Role of psychological intervention in pain management and quality of life of elderly patients with ankylosing spondylitis

Abstract

BACKGROUND

The treatment and management of ankylosing spondylitis (AS) among the elderly remain challenging, warranting the exploration of more effective intervention strategies.

AIM

To investigate the effects of psychological intervention on pain and quality of life (QoL) in elderly patients with AS.

METHODS

A total of 115 elderly patients with AS who sought medical care at Changzhi People’s Hospital between September 2022 and September 2025 were enrolled. Among them, 52 patients (control group) received routine intervention, while 63 patients (research group) received routine care plus psychological intervention. Data were collected on psychological status [Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS)], resilience Connor–Davidson Resilience Scale (CD–RISC), functional exercise compliance, joint function [Bath Ankylosing Spondylitis Functional Index (BASFI)], pain [Visual Analogue Scale (VAS)], and rehabilitation indicators, including chest expansion, occiput-to-wall distance (OWD), morning stiffness duration, and modified Schober test distance.

RESULTS

Post-intervention, the group demonstrated significantly lower SDS, SAS, BASFI, and VAS scores, as well as reduced OWD and morning stiffness duration, compared with the control group. Additionally, the research group exhibited higher post-intervention CD-RISC scores, greater functional exercise compliance, improved chest expansion and modified Schober test distance.

CONCLUSION

These findings support the clinical application of psychological intervention in the management of elderly patients with AS, given its ability to mitigate pain and improve QoL.

Key Words: Psychological intervention; Ankylosing spondylitis in the elderly; Pain management; Quality of life; Single-center study

Core Tip: This retrospective study evaluated the effects of psychological intervention on pain management and quality of life (QoL) in elderly patients with ankylosing spondylitis using a comprehensive set of clinical and psychological indicators. The results showed that the combination of routine care with psychological interventions yielded superior clinical outcomes compared with routine care alone, contributing to improvements in mental health, joint function, functional exercise compliance, pain relief, and rehabilitation, and overall QoL.

INTRODUCTION

Ankylosing spondylitis (AS) is a chronic, progressive autoimmune rheumatic disease characterized by persistent inflammation[1]. Globally, its prevalence was 0.07%-0.32%, with a higher incidence in males[2]. The disease can manifest as axial and peripheral symptoms, including inflammatory back pain, arthritis, oligoarthritis, and dactylitis. Because these manifestations are diverse and often overlapping, diagnosis may be delayed, causing uncontrolled inflammation, structural damage, and impaired physical function[3]. Such disease-related burdens can also contribute to significant psychological distress, warranting psychological counseling[4]. Remote communication has become increasingly important in chronic disease management because it enables continuous health monitoring and real-time contact with medical teams for patients, which is particularly valuable in helping alleviate the medical obstacles of elderly patients with AS[5]. The current AS treatment and management in elderly patients is challenging because age-related declines in skeletal muscle mass, physical function, and organ function, along with degenerative changes and higher complication risks, may increase susceptibility to adverse health outcomes compared with younger patients[6]. Therefore, optimizing disease management strategies is essential for improving quality of life (QoL) in this population. Current routine interventions for elderly patients with AS typically include pre-discharge health education, psychological counseling, and guidance on diet, medication, functional exercise. Although these measures provide certain benefits, their effectiveness in improving psychological well-being, pain management, functional exercise compliance, and QoL remains limited[7,8]. Reportedly, patients with AS frequently experience psychological disorders such as anxiety and depression, which may accelerate disease progression and adversely affect treatment compliance[9]. Psychological intervention has been reported to improve emotional health and functional outcomes while relieving pain and improving QoL[10]. Knitza et al[11] demonstrated the clinical effectiveness and safety of psychological intervention in patients with inflammatory rheumatic diseases, reporting reductions in psychological distress and improvements in QoL. These findings suggest that similar clinical advantages may be achievable in patients with AS.

However, evidence regarding the effects of psychological intervention on pain and QoL in elderly patients with AS remains limited. Consequently, this study evaluated a cognitive behavioral therapy (CBT)-based psychological intervention delivered through remote communication, aiming to provide more clinical management options for pain management and QoL improvement of elderly patients with AS.

MATERIALS AND METHODS

Case selection

Inclusion criteria: Meeting the diagnostic criteria for AS[12]; age 60-80; ability to perform self-care; no history of spinal procedures or health education before enrollment; good communication ability, clear consciousness, and normal cognitive function; ability to use WeChat or willingness to learn its use; and complete clinical data.

