Assessments in ankylosing spondylitis

Detection of the disease activity with ankylosing spondylitis through intravoxel incoherent motion diffusion-weighted MR imaging of sacroiliac joint

OBJECTIVE

To explore the value of the quantitative parameter of intravoxel incoherent motion diffusion (IVIM-DWI) at 3.0 T MRI of the sacroiliac joint in differentiating different disease activity statuses of ankylosing spondylitis (AS) and to compare it with traditional diffusion-weighted imaging (DWI) and Spondyloarthritis Research Consortium of Canada (SPARCC) score.

METHODS

56 AS patients (active group, inactive group) and 24 healthy controls were included. Clinical data, quantitative parameters of IVIM-DWI MR images and the SPARCC scores were collected. The Kruskal-Wallis test was used to compare the differences between the groups. Receiver operating characteristic (ROC) curve analysis of histogram data and the SPARCC scores identified the efficacy of the three groups. The Spearman correlation coefficients were used to analyse the correlation between the quantitative IVIIM-DWI parameters and the SPARCC score.

RESULTS

The f (10th percentile) and SPARCC score of the active group were significantly higher than those of the inactive group. The f (10th, 25th, 50th percentiles), Dslow (average, entropy, 10th ~ 90 th percentiles), Dfast (kurtosis, skewness), ADC (average, 10th ~ 90 th percentiles) and the SPARCC score of the active group were significantly higher than the control group (p < 0.05). The AUC of the SPARCC score was the highest (0.799) in the identification between the active and inactive groups, and the sensitivity and specificity were 69.23 and 82.35%, respectively, at the cut-off value of 12. The SPARCC score was positively correlated with each percentile and the average value.

CONCLUSIONS

Quantitative IVIIM-DWI parameters are helpful for the identification of different AS disease activity levels and are superior to traditional DWI. IVIM-DWI quantitative parameters had a good correlation with the SPARCC score.

ADVANCES IN KNOWLEDGE

A new MR technology-quantitative parameters of IVIM-DWI contribute to the identification of AS disease activity. IVIM-DWI quantitative parameters were well correlated with the SPARCC score.

From bowel inflammation to the bone and joints: musculoskeletal examination in inflammatory bowel disease (IBD)

Background

One of the most important complications in inflammatory Bowel Disease (IBD) are musculoskeletal manifestations that are reported in more than 50% of patients.

Objectives

In this study, we aimed to evaluate the musculoskeletal and radiologic manifestations in our IBD patients.

Methods

In this cross-sectional study on 96 mild-to-moderate IBD patients (76 UC, 18 CD and 2 undifferentiated IBD) with mean (SD) age of 39.28 (11.42) years, 44 (45.8%) were males and 52 were (54.2%) females. Patients were examined by an expert rheumatologist and their musculoskeletal symptoms were assessed. The musculoskeletal system was evaluated by Modified Schober test, Thoracic expansion (TE), Occiput to wall distance (OWD), and Patrick’s or FABER test. Peripheral joints were also examined in all four extremities. Then patients were referred for pelvic and lumbosacral x-ray. Sacroiliitis grading was performed using the New York criteria.

Results

Inflammatory low back pain was reported in 5 (5.2%), enthesopathy in 6 (6.5%) and dactylitis in 1 (1.1%). Positive Schober test was recorded in 5 (5.2%) and Patrick test in 3 (3.1%). Forty-nine (51%) cases had normal imaging with no sacroiliitis, endplate sclerosis was seen in 33 cases (34.4%), grade 3 and grade 4 were seen in 10 cases (10.4%).

Conclusions

In the present study, 34.4% of the IBD patients had mild radiologic changes as endplate sclerosis and 95% had a normal physical examination.

Treat-to-target in axial spondyloarthritis - what about physical function and activity?

In patients with axial spondyloarthritis (axSpA), pain, functional and structural impairments, reduced mobility and potential deformity of the axial skeleton are the most prominent health concerns. Limitations in physical function and spinal mobility are caused by both inflammation and structural damage, and therefore restrictions to physical function must be monitored throughout a patient's life. Consequently, the assessment of physical function is recommended as a key domain in the Assessment of Spondyloarthritis International Society-OMERACT Core Outcome Set. However, in comparison with disease activity, physical function seems to be a relatively neglected target of intervention in patients with axSpA, even though physical function is a major contributor to costs and disability in this disease. This Review aims to reacquaint rheumatologists with the targets for physical function, physical activity and performance by giving guidance on determinants of physical function and how physical function can be examined in patients with axSpA.

Successful evaluation of spinal mobility measurements with the Epionics SPINE device in patients with axial spondyloarthritis compared to controls

OBJECTIVE

To evaluate ES for quantification of spinal mobility in patients with axSpA.

METHODS

A total of 153 individuals, 39 females and 114 males, were examined:134 axSpA patients, 40 non-(nr-) and 94 radiographic (r)-axSpA, and 19 healthy controls (HC), respectively. The results were compared using mean ES scores and modeling was performed using multivariable logistic regression models resulting in good validity and high discriminative power.

