Does axSpA Usually Not Progress in Active Individuals?
No, physical activity alone does not prevent disease progression in axial spondyloarthritis—disease activity (inflammation) is the primary driver of structural damage, not physical activity level. While exercise is crucial for symptom management and function, controlling inflammation through appropriate pharmacological treatment is essential to prevent radiographic progression.
The Relationship Between Physical Activity and Disease Progression
Exercise improves symptoms and function but does not halt structural damage. The evidence clearly demonstrates that:
- Disease activity (measured by ASDAS, inflammatory markers) correlates with radiographic progression, not physical activity levels 1
- Physical therapy and exercise are strongly recommended for all stages of axSpA to improve pain, stiffness, and function—but this is separate from preventing structural damage 1
- People with osteoarthritis and axSpA should be especially encouraged to exercise as it shows strong and consistent effects on reducing pain and improving function 1
What Actually Drives Disease Progression
Inflammation is the key factor in structural damage progression:
- High disease activity leads to new syndesmophyte formation 1
- The presence of existing syndesmophytes is a risk factor for developing more syndesmophytes 1
- Elevated inflammatory markers (CRP/ESR) correlate more closely with radiographic progression than physical activity status 1
The Role of Exercise in axSpA Management
Exercise is mandatory for optimal management but serves different purposes than preventing structural damage:
- Combining pharmacological treatment with physical therapy is strongly recommended during all stages of disease 1
- Active physical therapy and supervised exercise is strongly recommended over passive therapy 1
- Exercise domains should include aerobic, resistance, flexibility, and neuro-motor training 2
- High-intensity exercise can improve disease activity and cardiovascular risk factors 2
Common Barriers to Exercise in axSpA Patients
Despite recognizing exercise importance, patients face significant obstacles:
- Pain (27%), fatigue (23%), lack of motivation (15%), and lack of time (10%) are reported barriers 3
- Only 27% of patients manage to exercise regularly (≥30 min, 2-3 times weekly) despite 89% perceiving physical activity as important 3
- Approximately 54% of axSpA patients perform physical activity at recommended levels, similar to the general population 4
Treatment Strategy to Prevent Progression
To actually prevent structural damage, focus on controlling inflammation:
- NSAIDs are first-line for symptom control but have inconsistent evidence regarding preventing radiographic progression 1
- The continuous use of NSAIDs is suggested only to control symptoms, not to attempt to control progression of structural damage 1
- Biologic DMARDs (anti-TNF agents, anti-IL-17 agents) and JAK inhibitors have been associated with reduced radiographic progression 5
- Approximately 75% of patients require biologics or JAK inhibitors to reduce symptoms, prevent structural damage, and improve quality of life 5
Monitoring Disease Activity (Not Just Physical Activity)
Regular monitoring should focus on inflammatory markers:
- Monitor every 3-4 months when initiating new therapy using ASDAS and/or SASDAS, CRP and/or ESR 1
- ASDAS more closely correlates with radiographic progression than BASDAI 1
- Routine MRI and radiographic studies for follow-up are strongly recommended against due to slow progression rates and cost 1
- Spinal radiographs should not be performed more frequently than once every 2 years if used at all 1
Critical Clinical Pitfall
Do not assume that physically active patients with axSpA are protected from disease progression. A patient who exercises regularly but has persistently elevated inflammatory markers or high disease activity scores remains at risk for structural damage and requires escalation of pharmacological therapy, not just encouragement to continue exercising 1, 5.