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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 24-30

Functional assessment tools for ankylosing spondylitis: A systematic review


Department of Musculoskeletal Sciences, Krishna College of Physiotherapy, KIMSDU, Karad, Maharashtra, India

Date of Submission24-Mar-2022
Date of Acceptance22-Jun-2022
Date of Web Publication12-Aug-2022

Correspondence Address:
Sandeep Babasaheb Shinde
Department of Musculoskeletal Sciences, Faculty of Physiotherapy, KIMSDTU, Karad, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jahas.jahas_11_22

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  Abstract 

Ankylosing spondylitis (AS) is a chronic, inflammatory, and debilitating condition of the spine that causes pain, decreased mobility, and deformity. AS primarily affects the axial skeletal system, causing pain and stiffness in the spine, which can lead to functional impairment, disability, and a poor quality of life. AS assessment formulates an outcome measure to check the disease process and impairment in individuals, and to identify the rapid progressive ones. It also measures the effectiveness of therapies and treatment. The purpose of this review was to find the current status of the functional tools used in the assessment of AS. A systematic review was done to study the functional assessment tools in patients with AS. Articles were selected based on the relevant topics and went through the selection process. The inclusion criteria of the review were as follows: (1) functional assessment, (2) sensitivity and specificity, (3) reliability, and (4) validity. This study included 11 articles that fulfilled the inclusion criteria and suggested that functional assessment tools are important in AS. Few articles suggest that certain tools are effective in the assessment of domains like pain and physical function, whereas few articles give a good measure of pre- and post-physical therapy and pharmacological intervention. The studies used for the review consisted of scales or questionnaires, which were either qualitative or quantitative type. The reviewed studies provided evidence that it was beneficial for assessing the function. There were a lack of data available in which one assessment tool measured all the parameters of AS. In recent advances, video-based motion capture system has turned out to be an effective modern functional assessment tool in AS.

Keywords: Ankylosing spondylitis, assessment, bath ankylosing spondylitis functional index (BASFI), Dougados Functional Index (DFI)


How to cite this article:
Dalvi SK, Shinde SB. Functional assessment tools for ankylosing spondylitis: A systematic review. J Ayurveda Homeopath Allied Health Sci 2022;1:24-30

How to cite this URL:
Dalvi SK, Shinde SB. Functional assessment tools for ankylosing spondylitis: A systematic review. J Ayurveda Homeopath Allied Health Sci [serial online] 2022 [cited 2022 Sep 26];1:24-30. Available from: http://www.dpujahas.org/text.asp?2022/1/1/24/353696




  Introduction Top


Spondyloarthropathies are a cluster of various chronic inflammatory rheumatic disorders that are categorized by inflammatory back pain, asymmetric peripheral arthritis, enthesitis, dactylitis, and tenosynovitis.[1] They are further divided into the following subtypes: (1) ankylosing spondylitis (AS), (2) psoriatic arthritis, (3) reactive arthritis, (4) enteropathic arthritis, (5) and undifferentiated spondyloarthropathies.[1] AS is a chronic inflammatory and progressive ailment that primarily affects the axial skeletal system, causing pain and stiffness in the spine, which can lead to functional impairment, disability, and poor quality of life.[1] AS assessment is a method of determining the disease process, impairment in individuals, and identifying those who are rapidly progressing, as well as determining the efficacy of therapies and treatments.[1] Besides the axial skeleton and the peripheral joints, it can also affect the extra-articular areas such as the eyes and bowel.[2] It usually appears in late adolescence, but symptoms can appear up to 8 years after a diagnosis.[2] The time between the start of symptoms and the diagnosis of AS is usually quite long, which results in poor clinical outcomes and contributes to both physical and occupational handicaps.[2] The prevalence of AS is 0.03%–18% higher in seronegative arthropathies.[3] However, HLA-B27 gene3 is of considerable importance in diagnosing AS. Low back pain and stiffness in the morning are the most common symptoms.[3] The disease causes not only structural damage but also physical issues and disability. Assessment forms the main diagnostic criteria for AS.

