To move or not to move: The paradoxical effect of physical exercise in axial spondyloarthritis

In the last years, new researches focused on the role of biomechanical stress and microdamage in the pathogenesis of inflammatory arthritis and, in particular, in axial spondyloarthritis (axSpA). Animal models showed how entheseal stress and physical exercise could contribute to the development of inflammation and new bone formation at entheseal and articular sites, by activating innate immune system and the release of cytokines. Furthermore, clues of the involvement of biomechanical stress in the development of axSpA are present in clinical experiences. However, rehabilitation and exercise programmes are the cornerstone of treatment for axSpA, reducing disease activity and improving spinal function and quality of life. The concept of mechanical stress as a contributor to disease development and progression represents, potentially, a conceptual challenge for this approach. The aim of this review is to discuss the current evidence on the intriguing contribution of the biomechanical stress to the pathogenesis of inflammation and new bone formation and to evaluate and reflect on the role of exercise in the treatment and in the management of the disease, considering both the beneficial effects and its possible paradoxical action.