Comparative effectiveness of exercise interventions for axial spondyloarthritis: a systematic review and network meta-analysis

Background Exercise is central to the nonpharmacological management of axial spondyloarthritis (axSpA), but the comparative effectiveness of different modalities remains uncertain.Objective To compare seven exercise modalities in adults with axSpA, generate probabilistic rankings, and assess certainty of evidence.Methods We searched PubMed, Embase, Web of Science, the Cochrane Library, CNKI, Wanfang, VIP, and CBM from inception to November 1, 2025, for randomized controlled trials of structured exercise in adults with axSpA. Interventions were classified as mobility exercise, strength exercise, aerobic exercise, Pilates, Tai Chi, Qigong, or yoga. Co-primary outcomes were the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), and Bath Ankylosing Spondylitis Metrology Index (BASMI). Secondary outcomes were visual analog scale (VAS) pain, Ankylosing Spondylitis Disease Activity Score based on C-reactive protein (ASDAS-CRP), 6-minute walk test (6MWT), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and Ankylosing Spondylitis Quality of Life (ASQoL). We performed frequentist random-effects network meta-analyses and assessed certainty using CINeMA.Results Fifty-nine randomized trials involving 3404 participants were included. Heterogeneity was moderate to high for most outcomes. Compared with usual care, Pilates showed the largest effects on BASDAI (MD -1.72, 95% CI -2.79 to -0.66), BASFI (MD -1.65, 95% CI -2.74 to -0.56), and VAS pain (MD -9.60, 95% CI -13.81 to -5.38). Yoga also reduced VAS pain (MD -3.38, 95% CI -6.13 to -0.63). Qigong was the only modality associated with significant reductions in both ESR (MD -10.71, 95% CI -14.55 to -6.87) and CRP (MD -6.99, 95% CI -10.52 to -3.46). No modality significantly improved BASMI, ASDAS-CRP, 6MWT, or ASQoL. Rankings varied by outcome, and few active modalities differed significantly. Certainty was low to moderate for most comparisons.Conclusion Exercise interventions improved disease activity, physical function, and pain compared with usual care. Pilates and Qigong showed the most favorable outcome-specific effects, but no modality was definitively superior. Exercise selection should be individualized.Registration PROSPERO (CRD420251231497). Registration was retrospective.