In the previous year before 2010, there was less number of standard and objective assessment tools available for the function.[4],[5] Therefore, there is a need to conduct studies that provide us with proper assessment for AS. Even though radiographs are the gold standard to diagnose AS,[5] still they are insensitive to change and quite expensive. Along with it, they are time-consuming and potentially dangerous.[5] Therefore, self-administered measures to assess disease activity and function in AS were been developed over the past few years which also gives an objective assessment for AS.[5] Mobility of spine (metrological assessment of spinal mobility) has been used as one of the criteria to assess AS, as well as follow-up, and responsiveness to the treatment. Recent advancement in AS is automated motion capture that captures the human movement in an objective and qualitative manner as it gives a higher level of precise and objective assessment and has been used in sports and clinical medicine.[5] Many high-cost biological therapies have been used in the treatment of AS, so we require more defined and reliable measurable tools to assess the therapeutic results.[5]

Imaging studies are the predominant ones that are used for the diagnosis of spondyloarthropathies as it provides a helping hand to establish a diagnosis in adjunct to symptoms and signs. Earlier the gold standard investigation for AS was radiography (X-ray).[5] Usually, diagnostic radiographic changes start appearing or may require 5 years for the development of symptoms.[5] However, recent advancements were done and CT scan was then used as a diagnosing AS.[5] Normally, it takes 2 years to see changes in CT from the onset of symptoms to the development.[5] Although it has more radiation exposure and low sensitivity to change, it is not a valid tool for monitoring the structural impairment.[5] Another diagnosing tool was radionuclide in which bone scanning was done to provide information about the skeleton and helpful in mapping inflammation site.[5] As it has a low sensitivity of approximately 51.8%, so not used for assessment.[5] AS is a chronic inflammatory and progressive condition that makes the person disable and gradually activities start diminishing.[6] The pain free or less painful position is the recumbence posture that is the flexion deformity of spine that causes marked restriction of function in lower limb like walking, standing, and sitting positions which produces discomfort.[6] Once it starts affecting the function, social activities or participation is also restricted which makes the person feel socially unacceptable and unhappy with their presence.[6] Pain and decrease quality of life may lead the patient to face drug or alcohol abuse.[6]

As stated above, AS is a chronic inflammatory and progressive condition that makes the person disabled, and gradually activities start diminishing.[6] Chronic diseases can have a negative influence on individuals not just in terms of physical pain, impaired function, and reduced quality of life, but also on their mental health. Because AS can strike at any age, generally in early adulthood, sufferers must learn to live with their disease for the rest of their lives. AS, like other chronic diseases, can have an impact on quality of life, morbidity, mortality, paid and unpaid work, and healthcare costs. Physical impairment is a prominent clinical characteristic of AS. Activities involving bending forward at the waist and being able to perform a full day of regular exercise are the most difficult for persons with AS.[7],[8] Although it has been claimed that the majority of function loss happens within the first 10 years of disease initiation, more longitudinal research is needed to completely understand the rate of disability progression. As a result of the loss of function, people with AS report feeling less energized. Fatigue is also linked to lower function.[9],[10] Patients with AS have lower physical functioning as well as a lower quality of life. Significant variations in all physical and psychological areas have been observed between AS patients and the general population using generic quality of life measures.[11]

Physical functionality is one of the most important outcomes in chronic rheumatological illnesses. The most common difficulty areas for people with AS were activities that were critical to their daily functioning.[12] Driving a car, disrupted sleeping, and shopping were the most commonly cited difficulties as well as having enough energy for social activities. There are several issues that need to be addressed. The lives and functioning of the people were severely influenced.[12] To address these problems, an interdisciplinary and multifaceted approach is needed: one that includes traditional medications, physical and occupational therapy, as well as an educational component, increased attention to environmental structural, social, and economic issues, and mental stumbling blocks. As a result, one of the key therapy aims is to improve physical function while maintaining a reasonable degree of health.[12]

As per the data available for the prevalence of AS, the male–to-female ratio was 3:1.[13] Quality of life is usually affected in ankylosing spondylosis as it is not well documented.[13] In chronic rheumatic disease, multidimensional assessments are the appropriate ways of assessing the efficiency of treatment, disability, and function, whereas the unidirectional ones may lack few assessments in domains of impairment and function.[14] In ankylosing spondylosis, measuring disease activity and progression can be difficult. Both strengths and weaknesses should be included in the assessment instrument. Accuracy, feasibility, and discrimination must all be considered while selecting or comparing devices for measuring physical functional ability in a research or clinical situation.[15]


  Materials and Methods Top


Search strategy

A systematic review was done to study the functional assessment tools in AS patients. Using the MeSH search terms AS, function assessment tools, assessment index, quality of life, recent advances, and free words, an electronic search for pertinent articles was conducted using the Google Scholar, PubMed, MEDLINE, Pedro, Research Gate, and CINHAL databases from 1995 to March 2022 for this review. In addition to this, relevant books were also searched manually. Articles were chosen based on the expertise, self-awareness, and reflective practice of the authors.

