie Yang, Pengxue Guo, Chunlin Ren, Zhengfei Duan & Yasu Zhang

  2. School of Traditional Chinese Medicine, Henan University of Chinese Medicine, Zhengzhou, Henan, China

    Xinmin Li

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All authors contributed to the study’s conception and design. Jing Wang wrote the first draft of the manuscript, and Fangjie Yang, Zhenfei Duan, Chunlin Ren, and Pengxue Guo performed material preparation, data collection, and analysis. Subsequent revisions and comments on previous versions of the manuscript were conducted by Xinmin Li and Yasu Zhang. All authors read and approved the final manuscript.

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Wang, J., Li, X., Yang, F. et al. Efficacy and safety of mind-body exercise for patients with axial spondyloarthritis: a systematic review and meta-analysis. J Orthop Surg Res 19, 586 (2024). https://doi.org/10.1186/s13018-024-05072-5

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Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X