Exclusion criteria: Other spinal diseases, comorbid inflammatory joint diseases or fractures, malignant tumors, chronic diseases such as diabetes or hypertension, hepatorenal dysfunction, cardio-cerebrovascular diseases, severe organic diseases, limb dysfunction, and pregnancy or lactation.

A total of 115 elderly patients with AS who visited Changzhi People’s Hospital between September 2022 and September 2025 were enrolled according to the above criteria. Patients were assigned based on the intervention they actually received, resulting in a control group of 52 patients who received routine intervention and a research group of 63 patients who additionally received psychological intervention. Baseline characteristics were comparable between the two groups (P > 0.05).

Intervention methods

Patients in the control group received routine intervention, including pre-discharge health education, psychological counseling, and guidance regarding diet, medication, and functional exercise. Patients were instructed to master the relevant content, maintain healthy behaviors and habits, and adhere to prescribed functional exercises post-discharge. Weekly follow-up via WeChat or telephone and monthly outpatient visits were conducted to monitor rehabilitation progress.

In the research group, psychological intervention based on the principles of CBT was implemented in addition to routine intervention. The intervention components were as follows.

Cognitive restructuring: Nurses provided educational articles and videos through WeChat to teach self-regulation strategies and assisted patients in developing plans to improve psychological adjustment.

Behavioral activation: Patients were instructed to assess and record pain levels and to use attention diversion, music therapy, acupressure, and other methods for pain management. They were advised to seek medical attention promptly in cases of severe pain. Potential daily-life problems were anticipated in advance, and coping strategies were discussed with patients to reduce psychological stress caused by unexpected difficulties.

Psychological counseling: Nurses maintained continuous communication with patient post-discharge through WeChat, expressed empathy toward their experiences and psychological concerns, provided encouragement and support, and guided them in developing self-motivation skills.

Social support: Patients’ adherence to dietary, medication, and exercise recommendations was regularly evaluated after discharge. Patients demonstrating good adherence received praise, whereas those with shortcomings were provided with encouragement and support to strengthen confidence. Additionally, patients and their family members were encouraged to adopt a perspective-taking approach to reinforce patients’ sense of family responsibility and motivation for treatment.

Patients in the research group also received weekly follow-up through WeChat or telephone and monthly outpatient follow-up visits. They were additionally instructed to seek timely medical care when experiencing severe pain.

Data collection and outcome measures

Mental status: All patients received pre- and post-interventional psychological status assessments using the Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS). Each scale contains 20 items scored on a 4-point scale, totaling 20-80. Higher scores indicate greater severity of anxiety or depression[13].

Resilience scale: Psychological resilience was assessed pre- and post-intervention using the Conno-Davidson Resilience Scale (CD–RISC), which includes three dimensions: Tenacity (13 items), strength (8 items), and optimism (4 items). Each item is scored 0-4 points. Higher total scores indicate better psychological resilience[14].

Functional exercise compliance: Functional exercise compliance was evaluated using a self-developed questionnaire covering exercise standard adherence, exercise intensity, and exercise duration. Scores ≥ 90 were classified as excellent, scores of 60-89 as good, and < 60 as poor. The excellent-and-good compliance rate was calculated as the sum of the excellent and good rates. The questionnaire demonstrated a content validity index of 0.822 and a Cronbach’s alpha coefficient of 0.719.

Joint function: Joint function was assessed using the Bath Ankylosing Spondylitis Functional Index (BASFI), which consists of 10 items. Patients rated the difficulty of performing each activity, with scores ranging from 0 (easy to perform) and 10 (impossible to perform). Higher scores indicate poorer joint function[15].

Pain: Patients were assessed pre- and post-intervention using the Visual Analogue Scale (VAS), totaling 0-10. A score of 0 indicates no pain, whereas a score of 10 indicates severe, unbearable pain. Higher scores indicate greater pain intensity[16].

Rehabilitation status

Chest expansion, occiput-to-wall distance (OWD), morning stiffness duration, and modified Schober test distance pre- and post-intervention.

Chest expansion: With the patient standing and either allowing the arms to hang naturally or crossing them behind the head, chest circumference was measured at the fourth intercostal space using a flexible measuring tape. Measurements were obtained at maximal inspiration and expiration. Chest expansion was calculated as the difference between the two values.

OWD: Patients stood barefoot against a wall with their legs together, heels, hips, and scapulae touching the wall, eyes facing forward, and chin retracted. The horizontal distance between the highest point of the occipital protuberance and the wall was measured using a ruler (normal reference value: 0 cm).

Morning stiffness duration: The duration was recorded from the onset of stiffness or discomfort after waking, mainly involving the neck, back, and waist, until significant relief or disappearance following physical activity. The interval was the morning stiffness duration.

Modified Schober test distance: With the patient standing upright, the midpoint of the line connecting the posterior superior iliac spines was identified and marked as “Point 0”. Additional marks were placed 10 cm above and 5 cm below this point. Patients were instructed to bend forward maximally, and the distance between the two marks after flexion was measured. The difference between this value and the baseline distance of 15 cm represented the lumbar flexion range of motion.

QoL

QoL was assessed pre- and post-intervention using the Generic Quality of Life Inventory-74 (GQOLI-74), which assesses physical, psychological, and social functioning. All dimensions are scored on a percentage scale, with higher scores indicating superior QoL[17].

Statistical analysis

Normally distributed continuous data are expressed as mean ± SD. Between-group comparisons were performed using the independent-samples t-test, whereas within-group pre- and post-intervention comparisons were analyzed using the paired t-test. Non-normally distributed data are expressed as median (interquartile range) and analyzed using the Mann–Whitney U test for between-group comparisons and the Wilcoxon signed-rank test for within-group comparisons. Categorical data are expressed as number of cases and percentages n (%) and compared using the χ² test. Data analyses were performed using SPSS 22.0. A two-sided P < 0.05 was considered statistically significant.

RESULTS

Baseline data of the two groups of elderly patients with AS

The study groups were comparable at baseline (P > 0.05), with no significant differences in sex, age, disease duration, disease type, and affected segment, Bath Ankylosing Spondylitis Disease Activity Index scores, C-reactive protein, erythrocyte sedimentation rate, or medication use, including non-steroidal anti-inflammatory drugs, conventional synthetic disease-modifying antirheumatic drugs, biological disease-modifying antirheumatic drugs, and glucocorticoids (P > 0.05, Table 1).

Table 1 Baseline data of two groups of elderly ankylosing spondylitis patients, n (%)/mean ± SD.

Variable	Control group (n = 52)	Research group (n = 63)	χ2/t	P value
Sex			0.034	0.855
Male	28 (53.85)	35 (55.56)
Female	24 (46.15)	28 (44.44)
Age (years)	69.52 ± 4.91	68.51 ± 4.96	1.092	0.277
Disease course (years)	6.02 ± 2.95	6.63 ± 3.03	1.087	0.279
Disease type			0.668	0.414
Axial	32 (61.54)	34 (53.97)
Peripheral	20 (38.46)	29 (46.03)
Diseased segment			0.960	0.619
L3-4	19 (36.54)	20 (31.75)
L4-5	20 (38.46)	22 (34.92)
L4-S1	13 (25.00)	21 (33.33)
BASDAI (points)	5.69 ± 1.73	5.54 ± 1.68	0.470	0.639
CRP (mg/L)	30.85 ± 6.44	30.51 ± 6.86	0.272	0.786
ESR (mm/h)	59.62 ± 10.42	60.87 ± 10.17	0.649	0.518
Medication
NSAIDs	42 (80.77)	49 (77.78)	0.154	0.694
csDMARDs	15 (28.85)	21 (33.33)	0.267	0.606
bDMARDs	13 (25.00)	18 (28.57)	0.185	0.668
Glucocorticoids	10 (19.23)	10 (15.87)	0.224	0.636

BASDAI: Bath Ankylosing Spondylitis Disease Activity Index; CRP: C-reactive protein; ESR: Erythrocyte sedimentation rate; NSAIDs: Non-steroidal anti-inflammatory drugs; csDMARDs: Conventional synthetic disease-modifying antirheumatic drugs; bDMARDs: Biological disease-modifying antirheumatic drugs.

Psychological status of the two groups of elderly patients with AS

Psychological status was assessed using the SDS and SAS. Baseline scores were comparable between the two groups (P > 0.05). Following intervention, both groups exhibited significant reductions in SDS and SAS scores (P < 0.05), with a greater magnitude of improvement observed in the research group than in the control group (P < 0.05, Figure 1).

Figure 1 Psychological status of two groups of elderly ankylosing spondylitis patients. A: Pre- and post-interventional Self-Rating Depression Scale scores; B: Pre- and post-interventional Self-Rating Anxiety Scale scores. Note: ^aP < 0.05, ^bP < 0.01 vs before intervention; ^cP < 0.05 vs control. SDS: Self-Rating Depression Scale; SAS: Self-Rating Anxiety Scale.

