Axial spondyloarthritis: new advances in diagnosis and management

Axial spondyloarthritis (axSpA) is an inflammatory disease of the axial skeleton associated with significant pain and disability. Previously, the diagnosis of ankylosing spondylitis required advanced changes on plain radiographs of the sacroiliac joints. Classification criteria released in 2009, however, identified a subset of patients, under the age of 45, with back pain for more than three months in the absence of radiographic sacroiliitis who were classified as axSpA based on a positive magnetic resonance imaging or HLAB27 positivity and specific clinical features. This subgroup was labeled non-radiographic (nr)-axSpA. These patients, compared with those identified by the older New York criteria, contained a larger percentage of women and demonstrated less structural damage. However, their clinical manifestations and response to biologics were similar to radiographic axSpA. The discovery of the interleukin (IL) IL-23/IL-17 pathway revealed key molecules involved in the pathophysiology of axSpA. This discovery propelled the generation of antibodies directed toward IL-17A, which are highly effective and demonstrate treatment responses in axSpA that are similar to those observed with anti-TNF agents. The finding that agents that block IL-23 were not effective in axSpA came as a surprise and the potential underlying mechanisms underlying this lack of response are discussed. New agents with dual inhibition of the IL-17A and F isoforms and some oral small molecule agents that target the Jak-STAT pathway, have also shown efficacy in axSpA.

The bone mineral density of hip joint was reduced in the initial stage of ankylosing spondylitis?

The osteoporosis was common complication of ankylosing spondylitis (AS), but it was frequently unrecognized in the initial stage of the disease. This study was to compare areal bone mineral density (BMD) of hip joints in early AS patients with that in healthy controls, to explore the progress of bone loss in cortex and spongiosa in early AS.Quantitative computed tomography (QCT) of hip was performed in 60 AS patients (modified New York criteria for AS, with grade 2 sacroiliitis in computed tomography) and 57 healthy controls. The QCT measurements of AS patients were compared with the measurements of healthy controls.The AS patients had lower areal BMD in cortical bone and total bone of proximal femur in early AS patients (P < .01), than the controls. But there were not significant different of areal BMD in spongiosa of proximal femur between the early AS patients and healthy controls. Strong correlations were found between body mass index BMI, areal BMD in cortical bone (rs = 0.410, P < .001; rs = 0.422, P < .001) and total bone (rs = 0.368, P < .001; rs = 0.266, P = .003) both in AS patients and healthy controls.The results indicate that osteopenia/osteoporosis is general in early stage of AS. What is more, the osteopenia/osteoporosis in cortex is earlier than in spongiosa of proximal femur in early AS.

Nonradiographic axial spondyloarthritis: clinical and therapeutic relevance

Current classification criteria for axial spondyloarthritis (axSpA) provide for the inclusion of patients with a wide range of presentations and manifestations. While not considered a formal subclassification, patients are often divided into radiographic or nonradiographic axSpA based on the presence or absence of radiographic sacroiliitis. This review will focus on nonradiographic axSpA and will discuss clinical manifestations of disease that distinguish, or in many cases do not distinguish, this entity from other individuals with axSpA. This review will also cover treatment paradigms for nonradiographic axSpA, particularly the use of biologic therapies, where current data suggest that nonradiographic disease should be managed largely the same as radiographic disease, or classical ankylosing spondylitis.

Axial spondyloarthritis

The term axial spondyloarthritis covers both patients with non-radiographic and radiographic axial spondyloarthritis, which is also termed ankylosing spondylitis. The disease usually starts in the third decade of life with a male to female ratio of two to one for radiographic axial spondyloarthritis and of one to one for non-radiographic axial spondyloarthritis. More than 90% heritabilty has been estimated, the highest genetic association being with HLA-B27. The pathogenic role of HLA-B27 is still not clear although various hypotheses are available. On the basis of evidence from trials the cytokines tumour necrosis factor (TNF)-α and interleukin-17 appear to have a relevant role in pathogenesis. The mechanisms of interaction between inflammation and new bone formation is still not completely understood but clarification will be important for the prevention of long-term structural damage of the bone. The development of new criteria for classification and for screening of patients with axial spondyloarthritis have been crucial for the early indentification and treatment of such patients, with MRI being the most important existing imaging method. Non-steroidal anti-inflammatory drugs and TNF blockers are effective therapies. Blockade of interleukin-17 is a new and relevant treatment option.

[MRI of axial spondyloarthritis: diagnostic role and pitfalls]

MRI has become a major tool for the diagnosis of axial spondyloarthritis and provides objective signs based on which therapy can be initiated. In clinical practice, ASAS classification criteria are often applied for the diagnosis of spondyloarthritis at a pre-radiographic stage. However, MRI signs of spondyloarthritis as stated in ASAS criteria lack specificity, and can be encountered in a wide array of diagnoses, in particular degenerative and mechanical conditions. In this article, we will review the role of MRI in the diagnosis and classification of spondyloarthritis, general technical considerations, the elementary MRI signs of axial spondyloarthritis, as well as diagnostic pitfalls. We also provide a practical approach on how to avoid overdiagnosis of spondyloarthritis and to improve the diagnostic value of MRI.

[The working classification and early diagnostics of ankylosing spondylitis]

A work classification of ankylosing spondylitis is presented including such novel concepts as the stage of the disease (instead of sacroiliitis), extra-axial and extra-skeletal manifestations. Modern approaches to the evaluation of disease activity are described Extensive explanations of these notions are presented together with the recommendations on formulation of diagnosis. The advent of new and more eficacious methods of visualization as well as more sensitive and specific criteria for inflammatory nature of back pain are considered The authors modified the traditional criteria for ankylosing spondylitis and developed their version to be verified in clinical practice in this country.

Axial spondyloarthritis: thoughts about nomenclature and treatment targets

The spondyloarthritides (SpA) are a heterogenous group of rheumatic diseases which are genetically linked. The strongest genetic factors, HLA B27, ERAP-1 and IL-23R, are found at variable rates in subgroups. The new nomenclature differentiates predominantly axial SpA (axSpA) from predominantly peripheral SpA (pSpA). Axial SpA (Ax-SpA) is further classified as classical ankylosing spondylitis (AS) and a non-radiographic form, nr-axSpA, which may occur in association with psoriasis (Pso) or chronic inflammatory bowel disease (IBD). Peripheral SpA includes patients with psoriatic arthritis (PsA) and IBD, patients who report a triggering infection (reactive arthritis), and other patients who may be classified simply as 'undifferentiated'. The most relevant target of therapy clinically is reduction of disease activity, which is associated with control toward ablation of inflammation, normalisation and/or improvement of function and mobility, prevention of osteoporotic fractures, and inhibition of structural changes (new bone formation) in the spine.

[Scoring of disease activity using BASDAI and ASDAS method in ankylosing spondylitis]

Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is the most frequently used ankylosing spondylitis activity assesment by which through 6 questions 5 basic diseases symptoms (fatigue, back pain, joint pain/swelling, enthesitic points, intensity and duration of morning stiffness) are being evaluated. In distinction from mentioned, Ankylosing Spondylitis Disease Activity Score (ASDAS) is the first validated index for the AS activity assessment with the patient's assessments of the disease symptoms (back pain, duration of the morning stiffess, activity of the disease, pains and swelling of the peripheral joints) includes the acute phase reactants (SE or CRP). We compared BASDAI and ASDAS indexes to the group of patients with the AS, in order to evaluate their congruence and to evaluate the inluence of SE, fatigue and back pain at obtained values. The cross-sectional study was performed in a group of 36 patients with the AS whose disease activity levels were evaluated by the BASDAI and ASDAS (SE) index. Statistical data analysis was performed by Student t-test and frequency tables for non-parameter data. As it has been expected the significant correlation between BASDAI and ASDAS indexes has been confirmed (r=0.796; p=0.00). BASDAI/ASDAS average value of all of the patients was 4.2/2.8. From 36 patients with the AS according to the BASDAI index 42% had mild active disease (BASDAI <4), while according to ASDAS index 44% patients had very active disease (ASDAS 2.1-.5.3). Higher activity of the disease according to ASDAS index is the result of the elevated sedimentation which is assessed only in ASDAS index. Patients with higher BASDAI index statistically have more significantly expressed fatigue and spinal pain without statistically significant difference in sedimentation (p=0.120). Examinees with higher ASDAS index have also significantly more expressed fatigue and back pain, but unlike BASDAI they have sedimentation (p=0.001). ASDAS is more recent clinical indicator of the AS activities which could be compared to BASDAI instrument. In this group of patients ASDAS seems to be more sensitive index because it discriminates more patients with the active disease.

