Living Well With DISH

How Manual Therapy, Exercise, and Breathing Can Improve Comfort, Function, and Quality of Life

Diffuse Idiopathic Skeletal Hyperostosis, commonly known as DISH, is often described in purely structural terms, extra bone formation along ligaments and tendons, especially in the spine.

While this definition is accurate, it tells only part of the story. Population studies suggest that approximately 10 to 12 percent of adults overall may have DISH, and prevalence increases significantly with age, with some estimates reaching 15 to 25 percent in adults over 50. Based on Calgary’s population of about 1.3 million people, this suggests that roughly 130,000 to 155,000 local residents may be living with DISH, many of them undiagnosed.

For many individuals, receiving a diagnosis of DISH can feel discouraging. Some are told that “nothing can be done” beyond medication or learning to live with stiffness. Yet, in clinical practice, this is not the whole truth.

Although the bony changes of DISH cannot be reversed, many of the symptoms that interfere with daily life are modifiable. With the right combination of manual therapy, targeted exercise, breathing training, and functional movement, many people experience meaningful improvements in pain, mobility, sleep, and overall quality of life.

This article explores how an integrated, evidence-informed approach can help individuals with DISH move more comfortably and maintain independence.

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Understanding DISH in Plain Language

DISH is a condition in which ligaments and connective tissues gradually calcify, most commonly along the front and side of the spine. Over time, this can lead to partial or complete fusion of spinal segments. It is most frequently seen in adults over 50 and is often associated with metabolic factors such as diabetes and obesity.

Common symptoms include:

• Spinal stiffness, especially in the morning

• Reduced range of motion

• Neck, mid-back, or low-back discomfort

• Shoulder or hip tightness

• Reduced chest expansion

• Fatigue and poor sleep

• Occasionally, difficulty swallowing when the cervical spine is involved

Importantly, many people with DISH have significant imaging findings but relatively mild symptoms, while others experience substantial discomfort. This variability highlights the importance of individualized care.

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Why Pain and Stiffness Occur in DISH

Although DISH involves bone formation, most daily discomfort does not come directly from the bone itself. It comes from how the rest of the body adapts to stiffness.

When segments of the spine become rigid, surrounding structures must compensate.

This often leads to:

• Chronic muscle guarding

• Fascial thickening and restriction

• Overload of joints above and below stiff segments

• Reduced rib and thoracic mobility

• Altered posture

• Shallow breathing patterns

• Increased nervous system sensitivity

A helpful analogy is that of a bridge. When one section becomes rigid, surrounding sections absorb more stress. Over time, they fatigue and become irritated.

The good news is that these secondary changes are responsive to conservative care.

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Manual Therapy: Restoring Balance Around Stiff Segments. What Manual Therapy Can and Cannot Do

Manual therapy does not remove calcification. It does not “cure” DISH.

What it can do is improve how the body functions around the affected areas.

Appropriately applied manual techniques aim to:

• Reduce protective muscle tension

• Improve fascial mobility

• Restore rib cage mechanics

• Improve mobility in adjacent joints

• Reduce mechanical strain

• Improve proprioception and movement confidence

In clinical terms, hands-on care in DISH is best directed toward load redistribution, neuromuscular downregulation, and restoration of regional interdependence.

Safety Considerations

Because DISH can increase fracture risk in advanced cases, particularly in ankylosed spines, aggressive high-velocity manipulation is generally not appropriate. Care should be conservative, individualized, and focused on surrounding tissues and regions.

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Exercise: The Foundation of Long-Term Improvement

Exercise is the most consistently supported conservative intervention for individuals with DISH. Research shows that structured, long-term mobility and strengthening programs can lead to measurable improvements in function and symptoms when performed consistently.

In DISH, exercise is not about pushing through stiffness. It is about teaching the nervous system and connective tissues to move safely again.

The Four Pillars of Exercise in DISH

1. Gentle Mobility

Purpose: Maintain available range and prevent further restriction

The goal of mobility work in DISH is to keep joints and soft tissues moving within a comfortable range, not to force flexibility.

Helpful examples:

• Cat–Camel (small range) On hands and knees or seated, gently round and arch the spine within a pain-free range.6–10 slow repetitions.

• Seated Thoracic Rotation Sit upright, cross arms over chest, and gently rotate side to side. Keep the movement slow and controlled.

• Open Book Stretch (Side-Lying Rotation) Lying on your side with knees bent, rotate the upper arm and chest open toward the ceiling. Hold briefly, then return.

