welcome to spa sig august 2, 2006 mr 304 : 15.30-16.30

Welcome to SpA SIGWelcome to SpA SIG

August 2, 2006August 2, 2006

MR 304 : 15.30-16.30

How you diagnose and assess

disease activity in AS:

Results of a questionnaire study

Ratanavadee Nanagara, M.D.

Allergy-Immunology-Rheumatology Unit

KhonKaen University

Thailand

parameters being used in common practice for

diagnosis and assessment of AS patients.

parameters being used in common practice for

diagnosis and assessment of AS patients.

comments, suggestion, and revised by experience AS researcherscomments, suggestion, and revised by experience AS researchers

80 parameters for AS diagnosis, 32 for AS assessment

electronically distributed

QuestionnaireQuestionnaire

to assess the degree of importance of …parameters

used for diagnosis and assessment of AS patients …

*** rheumatologist running clinical practice for at least 5-10 years

….. up to the individual opinion.. used in clinical

practice, not in research….

* each item was scored as 1 or 2 or 3.

1 = not important

2 = moderate important

3 = extremely important

Purpose

“The must”“The must”

Australia (1) Lionel Schachna Hongkong (4) Isaac YIM, Cheuk-wanLai Shan TamLau Chak SingLee Ka Wing

India (4) Ashok KumarRohini HandaVed ChaturvediVikas Agarwal

Indonesia (1) John Darmawan

Korea (3) Sang-Hoon, Lee.Tae-Hwan KimTae Jong Kim

Malaysia (4) Gun Suk ChynLew LWGSwan Sim YeapSwee Gaik Ong

Philippines (4) Evelyn SalidoJuan Javier LichaucoJulie Li YuSandra V. Navarra

Singapore (5) Anita LimChew Li-ChingJulian ThumbooKok Ooi KongSpore Bernard Thong

Taiwan (1) Chung-Tei Chou

Thailand (4) Boonjing SiripaitoonRatanavadee NanagaraSittichai UkritchonWorawit Laoraenu

31 responders

from 10 APLAR countries

31 responders

from 10 APLAR countries

Results analysisResults analysis

> 80% of responders scored as important ( 2 + 3)> 80% of responders scored as important ( 2 + 3)

Parameter for diagnosisParameter for diagnosis

including: CRP, ESR, most plain films, and MRI

70% agree with B-27 study, less with RF

including: CRP, ESR, most plain films, and MRI

70% agree with B-27 study, less with RF

Parameter for assessmentParameter for assessment

Including: VAS, BASFI, BASDAI, GA, +BASMIIncluding: VAS, BASFI, BASDAI, GA, +BASMI

43 / 57 clinical parts

29 / 32 items listed

9 / 23 Lab. tests

> 80% of responders scored as “The Must” (3)> 80% of responders scored as “The Must” (3)

433 / 57 clinical parts


film pelvisfilm pelvis9 1 / 23 Lab. tests

Schober testSchober test

Inflammatory back pain, morning pain, Schober testInflammatory back pain, morning pain, Schober test


29 1 / 32 items listed

> 60% of responders scored as “The Must” (3)> 60% of responders scored as “The Must” (3)

433 10 / 57 clinical parts


film pelvisfilm pelvis91 1 / 23 Lab. tests

Schober, morning painperipheral joints & eye exam,VAS (pain, global), BASDAI,

Schober, morning painperipheral joints & eye exam,VAS (pain, global), BASDAI,

back pain characteristics eye sign, sausage digitschest expansion

back pain characteristics eye sign, sausage digitschest expansion


291 6 / 32 items listed

50-60 % scored for chest expansion, enthesitis BASFI, CRP, ESR

50-60 % scored for chest expansion, enthesitis BASFI, CRP, ESR

50% scored for MRI, 30% scored for B-2750% scored for MRI, 30% scored for B-27

Conclusion (1)

1. Majority of the responders agree that most parameters used for

diagnosis and assessment of AS patients are important.

2. However, limited numbers of these parameters have been using

in their clinical practice.

3. At least, characteristics of back pain, Schober test, chest and

eye exam, and film pelvis were evaluated by 80% of the

responders.

4. About half used MRI of SI joint for AS diagnosis, while one

third need genetic study.

5. Half of the responders used AS measurement parameters

(BASDAI, BASFI, VAS) and inflammatory parameters (CRP, ESR) during

AS assessment for their optimal care.