Study selection

Studies that were only concerned with the assessment tools used in AS and were published in English up through March 2022 were subjected to a systematic evaluation. The selection criteria of the review were as follows: (1) functional assessment, (2) sensitivity and specificity, (3) reliability, and (4) validity.

Data extraction

Two reviewers separately reviewed each step of the selection and extraction methods. The retrieved references’ titles and abstracts were evaluated. The full texts of relevant publications were examined and included if they matched the criteria for inclusion.


  Results Top


[Figure 1] summarizes the process of study selection. Initial searching identified 20,767 citations. Following the first screening, 4315 articles were excluded and 2549 citations were retained for the second screening; after reviewing the titles, 1758 were excluded and 791 were considered of interest. Looking at the abstracts, few were excluded. This study finally included 11 papers.
Figure 1: Summary of the selection process

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A study by Jane Zochling has reviewed a few scales of which four were on functional assessment.

  1. The Ankylosing Spondylitis Quality of Life Scale (ASQOL) is an 18-item questionnaire that evaluates the severity of the disease. As the score rises, so does the severity of the impairment. The article’s drawback was that it did not address actions of involvement that were not covered by other outcome measures.[16]


  2. The Bath Ankylosing Spondylitis Disease Activity Index has six aspects (BASDAI). This study looks at back pain, fatigue, peripheral joint soreness, edema, localized tenderness, and the duration and degree of morning stiffness. It takes about 3–2 min to finish.[16]


  3. The Bath Ankylosing Spondylitis Functional Index (BASFI) consists of 10 functional anatomy elements. Bending, reaching, changing position, standing turning, and mounting steps are eight of the 10 items. Two items examine the patient’s ability to cope with day-to-day living. Completion time is less than 3 min.[16]


  4. The Dougados Functional Index (DFI) consists of 20 criteria that include daily activities such as dressing, bathing, standing, climbing stairs, changing positions, bending, and coughing. The scale runs from 0 to 40. The lower the score, the more functionally impaired you are.[16]


Also, a study by Jone et al. conducted on single scale stated that Bath AS Patient Global Score (BAS-G) assesses the patient's well-being along with the disease activity, function, and spinal mobility. Along with this, the author also compared BAS-G with the other assessment tools like BASDAI, BASFI that BASMI where all the domains correlated well with all the domains which showed a good co-relation when compared.[17]

A retrospective study was conducted by Henry Halm, and Fetermetz regarding the result of surgical correction of kyphotic deformities of spine in AS based on modified arthritis impact measurement scales, which was a questionnaire consisting of 8 scales and 60 plus items which included mobility, physical, household, daily, social activity, pain, anxiety and depression. Two of the items demonstrated a considerable improvement in function, as well as making the patient more efficient in his or her return to work.[6] BASFI and DFI measure all the function but were unable to measure, so ARIMS was done in AS. There were significant changes in the P value.[6]

A cohort study on measuring disabilities in AS by Eyres et al. stated that BASFI and RLDQ were compared and they were highly significant with P < 0.0001. Also, both the tools BASFI and DFI have been selected as an appropriate ways to assess function. Both these measures are in common use and have undergone assessment and validation studies.[18],[19],[20]

Anderson et al. evaluated the Ankylosing Spondylitis Assessment Group’s and proposed the definition of short-term improvement in AS. The results reveal that clinical trial data were used to refine item choices in the domains, and a range of candidate improvement definitions were generated, tested, and compared to the performance of these candidate criteria. Physical function, pain, patient global evaluation, and inflammation all showed improvements of more than 20% and a net improvement of more than 10 units on a scale of 0–100, with no worsening. The mirror definition of deterioration in a certain domain is worsening by >20% and by >10 units on a scale of 0–100.[21]

