Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

The assessment of ankylosing spondylitis in clinical practice

Nature Clinical Practice Rheumatology volume 3, pages 496–503 (2007)Cite this article

Abstract

Ankylosing Spondylitis (AS) is a chronic inflammatory arthritis that predominantly affects the axial skeleton in adolescent patients causing spinal pain and stiffness. There is a marked delay, on average 8 years, between onset of disease symptoms and clinical diagnosis. The distinction between the symptoms of mechanical and inflammatory back pain remains one of the main contributing factors for the delay in diagnosis. Several classification criteria exist to aid the diagnosis of AS, but their accuracy is poor. The Ankylosing Spondylitis Assessment Study group (ASAS) has defined a core set of domains for clinical outcome measurement in AS in order to assess the disease process in individual patients and to identify those with rapidly progressive disease. New therapies, such as the tumor necrosis factor (TNF) inhibitors, have transformed the treatment paradigm in AS, especially for those patients with aggressive disease. Thus, the definition of both patient selection criteria for these agents and the development of clinical methods to assess response to therapy have become a priority. This Review focuses on measuring the degree of disease activity, function and damage in patients with AS in an ambulatory care setting, and the assessment of suitability of various outcome measures for monitoring response to treatment with TNF inhibitors.

Key Points

  • The clinical assessment of AS remains a challenge for both researchers and clinicians

  • The identification of the origin of inflammatory back pain using MRI facilitates earlier diagnosis of AS-related pain

  • Assessment of clinical outcomes in practice should include spinal pain and stiffness, patient global, physical function, inflammation and spinal mobility

  • There are clear country-specific guidelines for patient selection for anti-TNF therapy

  • The ASAS-IC and the BASDAI 50 can be used in clinical practice to assess patient response to anti-TNF therapy

This is a preview of subscription content, access via your institution

Relevant articles

Open Access articles citing this article.

Access options

Rent or buy this article

Get just this article for as long as you need it

$39.95

Learn more

Prices may be subject to local taxes which are calculated during checkout

References

  1. Moll JM et al. (1974) Associations between ankylosing spondylitis, psoriatic arthritis, Reiter's disease, the intestinal arthropathies, and Behcet's syndrome. Medicine (Baltimore) 53: 343–364

    Article  CAS  Google Scholar 

  2. van der Linden S et al. (1984) Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum 27: 361–368

    Article  CAS  PubMed  Google Scholar 

  3. Stone M et al. (2005) Juvenile-onset ankylosing spondylitis is associated with worse functional outcomes than adult-onset ankylosing spondylitis. Arthritis Rheum 53: 445–451

    Article  PubMed  Google Scholar 

  4. Ward MM (1998) Quality of life in patients with ankylosing spondylitis. Rheum Dis Clin North Am 24: 815–827

    Article  CAS  PubMed  Google Scholar 

  5. Zink A et al. (2000) Disability and handicap in rheumatoid arthritis and ankylosing spondylitis—results from the German rheumatological database. German Collaborative Arthritis Centers. J Rheumatol 27: 613–622

    CAS  PubMed  Google Scholar 

  6. Spoorenberg A et al. (1999) Relative value of erythrocyte sedimentation rate and C-reactive protein in assessment of disease activity in ankylosing spondylitis. J Rheumatol 26: 980–984

    CAS  PubMed  Google Scholar 

  7. van der Heijde D et al. (1997) Preliminary core sets for endpoints in ankylosing spondylitis. Assessments in Ankylosing Spondylitis Working Group. J Rheumatol 24: 2225–2229

    CAS  PubMed  Google Scholar 

  8. Jones SD et al. (1996) The Bath Ankylosing Spondylitis Patient Global Score (BAS-G). Br J Rheumatol 35: 66–71

    Article  CAS  PubMed  Google Scholar 

  9. Calin A et al. (1994) A new approach to defining functional ability in ankylosing spondylitis: the development of the Bath Ankylosing Spondylitis Functional Index. J Rheumatol 21: 2281–2285

    CAS  PubMed  Google Scholar 

  10. Dougados M et al. (1988) Evaluation of a functional index and an articular index in ankylosing spondylitis. J Rheumatol 15: 302–307

    CAS  PubMed  Google Scholar 

  11. Zochling J et al. (2006) ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann Rheum Dis 65: 442–452

    Article  CAS  PubMed  Google Scholar 

  12. Brandt J et al. (2003) Six-month results of a double-blind, placebo-controlled trial of etanercept treatment in patients with active ankylosing spondylitis. Arthritis Rheum 48: 1667–1675

