Exercise Recommendations for Non-Radiographic Axial Spondyloarthritis
Active, supervised physical therapy combined with pharmacological treatment is strongly recommended for all patients with nr-axSpA, prioritizing structured exercise programs over passive modalities. 1
Core Exercise Framework
The optimal exercise approach for nr-axSpA follows four essential domains that should be incorporated into treatment 2:
- Aerobic exercise: Target ≥150 minutes/week of moderate-intensity OR ≥75 minutes/week of vigorous-intensity activity 1, 3
- Resistance/strength training: Perform ≥2 sessions per week focusing on muscle strengthening 1, 4
- Flexibility exercises: Include spinal mobility and stretching routines regularly 2
- Neuromotor exercise: Incorporate balance and coordination activities 2
Supervision and Delivery
Supervised exercise programs are strongly preferred over unsupervised home-based exercise because they demonstrate superior outcomes in disease activity, function, and adherence 1. The 2023 PANLAR guidelines emphasize that physical therapy should be managed by experts in physical medicine and rehabilitation 1.
However, for patients without access to supervised programs, home-based exercises are acceptable only after proper training on correct technique 1. This pragmatic approach acknowledges healthcare access limitations while maintaining safety standards 1.
Specific Exercise Modalities
Land-based exercises are conditionally recommended over aquatic therapy 1, though both modalities are effective. The most commonly performed and beneficial activities include 3, 5:
- Walking (energetic/brisk walking for cardiovascular benefit)
- Cycling
- Swimming (particularly beneficial for those with limited mobility)
- Gym-based strength training
Recent evidence demonstrates that high-intensity exercise can improve disease activity and cardiovascular risk factors in axSpA patients, suggesting that intensity matters 2. This challenges traditional conservative approaches and supports progressive exercise prescription.
Critical Safety Considerations
Spinal manipulation is strongly contraindicated in patients with spinal fusion or advanced spinal osteoporosis due to serious adverse event risk 1. This is a non-negotiable safety recommendation based on indirect evidence of harm 1.
Physical therapists must screen for these contraindications before initiating treatment, as paraspinal muscle atrophy and structural changes may be present even in early nr-axSpA 6.
Integration with Pharmacotherapy
Exercise must be combined with appropriate pharmacological management—it is not a standalone treatment 1. The 2017 ASAS-EULAR guidelines emphasize that patients should be educated about axSpA and encouraged to exercise regularly, with physical therapy considered as an adjunct to medical management 1.
Regular exercise on a consistent basis is essential, not sporadic activity 1. Patients should be counseled that exercise benefits include improved physical fitness, cardiovascular function, and disease-related health status 3, 5.
Common Pitfalls
The major gap in current practice is that only 34-37% of axSpA patients fulfill both aerobic AND muscle-strengthening components of WHO recommendations 3. Patients are significantly more likely to meet aerobic targets (72-77%) than strength training targets (36-40%) 3.
Passive physical therapy modalities (massage, ultrasound, heat) are strongly discouraged in favor of active exercise interventions 1. This represents a critical practice point, as passive treatments do not provide the functional and disease-modifying benefits of active exercise 1.
Supervised group exercise participants tend to be older with longer disease duration and worse spinal mobility, suggesting that exercise programs may not be reaching younger, earlier-stage patients who could benefit most 4.
Monitoring and Adjustment
Physical activity levels should be assessed regularly, as higher exercise volumes correlate with better disease-related health status (ASAS-HI) and quality of life (ASQoL), independent of age, sex, BMI, disease activity, and physical function 3. This dose-response relationship supports encouraging maximum tolerated exercise participation 3.
The evidence supports that exercise interventions benefit patients across all disease stages—active nr-axSpA, stable disease, and advanced disease with structural changes 1—making it a universal recommendation regardless of disease phase.