• Rib Expansion Breathing Place hands on lower ribs. Inhale slowly through the nose, feeling the ribs expand sideways, then exhale fully.5–8 slow breaths.

• Neck Range of Motion (Comfort Range Only) Gentle nodding, turning, and side bending without forcing end range.

These movements should feel “loosening,” not painful. Mild stiffness is acceptable, sharp pain is not.

2. Postural and Strength Training

Purpose: Reduce overload on stiff segments

Strength training helps surrounding muscles share the workload so stiff areas are not overstressed.

Key exercises:

Scapular and Upper Back Support

• Band Rows Pull resistance band toward chest while squeezing shoulder blades.2 sets of 10–15 reps.

• Wall Angels Back against wall, arms in “goalpost” position, slowly slide arms up and down. Focus on posture.

• Prone “Y” and “T” Raises (Light Resistance) Strengthens upper back stabilizers.

Deep Neck Support

• Chin Tucks (Supine or Standing) Gently draw chin backward without tilting head. Hold 5 seconds, repeat 8–10 times.

Core Stability

• Modified Plank (Wall or Knees) Maintain neutral posture while breathing normally.

• Dead Bug (Modified) Lying on back, slowly move opposite arm and leg while keeping trunk stable.

Hip and Glute Strength

• Glute Bridges Lift hips while squeezing glutes.

• Sit-to-Stand Repetitions From chair, stand up and sit down with control.

• Side-Lying Leg Raises Strengthens hip stabilizers.

Strong hips and trunk reduce mechanical stress on the spine.

3. Aerobic Conditioning

Purpose: Improve circulation, pain control, and energy levels

Low-impact aerobic activity supports joint nutrition, nervous system regulation, and overall health.

Recommended options:

• Walking Start with 10–15 minutes, progress toward 30–40 minutes most days.

• Stationary or Outdoor Cycling Upright posture preferred if tolerated.

• Swimming or Aqua Jogging Excellent for those with joint sensitivity.

• Water Walking or Pool Exercises Reduces spinal loading while improving fitness.

General target: Aim for moderate intensity, you should be able to talk but not sing during activity.

4. Functional Movement Training

Purpose: Transfer gains into daily life

These exercises help turn therapy into practical independence.

Useful drills:

Sit-to-Stand Practice

• Stand from chair without using hands when possible.

• Keep chest upright and knees aligned.

• 2 sets of 6–12 repetitions.

Lifting Mechanics

• Practice hip hinge with light object.

• Keep load close to body.

• Avoid twisting while lifting.

Carrying Exercises

• Carry light weights or groceries evenly in both hands.

• Maintain upright posture.

• Walk 30–60 seconds.

Postural Endurance

• Wall-supported standing posture drills

• Seated posture holds with breathing

• Breaks every 30–45 minutes

These reinforce safe movement patterns during real-life activities.

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Programming Principles

For best results, exercise programs for DISH should follow these guidelines:

• Prioritize consistency over intensity Daily moderate movement beats occasional hard sessions.

• Progress slowly Increase volume or difficulty every 2–4 weeks, not every few days.

• Respect fatigue signals Persistent pain, worsening stiffness, or poor sleep signal the need to scale back.

• Think in months, not weeks Meaningful adaptation occurs over time.

• Reassess regularly Programs should evolve as strength and tolerance improve.

Small, steady inputs practiced consistently accumulate into meaningful long-term change.

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Breathing: A Critical and Often Overlooked Component

Thoracic stiffness in DISH frequently limits rib expansion, leading to shallow, inefficient breathing patterns. Over time, this alters nervous system regulation and contributes to ongoing symptoms.

Restricted breathing is associated with:

• Increased sympathetic nervous system activity

• Elevated stress hormone levels

• Poor sleep quality

• Increased pain sensitivity

• Reduced exercise tolerance

• Greater fatigue

When breathing becomes shallow and rapid, the body remains in a low-grade “fight or flight” state. This makes pain harder to control and recovery more difficult.

Breathing retraining helps restore efficient mechanics and supports autonomic balance.

Core Breathing Recommendations for DISH

1. Slow Paced Nasal Breathing (Foundational Practice)

This is the primary breathing exercise I recommend for most individuals with DISH.

How to practice:

• Inhale slowly through the nose for 4–5 seconds

• Exhale slowly through the nose or gently through the mouth for 6–7 seconds

• No breath holding

• Breathing remains quiet and relaxed

This produces approximately 5–6 breaths per minute, which has been shown to optimize heart rate variability and vagal tone.