RESULTS

ES measurements showed meaningful differences between axSpA patients and HC (all p<0.001) as well as between r- and nr-axSpA (p<0.01). In axSpA patients a negative correlation between ES and BASMI values was found: -0.76≤r≤-0.52 (p<0.05). BASFI scores showed a similar trend (r > -0.39). Patients with r-axSpA had a more limited and slower spinal mobility than those with nr-axSpA. Other patient reported outcomes did almost not correlate.

CONCLUSION

This study shows that the ES is an objective performance measure and a valid tool to assess spinal mobility in axSpA, also based on OMERACT criteria. RoK and RoM scores provide additional information on physical function of axSpA patients.

IL-33 Gene Polymorphisms as Potential Biomarkers of Disease Susceptibility and Response to TNF Inhibitors in Rheumatoid Arthritis, Ankylosing Spondylitis, and Psoriatic Arthritis Patients

Objective

Rheumatoid arthritis (RA), ankylosing spondylitis (AS), and psoriatic arthritis (PsA) belong to inflammatory rheumatic diseases, the group of conditions of unknown etiology. However, a strong genetic component in their pathogenesis has been well established. A dysregulation of cytokine networks plays an important role in the development of inflammatory arthritis. Interleukin 33 (IL-33) is a recently identified member of the IL-1 family. To date, the significance of IL-33 in inflammatory arthritis has been poorly studied. This research aimed to investigate the potential of IL-33 gene polymorphisms to serve as biomarkers for disease susceptibility and TNF inhibitor response in RA, AS, and PsA patients.

Materials and Methods

In total, 735 patients diagnosed with RA, AS, and PsA and 229 healthy individuals were enrolled in the study. Genotyping for three single nucleotide polymorphisms (SNPs) within the IL-33 gene, namely, rs16924159 (A/G), rs10975519 (T/C), and rs7044343 (C/T), was performed using polymerase chain reaction amplification employing LightSNiP assays.

Results

In the present study, the IL-33 rs10975519 CC genotype was associated with a decreased risk of developing RA in females, while the IL-33 rs16924159 polymorphism was associated with the efficacy of anti-TNF therapy and clinical parameters for RA and AS patients. The IL-33 rs16924159 AA genotype correlated with higher disease activity and worse clinical outcomes in RA patients treated with TNF inhibitors, and AS patients carrying the IL-33 rs16924159 AA genotype had higher disease activity and a worse response to anti-TNF therapy. That indicates a deleterious role of the IL-33 rs16924159 AA genotype in the context of RA, as well as AS.

Conclusions

The obtained results suggest that IL-33 gene polymorphisms might be potential candidate biomarkers of disease susceptibility and anti-TNF treatment response in patients with inflammatory rheumatic diseases.

Evaluation of an ankylosing spondylitis education and self-management program: Beneficial effects on ankylosing spondylitis specific outcomes

BACKGROUND

Self-management programs have demonstrated significant health benefits in people with musculoskeletal diseases.

AIM

To examine the benefits of a tailored ankylosing spondylitis self-management program (ASSMP) delivered by trained health professionals for people with ankylosing spondylitis (AS) relative to health status, quality of life and disease activity.

METHODS

ASSMP was developed within a continuous quality improvement framework following a needs assessment and focus group discussions. Formal feedback from the group after each 6 week program cycle group by questionnaire helped refine the ASSMP. Patient health status, quality of life and disease activity were assessed at multiple time points up to 12 months.

RESULTS

Fifty-five percent were female; mean age 48.5 ± 15.2 years. Median time to AS diagnosis was 4 years (interquartile range: 1-10). AS disease activity Bath Ankylosing Spondylitis Global Score scores improved at 3, 6 and 12 months (P < .001). Bath Ankylosing Spondylitis Disease Activity Index improved at 6 weeks and was sustained at 3, 6 and 12 months (P < .001). The Ankylosing Spondylitis Quality of Life improved at 3, 6 and 12 months (P < .001). Bath Ankylosing Spondylitis Functional Index improved by 12 months (P < .001). Participants reported less nocturnal back pain at 6 months and was sustained at 12 months (P < .001). Patients Global Disease Activity improved by 6 months (P = .012), Multi-Dimensional Assessment of Fatigue and a Global Fatigue Index at 6 months (P = .003), Hospital Anxiety and Depression Scale - Anxiety at 12 months (P = .001), Evaluation Ankylosing Spondylitis Quality of Life at 6 months (P = .001) and Pain Self-Efficacy Questionnaire at 12 months (P = .002).

CONCLUSION

This ASSMP demonstrated significant and sustained benefit in symptoms, disease activity measures and quality of life in a condition that results in significant impairment, disability and poorer quality of life. The cost effectiveness and benefit of this program should be tested.

