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

How to Monitor Disease Activity of Axial Spondyloarthritis in Clinical Practice

PURPOSE OF REVIEW

Treatment guided by periodic and quantitative data assessment results in better outcomes compared to using clinical gestalt. While validated generic as well as specific disease activity measures for axial spondyloarthritis (axSpA) are available, there is vast scope to improve their actual utilization in routine clinical practice. In this review, we discuss available disease activity measures for axSpA, describe results from the survey conducted among general rheumatologists as well as Spondyloarthritis Research and Treatment Network (SPARTAN) members about disease activity measurement in daily practice, and discuss ways to improve axSpA disease activity using technological advances. We also discuss the definitions of active disease and target for the treatment of axSpA.

RECENT FINDINGS

The 2019 American College of Rheumatology (ACR)/Spondylitis Association of America (SAA)/Spondyloarthritis Research and Treatment Network (SPARTAN) axSpA treatment guidelines conditionally recommend the regular monitoring of disease activity using a validated measure such as Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) or Ankylosing Spondylitis Disease Severity Index (ASDAS). Assessment of Spondyloarthritis International Society (ASAS)-European Alliance of Associations for Rheumatology (EULAR) guidelines recommend ASDAS as the most appropriate instrument for the assessment of disease activity, preferably calculated using C-reactive protein (CRP). ASAS has selected a core set of variables which were updated recently and have been endorsed by the Outcome Measures in Rheumatology Clinical Trials (OMERACT) group in order to bring homogeneity in assessment of axSpA. In a recent study, Patient-Reported Outcomes Measurement Information System (PROMIS®) measures were able to discriminate inactive, moderate, and high-very high ASDAS activity groups. A newly developed semi-objective index P4 (pain, physical function, patient global, and physician global) correlates well with BASDAI and ASDAS in axSpA and can also be used for other rheumatic diseases in busy clinical practices. Regular disease activity monitoring is critical for long-term management of axSpA and shared decision-making. The integration of electronic health records and smart devices provides a great opportunity to capture patient-reported data. Automated capture of electronic patient-reported outcome measures (ePROMs) is a highly efficient way and results in consistent regular monitoring and may improve the long-term outcomes. While currently used measures focus only on musculoskeletal symptoms of axSpA, a composite disease activity measure that can also incorporate extra-articular manifestations may provide a better assessment of disease activity.

Piriformis syndrome as an overlooked cause of pain in a patient with axial spondyloarthritis: a case report

Piriformis syndrome is a neuromuscular disorder characterized by hip, buttock, and leg pain. Axial spondyloarthritis is a rheumatic disease primarily affecting the sacroiliac joint and the spine. Due to their anatomical proximity, the potential relationship between piriformis syndrome and sacroiliitis has been discussed for some time. However, literature review revealed that there is no study on piriformis syndrome in individuals with axial spondyloarthritis. Here, we present the case of a 30-year-old female with axial spondyloarthritis who developed severe low back, hip, and buttock pain that persisted despite initial treatment for axial spondyloarthritis. We first re-evaluated her condition through physical examination, magnetic resonance imaging, and an injection test for piriformis syndrome. Following a comprehensive assessment, the patient was diagnosed with both axial spondyloarthritis and piriformis syndrome. Subsequently, a tailored treatment plan was devised, addressing both conditions, and after a 3-month course of treatment, we obtained significant reduction in pain of the patient. This is the first case report in literature, where we used injection test to confirm the diagnosis of the piriformis syndrome in a patient with axial spondyloarthritis. We therefore strongly advocate considering piriformis syndrome as a potential etiology for pain in individuals with axial spondyloarthritis consistently. This recognition is important as piriformis syndrome does not respond adequately to non-steroidal anti-inflammatory drugs and may lead to unnecessary use of biological disease-modifying antirheumatic drugs. Timely identification and intervention are imperative in ensuring optimal patient care.

Correlation between clinical disease activity and sacroiliac magnetic resonance imaging detection in axial spondyloarthropathy

Objectives

The study aimed to evaluate the correlation between the clinical disease activity of axial spondyloarthropathy (axSpA) and magnetic resonance imaging findings of the sacroiliac joint.

Patients and methods

Thirty-two patients (21 males, 11 females; mean age: 39.3±9.2 years; range, 18 to 55 years) who were diagnosed with axSpA according to the Assessment in Spondyloarthritis International Society classification criteria between November 2015 and August 2017 were included in this cross-sectional study. Visual Analog Scale (VAS), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score (ASDAS)-erythrocyte sedimentation rate (ESR), and ASDAS-C-reactive protein (CRP) were used as the indicators of clinical activity. Magnetic resonance imaging of the sacroiliac joint was performed and the Spondyloarthritis Research Consortium of Canada (SPARCC) score was evaluated by a radiologist who was blinded to the clinical and laboratory parameters of the patients.

Results

The mean duration of symptom onset was 9.3±7.7 years, and the mean duration of diagnosis was 3.6±2.8 years. Human leukocyte antigen (HLA)-B27 was positive in 16 (50%) patients. There was no correlation between the SPARCC score and VAS, BASDAI, MASES, BASFI, ASDAS-CRP, ASDAS-ESR, ESR, and CRP values (p>0.05). In the HLA-B27 subgroup analyses, a statistically significant correlation was found between HLA-B27-negative patients and SPARCC score (r=0.639, p=0.008).

Conclusion

No relationship was found between other clinical disease parameters and sacroiliac joint imaging findings, except for the relationship between the SPARCC and BASDAI in HLA-B27- negative patients with axSpA.

Effect of cervical stabilization exercises on cervical position error in patients with axial spondyloarthritis: a randomized controlled pilot study

OBJECTIVE

To investigate the effect of cervical stabilization exercises on cervical position error in patients with axial spondyloarthritis (axSpA).

MATERIALS AND METHODS

Thirty-nine patients with axSpA were randomly allocated to two groups as exercise group (n = 20, 11 males) and control group (n = 19, 12 males). The exercise group performed a progressive home-based cervical stabilization exercise program, while the control group did not receive any exercise intervention. To control exercise adherence and progression, text messages and video instructions were delivered via a freeware and cross-platform messaging service on a weekly basis. All patients were evaluated regarding physical characteristics, disease activity (Bath Ankylosing Spondylitis Disease Activity Index), functional status (Bath Ankylosing Spondylitis Functional Index), and spinal mobility (Bath Ankylosing Spondylitis Metrology Index). Cervical position error was evaluated in flexion, extension, rotation, and lateral flexion directions. All evaluations were performed at baseline and after 6 weeks.

RESULTS

Baseline physical and disease-related characteristics were similar between the groups (p > 0.05). After 6 weeks, significant improvements were observed in cervical position error in all directions in the exercise group (p < 0.05), whereas no improvements were detected in the control group (p > 0.05).

CONCLUSION

A 6-week home-based cervical stabilization exercise program seems to be beneficial for improving impaired cervical proprioception in patients with axSpA.

Use of the Oswestry Disability Index in ankylosing spondylitis

OBJECTIVE

The Oswestry Disability Index is considered the gold standard in the evaluation of disability in patients with chronic mechanical back pain. The aim of this study was to assess the applicability of Oswestry Disability Index in patients with ankylosing spondylitis and its relationship with disease assessment parameters for ankylosing spondylitis.

METHODS

A total of 100 patients diagnosed with ankylosing spondylitis were included in the study group. The control group consisted of 50 individuals with nonspecific low back pain. The Oswestry Disability Index and Bath Ankylosing Spondylitis Disease Activity Index were applied to both groups. In addition, the Visual Analog Scale, the Ankylosing Spondylitis Disease Activity Score C-Reactive Protein, the Ankylosing Spondylitis Disease Activity Score-the Erythrocyte Sedimentation Rate, the Bath Ankylosing Spondylitis Functional Index, Bath Ankylosing Spondylitis Metrology Index, and the Ankylosing Spondylitis Quality of Life scales were applied in the study group. the Erythrocyte Sedimentation Rate, C-Reactive Protein levels, and HLA-B27 analysis were noted as laboratory markers in ankylosing spondylitis patients.

RESULTS

The scores of Oswestry Disability Index had a significant correlation with scores of Bath Ankylosing Spondylitis Disease Activity Index in ankylosing spondylitis patients (r=0.543) and in the control group (r=0.401). There was a significant correlation between the scores of Oswestry Disability Index and the Bath Ankylosing Spondylitis Functional Index (r=0.544), Bath Ankylosing Spondylitis Metrology Index (r=0.317), the Ankylosing Spondylitis Quality of Life (r=0.723), the Ankylosing Spondylitis Disease Activity Score-the Erythrocyte Sedimentation Rate (r=0.501), the Ankylosing Spondylitis Disease Activity Score C-Reactive Protein (r=0.530), Visual Analog Scale-Rest (r=0.476), and Visual Analog Scale-Activity (r=0.441) values in patients with ankylosing spondylitis.

