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ST05_Mar12
Normative values for the Bath Ankylosing Spondylitis
Metrology Index (BASMI)
Lucy Chilton-Mitchell1
Anna Hart, 2 Jane Martindale, 1,2 Lynne Goodacre3
1 Wrightington Wigan and Leigh NHS Foundation Trust, 2 Lancaster University, 3 R and D North West
Outline
• Background to study
• Methodology
• Results
• Discussion and implications for practice
• Limitations of study
• Future work
• Key messages
• Background• Methodology• Results• Discussion• Future Work• Key messages
Spinal mobility in AS
• Natural history of AS‘Progressive restriction in spinal mobility’1
• Background• Methodology• Results• Discussion• Future Work• Key messages
• Google image search
‘ Ankylosing Spondylitis and age’
Assessment of spinal mobility in AS • Background• Methodology• Results• Discussion• Future Work• Key messages• Loss of spinal mobility important clinical sign
- Modified NY criteria2
- ASAS core domain3
• Recommended measure of spinal mobility (ASAS) – BASMI3
• Spinal mobility- Obtain baseline measurement4
- Monitor change over time4
- Assess the impact of clinical interventions3
BASMI scoring systems
BASMI 2 scoring system(4)
BASMI 10 scoring system(5)
BASMI linear scoring system(6)
• Background• Methodology• Results• Discussion• Future Work• Key messages
BASMI10
Are we correct to expect a score of zero is representative of normal spinal movement in a healthy population?
• Background• Methodology• Results• Discussion• Future Work• Key messages
0 = No mobility limitation
10 = Severe mobility limitation
Work informing this study
• Inter- and intra-rater reliability of BASMI7
• Incidental finding– Some healthy volunteers had worse BASMI scores than AS
patients– 7 healthy volunteers– BASMI scores ranged 0.7-2.0– Mean BASMI score 1.3
This study suggests that a score of zero should not be expected in a healthy population
• Background• Methodology• Results• Discussion• Future Work• Key messages
Spinal changes with age • Background• Methodology• Results• Discussion• Future Work• Key messages
• Google image search
‘ Spinal posture and age’
Literature on ageing….
If spinal ROM decreases with increasing age, should we expect the BASMI to increase with age also?
• Background• Methodology• Results• Discussion• Future Work• Key messagesYoudas et al8
Chen et al9
Finnsback et al10
Moll & Wright11
Saidu et al12
Einkauf et al13
Fitzgerald et al14
Intolo et al15
Aim
To explore the normative values for total BASMI score in healthy men and women
in a UK population
• Background• Methodology• Results• Discussion• Future Work• Key messages
Methodology
• Cross-sectional study
• 168 participants recruited - UK population
• Stratified by gender and age
• 14 Physiotherapists involved in recruiting and measuring participants
• ASSIGNw consensus of measurement for each domain was followed 7
• Exclusion criteria:– Pregnancy– Diagnosis of AS/Axial SpA,– Acute back problems– Chronic back problems,– Impairment limiting normal movement at time of measurement
Age range 18-30 30-50 50 and over
Gender Male Female Male Female Male Female
Number 2 2 2 2 2 2
• Background• Methodology• Results• Discussion• Future Work• Key messages
Statistical analysis
• Descriptive statistics were obtained:– Therapist experience– Total BASMI scores– BASMI component scores– Percentage scoring zero on the BASMI
• Age-specific centiles were calculated16
- Centiles presented start at age 25 and increase in 10 year intervals
• Background• Methodology• Results• Discussion• Future Work• Key messages
Results
• 168 participants (age range 18-85)
- Males = 84, Females= 84
- 18-30 = 56, 30-50 = 56, 50+= 56
• BASMI scores: 0 – 4.4
• 1.2% individuals scored 0
• BASMI scores increased with increasing age
• Corresponding trends with BASMI component scores
• No gender differences
• Background• Methodology• Results• Discussion• Future Work• Key messages
