Various aspects of the habits and lifestyle of patients with axSpA can affect their physical health, mental health, and indeed response to therapy. A multifaceted, individualized physical activity program is recommended in order to preserve/improve spinal mobility, maintain functional capacity, and reduce stiffness and pain (Gyurcsik et al. 2012; Elyan and Khan 2008). This recommendation is supported by evidence showing that individual exercise programs reduce pain and enhance physical function in patients with axSpA, especially in those with severe disease (Dagfinrud et al. 2005; Ince et al. 2006; Karapolat et al. 2009; Kisacik et al. 2016; O'Dwyer et al. 2015; Santos et al. 1998; Tubergen and Hidding 2002).

Unhealthy lifestyle habits can have a negative effect on the course of axSpA (Averns et al. 1996). Patients with axSpA who are smokers experience higher disease activity than those who never smoke (Chung et al. 2012; Kaut et al. 2017; Zhao et al. 2017; Zhang et al. 2015). Stopping smoking is associated with reduced disease activity and improved physical function and quality of life (Jones et al. 2017), and should therefore be recommended as part of the treatment strategy for patients with axSpA (Chung et al. 2012; Zhao et al. 2017; Jones et al. 2017).

The impact of alcohol consumption in axSpA is less clearly understood. While some studies suggest that heavy alcohol consumption may be linked with impaired physical functioning in patients with axSpA (Zhang et al. 2015), others have reported benefits of moderate alcohol consumption. Further research is required to establish if this is due to biological effects of alcohol on inflammation or disease-associated behavior modification (Rohde et al. 2017; Zhao et al. 2018).

10.1 Physical or Sporting Activity

Walking was the most frequently reported activity, which may be due to the fact that it is free, accessible, and relatively easy (Fig. 10.1). Stretching, swimming, hiking, and cycling were the next most commonly performed physical activities, with dancing, tennis, and aquatic therapy least frequently reported.

Fig. 10.1
figure 1

Participation in physical or sporting activity reported by respondents (N = 2,846)

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Previous studies in patients with axSpA have demonstrated that exercise is associated with improvements in health status (Sveaas et al. 2020; Sveaas et al. 2014; Heijde et al. 2017a). European IMAS participants who engaged in physical activity spent from approximately 2–6 h per week on an activity. The greatest amount of time each week was spent on walking (Supplemental Table 10.1). In total, the mean (SD) number of hours respondents spent on all physical activity was 8.9 (7.3) per week.

The WHO states that physical activity has multiple benefits for both physical and psychological health. The WHO recommendation for adults aged from 18 to 64 years old is to perform at least 150 min of physical activity per week to achieve these benefits (Mengshoel 2008). Most IMAS survey participants (84.5%) did sufficient physical activity to comply with the WHO recommendation (Table 10.1).

Table 10.1 Distribution of survey participants according to compliance with the WHO physical activity recommendation (N = 2,286)
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10.1.1 Association Between Physical Activity and Physical Health

Survey participants who reported practicing any type of physical activity presented with statistically lower levels of disease activity (BASDAI), Functional Limitation Index, and Spinal Stiffness Index than those who did not partake in such activity (Table 10.2). Respondents with BASDAI < 4 participated in more physical activities and for a longer period of time than those with BASDAI ≥ 4 (Supplemental Tables 10.2 and 10.3), while spinal stiffness was less severe in participants who engaged in physical activity (Supplemental Fig. 10.1; Supplemental Tables 10.4 and 10.5). Both disease activity (BASDAI) and spinal stiffness were also lower in participants who met WHO recommendations for physical activity than in those who did not (Supplemental Tables 10.6 and 10.7. The differences between groups in these comparisons are relatively small in magnitude and as such physical activity alone may not be sufficient for clinically-relevant improvements in outcomes. However, together with other healthy lifestyle habits such as smoking cessation (see Sect. 10.2), such differences may contribute to improvements in the overall health of patients with axSpA.

Table 10.2 Mean BASDAI score, Functional Limitation Index, and Spinal Stiffness Index of survey participants by physical activity status
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The reasons for respondents’ non-participation in sports was not collected in the IMAS survey so it is unclear if this was due to choice or an inability to take part due to their disease. It should be noted, however, that a number of participants in the survey reported difficulties doing exercise as a result of their disease.