CONCLUSION

Evaluation of Oswestry Disability Index in conjunction with Bath Ankylosing Spondylitis Disease Activity Index may warn the physician to interpret high Bath Ankylosing Spondylitis Disease Activity Index scores in the context of mechanical pain. Therefore, the use of Oswestry Disability Index in patients with ankylosing spondylitis will be beneficial.

A comparison of the clinical characteristics and quality of life of male and female patients with non-radiographic axial spondyloarthritis

OBJECTIVE

The aim of this study was to compare the clinical characteristics and quality of life of male and female patients with non-radiographic axial spondyloarthritis (nraxSpA) to determine the differences and similarities.

PATIENTS AND METHODS

The study included 100 patients, comprising 50 males and 50 females, aged 18-65 years, who presented at the Rheumatology Clinic and were diagnosed with nr-axSpA according to the Assessment of Spondyloarthritis International Society (ASAS) criteria. The data of patient age, gender, body mass index, disease duration, and drugs used were recorded. Disease activity was evaluated with the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), mobility with the Bath Ankylosing Spondylitis Metrology Index (BASMI), functional status with the Bath Ankylosing Spondylitis Functional Index (BASFI), enthesitis with the Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), and quality of life with the Ankylosing Spondylitis Quality of Life (ASQoL). The patients with nr- axSpA were separated into groups as male and female, and the demographic and clinical data were compared.

RESULTS

The mean age of female patients was determined to be statistically significantly higher than that of the male patients (39.04 ± 0.70 vs. 34.28 ± 9.26 years, p:0.014). A statistically greater number of male patients were smokers (p:0.007). The disease duration and time since diagnosis were determined to be significantly longer in females than in males (p:0.029, p:0.004). Peripheral arthritis was determined at a significantly higher rate in females (p < 0.001). The MASES score was 2.66 ± 3.46 in females and 0.52 ± 1.03 in males, and the difference was statistically significant (p < 0.001). The BASDAI score was significantly higher in females (3.74 ± 2.35) than in males (2.88 ± 1.95) (p:0.05). No statistically significant difference was determined between the two groups in respect of BASFI, BASMI, ASQoL, and other parameters.

CONCLUSION

The results showed older age, longer disease duration and time to diagnosis, higher rates of peripheral arthritis, and higher MASES and BASDAI scores in the female patients. Thus, there are some differences between male and female patients. Further studies should determine what kind of changes these differences will make in the clinical status, follow-up and treatment of patients.

Evaluation of the relationship between blood cell markers and inflammation, disease activity, and general health status in ankylosing spondylitis

OBJECTIVE

The aim of this study was to assess the relation of systemic immune inflammation index, systemic inflammation response index, and systemic inflammation aggregate index with disease activity, functional status, and general health status in ankylosing spondylitis.

METHODS

Patients with ankylosing spondylitis and healthy volunteers were included in this cross-sectional study. Demographic data; disease activity measurements such as the Bath Ankylosing Spondylitis Disease Activity Index, the Ankylosing Spondylitis Disease Activity Score with C-reactive protein, and the Ankylosing Spondylitis Disease Activity Score with erythrocyte sedimentation rate; functional status such as the Bath Ankylosing Spondylitis Functional Index; and general health status such as the Assessment of Spondyloarthritis International Society Health Index of the patients were recorded. C-reactive protein, erythrocyte sedimentation rate, platelet to lymphocyte ratio, neutrophil to lymphocyte ratio, monocyte to lymphocyte ratio, systemic immune inflammation index, systemic inflammation response index, and systemic inflammation aggregate index values were recorded. Patients were grouped as active and remission according to the Bath Ankylosing Spondylitis Disease Activity Index score and as inactive-low and high-very high disease activity according to the Ankylosing Spondylitis Disease Activity Score. The correlation of laboratory parameters with disease-related parameters was tested.

RESULTS

The indexes were significantly higher in patients compared to controls (p<0.001, for platelet to lymphocyte ratio p=0.03). No significant differences existed in any blood cell-derived indexes among patient groups categorized by disease activity (p<0.05 for all). Systemic immune inflammation index was weakly correlated with Ankylosing Spondylitis Disease Activity Score with C-reactive protein (ρ=0.197 and p=0.049) and Ankylosing Spondylitis Disease Activity Score-erythrocyte sedimentation rate (ρ=0.201 and p=0.045). Systemic immune inflammation index was not correlated with Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index, and Assessment of Spondyloarthritis International Society Health Index. No correlation was found between other indexes and disease-related variables. Platelet to lymphocyte ratio, systemic immune inflammation index, systemic inflammation response index, and systemic inflammation aggregate index showed a weak positive correlation with C-reactive protein and erythrocyte sedimentation rate (ρ=0.200-0.381).

CONCLUSION

Systemic immune inflammation index, systemic inflammation response index, and systemic inflammation aggregate index can be used to indicate systemic inflammatory burden in ankylosing spondylitis patients. However, these indexes are not effective in indicating patients' disease activity, general health status, and functional status.

Hearing loss can also be seen in patients with nonradiographic axial spondyloarthropathies as well as radiographic axial spondyloarthropathies

Objectives

Hearing loss has been described in patients with radiographic axial spondyloarthropathies (R-AxSpA) but has not been studied in patients with non-radiographic axial spondyloarthropathies (NR-AxSpA); accordingly, the aim of the study was to compare hearing loss in patients with NR-AxSpA, R-AxSpA, and healthy individuals.

Patients and methods

This cross-sectional observational study was conducted with 68 participants (30 males, 38 females; mean age: 39.8±7.4 years) between March 2021 and March 2022. Of the participants, 16 were patients with NR-AxSpA, 15 were patients with R-AxSpA, and 37 were healthy controls. Disease activity and radiological and audiological features were analyzed. The audiological assessment included pure-tone audiometric tests at octave frequencies of 250 to 8000 Hz and transient evoked otoacoustic emissions.

Results

Hearing loss was found in three (8%) in the healthy group, five (31.3%) in the NR-AxSpA group, and 10 (66.7%) in the R-AxSpA group. The chi-square analysis showed a statistical significance (p=0.001). Values of audiometric tests yielded significant differences between the control and R-AxSpA group and also the control and NR-AxSpA group. For the air conduction studies, the statistical significance began at 1000 Hz in the R-AxSpA group. It was found that in the NR-AxSpA group, the statistical difference started in higher frequencies. The bone conduction audiometric studies were similar to air conduction studies. Transient evoked otoacoustic emission studies showed that the R-AxSpA group was significantly affected compared to the control and NR-AxSpA groups. There was no statistical difference between the control and NR-AxSpA groups.

Conclusion

Both NR-AxSpA and R-AxSpA patients had hearing loss; however, in pure-tone audiometric tests, the abnormalities began in lower frequencies in the R-AxSpA group than in the NR-AxSpA group.

Biopsychosocial factors should be considered when evaluating central sensitization in axial spondyloarthritis

To identify the determinants of central sensitization (CS) in patients with axial spondyloarthritis (axSpA). Central Sensitization Inventory (CSI) was used to determine CS frequency. Disease-related variables including Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score (ASDAS-CRP/-ESR), Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), Bath Ankylosing Spondylitis Functional Index (BASFI), Ankylosing Spondylitis Quality of Life Questionnaire (ASQoL) and Numeric Rating Scale (NRS)_GLOBAL were assessed. Biopsychosocial variables were evaluated by the Multidimensional Scale of Perceived Social Support (MSPSS), Brief Illness Perception Questionnaire (B-IPQ), Hospital Anxiety and Depression Scale (HADS) and subscales for Anxiety (HADS-A) and Depression (HADS-D), and Jenkins Sleep Evaluation Scale (JSS). To determine the predictors of the development and severity of CS, multiple linear and logistic regression analyses were performed. The frequency of CS was 57.4% in the study population (n = 108). CSI score was correlated with the duration of morning stiffness, BASDAI, ASDAS-CRP, ASDAS-ESR, NRS_GLOBAL, BASFI, MASES, ASOoL, JSS, HADS, and B-IPQ total scores (ρ ranged from 0.510 to 0.853). Multiple regression analysis indicated that BASDAI (OR: 10.44, 95% CI: 2.65-41.09), MASES (OR: 2.47, 95% CI: 1.09-5.56) and HADS-A (OR: 1.62, 95% CI: 1.11-2.37) were independent predictors of the development of CS. Additionally, higher NRS_GLOBAL, JSS, HADS-D, and HADS-A scores appeared to determine the severity of CS. This study confirms that worse disease activity, more enthesal involvement, and anxiety independently predict the development of CS. Additionally, higher patient-perceived disease activity, sleep impairment and poor mental health significantly contribute to the severity of CS.

Identifying frailty and its associated factors in patients with axial spondyloarthritis

BACKGROUND AND AIM

Frailty is an elderly people phenomenon; however, younger adults with comorbidities may show a higher trajectory of frailty toward older age. The frailty status of middle-aged patients with axial spondyloarthritis (axSpA) remains little researched. We aimed to identify frailty status and to investigate the association of clinical, sociodemographic, and psychosocial factors with frailty.