Quantitative DCE-MRI: an efficient diagnostic technique for evaluating early micro-environment permeability changes in ankylosing spondylitis

BACKGROUND

In the management of early inflammatory joint of ankylosing spondylitis (AS), there is a need for reliable noninvasive quantitative monitoring biomarker to closely assess status of synovitis progression. Cognizant to this,studies geared on improving techniques for quantitative evaluation of micro-environment permeability of the joint space are necessary. Such improved techniques may provide tissue perfusion as important biological parameters and can further help in understanding the origin of early changes associated with AS. The purpose of this study was to prospectively evaluate the diagnostic performance and determine longitudinal relationships of early micro-environment active in the joint space of the sacroiliac joint (SIJ) with a rat model by using quantitative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).

METHODS

Thirty wistar male rats were randomly assigned to the model (n = 15) or control (n = 15) group. All rats underwent DCE-MRI of SIJ region at fixed time points (12, 17 and 22 weeks),between September 2018 and October 2019. Differences in permeability parameters between the two groups at the same time point were compared by using an independent samples t test. Spearman correlations of DCE-MRI parameters with different time points in model group were analyzed. All statistical analyses were performed with software.

RESULTS

At 12 weeks,the K^trans,K_ep and V_e values in the model group were slightly lower than those in control group,but all the differences were not statistically significant (p > 0.05). Compared with control group,the transfer constant (K^trans) values increased significantly at 17 weeks and 22 weeks in model group,while the rate constant (K_ep) and volume of extravascular extracellular space (V_e) significantly increased only at 22 weeks(p < 0.05). The K^trans,K_ep and V_e were positively correlated with increasing time points (r = 0.946, P<0.01 for K^trans; r = 0.945, P<0.01 for K_ep; and r = 0.832, P<0.01 for V_e).

CONCLUSION

Quantitative DCE-MRI parameters are valuable for evaluating the early longitudinal relationship of micro-environment permeability changes in the joint space of SIJ.

Effects of non-manipulative osteopathic management in addition to physical therapy and rehabilitation on clinical outcomes of ankylosing spondylitis patients: A preliminary randomized clinical trial

INTRODUCTION

Ankylosing Spondylitis (AS) is reported to impair quality of life, physical and functional ability of patients. Rehabilitation and physical therapy is usually proposed to improve AS patient clinical conditions. Besides, an osteopathic management has not been extensively studied in the field of inflammatory diseases. = OBJECTIVE: To investigate the effects of osteopathic approach in addition to conventional rehabilitation management on clinical and functional outcomes among patients with AS.

EQUIPMENT AND METHODS

Eighteen patients with AS were recruited to participate to a physical therapy and rehabilitation (PTR) program over an 18-week period. They were randomly allocated into two groups to complete PTR only or PTR combined with osteopathic management without manipulative techniques (OSTEO group). Thoracolumbar maximal isometric strength (for flexion, extension, lateroflexion, and axial rotation) and flexibility, functional index, pain intensity and quality of life (self-assessment questionnaires) were assessed before and after the protocol.

RESULTS

Significant improvements were observed for the OSTEO group in strength, flexibility, disease activity and pain compared to the PTR group. However the difference between groups did not reach statistical significance for all the post-intervention measures. No significant correlation was found between functional, disability data or pain intensity and disease duration for both groups.

CONCLUSION

The results suggest that osteopathic management in addition to a physical therapy and rehabilitation program may be beneficial for individuals who suffer from AS. Further investigations are required using larger sample sizes to confirm these preliminary results.

Comparative analysis of the diagnostic values of T2 mapping and diffusion-weighted imaging for sacroiliitis in ankylosing spondylitis

OBJECTIVE

To investigate the diagnostic values of T2 mapping and diffusion-weighted imaging (DWI) for active sacroiliitis in ankylosing spondylitis (AS) and to evaluate the correlations of T2 and ADC values with Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Spondyloarthritis Research Consortium of Canada (SPARCC) scores.

METHODS

A total of 77 AS patients with sacroiliitis and 45 healthy controls were enrolled. All patients were scanned by standard magnetic resonance imaging longitudinal relaxation time (T1)-weighted imaging (T1WI), fat-saturated T2-weighted imaging (FS-T2WI)] and DWI, and T2 mapping of the sacroiliac joints. According to whether subchondral bone marrow edema was present in the FS-T2WI sequence, the 77 patients were divided into an active group (41 cases) and an inactive group (36 cases). The T2 and apparent diffusion coefficient (ADC) values of the subchondral bone marrow were measured in the active group, the inactive group, and the healthy control group. The average T2 and ADC values were compared among the three groups. Receiver operating characteristic (ROC) curves were used to analyze the diagnostic efficacy of T2 and ADC values for sacroiliitis. The correlations of T2 and ADC values with the BASDAI score and the SPARCC score were analyzed.