[The recognition of patients with spondyloarthritis. New classification criteria]

Spondyloarthritis (SpA) is an umbrella term for a group of rheumatic diseases characterised by inflammation of the sacroiliac (SI) joints and vertebral column; today, differentiation is made between axial SpA and peripheral SpA. Ankylosing spondylitis (Bechterew's disease) is the most typical form of axial SpA whereby sacroiliitis can be found on X-rays of the SI joints. Axial SpA can, however, also be present without radiographic evidence of sacroiliitis. A range of SpA-related symptoms can also manifest themselves outside the musculoskeletal system, for example, uveitis, psoriasis and inflammatory intestinal diseases. Tumour necrosis factor (TNF)-α inhibitors play an important role in the treatment of SpA. New classification criteria have recently been established in which MRI of the SI joints and the presence of the HLA-B27 tissue antigen are key. Axial and peripheral SpA should be recognized early in order to be able to successfully treat these conditions.

[International Classification of Functioning, Disability and Health (ICF) in the most important diseases and conditions of rheumatology practice]

Musculoskeletal conditions are common throughout the world and their impact on individuals and society is enormous. The integrative and bio-psycho-socialy based model, the International Classification of Functioning, Disability and Health (ICF) is highly useful for structuring determinants of disability in these conditions. ICF encompasses health and health-related domains: body functions and structure, activity and participation and environmental factors. In clinical settings ICF is used for functional status assessment, goal setting and treatment planning and monitoring, as well as outcome measurement. In clinical practice the implementation of ICF is facilitated by the use of the ICF-based applications, such as ICF sheets or ICF Core Sets. In this article it is reported on the most important musculoskeletal conditions in rheumatology practice from the point of view of ICF and is complementary to the article by the same author that appeared in the previous issue of this journal.

How should we diagnose spondyloarthritis according to the ASAS classification criteria: a guide for practicing physicians

The Assessment of SpondyloArthritis International Society (ASAS) group has recently developed criteria to classify patients with axial SpA with or without radiographic sacroiliitis, and criteria to classify patients with peripheral SpA. The ASAS axial criteria consist of 2 arms and can be applied in patients with back pain (>3 months almost every day). In one arm, imaging (radiographs and magnetic resonance imaging [MRI]) has an important role, in the other arm--HLA-B27. MRI can detect active inflammation and structural damage associated with SpA. According to the ASAS axial SpA criteria, patients with chronic back pain aged less than 45 years at onset can be classified as having axial SpA if sacroiliitis on imaging (radiographs or MRI) plus 1 further SpA feature are present, or if HLA-B27 plus 2 further SpA features are present. The ASAS peripheral criteria can be applied in patients with peripheral arthritis (usually asymmetric arthritis predominantly involving the lower limbs), enthesitis, or dactylitis. Patients can be classified as having peripheral SpA if 1 of the following features is present: uveitis, HLA-B27, preceding genitourinary or gastrointestinal infection, psoriasis, inflammatory bowel disease, sacroiliitis on imaging (radiographs or MRI), or if 2 of the following features besides the entry feature are present: arthritis, enthesitis, dactylitis, inflammatory back pain, or a positive family history of SpA.

Classification of juvenile spondyloarthritis: Enthesitis-related arthritis and beyond

Spondyloarthritis (SpA) refers to a spectrum of immune-mediated inflammatory diseases with overlapping features, which differ from other types of inflammatory arthritis in genetic predisposition, pathogenesis and outcome. SpA frequently involves the axial skeleton, and can result in abnormal bone formation with eventual ankylosis of the spine, resulting in substantial disability. SpA often begins as an 'undifferentiated' disease, the presentation of which differs in children and adults; most notably, spinal involvement is uncommon, while hip arthritis and enthesitis are frequently seen in juvenile-onset disease. Currently, the classification of SpA in adults and children is approached differently. Using the International League of Associations for Rheumatology (ILAR) system for juvenile idiopathic arthritis, most childhood SpA is classified as enthesitis-related arthritis. However, in contrast to adult SpA classification, the presence of, or a family history of, psoriasis dictates a separate category of juvenile idiopathic arthritis. More importantly, the ILAR system does not specifically recognize the presence of axial disease in juvenile SpA. Resolution of these issues will improve communication and the transitioning of patients from pediatric to adult clinics, will facilitate research in genetics and pathogenesis, and will be particularly important in the evaluation of tumor necrosis factor inhibitors and other biologic agents for early, axial SpA.

[Rheumatoid arthritis and ankylosing spondylitis-rheumatologic highlights 2009]

In this year rheumatology highlights, we will especially note a new treatment, the tocilizumab, an interleukin-6 targeting therapy, effective and adequately safe for the treatment of rheumatoid arthritis. New classification criteria for axial spondylarthropathy have also been published, criteria that should facilitate earlier diagnosis, a diagnosis that should be pursue like a diagnosis of rheumatoid arthritis even in the absence of an inflammatory biological syndrome.

Identification of similarities and differences in functioning in persons with rheumatoid arthritis and ankylosing spondylitis using the International Classification of Functioning, Disability and Health (ICF)

OBJECTIVE

The objective of this study is to identify similarities and differences in functioning in AS and RA using the ICF as the framework for the description of functioning.

METHODS

The Comprehensive ICF Core Sets for RA and AS were compared qualitatively regarding their content. A comparison study of common second-level ICF categories from both ICF Core Sets collected in two different cross-sectional studies in the Netherlands was performed. Significant differences regarding the level of impairments, limitations or restrictions were analyzed within the Mann-Whitney U-Test. To study whether the common ICF categories have different meaning for the two populations the Rasch model for dichotomous response option was used.

RESULTS

The Comprehensive ICF Core Set for AS includes 74 ICF categories in 19 chapters and the Comprehensive ICF Core Set for RA includes 96 ICF categories in 22 chapters. Interviews among 87 patients with AS and 143 patients with RA on 24 of the common ICF categories revealed significant differences regarding the extent of problems. DIF analyses reflect that the meaning of some ICF categories, such as 'd410 Changing basic body positions' is different in relation to functioning depending on the health condition.

CONCLUSION

This study was the first to compare functioning in AS and RA based on the ICF. The results confirmed to a large extend the experiences well known from other studies and thereby showed that the ICF is useful to describe and compare functioning. Some aspects could be identified which are not easy to understand with existing evidence and need to be explained in the future.

Classification criteria for rheumatoid arthritis and ankylosing spondylitis

The history of classification and diagnostic criteria for rheumatoid arthritis (RA) and ankylosing spondylitis (AS) is similar and different. Important criteria sets have been published for both disease in the mid eighties, for AS in 1984 and for RA in 1987. The leading clinical symptoms, inflammatory back pain (IBP) in AS and the predominant polyarticular symmetric involvement of the hands in RA were, of course, central, and so was morning stiffness as a major clinical sign of an inflammatory disease state. In RA, there was more focus on laboratory parameters (rheumatoid factor), while this could have been the case also in AS (HLA B27) but this was not recognized at this point in time. In contrast, imaging has played a more important role in AS - especially because the sacroiliac joints are involved in the vast majority of AS patients, while in RA radiographic changes of the joints of hands and feet may contribute to the diagnosis. However, in both diseases, early structural changes visualized by conventional radiography rather have prognostic impact since these patients are much more likely to progress in comparison to others who do not have cartilage and joint damage early in the course of the disease. Further developments of criteria for AS have broadened the spectrum of AS to spondyloarthritis (SpA) and axial SpA which covers most early forms. The leading clinical symptom is chronic back pain in young adults and IBP. New criteria for RA which include more patients with early disease and anti-CCP antibodies as new markers are being developed. This is important since early treatment strategies are increasingly and successfully used to treat inflammatory diseases more efficiently.

