Exercise guide
Exercise is one of the main treatments for ankylosing spondylitis (AS) and axial spondyloarthritis (axial SpA), alongside medicines. AS back pain usually eases with movement and gets worse with rest, and in trials, exercise programmes improved function, pain and disease activity compared with no exercise. The gains are real but modest, and no treatment can undo fusion that has already happened.
This guide turns the programme the National Institute for Health and Care Excellence (NICE) recommends into a 20-minute daily routine for your spine, posture and breathing. It then covers how much cardio and strength to add, what a trial of hard exercise found, how to adapt for flares and a stiff or fused spine, and the warning signs that need urgent help.
International recommendations from the Assessment of SpondyloArthritis international Society and the European Alliance of Associations for Rheumatology (ASAS-EULAR) say people with axial SpA should be encouraged to exercise regularly, and NICE recommends a structured programme set by a specialist physiotherapist. The National Axial Spondyloarthritis Society (NASS) calls exercise "the single most important thing you can do to help yourself".
In a review of 14 trials with 1,579 people, exercise programmes improved everyday function by about 1.3 points and disease activity by about 0.9 points on 0 to 10 scales, and pain by about 2 points, compared with no exercise. Spinal movement improved only a little, and the evidence for that is weak.
Source 4
Do some stretching and mobility work every day, covering your whole spine, your posture and your breathing. Add about 150 minutes a week of cardio, such as walking, cycling or swimming, and strength exercises on at least 2 days a week.
In 100 people with active axial SpA, 3 months of supervised hard intervals and strength training reduced disease activity and inflammation and improved function and heart health. The gains in tiredness and mood had faded a year later, by which time most people had stopped training.
Spinal fractures are more common with AS, though estimates of how much more vary widely between studies, and a fused spine can break even after a minor injury. See a health professional after any fall or knock, especially if your pain increases. NASS's safety advice (in the copy of its website archived in October 2025) is to talk to your physiotherapist before contact sport.
Go to A&E or call 999 (911 in the US) for numbness around your genitals or bottom, weakness or numbness in both legs, or new problems controlling your bladder or bowels. A painful red eye, sensitivity to light or blurred vision needs an eye assessment the same day.
AS is a long-term condition in which the spine and other parts of the body become inflamed. It's a type of axial SpA in which the changes in the spine show on an X-ray; in non-radiographic axial SpA they don't (though they can sometimes show on an MRI scan), but the symptoms and treatment are similar. Over time, the inflammation can lead to new bone growth, and in some people parts of the spine join up (fuse) and lose flexibility.
It usually starts between 18 and 40. Back pain and stiffness are the main symptoms: the pain gets better with exercise but not with rest, is worse in the morning and at night, and can affect the buttocks. Other joints such as the hips and knees can be inflamed, as can the places where tendons attach, such as the heel, the top of the shin and where the ribs join the breastbone, which can make deep breaths painful. Tiredness is common, and some people also have eye inflammation (iritis), psoriasis or inflammatory bowel disease.
Source 16
Our back pain guide covers the many other causes of back pain. NICE asks GPs to refer people to a rheumatologist if their low back pain started before 45 and has lasted more than 3 months, and they have 4 or more of these:
Source 2
More than 8 in 10 people with AS carry a gene variant called HLA-B27, but so do about 8 in 100 people in general, and most of them never get AS. A blood test for it can help, but it doesn't confirm or rule out AS on its own.
Source 15
Axial SpA affects about 0.3% to 1.4% of people. NICE says it "affects a similar number of women as men", though more men develop the form that shows on X-rays. The exercise trials were about 70% men, but nothing in the evidence suggests women and men should exercise differently.
Most people with AS stay fully independent or only mildly affected in the long term. Some develop severely restricted movement in the spine, usually the lower back, where the bones have fused, and their posture can become fixed in one position.
Source 6
When the places where the ribs join the breastbone are inflamed, deep breaths can hurt and the chest may not expand fully. Limited chest expansion is one of the signs doctors look for.
Osteoporosis can develop in the spine, and the risk of spinal fractures rises the longer you have AS. NICE suggests considering a bone density check every 2 years; new bone growth can make spine readings look falsely high, so hip readings may be more reliable.
