Ankylosing Spondylitis and Balance

Use of posturography in patients with ankylosing spondylitis: A systematic review

Background

Ankylosing spondylitis (AS) is characterised as a chronic inflammatory disease of the axial skeleton. The force platform is an option for performing the postural assessment of these individuals.

Objectives

To review and evaluate the behaviour of the centre of pressure (CoP) variables during the postural control examination in patients with AS compared to a control group.

Method

A systematic review, registered in PROSPERO, that followed the PRISMA Statement. A search was carried out in the following databases: Medline, Web of Science, Embase, Scopus, and Scielo, from 1945 to 2023. Studies were selected that aimed to understand the use of the force platform for the assessment of postural control. The risk of bias assessment was performed using the AXIS tool.

Results

Five studies were included, with a total of 247 participants. The assessment of risk of bias presented high scores in the AXIS tool. Patients with a diagnosis of AS presented increased thoracic kyphosis in most of the studies, as well as large displacements in the anteroposterior (AP) and mediolateral (ML) directions, and altered total mean velocity (TMV) and frequency, indicating worse postural stability. Regarding the functional status, the most used questionnaires were the Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI) and Bath Ankylosing Disease Activity Index (BASDAI).

Conclusion

Patients with ankylosing spondylitis present postural instability, verified by means of higher values of centre of posture variables.

Clinical implications

Individuals with ankylosing spondylitis presented postural instability and balance deficit. Therefore, exercises for balance training and postural control are essential in the clinical management of these patients.

Evaluation of preoperative calculation methods of osteotomy size in ankylosing spondylitis with thoracolumbar or lumbar kyphosis

BACKGROUND

To evaluate the accuracy of different preoperative calculation methods of osteotomy size in ankylosing spondylitis with thoracolumbar or lumbar kyphosis and analyze its clinical significance.

METHODS

Twenty-two cases of AS patients with thoracolumbar or lumbar kyphosis, from January 2015 to December 2018, who underwent one-level SPO surgery in our hospital, were retrospectively reviewed. The sagittal parameters were measured at pre-operation and last follow up using Surgimap software, and theoretical values of sagittal parameters were calculated according to pre-operative PI. The osteotomy angles of different methods were measured using Surgimap software. Paired t test was used to for the statistical analysis.

RESULTS

The mean follow-up time of all patients was 30.00 [Formula: see text] 3.56 months. The osteotomy sites were located at T12 in 3 cases, L1 in 6 cases, L2 in 9 cases, and L3 in 4 cases. Compared to pre-operative sagittal parameters, post-operative PT, SS, LL, and SVA were significantly improved (P [Formula: see text] 0.05). Compared to the OVA (46.57 [Formula: see text] 2.32 [Formula: see text]), there was a significantly larger angle predicted by Surgimap method (53.80 [Formula: see text] 9.79 [Formula: see text]), CAM-HA method (56.61 [Formula: see text] 8.58 [Formula: see text]), and HP-HA method (60.07 [Formula: see text] 13.58 [Formula: see text]), respectively (P [Formula: see text] 0.05). But no significant difference was found between the postoperative osteotomy angle and those of SFA method (51.24 [Formula: see text] 12.14 [Formula: see text]) and FBI method (48.08 [Formula: see text] 12.49 [Formula: see text]) (P [Formula: see text] 0.05).

CONCLUSION

For AS patients with thoracolumbar or lumbar kyphosis, the SFA method, FBI method, and Surgimap method can be used to predict the osteotomy angle precisely, however, considering the rationality of parameter settings and the operability, SFA method is relatively more suitable for such population.

How does Spinal Mobility Affect Balance and Postural Control in Patients with Ankylosing Spondylitis? A Cross-Sectional Study

Purpose Alterations in spinal mobility lead to impaired postural control and balance, an increased risk of falls and a decrease in quality of life. The purposes of this study were to investigate the relationship between spinal mobility, postural control and balance and to compare spinal mobility and balance with a view to disease severity in patients with ankylosing spondylitis (AS).

Methods 137 patients with AS were divided into 2 groups by tragus-to-wall distance (TWD): (Group I=mild AS, n=51), (Group II=moderate AS, n=86). Balance was assessed with the Single-Leg Balance Test, the Timed Up and Go Test (TUG) and the Berg Balance Scale (BBS). Spinal mobility was measured by BASMI Index [TWD, cervical rotation (CR), Modified Schober Test (MST), lumbar lateral flexion (LLF), intermalleolar distance (IMD) and thoracic expansion (TE)] and was compared between the groups. The association with balance was investigated.

