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Axial spondyloarthritis — SCE Rheumatology MCQ

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ModerateExerciseAxial spondyloarthritisSCE Rheumatology

A 44-year-old man with radiographic axial spondyloarthritis has received secukinumab for 6 months. His inflammatory symptoms have improved substantially: he has no nocturnal pain or peripheral synovitis, CRP is 2 mg/L and ASDAS-CRP is 1.6. He nevertheless has persistent restriction of cervical rotation, lumbar flexion and chest expansion, which interferes with driving and desk work. He has never been assessed by a specialist physiotherapist. He swims intermittently and requests hydrotherapy instead of land-based exercise because warm water temporarily relieves his stiffness. There is no recent trauma, focal vertebral tenderness, neurological deficit or severe progressive spinal deformity. Which exercise-management recommendation is most appropriate?

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Correct answer: E — Start specialist physiotherapist-led multimodal exercise, using hydrotherapy as an adjunct if helpful

The persistent limitation is predominantly functional despite good inflammatory control, so changing biologic therapy is not indicated. He should be referred to a physiotherapist with relevant specialist experience for an individualised, structured exercise programme. NICE specifies that this should incorporate stretching, strengthening and postural work, deep breathing, spinal extension, range-of-motion exercises across the cervical, thoracic and lumbar spine, and aerobic exercise. Hydrotherapy may be considered, but as an adjunct rather than a replacement for this programme. A is plausible because swimming provides aerobic activity and may improve symptoms, but self-directed swimming alone does not deliver the required comprehensive, individually adapted programme. B reverses the recommended sequence: hydrotherapy can support pain control and function but should not replace structured land-based exercise. C overemphasises passive treatment; active exercise is the core intervention and should not be deferred until mobility has improved. D includes two important exercise domains but omits posture, spinal extension, whole-spine range of motion and deep-breathing work, which are particularly relevant given his restricted spinal and chest mobility. E therefore provides the appropriate disease-specific intervention while accommodating his preference for warm-water exercise.

Reference: Spondyloarthritis in over 16s: diagnosis and management — Recommendations (Published 28 February 2017; checked 19 August 2026) — https://www.nice.org.uk/guidance/NG65/chapter/Recommendations Spondyloarthritis: Quality statement 3 — Physiotherapy (28 June 2018) — https://www.nice.org.uk/guidance/qs170/chapter/quality-statement-3-physiotherapy EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis: 2025 update (26 April 2026) — https://pubmed.ncbi.nlm.nih.gov/42036268/