In previous studies, patients with axSpA have highlighted having to give up certain sports due to their disease (World Health Organization (WHO). Recommended levels of physical activity for adults aged 18–64 years 2019); conversely, patients in other studies have suggested that axSpA has actually forced them to increase their levels of exercise above levels pre-diagnosis (Hamilton-West and Quine 2009). Regardless, the benefits of exercise in the management of axSpA are well characterized (Ince et al. 2006; Karapolat et al. 2009; Kisacik et al. 2016; O'Dwyer et al. 2015; Santos et al. 1998; Tubergen and Hidding 2002) and patients should be encouraged to discuss their exercise regime with their HCP to find a level and activity that best suits their needs.

10.2 Lifestyle Habits

While the majority of survey participants reported that they were non-smokers, almost one-third were smokers (Fig. 10.2).

Fig. 10.2
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Smoking status of survey participants (N = 2,751)

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Approximately two out of five survey participants reported occasional consumption of alcohol (no specific definition of ‘occasional’ was stated in the survey), with just over a quarter of respondents indicating that they never consumed alcohol (Fig. 10.3). Few participants (2.7%) reported daily alcohol consumption.

Fig. 10.3
figure 3

Frequency of alcohol consumption by survey participants (N = 2,751)

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10.2.1 Smoking and Physical Health

Survey participants who were smokers presented with statistically higher mean BASDAI, Spinal Stiffness Index, and Functional Limitation Index scores than non-smokers (Table 10.3). While the magnitude of the differences between groups in these indices is relatively small (0.4, 0.4, and 0.8, respectively) and therefore unlikely to be clinically relevant in isolation, they may contribute to improvements in patient outcomes when taken together with other healthy lifestyle habits.

Table 10.3 Mean BASDAI, Spinal Stiffness Index, and Functional Limitation Index scores of survey participants by smoking statusa
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Previous survey data have linked smoking with greater disease activity, spinal stiffness, and physical limitations (Zhang et al. 2015). Furthermore, data from the German Spondyloarthritis Inception Cohort (GESPIC) study, a longitudinal study conducted in Germany, found that heavy smokers had increased structural damage to the spine, while occasional smokers had the same health outcomes as non-smokers (Poddubnyy et al. 2013). Although a topic of ongoing research, smoking is thought to influence the disease course of axSpA by altering gene expression linked to immune function (O'Rielly et al. 2015). Consequently, current ASAS-EULAR treatment guidelines for axSpA state that all patients should be encouraged to stop smoking (Heijde et al. 2017b).

10.2.2 Alcohol Consumption and Physical Health

Participants who never consumed alcohol presented with higher mean BASDAI scores and higher Functional Limitation Index scores compared with those who drank alcohol either daily or occasionally (Table 10.4). Although the small differences in BASDAI score between groups are unlikely to be clinically relevant, differences in Functional Limitation Index were up to 7, which suggests they may have some clinical relevance despite the disparity in sample sizes between groups.

Table 10.4 Mean BASDAI and Functional Limitation Index scores of survey participants by alcohol consumptiona
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The effects of alcohol consumption on axSpA remain unclear. A Chinese study of 425 patients with AS treated at a single center showed that moderate alcohol consumption was associated with higher disease activity (Zhang et al. 2015); however, several other studies have suggested potential benefits of moderate alcohol consumption in axSpA, potentially due to an anti-inflammatory effect (Rohde et al. 2017; Zhao et al. 2018). Although the results of the IMAS survey support the latter conclusion, further research is needed to investigate the effects of alcohol in patients with axSpA.

10.3 Conclusions

  • Walking was the most common physical activity reported by participants; other common activities included stretching, swimming, hiking, and cycling.

  • Most participants (84%) did sufficient physical activity to comply with the WHO recommendation of 150 min per week.

  • Exercise forms an integral part of the management of axSpA and, therefore, all patients should be encouraged to discuss their exercise regime with their HCP to find a level and activity that best suits their needs.

  • While the majority of participants reported that they did not smoke, almost one-third were smokers.

    • In accordance with current treatment recommendations, all patients with axSpA should be encouraged to stop smoking.

  • Although moderate alcohol consumption (one to three times a month) was associated with a lower degree of functional limitation compared with drinking every day or not drinking at all, further research is required on the effect of alcohol on axSpA based on the relatively scant evidence published on this topic to date.