Move or Fuse

A word before we begin

If you spend twelve hours a day hunched over a laptop and eight hours curled in a tight foetal sleep, and your immune system is laying down new bone everywhere it sees chronic inflammation, the spine that eventually fuses — if it fuses — will be hunched and curled. If you spend an hour every morning moving every joint through its full range, sit tall, sleep flat, walk daily, and treat your spine like the precious, irreplaceable thing it is, the same disease can leave you decades later still able to look up at the sky, turn your head to back the car, and stand tall.

The medication keeps the inflammation from rampaging. Your movement decides what shape the rest of your life takes.

— if you take one sentence from this, take this one

Why movement is medicine

Most people are told “exercise is good for you.” That isn't enough. In AS, exercise is doing seven distinct, mechanistically different things — and understanding each one changes how you train.

• 1 · controls inflammationIn a 2016 trial, six months of structured exercise lowered serum calprotectin and improved ASDAS-CRP in both AS and nr-axSpA — an effect comparable to a low-dose drug. Contracting muscle releases anti-inflammatory signals; your training session is, molecularly, talking down the systems attacking your spine.
• 2 · sets the fusion shapeYour spine may or may not fuse — but if any segment does, the position it fuses in is decided years in advance by what shape you spend your time in. Extension leaves you able to look ahead and breathe; flexion does not.
• 3 · protects the chest & lungsAS attacks the costovertebral and costosternal joints. Untreated, chest expansion shrinks from 5+ cm toward 1–2 cm. A year of structured Pilates improved chest expansion by ~88% in one cohort. Breathing well is a primary reason to exercise, not a side-effect.
• 4 · cuts cardiovascular riskAS carries 30–60% higher cardiovascular mortality — inflammation, NSAIDs, inactivity. Aerobic exercise mitigates every one. A 2020 RCT improved VO₂ max, BASDAI, BASMI and respiratory muscle strength in 12 weeks.
• 5 · treats fatigue & low moodAbout one in three AS patients has clinically significant depression; almost all describe disease fatigue as a major burden. Structured programs improve ASQoL by 2.5–3.5 points — a clinically meaningful difference.
• 6 · builds the muscular corsetWhen discs and ligaments are inflamed and unreliable, the deep stabilizers (multifidus, transverse abdominis, deep neck flexors) are what keep the spine functional. They atrophy within weeks of reduced activity; targeted work rebuilds them.
• 7 · gives you agencyAS brings a profound loss of control. Daily movement is the one thing the disease cannot take from you — and patients who do it consistently report better mental health than equivalent patients who don't.

The morning stiffness window

Inflammatory back pain has a signature: worse with rest, better with movement. Inflammation pools in immobile joints overnight, so you wake stiff — not because anything new is wrong, but because nothing has moved for eight hours. NSAIDs relieve it partly; movement relieves it fully. Lying in bed catastrophizing makes it worse.

The practical implication: you build your day around a non-negotiable 10–15 minute morning routine. This is the single most evidence-supported daily habit in AS. Adapt the structure below to your body and your physiotherapist's guidance.

Patients who do this daily for a year report dramatically less pain, better posture, and almost never the “where did the day go, I haven't moved” crash that catches sedentary people by 4 pm.

The seven pillars

Generic advice — “walk more, stretch a bit” — won't get you where you need to be. A proper AS program touches seven distinct domains, each with its own purpose and dose. Most patients do one or two well and ignore the rest.

Pillar 1 · Spinal mobility — every segment, every direction, every day

The spine has six movements: flexion, extension, lateral flexion left and right, and rotation left and right. AS fuses joints in whichever direction you don't take them. The rule: every segment travels through its full available range every single day.

• cat-cow ×10Flexion and extension of the whole spine, on hands and knees.
• thoracic rotations ×10Sitting cross-legged, rotate the trunk each way — frees the often-stiff mid-back.
• standing back extension ×10Hands on hips, gently arch backward. The most important movement — AS preferentially loses extension.

Pillar 2 · Postural training — where the long-term battle is fought

Your spine fuses in the shape of your habits. The postural battle is fought in the eight hours you don't think you're exercising — at the desk, in the car, on the sofa.

• wall standDaily: head, shoulders and buttocks touching the wall, heels 5–10 cm out, 30 seconds. If your head won't easily touch, that's the first thing to fight for.
• chin tucksPull the head straight back (a ‘double chin’), not down — the antidote to forward-head posture. Ten reps, several times daily.
• tragus-to-wallA standard AS metric your physio should track. Movement keeps it small; hunched sitting grows it.

Pillar 3 · Strengthening — the muscular corset

The deep, slow muscles fail first in AS. Big surface muscles aren't the priority — the posterior chain and deep stabilizers are.

Pillar 4 · Aerobic conditioning — cardiovascular protection

AS roughly doubles cardiovascular risk; consistent aerobic work is the most powerful counter. Aim for at least 150 minutes/week of moderate cardio (or 75 of vigorous), across 3–5 sessions.

• swimmingGold standard — water unloads the spine, backstroke and freestyle reinforce extension, the breathing trains the chest wall.
• walkingUniversally available, low-risk. Brisk pace, good posture, 30 minutes is the floor.
• HIIT (with a blessing)A 2018 RCT showed 12 weeks of intervals improved cardiovascular health and reduced disease activity without worsening inflammation. Do it with a physio's sign-off, not against advice.

Pillars 5–7 · Stretching, breathing, balance

• stretchingAS attacks entheses — Achilles, plantar fascia, hip flexors, pec insertions. Hold key stretches (hip flexors, hamstrings, pecs, calves, glutes) 30 seconds, breathing through, no bouncing.
• breathingThe most under-practiced category. Five minutes daily: maximal-inhale breaths, diaphragmatic breathing, lateral rib expansion with a band. Measure chest expansion monthly — loss is your earliest warning AS is winning at the chest wall.
• balanceIncreasingly important the longer you have AS. Single-leg stands, tandem walks, tai chi. A fall in a fused spine is catastrophic — the spine can't absorb impact through flexion.

Best modalities

The most rigorous comparative evidence comes from network meta-analyses that rank interventions across trials. Here's what they consistently find.

• 🥇 aquatic therapyA 2025 network meta-analysis ranked aquatic stretching highest for BASDAI, BASFI and ASQoL (SUCRA 85.5 / 99.6 / 88.4%). Buoyancy unloads the spine (you weigh ~30% of land weight at chest depth), warm water relaxes muscle, and water gives resistance without weights. The catch is access — true hydrotherapy pools are rare; NASS and SAA keep directories.
• 🥈 Pilates (mat, posture-led)Eight to twelve weeks of structured, breath-coordinated Pilates improves BASDAI, BASMI, chest expansion and quality of life. Caution: skip the high-flexion variants (rolling like a ball, deep C-curves) — an AS-literate instructor modifies these.
• 🥉 aerobic + stretching combosCombination programs beat single-modality ones: aerobic + Pilates best for BASDAI/BASMI, aerobic + stretching best for chest expansion. Don't do just one thing.
• yoga — with caveatsReal value for flexibility, balance and breath — but favor extension over flexion, avoid headstands/shoulder stands and deep folds. Iyengar and restorative styles are friendliest; tell the teacher you have AS.
• tai chi — quietly excellentTop-ranked for balance and fall prevention with negligible injury risk. If a class is accessible, it touches mobility, balance, breath and meditation at once.

A complete weekly program

A real, evidence-based weekly schedule that covers all seven pillars. Adapt it, don't worship it — and show it to your physiotherapist to customize.

Flare management

Flares are not the time to stop moving. They're the time to shift to the lowest sustainable dose of the right movements until the storm passes. The body that doesn't move during a flare emerges worse than it entered.

• don't stop entirelyEven 10 minutes of gentle mobility is medicine. The body adapts to disuse within days — a week of nothing can set you back a month.
• drop to flare-day workThe morning routine slower and gentler (in bed or the shower), pool walking, gentle stretching in a hot bath, diaphragmatic breathing, a short slow walk.
• heat, not iceAS is inflammatory at a different level than acute injury — heat helps; cold often worsens the stiffness.
• sleep over volumeDuring a flare, prioritize sleep over hitting weekly numbers. Recovery is part of the program.
• call your rheumatologistA flare that won't settle in a week or two with rest and gentle movement may mean your medical regimen needs adjusting. Don't suffer through alone.
• the 10% rule backOnce it passes, add ~10% of volume back per week — not all at once.

The other 22 hours

You can do everything right for two hours a day and undo it with the other twenty-two — especially the eight in bed. The position the spine sleeps in is the position it spends most of its life in.

Sleep · Default to flat

• on your back, thin pillowSleep ‘as flat as possible’ to encourage extension and prevent flexion contractures. One pillow under the knees can ease lumbar strain.
• avoid the foetal curlThat's the position AS wants to lock you into. Active avoidance, even at the cost of some early discomfort, pays off over years. Side-sleepers: a pillow between the knees.
• firm mattressMemory foam that creates a ‘valley’ lets the spine sag into bad positions.

Desk, car, lifting · Engineer the day

• Monitor at eye level; keyboard at elbow height; lumbar support behind the lower back
• Sit-stand desk if possible — alternate every 30–60 minutes
• Every 25 minutes: stand, five chin tucks, a minute's walk (set a timer)
• Driving: lumbar roll, upright seat, mirrors set so a slouch hides them
• On flights: aisle seat, walk hourly, seated thoracic rotations
• Lift from hips and knees, never the lumbar spine; carry loads close

Mistakes that make AS worse

The patient who exercises with bad mechanics is sometimes worse off than the one who doesn't exercise at all. The most common mistakes:

• generic gym coreSit-ups, crunches, flexion ‘ab work’ reinforce the position the disease wants. Replace with anti-flexion work — dead bugs, bird-dogs, planks, pallof presses.
• racing-posture cyclingThe forward-leaning road-bike position is literally the shape AS wants to fuse you into. Switch to an upright/hybrid or recumbent bike.
• stopping during flaresModify, don't quit. Disuse undoes you fast.
• pushing through sharp painInflammatory ache is different from injury pain. New sharp pain = stop, reassess, possibly see your physio.
• only what feels goodMost people do their favorite one or two pillars and skip the rest — a great walker with a stiff back, a strong lifter with a frozen chest. Touch all seven.
• no warm-upCold AS tissue tears more easily than cold healthy tissue. Always start with 3–5 minutes of light movement.
• comparing to a ‘normal’ bodyYour full range may be smaller. Your range is what you train — maintaining your own ceiling matters far more than reaching someone else's.

Finding the right physio

A great AS physio changes everything. A generic one who treats your back like a normal back can actively harm you. The difference matters.

The future & special cases

The next decade · Wearables, tele-rehab, AI

• wearable-assisted programsA 2022 RCT delivered a home program by smartwatch + app; the intervention group beat controls on ASDAS, BASDAI, BASFI, BASMI, chest expansion and VO₂ max — at 84% adherence.
• tele-rehabilitationSince 2020, video-supervised PT has been validated as roughly equivalent to in-person care for many patients, vastly improving access.
• AI-personalized prescriptionEarly systems adjust your program from BASDAI, wearable data and symptoms — easing back at flare risk, pushing when recovery markers are good.
• VR-guided home rehabGamified, motion-tracked sessions that correct form. Adherence is the biggest determinant of long-term outcomes — whatever keeps you doing the work is worth its weight.

Life phases · When the picture changes

• pregnancyKeep moving throughout — swimming and prenatal yoga are excellent; avoid supine after the second trimester. Rebuild gradually postpartum, prioritizing pelvic floor and deep core.
• advanced fusionPrinciples unchanged, execution adapts: hydrotherapy and balance work become central; chair- and bed-based versions keep the morning routine alive. An AS-specialist physio is essential.
• active uveitisAvoid head-down positions — no inversions, downward dogs or aggressive forward folds — until the eye settles.
• older patients (60+)Bone health becomes a parallel priority — osteoporosis is common in long-standing AS. Add weight-bearing work for bone, prioritize fall prevention, ensure vitamin D and calcium.

The mini-directory

Working starting points — organizations, evidence, and the small kit that replaces most of a gym. Treat forums as hypotheses to test with your physio; treat the trials and society resources as ground truth.

Now go move

I'll close with the sentence I started with, because if any line here is worth carrying forward in your life with AS, it's this one: your body fuses in the position you let it rest in.

The drugs of the last twenty years have changed what fusion you'll experience — for many, they prevent most of it. But the shape of the body you'll have in your sixties and seventies — the chest you'll breathe with, the neck you'll use to look up at your grandchildren, the spine you'll walk with — is not decided by the drugs. It's decided by what you do, this morning, and tomorrow morning, and the morning after that.

Ten minutes when you wake. Thirty minutes most days. One pool session a week if you can. The seven pillars touched across the week. The choice, every single day, to move into the position you want to live in.

— small, daily, unglamorous, lifelong, and quietly heroic

References

1. Sveaas SH, et al. — Exercise reduces serum calprotectin and improves ASDAS in axial SpA. PMC5124318. (2016)
2. Sveaas SH, et al. — High-intensity interval training in spondyloarthritis — safety & efficacy. PubMed 30356536. (2018)
3. Network meta-analysis of exercise modalities in AS. — Aquatic stretching ranked highest (SUCRA). PMC12662062. (2025)
4. Dose-response meta-analysis of exercise in AS. — Combination programs superior. PMC12864062. (2025)
5. Wang Y, et al. — Wearable-assisted home exercise RCT in AS — 84% adherence. PMC8808346. (2022)
6. Sezici E, et al. — Aerobic exercise improves VO₂ max, BASDAI, BASMI in AS. PubMed 32202181. (2020)
7. Cochrane Collaboration. — Physiotherapy interventions for ankylosing spondylitis — foundational review. (2008)