Across observational studies, people with AS had higher odds of a heart attack (about 1.6 times) and a stroke (about 1.5 times). The NHS advises stopping smoking, losing excess weight, and regular exercise: "150 minutes of exercise a week can greatly improve your health".
Anti-inflammatory painkillers (NSAIDs) come first. If symptoms aren't controlled, biological medicines such as anti-TNF (tumour necrosis factor) medicines, or newer tablets called JAK inhibitors, can help. Steroid injections can ease a single inflamed joint, and surgery is sometimes needed for a damaged hip or, rarely, the spine. Exercise adds benefit on top of medicines.
A 2019 Cochrane review pooled 14 trials with 1,579 people (70% men, average age 45), mostly 12-week programmes of strength, flexibility, stretching and breathing exercise, usually alongside medicines. Compared with no exercise, function improved by 1.3 points and disease activity by 0.9 points on 0 to 10 scales (moderate-certainty evidence), and pain by 2.1 points (low certainty), the one change big enough for people to notice. Spinal movement and tiredness improved a little, but that evidence is very uncertain.
Source 4
When people who exercised were compared with people having usual care, the differences were small: function 0.4 points and pain 0.5 points better (moderate certainty), and disease activity 0.7 points (low certainty). Possible harms couldn't be judged, because few were reported.
Source 4
An older Cochrane review of 11 trials (763 people) found that exercising at home or with supervision was better than no exercise (low-quality evidence), and that supervised group physiotherapy did a little better than exercising at home (moderate quality). ASAS-EULAR says supervised exercise is more effective than home exercise, and that people keep going more when they're supervised.
In a Norwegian trial, 100 people with active axial SpA did 3 months of high-intensity training (hard 4-minute intervals and strength work, 3 times a week, 2 sessions supervised) or carried on as usual; 97 of the 100 finished. Disease activity scores fell (by 0.6 and 1.2 points), and inflammation, function and heart health improved. The authors say this "debunks concerns that high intensity exercise might exacerbate disease activity". Tiredness, mood and general health improved at 3 months but not at 12, when 40% were still exercising regularly.
In 106 people with AS (40% women), 12 weeks of individually monitored moderate cardio, 3 times a week on top of a weekly flexibility class, improved fitness. Overall disease activity didn't change significantly, though pain in joints outside the spine did.
Source 21
No trial has shown that exercise prevents or reverses fusion, and spinal movement changed little in the trials. The NHS says treatment as a whole can help delay the condition's progress. Whether very heavy loads or excessive exercise could speed up damage hasn't been studied: ASAS-EULAR lists it as a research question.
In a meta-analysis of observational studies, people with AS had 1.6 times the odds of a heart attack and 1.5 times the odds of a stroke. Regular exercise is one way to lower that risk, alongside not smoking and treating blood pressure and cholesterol.
NICE recommends referral to a specialist physiotherapist for an individual, structured programme of stretching, strengthening and posture exercises, deep breathing, spinal extension (bending backwards), range of movement exercises for the lower, middle and upper back and the neck, and aerobic exercise. Ask your rheumatology team for a referral.
Source 2
The NHS says some daily stretching and exercise is important, even if you swim or play sport. 10 to 20 minutes covers it (our editorial time). If mornings are stiff, NASS's safety advice suggests exercising later in the day.
Move within a comfortable range. NASS says mild aches while you exercise are normal and should ease off once you've finished; if more than mild aches follow, get advice. Expect good days and bad days.
Source 12
NICE includes posture exercises in its programme, NASS lists posture control among the main aims of exercise, and NASS suggests keeping a good posture in every exercise: "The mirror is your friend."
Inflammation where the ribs join the breastbone can make deep breaths painful. NICE includes deep breathing in its programme, and NASS lists lung capacity as an aim. Rib-expansion breathing and arm reaches with the breath fit into a daily routine (our editorial choice).
Every day, slowly and within a comfortable range: about 8 slow repetitions, or 3 holds of 30 seconds for the sphinx (our editorial starting point). Skip prone press-ups if they send pain down a leg.
3D demoCat-cowBeginner · No equipment
3D demoThoracic rotationBeginner · No equipment
3D demoSide-lying Open Book RotationBeginner · No equipment
3D demoProne press-up (McKenzie press-up)Beginner · No equipment
3D demoSphinx pose (Salamba Bhujangasana)Beginner · No equipment
3D demoLow cobra (Bhujangasana)Beginner · No equipment
3D demoOverhead side bendBeginner · No equipment
3D demoMermaid (Pilates seated side bend)Beginner · No equipmentChin tucks: 10 holds of 5 seconds. Wall angels and Y-T-W raises: 8 slow repetitions, in whatever range you have. Keep your elbow at or below shoulder height in the chest stretch.
