Ankylosing spondylitis & axial spondyloarthritis
Exercise as medicine.
Your evidence-based movement guide — every exercise matched to the research that supports it.
Combined resistance and cardio training improves disease activity, function, and spinal mobility. Pilates reduces disease activity and stiffness. Aquatic exercise unloads the spine while building strength. Spinal mobility work preserves the range of motion that AS tries to steal. This page teaches you how to do each one safely.
The evidence. A meta-analysis of 20 RCTs with 1,670 patients (Zhang 2025, Archives of Physical Medicine and Rehabilitation) found exercise therapy reduced axSpA disease activity (BASDAI) by WMD −0.78, functional impairment (BASFI) by WMD −0.49, spinal mobility loss (BASMI) by WMD −0.49, and disease activity score (ASDAS) by WMD −0.44. Pain improved (SMD −0.47) and fatigue improved (SMD −0.49). The Sveaas 2020 ESpA RCT (n=100, Norway, 12 weeks, 3×/week) is the anchor trial: supervised high-intensity combined cardiorespiratory and strength training, producing the improvements in disease activity, fatigue, and emotional distress that informed the EULAR 2018 recommendation that physical activity should be an integral part of standard care in spondyloarthritis.
Start here. Bodyweight only. This tier builds the movement patterns you'll load later. The Zhang 2025 meta-regression found single sessions longer than 60 minutes produced the strongest BASFI improvements — so take your time, combine these with the spinal mobility tab, and don't rush.
Bodyweight squat
3 sets · 10–12 reps · 60s rest
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- Feet shoulder-width apart, toes turned slightly outward
- Sit back and down — chest lifted, eyes forward
- Knees track over toes, never collapsing inward
- Push through your whole foot to stand — squeeze glutes at top
axSpA note: If hip involvement or lower back stiffness limits depth, squat to a chair or box. Morning stiffness is common — warm up with 5 minutes of walking first. The movement pattern matters more than the depth.
1:00 between sets
Reverse lunge
3 sets · 8 each leg · 60s rest
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- Stand tall, step one foot backward — land on the ball of the back foot
- Lower back knee toward the floor, both knees near 90°
- Push through the front heel to return to standing
axSpA note: Reverse lunges are easier on the knees than forward lunges. If balance is limited by spinal rigidity, hold a wall or chair with one hand.
1:00 between sets
Hip hinge (deadlift pattern)
3 sets · 10 reps · 60s rest
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- Feet hip-width apart, soft bend in the knees
- Slide hands down your thighs as you push hips backward
- Keep back flat — imagine a broomstick along your spine
- Lower until you feel a deep hamstring stretch, then drive hips forward to stand
axSpA note: This is a critical pattern for AS. Strengthening the posterior chain — glutes, hamstrings, spinal erectors — directly counteracts the forward-flexion posture that progresses with spinal fusion. If thoracic kyphosis limits a flat back position, hinge only as far as form allows.
1:00 between sets
Wall push-up → floor push-up
3 sets · 8–12 reps · 60s rest
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- Start at a wall, progress to countertop, then knees, then full floor
- Hands slightly wider than shoulder-width, elbows at ~45°
- Lower chest toward the surface, push away to return
axSpA note: Push-ups open the chest — counteracting the thoracic kyphosis that develops as the disease progresses. Focus on squeezing shoulder blades together at the bottom of each rep.
1:00 between sets
Overhead press (bodyweight)
3 sets · 10 reps · 60s rest
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- Stand tall, arms in goalpost position — elbows at shoulder height, bent 90°
- Press hands straight overhead until arms are fully extended
- Lower back to goalpost with control — 2 seconds down
axSpA note: Overhead pressing is especially important in AS — it fights the loss of shoulder flexion and thoracic extension that comes with progressive disease. If cervical fusion limits looking up, keep your gaze forward and press to whatever height your spine allows.