Results Spinal mobility and BBS scores in Group II were worse than in Group I (p<0.05). Static balance and TUG of the groups were similar (p>0.05). Dynamic balance was weakly correlated with MST, LLF and IMM and moderately correlated with CR, TE and BASMI. Static balance was weakly correlated with spinal mobility (p<0.05). There was no correlation between TWD and any balance domains (p>0.05).

Conclusions In patients with AS, spinal mobility and dynamic balance worsen as the disease progresses, whereas static balance does not change. Such changes in mobility and balance can negatively affect patients’ participation in daily life and increase their risk of falls. Therefore, detailed evaluation of balance, balance training and fall prevention approaches need to be implemented in the rehabilitation programs of patients with AS.

Association of Core Muscle Endurance Times With Balance, Fatigue, Physical Activity Level, and Kyphosis Angle in Patients With Ankylosing Spondylitis

BACKGROUND/OBJECTIVE

Core muscle endurance (CME), which is the ability of sustaining the activity of trunk muscles, has been shown to be lower in patients with ankylosing spondylitis (AS). The aim was to investigate the possible relationship between CME times and balance, fatigue, physical activity (PA) level, and thoracic kyphosis angle.

METHODS

Fifty-one patients with AS with a mean age of 41.0 years (interquartile range, 25/75 years; 29.0/51.0 years) were included in the study. Core muscle endurance times were assessed by using trunk extension, trunk flexion, and side bridge tests. Overall stability index, anteroposterior stability index, mediolateral stability index, and limits of stability were evaluated with the Biodex Balance System. Fatigue and PA levels were surveyed using Fatigue Severity Scale and International Physical Activity Questionnaire, respectively. Thoracic kyphosis angle was measured by using a digital inclinometer. Additionally, CME times were compared for "high-fatigue" versus "low-fatigue" and as "low PA" versus "moderate/high PA" groups. Spearman correlation coefficients and Mann-Whitney U test were used for statistical analysis.

RESULTS

Significant correlations were detected between overall stability index, anteroposterior stability index, Fatigue Severity Scale, International Physical Activity Questionnaire, and all CME tests (p < 0.05) and between mediolateral stability index and side bridge test (p < 0.05). Limits of stability correlated only with side bridge test (p < 0.05). Core muscle endurance significantly differed between high-fatigue and low-fatigue groups (p < 0.05), except trunk flexor test (p > 0.05). No significant differences were observed between low PA and moderate/high PA groups (p > 0.05), except side bridge test (p < 0.05).

CONCLUSIONS

Core muscle endurance times seem to be related to PA level, fatigue, and balance but not with thoracic kyphosis angle. Assessing CME in patients with AS might help in planning individualized exercise programs.

Y-Osteotomy for Correction of Residual Postoperative Thoracic Kyphotic Deformity in a Patient With Ankylosing Spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disease that mainly affects the thoracic spine leading to severe kyphosis. This results in severe functional impairment and sagittal plane imbalance. Surgery is commonly recommended; however, there are many challenges that a spine surgeon may encounter. Several osteotomy techniques have been described to correct these deformities. We describe the use of a relatively novel technique, Y-shape osteotomy, as a surgical option for residual postoperative thoracic kyphotic deformity in a patient with AS with good clinical and radiological outcomes.

Static foot posture and its relation to clinical variables in ankylosing spondylitis

AIM

Postural abnormalities of the foot are common in rheumatic diseases. Static foot posture is a poorly studied clinical parameter in ankylosing spondylitis (AS). The aim of the study was to evaluate static foot posture in patients with AS and to determine the potential impact of clinical variables on foot posture.

METHOD

Fifty patients with AS and 40 age- and sex-matched healthy controls were enrolled in the study. Disease activity was measured using the Ankylosing Spondylitis Disease Activity Score. Axial mobility was evaluated with the Bath Ankylosing Spondylitis Metrology Index three-point answer scale. Functional status was assessed by the Bath Ankylosing Spondylitis Functional Index and Health Assessment Questionnaire-Disability Index. Enthesitis and foot posture were evaluated by the Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) and Foot Posture Index-6, respectively.

RESULTS

Patients with AS revealed significantly higher scores of foot posture index when compared with controls (P = 0.005). Abnormal foot posture (pronated and supinated) was more common in the patient group (P < 0.01). According to the multinomial logistic regression analysis, a higher MASES score was associated with supinated foot posture in AS patients (odds ratio 1.47, 95% confidence interval 1.03-2.09, P = 0.035). In addition, supinated foot posture was associated with enthesitis of the Achilles tendon (P = 0.002).

CONCLUSION

Enthesitis is related to deteriorated static foot posture in patients with AS. Enthesitis of the Achilles tendon is closely associated with the supinated foot posture.