METHODS

This study included 114 patients aged between 40 and 65 years. The patients were classified as frail, pre-frail, and robust according to Fried's phenotype and the Kihon Checklist (KCL). Physical function, quality of life, depression, anxiety, and disease-related factors were assessed. Between-group comparisons and multinomial logistic regression analysis were performed.

RESULTS

Frailty and pre-frailty prevalences were 20.2% and 49.1% for Fried's phenotype and 36.0% and 33.3% for the KCL. Frail adults had impaired physical function and increased disease activity compared to pre-frail and robust patients. Adjusted multinomial logistic regression analysis revealed that disease activity (odds ratio [OR] = 1.62, 95% CI = 1.12-2.34) and Short Physical Performance Battery (OR = 0.32, 95% CI = 0.18-0.56) were associated with Fried's phenotype-determined frailty. Disease activity (OR = 1.91, 95% CI = 1.11-3.26), Bath Ankylosing Spondylitis Functional Index (OR = 2.70, 95% CI = 1.56-4.67), and depression (OR = 1.55, 95% CI = 1.18-2.02) were associated with the KCL determined frailty.

CONCLUSION

Frailty and pre-frailty are commonly detected in middle-aged individuals with axSpA. Our findings highlight a possible need for frailty screening and preventive programs targeting middle-aged axSpA patients.

The relationship between central sensitization and disease activity, quality of life, and sleep quality among patients with axial spondyloarthritis

BACKGROUND

Central sensitization (CS) has been held responsible in previous studies for persistent pain and persistently high disease activity in axial spondyloarthritis (axSpA). Sleep disturbance is also regarded as an important problem for patients with axSpA.

AIMS

This study determines the CS levels of patients with axSpA compared to healthy controls (HC) and investigates its relationship with disease activity, quality of life (QoL), and sleep quality.

METHODS

Eighty-two patients with axSpA (group 1: mean age 38.83 ± 10.11 (76.8%male)) and 40 healthy volunteers (group2: mean age 38.58 ± 7.48 (77.5%male)) were included in this cross-sectional observational study. Evaluation parameters were visual analog scale (VAS), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score (ASDAS-CRP), Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), Short Form-36 (SF-36), Central Sensitization Inventory (CSI), and Pittsburgh Sleep Quality Index (PSQI). Also, participants were divided into subgroups as CSI < 40 and CSI ≥ 40. Groups were compared to themselves. A correlation between the patients' CSI scores and other evaluation parameters was examined.

RESULTS

CS rates were 45.1% and 7.5% for axSpA and HC, respectively (p < 0,001). The frequency of severe forms of CS was higher in patients with axSpA than in the healthy controls (p < 0.05). AxSpA patients with CS exhibited significantly higher pain, MASES, BASDAI, ASDAS-CRP, and PSQI scores than axSpA patients without CS (p < 0.05). A close relationship between CS severity and the female gender, pain, disease activity, sleep quality, and QoL was found among axSpA patients.

CONCLUSIONS

Clinical CS is common among axSpA patients. CS adversely affects disease activity, pain, sleep quality, and QoL of axSpA patients. CS should be considered when planning axSpA treatment.

Drug retention rate and predictive factors of drug survival for secukinumab in radiographic axial spondyloarthritis

The drug retention rate has been an important indicator for evaluating the treatment tolerance. Unfortunately, our knowledge of the secukinumab retention rate in radiographic axial spondyloarthritis (r-AxSpA) is limited. The objective of this study was to assess the retention rate of secukinumab and evaluate predictive factors of drug survival based on data from a real-life cohort. We retrospectively assessed 147 r-AxSpA patients between May 2018 and January 2020 from the HUR-BIO database. Secukinumab retention rates were analyzed using the Kaplan-Meier method and Cox proportional hazard model was used for predictors factors. The global retention rate of secukinumab was 55% at 12 months. r-AxSpA patients with obesity had a lower frequency of secukinumab discontinuation (29% vs. 50%, p = 0.013) in comparison r-AxSpA patients without obesity. In multivariate analysis, multiple TNFi usage had a higher risk of secukinumab discontinuation [HR 1.99 (1.09-3.62), p = 0.024]; on the other hand, obesity had a lower risk [HR 0.45 (0.27-0.90), p = 0.008]. Except for not using multiple TNFi, this real-life analysis showed for the first time that obesity is not an adverse risk factor for secukinumab drug retention in r-AxSpA. Secukinumab, which is an interleukin-17A inhibitor, could act via a different pathway than tumor necrosis factor inhibitors (TNFi). The identification of predictive factors such as obesity that may affect the individual drug selection may provide more appropriate biologic treatment strategies for r-AxSpA.

Comparison of the effects of aerobic training alone versus aerobic training combined with clinical Pilates exercises on the functional and psychosocial status of patients with ankylosing spondylitis: A randomized controlled trial

To compare the effects of aerobic training versus aerobic training combined with clinical Pilates exercises (CPE) on the functional and psychosocial status of patients with ankylosing spondylitis (AS). Twenty-eight patients with ankylosing spondylitis (AS) were randomized into 2 groups. Group 1 (n = 14) performed both aerobic training and CPE, whereas group 2 (n = 14) performed aerobic training alone. Functional status of the patients was assessed using the Bath Ankylosing Mobility Index (BASMI), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), back scratch test (BST), single leg stance test, functional reach test, a dynamometer, chair sit and stand test, and 6-minute walk test (6MWT), and the psychosocial status of the patients was assessed using the Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire, the Multidimensional Assessment of Fatigue (MAF), Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety Depression Scale (HADS), and Tampa Scale of Kinesiophobia (TSK). Both training programs were conducted for 8 weeks, and then, the assessments were repeated. A statistically significant improvement was observed in the BASMI (p = .001), BASDAI (p = .001), BASFI (p = .002), BST (right, p = .05; left, p = .025), functional reach test (p = .013), back muscle strength (p = .033), 6MWT (p = .011), ASQoL (p < .001), MAF (p = .01), and PSQI (p = .013) scores in group 1. A significant difference was observed in the BASDAI (p = .028), chair sit and stand test (p = .022), 6MWT (p = .04), and ASQoL (p = .04) scores in group 2. CPE in addition to aerobic training was more effective in improving the functional and psychosocial status of the patients with AS.

The relationship between the frequency and severity of restless legs syndrome and anaemia in patients with ankylosing spondylitis

Background Background The study aims to determine the frequency of restless legs syndrome (RLS) in patients with ankylosing spondylitis (AS) and the relationship between the International Restless Legs Syndrome Study Group Rating Scale (IRLSSG-RS) score and anemia. Material and Methods It was a case-control study that included 106 patients with AS and 106 age- and sex-matched healthy controls in the rheumatology clinic of a training and research hospital. The patients were divided into two groups according to their hemoglobin levels. A hemoglobin level lower than 12 g/dL in women and less than 13 g/dL in men was the criterion for anemia. Results Although the frequency of RLS was higher in AS patients than in control groups, there was no significant difference in the IRLSSG-RS score between AS patients and control groups. 23 (57.5%) of the AS patients with anemia had RLS, and the IRLSSG-RS score was 21.3±5.7. Of the AS patients without anemia, 11 (16.7%) had RLS, and the IRLSSG-RS score was 15±6. Statistically significant differences between AS patients with and without anemia regarding RLS frequency and IRLSSG-RS score were found. The IRLSSG-RS scores of AS patients were negatively correlated with serum iron and hemoglobin level. Conclusions Patients with AS had a higher RLS frequency than the control group; AS patients with anemia had a higher RLS and IRLSSG-RS score than AS patients without anemia. Also, a negative and significant correlation was found between the IRLSS-RS score and serum iron and hemoglobin levels in AS patients.

Evaluation of the ischemia modified albumin levels in familial Mediterranean fever patients

BACKGROUND

Familial Mediterranean fever (FMF) is an autoimmune disease with periodic fever attacks recurring with mutations in the MEFV gene and chronic inflammation. The new molecule which is formed as a result of the chemical changes made by oxidative free radicals in the albumin molecule during ischemic events is called ischemia modified albumin (IMA).

AIM

The aim of this study is to evaluate the IMA levels as a predictor of the cardiovascular risk factor in FMF patients in the attack-free period and to evaluate the relationship between IMA and inflammation markers.

METHODS

Forty FMF patients without any additional disease, non-smokers, and in their attacks-free period, 40 ankylosing spondylitis patients whose disease activity criteria is less than 4 from Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and 39 healthy adults were included in the cross-sectional analytical research.

RESULTS

The value of IMA was statistically significantly higher in the AS group compared to the control group (p = 0.01). The positive correlations between IMA and ESR, LDL, total cholesterol, triglyceride, CRP, and fibrinogen were statistically significantly determined in FMF patients (respectively; r = 0.594; p < 0.001, r = 0.382; p = 0.015, r = 0.335; p = 0.034, r = 0.363; p = 0.021, r = 0.597; p < 0.001, r = 0.656; p < 0.001). The positive correlations between IMA and ESR, CRP were found in AS patients (respectively; r = 0.383; p = 0.015, r = 0.382; p = 0.015).