1:00 between sets
Moderate aerobic training
After strength work · 15–20 min · 50–70% max HR
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Video coming soon
- Options: Brisk walking, cycling, swimming, elliptical
- Intensity check: You should be able to hold a conversation but not sing
- Heart rate target: 50–70% of max HR (220 minus your age × 0.5–0.7)
- Build from 15 minutes to 30–40 minutes over 4–6 weeks
Why combined? The Sveaas 2020 ESpA protocol combined strength work with cardiorespiratory training in each session (3×/week, 12 weeks). The Zhang 2025 meta-analysis confirmed VO2peak improved by +3.16 mL/kg/min across the axSpA exercise literature. Doing both in one session — strength first, then cardio — mirrors the protocol with the strongest evidence.
20:00 cardio session
Adding load · 60–70% of your 1-rep max. This matches the moderate-intensity protocols from the axSpA literature, including several trials in the Zhang 2025 meta-analysis. The ACSM classifies 60–70% 1RM as moderate intensity — sufficient to build strength in beginner-to-intermediate lifters. Only progress here once bodyweight work is well tolerated and morning stiffness is manageable.
Goblet squat
4 sets · 8 reps · 90s rest · 60–70% 1RM
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- Hold a dumbbell or kettlebell at your chest, elbows tucked
- Same squat pattern — sit back, chest up, knees tracking toes
- Control the descent (3 seconds down), drive up with intent
How to find 60–70% 1RM: If the heaviest single squat you can do with good form is 50 lb, your working weight is 30–35 lb. Retest every 6–8 weeks.
1:30 between sets
Romanian deadlift
4 sets · 8 reps · 90s rest · 60–70% 1RM
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- Hold dumbbells in front of thighs, palms facing you
- Push hips back, slide weights down your legs
- Stop at deep hamstring stretch, drive hips forward to stand
axSpA note: The posterior chain is your best defense against forward-flexion posture. Load this pattern deliberately — these are the muscles that keep you upright as the disease progresses.
1:30 between sets
Dumbbell walking lunge
3 sets · 10 steps each leg · 90s rest
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- Hold dumbbells at your sides, shoulders back and down
- Step forward into a lunge — both knees to ~90°
- Keep torso upright throughout
1:30 between sets
Dumbbell shoulder press
4 sets · 8 reps · 90s rest · 60–70% 1RM
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- Seated or standing, dumbbells at shoulder height, palms forward
- Press straight overhead until arms are fully extended
- Lower with control — 2 seconds down
axSpA note: If cervical fusion limits overhead range, substitute a high incline dumbbell press (bench at ~70°). The goal is thoracic extension under load — meet your spine where it is.
1:30 between sets
Seated cable row / band row
4 sets · 10 reps · 90s rest · 60–70% 1RM
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- Seated upright, pull handles toward your lower ribs
- Squeeze shoulder blades together at the end of each rep — hold 1 second
- Control the return — don't let the weight snap back
Why rows matter in axSpA: Rows strengthen the rhomboids, mid-trapezius, and rear deltoids — the muscles that retract the shoulder blades and open the chest. This directly counteracts the thoracic kyphosis that is the hallmark postural change in AS.
1:30 between sets
High intensity · 80–85% of your 1-rep max. The Sveaas 2020 ESpA RCT used high-intensity combined training (cardiorespiratory + strength, 3×/week, 12 weeks, supervised). At this intensity, train 2–3×/week with full recovery between sessions. Always use a spotter or safety equipment. Important limitation: Most axSpA trials did not stratify by disease severity — radiographic vs. non-radiographic axSpA, degree of ankylosis, or BASMI at baseline. This evidence applies most clearly to patients with mobile or early-disease spines, not fused spines. If you have significant spinal fusion, work with a physiotherapist to adapt these movements to your individual range.