The Sagittal Parameters and Efficacy of Pedicle Subtraction Osteotomy in Patients with Ankylosing Spondylitis and Kyphosis Under Different Lumbar Sagittal Morphologies

OBJECTIVE

This study aimed to compare the changes in sagittal parameters and the efficacy of pedicle subtraction osteotomy (PSO) in patients with ankylosing spondylitis (AS) and kyphosis under different lumbar sagittal morphologies and to explore the effect of sagittal morphology on the selection of PSO levels.

METHODS

A total of 24 patients with AS and thoracolumbar kyphosis (TK) who were admitted to the First Affiliated Hospital of Xinjiang Medical University between 2008 and 2019 were enrolled in this study. They were divided into two groups: a lumbar lordosis group (n = 14) and a lumbar kyphosis group (n = 10). Changes in sagittal parameters, lumbar Japanese Orthopaedic Association (JOA) scores, and visual analog scale (VAS) scores for lumbar pain before and after operation were compared between the two groups to evaluate postoperative efficacy.

RESULTS

The preoperative lumbar lordosis (LL) was -29.29 ± 5.40 (lordosis) and 13.50 ± 3.65 (kyphosis) (P < 0.01), and the preoperative sagittal vertical axis (SVA) was 171.35 ± 25.46 (lordosis) and 223.58 ± 21.87 (kyphosis) (P < 0.01). Preoperative global kyphosis (GK) was 75.71 ± 5.26 (lordosis) and 86.30 ± 10.32 (kyphosis) (P < 0.05). All patients in the lordosis group underwent PSO surgery at the twelfth thoracic vertebra (T12) or the first lumbar spinal vertebra (L1), while all patients in the kyphosis group underwent the surgery at the second or third lumbar spinal vertebra (L2 or L3). The differences in postoperative GK, LL, and SVA between the two groups were not significant (P > 0.05). The JOA scores of the two groups increased from 13.00 ± 0.83 (lordosis) and 11.30 ± 0.93 (kyphosis) before surgery to 21.00 ± 0.67 and 19.70 ± 0.60 after surgery (P < 0.05).

CONCLUSION

Preoperative lumbar sagittal morphology needs to be considered when selecting the optimal osteotomy plane. An osteotomy can achieve the greatest success in patients with lumbar kyphosis at L2/L3; for patients with lumbar lordosis, it can achieve satisfactory outcomes at T12/L1.

BMP2 variants in the risk of ankylosing spondylitis

The purpose of the study was to explore the genetic effects of bone morphogenetic protein (BMP2) polymorphisms on the susceptibility to ankylosing spondylitis (AS) in Chinese Han population. The case-control study included 120 AS cases and 110 healthy controls. Hardy-Weinberg equilibrium test was performed in control group. BMP2 rs235768 and rs3178250 polymorphisms were analyzed by polymerase chain reaction and direct sequencing. Additionally, the χ²  test was used to estimate association strength between BMP2 genetic polymorphisms and AS susceptibility, and the results were assessed via odds ratio (OR) with the corresponding 95% confidence interval (95%CI). Results adjustment was performed using logistic regression analysis. AA, AT, TT genotype and A, T allele frequencies of BMP2 rs235768 polymorphism presented no significant differences between case and control groups (P > .05 for all). TC genotype of rs3178250 polymorphism showed significantly higher in case group than that in control group (P = .048). After adjusting, TC genotype was a risk factor for AS (OR = 2.095; 95%CI = 1.086-4.038; P = .027). BMP2 rs3178250 polymorphism may increase individual susceptibility to AS in Chinese Han population.

Prevalence of ankylosing spondylitis in a Chinese population: a systematic review and meta-analysis

Ankylosing spondylitis (AS) is a common inflammatory rheumatic disease that affects the axial skeleton. In this study, we systematically reviewed Chinese AS epidemiological studies from the past 15 years to elucidate its prevalence and provide scientific data for China's health care system. AS epidemiological research in China was summarized by conducting a literature review. A review and statistical analysis of the literature on the epidemiology of AS in mainland China published from May 2005 to May 2019 were performed via a meta-analysis. We calculated the prevalence of AS and analysed differences by sex, region, and population source using STATA12.0 software. Eleven papers including 122,558 subjects from mainland China were included. Over the past 15 years, the total prevalence of AS in mainland China was 0.29% (95% CI 0.22-0.35%), ranging from 0.42% (95% CI 0.31-0.52%) in males to 0.15% (95% CI 0.13-0.18%) in females; the difference in the prevalence of AS by sex was statistically significant (P < 0.001). The prevalence of AS in both southern and northern China was 0.31% (95% CI 0.21-0.42% and 0.21-0.40%, respectively), with no significant difference noted (P = 0.816 > 0.005). The prevalence of AS in Chinese military populations was 0.27% (95% CI 0.09-0.45%), and in community populations, it was 0.29% (95% CI 0.23-0.35%). There was no statistically significant difference in the prevalence of AS by sampling resource (P = 0.115 > 0.005). The prevalence of AS in China was 0.29% and continues to increase. Sex differences in its prevalence were identified; the prevalence rate was 2.8 times higher in males than in females. Epidemiologists in China should formulate precise scientific investigations to provide additional authoritative epidemiological data for the prevention and treatment of AS.

