Physical therapy in axial spondyloarthritis: guidelines, evidence and clinical practice

Key points

1. 01International guidelines (EULAR, ACR/SAA/SPARTAN, French and ASAS-EULAR) all recommend exercise and physical therapy as a core, integral part of standard care for axial spondyloarthritis.
2. 02EULAR defines four exercise domains to target: aerobic (cardiorespiratory), flexibility, resistance (strength), and neuro-motor.
3. 03Recent large multicentre trial data show high-intensity exercise can reduce pain, fatigue and stiffness and improve cardiovascular risk factors.
4. 04Most patients do not meet exercise recommendations, and adherence tends to fall as disease duration increases.
5. 05Strength (resistance) training and the optimal exercise dose are under-studied domains that need further research.

How it was conducted

Design

Narrative current-opinion review of guidelines, trials and systematic reviews on exercise in axial spondyloarthritis

Focus

Active physical therapy interventions (land-based exercise and aquatic hydrotherapy) rather than passive interventions such as massage or electrotherapy

Framework

EULAR four exercise domains: aerobic, flexibility, resistance (strength), and neuro-motor

Outcomes discussed

Disease activity (BASDAI, ASDAS), physical function (BASFI), cardiorespiratory fitness, comorbidity burden, and exercise adherence

What they found

• Approximately 30% of patients with axial spondyloarthritis have both axial and peripheral involvement.
• A large multicentre randomised trial used a 12-week intervention with two supervised aerobic and strength sessions per week plus one own aerobic session, and found this combination of aerobic and strength training yielded the greatest benefits for disease activity (ASDAS, BASDAI), physical function (BASFI) and cardiovascular health.
• A systematic review and meta-analysis of aerobic exercise versus standard physiotherapy showed no additional benefit in BASDAI or BASFI scores, with exercise dosages not defined and BASDAI the only disease-activity measure.
• In a cross-sectional study of 203 patients, only 54.7% were exercising at the WHO recommended level, with walking and swimming the most frequent activities.
• Other literature suggests fewer than 25% of patients with ankylosing spondylitis exercise three or more times per week.
• In one intervention study, 64% met the physical activity guideline and half of patients (n = 99) used physical therapy to facilitate engagement.
• A Cochrane-linked review evaluated exercise programmes within 12 trials including 826 patients, finding muscular strength training in only five trials, with poor or no descriptions of the strength exercises and resistance not dosed by any standardized measure.
• In the French DESIR cohort, early physical therapy (at least eight supervised sessions in the first 6 months) showed no functional benefit for patients with early spondyloarthritis in daily clinical practice.

Limitations

• This is a narrative current-opinion review, not a systematic review or meta-analysis, so it does not pool studies or formally appraise risk of bias.
• Specific guidance on the amount (dose, frequency, intensity, duration) of exercise needed for benefit is lacking, and the dose-response relationship is not established.
• Evidence is limited for early and nonradiographic axial spondyloarthritis, with conflicting findings on whether early physiotherapy helps.
• Most patient-reported physical activity measures rely on recall and are subjective, and strength training and neuro-motor exercise are poorly defined and under-evaluated.

Why it matters

For patients

Regular exercise across aerobic, flexibility, strength and balance activities is a safe and central part of managing your condition, ideally tailored to your preferences with help from a physiotherapist.

For clinicians

Strongly recommend and individualise exercise covering all four EULAR domains, consider higher-intensity combined aerobic and strength programmes, and address comorbidities such as cardiovascular disease and low adherence.

For readers

Exercise is firmly endorsed for axial spondyloarthritis, but the field still lacks agreement on the optimal type and dose, especially for resistance training and early disease.