Ankylosing spondylitis (AS) is a type of arthritis that mainly affects the spine. Although there is no known cause or cure, exercise can the helpful for managing the pain and stiffness often associated with AS. We asked an exercise physiologist which exercises are best (and which to avoid) for those living with ankylosing spondylitis…

So what is ankylosing spondilytis (AS)?

Ankylosing spondylitis is a type of arthritis that affects a small proportion (about 0.5%) of the population. It’s also commonly under recognized in those suffering with back pain. The inflammation that occurs particularly affects the sites at which tendons or ligaments join onto bone (called the enthesis). The most commonly affected region is the sacroiliac joints, which is where the spine joins onto the pelvis. Inflammation can also occur at other organs in addition to the musculoskeletal system, such as in the eyes, intestines, and lungs.

If left untreated, the chronic inflammation present within the spine and other musculoskeletal structures leads to uncontrolled increase in bone formation that results in stiffening, and ultimately fusion, of the joints. This causes in a loss of motion and often deformity, especially in the spine, where an individual develops a stooped flexed hip posture. This can make it difficult to perform daily activities such as walking. Loss of movement and deformity is usually a late manifestation of the disease.

Diagnosing ankylosing spondilytis

In Australia, it takes an average of 5 – 7 years from onset of symptoms to AS diagnosis. I find this incredibly sad! It’s common for individuals to try numerous practitioners and remedies to manage their pain, typically without long lasting improvement.

So how is inflammatory back pain different to mechanical back pain?

The Assessment of SpondyloArthritis international Society (ASAS) highlights that the following features of back pain are most suggestive of an inflammatory spinal disease, such as AS:

• Age at onset <40 years
• Insidious onset
• Improvement with exercise (Individuals feel better when they move/remain active)
• No improvement with rest
• Pain at night with improvement upon getting out of bed

When at least 4 of these 5 features are present, the back pain is typically related to inflammation of the spine. The appropriate management and treatment of inflammatory back pain (and other inflammatory conditions) is very different to other types of back pain. Establishing the correct diagnosis (usually from a Rheumatologist) is an essential step in helping sufferers to get the best possible care.

Other features suggestive of inflammation at the spine and sacroiliac joints include:

• Duration of back pain extending beyond 3 months
• Morning stiffness lasting more than 30 minutes
• Alternating buttock pain
• Waking during the second half of the night only

How can an exercise physiologist help?

Accredited Exercise Physiologists (AEPs) are well placed to assist those with Ankylosing Spondylitis, both before and after the condition is diagnosed. They have an understanding of the symptoms and complexities surrounding inflammatory back pain. Armed with this knowledge, your exercise physiologist can assist individuals with suspected inflammatory back pain get to a rheumatologist as soon as possible.

After diagnosis, the role of your exercise physiologist is even more crucial. Working alongside your GP and rheumatologist, your AEP will prescribe exercise interventions that are safe, effective and tailored to your individual needs.

What to expect when you see an AEP

1. Assessment: A thorough assessment is performed before prescribing exercise. This will include musculoskeletal and psychosocial factors, as well as AS-specific measures (like spinal mobility and chest expansion). Strength, balance and cardiovascular fitness might also be tested.

2. Exercise Prescription: Your exercise physiologist develops an exercise program based on both your current capacity and your goals for the future. They will also provide you with education regarding flares and activity pacing.

What exercises are best?

Individual exercise prescription generally emphasises spinal mobility, which is paramount for best management of AS. It’s also important to maintain mobility of peripheral joints. A higher frequency of specific lower back exercises has been shown to be associated with slower progress of functional disability over 5 years. For this reason, dosage of mobility exercises should be negotiated in a way so that the program can be done consistently!

People living with AS also have an increased risk of developing cardiovascular disease. For this reason, your exercise program should incorporate sufficient levels of aerobic exercise. Strengthening exercises and functional fitness are also important components to include in a balanced exercise programme.

What should you avoid?

Activities that are high impact, such as some football codes, martial arts or long-distance road running, should be avoided in AS. These types of exercises increase the risk of symptom exacerbation or structural damage to an inflamed or ankylosed spine. Avoiding high impact activities is particularly important in AS cases where the disease is more active, severe or long-standing.

Where to get advice

If you have persistent back pain or have been diagnosed with ankylosing spondylitis, speak to your doctor or rheumatologist. They may refer you directly to an exercise physiologist. Alternatively, there’s over 5,000 AEPs all around Australia that can help you to exercise right. To find one near you, click here.

Written by Sarah Comensoli. Sarah is an Accredited Exercise Physiologist at BJC Health.