Spondyloarthropathy physiotherapy — where the evidence sits in 2026
An updated clinical commentary on spondyloarthropathy: axial and peripheral presentations, and exercise as a primary intervention alongside medical management.
Spondyloarthropathy (SpA) sits at an interesting intersection for physiotherapy: it's a condition where medical management — particularly with biologics — has advanced significantly, yet exercise and physiotherapy remain a cornerstone of care rather than an afterthought. This commentary outlines where the evidence sits and how physiotherapy integrates with medical management.
A spectrum, not a single condition
SpA encompasses a group of related conditions — axial spondyloarthritis (including ankylosing spondylitis) and peripheral presentations, with overlap into psoriatic and enteropathic forms. The presentations differ, and so does the physiotherapy emphasis, but the unifying theme is inflammatory involvement that responds to both medical and movement-based intervention.
Exercise as a primary intervention
For axial SpA in particular, exercise is not adjunctive — it's a core, guideline-endorsed component of management. [VERIFY against current ASAS/EULAR recommendations.] The emphasis falls on:
- Mobility and spinal range — countering the tendency toward reduced flexibility
- Postural and extensor work — addressing the characteristic flexion posture risk
- Cardiorespiratory fitness — relevant to both function and chest expansion
- Strength — supporting function and general health
Working alongside medical management
The advent of effective biologic therapy hasn't reduced the role of physiotherapy — if anything, it's enhanced it. Better inflammatory control often means patients can engage more fully and progress further with exercise. The two work synergistically.
Physiotherapy complements — it doesn't replace — disease-modifying medical management. Patients should always continue prescribed treatment as directed by their rheumatologist. Our role is function, mobility, and quality of life alongside that.
Peripheral and enthesitis considerations
Peripheral SpA and enthesitis bring their own considerations — load management around affected entheses, monitoring of symptom response, and careful graduation of activity. The principles of inflammatory load management apply: modify rather than cease, and progress as symptoms allow.
Practical referral notes
- Early physiotherapy involvement supports long-term function — ideally not delayed until significant restriction develops.
- Co-management communication is valuable; brief updates between physiotherapy and rheumatology help align approaches, particularly around flares and medication changes.
- Long-term, not episodic. SpA management benefits from an ongoing relationship and a self-management framework rather than discrete treatment blocks.
Summary
In 2026, the picture for SpA is one of integration: advanced medical management and structured exercise working together. Physiotherapy's role remains central, and early, coordinated involvement gives patients the best functional outcomes. [VERIFY] Specific protocol details should be confirmed against current ASAS/EULAR recommendations and tailored to the individual presentation.
I'm always glad to correspond with colleagues on complex SpA presentations — contact details below.
References
- 1. Ramiro S, Nikiphorou E, Sepriano A, et al. ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update. Annals of the Rheumatic Diseases. 2023;82:19–34. [Link]
This article is a clinical draft. All [VERIFY] flags must be confirmed by Emil Terbio before publication. References are provided for context only and do not constitute endorsement of any specific study or guideline.