RESULTS

The T2 and ADC values in the active group were higher than those in the inactive group, while that in the inactive group were significantly higher than those in the healthy control group (p < 0.0001). The T2 and ADC values of the AS patients were positively correlated with BASDAI scores, and the correlation coefficients (r) were 0.786 (p < 0.0001) and 0.842 (p < 0.0001), respectively. The areas under the ROC curves (AUCs) of T2 and ADC values between the active and inactive groups, the active group and the healthy control group, and the inactive group and the healthy control group were 0.889 (95% CI, 0.80-0.95) and 0.917 (95% CI, 0.83-0.97), 0.982 (95% CI, 0.93-1.00) and 0.984 (95% CI, 0.93-1.00), and 0.628 (95% CI, 0.51-0.73) and 0.871 (95% CI, 0.78-0.94), respectively. The T2 and ADC values of the AS patients in the active group were positively correlated with SPARCC scores, and the correlation coefficients (r) were 0.757 (p < 0.0001) and 0.764 (p < 0.0001), respectively.

CONCLUSION

T2 and ADC values can be used to quantitatively assess the activity of AS, and the efficacy of the ADC value in the diagnosis of AS was higher than that of the T2 value.

[Epionics SPINE-use of an objective method to examine spinal mobility in patients with axial spondyloarthritis]

Axial spondylarthritis (axSpA) is a chronic inflammatory disease of the spine that can be associated with loss of physical function, mobility and upright postural impairment. Established tools for the assessment of function that are largely based on subjective perception are semiquantitatively recorded by standardized questionnaires (Bath ankylosing spondylitis functional index, BASFI), while measurement of spinal mobility of patients with axSpA is based on physical examination of various movement regions particularly the axial skeleton (Bath ankylosing spondylitis metrology index, BASMI). Recently, a performance test has been added to assess the range of motion and speed of certain tasks (AS performance-based improved test, ASPI); however, since these tests have limited reliability and reproducibility, more objective tests would be desirable. In this study the spinal mobility of patients with axSpA was quantified using the Epionics SPINE device (ES) and data were evaluated using the outcome measures in rheumatology (OMERACT) criteria. The ES automatically measures various patterns of spinal movements using electronic sensors, which also assess the range and speed of carrying out movements. Patients with back pain from other causes and persons without back pain served as controls. The measurement results obtained with ES differed between the groups and correlated with BASMI values (r = 0.53-0.82, all p = <0.03). Patients with radiographically detectable axSpA had more limited and slower mobility than those with non-radiographically detectable axSpA. Overall, the results presented here suggest that ES measurements represent a valid and objective measurement procedure of spinal mobility for axSpA patients.

The clinical utility of human leucocyte antigen B27 in axial spondyloarthritis

The association between HLA-B27 and AS was first established in the early 1970s. Since then, our understanding of this disease has changed, such that we now recognize AS to be the extreme of the clinical phenotype within a disease spectrum known as axial SpA (axSpA). Recent advances in therapeutic options have driven the need for earlier diagnosis and many screening strategies have been proposed to facilitate this. In parallel, our understanding of axSpA genetics, and especially the contribution of HLA-B27, has expanded. In this article we will present and discuss the evidence supporting the use of HLA-B27 in clinical practice. We will briefly summarize the evolution of the concept of axSpA, the prevalence of HLA-B27 and axSpA and the potential role of HLA-B27 in the aetiopathogenesis of axSpA and focus on the utility of HLA-B27 in everyday clinical practice.

Turkish Version of Evaluation of Ankylosing Spondylitis Quality of Life Questionnaire in Patients With Ankylosing Spondylitis: A Validation and Reliability Study

Objectives

This study aims to translate the Evaluation of Ankylosing Spondylitis Quality of Life (EASi-QoL) into the Turkish language and test its validity and reliability.

Patients and methods

A total of 100 AS patients (74 males; 26 females; mean age 38.2±9.9 years; range 21 to 63 years) were included. The mean disease duration was 115.9±91.6 months. EASi-QoL was translated from English into Turkish, and synthesis, back translation, revision, and pretest stages were performed. All patients were asked to complete the Turkish version of EASi-QoL. The internal consistency of EASi-QoL was determined with Cronbach's alpha coefficient, and test-retest reliability was assessed by calculating the intra-class correlation coefficient. Confirmatory and explanatory factor analyses were performed to assess structural validity. Construct validity was also investigated by comparing the results of EASi-QoL with the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Ankylosing Spondylitis Disease Activity Score, Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), and AS-specific QoL scale.

Results

Cronbach's alpha coefficient was 0.910 in the physical function category, 0.893 in the disease activity category, 0.935 in the emotional well- being category, and 0.930 in the social contribution category (α>0.7). Factor loadings of all items in EASi-QoL were higher than 0.7, indicating the high reliability of the questionnaire. There was also a strong positive correlation between all subcategories of EASi-QoL (physical function, disease activity, emotional well-being and social participation) and AS-specific QoL scale, BASDAI, Bath BASFI, patient's global assessment and pain severity. MASES and BASMI showed a moderate correlation with emotional well-being and social participation categories of EASi-QoL.