Conclusion (2)

15:30-15:42 How APLAR countries can contribute to international research

David YU USA

15:42-15:54 How you diagnose and assess disease activity in AS, results of a questionnaire study

Ratanavadee Nanagara Thailand

15:54-16:06 Are UspA and AS 2 different diseases? Result from cohort study

Chung-Tei Chou Taiwan

16:06-16:18 Towards a perfect epidemiological Study of SpA, experience in China

Swee Cheng Ng Singapore

16:18-16:30 Do UspA patients respond to TNF blockersJieruo Gu China

Parameters used in diagnosis of AS S1%

S2%

S3%

2+3%

History not imp. must

Gender 25.8 45.2 29.0 74.2

Age 9.7 51.6 38.7 90.3

Ethnicity 58.1 22.6 19.4 41.9

Family history of SpA 3.2 41.9 54.8 96.8

Family history of psoriasis or IBD or iritis 6.5 51.6 41.9 93.5

History of HLA-B27 in family members 19.4 58.1 22.6 80.6

Age of onset of symptoms of AS 3.2 48.4 45.2 93.5

> 50% used in clinical practice

Parameters used in diagnosis of ASS1%

S2%

S3%

2+3%


History of preceding diarrhea or genital discharge or balanitis 12.9 51.6 35.5 87.1

History of preceding injury 71.0 22.6 6.5 29.0

History of psoriasis 6.5 48.4 45.2 93.5

History of IBD 0.0 54.8 45.2 100.0

History of iritis 0.0 32.3 67.7 100.0

History of buttock pain 0.0 25.8 74.2 100.0

Whether buttock pain is alternating 32.3 32.3 35.5 67.7

Whether patient is waken up by night pain 9.7 19.4 71.0 90.3

> 50% used in clinical practice > 70%


S2%

S3%

2+3%


History of cervical spinal pain 22.6 35.5 41.9 77.4

History of thoracic spinal pain 22.6 35.5 41.9 77.4

History of lumbar spinal pain 6.5 35.5 58.1 93.5

Whether spinal pain is "inflammatory" by Calin definition 0.0 6.5 93.5 100.0

Age of onset of spinal pain before age 40 3.2 25.8 71.0 96.8

Whether onset of spinal pain is insidious 12.9 51.6 35.5 87.1

Duration of spinal pain if it is more than 3 months 9.7 32.3 58.1 90.3



S2%

S3%

2+3%


Whether spinal pain is improved by exercise 3.2 25.8 71.0 96.8

Whether there is morning stiffness of spine 3.2 9.7 87.1 96.8

Whether spinal pain is improved by rest 25.8 25.8 48.4 74.2

Whether spinal pain is relieved by NSAIDs 19.4 41.9 38.7 80.6

Presence of peripheral joint pain 6.5 48.4 45.2 93.5

Presence of peripheral joint stiffness 9.7 54.8 35.5 90.3

Whether peripheral joint pain is oligo in number, asymmetrical and predominantly in lower extremities 6.5 45.2 48.4 93.5


