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

Background: Exercise interventions have been widely applied as an adjunctive treatment for ankylosing spondylitis (AS), effectively alleviating pain, improving function, and enhancing quality of life. However, the efficacy of different exercise modalities remains inconclusive. 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 performed across six databases to identify studies assessing the impact of exercise interventions on AS. The primary outcomes analyzed included 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 conducted using the frequentist approach in STATA 18.0, while effect publication bias analysis used Review Manager 5.4. Results: Forty-eight studies involving 3,140 participants were included, published between 2002 and 2024. Compared to the control group, all exercise interventions demonstrated varying degrees of benefit in improving BASDAI, BASFI, BASMI, and ASQoL scores. For BASDAI, the 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]) exhibited significant symptom relief, with ASE ranking highest (surface under the cumulative ranking curve (SUCRA) = 85.5). For BASFI, statistically significant improvements were observed with the 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]). ASE had 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 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]) demonstrated statistical significance, 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 exhibited the most significant improvements in BASDAI, BASFI, and ASQoL, suggesting its superiority as an intervention. Additionally, CHC demonstrated the most significant potential for BASMI improvement. ASE is the most effective exercise modality for symptom relief, functional enhancement, and quality-of-life improvement, warranting further promotion in clinical practice.