Conclusion

Turkish version of EASi-QoL is a reliable and valid scale that can be used in clinical practice to evaluate QoL in detail in patients with AS.

Comparison of bi-exponential and mono-exponential models of diffusion-weighted imaging for detecting active sacroiliitis in ankylosing spondylitis

Background There has been a growing need for a sensitive and effective imaging method for the differentiation of the activity of ankylosing spondylitis (AS). Purpose To compare the performances of intravoxel incoherent motion (IVIM)-derived parameters and the apparent diffusion coefficient (ADC) for distinguishing AS-activity. Material and Methods One hundred patients with AS were divided into active (n = 51) and non-active groups (n = 49) and 21 healthy volunteers were included as control. The ADC, diffusion coefficient ( D), pseudodiffusion coefficient ( D*), and perfusion fraction ( f) were calculated for all groups. Kruskal-Wallis tests and receiver operator characteristic (ROC) curve analysis were performed for all parameters. Results There was good reproducibility of ADC /D and relatively poor reproducibility of D*/f. ADC, D, and f were significantly higher in the active group than in the non-active and control groups (all P < 0.0001, respectively). D* was slightly but significant lower in the active group than in the non-active and control group ( P = 0.0064, 0.0215). There was no significant difference in any parameter between the non-active group and the control group (all P > 0.050). In the ROC analysis, ADC had the largest AUC for distinguishing between the active group and the non-active group (0.988) and between the active and control groups (0.990). Multivariate logistic regression analysis models showed no diagnostic improvement. Conclusion ADC provided better diagnostic performance than IVIM-derived parameters in differentiating AS activity. Therefore, a straightforward and effective mono-exponential model of diffusion-weighted imaging may be sufficient for differentiating AS activity in the clinic.

Predictive factors of radiographic progression in ankylosing spondylitis

BACKGROUND/AIMS

The course of ankylosing spondylitis (AS) is rather variable, and the factors that predict radiographic progression remain largely obscure. In this study, we tried to determine the clinical factors and laboratory measures that are useful in predicting the radiographic progression of patients with AS.

METHODS

In 64 consecutive patients with AS, we collected radiographic and laboratory data over 3 years. Radiographic data included images of the sacroiliac (SI) and hip joints and laboratory data included areas under the curve (AUC) of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), alkaline phosphatase (ALP), and hemoglobin (Hb). We investigated associations among changes in radiographic scores, initial clinical manifestations and laboratory measurements.

RESULTS

Changes in scores for the SI joint and lumbar spine did not correlate with AUC for ESR, CRP, or ALP. AUC for Hb did not significantly correlate with radiographic progression in any joint. Patients with hip arthritis at the initial visit showed significantly higher radiographic score changes after 3 years in the SI and hip joint compared to those without hip arthritis. Patients who had shoulder arthritis as the initial manifestation had significantly increased AUCs for ESR and CRP compared to those without shoulder arthritis. However, at 3 years, the change of the lumbar spine score was significantly higher in patients without shoulder arthritis.

CONCLUSIONS

These results indicate that hip arthritis at presentation is a useful clinical marker for predicting the structural damage to the SI and hip joint, and suggest that initial shoulder arthritis correlates with slower radiographic progression of the lumbar spine.

Detection of Active Sacroiliitis with Ankylosing Spondylitis through Intravoxel Incoherent Motion Diffusion-Weighted MR Imaging

OBJECTIVE

To confirm feasibility and assess intravoxel incoherent motion (IVIM) to differentiate active sacroiliitis and ankylosing spondylitis..

METHODS

Forty-one patients were divided into two groups, an active group (n = 20) and a chronic group (n = 21), according to the Bath Ankylosing Spondylitis (AS) Disease Activity Index (BASDAI) and laboratory parameters. In addition, 21 healthy volunteers were chosen as the control group. Tissue diffusivity (Dslow), perfusion fraction (f), and pseudo-diffusion coefficient (Dfast) values were obtained for all three groups. One-way analysis of variance and receiver operating characteristic analysis were performed for all parameters.

RESULTS

There was good interobserver agreement on the measurements between the two observers. The optimal cut-off values (with respective AUC, sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio) between active and chronic groups were Dslow = 0.53 × 10(-3) mm(2)/s (0.976, 90%, 95.2%, 18.9, 0.10) and f = 0.09 (0.545, 20%, 95.5%, 4.2, 0.84), and between chronic and control groups were Dslow = 0.22 × 10(-3) mm(2)/s (0.517, 9.52%, 100%, no number, 0.9) and f = 0.09 (0.935, 95.24%, 80.95%, 5, 0.059).

CONCLUSION

Dslow and f of IVIM diffusion-weighted (DW)-MRI in AS show a significant difference in the values of diffusion of water molecules and fractional perfusion-related volume among the three groups.

KEY POINTS

• D slow can be used to differentiate the activity of AS. • With perfusion fraction, the sensitivity of differentiating the AS activity is improved. • IVIM DWI plays an important role in detecting the activity in patients with AS.

