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

Reduced sleep quality is highly prevalent and associated with physical function and cardiorespiratory fitness in patients with axial spondyloarthritis: a cross-sectional study

OBJECTIVES

To assess sleep quality, and its associations with physical function, cardiorespiratory fitness, and spinal mobility, in axial spondyloarthritis (axSpA) patients.

METHOD

Baseline data from the Exercise for Spondyloarthritis trial were used. Assessments included [Pittsburgh Sleep Quality Index (PSQI), 0-21, 21 = worst], performance-based physical function [Ankylosing Spondylitis Performance Index (ASPI), seconds, higher = worse], patient-reported physical function [Bath Ankylosing Spondylitis Functional Index (BASFI), 0-10, 10 = worst], cardiorespiratory fitness [peak oxygen uptake (V O2peak), mL/kg/min, lower = worse], and spinal mobility [Bath Ankylosing Spondylitis Metrology Index (BASMI), 0-10, 10 = worst]. Associations were examined in separate models using multiple linear regression.

RESULTS

Ninety-nine patients with axSpA were included, 53% female, mean age 46 years, and 72% with high disease activity (ASDAS-C-reactive protein ≥ 2.1), of whom 84 (85%) had reduced sleep quality. Sleep disturbance was most frequently reported (65%), followed by poor subjective sleep quality (53%), daytime dysfunction (41%), and increased sleep latency (41%). Positive associations were observed between PSQI and ASPI [β = 0.10, 95% confidence interval (CI) 0.01, 0.19] and PSQI and BASFI (β = 0.85, 95% CI 0.51, 1.20), and there was an inverse association between PSQI and V O2peak (β = -0.14, 95% CI -0.27, -0.01), adjusted for age and sex. There was no association between PSQI and BASMI.

CONCLUSION

Reduced sleep quality was common in axSpA patients with moderate to high disease activity. Better sleep quality was associated with better physical function and higher cardiorespiratory fitness. There was no association between sleep quality and spinal mobility.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02356874.

Impact of daily physical therapy over 2 weeks on spinal mobility including objective electronic measurements and function in patients with axial spondyloarthritis

Background

Patients with axial spondyloarthritis (axSpA) are often compromised by impaired function and mobility. The standardized 2-week inpatient program 'multimodal rheumatologic complex treatment' (MRCT) was designed for patients with axSpA. The Epionics SPINE (ES) is an objective tool validated to assess mobility.

Objective

To investigate the impact of MRCT on physical function and mobility including range of motion (RoM) and kinematics (RoK).

Design

Single-center interventional, observational trial.

Methods

Patients with axSpA presenting with high disease activity and impaired physical function were consecutively recruited to undergo MRCT. Assessments performed before (V1) and after (V2) the intervention included Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis functional index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), the ankylosing spondylitis physical performance index (ASPI), the Short Physical Performance Battery (SPPB), and ES measurements.

Results

At baseline, the 80 patients included had: BASDAI 5.5 ± 1.5, BASFI 5.6 ± 2.0, BASMI 4.2 ± 1.8, SPPB 13.8 ± 1.8, and ASPI 37.3 ± 18.1 s. Clinically relevant improvements between V1 versus V2 were noted for BASFI, BASMI, and all other assessments (p < 0.001), and also for ES measures of RoK (all p < 0.003) and RoM (all p < 0.04), while a positive trend was seen for flexion and extension (RoM). There was no significant effect of changes in medication (all p > 0.05).

Conclusion

The 2-weeks MRCT was associated with definite improvements of function and mobility. Importantly, the effect of this extensive physical activity was confirmed by using the ES as an objective tool to assess spinal mobility. The ES demonstrated for the first time that the RoK of spinal mobility can significantly improve related to an exercise intervention.

Trial registration

Ethical Committee: Ruhr-Universität (reference-number: 19-6735-BR).

