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Axial spondyloarthritis — SCE Rheumatology MCQ

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ModerateNonpharmacological TherapyAxial spondyloarthritisSCE Rheumatology

A 42-year-old man with radiographic axial spondyloarthritis has received adalimumab for 10 months. His inflammatory spinal pain and morning stiffness have improved substantially, his ASDAS-CRP is 1.5, and there is no peripheral synovitis or enthesitis. However, he remains physically deconditioned, with restricted cervical rotation, a chest expansion of 2.5 cm and a BASMI of 5.2. He has no focal neurological symptoms or recent trauma. He has never seen a specialist physiotherapist and currently swims occasionally. He asks whether exercising in a warm-water pool could replace other forms of exercise. Which is the single most appropriate nonpharmacological management plan?

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Reveal the answer and explanation

Correct answer: D — Refer to a specialist physiotherapist for an individualised structured multicomponent exercise programme, using hydrotherapy as an adjunct if helpful

Explanation lettering: B = shown as A · C = shown as B · A = shown as C · E = shown as D · D = shown as E

Despite good pharmacological control of inflammatory disease, this patient has clinically important impairment in spinal mobility, chest expansion and physical conditioning. NICE recommends referral of adults with axial spondyloarthritis to a specialist physiotherapist for an individualised structured programme incorporating stretching, strengthening, postural and spinal-extension exercises, deep breathing, movement of the lumbar, thoracic and cervical spine, and aerobic exercise. Hydrotherapy may be considered for pain and function, but as an adjunct rather than a replacement for this programme. A is therefore incorrect because hydrotherapy should not become the sole or principal exercise strategy. B includes useful aerobic activity, but generic self-directed exercise does not provide the initial specialist assessment or the required multicomponent prescription. C overemphasises passive treatment and incorrectly restricts aerobic exercise; radiographic disease is not itself a contraindication to appropriately tailored aerobic activity. D would be appropriate if difficulties with work or everyday activities required aids, adaptations or task modification, but it does not address his principal deficits in spinal mobility and cardiorespiratory conditioning. E provides the recommended sequence: specialist assessment, an individualised structured programme and optional adjunctive hydrotherapy.

Reference: Spondyloarthritis in over 16s: diagnosis and management — Recommendations (Published 28 February 2017; last reviewed 4 March 2025) — https://www.nice.org.uk/guidance/ng65/chapter/Recommendations Spondyloarthritis quality standard QS170 — Quality statement 3: Physiotherapy (28 June 2018) — https://www.nice.org.uk/guidance/qs170/chapter/quality-statement-3-physiotherapy