Juvenile idiopathic arthritis. Subgroup characteristics and comparisons between rheumatoid arthritis-like subgroups and ankylosing spondylitis-like subgroups

In terms of adult-onset definitions, rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are rarely diagnosed in children. Adult RA is in most aspects similar to seropositive polyarticular arthritis in children, but AS differs in its clinical presentation according to age at onset. In general, the nomenclature and classifications of arthritis in children encompass subgroups with specific signs or laboratory tests and pathogenic mechanisms that distinguish one clinical form from the other. While one of these subgroups corresponds to RA, the one related to AS usually includes children with undifferentiated SpA and not definite AS. Thus, comparisons of RA and AS in children actually correspond to comparisons of various forms of childhood arthritis, currently classified as juvenile idiopathic arthritis (JIA) and AS in its early undifferentiated form. In this paper, we review these to finally compare the two populations.

How did ankylosing spondylitis become a separate disease?

Individual patients whose disease in retrospect is compatible with a diagnosis of ankylosing spondylitis (AS) began to be described in the 19th century, at a time when "rheumatism" comprised an undefined conglomeration of ailments. In the 1890s, rheumatoid arthritis (RA) began to be extricated from rheumatic fever and gout. But what criteria should delimit the diagnosis of RA? The first assistance came with the introduction of radiology in the first decade of the new century. By the 1930s, objective radiologic distinctions between RA and A S were being made, beginning with the preferential involvement of the sacroiliac joints in AS. The first useful serologic test was developed in the 1950s: "rheumatoid factor" that eventually is present in about three-fourths of cases of RA, but is absent in AS. In the 1970s discovery of clinical associations with specific histocompatibility antigens finalized the distinction between RA and AS with the discovery that one antigen, B-27, is associated ten times as frequently with AS than with RA, while it occurs no more frequently with RA than in the general population. Associations between B-27 and certain radiologic appearances has further been mutually confirmatory of their diagnostic significance.

[The reliability and validity of a Croatian version of the Bath Ankylosing Spondylitis Functional Index (BASFI) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) in patients with ankylosing spondylitis]

The aim of the study was to investigate the reliability and the validity of the Croatian version of the Bath Ankylosing Spondylitis Functional Index (BASFI) and Bath Ankylosing Spondylitis Disease Activity index (BASDAI) in patients with ankylosing spondylitis (AS). Patients with established diagnosis of AS participated in the study. Fifty-two and 48 patients were included for the evaluation of BASFI and BASDAI, respectively. For translation international translation steps were followed. For reliability patients recompleted both indices on the following day. To assess validity following parameters were obtained: spinal mobility in sagittal plane, chest expansion index, erythrocyte sedimentation rate, serum C-reactive protein, level of pain and patient's global health. Apart from descriptive statistics Spearman's rho coefficient was used. Correlation between BASFI and BASDAI score was 0.621. The mean BASFI scores on two occasions (within 24 hours) were 4.82 +/- 2.67 versus 4.88 +/- 2.52 (r = 0.961; p < 0.01), and for BASDAI scores were 5.46 +/- 2.30 versus 5.32 +/- 2.19, respectively (r = 0.959; p < 0.01). Stability index for both indices was 0.98. High correlation was found for each repeated question of BASFI and BASDAI. For both indices congruent validity demonstrated the best correlation with cervical and thoracic mobility. Also, the correlation was observed for BASFI with spinal mobility in lumbar region and with chest expansion index, and for BASDAI with the level of pain. Our findings indicate that Croatian version ofBASFI and BASDAI is reliable and valid. Therefore, it can be used in clinical research as well as in clinical practice.

The reliability and validity of a Korean translation of the BASDAI in Korean patients with ankylosing spondylitis

OBJECTIVES

The objective of this study was to develop a Korean version of the original English version of BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) and to evaluate its reliability and validity in Korean patients with Ankylosing Spondylitis (AS).

METHODS

A total of 50 outpatients diagnosed as AS by the modified New York criteria participated. To develop a Korean version of the BASDAI, we followed rigorous international translation steps and evaluated reliability and validity by calculating Cronbach's alpha and correlation coefficients between BASDAI score and clinical parameters (e.g., ESR, CRP, modified Schober test index, finger-to-ground index, and Bath Ankylosing Spondylitis Radiologic Index Score, and bone mineral density).

RESULTS

Cronbach's alpha (= 0.75) was acceptable. The distribution of item responses evaluated by the ceiling and floor effects showed appropriate proportions and a good discrimination with the Korean version of the BASDAI. The correlations among the mean BASDAI score and five scales for the convergent validity was significantly correlated with each other (all P-values < 0.01). The correlations between the BASDAI score and both erythrocyte sedimentation rate and C-reactive protein for the criterion validity were positively correlated (all P-values < 0.05). The results of this study showed that the Korean translation of the BASDAI is an efficient tool in terms of its reliability and validity for the measurement of the disease activity in patients with AS.

CONCLUSIONS

The Korean version of the BASDAI could be used in clinical research to assess and evaluate the course of disease activity in Korean AS patients.

Spondyloarthritis update: new insights regarding classifcation, pathophysiology, and management

There has been a burgeoning interest in the spondyloarthritides (SpAs) due to a confluence of elements. Basic science research has provided new insight into the unique pathophysiology of synovium, enthesium, and bone, highlighting the important differences from rheumatoid arthritis (RA). Through collaborative research of international working groups, classification criteria for psoriatic arthritis (PsA) and ankylosing spondylitis (AS) have been developed or are being refined to aid characterization and diagnosis of SpAs and aid in research. These same working groups, under the umbrella of Outcome Measures in Rheumatology Clinical Trials (OMERACT), have developed domain core sets to be measured in clinical trials and registries, and which allow validation of reliable outcome measures. Both through clinical trials and observational data from national clinical registries, the relative effectiveness and safety of old and new therapies are being demonstrated. This has been particularly shown with long-term data on anti-TNF therapy. Newer anti-TNF therapies are being developed, as are treatments with different mechanisms of action in order to treat patients who do not have long-term effectiveness or develop side effects to older disease modifying therapy and anti-TNFs. International treatment recommendations have been or are being developed based on the evidence base from clinical trials.

Adalimumab, etanercept and infliximab for the treatment of ankylosing spondylitis: a systematic review and economic evaluation

OBJECTIVES

To assess the comparative clinical effectiveness and cost-effectiveness of adalimumab, etanercept and infliximab for the treatment of ankylosing spondylitis (AS).

DATA SOURCES

Major electronic databases were searched up to November 2005. Unpublished evidence such as conference abstracts, reviews of published economic evaluations, and company submissions to the National Institute for Health and Clinical Excellence (NICE) were also reviewed.

REVIEW METHODS

The assessment was conducted according to accepted procedures for conducting and reporting systematic reviews and economic evaluations. Full economic evaluations that compared two or more options for treatment and considered both costs and consequences were eligible for inclusion in the economic literature review.