Barbell back squat
5 sets · 5 reps · 2–3 min rest · 80–85% 1RM
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Video coming soon
- Barbell across upper back (not neck), feet shoulder-width
- Brace core, descend with control
- Depth as mobility allows — do not force range you don't have
- Drive up with intent — always use a squat rack with safety bars
axSpA note: If thoracic kyphosis prevents a safe bar position on your upper back, use a safety squat bar or substitute front squats / goblet squats at this intensity instead. Never compromise neck position to hold a barbell.
2:30 between sets
Barbell deadlift
5 sets · 5 reps · 2–3 min rest · 80–85% 1RM
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Video coming soon
- Bar over midfoot, feet hip-width, hands just outside knees
- Flat back, chest up, push the floor away with your legs
- Lock out standing tall — hips forward, shoulders back, glutes squeezed
axSpA note: If spinal fusion prevents a full hip hinge to the floor, use a trap bar (hex bar) or elevate the bar on blocks. The posterior chain loading is the goal, not how low the bar starts.
2:30 between sets
Overhead press
5 sets · 5 reps · 2–3 min rest · 80–85% 1RM
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Video coming soon
- Bar at collarbone height, grip just outside shoulders
- Brace core, squeeze glutes, press bar straight overhead
- Lock out overhead with bar directly over midfoot
axSpA note: If cervical fusion prevents looking up as the bar passes, use a landmine press or high incline barbell press instead. These provide thoracic extension loading without requiring full cervical range.
2:30 between sets
HIIT protocol (post-strength)
After strength work · 4 × 4 min intervals · 85–95% max HR
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Video coming soon
- Warm-up: 5 minutes at easy pace
- Intervals: 4 rounds of 4 minutes at 85–95% max HR, with 3 minutes active recovery
- Mode: Bike, rower, or elliptical preferred — less spinal impact than running
- Cool-down: 5 minutes at easy pace, then stretch
axSpA note: The Sveaas secondary analysis showed high-intensity exercise significantly improved fatigue, sleep quality, and mood in axSpA patients. Only attempt HIIT once you have 4–6 weeks of moderate cardio as a base. If you are in a flare, drop to moderate intensity until it resolves.
4:00 high intensity
The evidence. The 2025 network meta-analysis of 32 RCTs with 1,757 axSpA patients (Frontiers in Physiology) ranked aerobic exercise combined with Pilates as the most effective intervention for reducing both BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) and BASMI (Bath AS Metrology Index — spinal mobility). Pilates emphasizes spinal articulation, core stabilization, and controlled breathing — all directly relevant to the postural and mobility challenges of axSpA. The Altan 2012 RCT (12 weeks, 3×/week, supervised Pilates in axSpA) is one of the anchor trials in this literature.
A beginner Pilates flow for axSpA · 25–30 minutes · 3× per week · no equipment
Lateral breathing + pelvic floor
8–10 breath cycles · Foundation of every Pilates movement
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Video coming soon
- Lie on your back, knees bent, feet flat. Hands on lower ribs
- Inhale through the nose — feel ribs expand laterally (sideways)
- Exhale slowly through pursed lips — draw navel toward spine
- On each exhale, lightly engage your pelvic floor
axSpA note: Lateral rib expansion is specifically limited in AS as costovertebral joints stiffen. This breathing pattern is both a Pilates foundation and a direct intervention for chest expansion — one of the clinical measures the Zhang 2025 meta-analysis tracked.
3:00 breathing practice
Pelvic tilts + bridge
8 tilts → 8 bridges · Spinal articulation
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Video coming soon
- Same position. Exhale and tilt your pelvis — press lower back flat into floor
- Inhale and release to neutral
- Progress: on the exhale/tilt, peel hips off the floor into a bridge
- Roll spine up one vertebra at a time — hold 3 seconds at top
axSpA note: If spinal fusion limits segmental rolling, bridge as one unit — the glute and hamstring loading is still valuable. Don't force vertebra-by-vertebra movement that your spine can't produce.