2 holds of 30 seconds on each side, to a mild stretch. Pad your knee in the hip flexor stretch.
5 slow breaths each, filling your lower ribs. Sitting or standing is fine.
At least 150 minutes a week of moderate activity, such as brisk walking, cycling or swimming, spread across the week, or 75 minutes of vigorous activity. Moderate means you can talk but not sing.
Work all the major muscle groups on at least 2 days a week. NICE includes strengthening in its programme.
NASS's general advice (in its safety page as archived in October 2025) is low weights and high repetitions. In the Norwegian trial, people lifted the most they could manage 8 to 10 times, for 2 to 3 sets, with supervision, and it was safe. Our editorial starting point: 12 to 15 repetitions with a light weight, moving on to heavier sets with input from a physiotherapist or trained instructor, especially if your spine is fused or your bones are thin.
The trial's cardio was a 10-minute warm-up, then 4 bursts of 4 minutes at 90% to 95% of maximum heart rate with 3 easier minutes between, twice a week, plus a longer session at home. Pain up to 5 out of 10 was allowed if it settled by the next day. People were screened first, and one person with chest pain switched to moderate exercise after seeing a cardiologist.
Source 9
NICE suggests considering hydrotherapy (exercise in a warm pool) alongside exercise for pain and function. The NHS says swimming or sport "is usually fine, although some daily stretching and exercise is also important". In one trial, a spa-based exercise course followed by group physiotherapy did better than group physiotherapy alone.
Supervised exercise does a little better than exercising alone, and helps people keep going. A physiotherapist can set your programme, and NASS runs exercise sessions through its local branches.
2 days a week: 2 to 3 sets of 12 to 15 with a light weight to start (our editorial reading of NASS's low weights, high repetitions advice). Keep a long spine, and swap sit-ups for planks and bird dogs.
3D demoDumbbell goblet squatIntermediate · A dumbbell
3D demoLeg pressBeginner · Strength machine
3D demoHip-hinge practiceBeginner · No equipment
3D demoDumbbell Romanian deadliftIntermediate · A dumbbell
3D demoBand rowBeginner · A band + An anchor point
3D demoSeated cable rowBeginner · A cable machine
3D demoLat pulldownBeginner · A cable machine
3D demoIncline push-upBeginner · A bench or box
3D demoChest press machineBeginner · Strength machine
3D demoBird dogBeginner · No equipment
3D demoForearm plankIntermediate · No equipment
3D demoBack extension on a 45-degree benchIntermediate · A bench or boxBuild towards 150 minutes of cardio a week, at a pace where you can talk but not sing. Swimming counts too. For balance, 2 to 3 holds of 20 to 30 seconds on each leg, beside a counter.
3D demoTreadmill walkingBeginner · Cardio machine
3D demoStationary cyclingBeginner · Cardio machine
3D demoElliptical trainerBeginner · Cardio machine
3D demoIndoor Rowing (Rowing Machine)Beginner · Cardio machine
3D demoSingle-leg standBeginner · A wall
3D demoTandem stance and heel-to-toe walkBeginner · A wallNICE says a flare plan should include self-care such as exercises and stretching. NASS suggests checking with a health professional before starting a new programme during a flare, and notes that many people prefer to avoid high-impact sport during one.
Keep your daily routine going at a smaller range, swap impact for swimming or cycling, drop the weights for a few days, and build your strength sessions back up over a week or two.
The NHS says to rest the joint for up to 48 hours after a steroid injection.
Source 5
Flares that keep coming back or don't settle, or flares while you're taking biological medicines, need advice from your specialist team.
Source 2
In a large UK primary care study, people with AS had about 3 times the odds of a spinal fracture, and a review of 6 studies put it at about 4 times. Both estimates are very uncertain: the plausible range runs from about 1 to 7 times. Hip and forearm fractures weren't clearly more common. The NHS says the risk rises the longer you have AS.