RESULTS

Nine placebo controlled randomised controlled trials (RCTs) were included in the review of clinical effects. These included two studies of adalimumab, five of etanercept and two of infliximab in comparison with placebo (along with conventional management). No RCTs directly comparing anti-tumour necrosis factor-alpha (TNF-alpha) agents were identified. Meta-analyses were conducted for data on Assessment in Ankylosing Spondylitis (ASAS) (20, 50 and 70% improvement), mean change in Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and mean change in Bath Ankylosing Spondylitis Functional Index (BASFI) at 12 weeks following initiation of anti-TNF-alpha therapy or placebo for all three drugs. Meta-analyses were also conducted at 24 weeks for etanercept and infliximab. Each meta-analysis of anti-TNF-alpha therapy demonstrated statistically significant advantages over placebo, although there was no significant difference between individual anti-TNF-alpha agents. At 12 weeks, ASAS 50% responses were 3.6-fold more likely with anti-TNF-alpha treatment than placebo. Compared with baseline, BASDAI scores were reduced by close to 2 points at 12 weeks. Functional scores (BASFI) were reduced at 12 weeks. Six full economic evaluations (two peer-reviewed published papers, four abstracts) were included in the review. The conclusions among economic evaluations were mixed, although the balance of evidence indicates that over short time-frames anti-TNF-alpha therapies are unlikely to be considered cost-effective. The limitations of the clinical outcome data impose restrictions on the economic assessment of cost-effectiveness. Direct unbiased RCT evidence is only available in the short term. Current assessment tools are limited and at present BASDAI and BASFI are the best available, although not designed for, or ideal for, use in economic evaluations. The review of the three models submitted to NICE identified a number of inherent flaws and errors. The incremental cost-effectiveness ratios (ICERs) of etanercept and adalimumab were roughly similar, falling below an assumed willingness-to-pay threshold of 30,000 pounds. The ICER for infliximab was in the range of 40,000-50,000 pounds per quality-adjusted life-year (QALY). The short-term (12-month) model developed by this report's authors confirmed the large front-loading of costs with a result that none of the three anti-TNF-alpha agents appears cost-effective at the current acceptable threshold, with infliximab yielding much poorer economic results (57,000-120,000 pounds per QALY). The assumptions of the short-term model were used to explore the cost-effectiveness of the use of anti-TNF-alpha agents in the long term. This model is far more speculative than the first since trends and parameter values must be projected far beyond the available evidence. Sensitivity analyses reveal wide variations in estimates of cost over the long term although it is considered unlikely that costs will decrease over time.

CONCLUSIONS

The review of clinical data related to the three drugs (including conventional treatment) compared with conventional treatment plus placebo indicates that in the short term (12-24 weeks), the three treatments are clinically effective in relation to assessment of ASAS, BASDAI and BASFI. Indirect comparisons of treatments were limited and did not show a significant difference in effectiveness between the three agents. The short-term economic assessment indicates that none of the three anti-TNF-alpha agents is likely to be considered cost-effective at current acceptability thresholds, with infliximab consistently the least favourable option. There is an absence of evidence concerning a number of limiting factors related to patients suffering from AS, the disease itself and its treatment. In order to obtain robust estimates of the longer term clinical effectiveness and cost-effectiveness of anti-TNF-alpha agents for AS, clinical trials that aim to address these limiting factors need to be conducted.

[A comparison of respiratory muscle strength, pulmonary function tests and endurance in patients with early and late stage ankylosing spodylitis]

BACKGROUND

Ankylosing spondylitis (AS) is a multisystemic disease in which pulmonary function is altered owing mainly to the restriction of chest wall involvement. A restrictive ventilatory defect has been extensively reported. This has been suggested to be a consequence of reduced mobility of the thoracic cage. Respiratory function in AS shows a typical restrictive pattern but pulmonary compliance, diffusion capacity, and arterial blood gases are normal.

OBJECTIVE

The objective of the present study was to compare pulmonary function tests (PFT), respiratory muscle strength (MIP, MEP) and endurance (MVV) in early and late AS.

METHODS

A total of 35 patients (30 males, 5 females) took part, all of whom met the New York criteria for AS. Patients were divided into two groups for the comparison of early (disease duration <10 years, 20 patients) and late (disease duration >10 years, 15 patients) manifestations in pulmonary function tests, respiratory muscle strength and endurance, dyspnea score, chest expansion, and BASFI score. In addition, 21 healthy controls were compared with the AS patients. Measurement of chest expansion was performed in all subjects. Pulmonary function tests were performed by spirometry. Respiratory muscle strength was evaluated by a mouth pressure meter (MPM). Functional status was assessed by BASFI in all AS patients.

RESULTS

There was no significant difference in body mass index between the groups. The FVC and FEV(1) were significantly lower in late AS (p=0.003, p=0.03, restrictive ventilatory defect ). Chest expansion was significantly lower in late AS (p<0.05). There was no significant difference for MIP or MEP values between late AS, early AS and the controls (p>0.05). Endurance (MVV) was significantly lower in late AS patients (p=0.05). Although the BASFI and dyspnea scores were higher in late AS, they did not reach significant levels. In addition, age was negatively correlated with MIP and MEP in late AS (r=-0.733; p=0.02, r=-0.667; p=0.05).

CONCLUSION

This study demonstrates that FVC and FEV(1) (hallmarks of a restrictive pattern), MVV (endurance) and chest expansion are especially involved in long-standing AS. Therefore, improvement of the thoracic cage should be taken into consideration, especially in early AS. These patients should be encouraged to make regular respiratory exercises for preventing the limitation of chest expansion and also improving cardiopulmonary fitness and respiratory endurance.

Scoring inflammatory activity of the spine by magnetic resonance imaging in ankylosing spondylitis: a multireader experiment

OBJECTIVE

Magnetic resonance imaging (MRI) of the spine is increasingly important in the assessment of inflammatory activity in clinical trials with patients with ankylosing spondylitis (AS). We investigated feasibility, inter-reader reliability, sensitivity to change, and discriminatory ability of 3 different scoring methods for MRI activity and change in activity of the spine in patients with AS.

METHODS

Thirty sets of spinal MRI at baseline and after 24 weeks of followup, derived from a randomized clinical trial comparing a tumor necrosis factor (TNF)-blocking drug (n = 20) with placebo (n = 10) and selected to cover a wide range of activity at baseline and change in activity, were presented electronically in a partial latin-square design to 9 experienced readers from different countries (Europe, Canada). Readers scored each set of MRI 3 times, using 3 different methods including the Ankylosing Spondylitis spine Magnetic Resonance Imaging-activity [ASspiMRI-a, grading activity (0-6) per vertebral unit in 23 units]; the Berlin modification of the ASspiMRI-a; and the Spondyloarthritis Research Consortium of Canada (SPARCC) scoring system, which scores the 6 vertebral units considered by the reader as the most abnormal, with additional scores for "depth" and "intensity." Both the order of the methods used by each reader and the timepoints (before/after treatment) were randomized. Feasibility of each scoring system was evaluated by measuring the mean time needed to score each set of MRI, and inter-reader reliability was evaluated by smallest detectable change (SDC) and by intraclass correlation coefficients (ICC) for all readers together and for all possible reader pairs separately. Sensitivity to change was investigated by calculating Guyatt's effect size on change scores. Discriminatory ability was assessed using Z-scores (Mann-Whitney test) comparing change in score between patients treated with TNF-blocking drug and placebo.

RESULTS

The mean time to score one set of MRI was shortest for the Berlin method. SDC was lowest for the Berlin method and highest for SPARCC. Overall inter-reader ICC per method were between 0.49 and 0.77 for scoring activity status, and between 0.46 and 0.72 for scoring activity change. ICC for all possible reader pairs showed much more fluctuation per method, with lowest observed values of about 0.05 (very low agreement) and highest observed values over 0.90 (excellent agreement). In general, ICC for SPARCC were consistently higher than for other systems. Sensitivity to change differed per reader, and was more consistent with SPARCC than with the other methods, but was in general excellent for all 3 methods. Discrimination between groups (TNF-blocker vs placebo) assessed by Z-scores was good and comparable among methods.