A cross-sectional cohort study of 95 Italian patients found that the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) scores were more trustworthy (0.874 and 0.941), that both scoring systems associated strongly with BASMI (P = 0.01), and that only the mSASSS exhibited a significant link with BASFI29 (P = 0.02).[22] The mSASSS was employed in a cohort study of 75 participants, and the results showed that the mSASSS scores were more accurate (0.831 and 0.840). The BASMI and BASFI had substantial correlations with the two scoring systems (mSASSS r = 0.557; r = 0.319; BASRI-spine r = 0.605, r = 0.285).[19]


  Discussion Top


The goal of this systematic review was to summarize and identify the current research on AS functional evaluation techniques. In AS, there is no gold standard assessment technique for determining function. According to the symptoms and need, there are different assessment tools used which are mentioned in [Table 1] with available data on the research website with some insufficiency of data in the certain article regarding sensitivity, reliability, validity, and specificity.
Table 1: Summary of studies

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An article by Jane Zochling summarized many scales of which four of them were on function assessment. ASQOL has 18 items that assess the impairment. It takes about 2–16 min to complete with the specificity, sensitivity, reliability, and validity as mentioned in the above table. The score increases the impairment status also increases. The article’s drawback was that it did not address actions of involvement that were not covered by other outcome measures.[3] The BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) has six items. It focuses on back pain, exhaustion, peripheral joint discomfort, edema, regional tenderness, and morning stiffness length and severity.[3] Sensitive to change which makes it useful for further research and takes 2-3 minutes.[3] Bath Ankylosing Spondylitis Functional Index (BASFI) includes 10 items that constitute functional anatomy. Out of the 10 items, 8 items namely bending, reaching, changing position along with standing turning, and climbing steps. Two items assess the ability of the patient for coping with everyday life. It takes less than 3 min to complete. The DFI consists of 20 elements that include daily activities such as dressing, bathing, standing, climbing stairs, changing positions, bending, and coughing. The scale runs from 0 to 40. The lower the score, the greater the functional deficit there is. No comparison was done by the author with one single scale with another.[16]

A study conducted by Jone et al on single scale stated that bath AS Patient Global Score (BAS-G) assesses the patient's well-being along with the disease activity, function, and spinal mobility. They also compared the other assessment tool like BASDAI, BASFI than BASMI. All the domains correlated well with all the domains, which showed that a good correlation was achieved with others.[17] On the contrary, Moncur et al. have mentioned about few scales in which the Revised Leeds Disability Questionnaire (RLDQ) scale measured the functional status in AS which was a self-administered questionnaire of four categories including mobility, bending down, and posture. The score of each category ranged from 0 to 3. The higher the score, the greater the impairment. Other scales were also summarized individually but no comparison was shown of one scale with another.[23]

Guillemin et al. conducted a study on AS patient to check Quality of life by Arthritis Impact Measurement Scales 2, a modified Arthritis Impact Measurement Scales Questionnaire (AIMS 2, AMAIMSQ) which was a self-reported questionnaire comprised of 57 core component in five dimensions that were physical, affect, symptoms, role, and social interaction. The study showed deterioration in the three components that are physical, affect, symptoms, and may cause harm to the role and social interaction. This study also said that it could give better care management for persons with AS.[13] Here individual domains are scored and measured. On the contrary, more studies were also searched based on symptoms that cause functional disability and a loss in quality of life, and they are as follows. A study by Bahouq et al., constituted of 16 items that assess the fatigue levels in AS. They assessed the extent to which fatigue had interfered in daily life. Five dimensions of fatigue were assessed, which were MAF1-Degree, MAF2-Severity, MAF3-Distress, MAF4-ADL’s, and MAF5-Timing. Fatigue can thus be stated as a primary reason for functional inactivity in persons with AS.[24] Aloush et al. conducted a cohort study on women with AS having fibromyalgia (FM). The study concluded that FM was diagnosed in half of the women with AS. Higher disease activity indices (BASDAI and BASFI) were related to the existence of FM, but no severity in physical function was identified.[25]

