Living Well With DISH

Exercise, Movement, and Practical Strategies for Maintaining Function

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 DISH affects approximately 12 percent of adults worldwide, although estimates vary considerably among populations. Prevalence increases with age, is higher in men, and is influenced by the population studied, imaging method, and diagnostic criteria used.

Because many people with DISH have few or no symptoms, the condition is often discovered incidentally on imaging performed for another reason. Its prevalence within Calgary is unknown, and global estimates cannot be reliably applied to the city’s entire population.

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 commonly recommended to help people with DISH maintain available mobility, muscular strength, aerobic capacity, and independence. However, DISH-specific exercise research remains limited.

In one small pilot study, a 24-week program incorporating mobility, stretching, and strengthening produced modest improvements. Only the change in lumbosacral flexion reached statistical significance, although approximately half of the participants reported feeling better.

These findings are encouraging but preliminary. Exercise should be presented as a practical component of symptom management rather than a proven method of altering the underlying disease.

The objective is not to force movement through ankylosed segments. It is to maintain available motion, strengthen the surrounding regions, and progressively build the capacity required for daily life.

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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References

1. Al-Herz, A., Snip, J. P., Clark, B., & Esdaile, J. M. (2008). Exercise therapy for patients with diffuse idiopathic skeletal hyperostosis. Clinical Rheumatology, 27(2), 207–210.

2. Harlianto, N. I., Kuperus, J. S., Mohamed Hoesein, F. A. A., de Jong, P. A., de Ru, J. A., Öner, F. C., & Verlaan, J. J. (2022). Diffuse idiopathic skeletal hyperostosis of the cervical spine causing dysphagia and airway obstruction: An updated systematic review. The Spine Journal, 22(9), 1490–1503.

3. Laborde, S., Allen, M. S., Borges, U., Dosseville, F., Hosang, T. J., Iskra, M., Mosley, E., Salvotti, C., Spolverato, L., Zammit, N., & Javelle, F. (2022). Effects of voluntary slow breathing on heart rate and heart rate variability: A systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews, 138, 104711.

4. Le, H. V., Wick, J. B., Van, B. W., & Klineberg, E. O. (2021). Diffuse idiopathic skeletal hyperostosis of the spine: Pathophysiology, diagnosis, and management. Journal of the American Academy of Orthopaedic Surgeons, 29(24), 1044–1051.

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

6. Nascimento, F. A., Gatto, L. A. M., Lages, R. O., Neto, H. M. P., Demartini, Z., & Koppe, G. L. (2014). Diffuse idiopathic skeletal hyperostosis: A review. Surgical Neurology International, 5(Suppl 3), S122–S125.

7. Okada, E., Ishihara, S., Azuma, K., Michikawa, T., Suzuki, S., Tsuji, O., et al. (2021). Metabolic syndrome is a predisposing factor for diffuse idiopathic skeletal hyperostosis. Neurospine, 18(1), 109–116.

8. Oudkerk, S. F., Mohamed Hoesein, F. A. A., Öner, F. C., Verlaan, J. J., de Jong, P. A., Kuperus, J. S., et al. (2020). Diffuse idiopathic skeletal hyperostosis in smokers and restrictive spirometry pattern: An analysis of the COPDGene cohort. The Journal of Rheumatology, 47(4), 531–538.

9. Resnick, D., & Niwayama, G. (1976). Radiographic and pathologic features of spinal involvement in diffuse idiopathic skeletal hyperostosis. Radiology, 119(3), 559–568.

10. Weng, R., Guo, H., Ma, L., Lin, T., Han, W., Zhong, X., Liu, C., Li, Y., Zhu, G., & Huang, X. (2025). Global prevalence estimates of diffuse idiopathic skeletal hyperostosis: A systematic review and meta-analysis. Frontiers in Endocrinology, 16, 1517168.

11. Westerveld, L. A., Verlaan, J. J., & Oner, F. C. (2009). Spinal fractures in patients with ankylosing spinal disorders: A systematic review of the literature on treatment, neurological status, and complications. European Spine Journal, 18(2), 145–156.

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DR. BRIAN ABELSON, DC. - The Author

Dr. Brian Abelson is a chiropractor, author, and educator with more than 30 years of clinical experience in musculoskeletal care, rehabilitation, and sports performance. His educational work focuses on musculoskeletal conditions, human movement, sports biomechanics, and evidence-informed approaches to treatment and rehabilitation.

He is the developer of Motion Specific Release (MSR) and Clinical Director of Kinetic Health in Calgary, Alberta, Canada.

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