Objective evaluation of physical functioning after tumor necrosis factor inhibitory therapy in patients with ankylosing spondylitis: a selection of 3 feasible performance-based tests

OBJECTIVE

(1) To select a limited number of performance-based tests that are reliable, show improvement in physical functioning after tumor necrosis factor inhibitor (TNFi) therapy in patients with ankylosing spondylitis (AS), and generate information equivalent to the full set of tests, and (2) are feasible for use in daily clinical practice.

METHODS

Eight performance-based tests were evaluated. To eliminate redundant testing, the tests that showed adequate reliability, the highest standardized response mean (SRM), and the largest proportion of patients with an improved performance-based physical functioning were selected. The selected tests were combined into a new criterion for improvement in physical functioning (AS Performance-based Improvement; ASPI). The number and percentage of improved patients identified with the ASPI and identified with the full set of performance tests were compared.

RESULTS

Reliability for all tests was adequate to excellent (ICC 0.73-0.96). The tests for bending, putting on socks, and getting up from the floor had the highest SRM (0.52-0.74) and showed the largest proportion of improved patients after TNFi therapy. The combination of these 3 tests was feasible in daily clinical practice and showed improved physical functioning after TNFi therapy in 67% of the patients.

CONCLUSION

The 3 selected tests are recommended for use in daily practice because they generate information comparable to the full set. They are reliable and feasible, and the combination of these tests showed improved physical functioning after TNFi therapy in 67% of the patients. Evaluation of physical functioning might be improved by adding these tests to other AS outcome measures.

New population-based reference values for spinal mobility measures based on the 2009-2010 National Health and Nutrition Examination Survey

OBJECTIVE

To report population-based percentile reference values for selected spinal mobility measures in a nationally representative sample of 5,001 US adults ages 20-69 years who were examined in the 2009-2010 US National Health and Nutrition Examination Survey (NHANES).

METHODS

Occiput-to-wall distance (OWD), thoracic expansion (TE), and anterior lumbar flexion (ALF; by modified Schober test) were measured by trained examiners in a standardized manner. TE was measured at the xiphisternal level, while the lower reference point for ALF was a line marked at the level of the superior margin of the lateral iliac crests. We report reference values based on the 95th percentile for the OWD and the 5th percentile for TE and ALF, as well as other summary statistics for these measures, in the study population.

RESULTS

An OWD of >0 was present in 3.8% of the participants, while 8.8% of them had out-of-range values for TE based on the commonly used threshold of 2.5 cm. The 95th percentile of the OWD measurement was 0, while the 5th percentile for TE and ALF were 1.9 cm and 2 cm, respectively. The spinal measures were significantly associated with sex, age, ethnicity, height, and body mass index (BMI). Exclusion of individuals with severe obesity (BMI >35 kg/m(2) ) changed the proposed reference values for TE and ALF to 2.2 cm and 1.9 cm, respectively.

CONCLUSION

We verified a reference value of 0 for the OWD in the general population. Using the reported population-based percentile values, new reference values for TE and ALF can be derived.

The relationship between disease activity measured by the BASDAI and psychological status, stressful life events, and sleep quality in ankylosing spondylitis

Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is a standard instrument regularly used to assess disease activity of patients with ankylosing spondylitis (AS). However, the well-being of a patient is also affected by impairment of function as well as psychological status and other factors. The objective of this study was to evaluate if psychological status, stressful life events, and sleep quality contribute significantly to BASDAI. Six hundred eighty-three AS patients satisfying the Modified New York Criteria for AS were recruited from the rheumatology clinics of seven hospitals in China. Patients with other concomitant disorders were excluded. Participants were requested to complete a set of clinical examinations and the following questionnaires: Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Zung Self-Rating Anxiety Scale (SAS), Zung Self-Rating Depression Scale (SDS), Pittsburgh Sleep Quality Index Questionnaire (PSQI), Health Assessment Questionnaire for Spondyloarthropathies (HAQ-S), and Social Readjustment Rating Scale (SRRS). Spearman correlation analysis showed that BASDAI was highly associated with degree and duration of morning stiffness, overall pain, nocturnal back pain, overall back pain, anxiety, and BASFI (all P < 0.001), but were not associated with education, HAQ-S, and sleep medication in PSQI (P > 0.05). Multiple stepwise regression analysis indicated that overall pain was the maximal statistical contribution in predicting disease activity (standardized coefficient, 0.335). In hierarchic multiple regression analysis, psychological variables added an only additional 2.7% to the overall R(2) beyond that accounted for by demographic and medical variables, resulting in a final R(2) of 53.5%. Although BASDAI is a very good measurement of pain and stiffness and to a certain extent effect of functional impairment in AS, it barely takes into account psychological status, stress life events, and sleep quality These factors should be evaluated by other modalities.