3:00 tilts + bridges
Single leg stretch + toe taps
8 each leg · Core stability under movement
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Video coming soon
- Tabletop position — both knees bent 90° over hips
- Slowly lower one toe to the floor, return to tabletop
- Alternate sides. 8 each leg
4:00 core sequence
Cat-cow + thread the needle
8 cycles + 20s hold each side · Spinal mobility
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Video coming soon
- Hands and knees — wrists under shoulders, knees under hips
- Inhale: drop belly, lift chest and tailbone (cow). Exhale: round spine upward (cat)
- 8 slow cycles, then thread one arm under the opposite arm
- Hold 20 seconds each side — this releases the thoracic spine
axSpA note: Cat-cow is one of the most important movements for axSpA. Even if spinal fusion limits the range, the gentle oscillation maintains whatever segmental motion remains and prevents further stiffening of adjacent segments. Move within your available range — don't force it.
5:00 spinal mobility
Prone press-up + swimming
8 press-ups + 30s swimming · Extension + posterior chain
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Video coming soon
- Lie face down, hands under shoulders
- Press-up: push chest off the floor, keeping hips down — hold 5 seconds at top
- 8 reps, then: extend arms and legs, alternately lift opposite arm/leg (swimming)
- 30 seconds of swimming — small, controlled movements
axSpA note: Prone extension directly counters the flexion posture of AS. This is one of the most commonly prescribed physiotherapy exercises for ankylosing spondylitis — and for good reason. Even 5 minutes daily makes a measurable difference in thoracic extension over time.
5:00 extension work
Spine stretch + saw
6 stretches + 6 saws each side · Rotation + flexibility
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Video coming soon
- Seated tall, legs wider than hips, feet flexed
- Spine stretch: exhale, round forward reaching past toes. Stack back up
- Saw: twist torso, reach opposite hand toward outside of opposite foot
- 6 each side
axSpA note: Thoracic rotation is one of the first ranges of motion lost in AS. The saw targets it directly. Work within your available range — the stretch should feel like a gentle pull, never sharp pain.
5:00 flexibility
The evidence. The Gandomi 2022 RCT (3 parallel groups, assessor-blinded, BMC Sports Science, Medicine and Rehabilitation) compared aqua-based Pilates vs. aqua-based stretching vs. control in AS patients. Both aquatic interventions improved pain, physical function, spinal mobility, and quality of life compared to control. The aquatic environment reduces spinal loading by up to 90% while providing natural resistance — making it ideal for axSpA patients whose land-based exercise is limited by pain or stiffness. The Fernández García 2015 RCT (8 weeks, 3×/week, aquatic fitness + relaxation) confirmed improvements in BASFI and BASDAI.
Pool-based session · 30–40 minutes · 2–3× per week · warm water (30–34°C / 86–93°F)
Water walking + arm sweeps
5 min · Chest-deep water · Easy pace
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Video coming soon
- Walk forward and backward in chest-deep water for 2 minutes
- Add large arm sweeps through the water — forward circles, then backward
- Side-step for 1 minute each direction
Why warm water? Warm water (30–34°C) reduces muscle spasm and morning stiffness — two hallmarks of axSpA. Buoyancy unloads the spine while water resistance builds strength. The Gandomi 2022 trial specifically used a warm-water pool.
5:00 warm-up
Water squats + lunges + wall push-ups
3 sets each · 10 reps · water resistance
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Video coming soon
- Water squats: same squat pattern, chest-deep water provides resistance on the way up
- Water lunges: step forward, lower, push back — water provides deceleration
- Pool wall push-ups: hands on pool edge, push away — gravity + water resistance
- 3 sets of 10 reps each exercise, 30s rest between sets
10:00 strength block
Aqua spinal rotation + extension
Continuous flow · Use water for support
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Video coming soon
- Trunk rotations: arms extended at water surface, rotate torso left and right slowly
- Aqua cat-cow: hands on pool wall, alternate arching and rounding the spine
- Supine float (with noodle): lie back, arms wide, let the water extend your thoracic spine
- Side bends: stand tall, slide one hand down the thigh, return to center
axSpA note: Water supports your body weight while you work through spinal mobility. This allows ranges of motion that may not be achievable on land. The supine float is especially valuable — passive thoracic extension with zero compressive load.
10:00 mobility block
Lap swimming or water jogging + cool-down
8 min cardio + 2 min cool-down
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Video coming soon
- Swim laps (any stroke) or water jog for 8 minutes at moderate intensity
- Backstroke is ideal for axSpA — it promotes spinal extension
- Cool-down: 2 minutes of gentle walking, then float and breathe
axSpA note: Swimming is one of the most consistently recommended activities for ankylosing spondylitis across guidelines. Backstroke specifically counters thoracic flexion. Avoid breaststroke if cervical extension is limited.
10:00 cardio + cool-down
The evidence. Spinal mobility (BASMI) improved significantly across the axSpA exercise literature — WMD −0.49 in the Zhang 2025 meta-analysis of 12 studies. The 2025 NMA ranked aerobic exercise + Pilates as the top modality for BASMI improvement. The EULAR 2018 recommendations specifically state that physical activity targeting spinal mobility should be integral to axSpA care. This tab is not one modality — it is the daily maintenance work that preserves whatever range of motion you currently have. Use it every morning to counter overnight stiffness, and again before bed.
Daily mobility routine · 15–20 minutes · every morning + before bed
Neck range of motion series
5 reps each direction · Slow, controlled
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Video coming soon
- Chin tucks: pull chin straight back (double chin), hold 5 seconds × 10
- Rotation: turn head left, hold 5 seconds. Turn right, hold 5 seconds. 5 each
- Lateral flexion: ear toward shoulder (don't lift shoulder). 5 each side
- Extension: look up gently toward the ceiling. 5 reps, hold 3 seconds each
axSpA note: Cervical fusion begins insidiously. This series preserves whatever cervical range you have. If any direction is fully fused, skip that direction and focus on the others — maintaining what's left is the priority.
3:00 cervical mobility
Thoracic rotation + extension
8 reps each · The most important range to preserve
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Video coming soon
- Open book: side-lying, knees stacked, top arm opens to the opposite side. 8 each
- Foam roller extension: lie face-up over a roller at mid-back, arms overhead. Hold 30s × 3
- Seated rotation: cross arms on chest, rotate as far as comfortable. 8 each side
axSpA note: Thoracic rotation and extension are the ranges that matter most in daily life — looking over your shoulder while driving, reaching overhead, taking a full breath. These are the ranges AS attacks first.
4:00 thoracic mobility
Rib expansion + doorway stretch
10 breaths + 30s holds · Directly measured in trials
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Video coming soon
- Hands on lower ribs, inhale maximally through the nose — push ribs out against your hands
- 10 maximal breaths — focus on lateral expansion, not belly breathing
- Doorway stretch: forearms on door frame, step through gently. Hold 30 seconds × 3
axSpA note: Chest expansion is a clinical measure tracked in axSpA trials and used diagnostically. The Zhang 2025 meta-analysis did not find a significant pooled effect on chest expansion (WMD 0.14, 95% CI −0.02 to 0.30) — but this may reflect measurement sensitivity rather than lack of benefit. Maintaining rib cage mobility directly supports breathing capacity.
3:00 chest expansion
Cat-cow + child's pose + prone extension
8 cycles + 30s holds · Lumbar mobility
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Video coming soon
- Cat-cow: 8 slow cycles matching breath to movement
- Child's pose: sit back on heels, arms extended forward. Hold 30 seconds
- Prone press-up: lie face down, push chest off floor, hips stay down. 8 reps, hold 5s each
- Knee-to-chest: lie on back, pull one knee to chest. 30 seconds each side
axSpA note: Sacroiliac joint involvement is often the first site of disease. These movements gently mobilize the lumbar spine and SI region. If lumbar fusion is present, the range will be limited — work within it. Adjacent segment preservation is the goal.