Factors associated with depressive symptoms in patients with ankylosing spondylitis in Northern Taiwan

Patients with ankylosing spondylitis (AS) experience impaired physical function and reduced quality of life, which puts this group at high risk for depression. Identifying factors associated with depressive symptoms could improve outcomes for this at-risk group. However, few studies have examined the relationship between demographic and clinical variables and depressive symptoms in patients with AS. This cross-sectional correlation study recruited patients with AS by convenience sampling from the division of immunology and rheumatology of a medical center in Northern Taiwan. Participants (N = 120) included 91 males and 29 females, age ≥ 20 years. Data were collected from chart reviews, and structural questionnaires, which included demographic information regarding employment status, history of falls, impact of AS on work; clinical information relative to AS was obtained from structural questionnaires: the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and functional index (BASFI), Numerical Rating Scale (NRS), Body Image Scale (BIS), and Beck Depression Inventory-II (BDI-II). Multiple regression analysis identified predictors of depression. The mean BDI-II score was 9.50 ± 8.30; 25% had scores indicating mild to severe depressive symptoms. Mean score on the BIS was 68.17 ± 16.14; 14.2% had fallen within the previous year; and 57.5% reported AS affected their work. Variables associated with depressive symptoms were work affected by AS (β = 0.14, p = .049), occurrence of a fall within the previous year (β = 0.14, p = .032), higher scores on the BASDAI (β = 0.21, p = .032), and lower body image (β = −0.38, p < .001). Clinical professionals should regularly assess patients with AS for depressive symptoms. Health care planning should provide instruction in fall prevention and control of disease activity, and strategies to improve body image, which could improve patients’ self-management capabilities and body image as well as mitigate depressive symptoms.

Effect of anti-tumor necrosis factor α treatment on radiographic progression in patient with ankylosing spondylitis: A systematic review and meta-analysis

BACKGROUND

Efficacy of anti-tumor necrosis factor (anti-TNF)α treatment in patient with active ankylosing spondylitis (AS) had been proved by many clinical studies. Inflammation and new bone formation in spine were two pivotal aspects in AS. TNF α inhibitor could eliminate inflammation including clinical and laboratory inflammatory manifestation. Paradoxical results whether TNF α antagonist could delay radiographic progression in AS were often been reported simultaneously.

OBJECTIVES

To review the literature about the effect of TNF α inhibitor on radiographic progression and disease activity in patient with AS.

METHODS

We conducted a comprehensive search including Medline, EMBASE and the Cochrane Library from 1 January 2000 to 15 August 2017. Two reviewers independently supplemented with hand searching for the reference lists of inclusion. All trials focusing on radiographic progression or disease activity in patients with AS treated with anti-TNF α agents. Primary outcomes were modified Stokes AS Spinal Score (mSASSS), as well as Bath AS disease activity index (BASDAI) and Bath AS functional index (BASFI). Two reviewers independently selected studies and analyzed data. Methodological quality was assessed using the Newcastle-Ottawa scale (NOS). We pooled effects recorded on different scales as Standardized mean differences (SMDs) with 95% confidence intervals (CIs) using random-effects models.

RESULTS

We included 14 studies of low to moderate risk of bias with 3,186 patients, compared with control group, there was no effect of mSASSS changes (SMD = -0.12, 95% CI: -1.17-0.93, p value = .82, I² = 95%) and follow-up (SMD = 0.03, 95% CI: 0.21-0.26, p value = .82, I² = 36%) estimation in anti-TNF α group. However anti-TNF α agent treatment led to remarkable improvements on both Bath AS disease activity index (BASDAI) (SMD = 1.06, 95% CI: 0.22-1.89, p value = .01, I² = 96%) and Bath AS functional index (BASFI) (SMD = 0.93, 95% CI: 0.24-1.92, p value = .01, I² = 97%) scores at 12 weeks.

CONCLUSION

Our meta-analysis found no significant effect on delaying radiographic progression in AS treated with TNF α inhibitor, although TNF α inhibitor could do improve significantly disease activity and physical function in AS.