CONCLUSION

IMA can be used as a predictor similar to cardiovascular risk factors and it is a precious marker for inflammation. The use of IMA in these fields and the multi-centred and comparative studies about predictability of it may contribute to science.

Inflammatory Arthritis Facilitators and Barriers (IFAB) for physical activity questionnaire: cross-cultural adaptation into Turkish and evaluation of its psychometric properties

PURPOSE

We aimed to conduct the translation and cross-cultural adaptation of the Inflammatory arthritis Facilitators and Barriers (IFAB) questionnaire into Turkish language for patients with axial spondyloarthritis (axSpA) and analyze the psychometric properties of the IFAB-Turkish version (IFAB-Tr).

METHODS

Data from ninety-three patients with axSpA were analyzed who completed the IFAB-Tr, Health Assessment Questionnaire (HAQ), Hospital Anxiety and Depression Scale (HADS) and Bath Ankylosing Spondylitis Functional Index (BASFI). Internal consistency, test-retest reliability, convergent validity, floor and ceiling effect, measurement error were examined. Exploratory factor analysis (EFA) and confirmatory factor analysis were conducted.

RESULTS

Small modification was needed in the translation and cultural adaptation process. Internal consistency of the IFAB-Tr total score was 0.71 and test-retest reliability was excellent for IFAB-Tr (ICC = 0.90). A moderate negative correlation was found between IFAB-Tr total score and HAQ, HADS, BASFI scores. No floor and ceiling effect was detected. Minimal detectable change was 10.34 points. EFA revealed two factors which accounted for 55% of the variance.

CONCLUSIONS

The IFAB was successfully translated into the Turkish language and seems suitable for evaluating barriers and facilitators for physical activity in rheumatic diseases and could be used in clinical settings before designing a physical activity intervention.IMPLICATIONS FOR REHABILITATIONThe Turkish version of the Inflammatory arthritis FAcilitators and Barriers (IFAB) is a valid and reliable tool to assess barriers and facilitators to physical activity for patients with axial spondyloarthritis.More work is needed to assess all psychometric properties of the IFAB questionnaire in other inflammatory rheumatic disorders.The Inflammatory arthritis FAcilitators and Barriers questionnaire in Turkish is an easy and quick way to determine potential barriers to physical activity in clinical and research settings.

Sonographic Comparison of Neck Extensor Muscle Thickness of Ankylosing Spondylitis and Non-radiographic Axial Spondyloarthritis Patients with Healthy Volunteers

Introduction This study examines the neck extensor muscle thickness of patients with ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA) by comparing them with healthy volunteers. It also aims to evaluate the relationship between muscle thickness and disease activity, functional parameters, neck disability and quality of life in patients with AxSpA.

Method In this cross-sectional study, 30 patients with AS and 30 patients with nr-AxSpA who were admitted to a Physical Medicine and Rehabilitation outpatient clinic were included consecutively. Thirty healthy participants were included as a control group. The thickness of muscles was measured bilaterally by ultrasound and the muscle thickness average was recorded. All patients with axSpA were asked to complete the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Functional Index (BASFI), the Bath Ankylosing Spondylitis Metrology Index (BASMI), the Ankylosing spondylitis Quality of Life (AsQoL) scale and the Neck Disability Index (NDI).

Results Mean patient age was 42.36±10.0 in the AS group, 38.13±7.94 in the nr-axSpA group and 39.06±8.25 in the healthy group. A statistically significant decrease was found in multifidus, semispinalis capitis, semispinalis cervicis and splenius capitis muscle thickness in AS patients compared with the healthy group, and in semispinalis cervicis muscle thickness in nr-axSpA patients compared with the healthy group. However, when trapezius muscle thickness was compared between the groups, no statistical difference was found. There was a significant negative correlation between neck extensor muscle thickness and age, BASDAI, NDI and AsQoL in patients with axSpA.

Conclusion The thickness of the neck extensor muscles is decreased in patients with AxSpA compared with healthy individuals, and this situation can be reliably detected by ultrasound.

Physicians' Biological Drug Preference in Patients With Rheumatoid Arthritis and Spondyloarthritis With a History of Malignancy: Perspectives From the Treasure Database

OBJECTIVE

Because of concerns about malignancy risks, using biological disease-modifying antirheumatic drugs (bDMARDs) in patients with a history of malignancy remains a challenging issue in rheumatology practice. This study aimed to investigate bDMARD preferences of physicians when treating of rheumatoid arthritis (RA) and spondyloarthritis (SpA) patients with a history of malignancy.

METHODS

The data for this cross-sectional study were gathered from the TReasure database using a date range of December 2017 and January 2020. Biological disease-modifying antirheumatic drug preferences were analyzed for 40 RA patients and 25 SpA patients with a history of malignancy.

RESULTS

The most frequently prescribed bDMARD was rituximab, which was given to 28 RA patients (70%). For 25 patients (62.5%), the time between the diagnosis of malignancy and starting on a bDMARD regimen was less than 60 months, with a median interval of 43.5 months. Among SpA patients, the preferred bDMARDs were secukinumab and etanercept, which were each administered to 7 patients (28%). For 13 SpA patients (52%), the time between the diagnosis of malignancy and starting on bDMARDs was less than 60 months, with a median interval of 97 months.

CONCLUSIONS

The observed bDMARD preferences may be related to the therapeutic effects of rituximab on lymphoproliferative malignancies, the protective effects of secukinumab on tumor progression, and the short half-life of etanercept. Biological disease-modifying antirheumatic drugs should be used in RA and SpA patients with malignancy in case of high inflammatory activity.

Alexithymia in ankylosing spondylitis

Objectives

This study aims to determine the effect of ankylosing spondylitis (AS) on alexithymia.

Patients and methods

In this study, a total of 55 AS patients (30 males, 25 females; mean age: 40±8 years; range, 21 to 57 years) who were under follow-up and 55 age- and sex-matched healthy volunteers (31 males, 24 females; mean age: 38.9±8.5 years; range, 21 to 53 years) were included between March 2016 and August 2016. Toronto Alexithymia Scale (TAS), and Beck Depression Inventory (BDI) were performed to assess both patient and control groups. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), and Ankylosing Spondylitis Quality of Life (ASQoL) were performed to assess AS patients.

Results

The mean diagnosis time in the patient group was 5.18±4.32 (range, 1 to 18) years. Compared to the control group, depression scores were higher in the patient group and the alexithymic characteristics were significantly higher in the patient group (p<0.05). There was a positive correlation between complaint duration and BASMI, BASFI, and ASQoL scores (p<0.01). In our study, alexithymia rate was significantly higher in women (p<0.05).

Conclusion

As in all inflammatory chronic diseases, depression and anxiety are commonly seen in AS patients. Alexithymia of these patients should be considered carefully.

Effects of the COVID-19 pandemic on psychology and disease activity in patients with ankylosing spondylitis and rheumatoid arthritis

Background/aim

The COVID-19 outbreak is known to increase stress levels of most patients with chronic diseases. Patients with ankylosing spondylitis (AS) and rheumatoid arthritis (RA) are highly susceptible to environmental stress. In the current study, we aimed to determine how the COVID-19 pandemic psychologically affected patients with chronic progressive diseases such as AS and RA and the effects of these psychological factors on disease activity.

Materials and methods

Age and sex-matched patients with AS (n = 80), RA (n = 80), and healthy controls (n = 80) were included in the study. All participants were evaluated with the “Perceived COVID-19 Threat Form (PCTF)”, “Suicide-Ideation Scale (SIS)”, “Hospital Anxiety and Depression Scale (HADS)”, “The Ability to Cope with Trauma (PACT)”, and “Psychological General Well-Being Index (PGWB)” scales. BASDAI was used in patients with AS, and DAS28 was used in patients with RA to assess disease severity.

Results

Compared to healthy individuals, patients with RA and AS had lower PGWB scores and higher HADS depression and anxiety subscale scores. Almost all psychometric assessment test scores were worse in AS patients with high-disease activity compared to those in low-disease activity. PACT scores were higher in patients with moderate RA compared to patients with mild RA (p = 0.006). While a positive correlation was identified between BASDAI and most of the psychometric assessment test scores (r = 0 .36 for PCTF, r = 0.53 for depressive scores, r = 0.54 for anxiety scores, r = 0.57 for suicidal ideation), DAS28 scores were found to be associated only with PACT total and PACT perceived forward-focused subscale scores (r = –.26 and r = .33, respectively).

Conclusion

Psychologically, AS and RA patients were found to be worse off compared to healthy controls. The perceived COVID threat and psychological status were associated with disease activity in AS, but not RA patients. Patients with chronic illnesses may be more vulnerable to the psychological effects of the pandemic, which can worsen disease activity.