    Article  CAS  PubMed  Google Scholar 

  13. Stone M et al. (2005) Juvenile-onset ankylosing spondylitis is associated with worse functional outcomes than adult-onset ankylosing spondylitis. Arthritis Rheum 53: 445–451

    Article  PubMed  Google Scholar 

  14. Davis JC Jr et al. (2005) Baseline factors that influence ASAS 20 response in patients with ankylosing spondylitis treated with etanercept. J Rheumatol 32: 1751–1754

    CAS  PubMed  Google Scholar 

  15. Garrett S et al. (1994) A new approach to defining disease status in ankylosing spondylitis: the Bath Ankylosing Spondylitis Disease Activity Index. J Rheumatol 21: 2286–2291

    CAS  PubMed  Google Scholar 

  16. Calin A et al. (1999) Defining disease activity in ankylosing spondylitis: is a combination of variables (Bath Ankylosing Spondylitis Disease Activity Index) an appropriate instrument? Rheumatology (Oxford) 38: 878–882

    Article  CAS  Google Scholar 

  17. Yildirim K et al. (2004) Relationship between some acute phase reactants and the Bath Ankylosing Spondylitis Disease Activity Index in patients with ankylosing spondylitis. South Med J 97: 350–353

    Article  PubMed  Google Scholar 

  18. Ruof J and Stucki G (1999) Validity aspects of erythrocyte sedimentation rate and C-reactive protein in ankylosing spondylitis: a literature review. J Rheumatol 26: 966–970

    CAS  PubMed  Google Scholar 

  19. Sheehan NJ et al. (1986) Lack of correlation between clinical disease activity and erythrocyte sedimentation rate, acute phase proteins or protease inhibitors in ankylosing spondylitis. Br J Rheumatol 25: 171–174

    Article  CAS  PubMed  Google Scholar 

  20. Molloy C et al. (2007) Lipid bioprofiles and correlation with disease activity measures in the spondyloarthropathies [abstract]. Ann Rheum Dis 66

  21. Braun J et al. (2002) Anti-tumour necrosis factor alpha therapy for ankylosing spondylitis: international experience. Ann Rheum Dis 61 (Suppl 3): iii51–iii60

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Rudwaleit M et al. (2004) Prediction of a major clinical response (BASDAI 50) to tumour necrosis factor alpha blockers in ankylosing spondylitis. Ann Rheum Dis 63: 665–670

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Stone MA et al. (2004) Cytokine correlates of clinical response patterns to infliximab treatment of ankylosing spondylitis. Ann Rheum Dis 63: 84–87

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Kim TH et al. (2005) Cartilage biomarkers in ankylosing spondylitis: relationship to clinical variables and treatment response. Arthritis Rheum 52: 885–891

    Article  CAS  PubMed  Google Scholar 

  25. Robertson LP and Davis MJ (2004) A longitudinal study of disease activity and functional status in a hospital cohort of patients with ankylosing spondylitis. Rheumatology (Oxford) 43: 1565–1568

    Article  CAS  Google Scholar 

  26. Stone MA et al. (2007) Longitudinal Analyses of disease outcomes in Ankylosing Spondylitis yield insight into the natural history of AS [abstract]. Ann Rheum Dis 66

  27. Jenkinson TR et al. (1994) Defining spinal mobility in ankylosing spondylitis (AS). The Bath AS Metrology Index. J Rheumatol 21: 1694–1698

    CAS  PubMed  Google Scholar 

  28. Wanders A et al. (2005) Association between radiographic damage of the spine and spinal mobility for individual patients with ankylosing spondylitis: can assessment of spinal mobility be a proxy for radiographic evaluation? Ann Rheum Dis 64: 988–994

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Kennedy LG et al. (1995) Ankylosing spondylitis: the correlation between a new metrology score and radiology. Br J Rheumatol 34: 767–770

    Article  CAS  PubMed  Google Scholar 

  30. Kaya T et al. (2006) The relationship between severity and extent of spinal involvement and spinal mobility and physical functioning in patients with ankylosing spondylitis. Clin Rheumatol 25: 835–839

    Article  PubMed  Google Scholar 

  31. Maksymowych WP et al. (2006) Development and validation of the Edmonton Ankylosing Spondylitis Metrology Index. Arthritis Rheum 55: 575–582

    Article  PubMed  Google Scholar 

  32. Braun J (2006) INSPIRE Lateral flexion: A new method to measure lateral spinal mobility in patients with spondyloarthritis [abstract]. Arthritis Rheum 54: S476