4:00 lumbar mobility
Hip flexor stretch + wall posture check
30s holds + posture assessment · Daily anchor
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Video coming soon
- Half-kneeling hip flexor stretch: back knee on a pad, lean forward gently. 30s each side × 2
- Figure-4 stretch: lie on back, cross ankle over opposite knee, pull toward chest. 30s each
- Wall posture check: stand with back to wall — try to touch heels, glutes, shoulder blades, and occiput (back of head) to the wall simultaneously
axSpA note: The wall posture check is both a stretch and a self-assessment tool. If your occiput can't touch the wall, that's a measurable sign of thoracic kyphosis or cervical involvement — share this with your rheumatologist. Tracking this over time gives you a simple way to monitor your posture at home.
4:00 hips + posture
The evidence. The Zhang 2025 meta-analysis showed exercise significantly reduced fatigue in axSpA (SMD −0.49) — and prolonged sitting worsens the very stiffness axSpA patients already struggle with. A 2025 systematic review of 26 studies confirmed exercise snacks improve glucose metabolism, blood pressure, endothelial function, and cerebral blood flow. For axSpA specifically, breaking up sitting with movement counteracts the positional stiffening that makes the next time you stand up feel like starting over.
One movement every 30 minutes of sitting · 60–90 seconds each
Stand and sit × 10
Pathway: GLUT4 translocation → glucose clearance
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Video coming soon
- Stand fully and sit back down 10 times without using your hands
- Muscle contraction pulls glucose from the blood without needing insulin
1:00 snack time
Standing spinal rotation
Pathway: Costovertebral + thoracic joint mobilization
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Video coming soon
- Stand tall, cross arms on chest, rotate torso left then right — 10 each side
- This is the axSpA-specific snack: every rotation mobilizes the costovertebral and facet joints that AS stiffens first
1:30 snack time
Bodyweight squats × 10
Pathway: Myokine release → exercise IL-6 → IL-1ra
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Video coming soon
- 10 full squats at your desk — same form as the beginner tier
- Muscle contraction releases exercise IL-6, triggering your body's own anti-inflammatory response
1:00 snack time
Doorway chest stretch
Pathway: Pectoralis lengthening → thoracic extension
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Video coming soon
- Forearms on door frame, step one foot through — hold 30 seconds
- Switch foot forward, hold another 30 seconds
- This counteracts the forward-rounded posture that sitting reinforces — especially important in axSpA
1:00 snack time
Staircase climb × 1–2 flights
Pathway: Cardiac output → cerebral blood flow → brain perfusion
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Video coming soon
- Walk up 1–2 flights at a moderate pace, then walk back down
- Increased cardiac output drives blood flow to your brain — delivering glucose, oxygen, and clearing metabolic waste
1:30 snack time
Your axSpA exercise prescription
Combined resistance + cardio training 2–3× per week — the disease-modifying backbone, mirroring the Sveaas protocol. Pilates 2–3× per week — the top-ranked modality for BASDAI and BASMI improvement. Aquatic exercise 1–2× per week if accessible — unloads the spine while building strength. Spinal mobility work daily — morning and evening, non-negotiable. Exercise snacks every 30 minutes of sitting — because axSpA stiffens faster when you're still. Five pathways. One prescription.
Sarah Luebker, DO
Read the full story →This page is for education and does not replace medical advice. Most axSpA exercise trials did not stratify by disease severity — radiographic vs. non-radiographic axSpA, degree of ankylosis, or baseline spinal mobility. The evidence applies most clearly to patients with mobile or early-disease spines. If you have significant spinal fusion, work with a physiotherapist to adapt these movements to your individual range. Do not stop or change medications based on anything you read here.