Ankylosing Spondylitis.
What is ankylosing spondylitis?
Ankylosing spondylitis (AS) — now classified under the broader umbrella of axial spondyloarthritis (axSpA) — is a chronic inflammatory condition primarily affecting the sacroiliac joints and spine. It is characterised by inflammation at the entheses (the points where tendons and ligaments attach to bone) and within the joints of the axial skeleton, producing pain, stiffness and, over time in severe or poorly managed cases, new bone formation that can lead to fusion of spinal segments.
AS is caused by inflammation of the spinal joints leading to stiffness and reduced spinal movement. Immune cells positive for human leukocyte antigen B27 (HLA-B27) are thought to be involved in the pathophysiology. Approximately 90% of people with AS carry the HLA-B27 gene, though the majority of HLA-B27 positive individuals do not develop the condition. AS predominantly affects young adults, typically presenting between the ages of 15 and 45, and was historically thought to be more common in men — though it is now recognised that women develop axSpA at similar rates but with different clinical features that were frequently missed under older diagnostic criteria.
For a broader overview of the spondyloarthropathy family of conditions including psoriatic arthritis, reactive arthritis and enteropathic arthritis, see our spondyloarthropathies page.
What are the symptoms?
The hallmark symptoms are chronic lower back and buttock pain — often bilateral — and morning stiffness lasting more than 45 minutes that characteristically improves with activity and worsens with rest. This inflammatory pattern — pain that is worse with inactivity and better with movement — is the most important distinguishing feature from mechanical lower back pain, where the opposite pattern is typical.
Sacroiliac joint pain is typically one of the earliest manifestations, often preceding the development of visible spinal changes by years. Progressive spinal stiffness — particularly affecting thoracic extension and rotation — develops as the condition advances. Peripheral joint involvement (hips, knees, shoulders, heels) occurs in approximately a third of patients. Anterior uveitis (eye inflammation) affects up to 40% of AS patients and requires urgent ophthalmological assessment when it occurs. Fatigue is a frequent and often underappreciated feature.
In more advanced or untreated disease, ossification of the spinal ligaments and disc spaces produces the characteristic "bamboo spine" on X-ray and can significantly restrict spinal mobility and respiratory capacity.
How is it diagnosed?
The modified New York criteria require radiographic sacroiliitis on X-ray plus at least one clinical feature (inflammatory back pain, limited spinal mobility, or limited chest expansion). However, X-ray changes typically lag behind the onset of inflammation by years — sometimes a decade or more — which is why many patients with active disease are not captured by these criteria.
The ASAS criteria for axial spondyloarthritis incorporate MRI evidence of active sacroiliac inflammation (bone marrow oedema on STIR sequences) as an alternative to X-ray findings, allowing earlier diagnosis. Referral to a rheumatologist is essential for definitive diagnosis, appropriate medical management, and access to biologic therapies (TNF inhibitors and IL-17 inhibitors) for patients with active disease not adequately controlled by conventional anti-inflammatory treatment.
Arthritis Australia provides comprehensive patient information on ankylosing spondylitis and related conditions.
Why is physiotherapy essential for ankylosing spondylitis?
Physiotherapy exercises on pain, range of motion, and quality of life in AS patients show meaningful improvements through structured rehabilitation programs. Exercise is not merely adjunctive to medical management in AS — it is one of the most evidence-based treatments available, recommended as a core component of management by major international guidelines alongside anti-inflammatory medication and biological therapies.
The fundamental principle underlying AS physiotherapy is that movement is medicine. Unlike mechanical back pain where temporary rest can be appropriate, AS consistently worsens with inactivity and improves with movement. Regular, structured exercise maintains the spinal mobility that the inflammatory process would otherwise progressively restrict. Patients who exercise consistently maintain better function, less pain and slower structural progression than those who do not — and this benefit occurs regardless of whether they are on biological therapies.
How can physiotherapy help?