NICE says people with axial SpA may be prone to fractures and should see a health professional after a fall or injury, particularly if their pain increases. ASAS-EULAR warns that with a fused spine, a fracture is more likely "even with a minor trauma" and usually has a worse outcome. Our advice: get new or worse neck or back pain after a fall checked the same day.
NASS's safety advice says contact sports can break thin bones or a stiff or fused spine, so discuss them with your physiotherapist. High-impact sport such as running can bring on a flare in some people: if you already run, watch your symptoms and be ready to change what you do, and get advice before starting. The NHS also says to check with your physiotherapist or rheumatologist before taking up a new sport.
With a fused spine or osteoporosis, avoid activities with a high chance of falls or blows to the head and neck, such as contact sport, horse riding, skiing or trampolining. Use handrails, and practise balance.
If you have osteoporosis, our osteoporosis guide covers bone-building exercise. With low bone density or a fused spine, swap sit-ups, toe touches and loaded forward bends for back extensions, planks and hip hinges, and skip yoga poses that load the neck, such as headstands, shoulderstands and plough (our editorial advice).
Do the daily routine every day, and add 2 strength sessions and your cardio through the week. The Norwegian 4x4 intervals are for people cleared to train hard, and not during a flare. With osteoporosis or a fused spine, skip the foam roller in the upper back routine unless a physiotherapist has cleared it.
A 20-minute daily routine for ankylosing spondylitis and axial spondyloarthritis: breathing, neck, upper and lower back, spinal extension, hips and posture.
20 minBeginner15 movesA wallA 30-minute routine for a rounded upper back in later life, built from the SHEAF trial: floor back-strengthening, posture practice and gentle mobility.
30 minBeginner13 movesA bench or box, A wallA 12-minute routine for a stiff upper back and rounded shoulders: chin tucks, wall angels, Y-T-W raises and open books.
12 minBeginner8 movesA foam roller, A wallA steady 30 to 45 minute cardio session at talk-but-not-sing pace: walk, cycle, row or cross-train, counting toward weekly activity guidelines.
40 minBeginner3 movesCardio machine, A wallA 25-minute standing cardio circuit with no jumping: marching, step jacks, sit-to-stands, punches, step-ups and wall push-ups, with a seated option for most moves.
25 minBeginner9 movesA bench or box, A stepA 20-minute full-body dumbbell workout: two supersets of squats, rows, Romanian deadlifts and push-ups. Twice a week covers the minimum dose.
20 minBeginner8 movesA dumbbell, A bench or boxA beginner full-body gym workout: goblet squats, dumbbell bench press, lat pulldowns, Romanian deadlifts and dead bugs, with sets, reps and rest.
45 minBeginner12 movesCardio machine, A bandThe Norwegian 4x4, a well-studied interval session for raising VO2 max: four 4-minute hard efforts with 3 easy minutes between, on a bike, rower or treadmill.
40 minIntermediate3 movesCardio machine, A wallBalance practice in 10 minutes: tandem stance, single-leg stands, marches, heel walks, tree pose and floor transfers.
10 minBeginner7 movesA wall, A bench or boxGo to A&E or call 999 if you have AS and develop any of these. The first four are signs of cauda equina syndrome, a rare complication where the nerves at the bottom of the spine are squeezed:
See a health professional, especially if your pain is new or worse: with a fused spine, a minor injury can break a bone. Our editorial advice is to get checked the same day, and to call 999 and keep still if you have numbness, tingling or weakness in your arms or legs, or can't move normally.
NICE asks for an eye assessment the same day for symptoms of eye inflammation (uveitis), such as eye pain, redness, sensitivity to light or blurred vision. The NHS says to ask for an urgent GP appointment or contact NHS 111; untreated, it can cause the loss of some or all of your vision.
NASS's safety advice (as archived in October 2025) suggests checking first if you:
Seek medical advice if you feel faint, short of breath, dizzy or unwell, or get chest pain you're not used to, while you're exercising.
Source 12
AS back pain typically gets better with exercise and doesn't improve, or gets worse, with rest. Exercise is part of the treatment in every guideline.
NASS: "To manage your axial SpA well it's not enough to rely on medication. You also need to exercise." ASAS-EULAR says exercise has benefits independent of medicines, and most people in the trials were already taking them.