Dosage:

• 5–10 minutes

• Once or twice daily

• Ideally morning and evening

Benefits:

• Improves parasympathetic activity

• Reduces muscle tension

• Lowers pain sensitivity

• Improves sleep onset

• Enhances recovery

2. Rib Expansion Breathing (Thoracic Mobility + Respiration)

This addresses both breathing mechanics and rib stiffness.

How to practice:

• Place hands on the lower ribs

• Inhale through the nose, directing air into the sides and back of the rib cage

• Feel ribs expand laterally

• Exhale slowly and fully

• Maintain relaxed shoulders

Dosage:

• 6–10 slow breaths

• 1–2 times daily

• Can be combined with gentle mobility work

Benefits:

• Improves rib cage mobility

• Enhances lung expansion

• Reduces thoracic rigidity

• Supports posture

3. Resonance Breathing (Pain and Stress Regulation)

This technique is particularly useful for individuals with chronic pain and sleep disturbance.

How to practice:

• Inhale for 5 seconds

• Exhale for 5 seconds

• Total cycle = 10 seconds

• Equals 6 breaths per minute

This rhythm synchronizes cardiovascular and respiratory systems.

Dosage:

• 5 minutes initially

• Progress to 10–15 minutes

• Especially useful before sleep

Benefits:

• Improves heart rate variability

• Reduces stress reactivity

• Enhances pain modulation

• Improves sleep quality

4. Breathing During Movement

Breathing should be integrated into exercise and daily activity.

General guideline:

• Exhale during effort

• Inhale during return

• Avoid breath-holding

Examples:

• Exhale when standing from a chair

• Exhale during lifting

• Exhale during resistance exercises

This prevents unnecessary spinal bracing and reduces fatigue.

Weekly Breathing Structure (Practical Template)

For most individuals with DISH:

Daily

• 5–10 minutes slow paced breathing (5–6 breaths/min)

• 6–10 rib expansion breaths

Evening (3–5x/week)

• 10 minutes resonance breathing

During Exercise

• Conscious relaxed breathing

This requires minimal time but produces cumulative benefits.

Why Breathing Matters in Pain and Recovery

Slow, controlled breathing influences pain through multiple mechanisms:

• Activates vagal pathways

• Reduces central sensitization

• Improves oxygen delivery

• Modulates inflammatory signaling

• Enhances emotional regulation

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The Integrated Care Model

In clinical experience, the most reliable improvements occur when care is integrated rather than fragmented.

An effective DISH program typically includes:

1. Manual therapy to improve tissue mobility

2. Targeted exercise to maintain gains

3. Breathing training to regulate the nervous system

4. Functional movement training

5. Ongoing education and reassurance

None of these elements works optimally in isolation. Together, they reinforce each other.

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Realistic Outcomes and Expectations

Every individual with DISH is different. Disease severity, general health, lifestyle, and consistency all influence outcomes.

That said, many individuals who commit to a structured, long-term program experience:

• Reduced pain

• Improved sleep

• Increased daily activity

• Reduced stress

• Greater confidence in movement

• Improved quality of life

No practitioner can guarantee results. However, combining manual therapy, exercise, and breathing strategies offers people the best opportunity to move more comfortably and remain active.

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Guidance for Practitioners

Clinicians working with DISH should consider the following principles:

• Avoid forcing motion through ankylosed segments

• Prioritize adjacent regions

• Emphasize neuromuscular control

• Monitor fatigue carefully

• Progress conservatively

• Educate continuously

• Encourage long-term self-management

Education is as important as technique. Patients who understand their condition are more likely to engage consistently and avoid fear-driven inactivity.

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When to Seek Further Medical Evaluation

Individuals with DISH should seek prompt assessment if they experience:

• New or progressive weakness

• Balance difficulties

• Bowel or bladder changes

• Significant pain after minor trauma

• Difficulty swallowing or breathing

These symptoms may indicate complications requiring medical attention.

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A Message of Realistic Hope

A diagnosis of DISH does not mean inevitable decline.

While the bony changes remain, the body around them is highly adaptable. Muscles, fascia, joints, breathing patterns, and nervous system responses can all improve with the right guidance.

Through thoughtful manual therapy, individualized exercise, breathing retraining, and functional movement, many people regain comfort, confidence, and independence.

The goal is not perfection. It is steady, sustainable progress over time.