Spinal mobility exercises — specifically targeting extension, lateral flexion and rotation in both the thoracic and lumbar spine — are the most important exercise type for AS. These movements are precisely what the inflammatory stiffening process restricts, and regular practice literally maintains the range of motion that would otherwise be lost. Extension work is particularly critical: the characteristic kyphotic deformity of advanced AS develops because gravity pulls the stiffening spine into flexion, and sustained extension exercise directly counteracts this tendency.
Thoracic cage mobility and chest expansion work address the rib cage involvement that can reduce respiratory capacity in AS. Breathing exercises that combine thoracic extension with inhalation are valuable both for chest expansion and for spinal mobilisation.
Physiotherapy for AS incorporates joint mobility exercises designed to maintain or increase range of motion in affected joints, strengthening exercises to reinforce muscles supporting the spine and other affected joints, and posture training to promote optimal spinal alignment and reduce discomfort.
Hip mobility and strengthening is important given the frequency of hip involvement in AS and the critical role of hip function in maintaining upright posture and gait mechanics as spinal stiffness increases. Manual therapy — gentle spinal mobilisation, posterior chest wall mobilisation — reduces pain and maintains joint mobility, though the approach differs from mechanical back pain: sustained low-load mobilisation rather than high-velocity manipulation is appropriate given the inflammatory and potentially structural nature of the joint changes.
Pain management using manual therapy, hot and cold applications, and dry needling assists with symptom control alongside the exercise program.
Clinical Pilates provides an excellent structured environment for the spinal mobility and stabilising work central to AS management. The emphasis on thoracic extension, body awareness and breathing integration makes it particularly well aligned with AS rehabilitation goals.
Real time ultrasound guides deep stabiliser retraining where inflammatory pain has disrupted normal spinal muscle activation.
Exercise physiology contributes to cardiovascular fitness and overall physical capacity — both significantly impaired in many AS patients and independently associated with quality of life and disease outcomes. Eligible patients may access exercise physiology through a Chronic Disease Management Plan with a GP referral.
Our physiotherapist Yulia Khasyanova and Exercise Physiologist Ash O'Regan both have experience in inflammatory spinal conditions and are members of the Australian Physiotherapy Association.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
Book your initial physiotherapy appointment
Ankylosing spondylitis (AS) — now classified under the broader umbrella of axial spondyloarthritis (axSpA) — is a chronic inflammatory condition primarily affecting the sacroiliac joints and spine. It is characterised by inflammation at the entheses (the points where tendons and ligaments attach to bone) and within the joints of the axial skeleton, producing pain, stiffness and, over time in severe or poorly managed cases, new bone formation that can lead to fusion of spinal segments.
AS is caused by inflammation of the spinal joints leading to stiffness and reduced spinal movement. Immune cells positive for human leukocyte antigen B27 (HLA-B27) are thought to be involved in the pathophysiology. Approximately 90% of people with AS carry the HLA-B27 gene, though the majority of HLA-B27 positive individuals do not develop the condition. AS predominantly affects young adults, typically presenting between the ages of 15 and 45, and was historically thought to be more common in men — though it is now recognised that women develop axSpA at similar rates but with different clinical features that were frequently missed under older diagnostic criteria.
For a broader overview of the spondyloarthropathy family of conditions including psoriatic arthritis, reactive arthritis and enteropathic arthritis, see our spondyloarthropathies page.
What are the symptoms?
The hallmark symptoms are chronic lower back and buttock pain — often bilateral — and morning stiffness lasting more than 45 minutes that characteristically improves with activity and worsens with rest. This inflammatory pattern — pain that is worse with inactivity and better with movement — is the most important distinguishing feature from mechanical lower back pain, where the opposite pattern is typical.
Sacroiliac joint pain is typically one of the earliest manifestations, often preceding the development of visible spinal changes by years. Progressive spinal stiffness — particularly affecting thoracic extension and rotation — develops as the condition advances. Peripheral joint involvement (hips, knees, shoulders, heels) occurs in approximately a third of patients. Anterior uveitis (eye inflammation) affects up to 40% of AS patients and requires urgent ophthalmological assessment when it occurs. Fatigue is a frequent and often underappreciated feature.
In more advanced or untreated disease, ossification of the spinal ligaments and disc spaces produces the characteristic "bamboo spine" on X-ray and can significantly restrict spinal mobility and respiratory capacity.
How is it diagnosed?
The modified New York criteria require radiographic sacroiliitis on X-ray plus at least one clinical feature (inflammatory back pain, limited spinal mobility, or limited chest expansion). However, X-ray changes typically lag behind the onset of inflammation by years — sometimes a decade or more — which is why many patients with active disease are not captured by these criteria.
The ASAS criteria for axial spondyloarthritis incorporate MRI evidence of active sacroiliac inflammation (bone marrow oedema on STIR sequences) as an alternative to X-ray findings, allowing earlier diagnosis. Referral to a rheumatologist is essential for definitive diagnosis, appropriate medical management, and access to biologic therapies (TNF inhibitors and IL-17 inhibitors) for patients with active disease not adequately controlled by conventional anti-inflammatory treatment.
Arthritis Australia provides comprehensive patient information on ankylosing spondylitis and related conditions.
Why is physiotherapy essential for ankylosing spondylitis?
Physiotherapy exercises on pain, range of motion, and quality of life in AS patients show meaningful improvements through structured rehabilitation programs. Exercise is not merely adjunctive to medical management in AS — it is one of the most evidence-based treatments available, recommended as a core component of management by major international guidelines alongside anti-inflammatory medication and biological therapies.
The fundamental principle underlying AS physiotherapy is that movement is medicine. Unlike mechanical back pain where temporary rest can be appropriate, AS consistently worsens with inactivity and improves with movement. Regular, structured exercise maintains the spinal mobility that the inflammatory process would otherwise progressively restrict. Patients who exercise consistently maintain better function, less pain and slower structural progression than those who do not — and this benefit occurs regardless of whether they are on biological therapies.
How can physiotherapy help?
Spinal mobility exercises — specifically targeting extension, lateral flexion and rotation in both the thoracic and lumbar spine — are the most important exercise type for AS. These movements are precisely what the inflammatory stiffening process restricts, and regular practice literally maintains the range of motion that would otherwise be lost. Extension work is particularly critical: the characteristic kyphotic deformity of advanced AS develops because gravity pulls the stiffening spine into flexion, and sustained extension exercise directly counteracts this tendency.
Thoracic cage mobility and chest expansion work address the rib cage involvement that can reduce respiratory capacity in AS. Breathing exercises that combine thoracic extension with inhalation are valuable both for chest expansion and for spinal mobilisation.
Physiotherapy for AS incorporates joint mobility exercises designed to maintain or increase range of motion in affected joints, strengthening exercises to reinforce muscles supporting the spine and other affected joints, and posture training to promote optimal spinal alignment and reduce discomfort.
Hip mobility and strengthening is important given the frequency of hip involvement in AS and the critical role of hip function in maintaining upright posture and gait mechanics as spinal stiffness increases. Manual therapy — gentle spinal mobilisation, posterior chest wall mobilisation — reduces pain and maintains joint mobility, though the approach differs from mechanical back pain: sustained low-load mobilisation rather than high-velocity manipulation is appropriate given the inflammatory and potentially structural nature of the joint changes.
Pain management using manual therapy, hot and cold applications, and dry needling assists with symptom control alongside the exercise program.
Clinical Pilates provides an excellent structured environment for the spinal mobility and stabilising work central to AS management. The emphasis on thoracic extension, body awareness and breathing integration makes it particularly well aligned with AS rehabilitation goals.
Real time ultrasound guides deep stabiliser retraining where inflammatory pain has disrupted normal spinal muscle activation.
Exercise physiology contributes to cardiovascular fitness and overall physical capacity — both significantly impaired in many AS patients and independently associated with quality of life and disease outcomes. Eligible patients may access exercise physiology through a Chronic Disease Management Plan with a GP referral.
Our physiotherapist Yulia Khasyanova and Exercise Physiologist Ash O'Regan both have experience in inflammatory spinal conditions and are members of the Australian Physiotherapy Association.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
Book your initial physiotherapy appointment