The effect of Pulmonary Rehabilitation Programme on work productivity and clinical parameters in patients with ankylosing spondylitis

OBJECTIVE

The objective of the present study was to investigate the effect of the Pulmonary Rehabilitation Programme on work productivity, disease activity, functional status, quality of life, respiratory function tests (RFTs), physical capacity and depression in ankylosing spondylitis (AS) patients.

METHOD

Twenty-five patients diagnosed with AS were included in this study. The disease severity was evaluated with Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), functional status was evaluated with Bath Ankylosing Spondylitis Functional Index (BASFI), quality of life was evaluated with AS-Related Quality of Life Scale (ASQOL), physical capacity was evaluated with the 6-min walking test (6MWT), depression level was evaluated with Beck Depression Scale (BDS) and work productivity was evaluated with Spondyloartropathy Work Productivity and Activity Impairment (WPAI-SpA) Survey. Finally, RFT was evaluated with spirometry measurement. The patients were included in the Pulmonary Rehabilitation Programme for 8 weeks.

RESULTS

A total of 30% of the patients who were included in this study were unemployed, 35% of them were on and below the hunger limit, 25% were on and below the poverty line, and 40% were on the normal income line. No significant changes were detected in the RFTs after the exercise programme in AS patients (P > .05), but significant improvements were detected in the BASDAI, BASFI, WPAI, 6MWT, ASQOL and BDS (P < .001).

CONCLUSION

Pulmonary Rehabilitation Programme was found to be an effective method of improving work productivity in AS patients. Also, the Pulmonary Rehabilitation Programme has positive effects on disease activity, functional status, physical capacity, depression level, and quality of life.

Correlation between C-Reactive Protein to Albumin Ratio and Disease Activity in Patients with Axial Spondyloarthritis

Background

The C-reactive protein (CRP) to albumin (ALB) ratio (CAR) has emerged as a novel inflammatory biomarker. This study was designed to investigate the role of CAR in the disease activity of axial spondyloarthritis (axSpA).

Methods

A total of 241 patients and 61 healthy controls were retrospectively enrolled in this study. AxSpA patients were further divided into the inactive group (n = 176) and active group (n = 65) according to Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) cutoff value of 4. Laboratory data and clinical assessment indices were recorded. Spearman's correlation analysis, receiver operation characteristic (ROC) curve analysis, and binary logistic regression analysis were performed.

Results

In axSpA patients, CAR was significantly higher than the healthy group (P < 0.001). Similarly, axSpA patients in the active group had higher CAR than the inactive group (P < 0.001). Besides, CAR was positively correlated with erythrocyte sedimentation rate (ESR) (r = 0.704, P < 0.001), CRP (r = 0.996, P < 0.001), BASDAI (r = 0.329, P < 0.001), and Bath Ankylosing Spondylitis Functional Index (BASFI) (r = 0.330, P < 0.001). ROC curve analysis suggested that the area under the curve (AUC) of CAR for axSpA of the active group was 0.701, which was higher than that of CRP and ESR. The optimal cutoff point of CAR for axSpA of the active group was 0.3644, with a sensitivity and specificity of 58.5% and 79.0%. Binary logistic analysis results revealed that CAR was an independent predictive factor for axSpA disease activity (odds ratio = 4.673, 95% CI: 1.423-15.348, P = 0.011).

Conclusions

CAR was increased in axSpA and axSpA of the active group. CAR may be a novel and reliable indicator for axSpA disease activity.

Cervical proprioception accuracy is impaired in patients with axial spondyloarthritis

BACKGROUND

Proprioception is the awareness of body parts and includes joint position sense, kinesthesia, and sense of force. Cervical spine is one of the major affected areas in axial spondyloarthritis (axSpA), and is an essential region for proprioceptive receptors.

OBJECTIVE

To investigate the cervical joint proprioceptive accuracy by using cervical joint positioning error (JPE) method in patients with axSpA and healthy controls.

DESIGN

Cross-sectional study.

METHODS

JPE was calculated for cervical motions in the directions of flexion, extension, rotations, and lateral flexions. Time since diagnosis, symptom duration, spinal mobility, functional status, quality of life, disease activity, and pain were evaluated in axSpA patients. Cervical JPE of axSpA patients was also compared according to radiographic status, biologic use, and existence of cervical syndesmophytes.

RESULTS

Eighty-two axSpA patients (52 males) and 71 healthy subjects (53 males) were evaluated. Cervical JPE was higher in patients with axSpA compared to healthy subjects (p < 0.001), except left lateral flexion (p = 0.10). Cervical proprioceptive accuracy for extension and left rotation was better in biologics+ subgroup compared to biologic- subgroup (p < 0.05). No other differences were detected related to radiographic status nor existence of cervical syndesmophytes (p > 0.05).

CONCLUSION

Cervical proprioception accuracy is impaired in patients with axSpA. It seems that controlling disease activity by using appropriate medication may have a positive effect on cervical proprioception accuracy.

Serum Oxytocin Levels in Patients with Ankylosing Spondylitis and Non-Radiographic Axial Spondyloarthritis and their Association with Disease Activity

Objectives Spondyloarthritis refers to a group of chronic inflammatory diseases that particularly involve the sacroiliac joints and spine but may also have an influence on extra-articular involvement in some patients. Oxytocin is a peptide hormone released from the hypothalamus and stored in the pituitary gland. It is known to have anti-inflammatory effects. The aim of this study was to investigate the serum levels of oxytocin and their potential association with disease activity and spinal mobility in patients with ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nrAxSpA).

Material and Methods Seventy-one patients with nrAxSpA, 38 patients with AS and 67 healthy control subjects were included in this study. Disease activity was assessed by the Bath Ankylosing Spondylitis Disease Activity Index, and spinal mobility by the Bath Ankylosing Spondylitis Metrologic Index. Laboratory examinations included complete blood count, ESR, CRP and oxytocin tests.

Results There was no significant difference in serum levels of oxytocin among the 3 groups (p=0.973). However, serum levels of oxytocin correlated negatively with both ESR (r=− 0.359, p=0.027), CRP (r=− 0.316, p=0.056) and BASDAI scores (r=− 0,448, p=0.005) in patients with AS. On the other hand, serum levels of oxytocin had a negative correlation only with ESR in patients with nrAxSpA (r=− 0.321 p=0.009).Conclusion This study lays the foundation for further studies that may aim to investigate how addition of oxytocin to the treatment regimen impacts on disease activity in patients with AS who exhibit particularly low levels of oxytocin during the active disease period.

The Role of Sacroiliac Joint Steroid Injections in the Treatment of Axial Spondyloarthritis

Objectives

This study aims to investigate the effects of fluoroscopy-guided sacroiliac joint steroid injection in patients with acute bilateral sacroiliitis diagnosed with axial spondyloarthritis (axSpA) and how those injections affect the current need for nonsteroidal anti-inflammatory drug (NSAID) usage.

Patients and methods

We retrospectively evaluated 43 patients (28 males, 15 females; mean age, 31.7±6.3 years; range, 18 to 44 years) fulfilling the Assessment of SpondyloArthritis international Society 2009 criteria for axSpA between June 2015 and May 2016. One group included 22 patients (injection group) treated with sacroiliac joint steroid injection (triamcinolone acetonide) and the other group included 21 patients (non-injection group) not receiving the injection. All 43 patients in both groups were treated with indomethacin peroral. Pre-treatment, first week and first, third and sixth month follow-up examinations were evaluated.

Results

A ≥50% reduction in the numeric rating scale score compared with the baseline was considered as significant pain relief. The mean pain relief rates in patients receiving injections were higher at all inspections. This difference was statistically significant at first week (p<0.05). When groups were compared, no difference was found in the Bath Ankylosing Spondylitis Disease Activity Index scores (p>0.05). There was no statistically significant difference between the two groups when indomethacin dose was evaluated cumulatively for six months (p>0.05).

Conclusion

Fluoroscopy-guided sacroiliac joint steroid injections can be recommended in patients with active sacroiliitis, particularly in those with severe axial pain, for rapid analgesia in the initial term. It was concluded that steroid injections applied to the sacroiliac joint did not affect disease activity. It is noteworthy that there is a trend to reduce the use of NSAIDs in patients receiving these injections, although it does not make a statistically significant difference in the long term.

The adaptation of the Turkish version of the Assessment of Knowledge in Ankylosing Spondylitis Patients by a Self-Administered Questionnaire

Objectives

The aim of this study was to adapt the Assessment of Knowledge in Ankylosing Spondylitis Patients by a Self-Administered Questionnaire for the Turkish ankylosing spondylitis (AS) patients.

Patients and methods

Between May 2016 and December 2016, a total of 100 AS patients (72 males, 28 females; mean age 43.4 years; range, 21 to 73 years) were included in the study. A forward (into Turkish) and backward translation of the questionnaire was performed. Reliability was evaluated using the Cronbach alpha (α) value, test-retest reliability, and intra-class correlations (ICCs). The correlations with demographic data including age, sex, time since diagnosis, and education status and with the disease-specific assessments including Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and the Ankylosing Spondylitis Quality of Life (ASQOL) questionnaire were investigated.

Results

The Turkish version of the questionnaire showed a good reliability (Cronbach-α: >0.70, ICC: >0.90). A significant correlation was found with the education status (p<0.001). However, no significant correlation was observed between the questionnaire and the other parameters (p>0.05).

Conclusion

Our study results show that the Turkish version of the questionnaire seems to be reliable for use in Turkish AS patients.

Reliability and validity of the Turkish Version of Arthritis Research UK Musculoskeletal Health Questionnaire

Objectives

This study aims to investigate the validity and reliability of the Turkish version of the Musculoskeletal Health Questionnaire (MSK-HQ-T) for assessing the general health status in patients with axial spondyloarthritis (ax-SpA).

Materials and methods

One hundred ax-SpA patients (42 males, 58 females; mean age 40.3±9.1 years; range, 18 to 65 years) who were able to speak and understand Turkish language were included in this study. All participants answered MSK-HQ-T, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI) and Short-Form 36 (SF-36). MSK-HQ-T was repeated five-seven days later for test-retest and internal consistency reliability.

Results

The Cronbach's alpha value was 0.912, demonstrating high internal consistency. The test-retest score of MSK-HQ-T was 0.968, which was significant. The correlation of MSK-HQ-T with the subgroup scores of SF-36 was statistically significant (p<0.001). The correlation between MSK-HQ-T and the total scores of BASDAI and BASFI was statistically significant (r=-0.788, p<0.001; r=-0.743, p<0.001).

Conclusion

The MSK-HQ-T is a reliable and valid questionnaire to assess general health status in Turkish patients with ax-SpA.

Is fibromyalgia frequency increasing in axial spondyloarthritis? Association with fibromyalgia and biological therapies

Fibromyalgia (FM) is known a common painful syndrome and its frequency is increased in inflammatory rheumatic diseases. We aimed to assess FM frequency in axial spondyloarthritis (AxSpA) patients and age- and sex-matched healthy controls with the 2011 ACR FM criteria. We evaluated the association between receiving biologic disease-modifying antirheumatoid drugs (bDMARD) and presence of FM. 127 patients with Ax-SpA and 73 age- and sex-matched controls were included. Individuals were assessed according to modified 2011 ACR diagnostic criteria for FM. The pain was evaluated by visual analog scale (VAS). Disease activity was assessed by Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Ankylosing Spondylitis Disease Activation Score (ASDAS). Spinal limitation, quality of life, and functionality were assessed. Drug therapies were noted. AxSpA and control group had similar FM rates. 43 (33.9%) patients in AxSpA group and 22 (30.1%) patients in control group had FM diagnosis (p = 0.589). Age, gender, BMI, and CRP values were similar in the AxSpA patients with and without FM, while global VAS and ASDAS scores were higher in patients with FM. Biologic DMARD use was higher in the AxSpA patients with FM; however, the difference was not statistically significant. In conclusion, FM frequency does not increase in AxSpA patients as compared to healthy controls. FM awareness is one of the key points to determine the appropriate treatment due to the influence on disease activity.

Effects of Ankylosing Spondylitis on Erectile Function

Objectives:

Ankylosing spondylitis (AS), which is a chronic rheumatologic disorder, may be associated with erectile dysfunction (ED). This study aims to investigate the incidence of erectile dysfunction in patients with AS with a control group and to investigate the risk factors for ED.

Methods:

All demographic data were recorded. Participants in both groups filled in the IIEF-5 (International Index of Erectile Function), Beck Depression Index (BDI) and Beck Anxiety Index (BAI) questionnaires, whereas patients with AS additionally filled in Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrological Index (BASMI) and Ankylosing Spondylitis Quality of Life (ASQoL) questionnaires. Patients were compared concerning erectile function and predictive factors. Fifty patients with the AS diagnosis and fifty healthy males were included in this study.

Results:

ED of all degrees was present in 38% and 30% of males in the AS group and control group, respectively, with no statistical difference. However, the mean IIEF-EF domain score of the AS group (22.3±7.0) was significantly lower than the control group (25.7±4.3) (p=0.004). In addition, BDI and BAI scores were significantly higher in the AS group. When we have divided patients in the AS group into two, according to the presence or absence of the ED, the mean IIEF-EF domain score of patients with ED was lower than AS patients without ED. No difference was detected in both groups concerning age and the duration of the disease. Patients who had ED in the AS group had significantly higher scores in BASDAI, BASFI, depression and anxiety; however, no significant difference was detected among groups regarding BASMI scores.

Mean IIEF score was lower in patients with AS, and this had a negative correlation with BASDAI, BASFI, ASQoL, BDI and BAI scores.

Conclusion:

Erectile function scores were slightly lower in the AS group than the control group in our study. ED risk factors were shown as disease activity and psychological status.

How Does Smoking Cessation Affect Disease Activity, Function Loss, and Quality of Life in Smokers With Ankylosing Spondylitis?

BACKGROUND

Ankylosing spondylitis (AS) is a chronic systemic inflammatory disease that can progressively restrict spinal mobility.

OBJECTIVE

This study aimed to investigate how smoking cessation by AS patients affects disease activity and their psychological state, physical mobility, lung function, and quality of life.

MATERIALS AND METHODS

This was a longitudinal, single-blind, controlled, and observational study on 92 AS patients. Pulmonary function test, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index, Bath Ankylosing Spondylitis Metrology Index, chest expansion, Short-Form 36, and Ankylosing Spondylitis Quality of Life were evaluated. The patients were divided into smokers (group 1 = 54) and nonsmokers (group 2 = 38). The smokers were divided further into subgroups of those who quit smoking (group 1a = 17) and those who did not (group 1b = 37). Groups 1a and 1b patients were compared in terms of their baseline data and data 6 months after smoking cessation. In addition, group 1a patients' baseline data and data 6 months after smoking cessation were compared statistically.

RESULTS

There was no statistically significant difference between groups 1a and 1b after 6 months in terms of the evaluated parameters, except for BASDAI. Bath Ankylosing Spondylitis Disease Activity Index was significantly lower in group 1a than group 1b (p = 0.02), indicating that. When the baseline data and data after 6 months of group 1a were compared, a significant improvement was found in BASDAI (p = 0.001), Bath Ankylosing Spondylitis Functional Index (p = 0.001), chest expansion (p = 0.001), ankylosing spondylitis quality of life (p = 0.003), and subparameters physical function (p = 0.015), physical role strength (p = 0.05), power/live/vitality (p = 0.025), social functioning (p = 0.039), pain (p = 0.036), and general health perception (p = 0.05) of Short-Form 36, as well as forced expiratory volume in the first second (p = 0.003) and forced vital capacity (p = 0.007).

CONCLUSIONS

We observed significant improvements in disease activity, physical mobility, and quality of life in AS patients who quit smoking.

Self-Reported Medication Adherence in Patients With Ankylosing Spondylitis: The Role of Illness Perception and Medication Beliefs

Objectives

This study aims to investigate medication adherence in Turkish patients with ankylosing spondylitis (AS) and analyze the related factors for non-adherence.

Patients and methods

Ninety-nine patients with AS (60 males, 39 females; mean age 41.3±8.4 years; range, 18 to 66 years) were included in the study. Sociodemographic and clinical data were collected. Disease activity (Bath Ankylosing Spondylitis Disease Activity Index, C-reactive protein, and erythrocyte sedimentation rate), functional status (Bath Ankylosing Spondylitis Functional Index), spinal pain and fatigue (visual analog scale), quality of life (Ankylosing Spondylitis Quality of Life), and depression and anxiety (Hospital Anxiety and Depression Scale) were evaluated. Adherence to anti-rheumatic drugs was elicited using the Compliance Questionnaire on Rheumatology (CQR). Medication beliefs were assessed using the Beliefs about Medicines Questionnaire (BMQ), and illness perception using the Brief Illness Perception Questionnaire (B-IPQ).

Results

Non-adherence was reported in 64 patients (64.6%). No significant relationship between demographic, clinical, or psychological factors and adherence was found, except for disease duration (p=0.031). High B-IPQ treatment follow-up, illness coherence, and BMQ-Specific necessity scores were associated with good adherence (p=0.007, p=0.039, and p=0.002, respectively). BMQ-General overuse and harm scores showed an inverse correlation with the CQR score (p=0.005 r=-0.278; p=0.029 r=-0.219, respectively). Longer disease duration [odds ratio (OR): 0.98, 95% confidence interval (CI): 0.97-0.99] and higher B-IPQ item-1 score regarding the effect of the illness on the individual's life (OR: 0.58, 95% CI: 0.42- 0.81) were important predictors of low adherence.

Conclusion

Nearly three out of five AS patients were identified as at risk for non-adherence with the CQR. Medication adherence is influenced by the patient’s beliefs about medicines and illness perceptions, and these may be key targets for future interventions to improve medication adherence.