CONCLUSION

This experiment demonstrates the feasibility of multiple-reader MRI scoring exercises for method comparison, provides evidence for the feasibility, reliability, sensitivity to change, and discriminatory capacity of all 3 tested scoring systems to be used in assessing spinal activity on MRI in patients with AS in clinical trials. On the basis of these results it is not possible to prioritize one of the 3 methods.

Is there a preferred method for scoring activity of the spine by magnetic resonance imaging in ankylosing spondylitis?

This report summarizes the discussion during a module update at OMERACT 8 on scoring methods for activity in the spine on magnetic resonance imaging. The conclusion was that the 3 available scoring methods are all very good with respect to discrimination and feasibility: the Ankylosing Spondylitis spine MRI score for activity (ASspiMRI-a), the Berlin method (a modification of the ASspiMRI-a), and the Spondyloarthritis Research Consortium of Canada Magnetic Resonance Imaging Index for Assessment of Spinal Inflammation in AS (SPARCC). All 3 methods were judged to be similar with respect to responsiveness and discrimination, although the differences in between-reader intraclass correlation coefficients (ICC) were judged to be relevant (the SPARCC method provided consistently higher ICC). The Berlin and SPARCC methods were preferred most frequently. The development of a new method combining the best elements of all methods is an additional possibility.

Translation and validation of non-English versions of the Ankylosing Spondylitis Quality of Life (ASQOL) questionnaire

Background

The Ankylosing Spondylitis Quality of Life (ASQOL) questionnaire is a unidimensional, disease-specific measure developed in the UK and the Netherlands. This study describes its adaptation into other languages.

Methods

The UK English ASQOL was translated into US English; Canadian French and English; French; German; Italian; Spanish; and Swedish (dual-panel methods). Cognitive debriefing interviews were conducted with AS patients. Psychometric/scaling properties were assessed using data from two Phase III studies of adalimumab. Baseline and Week-2 data were used to assess test-retest reliability. Validity was determined by correlation of ASQOL with SF-36 and BASFI and by discriminative ability of ASQOL based on disease severity. Item response theory (Rasch model) was used to test ASQOL's scaling properties.

Results

Cognitive debriefing showed the new ASQOL versions to be clear, relevant and comprehensive. Sample sizes varied, but were sufficient for: psychometric/scaling assessment for US English and Canadian English; psychometric but not scaling analyses for German; and preliminary evidence of these properties for the remaining languages. Test-retest reliability and Cronbach's alpha coefficients were high: US English (0.85, 0.85), Canadian English (0.87, 0.86), and German (0.77, 0.79). Correlations of ASQOL with SF-36 and BASFI for US English, Canadian English, and German measures were moderate, but ASQOL discriminated between patients based on perceived disease severities (p < 0.01). Results were comparable for the other languages. US English and Canadian English exhibited fit to the Rasch model (non-significant p-values: 0.54, 0.68), confirming unidimensionality.

Conclusion

The ASQOL was successfully translated into all eight languages. Psychometric properties were excellent for US English, Canadian English, and German, and extremely promising for the other languages.

Radiological scoring methods for ankylosing spondylitis: a comparison between the Bath Ankylosing Spondylitis Radiology Index and the modified Stoke Ankylosing Spondylitis Spine Score

OBJECTIVE

The main objective of the present study was to test the interobserver reliability, truth, discrimination and feasibility of two scoring methods available in ankylosing spondylitis (AS) over a follow-up period of 3 years.

METHODS

Two blinded trained observers scored 95 AS radiographs from a cohort of AS patients. Each radiograph was scored by two scoring methods, the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS), and the Bath Ankylosing Spondylitis Radiology Index--spine (BASRI-spine). Interobserver agreement was analyzed by intraclass correlation coefficients (ICC). The construct validity was assessed by examining the correlation of the scoring methods with measures of spinal mobility (Bath Ankylosing Spondylitis Metronomy Index--BASMI), functional limitation (Bath Ankylosing Spondylitis Functional Index--BASFI) and disease duration. Bland and Altman's 95% limits of agreement method and effect size (ES) analysis were used to estimate the smallest detectable difference (SDD) of radiological progression and responsiveness.

RESULTS

The BASRI-spine reached intra- and interobserver ICC of 0.755 and 0.831, respectively. The mSASSS scores were more reliable, with ICC of 0.874 and 0.941, respectively. Both scoring systems correlated significantly with BASMI (p = 0.01), while only the mSASSS showed a significant correlation (p = 0.02) with BASFI. With regards to sensitivity to change, it was found that mSASSS classified the highest percentage of patients with more changes than the BASRI-spine (mSASSS: 35.8% vs. BASRI-spine: 15.8%). The ES analysis also suggested that the mSASSS was more responsive than BASRI-spine. Concerning feasibility, the BASRI-spine takes less time for scoring.

CONCLUSION

We have shown that the mSASSS offers advantages in measurement properties and is the most appropriate method by which to assess progression of structural damage in AS.

[Russian versions of disease activity and functional condition evaluation scale in patients with Bekhterev's disease]

The aim of the study was Russianization and evaluation of the main psychometric properties (reliability, validity, and sensitivity) of the questionnaires BASDAI, BASFI, and DFI After the translation and preliminary approbation of the questionnaires, 65 patients (64 men and 1 woman) with a valid, in accordance with modified New York criteria, diagnosis of ankylosing spondylitis (AS), were included in the study. The reliability of BASDAI, BASFI, and DFI scales was evaluated using test-retest method; the validity and sensitivity of the scales were evaluated as well. Test-retest analysis did not reveal significant differences between the primary and subsequent values of all the questionnaires. Cronbach a internal consistency coefficient was 0.891 for BASDAI, 0.976 for BASFI, and 0.978for DFI, which testified that the results were highly reproducible and reliable. For BASDAI questionnaire there were no significant cor- relations with laboratory indices of AS activity (ESR, C-reactive protein level etc.), but there were significant correlations with BASF values (r = 0.73, p < 0.001) and DFI (r = 0.67, p < 0.001). The values of BASFl significantly correlated with signs of spine flexibility (tests of Schober, Ott, Thomayer, and Forestier), chest wall excursions, the duration of the disease, and the presence of hip joint involvement. DFI values correlated only with some of the listed indices (Schober and Thomayer tests; chest wall excursions). When the sensitivity was tested, only changes in BASDAI values (improvement by 16.1%, p < 0.05) were statistically significant. For BASFI and DFI changes in the values were not significant, but they were more prominent for BASFI (6.4% vs. 1. 7%, respectively). In conclusion, BASDAI questionnaire is a highly reliable and sensitive tool, but it only takes into account clinical signs of the activity of the disease. BASFI and DFI scales possess equal reliability, but the validity and sensitivity of BASFI scale are higher.

Recognition and treatment of juvenile-onset spondyloarthritis

PURPOSE OF REVIEW

The purpose of this review is to discuss the classification, diagnosis and management of juvenile-onset spondyloarthritis.

RECENT FINDINGS

There have been changes in the classification criteria for juvenile-onset spondyloarthritis and magnetic resonance imaging has allowed for earlier detection of disease. Additionally, tumor necrosis factor-alpha blockers have been shown to be effective in the treatment of ankylosing spondylitis. There is evidence to suggest that early treatment may lead to better response. A high percentage of patients with enthesitis-related arthritis progress to develop ankylosing spondylitis within 10 years after presentation. Patients with juvenile-onset ankylosing spondylitis appear to have poorer functional outcomes.

SUMMARY

Juvenile-onset spondyloarthritis has variable clinical features that may lead to significant impairments. Improved classification criteria exist, but better techniques that are more sensitive are needed to diagnose disease earlier. New therapies appear to improve outcomes, but randomized controlled trials are needed in this population of patients.

