Physical Therapy in Axial Spondyloarthritis

Guidelines, Evidence and Clinical Practice

Christopher Martey; Raj Sengupta


Curr Opin Rheumatol. 2020;32(4):365-370. 

In This Article

Abstract and Introduction


Purpose of review: Physical therapy is recommended for the management of axial spondyloarthritis (axSpA) with the focus of promoting physical activity and prescribing exercise within four domains, outlined recently by the European League against Rheumatism (EULAR): aerobic, resistance, flexibility and neuro-motor exercise. There is an increasing evidence base to support physical therapy interventions in axSpA.

Recent findings: We present evidence supporting the use of exercise as treatment for patients with axSpA, recent updates among different exercise modalities, and make clear its critical place in the management of this condition. Recent large, multicentre data have shown that high-intensity exercise can improve disease activity and also positively impact cardiovascular risk factors in these patients. Although international treatment guidelines advocate the inclusion of physical activity and exercise for the optimal management of axSpA, specific guidance about the amount of exercise required to produce a beneficial effect is lacking.

Summary: Exercise must be used in the management of axSpA, and whilst hydrotherapy and flexibility exercises are traditionally the main focus, other applications, such as strength training, may be underutilized domains. Further studies are needed to determine the dose–response relationship between exercise and axSpA patient subsets.


Spondyloarthritis (SpA) encompasses a group of chronic, inflammatory heterogeneous diseases that predominantly affects the axial skeleton but can also present with peripheral (arthritis, enthesitis and/or dactylitis) and extra-articular (skin, gut and eye) disease manifestations.[1] Depending on the presence of definitive radiographic changes in the sacroiliac joints, the Assessment of Spondylorthritis International Society (ASAS) classification criteria have differentiated axSpA into radiographic and nonradiographic axSpA (nr-axSpA).[2] Approximately 30% of patients with axSpA have both axial and peripheral involvement[3] and patients with axSpA frequently report pain, stiffness, reduced mobility and fatigue problems, which may lead to impaired physical activity.[4]

The European League against Rheumatism (EULAR) produced their 'Research Roadmap to transform the lives of people with Rheumatic and Musculoskeletal Diseases' (also known as RheumaMap) in 2017, on rheumatic and musculoskeletal diseases (RMDs). It identifies the priorities and challenges in RMD research and innovation. In SpA, and with specific regard to physical activity, the RheumaMap outlines the need to further explore the impact of physical activity and lifestyle changes on the progression of SpA and sets out several research agendas including the need to: identify markers of response and nonresponse to physical activity; and evaluate the long-term effectiveness of physical activity at different intensities and types.

Physical Therapy

Whilst the advent of effective biologic disease-modifying antirheumatic drugs (bDMARDs) have dramatically benefitted patients with axSpA, nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy remain the cornerstones of initial treatment for all patients with axSpA.[5,6] Physical therapists, or physiotherapists, are healthcare professionals (HCPs) with a key focus on physical activity education, physical activity promotion and exercise rehabilitation. The American Physical Therapy Association (APTA) and Chartered Society of Physiotherapy (CSP) both acclaim their respective members as being skilled in exercise selection, prescription and management. A recently published systematic review[7] is physical therapy specific in its evaluation and identified a lack of standardized exercise programmes in the literature for those with axSpA. For the purpose of facilitating self-management within long-term condition management, this manuscript will henceforth focus on active physical therapy interventions (exercise), including both land-based and aquatic therapy (hydrotherapy), over passive physical therapy interventions (massage, manipulation and electrotherapy for example).