Responsiveness to therapy change of a global ultrasound assessment in spondyloarthritis patients

The objective of this study is to evaluate the responsiveness to therapy change of a global ultrasound (US) assessment in the short-term monitoring of spondyloarthritis (SpA) patients with peripheral involvement. Consecutive SpA patients with both clinical peripheral involvement and active disease (initiating or changing therapy) were included. All patients underwent both clinical and US assessment in day entering the study and after 3 months of follow-up. Peripheral global US assessment included the recognition of abnormal inflammatory findings at joint, tendon, and entheseal level according to standardized scanning methods. A total of 34 patients completed both basal and 3-month follow-up assessments. Acute phase reactants, both erythrocyte sedimentation rate and C-reactive protein, tenderness (68) and swollen (66) joint counts, Bath Ankylosing Spondylitis Disease Activity Index and Health Assessment Questionnaire decreased significantly at 3-month follow-up. Total score for the global US assessment also decreased significantly between basal and 3-month follow-up assessment [mean difference, 12.33 (IC 95 %, 9.23-15.42); p < 0.0001]. All individual component, joint, tendon, and enthesis scores, also showed a significant decrease during the follow-up period. A high degree of intra-observer reliability was found for the global US assessment (ICC [95 % CI]: 0.977 [0.961-0.993]). This global US assessment, including joints, tendons, and entheses, showed a good responsiveness to clinical changes and might be useful for monitoring SpA patients with peripheral involvement.

Fatigue in patients with spondyloarthritis associates with disease activity, quality of life and inflammatory bowel symptoms

The study aimed to assess the severity of fatigue in patients with axial spondyloarthritis (AxSpA), to assess the performance of two different fatigue measures in AxSpA, and to examine disease variables which may influence the severity of fatigue. Fatigue was examined among 67 patients with AxSpA using two measures: the fatigue Visual Analogue Scale (VAS) from the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Multidimensional Assessment of Fatigue (MAF) score. These measures were tested for convergent validity using linear regression analysis. Correlations between fatigue measured using both questionnaires, and key disease variables was examined using the following assessments: BASDAI, Bath Ankylosing Spondylitis Functional Index (BASFI), Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire, spondyloarthritis modification of the Dudley Inflammatory Bowel Symptom Questionnaire (DISQ) and pain VAS. Human leucocyte antigen (HLA) B27 and CRP were performed and followed by physical examination, Bath AS Metrology Index (BASMI) and Ankylosing Spondylitis Disease Activity Score (ASDAS). Correlations were assessed using multivariate regression analysis. Mean (±SD) fatigue measured by MAF (range 0-50) was 24.7 (±11.5) and 5.14 (±2.47) on the BASDAI VAS fatigue item (range 0-10). The MAF scores and BASDAI VAS fatigue were strongly correlated (r = 0.71, P < 0.001), but 50 % of variance remained unexplained, so both were retained as separate variables in bivariate and multivariate analyses. In multivariate regression models, a significant relationship for both fatigue measures was consistently noted with DISQ bowel symptom scores. MAF fatigue scores were most strongly associated with poorer ASQoL in multivariate models and mediated the effects of BASFI functioning, ASDAS disease activity and HLA-B27 status that were apparent in multivariate models. Patients with AxSpA experience substantial fatigue, which is associated with poorer quality of life. Fatigue VAS and MAF scores were strongly correlated. Factors most strongly associated with fatigue were disease activity and inflammatory bowel symptoms.

Description of the registry of patients with ankylosing spondylitis in Turkey: TRASD-IP

A web-based application patient follow-up program was developed to create a registry of patients with ankylosing spondylitis (AS) by the Turkiye Romatizma Arastirma Savas Dernegi (TRASD) AS Study Group. This study describes the methodological background and patient characteristics. The patient follow-up program is a web-based questionnaire, which contains sections on socio-demographic data, anamnesis, personal and family history, systemic and musculoskeletal examination, laboratory and imaging data and treatment. Between October 1, 2007 and February 28, 2009, 1,381 patients from 41 centers were included in the registry (1,038 males [75.2%]; mean age 39.5 ± 10.7 years). Mean disease duration was 12.1 ± 8.5 years, and mean time from initial symptom to diagnosis was 5 ± 6.8 years (median 2 years). HLA-B27 positivity was detected in 73.7% of 262 patients tested. Manifestations of extraarticular involvement were anterior uveitis (13.2%), psoriasis and other skin and mucous membrane lesions (6%) and inflammatory bowel disease (3.8%). The prevalence of peripheral arthritis was 11.2%. In 51.7% of patients, the Bath AS Disease Activity Index was ≥4. But since our patients consisted of the ones with more severe disease who referred to the tertiary centers and needed a regular follow-up, they may not represent the general AS population. Disease-modifying anti-rheumatic drugs were being used by 41.9% of patients, with 16.4% using anti-TNF agents. TRASD-IP (Izlem Programi: Follow-up program) is the first AS registry in Turkey. Such databases are very useful and provide a basis for data collection from large numbers of subjects. TRASD-IP gives information on the clinical and demographic profiles of patients, and the efficacy and safety of anti-TNF drugs, examines the impact on quality of life, and provides real-life data that may be used in cost-effectiveness analyses.