[Ankylosing spondylitis--current state of imaging including scoring methods]

Conventional radiography and magnetic resonance imaging (MRI) are currently the most widely used imaging methods for the initial diagnostic evaluation and follow-up of patients with ankylosing spondylitis (AS). Scintigraphy, computed tomography (CT), and positron emission tomography (PET) only play minor roles, although some are being further developed. AS is characterized by inflammatory changes to the sacroiliac joints (SIJs) and spine, as well as asymmetrical arthritis of the peripheral joints and joints near the trunk. The diagnosis of AS is based on clinical parameters and the presence of chronic inflammatory changes to the SIJs on conventional radiographs. Typical radiographic changes also involve the spine. MRI depicts not only chronic changes, but also active inflammatory lesions, which are important for the diagnosis of early disease and precursors of AS. The scoring system of choice for quantifying spinal changes depicted by conventional radiography is the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). MRI allows the quantitative evaluation of changes involving the SIJs and the spine. Various MRI scoring systems have been proposed to quantify these changes, but they require further validation. This review article presents the imaging modalities used in AS patients, typical findings, and relevant methods of analysis. The most recent developments are discussed.

[Clinical staging of ankylosing spondylitis]

OBJECTIVE

To compare the chronic changes between the sacroiliac joints (SIJ) and the spine or the hip joints in conventional radiography of patients with ankylosing spondylitis (AS) and discuss the clinical staging of this disease.

METHODS

All images of the joints of the AS patients were evaluated twice in blinded manner by two doctors. The cervical spine, lumbar spine, sacroiliac joints and hip joints were separately evaluated by BASRI, and the results were averaged and analyzed. Definite involvement was defined as a score > or=2.

RESULTS

Thirty-seven AS patients (81.0% male with mean age of 28.49 years) were examined, and 81.0% of them had definite involvement of the spine and 40.5% of hip involvement. Pearson product-moment correlation coefficient was 0.459 between BASRI-SIJ and BASRI-s, and 0.465 between BASRI-SIJ and BASRI-h.

CONCLUSION

Separately, the severity of SIJ changes can not represent the severity of changes in the spine and hip, etc, therefore SIJ changes may not be sufficient evidence for AS staging.

Performance of various criteria sets in patients with inflammatory back pain of short duration; the Maastricht early spondyloarthritis clinic

AIM

To describe how patients presenting with inflammatory back pain (IBP) of short duration can be classified by different sets of classification criteria for spondyloarthritis (SpA) and ankylosing spondylitis, and which clinical and imaging features are of discernible importance.

METHODS

68 patients with IBP of a maximum of 2 years' duration were included in the early spondyloarthritis cohort. Detailed history, clinical examination and imaging of sacroiliac joints by plain radiography and magnetic resonance imaging (MRI) were obtained. The Berlin criteria set for SpA that has a prominent place for MRI and human leucocyte antigen B27 was used to quantify the relative contribution of MRI in classifying SpA.

RESULTS

14 of the 68 patients had ankylosing spondylitis according to the modified New York criteria, 57 patients fulfilled the European Spondylarthropathy Study Group (ESSG) criteria for SpA, 48 patients fulfilled the Amor criteria for SpA (43 patients fulfilled both criteria sets) and 44 patients fulfilled the Berlin criteria for SpA. Only four patients did not fulfil any criteria set; 36 patients fulfilled ESSG, Amor and Berlin criteria. The 14 patients with ankylosing spondylitis fulfilled all three SpA criteria sets.

CONCLUSION

Among our selected cohort of patients with early IBP, the prevalence of SpA according to three different criteria sets is high. The ESSG criteria were the most sensitive, followed by the Amor criteria and the Berlin criteria. The modified New York criteria for ankylosing spondylitis appeared to be the most specific. In this cohort, the contribution of MRI and human leucocyte antigen B27 to purely clinical criteria in making a diagnosis of axial SpA was limited.

Effects of a multimodal exercise program for people with ankylosing spondylitis

BACKGROUND AND PURPOSE

Few randomized controlled studies have examined the effects of exercise in patients with ankylosing spondylitis (AS). This study investigated the effects of a 12-week, multimodal exercise program in patients with AS.

SUBJECTS

A convenience sample of 30 patients with AS (18 male, 12 female), with a mean age of 34.9 years (SD=6.28), participated in the study. Twenty-six subjects were classified as having stage I AS and 4 subjects were classified as having stage II AS according to the modified New York Criteria.

METHODS

This study was a randomized controlled trial. Subjects were assigned to either a group that received an exercise program or to a control group. The exercise program consisted of 50 minutes of multimodal exercise, including aerobic, stretching, and pulmonary exercises, 3 times a week for 3 months. Subjects in both groups received medical treatment for AS, but the exercise group received the exercise program in addition to the medical treatment. All subjects received a physical examination at baseline and at 12 weeks. The examinations were conducted under the supervision of a physician who specialized in physical medicine and rehabilitation and included the assessment of spinal mobility using 2 methods: clinical measurements (chin-to-chest distance, Modified Schober Flexion Test, occiput-to-wall distance, finger-to-floor distance, and chest expansion) and inclinometer measurements (gross hip flexion, gross lumbar flexion, and gross thoracic flexion). In addition, vital capacity was measured by a physiologist, and physical work capacity was evaluated by a doctorally prepared exercise instructor.

RESULTS

The measurements of the exercise group for chest expansion, chin-to-chest distance, Modified Schober Flexion Test, and occiput-to-wall distance were significantly better than those of the control group after the 3-month exercise period. The spinal movements of the exercise group improved significantly at the end of exercise program, but those of the control group showed no significant change. In addition, the results showed that the posttraining value of gross thoracic flexion of the exercise group was significantly higher than that of the control group. Physical work capacity and vital capacity values improved in the exercise group but decreased in the control group.

DISCUSSION AND CONCLUSION

In this study, a multimodal exercise program including aerobic, stretching, and pulmonary exercises provided in conjunction with routine medical management yielded greater improvements in spinal mobility, work capacity, and chest expansion.

[Early diagnosis of ankylosing spondylitis]

The present study surveys the problems of diagnostics of early ankylosing spondylitis (AS) and axial spondylarthritis (SpA). Epidemiologic studies repeatedly identified seven- to nine-year delay of diagnosis of AS from its development to its first manifestations. Delayed diagnostics is caused both by unfamiliarity of rheumatologists with the disease and the inappropriateness of New York classification criteria for early stages of AS. In this study, we suggest diagnostic algorithms allowing high probability diagnosis of AS/axial in X-ray silent stage (the so-called pre X-ray stage). Spondylarthritis represents approximately 5% of a total number of chronic low back pain (CLBP) cases. The probability grows up to 15% with the presence of inflammatory character of back pain. The presence of HLA B 27 increases the probability to 59% and the occurrence of other 1 or 2 clinical signs raises the probability up to 90%. Probability reaches 95% with positive MRI. The overall concept requires verification of new samples in a prospective study. After certification of such study, it will be possible to use biological medications for much more efficient therapy of patients in early AS stages.

Spondylarthrite ankylosante et ostéoporose

PURPOSE

Ankylosing Spondylitis (AS) is an inflammatory rheumatism characterized by its disease course with flares leading to progressive ankylosis of the spine related to paravertebral ligamentous and discal structures ossification. AS patients suffer significantly more vertebral fractures than control groups. These fractures could affect cervical spine. They are due to either ankylosis-related flawed spine compliance or AS-induced osteoporosis.

CURRENT KNOWLEDGE AND KEY POINTS

The physiopathology of this osteoporosis is multi-factorial, but essentially linked to AS-related inflammatory phenomenons. It is marked by reduced bone density (at lumbar spine and femoral neck), increased bone turnover (with increased urinary C-telopeptide cross-linked collagen type 1), but without any significant change in phosphocalcic blood parameters. Histological features are depressed bone formation, with either maintained or increased resorption.

FUTURE PROSPECTS

The screening of this osteoporosis is based upon investigating people at risk (progressive inflammatory AS) using dual-energy x-ray absorptiometry and biochemical markers of bone turnover. Treatment is based upon a modulation of both inflammatory phenomenons and bone remodelling using bisphosphonates and anti-TNF alpha.

Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria

OBJECTIVE

Back pain associated with ankylosing spondylitis (AS) is referred to as inflammatory back pain (IBP). The value of the clinical history in differentiating IBP from mechanical low back pain (MLBP) has been investigated in only a few studies. In this exploratory study, we sought to evaluate the individual features of IBP and to compose and compare various combinations of features for use as classification and diagnostic criteria.

METHODS

We assessed the clinical history of 213 patients (101 with AS and 112 with MLBP) younger than 50 years who had chronic back pain. Single clinical parameters and combinations of parameters were compared between the AS and MLBP patient groups.

RESULTS

Morning stiffness of >30 minutes' duration, age at onset of back pain, no improvement in back pain with rest, awakening because of back pain during the second half of the night only, alternating buttock pain, and time period of the onset of back pain were identified as independent contributors to IBP. Importantly, none of the single parameters sufficiently differentiated AS from MLBP. In contrast, several sets of combined parameters proved to be well balanced between sensitivity and specificity. Among these, a new candidate set of criteria for IBP, which consisted of morning stiffness of >30 minutes' duration, improvement in back pain with exercise but not with rest, awakening because of back pain during the second half of the night only, and alternating buttock pain, yielded a sensitivity of 70.3% and a specificity of 81.2% if at least 2 of these 4 parameters were fulfilled (positive likelihood ratio 3.7). If at least 3 of the 4 parameters were fulfilled, the positive likelihood ratio increased to 12.4.

CONCLUSION

A new set of criteria for IBP performed better than previous criteria in AS patients with established disease. A prospective study is needed to validate the diagnostic properties of the new candidate criteria set in patients with early disease.

Outcome-Parameter bei der ankylosierenden Spondylitis

Ankylosing spondylitis (AS) is a frequent inflammatory rheumatic disease and prototype of the Spondyloarthitides (SpA). During the last years outcome parameters have been developed to evaluate different aspects of the disease. Among these are the Bath AS Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI), Bath AS Metrology Index (BASMI), numeric rating scales for general pain, night pain, patients and physicians global assessment, as well as questionnaires to evaluate quality of life as the short Form (SF)- 36, Euroquol 5 Dimensions (EQ-5D), or the AS specific the ASQuol. These outcome parameters are the basis to conduct clinical trials. The ASessements in AS (ASAS) improvement criteria were developed to evaluate the short term efficacy of Non-Steroidal Antirheumatic Drugs (NSAIDs) and adjusted for the measurement of the high efficacy of the TNF-alpha blocking agents. To examine the x-rays of sacroiliac joints (SIG), the radiological criteria as part of the modified New York criteria are mostly used. For the x-rays of the spine the Bath AS Radiology Index (BASRI) is valuable in daily practice, but the modified Stokes AS Spine Score (mSASSS) is more sensitive for clinical trials. To examine Magnetic Resonance Images (MRI) of SIG and spine also scores are currently developed. Altogether, using the new outcome parameters it was possible to demonstrate the strikingly high efficacy of theTNF-alpha blocking agents. However, it could also be shown that conventional disease modifying antirheumatic drugs (DMARDs) are not effective in the treatment of the axial forms of SpA.

Spondyloarthritis research Consortium of Canada magnetic resonance imaging index for assessment of sacroiliac joint inflammation in ankylosing spondylitis

OBJECTIVE

To develop a feasible magnetic resonance imaging (MRI)-based scoring system for sacroiliac joint inflammation in patients with ankylosing spondylitis (AS) that requires minimal scan time, does not require contrast enhancement, evaluates lesions separately at each articular surface, and limits the number of sacroiliac images that are scored.

METHODS

A scoring method based on the assessment of increased signal denoting bone marrow edema on T2-weighted STIR sequences was used. MRI films were assessed blindly in random order at 2 sites by multiple readers. Intra- and interreader reliability was assessed by intraclass correlation coefficient (ICC); the 24-week response of patients with AS randomized to placebo:infliximab (3:8) was assessed by effect size and standardized response mean. The reliability and responsiveness of the scoring method were compared for STIR and gadolinium diethylenetriaminepentaacetic (Gd-DTPA)-enhanced MRI sequences.

RESULTS

We scanned 11 patients with AS with clinically active disease and 11 additional patients randomized to the trial of infliximab therapy. ICC for total sacroiliac joint STIR score ranged from 0.90 to 0.98 (P < 0.00001) and interobserver ICC for combined readers from the 2 sites was 0.84 (P < 0.0001). ICC for change scores was lower for STIR (ICC 0.53) than for Gd-DTPA-enhanced sequences (ICC 0.79). Responsiveness was poor, although fusion was evident in one-third of patients who received treatment (placebo:infliximab) and inflammation scores were low.

CONCLUSION

The Spondyloarthritis Research Consortium of Canada MRI index is a feasible and reproducible index for measuring sacroiliac joint inflammation in patients with AS.

Two Exercise Interventions for the Management of Patients with Ankylosing Spondylitis

OBJECTIVE

The purpose of this clinical trial was to evaluate the impact of a 4-month comprehensive protocol of strengthening and flexibility exercises developed by our research group versus conventional exercises for patients with Ankylosing Spondylitis (AS) on functional and mobility outcomes.

DESIGN

Randomized controlled trial. Forty-five patients diagnosed with AS according to the modified criteria of New York were allocated to control or experimental groups using a random numbers table. The control group was treated with a conventional protocol of physical therapy in AS, whereas the experimental group was treated with the protocol suggested by our research group. The conventional intervention consisted of 20 exercises: motion and flexibility exercises of the cervical, thoracic, and lumbar spine; stretching of the shortened muscles; and chest expansion exercises. The experimental protocol is based on the postural affectation of the AS and the treatment of the shortened muscle chains in these patients according to the Global Posture Reeducation (GPR) method. This intervention employs specific strengthening and flexibility exercises in which the shortened muscle chains are stretched and strengthened. The study lasted 4 mos. During this period, patients received a weekly group session managed by an experienced physiotherapist. Each session lasted an hour, and there were 15 total sessions. Changes in activity, mobility, and functional capacity were evaluated by an assessor blinded to the intervention, using the following previously validated scores from the Bath group: BASMI (tragus to wall distance, modified Schober test, cervical rotation, lumbar side flexion, and intermalleolar distance), BASDAI (The Bath Ankylosing Spondylitis Disease Activity Index), and BASFI (The Bath Ankylosing Spondylitis Functional Index).

RESULTS

Both groups showed an improvement (prepost scores) in all the outcome measures, mobility measures of the BASMI index, as well as in BASFI and BASDAI indexes. In the control group, the improvement in tragus to wall distance (P=0.009) and in lumbar side flexion (P=0.02) was statistically significant. Although the rest of the outcomes also improved, they did not reach a significant level (P>0.05). In the experimental group, the improvement in all the clinical measures of the BASMI index (P<0.01) and in the BASFI index (P=0.003) was statistically significant. The intergroup comparison between the improvement (prepost scores) in both groups showed that the experimental group obtained a greater improvement than the control group in all the clinical measures of the BASMI index, except in tragus to wall distance, as well as in the BASFI index.

CONCLUSIONS

The experimental protocol developed by our research group, based on the GPR method and specific strengthening and flexibility exercises of the muscle chains, offers promising results in the management of patients suffering from AS. Further trials on this topic are required.