Resilience of the two groups of elderly patients with AS

According to the CD-RISC assessment, baseline scores for all dimensions differed insignificantly between groups (P > 0.05). Scores across all dimensions increased significantly in both groups post-intervention (P < 0.05), with the research group demonstrating higher scores than the control group (P < 0.05, Figure 2).

Figure 2 Psychological resilience of two groups of elderly ankylosing spondylitis patients. A: Pre- and post-interventional tenacity dimension scores of the Conno-Davidson Resilience Scale (CD-RISC); B: Pre- and post-interventional CD-RISC strength dimension scores; C: Pre- and post-interventional CD-RISC optimism dimension scores. D: Pre- and post-interventional total CD-RISC scores. ^aP < 0.05, ^bP < 0.01 vs before intervention; ^cP < 0.05 vs control. CD-RISC: Conno-Davidson Resilience Scale.

Functional exercise compliance in the two groups of elderly patients with AS

Assessment of exercise compliance showed that the excellent-and-good compliance rate was significantly higher in the research group at 90.48% than in the control group at 75.00% (P = 0.026, Table 2).

Table 2 Functional exercise compliance in two groups of elderly ankylosing spondylitis patients, n (%).

Variable	Control group (n = 52)	Research group (n = 63)	χ2	P value
Excellent	22 (42.31)	33 (52.38)
Good	17 (32.69)	24 (38.10)
Poor	13 (25.00)	6 (9.52)
Excellent and good	39 (75.00)	57 (90.48)	4.947	0.026

Joint function and pain in the two groups of elderly patients with AS

Joint function and pain were assessed using the BASFI and VAS, respectively. No significant between-group differences were observed at baseline (P > 0.05). Post-intervention, BASFI and VAS scores decreased significantly in both groups (P < 0.05), with greater reductions observed in the research group (P < 0.05, Table 3).

Table 3 Joint function and pain in two groups of elderly ankylosing spondylitis patients, mean ± SD/median (interquartile range).

Variable	Control group (n = 52)	Research group (n = 63)	t/Z	P value
BASFI (points)
Before	39.38 ± 5.83	39.71 ± 6.54	0.283	0.778
After	23.54 ± 5.98	15.27 ± 4.12	8.749	< 0.001
VAS (points)
Before	6.00 (5.00, 8.00)	6.00 (5.00, 8.00)	-0.392	0.695
After	4.00 (3.00, 6.00)	3.00 (2.00, 4.00)	-4.961	< 0.001

BASFI: Bath Ankylosing Spondylitis Functional Index; VAS: Visual Analogue Scale.

Rehabilitation of the two groups of elderly patients with AS

Rehabilitation status was evaluated by ensuring chest expansion, OWD, morning stiffness duration, and modified Schober test distance. Baseline values were comparable between groups (P > 0.05). Post-intervention, the research group demonstrated significantly greater increases in chest expansion and modified Schober test distance, along with greater reductions in OWD and morning stiffness duration, compared with the control group (P < 0.05, Figure 3).

Figure 3 Rehabilitation of two groups of elderly ankylosing spondylitis patients. A: Pre- and post-interventional chest expansion across groups; B: Pre- and post-interventional occipital-wall distance measurements; C: Pre- and post-interventional morning stiffness duration; D: Pre- and post-interventional modified Schober test distances. ^aP < 0.05, ^bP < 0.01 vs before intervention; ^cP < 0.05 vs control.

QoL of the two groups of elderly patients with AS

GQOLI-74 assessment showed no significant between-group differences in baseline physical, psychological, and social functioning scores (P > 0.05). Post-intervention, scores in all dimensions increased significantly in both groups (P < 0.05), with more pronounced improvements observed in the research group (P < 0.05, Figure 4).

Figure 4 Quality of life of two groups of elderly ankylosing spondylitis patients. A: Pre- and post-interventional physical function scores of the Generic Quality of Life Inventory-74 (GQOLI-74); B: Pre- and post-interventional GQOLI-74 psychological function scores; C: Pre- and post-interventional GQOLI-74 social function scores. ^aP < 0.05, ^bP < 0.01 vs before intervention; ^cP < 0.05 vs control. GQOLI-74: Generic Quality of Life Inventory-74.

DISCUSSION

AS mainly affects the axial skeleton and sacroiliac joints, causing pain, inflammation-related stiffness, and impaired physical function, all of which negatively affect patients’ QoL across physical, psychological, and social domains[18]. Therefore, timely and effective interventions are essential to optimize both physical and psychological.