Validity of the bath ankylosing spondylitis disease activity index for the evaluation of disease activity in axial psoriatic arthritis

OBJECTIVE

To assess the validity of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) for the evaluation and definition of disease activity of axial psoriatic arthritis (PsA).

METHODS

Fifty-four peripheral PsA, 46 axial PsA, and 103 primary ankylosing spondylitis (AS) patients were assessed. Patients were classified as having axial PsA if they had grade 2 or higher unilateral sacroiliitis in the presence of spinal symptoms. The 3 groups of patients were evaluated using several measurements for AS. Assessments of acceptability, data quality, internal consistency, construct validity, and responsiveness of the BASDAI were undertaken. Disease activity of the disease was assessed in peripheral PsA and axial PsA patients using the BASDAI, and compared with those with AS.

RESULTS

For peripheral PsA patients, the Cronbach's alpha for the BASDAI was 0.783, for axial PSA patients it was 0.647, and for AS patients it was 0.786. The analysis of convergent validity showed that in peripheral PsA and axial PsA patients, the BASDAI was significantly correlated with other subjective disease activity parameters. For responsiveness, no association was found between changes in the BASDAI and changes in disease activity either in peripheral PsA or in axial PsA. BASDAI scores were similar in axial PsA and AS. Axial PsA patients with a BASDAI score >4 cm showed significant differences with peripheral PsA in terms of disease activity and were very similar to patients with AS.

CONCLUSION

The BASDAI performed similarly in evaluating disease activity in both axial and peripheral PsA. The BASDAI does not seem to be a good index for evaluating disease activity in axial PsA.

Endothelial dysfunction in ankylosing spondylitis improves after tumor necrosis factor-alpha blockade

Chronic inflammation in ankylosing spondylitis (AS) is associated with vascular endothelial dysfunction. Infliximab improves inflammatory disease activity in AS patients, but its effect on endothelial dysfunction has still not been tested in these patients. Twelve anti-TNF naive AS patients (mean age, 32.6 +/- 3.94 years; disease duration, 5.6 +/- 0.8 years) with high disease activity [Bath ankylosing spondylitis disease activity index (BASDAI score > 4)] despite treatment with stable doses of conventional disease modifying anti-rheumatic drugs (DMARDs) were investigated. Inflammatory disease activity [BASDAI and Bath ankylosing spondylitis functional index (BASFI) scores, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels], serum nitrite concentration, and endothelium-dependent and endothelium-independent vasodilation of the brachial artery were measured at baseline and 12 weeks of therapy after single intravenous infusion of infliximab (5 mg/kg). Previous DMARD(s) regimen remained unchanged throughout the study period. After treatment with infliximab, flow-mediated vasodilation improved from 9.81 +/- 1.70% to 26.93 +/- 2.34% (p < 0.001), whereas there was no significant change in endothelium-independent vasodilation with nitroglycerin and baseline diameter (13.65 +/- 2.10% versus 14.59 +/- 1.93%, p = 0.08, and 4.45 +/- 0.15 versus 4.46 +/- 0.15 mm, p = 0.3, respectively). Nitrite concentration reduced from 6.50 +/- 0.21 to 2.57 +/- 0.18 micromol/l (p < 0.001), ESR from 40.90 +/- 6.00 to 11.50 +/- 1.38 mm in the first hour (p < 0.001), and CRP level from 29.08 +/- 4.11 to 2.69 +/- 0.43 mg/dl (p < 0.001). BASDAI and BASFI scores were significantly reduced from 5.40 +/- 1.14 to 1.40 +/- 0.70 (p < 0.05) and 5.05 +/- 1.76 to 0.20 +/- 0.63 (p < 0.05), respectively. The study suggests that in ankylosing spondylitis, endothelial dysfunction is a part of the disease process and infliximab improves both endothelial dysfunction and inflammatory disease activity.

Appropriate management of axial spondyloarthritis

The management of axial spondyloarthritis includes a structured baseline assessment of the disease and follow-up of treatment efficacy using validated instruments. The treatment will depend on the severity and predominant manifestations of the disease. The cornerstone of management remains physical therapy and nonsteroidal anti-inflammatory drugs. Disease-modifying antirheumatic drugs such as sulfasalazine have shown efficacy only in treating peripheral arthritis, whereas thalidomide and pamidronate have shown some efficacy in treating axial inflammation. Anti-tumor necrosis factor-alpha agents are an efficacious option for treating signs and symptoms of axial disease, peripheral arthritis, and enthesitis, and for improving functional outcomes. They have not shown efficacy in reducing radiographic progression in axial disease. Recent evidence suggests that the new bone formation in ankylosing spondylitis may be due to upregulation of Wnt signaling in the osteoblastic pathway secondary to low serum DKK-1 levels, which are further suppressed by tumor necrosis factor inhibitor therapy.