Evaluation of the Turkish version of the Dougados functional index in ankylosing spondylitis

To investigate the reliability and validity of the Turkish version of the Dougados functional index (DFI) in patients with ankylosing spondylitis (AS). The Turkish version of DFI was obtained after a translation and back-translation process. Seventy consecutive patients with AS were enrolled. Patients were requested to complete the questionnaire on the day of admission (first visit), a second time within 24 h after admission (second visit), and on a third occasion. Reliability, validity and reproducibility of the Turkish version of the index were assessed. All the items showed significant correlations with the total index score with r-values ranging from 0.516 to 0.817. Cronbach alpha score was calculated as 0.908. Significant correlations were found between the total DFI score and Schober test (r=-0.293, P<0.05), occiput-wall distance (r=0.384; P<0.01) finger-to-floor distance (r=0.450, P<0.001), chest expansion (r=-0.331, P<0.01) and Dougados articular index (r=0.352, P<0.05). Good correlations were found between individual DFI items and the total score (r=between 0.533 and 0.882, p< 0.001) for the first and second visits, showing good reproducibility of the index.

CONCLUSION

the Turkish version of DFI has good reliability, validity and reproducibility, confirming its utility for trials in Turkish AS patients.

[Diagnosis and early diagnosis of ankylosing spondylitis]

Ankylosing spondylitis (AS) is often diagnosed not before 5-10 years after onset of clinical symptoms. The main reason for this delay is the late appearance of unequivocal radiographic sacroiliitis which is a prerequisite for making the diagnosis. It is important to realize that both the early stage without radiographic sacroiliitis and the late stage with radiographic sacroiliitis are part of the same disease and, therefore, should be considered as a disease continuum. The term axial spondyloarthritis (SpA) appears appropriate to describe this disease continuum. Diagnosing axial SpA without radiographic sacroiliitis, however, is difficult and associated with diagnostic uncertainties since there are no diagnostic criteria available. Considering all SpA features which are relevant for the diagnosis of axial SpA (with and without radiographic sacroiliitis), we have recently proposed a diagnostic algorithm based on calculations using Bayes' theorem to be applied in individual patients. This diagnostic algorithm enables the physician to diagnose or to exclude axial SpA with a high degree of confidence. An early and reliable diagnosis is relevant to both the patient and the physician since an early diagnosis allows the best therapy to be introduced and consequently maintained.

New directions in classification and outcome assessment in ankylosing spondylitis

In 2003, several manuscripts on the classification of patients as having ankylosing spondylitis and the further development of outcome assessment tools have been published. It is obvious that the use of radiographic sacroiliitis is a problematic part of the classification criteria because there is major interobserver variation and is one of the causes of a long delay between onset of symptoms and diagnosis. Especially in patients without human leukocyte antigen B27, the diagnostic delay is long. Existing outcome tools, such as the Bath Ankylosing Spondylitis Disease Activity Index, have been adapted and validated for use in other languages. New instruments to assess quality of life (Ankylosing Spondylitis Quality of Life Index; Patient Generated Index) and physical functioning (World Health Organization Disability Assessment Schedule II) have been developed and validated for the use in ankylosing spondylitis. In addition, a new and feasible tool to assess enthesitis has been constructed and validated. Because fatigue is an important symptom for patients with ankylosing spondylitis, a recommendation to use a specific fatigue instrument was created. The statistically derived Assessment in Ankylosing Spondylitis response criteria have been compared with expert opinion and are strict criteria. Responders as defined by the Assessment in Ankylosing Spondylitis response criteria also are considered by the experts as responders.

A Turkish version of the Bath Ankylosing Spondylitis Disease Activity Index: reliability and validity

The aim of this study was to develop a Turkish version of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and assess its reliability, validity, and sensitivity to change. The Turkish version was obtained after a translation and back-translation process. Seventy-one patients with ankylosing spondylitis were assessed with it. To assess its validity, patients were also evaluated with the Turkish version of the Bath Ankylosing Spondylitis Functional Index (BASFI), the Bath Ankylosing Spondylitis Metrology Index (BASMI), the Bath Ankylosing Spondylitis Patient Global Score (BAS-G), and physicians' assessments of disease activity. Over 24 h, the Turkish BASDAI did not show significant differences between the two assessments (P>0.05). Correlations were found between BASDAI and all of the evaluation parameters except BASMI (P<0.01). Both BASDAI and BASMI showed significant improvements after 8-week home exercise programmes. The results of this study show that the Turkish version of the BASDAI is reliable, valid, and sensitive to change.

[Adaption and validation of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) for use in Germany]

OBJECTIVE

The purpose of this study was the validation of a German translation of the Bath Ankylosing Spondylitis Index (BASDAI).

PATIENTS AND METHODS

The German translation of the BASDAI was validated using data of 134 patients with ankylosing spondylitis (AS) from a spondyloarthropathy cohort. For validation the BASDAI was compared with parameters assessed by physicians (physicians global, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), spinal mobility (BASMI), swollen joints, enthesitis (yes or no)), and parameters assessed by patients themselves (pain, function (BASFI) and quality of life (SF-12)). The discriminative validity was analyzed by comparison of BASDAI scores of patients subgroups who have different levels of disease severity. The sensibility to change was analyzed by using follow-up data of a clinical trial on efficacy of the anti-tumor necrosis factor (TNF) alpha agent infliximab in 70 AS-patients with active and severe disease.

RESULTS

The German translation of the BASDAI was easy to understand, the translation back to English corresponded well with the original English version. The 6 questions of the BASDAI represent different aspects of disease but correlated also well with each other (r < 0.65). There was a good internal consistency for all 6 questions (Cronbach's Alpha 0.82), strong correlations to the physician's global (r = 0.659), pain (r = 789), function (BASFI; r = 0.752) and to CRP and ESR confirming that the BASDAI assesses a comprehensive picture of patient's disease activity. For subgroups of patients with different levels of disease severity or with different manifestations the BASDAI showed good discriminative properties. The BASDAI was sensitive to change during treatment with infliximab (effect size 1.18).

CONCLUSION

The German translation of the BASDAI is easy to use, reliable, and sensitive to change for the assessment of disease activity in AS.

[The BASDAI-D--an instrument to defining disease status in ankylosing spondylitis and related diseases]

OBJECTIVE

Translation and validation of the Bath Ankylosing Spondylitis Disease Activity Index ( BASDAI) for defining disease status in ankylosing spondylitis (AS) and related diseases.

METHODS

The German version BASDAI-D was translated with only a few modifications. It contains six 10 cm horizontal visual analog scales to measure severity of fatigue, spinal and peripheral joint pain, tenderness and morning stiffness. A total of 318 patients with AS and other spondarthropathies completed the instrument at the beginning and at the end of their medical rehabilitation. Psychometric evaluation was performed separately for patients with AS corresponding to the modified New York Criteria ( SPA-NY, N=211) and for a second group of patients, which fulfilled the early diagnostic criteria for AS or the ESSG criteria of spondylarthropathies (Fd/Spond., N=86).

RESULTS

SPA-NY: Factor analysis yielded one factor explaining 54.8% of variance. The sum score with a standard deviation of 1.94 is nearly symmetrical distributed with mean of 4.7. Reliability analysis yielded high internal consistency (Cronbach's alpha=0.83). Corrected item-total correlations are also high and are large ranging from 0.48 to 0.71. Concerning concordant validity the BASDAI-D showed a substantial correlation with the scale bodily pain of the SF 36 (r = -0.72). There are no correlations with objective clinical parameters. Furthermore the assessment of disease activity by the physician correlates significantly, albeit low with the BASDAI-D. Sensitivity to change yields effect sizes up to 0.60. Fd/Spond.: The results for this group are almost identical with SPA-NY (one factor explaining 53.8% variance, mean 4.6+/-1.75; corrected item-total correlations from 0.50 to 0.75; correlation with the scale bodily pain r = -0.62). Analysis for subgroups showed higher scores for women in both groups SPA-NY and Fd/Spond.

CONCLUSION

BASDAI-D ist applicable for patients with AS and likewise for patients fulfilling the early diagnostic criteria for AS or the ESSG criteria of spondylarthropathies. In summary, BASDAID is reliable and valid. Because of its good acceptance and usability BASDAI-D is easy to use in research as well as in clinical practice.