Now talking about the working instability of patients with AS. A cross-sectional study was conducted by Fabreguet et al. Ankylosing Spondylitis Work Instability Scale (AS-WIS) showed a good correlation with the other assessment tool BASDAI, BASFI, and BAS-G. It also compared moderate-to-high work instability. About 3%–50% of work instability occurs in AS after 18–45 years’ disease duration. The work instability was 40.4% who had moderate-to-high work, which provided an impact on the work status.[4] As it was a cross-sectional study, the sample size was less and also was not able to tell about the job retention. From this, it can be concluded that functional tools may play a very important role in working population as they helped to check the work instability. Although AS is one of the debilitating conditions that once starts progressing, it causes further disabilities and may require surgical intervention as well. As a result, Henry Halm and Fetermetz published a pertinent article in which a retrospective study was carried out on 175 patients who underwent surgery to treat spinal abnormalities associated with AS. The study was based on modified arthritis impact measurement scales, a questionnaire (AS-AIMS 2, mAIMSQ) with 8 scales and more than 60 items, where mobility, physical, domestic, daily, and social activities, pain, anxiety, and sadness were among the factors taken into account. Two items showed a considerable improvement in function and also makes the patient more efficient to return back to work.[6] BASFI and DFI scale measure all the function but were unable to measure so ARIMS was done in AS.[6]

Lastly T Sigl et al. ICF-based comparison of disease-specific instruments measuring physical functional ability in AS may provide us with a comprehensive common framework for evaluating functioning and health, as ICF is widely acknowledged. Sixteen items included in physical functional ability tests were linked to the best appropriate ICF categories using established linkage and guidelines. The Bath Ankylosing Spondylitis Functional Index (BASFI), the DFI, the Health Assessment Questionnaire modified for spondyloarthropathies (HAQ-S), and the Revised Leeds Disability Questionnaire (RLDQ) were compared to the ICF in the study, and the studies were successfully able to link to the ICF, with the exception of the HAQ-S “illness” item.[15]

According to Hanne Dagfinrud, a study on the Impact of Functional Impairment in Ankylosing Spondylitis: Impairment, Activity Limitation, and Participation Restrictions was placed on 152 individuals with AS. Interviews were conducted using the Canadian Occupational Performance Measure (COPM), which characterized and measured the activity constraints and participation restrictions. They looked at variables that were classified and analyzed using the ICF model’s levels. The study concluded that the impairment characteristics only explained a portion of the activity limitations and participation restrictions reported by patients.[28]

All of the assessment instruments used in AS have advantages and disadvantages. Accuracy, feasibility, and discrimination must all be considered when choosing or comparing devices for measuring physical functional ability in a research or clinical situation. Nevertheless, there cannot be a comparison between them. It is not necessary to discriminate the tools because they have a different spectrum of items covered by the instruments.[26] There was a lack of data available in which one assessment tool measured all the parameters of AS. There are limited data found regarding a tool that assesses on everyday basis. The assessment tool used should be more cost-effective easy to administer, reliable, valid, and should be able to assess in OPD settings as well. Questionnaires that are quantitative and more valid and reliable need to be formulated that assess the functional disability of AS. Also, there was a lack of data available on vocational rehabilitation in patients with AS. Therefore, that gives future scope for research to carry out.


  Conclusion Top


This systematic review has provided an overview of the recent literature on functional assessment tools used for AS. The reviewed studies provided evidence that mentioned assessment tools are beneficial for assessing the function of individuals with AS. The main challenging part for patients with ankylosis spondylitis was the tasks that were essential for their daily functioning. As we know AS is a chronic progressive disease that has a negative influence on individuals not just in terms of physical pain, impaired function, and reduced quality of life but also in terms of their work. In the realm of rehabilitation and care of patients with ankylosis spondylitis, patient perspective and their needs have to be taken into consideration. To address these problems, the use of these assessment tools which are quantitative and qualitative in cases of AS help in developing the specific and accurate further treatment options/plans and also help in improving the quality of life, adaptation to the working environment in such individuals, avoiding surgical intervention. Similarly, it can be also used for better prognosis and also to avoid a long-term complications and maintain follow-ups regularly.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.



 
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Davis JC, van der Heijde D, Dougados M, Woolley JM Reductions in health-related quality of life in patients with ankylosing spondylitis and improvements with etanercept therapy. Arthritis Rheum 2005;53:494-501.  Back to cited text no. 11
    
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Landewé R, Dougados M, Mielants H, van der Tempel H, van der Heijde D Physical function in ankylosing spondylitis is independently determined by both disease activity and radiographic damage of the spine. Ann Rheum Dis 2009;68:863-7.  Back to cited text no. 12
    
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Abbott CA, Helliwell PS, Chamberlain MA Functional assessment in ankylosing spondylitis: Evaluation of a new self-administered questionnaire and correlation with anthropometric variables. Br J Rheumatol 1994;33:1060-6.  Back to cited text no. 14
    
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