Clinically relevant differences in spinal mobility related to daytime performance in patients with axial spondyloarthritis

OBJECTIVE

Patients with axial spondyloarthritis (axSpA) suffer from clinical symptoms like morning stiffness and back pain. Mobility of patients with axSpA is often impaired. The aim of this study is to compare the performance of patients with axSpA regarding mobility measures including performance-based tests and objective electronic assessments with the Epionics SPINE device (ES) at different times of the day compared with healthy controls (HC).

METHODS

Observational trial, consecutive inpatients with axSpA (n=100) and 20 HCs were examined in the morning (V1: before 10:00 am) and in the afternoon (V2: after 02:00 pm) by the Bath Ankylosing Spondylitis Metrology Index (BASMI), the AS physical performance index (ASPI), the Short Physical Performance Battery (SPPB) and ES measurements, including range of motion (RoM) and range of kinematics (RoK).

RESULTS

The assessments of patients with axSpA performed in the morning clearly differed from those in the afternoon, especially regarding performance-based tests. Significant improvements were seen for BASMI (4.0±3.8 to 3.8±1.9; p<0.001), ASPI (36.2±18.3 to 28.8±11.9 s; p<0.001), SPPB (10.1±1.5 to 10.7±1.4 points; p<0.001) and for ES measures of speed (RoK; p<0.018) but not for RoM, except for lateral flexion (13.3±7.4 to 14.7±8.2°; p=0.002). This time of assessment-related variability was not observed in HC.

CONCLUSION

The spinal mobility of patients with axSpA was worse in the morning but significantly improved in the afternoon. This was captured best by performance-based measures and was not seen in HC. The diurnal variation of mobility has implications for clinical studies, suggesting that the time of assessments needs to be standardised.

Implementing enhancements in supervised group exercise for people with axial spondyloarthritis: a hybrid effectiveness-implementation study

OBJECTIVES

The content of supervised group exercise (SGE) for axial spondyloarthritis (axSpA) has hardly changed in recent decades, despite new evidence-based insights to improve SGE quality. This pilot implementation study evaluated the effects and feasibility of enhancements in axSpA-specific SGE in four regions in the Netherlands.

METHOD

The implemented enhancements included: more high-intensity aerobic exercise; exercise personalization with periodic assessments; and patient education on home exercise. The implementation strategy included a one-day supervisor training course and telephone support. To evaluate effects, aerobic capacity [Six-Minute Walk Test (6MWT)], physical functioning [Ankylosing Spondylitis Performance-based Improvement (ASPI); improved/not improved], health status [Assessment of SpondyloArthritis international Society Health Index (ASAS HI) questionnaire], and home exercise engagement [Short QUestionnaire to ASsess Health-enhancing physical activity (SQUASH)] were assessed at baseline and after one year in 60 participants. Changes were analysed with the Wilcoxon signed-rank test. To evaluate feasibility, a survey of participants and semi-structured interviews with four SGE supervisors assessed uptake and satisfaction with the enhancements.

RESULTS

Aerobic capacity increased significantly and 35% of participants improved functioning, whereas health status and home exercise engagement did not change. The participants' survey and supervisors' interviews showed that high-intensity aerobic exercise was implemented successfully, exercise personalization and periodic assessments were implemented partially, and patient education was not implemented at all. Most participants were satisfied with the changes.

CONCLUSIONS

After this pilot implementation, SGE enhancements were only partially implemented. Nevertheless, aerobic capacity improved significantly and satisfaction with accomplished changes was high. Nationwide implementation would require adaptations to improve feasibility.

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

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

Future Challenges and Critical Approach to Metrology in Patients with Axial Spondyloarthritis

Axial spondyloarthritis (axSpA) is a rheumatic inflammatory chronic disease that mainly affects the spine, producing inflammation and structural damage at the vertebral level (erosions, syndesmophytes, and bony bridges) [...].

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Responsiveness and Interpretability of 2 Measures of Physical Function in Patients With Spondyloarthritis

BACKGROUND

Maintenance or improvement of physical function is an important treatment target in the management of patients with axial spondyloarthritis (axSpA); measurement tools that can detect changes in physical function are therefore important.