The Correlations Between Disease Specific Quality of Life, Short Form-36 and Clinical Variables in Patients With Ankylosing Spondylitis

Objectives

This study aims to assess the correlations between disease specific quality of life (QoL), general health status and clinical variables in patients with ankylosing spondylitis (AS), and also to determine a cutoff value for the disease specific QoL questionnaire.

Patients and methods

A total of 124 patients (80 males, 44 females; mean age 40.6±11.1 years; range, 20 to 65 years) who fulfilled the modified New York criteria for AS were included in this cross-sectional study. All patients received a comprehensive rheumatologic assessment including disease specific instruments for disease activity, functional status, spinal mobility and QoL. Furthermore, short form-36 (SF-36) was used to determine general health status. Pain levels of the patients were assessed with visual analog scale (VAS). Pearson’s analysis was used to assess correlation among variables, with moderate, strong, or very strong correlations if the value was between 0.40-0.69, 0.70-0.89, and 0.90-0.99, respectively. To determine a cutoff value for the ankylosing spondylitis quality of life (ASQoL) score, the area under the receiver operating characteristic curve (AUC) was computed according to clinical parameters which have the strongest correlations with ASQoL.

Results

The mean ASQoL score was 8.8±4.9. There was a significantly positive correlation between ASQoL and disease activity, functional status, spinal mobility and pain VAS whereas there was a significantly negative correlation between ASQoL and the SF-36 subscale scores except for mental health and emotional role (p<0.001). The strongest positive correlation was found between ASQoL and the Bath Ankylosing Spondylitis Disease Activity Index (r=0.721, p<0.001) whereas the strongest negative correlation was found between ASQoL and the first question of SF-36 (r=-0.844, p<0.001). A cutoff value of eight in ASQoL showed good discriminative properties for impaired QoL where sensitivity and specificity were simultaneously maximized according to disease activity (AUC=0.84 [95% confidence interval (CI): 0.770-0.908, p<0.001]) and the patients’ global health status (AUC=0.85 [95% CI: 0.782-0.923, p<0.001]) in patients with AS.

Conclusion

There was a strong correlation between ASQoL and disease activity as well as the patients’ global health status in patients with AS. A cutoff value of eight in ASQoL could be used with good discriminative properties for impaired QoL in AS.

Biological and genetic evaluation of IL-23/IL-17 pathway in ankylosing spondylitis patients

Ankylosing spondylitis is the most common form of the chronic inflammatory disease group known as spondyloarthritides. Recent discoveries of the CD4+ Th17 cells and IL-23/IL-17 axis have changed the paradigms in many autoimmune diseases. In this study, we aimed to evaluate the importance of IL-23/IL-17 pathway and IL-23 receptor polymorphism in the pathogenesis of ankylosing spondylitis. Blood samples for this study were obtained from 109 ankylosing spondylitis patients and 40 healthy control subjects. Serum levels of TNF-α, IL-6, IL-17, and IL-23 were measured by the ELISA method. The IL-23R gene polymorphisms rs11209026 (Arg381Gln) and rs4131362 (Val362Ile) were performed by the Sanger Sequence method. IL-6 levels were higher in the active and inactive ankylosing spondylitis groups than in the control group. However, levels of IL-17 and IL-23 were lower in the patient group. The frequency of IL-23R gene rs11209026 and rs4131362 polymorphism were 3.7% and 8.3% in the patient, respectively. As a result, dysregulation of the IL-23 / IL-17 pathway, which is caused by reduced levels of IL-17 and IL-23 in systemic circulation in patients with ankylosing spondylitis, may contribute to the pathogenesis of the disease by systemically producing chronic autoimmune inflammation.

Relationship between sleep quality and physical activity level in patients with ankylosing spondylitis

Introduction: Aim of this study was to investigate whether there is a relationship between exercise level and sleep quality in AS patients.Method: In our study, 150 AS patients and 80 healthy controls were included. Physical activity levels of both groups were evaluated using International Physical Activity Questionnaire (IPAQ-s) short form. Sleep quality of the participants was evaluated using Pittsburgh Sleep Quality Index (PSQI). Disease activity and functional status were measured by Bath AS Disease Activity Index and Bath AS Functional Index.Results: Subjective sleep quality, habitual sleep efficiency, sleep disturbance and Total PSQI scores were significantly higher in the patient group compared to healthy participants. The IPAQ score was found to be significantly lower in the patient group. Sleep disturbance, one of the components of PSQI, was found to be significantly higher in patients with low IPAQ score.Conclusions: Sleep disorders were found to be higher in AS patients than normal population and physical activity levels of AS patients were lower than normal population. In addition, Sleep disturbance was found to be high in patients with low physical activity. Therefore, it should be remembered that one of the causes of sleep disorders in AS patients may be related to low physical activity.

The relationship of serum vitamin D receptor levels with disease activity and clinical parameters in patients with ankylosing spondylitis

Objectives

The aim of this study was to investigate the relationship between serum vitamin D receptor (SVDR) levels and disease activity parameters in patients with ankylosing spondylitis (AS).

Patients and methods

Between July 2016 and January 2017, a total of 62 patients (51 males, 11 females; mean age 36.5±12.8 years; range, 23 to 49 years) with AS and 32 healthy volunteers (25 males, 7 females; mean age 41.57±13.6 years; range, 26 to 48 years) were included in the study. The SVDR levels were measured using the enzyme-linked immunosorbent assay. Erythrocyte sedimentation rate (ESR) and serum C-reactive protein (CRP) levels were recorded. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores were used to assess disease activity.

Results

Although there was no significant difference between the patient and control groups (p=0.66), SVDR levels were significantly elevated in patients with active AS (BASDAI score ≥4) (p=0.01). The SVDR levels significantly increased in AS patients with peripheral joint involvement and enthesitis (p=0.01, p=0.05, respectively). The SVDR levels significantly elevated in patients treated with non-steroidal anti- inflammatory drugs, compared to those treated with biological agents and control group (p=0.01, p=0.03, respectively). The SVDR levels were positively correlated with the BASDAI, CRP and ESR in the patient group (p=0.01, r=0.751; p=0.01, r=0.75; p=0.01, r=0.81, respectively).

Conclusion

Our study results suggest that serum SVDR levels are associated with the disease activity and clinical parameters in patients with AS. Based on these findings, SVDR level may be used as a marker of disease activity in AS.

Fatigue in Ankylosing Spondylitis Is Associated With Psychological Factors and Brain Gray Matter

Background: Ankylosing spondylitis (AS) is a rheumatic inflammatory disease with unknown etiology, and fatigue is one of the main systemic symptoms of AS. The aim of the current study was to explore the mechanism of AS-associated fatigue (ASF) from multiple aspects, including neuropsychological changes.

Method: A total of 120 AS patients and 78 age- and sex-matched healthy individuals were recruited into the study. Fatigue was assessed by the fatigue item of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Multidimensional Assessment of Fatigue (MAF) scale. Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale (HADS). The cortical thickness and subcortical gray matter volume were assessed using a Philips Achieva 3.0 T TX MRI scanner.

Result: Of the 120 AS patients, 103 (85.8%) reported varying degrees of fatigue. Among these fatigue cases, 33 (32.0%) were in the severe fatigue group (BASDAI-Fatigue ≥ 5), and 70 patients (68.0%) were considered to be in the mild fatigue group (BASDAI-Fatigue > 0 but <5). The BASDAI, ASDAS-CRP, HAD-A, and HAD-D scores of AS patients in the severe fatigue group were all significantly higher than those of patients in the mild fatigue and non-fatigue groups (all, P < 0.05). The structural equation model suggested that AS activity triggered the occurrence of fatigue by inducing psychological change. Finally, head MRI imaging found that the left thalamus volume in AS patients with severe fatigue was significantly larger than that in non-fatigue AS patients and healthy controls (both, P < 0.05).

Conclusion: The study revealed neuropsychological factors involved in fatigue in AS.

Serum Interleukin-23/17 Levels in Ankylosing Spondylitis Patients Treated with Nonsteroidal Anti-Inflammatory Drugs: A Prospective Cohort Study

Etiopathogenesis of ankylosing spondylitis (AS), a major subtype of a group of chronic inflammatory diseases known as spondyloarthropathies, is not clearly understood yet. In this study, we aimed to investigate the interleukin 23 (IL-23)/interleukin-17 (IL-17) pathway, which is a new cytokine pathway in inflammatory diseases. We evaluated serum IL-17 and IL-23 levels after 1-year follow-up in AS patients using only nonsteroidal anti inflammatory drugs (at need or continue). Forty-four AS patients and 40 healthy controls were included in the study. Clinical evaluations of disease activity were performed. Serum tumor necrosis factor-α (TNF-α), IL-6, IL-17, and IL-23 levels were evaluated. IL-17 and IL-23 levels of the patient group at baseline and 12 months were lower than the control group. There was no significant difference between the baseline and 12th month evaluations of the patient group. TNF-α levels were similar in all groups (in the baseline and 12th month of the patient group and in the control group). Although our results are in contrast to the literature findings, the IL-23/IL-17 pathway is a newly discovered pathway, and there may still be unknowns. New studies involving larger patient groups are needed for the factors affecting serum IL-23/IL-17 levels in patients with AS. We also think that it will be useful to make more comprehensive and long-term studies about which patients will respond well to IL-23/IL-17 blockade.