In this study, 115 elderly patients with AS were enrolled to compare the clinical effects of routine intervention alone with those of routine intervention combined with psychological intervention. The findings showed psychological intervention was associated with greater improvements in negative psychological states, reflected by more substantial reductions in anxiety and depression. Psychological disorders in elderly patients with AS arise from unbearable pain, impaired mobility, limited range of motion, and reduced QoL[15]. Through empathetic communication, psychological intervention facilitates a better understanding of patient’s experiences and psychological feelings while providing professional support, encouragement, and coping strategies. These measures may strengthen self-confidence, enhance motivation to overcome the disease, and improve self-adjustment abilities, thereby attenuating negative emotions. Qin et al[19] reported that music therapy improved physical and psychological recovery while reducing psychological tension and negative emotions in patients with AS, providing another intervention option for psychological management. Wang et al[20] demonstrated that psychological intervention effectively reduced anxiety and depression in patients with rheumatoid arthritis, supporting our findings. Additionally, psychological intervention significantly improved psychological resilience in elderly patients with AS. Enhanced resilience may contribute to reductions in adverse emotional states by improving the resilience levels of elderly patients with AS. Previous studies have demonstrated a negative correlation between resilience and both pain severity and disease activity[21]. Accordingly, it’s resilience enhancement in elderly patients with AS may help alleviate pain and inhibit disease progression by reducing thinking, decreasing avoidance behaviors, and strengthening patients’ sense of control over the disease[22,23].

Furthermore, psychological intervention showed clear advantages over routine intervention in improving patients’ functional exercise compliance, thereby elevating the excellent-and-good compliance rate from 75.00% to 90.48%. This improvement may be related to the effective alleviation of patients’ negative emotions and improvement of resilience following psychological intervention, which encourages patients to become more active in coping with diseases. Improved confidence and perceived self-efficacy may further promote proactive participation in functional exercises[24]. Additionally, psychological intervention was more effective in improving joint function and relieving pain. This may be attributed to the fact that psychological intervention helps patients overcome the fear of exercise and improve their functional exercise compliance, thereby strengthening joint function, facilitating effective functional recovery, and alleviating pain. Pain in elderly patients with AS is associated with inflammatory processes, nociception, and neuropathological changes, all of which may trigger anxiety, depression, fear of exercise, and even physical and psychological disabilities[25]. Psychological factors, including depression, helplessness, and maladaptive coping strategies, have also been associated with intensified pain perception in patients with rheumatoid arthritis[18]. These findings highlight the complex interaction between psychological status and pain and underscore the importance of targeted and effective management strategies. Zhao et al[26] reported that aquatic physical therapy significantly alleviated pain and reduced disease activity in patients with AS, suggesting another potential option for pain management in elderly patients. Evaluation of rehabilitation outcomes further demonstrated the superiority of psychological intervention over simple routine intervention alone for elderly patients with AS. These benefits may be attributable to effective improvements in joint functioning and functional exercise compliance under psychological intervention, as well as reductions in negative emotional states and pain levels, thus contributing to smooth patient recovery. Moreover, psychological intervention significantly improved patients’ QoL across physical, psychological, and social functioning domains. Meanwhile, psychological intervention can establish positive illness perceptions and coping strategies for patients, which helps to improve self-management, enhance rehabilitation efficacy, and improve QoL[27]. Moreno-Ligero et al[28] similarly reported that mobile health-based interventions for chronic pain not only reduced pain but also improved pain-related outcomes and QoL, highlighting a promising approach for managing elderly patients with AS.

Several study limitations should be acknowledged. First, this was a small-scale, single-center retrospective study, which may limit sample representativeness and the generalizability of the findings. Future multicenter prospective cohort studies with extended follow-up periods are warranted to evaluate the effects of psychological intervention more comprehensively and improve external validity. Second, AS patients with diabetes, hypertension, and other chronic diseases were excluded from this study. Although this approach reduced potential confounding, it may also limit the applicability of the results. Future studies should include AS patients with common chronic comorbidities and perform subgroup analyses to evaluate the effectiveness of the psychological intervention in more complex comorbidities. Third, eligibility required patients to use or learn to use WeChat. Consequently, elderly patients with AS and lower digital literacy, who may experience greater psychological distress and poorer treatment compliance, may have been underrepresented. Future studies should include elderly AS patients with different digital literacy levels and conduct subgroup analyses to further assess the impact of this factor.

CONCLUSION

In summary, psychological intervention combined with routine intervention provided greater clinical benefits than routine intervention alone in elderly patients with AS. The combined approach improved mental health, functional exercise compliance, joint function, rehabilitation outcomes, and QoL while reducing pain, supporting its broader clinical application.