9. Loss of cervical and lumbar lordosis
Paraspinal Muscle Spasm
Decreased Mobility symmetrically
Kyphotic Deformity leading to
Stooped over position
Chest flattening
Sacro iliac pain
Hip flexion and adduction
Knee Flexion
Shoulder internal rotation and adduction
10. Chest expansion
Occiput to wall distance
Finger to floor measurement
Intermalleolar straddle
Chin to Chest
Schober Test
Modified Schober Test
13. Straight leg raising test
Compression stress test
Distraction stress test
Axial Rotation stress test
Pump Handle
Gaenslen Test
Laquer’s Sign
Goldthwaite Sign
14.
15.
16.
17.
18.
19.
20.
21. Clinical Criteria
◦ Low back pain, > 3
months, improved by
exercise, not relieved
by rest
◦ Limitation of lumbar
spine motion, sagittal
and frontal planes
◦ Limitation of chest
expansion relative to
normal values for age
and sex
21
• Radiologic Criteria
– Sacroiliitis grade ≥ 2
bilaterally or grade 3 – 4
unilaterally
• Grading
– Definite AS if radiologic
criterion present plus at least
one clinical criteria
– Probable AS if:
• Three clinical criterion
• Radiologic criterion
present, but no signs or
symptoms satisfy clinical
criteria
22. Index Metric
BASFI Disability level
BASDAI Disease activity level
ASAS - IC Composite sum of disease activity
22
BASFI = Bath Ankylosing Spondylitis Functional Index
BASDAI = Bath Ankylosing Spondylitis Disease Activity Index
ASAS - IC = ASsessment in Ankylosing Spondylitis Improvement Criteria
23. Visual analog scale (VAS) – 10 cm
Mean score of 10 questions
Questions level of functional disability, including:
◦ Ability to bend at the waist and perform tasks
◦ Looking over your shoulder without turning your body
◦ Standing unsupported for 10 minutes without discomfort
◦ Rising from a seated position without the use of an aid
◦ Exercising and performing strenuous activity
◦ Performing daily activities of living
◦ Climbing 12 to 15 steps without aid
23
24. A self-administered instrument (using 10-cm horizontal
visual analog scales) that comprises 6 questions:
Over the last one week, how would you
describe the overall level of:
◦ Fatigue/tiredness
◦ AS spinal (back, neck) or hip pain
◦ Pain/swelling in joints other than above
◦ Level of discomfort from tender areas
◦ Morning stiffness from the time you awake
◦ How long does morning stiffness last?
24
25. ASAS 20: An improvement of > 20% and absolute
improvement of > 10 units on a 0–100 scale in > 3 of the
following 4 domains:
◦ Patient global assessment (by VAS global assessment)
◦ Pain assessment (the average of VAS total and nocturnal
pain scores)
◦ Function (represented by BASFI)
◦ Inflammation (the average of the BASDAI’s last two VAS
concerning morning stiffness intensity and duration)
Absence of deterioration in the potential remaining domain
◦ (deterioration is defined as > 20% worsening)
25
Editor's Notes
Modified New York Criteria for the Diagnosis of AS
Three sets of clinical and radiographic criteria have been introduced over the past 40 years. The Modified New York Criteria,1,2 developed in 1984, are now widely used to diagnose AS. Radiographic evidence of sacroiliitis is heavily relied on to diagnose AS because it is the best nonclinical indicator of disease. Diagnosis may be missed early on, though, because routine pelvic radiographs may not clearly demonstrate sacroiliitis in the initial stages of AS.3
Van der Linden S. Ankylosing spondylitis. In: Textbook of Rheumatology 5th ed. Kelly WN, Harris ED, Ruddy S, Sledge CB, eds. Philadelphia, PA: WB Saunders; 1996:969-982.
Van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum. 1984;27:361-368.
3. Khan MA. Spondyloarthropathies. In: Hunder GG, ed. Atlas of Rheumatology. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2002.
Disease Activity and Disability Assessment Instruments
Complete agreement does not exist with regard to the specific instruments that should be used to measure disease activity; however, a questionnaire directed at specialists in the field of AS indicates that many experts prefer the Bath AS Disease Activity Index (BASDAI) and/or the Bath AS Functional Index (BASFI).1,2 The ASsessment in Ankylosing Spondylitis Improvement Criteria (ASAS-IC), a composite of four domains, have also been evaluated recently and were concluded to be strict in defining response and highly specific as well.3
1.Braun J, Sieper J. Building consensus on nomenclature and disease classification for ankylosing spondylitis: results and discussion of a questionnaire prepared for the International Workshop on New Treatment Strategies in Ankylosing Spondylitis, Berlin, Germany, January 18-19, 2002. Ann Rheum Dis. 2002;61(suppl III):iii61-iii67.
2. Braun J, Pham T, Sieper J, et al for the ASAS Working Group. International ASAS consensus statement for the use of anti-tumor necrosis factor agents in patients with ankylosing spondylitis. Ann Rheum Dis. 2003;62:817-824.
3. van Tubergen A, van der Heijde D, Anderson J, et al for the ASAS Working Group. Comparison of statistically derived ASAS improvement criteria for ankylosing spondylitis with clinically relevant improvement according to an expert panel. Ann Rheum Dis. 2003;62:215-221.
Bath Ankylosing Spondylitis Functional Index (BASFI)
A mean score of 10 questions assesses disability level through the BASFI. Questions include the ability to bend at the waist and perform tasks, looking over your shoulder without turning your body, standing unsupported for 10 minutes without discomfort, rising from a seated position without the use of an aid, exercising and performing strenuous activity, performing daily activities of living, and climbing 12 to 15 steps without aid.
Calin A, Garrett S, Whitelock H, et al. A new approach to defining functional ability in ankylosing spondylitis: the development of the Bath Ankylosing Spondylitis Functional Index. J Rheumatol. 1994;21:2281-2285.
Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)
Questions about the level of fatigue, neck/back/hip pain, morning stiffness, and tender joints are combined to determine disease activity level using the BASDAI.
Garrett S, Jenkinson T, Kennedy, Whitelock H, Gaisford P, Calin A. A new approach to defining disease status in ankylosing spondylitis: the Bath Ankylosing Spondylitis Disease Activity Index. J Rheumatol. 1994;21:2286-2291.