In 100 people with active axial SpA, 3 months of hard intervals and strength training reduced disease activity and inflammation. What can bring on a flare in some people is high impact, such as running, rather than hard effort itself. Build up gradually, and get advice first if your spine is fused or your bones are thin.
No trial has shown that. Spinal movement changed little in the trials, and the NHS says damage that has already happened can't be reversed, though treatment as a whole can help delay the condition's progress. Exercise is for movement, posture, pain, function and your heart.
NICE says axial SpA affects a similar number of women as men, even though more men develop the form that shows on X-rays. The exercise advice is the same for everyone.
Strengthening is part of NICE's programme, and in the Norwegian trial, supervised squats, deadlifts and presses were safe. NASS's general advice is lighter weights and more repetitions; build up with a physiotherapist's input if your spine is fused or your bones are thin.
Swimming is a good choice, but the NHS says some daily stretching and exercise is also important. NICE's programme includes stretching, strengthening, posture work, deep breathing and aerobic exercise.
A mix of daily stretching and mobility for your whole spine, posture and spinal extension work, deep breathing, strength training and aerobic exercise: the programme NICE asks specialist physiotherapists to set. Compared with no exercise, programmes like this improved function, pain and disease activity in a review of 14 trials. The best exercise is one you'll keep doing.
Some stretching and mobility work every day, at least 150 minutes a week of moderate activity such as brisk walking, cycling or swimming, and strength exercises on at least 2 days a week. Build up gradually, and exercise later in the day if your mornings are stiff.
Nothing is off-limits for everyone, but contact sports can break thin or fused bones, so discuss them with your physiotherapist first. High-impact sport such as running can bring on a flare in some people. With a fused spine or osteoporosis, swap sit-ups and loaded forward bends for back extensions and planks, and avoid activities with a high chance of falls.
Yes. In a trial of 100 people with axial SpA, supervised squats, deadlifts, presses and rows, plus hard intervals, were safe and reduced disease activity. NASS's general advice is lighter weights and more repetitions with good posture, and it's worth a physiotherapist's advice first if your spine is fused or your bones are thin.
Not for everyone. NASS says running and other high-impact sport put extra stress on the leg joints and spine and can bring on a flare in some people, so if you already run, watch your symptoms and be ready to change what you do. Get a physiotherapist's advice before you start, and consider swimming or cycling during a flare.
Yes, swimming and exercise in a warm pool suit many people, and NICE suggests considering hydrotherapy alongside exercise for pain and function. The NHS says swimming is usually fine, but some daily stretching and exercise is also important, so add your daily routine and strength work.
Yes, modestly. Compared with no exercise, programmes improved function by about 1.3 points and disease activity by about 0.9 points on 0 to 10 scales, and pain by about 2 points. Supervised group exercise did a little better than exercising alone.
No trial has shown that exercise prevents or reverses fusion, and spinal movement improved only a little in the trials. The NHS says treatment as a whole can help delay the condition's progress, and keeping active helps your posture and range of movement. Exercise also helps pain, function, fitness and your heart.
Keep moving gently: NICE's flare plan includes exercises and stretching. Keep your daily routine going at a smaller range, swap impact for swimming or cycling, and build your strength work back up over a week or two. See your specialist team if flares keep coming back or don't settle.
Inflammation where the ribs join the breastbone can make deep breaths painful and stop your chest expanding fully. NICE includes deep breathing in its exercise programme, and NASS lists lung capacity as an exercise aim. Rib-expansion breathing and arm reaches with the breath fit into a daily routine.
Yoga can fit if it combines mobility, strength and breathing, which are parts of NICE's programme, but the trials pooled many types of exercise, so there's no strong evidence for yoga in particular. With a fused spine or osteoporosis, skip poses that load the neck, such as headstands, shoulderstands and plough.
Go to A&E or call 999 (911 in the US) for numbness around your genitals or bottom, weakness or numbness in both legs, sciatica in both legs, or problems controlling your bladder or bowels. After a fall or knock, see a health professional, ideally the same day, especially if your pain is new or worse, because a fused spine can break after a minor injury. A painful red eye, sensitivity to light or blurred vision needs an eye check the same day.
Exercise education, not a diagnosis or treatment plan, and clinical review of these guides is pending. Stop and get advice for chest pain, unusual breathlessness, dizziness or fainting, or new pain, and check with your doctor or midwife first if they have told you to limit activity. Health disclaimer.