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References

1. Al-Herz A, Snip JP, Clark B, Esdaile JM. Exercise therapy for patients with diffuse idiopathic skeletal hyperostosis. Clinical Rheumatology. 2008;27(2):207–210.

2. Luo TD, Varacallo M. Diffuse idiopathic skeletal hyperostosis. StatPearls. 2023.

3. Mader R, Verlaan JJ, Eshed I, et al. Diffuse idiopathic skeletal hyperostosis (DISH): where we are now and where to go next. RMD Open. 2017;3(1):e000472.

4. Nascimento FA, Gatto LA, Lages RO, et al. Diffuse idiopathic skeletal hyperostosis: a review. World Journal of Orthopedics. 2014;5(3):374–378.

5. Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. European Spine Journal. 2009;18(2):145–156.

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DR. BRIAN ABELSON, DC. - The Author

With over 30 years of clinical experience and more than 25,000 patients treated, Dr. Brian J. Abelson is the creator of Motion Specific Release (MSR), a multidisciplinary assessment and treatment system that integrates biomechanics, fascia science, neurology, manual therapy, exercise rehabilitation, and acupuncture. He is an internationally recognized best-selling author of 10 books and 200+ articles, and has trained healthcare professionals through structured MSR courses and clinical education programs throughout Canada and the United States. Dr. Abelson practices at Kinetic Health in Calgary, Alberta, and continues to develop educational resources focused on long-term function, resilience, and the health trajectory shaped by everyday choices.

For patients, his goal is simple, reduce pain, restore movement, and build long-term independence. For practitioners, MSR provides a practical framework you can integrate directly into daily clinical care.

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Why Choose MSR Courses and MSR Pro?

Elevate your clinical practice with Motion Specific Release (MSR) training and MSR Pro, a comprehensive, evidence-informed approach to musculoskeletal assessment and treatment designed to improve diagnostic precision, hands-on skill, and patient outcomes.

MSR proficiency goes far beyond videos and articles. True clinical mastery requires hands-on training, refinement of palpation and force application, and a deeper command of applied anatomy and biomechanics. MSR is a skill-based system built through deliberate practice, real-time feedback, and mentorship, where clinical reasoning and tactile execution come together.

Here’s why practitioners join MSR:

• Proven Clinical SystemDeveloped by Dr. Brian J. Abelson, DC, with over 30 years of clinical experience and more than 25,000 patients treated, MSR integrates the most effective components of osseous and myofascial therapies into a cohesive, repeatable framework. The system is grounded in clinical logic and supported by patient outcomes, with a clinic success rate exceeding 90% in decreasing pain and improving function.

• Comprehensive, Practical TrainingCourses blend rigorous clinical education with hands-on technique development. You’ll strengthen orthopedic and neurological examination skills while learning targeted myofascial procedures, fascial expansion concepts, and osseous adjusting and mobilization strategies that translate directly into daily practice.

• MSR Pro, Your Clinical LibraryAs an MSR Pro subscriber, you gain access to a growing library of 200+ MSR procedures, instructional videos, downloadable and fillable clinical forms, and in-depth practitioner resources that support the full clinical workflow, from intake to reassessment and exercise prescription.

• Ongoing Support and UpdatesMSR Pro includes an extensive resource base of 750+ videos, including technique instruction, rehabilitation exercise progression, and clinical application guidance, supported by a large MSK article library and condition-based resources. Content is actively updated and expanded to reflect evolving clinical needs and course development.

• A System Built for GrowthMSR is designed to help practitioners think clearly in complex presentations, develop adaptable strategies, and evolve as clinicians. This approach aligns with the broader Trajectory principle, better outcomes are built through the cumulative power of consistent, high-quality clinical decisions.

Unlock your practice’s full potential with MSR Courses and MSR Pro, and join a community of practitioners committed to excellence in musculoskeletal care.

Article Index

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YouTube Channel

Explore Dr. Abelson’s YouTube channel, Kinetic Health Online, with 200,000+ subscribers and 37+ million views.

The channel features a large library of evidence-informed musculoskeletal education, including Motion Specific Release (MSR) procedures that integrate fascial-based concepts, manual therapy, movement science, and select Traditional Chinese Medicine (TCM) principles.

You’ll also find:

• 70+ essential physical examination videos

• MSK condition tutorials and clinical education content

• Hundreds of mobility, strengthening, and rehab exercise demonstrations

• A dedicated Yang Style Tai Chi playlist, reflecting Dr. Abelson’s decades of teaching experience

 https://www.youtube.com/@kinetichealthonline

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