    Article  Google Scholar 

  33. D'Agostino MA et al. (2003) Assessment of peripheral enthesitis in the spondylarthropathies by ultrasonography combined with power Doppler: a cross-sectional study. Arthritis Rheum 48: 523–533

    Article  PubMed  Google Scholar 

  34. van der Heidje D et al. (2006) Efficacy and safety of adalimumab in patients with ankylosing spondylitis: results of a multicenter, randomized, double-blind, placebo-controlled trial. Arthritis Rheum 54: 2136–2146

    Article  Google Scholar 

  35. Balint PV et al. (2002) Ultrasonography of entheseal insertions in the lower limb in spondyloarthropathy. Ann Rheum Dis 61: 905–910

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Mander M et al. (1987) Studies with an enthesis index as a method of clinical assessment in ankylosing spondylitis. Ann Rheum Dis 46: 197–202

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Heuft-Dorenbosch L et al. (2003) Assessment of enthesitis in ankylosing spondylitis. Ann Rheum Dis 62: 127–132

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Braun J et al. (2002) Treatment of active ankylosing spondylitis with infliximab: a randomised controlled multicentre trial. Lancet 359: 1187–1193

    Article  CAS  PubMed  Google Scholar 

  39. Gladman DD et al. (2006) Evaluating enthesitis in patients with spondyloarthritis (SpA) [abstract]. Arthritis Rheum 54

  40. Borman P et al. (2006) Ultrasound detection of entheseal insertions in the foot of patients with spondyloarthropathy. Clin Rheumatol 25: 373–377

    Article  PubMed  Google Scholar 

  41. Anderson JJ et al. (2001) Ankylosing spondylitis assessment group preliminary definition of short-term improvement in ankylosing spondylitis. Arthritis Rheum 44: 1876–1886

    Article  CAS  PubMed  Google Scholar 

  42. Ward MM (2001) Response criteria and criteria for clinically important improvement: separate and equal? Arthritis Rheum 44: 1728–1729

    Article  CAS  PubMed  Google Scholar 

  43. Brandt J et al. (2004) Development and preselection of criteria for short term improvement after anti-TNF alpha treatment in ankylosing spondylitis. Ann Rheum Dis 63: 1438–1444

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Stone MA et al. (2004) Validation exercise of the Ankylosing Spondylitis Assessment Study (ASAS) group response criteria in ankylosing spondylitis patients treated with biologics. Arthritis Rheum 51: 316–320

    Article  CAS  PubMed  Google Scholar 

  45. Maksymowych WP et al. (2007) Evaluation and validation of the patient acceptable symptom state (PASS) in patients with ankylosing spondylitis. Arthritis Rheum 57: 133–139

    Article  PubMed  Google Scholar 

  46. Tubach F et al. (2006) Stability of the patient acceptable symptomatic state over time in outcome criteria in ankylosing spondylitis. Arthritis Rheum 55: 960–963

    Article  PubMed  Google Scholar 

  47. Keat A et al. (2005) BSR guidelines for prescribing TNF-alpha blockers in adults with ankylosing spondylitis. Report of a working party of the British Society for Rheumatology. Rheumatology (Oxford) 44: 939–947

    Article  CAS  Google Scholar 

  48. Maksymowych WP et al. (2003) Canadian Rheumatology Association Consensus on the use of anti-tumor necrosis factor-alpha directed therapies in the treatment of spondyloarthritis. J Rheumatol 30: 1356–1363

    CAS  PubMed  Google Scholar 

  49. Braun J et al. (2003) International ASAS consensus statement for the use of anti-tumour necrosis factor agents in patients with ankylosing spondylitis. Ann Rheum Dis 62: 817–824

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. van der Linden et al. (1984) Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum 27: 361–368

    Article  Google Scholar 

  51. Dougados M et al. (1991) The European Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthropathy. Arthritis Rheum 34: 1218–1227

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

The authors would like to thank Paul Doherty for his editorial assistance. Charles P Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

Author information

Authors and Affiliations

  1. R Sengupta is a Specialist Registrar in Rheumatology at the Royal National Hospital for Rheumatic Diseases in Bath, UK,

    Raj Sengupta

  2. M Stone is a Consultant Rheumatologist at the Royal National Hospital for Rheumatic Diseases and Reader at the University of Bath, UK.,

    Millicent A Stone

Authors
  1. Raj Sengupta
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Millicent A Stone
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Millicent A Stone.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Sengupta, R., Stone, M. The assessment of ankylosing spondylitis in clinical practice. Nat Rev Rheumatol 3, 496–503 (2007). https://doi.org/10.1038/ncprheum0591

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncprheum0591

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing