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IRD AS – Helps manage stiffness

Evidence summary (Updated 2022)
Stiffness frequent symptoms in people with ankylosing spondylitis. Fatigue can be particularly challenging to manage. There is a strong evidence base that physical activity and exercise interventions can help improve stiffness and subsequently some of the disease activity scores (1-5). Meta-analyses and systematic reviews consistently show a small to modest improvement in disease activity scores regardless of the physical activity prescription/specific exercise intervention (2-5). Pécourneau et al meta-analysis reported a weighted mean difference (interval) was -0.90 for the BASDAI and -0.72 for the functions score in favour of exercise programs (2).
More recent studies assessing stiffness in AxSpA in general has shown continued evidence of improvement with physical activity as seen in a recent randomised controlled trial of 100 patients by Sveaas et al (6) who assessed the benefits of regular high intensity exercise. After 3 months, the treatment group taking part in 3 x weekly intense cardiorespiratory and resistance training experienced significant improvements in joint stiffness compared to the control group. However, caution must be taken with their findings as these HIIT sessions were goal-orientated and specifically guided for patients with axSpA by specialist physiotherapists. Although this is only one study directly assessing stiffness, other studies that show improvement in BASDAI (which includes a question on morning stiffness) with physical activity as seen above can be used to further support this benefit.

Quality of evidence
Grade B – Moderate Quality evidence – 1 randomised controlled trial directly assessing stiffness, numerous other systematic reviews assessing BASDAI

Strength of recommendation
Grade 1 – Strong recommendation for AxSpA

There is a strong evidence that physical activity and exercise interventions can help improve symptoms of fatigue, pain and stiffness with improvement seen in disease activity scores. It should be recommended alongside medication. Recommending a gradual start with paced activity is a helpful way for individuals to regain control and address these symptoms.


  1. Millner JR, Barron JS, Beinke KM, et al. Exercise for ankylosing spondylitis: An evidence-based consensus statement. Semin Arthritis Rheum. 2016;45(4):411-427.
  2. Pécourneau V, Degboé Y, Barnetche T, Cantagrel A, Constantin A, Ruyssen-Witrand A. Effectiveness of Exercise Programs in Ankylosing Spondylitis: A Meta-Analysis of Randomized Controlled Trials. Arch Phys Med Rehabil. 2017.
  3. Saracoglu I, Kurt G, Okur EO, et al. The effectiveness of specific exercise types on cardiopulmonary functions in patients with ankylosing spondylitis: a systematic review. Rheumatol Int. 2017;37(3):409-421.
  4. Martins NA, Furtado GE, Campos MJ, Leitão JC, Filaire E, Ferreira JP. Exercise and ankylosing spondylitis with New York modified criteria: a systematic review of controlled trials with meta-analysis. Acta Reumatol Port. 2014;39(4):298-308.
  5. Sveaas SH, Smedslund G, Hagen KB, Dagfinrud H. Effect of cardiorespiratory and strength exercises on disease activity in patients with inflammatory rheumatic diseases: a systematic review and meta-analysis. Br J Sports Med. 2017;51(14):1065-1072.
  6. Sveaas SH, Bilberg A, Berg IJ, et al. High intensity exercise for 3 months reduces disease activity in axial spondyloarthritis (axSpA): a multicentre randomised trial of 100 patients. British Journal of Sports Medicine 2020;54:292-297.