OBJECTIVES

The objective of this study was to compare responsiveness and interpretability of the patient-reported Bath Ankylosing Spondylitis Functional Index (BASFI) and the Ankylosing Spondylitis Performed-Based Improvement (ASPI) in measuring change in physical function after exercise in patients with axSpA.

DESIGN

This was a sub-study of 58 patients nested within a randomized controlled trial comparing the effect of 12 weeks of exercise with usual care.

METHODS

Responsiveness and interpretability were assessed according to the Consensus-based Standards for the selection of health status Measurement Instrument. Responsiveness was assessed by testing 8 predefined hypotheses for ASPI and BASFI. Interpretability was assessed by: (1) using patients' reported change as an anchor ("a little better" = minimal important change) and (2) by categorizing patients with a 20% improvement as responders.

RESULTS

For ASPI and BASFI, 5 of 8 (63%) versus 2 of 8 (25%) of the predefined hypotheses for responsiveness were confirmed. The minimal important change values for improvement in physical function were 3.7 seconds in ASPI and 0.8 points (on a scale from 0 to 10) for BASFI. In the intervention group, 21 of 30 (70%) and 13 of 30 (43%) of the patients were categorized as responders measured with ASPI and BASFI, respectively. There was a tendency towards a floor effect in BASFI, as 8 of 58 (14%) patients scored the lowest value at baseline.

LIMITATIONS

This study was limited by its moderate sample size.

CONCLUSIONS

Our findings suggest that ASPI is preferable over BASFI when evaluating physical function after exercise interventions in patients with axSpA.

The Ankylosing Spondylitis Performance Index: Reliability and Feasibility of an Objective Test for Physical Functioning

OBJECTIVE

Physical function in patients with axial spondyloarthritis (axSpA) is currently evaluated through questionnaires. The Ankylosing Spondylitis Performance Index (ASPI) is a performance-based measure for physical functioning, which has been validated in Dutch patients with radiographic (r-) axSpA. The interrater reliability has not yet been determined. To our knowledge, this study is the first to evaluate the validity, reliability, and feasibility of the ASPI in another patient population, including both r- and nonradiographic (nr-) axSpA patients.

METHODS

Patients with axSpA were recruited from rheumatology clinics in Santiago, Chile. Dutch instructions were translated to Spanish by a forward-backward procedure. Study visits were performed at baseline and 1-4 weeks later. Four ASPI observers were involved, measuring the performance times of the 3 ASPI tests. Validity was assessed through a patient questionnaire (numeric rating scale 0-10: ≥ 6 sufficient). For reliability, intraclass correlation coefficients (ICC) were calculated (with 95% CI). Correlations between the ASPI and disease variables were tested with regression analyses.

RESULTS

Sixty-eight patients were included (57% male, 52% r-axSpA). All patients understood the Spanish instructions and considered the ASPI to reach its aim (84%) and representativeness (85%) for physical functioning. The overall interrater (n = 62) and test-retest (n = 39) reliability (ICC) of the 3 tests combined were 0.93 (0.88-0.96) and 0.94 (0.87-0.97), respectively. Eighty-two percent of the patients completed all tests and 94% finished in < 15 min (feasibility).

CONCLUSION

This study demonstrated a high validity and feasibility in an entirely different population, with both r-axSpA and nr-axSpA. The interrater and test-retest reliability was excellent. The ASPI instructions are now available for Spanish-speaking patients.

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

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

Monitoring ankylosing spondylitis: clinically useful markers and prediction of clinical outcomes

Patient assessment in axial spondyloarthritis (axSpA) is multidimensional, and monitoring of disease activity, function and radiographic progression is complex. There is no simple 'gold standard' for measuring disease activity in all individual patients, as disease activity in axSpA is the sum of many different aspects and a complexity that cannot be represented by a single variable. Limited spinal mobility is a cardinal sign of ankylosing spondylitis and loss of spinal mobility has been reported to be a prognostic factor and most often evaluated with the Bath Ankylosing Spondylitis Functional Index. Imaging of the spine and assessment of safety aspects plays an important role in the monitoring of patients with axSpA. The timeframe for collecting information regarding disease activity, function and radiographic progression are recommended on an individual basis.