Parameters used in diagnosis of AS S1% S2% S3%2+3%

History not Imp. must

Presence of pain in shoulders 22.6 58.1 16.1 74.2

Presence of pain in hips 3.2 48.4 48.4 96.8

Presence of pain at heels 6.5 41.9 51.6 93.5

History of sausage digits 6.5 32.3 61.3 93.5

Presence of rib cage and anterior chest wall pain

19.4 45.2 35.5 80.6

History of skin rash on any parts of the body 22.6 51.6 25.8 77.4

History of HLA-B27 blood test in patient 22.6 48.4 29.0 77.4



S2%

S3%

2+3%

Physical examination not Imp. must

Gait 19.4 48.4 16.1 64.5

Presence of abnormal posture 9.7 48.4 41.9 90.3

Occiput to wall distance 9.7 45.2 45.2 90.3

Tragus to wall distance 12.9 48.4 38.7 87.1

Degree of cervical rotation 6.5 51.6 41.9 93.5

Degree of cervical lateral rotation 12.9 51.6 35.5 87.1

Schober test for forward flexion of lumbar spine 0.0 9.7 87.1 96.8

Lateral flexion of lumbar spine 16.1 41.9 41.9 83.9

Finger to floor distance 25.8 48.4 25.8 74.2



S2%

S3%

2+3%


Intermalleolar distance 35.5 48.4 16.1 64.5

Measurement of chest expansion 6.5 29.0 64.5 93.5

Presence of sausage digits 9.7 32.3 58.1 90.3

Swelling of peripheral joints 3.2 48.4 48.4 96.8

Tenderness of peripheral joints 6.5 58.1 35.5 93.5

Swelling of heels 12.9 29.0 58.1 87.1

Tenderness of heels 6.5 45.2 48.4 93.5



S2%

S3%

2+3%


Range of motion of shoulders and hips 6.5 51.6 41.9 93.5

Physical exam for active sacroiliitis e.g. Patrick test 9.7 41.9 48.4 90.3

Physical exam for skin abnormalities 16.1 48.4 35.5 83.9

Physical exam for redness or swelling of eyes 6.5 48.4 45.2 93.5

Auscultation for aortic insufficiency 41.9 32.3 25.8 58.1


S2%

S3%

2+3%

Laboratory diagnosis not Imp. must 0.0

WBC 71.0 16.1 9.7 25.8

Differential wbc count 77.4 16.1 6.5 22.6

Hgb 45.2 38.7 16.1 54.8

Platelet count 45.2 35.5 19.4 54.8

Urine analysis 54.8 25.8 19.4 45.2

Standard blood chemistry 61.3 22.6 16.1 38.7


S2%

S3%

2+3%

Genetic & Serologic tests not Imp. must 3.2

HLA-B27 25.8 41.9 29.0 71.0

Rheumatoid factor 64.5 22.6 12.9 35.5

ANA 77.4 12.9 9.7 22.6

ESR 3.2 41.9 54.8 96.8

CRP 3.2 45.2 48.4 93.5



S2%

S3%

2+3%

Radiographic evaluation not Imp. must

X-ray of pelvis for sacroiliitis 0.0 6.5 93.5 100.0

Scoring of the degree of sacroiliitis 12.9 35.5 51.6 87.1

CT of sacroiliac joints 25.8 38.7 35.5 74.2

MRI of sacroiliac joints 16.1 32.3 51.6 83.9

MRI of spine 35.5 45.2 19.4 64.5

X-ray of hips 12.9 54.8 32.3 87.1



S2%

S3%

2+3%

Radiographic evaluation not Imp. must 0.0

Bone scan 41.9 45.2 12.9 58.1

X-ray of spine: cervical 19.4 51.6 29.0 80.6

X-ray of spine: thoracic 16.1 58.1 25.8 83.9

X-ray of spine: lumbar 9.7 38.7 51.6 90.3

Ultrasound 80.6 9.7 9.7 19.4

Bone density assessment 48.4 35.5 9.7 45.2


Parameters used in assessment of ASS1%

S2%

S3%

2+3%

Occupation 19.4 38.7 41.9 80.6

Whether occupation if physically demanding 12.9 45.2 41.9 87.1

Whether the patient has to take sick leave for his arthritis 9.7 51.6 38.7 90.3

Patient global assessment VAS 3.2 29.0 67.7 96.8

Degree of fatigue 19.4 51.6 29.0 80.6

BASDAI score 12.9 22.6 64.5 87.1



S2%

S3%

2+3%

Degree of peripheral joint pain in a VAS scale 22.6 35.5 41.9 77.4

Degree of spinal pain in a VAS scale 12.9 22.6 64.5 87.1

Degree of morning stiffness in a VAS scale 6.5 35.5 58.1 93.5

Duration of morning stiffness 6.5 16.1 77.4 93.5

BASFI score or other functional scoring systems 9.7 35.5 54.8 90.3

Other health questionnaires 29.0 51.6 16.1 67.7

Physician global assessment on a scale of 0-4 or 0-10 16.1 51.6 32.3 83.9



S2%

S3%

2+3%

Occiput to wall distance 3.2 58.1 38.7 96.8

Tragus to wall distance 12.9 41.9 45.2 87.1

Degree of cervical rotation 6.5 51.6 41.9 93.5

Degree of cervical lateral rotation 12.9 58.1 29.0 87.1

Schober test for forward flexion of lumbar spine 3.2 12.9 83.9 96.8

Lateral flexion of lumbar spine 12.9 51.6 35.5 87.1

Finger to floor distance 9.7 61.3 29.0 90.3

Intermalleolar distance 25.8 51.6 22.6 74.2

Measurement of chest expansion 6.5 35.5 58.1 93.5



S2%

S3%

2+3%

Presence of sausage digits 6.5 38.7 54.8 93.5

Swelling of peripheral joints 0.0 29.0 71.0 100.0

Tenderness of peripheral joints 0.0 58.1 41.9 100.0

Swelling of heels 12.9 35.5 51.6 87.1

Tenderness of heels 9.7 54.8 35.5 90.3

Range of motion of shoulders and hips 3.2 45.2 51.6 96.8

Physical exam for active sacroiliitis e.g. Patrick test 12.9 35.5 51.6 87.1

Physical exam for redness or swelling of eyes 0.0 38.7 61.3 100.0

ESR 0.0 41.9 58.1 100.0

CRP 0.0 45.2 54.8 100.0


welcome to spa sig august 2, 2006 mr 304 : 15.30-16.30

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