Leflunomide treatment in juvenile idiopathic arthritis

Juvenile idiopathic arthritis is the most common chronic rheumatic disease of childhood resulting in disability in untreated cases. Disease modifying anti-rheumatic drugs form the first-line treatment in JIA. However, the data about leflunomide (LFN) in treatment of JIA is limited. We reviewed the medical files of JIA patients who were followed-up regularly and had received LFN. A total of 38 patients were included to the study. Among them, 24 had oligoarticular JIA, eleven had polyarticular JIA, two had ERA and one had psoriatic arthritis. 36 were initially treated with methotrexate and two patients diagnosed with ERA were treated with sulfasalazine. Sulfasalazine treatment was switched to LFN due to inadequate response at the 3rd month of therapy. Methotrexate was ceased due to gastrointestinal intolerance in 36 patients. Of these 36 patients, 19 patients had either low disease activity (n = 13) or remission (n = 6). LFN was administered to 13 patients with low disease activity. During the follow-up of the six patients in remission, relapse ensued and LFN treatment was started. The remaining 17 patients had moderate (n = 10) or high (n = 7) disease activity requiring biologic agents. But due to inadequate response to biologic agents, LFN was added to the therapy. All of the patients were clinically inactive at the last visit. Only two adverse events resolving within 2 weeks were noted (Lymphopenia = 1, elevated liver enzymes = 1). LFN may be an alternative therapy in case of MTX intolerance or toxicity.

Effects of global postural reeducation exercise and anti-TNF treatments on disease activity, function, fatigue, mobility, sleep quality and depression in patients with active Ankylosing spondylitis: A prospective follow-up study

OBJECTIVE

The purpose of this study was to investigate the effects of combination therapy with global postural reeducation exercise (GPR) and anti-TNF treatments on clinical parameters in patients with active Ankylosing spondylitis (AS).

MATERIALS AND METHOD

Sixty patients with active AS were distributed into three groups. Group 1 was given anti-TNF therapy plus GPR program. Group 2 was given anti-TNF and conventional exercise therapy. Group 3 was accepted as the control group. Patients were assessed according to pain, disease activity (Bath Ankylosing Spondylitis Disease Activity Index), functionality (Bath Ankylosing Spondylitis Functional Index and walking performance), mobility (lumbar Schöber, chest expansion, hand-finger to floor distance), fatigue (Multidimensional Assessment Questionnaire), sleep quality (Pittsburgh sleep quality index), and depression.

RESULTS

The parameters were significantly improved in both groups receiving exercise and anti-TNF therapy compared to the control group after treatment. The anti-TNF plus GPR exercise therapy resulted in greater improvements than the anti-TNF plus conventional exercise therapy in pain, walking performance, and mobility.

CONCLUSIONS

Anti-TNF therapy and exercise were efficient in both groups on improving all clinic parameters. However, the improvements in pain, function, and mobility were greater in the active AS patients with GPR exercise method. Therefore, motivated patients should be encouraged to perform this method.

Effect of Clinical Pilates training on the fear of movement in patients with ankylosing spondylitis

Background/Aims:

Exercise training has been shown to be beneficial in reducing symptoms in patients with ankylosing spondilitis. However, exercise effect on fear and avoidance of movement has not been assessed. The aim of this study was to evaluate the effect of Pilates training on kinesiophobia, disease activity, functional status and quality of life in patients with ankylosing spondilitis.

Methods:

A total of 21 patients with ankylosing spondilitis with stable medication participated in the study. Tampa Scale for Kinesiophobia, Bath Ankylosing Spondilitis Disease Activity Index, Bath Ankylosing Spondilitis Functional Index, ankylosing spondilitis Quality of Life Questionnaire and Beck Depression Inventory were completed by patients before and after a 6-week modified Pilates training programme.

Findings:

The patients were 41.6 ± 11.8 years old and the mean disease duration was 68 ± 87months. Mobility, disease acitivity and functional scores improved with exercise training (P<0.05). Moreover, quality of life, depression and kinesiophobia levels also showed significant improvement (P<0.05).

Conclusions:

The results of this study showed that 6-week supervised modified Pilates training programme improved clinical symptoms in patients with Aankylosing spondilitis. Moreover, patients benefited from this exercise method regarding quality of life, depression and fear of movement (kinesiophobia) considerably.

Vitamin D levels in patients with ankylosing spondylitis: Is it related to disease activity?

Objective:

Ankylosing Spondylitis (AS) is an inflammatory rheumatic disease that mainly affects the axial spine. Osteopenia and osteoporosis are the main complications of AS. Vitamin D has functions on the immune system. In this study, we aimed to compare vitamin D levels and Bone Mineral Density (BMD) values between AS patients and controls.

Methods:

A total of 68 patients with axial AS and 34 healthy controls were enrolled in this study conducted between March 2018 and May 2018. Vitamin D concentrations, BMD values, disease activity, back mobility, functionality and radiologic damage were evaluated.

Results:

Vitamin D concentrations, the total BMD-femur and BMD-femur neck values were significantly lower in AS patients (p = 0.001, p = 0.011 and p = 0.003). No significant correlations were detected between vitamin D levels and BMD-femur total, BMD-femur neck values, disease activity, back mobility, functionality and radiologic damage scores (p > 0.05). Disease activity parameters were significantly and negatively correlated with total BMD-femur and BMD-femur neck values (p < 0.05).

Conclusion:

Our study demonstrates that AS patients have lower vitamin D levels, total BMD-femur and BMD-femur neck values. Higher disease activity increases bone loss in AS. Regular measurement of BMD and vitamin D should be kept in mind when planning a treatment in AS.

The effects of balance and postural stability exercises on spa based rehabilitation programme in patients with ankylosing spondylitis

BACKGROUND

Ankylosing spondylitis (AS) can cause severe functional disorders that lead to loss of balance.

OBJECTIVE

The aim of this study was to investigate the effects of balance and postural stability exercises on spa based rehabilitation programme in AS subjects.

METHODS

Twenty-one participants were randomized to the study (n= 11) and control groups (n= 10). Patients balance and stability were assessed with the Berg Balance Scale (BBS), Timed Up and Go (TUG) Test, Single Leg Stance Test (SLST) and Functional Reach Test (FRT). AS spesicied measures were used for assessing to other parameters. The treatment plan for both groups consisted of conventional transcutaneous electrical nerve stimulation (TENS), spa and land-based exercises 5 days per week for 3 weeks. The study group performed exercises based on postural stability and balance with routine physiotherapy practice in thermal water and in exercise room.

RESULTS

The TUG, SLST and FUT scores were significantly increased in the study group. In both groups, the BASMI, BASFI, BASDAI and ASQoL scores decreased significantly by the end of the treatment period (p< 0.05).

CONCLUSIONS

In AS rehabilitation, performing balance and stability exercises in addition to spa based routine approaches can increase the duration of maintaining balance and can improve the benefits of physiotherapy.

Nephrolithiasis in ankylosing spondylitis and its relationship with disease assessment scales

OBJECTIVE:

The aim of this study was to investigate the frequency of renal calculi in patients with ankylosing spondylitis (AS) and to determine its relationship with disease assessment variables.

METHODS:

The study was designed retrospectively, and it included a cohort of 320 patients with AS diagnosed using the Modified New York Criteria. A total of 119 patients who underwent renal ultrasonography (USG), in who the erythrocyte sedimentation rate, C-reactive protein, blood calcium, phosphorus, Vitamin D, parathormone, and urinary calcium excretion were measured, and who also had lateral cervical and lumbar radiography in the same time period were extracted from the cohort. All patients’ demographic characteristics and the results of blood and urine tests were recorded. The Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Functional Index (BASFI), Ankylosing Spondylitis Mobility Index (BASMI), and Modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) were evaluated in all patients.

RESULTS:

Thirteen of the 119 patients had renal calculi confirmed by USG data. The frequency of nephrolithiasis detected by USG was 10.9% in patients with AS. The disease lasted significantly longer in patients with renal calculi ([nephrolithiasis (+): 18.39±8.72 years; nephrolithiasis (−): 12.02±8.43 years, p=0.01]). The BASMI total score was significantly higher in the group of patients with renal calculi. There was not any significant difference in terms of blood samples, HLA-B27, BASDAI, BASFI, and mSASSS between groups.

CONCLUSION:

The frequency of renal stones is increased in patients with AS compared to healthy population. Especially patients who had AS for a long time and higher BASMI values are more susceptible to renal calculi. It is important to point out that the results of this type of studies would be more reliable if the study is conducted on large patient groups and population-based prevalence.