Total BASMI score
<30 years 30-50 years >= 50 years
M F M & F M F M & F M F M & F
Total BASMI score
0.8 0.8 0.8 1.0 1.4 1.2 2.2 1.6 2.0
• Zero is not a ‘normal’ score for an individual from a healthy population
• Increase in total BASMI score with increasing age
• Background• Methodology• Results• Discussion• Future Work• Key messages
Modified Schober’s Test
< 30 years 30-50 years >= 50 years
M F M & F M F M & F M F M & F
Modified Schober’s
(cm)6.5 6.6 6.5 6 6 6 5.5 6 6
Modified Schober’s
BASMI score1 1 1 2 2 2 3 2 2
• Decrease in Modified Schober’s test with increasing age
• Corresponding increase in component BASMI score
• Background• Methodology• Results• Discussion• Future Work• Key messages
Intermalleolar Distance
< 30 years 30-50 years >= 50 years
M F M & F M F M & F M F M & F
IMD (cm)110 117 115 113 107.5 112 95 104 102
IMD BASMI score 1 1 1 1 2 1 3 2 2
• Decrease in intermalleolar distance with age
• Corresponding increase in component BASMI score
• Background• Methodology• Results• Discussion• Future Work• Key messages
Cervical Rotation
< 30 years 30-50 years >= 50 years
M F M & F M F M & F M F M & F
Cx rotation (deg) 86 82.5 85 81.5 82.8 82 70.0 76.8 73.8
Cx rotation BASMI score 0 1 0 1 1 1 2 1.5 2
• Decrease in cervical rotation with age
• Corresponding increase in component BASMI score
• Background• Methodology• Results• Discussion• Future Work• Key messages
Tragus-to-wall distance
< 30 years 30-50 years >= 50 years
M F M & F M F M & F M F M & F
Tragus-to-wall (cm) 10.6 10.0 10.3 10.5 10.3 10.5 12.6 10.2 11.5
Tragus-to-wall BASMI
score1 1 1 1 1 1 1 1 1
• Small increase in tragus-to-wall distance with age
• No change in component BASMI score
• Suggests this measure is disease specific
• Background• Methodology• Results• Discussion• Future Work• Key messages
Lumbar side flexion
< 30 years 30-50 years >= 50 years
M F M & F M F M & F M F M & F
Lx lateral flexion (cm) 21.7 21.5 21.5 20.3 19.8 20.0 14.8 16.5 15.8
Lx lateral flexion
BASMI score
0 0 0 0 1 1 3 2 3
• Decrease in lumbar side flexion with age
• Corresponding increase in component BASMI score
• Background• Methodology• Results• Discussion• Future Work• Key messages
Centiles of total BASMI score• Background• Methodology• Results• Discussion• Future Work• Key messages
01
23
45
20 40 60 80 100Age
Total BASMI Score C_1_5C_1_25 C_1_50C_1_75 C_1_95
Centiles of total BASMI score• Background• Methodology• Results• Discussion• Future Work• Key messages
01
23
45
20 40 60 80 100Age
Total BASMI Score C_1_5C_1_25 C_1_50C_1_75 C_1_95
Implications for practice
• Illustrate to patients what a ‘normal’
age-matched individual would score on
the BASMI- Important in newly diagnosed- Inform expectations about treatment effects
• Potentially accounts for influence of age- Not just disease process- Important when assessing change over time
• Background• Methodology• Results• Discussion• Future Work• Key messages
Limitations of study
• Measurements taken by a number of different
therapists
• UK population only
• Sample size
• Did not account for factors such as height17, activity level etc.
• Background• Methodology• Results• Discussion• Future Work• Key messages
Future work
• Larger sample size
• Assess height, weight, activity level
• UK and other populations
• Background• Methodology• Results• Discussion• Future Work• Key messages
Key ‘take-home’ messages
• A total BASMI score of zero is not normal
in the healthy adult population
• The BASMI score increases with age in healthy individuals
• The normative values shown will aid interpretation of BASMI scores in individuals with AS/ Axial SpA
• Background• Methodology• Results• Discussion• Future Work• Key messages
Acknowledgements
• Supervisory team – Dr Jane Martindale and Dr Lynne Goodacre
• Anna Hart (medical statistician)
• WWL (especially CEO and Physiotherapy Lead)
• Lancaster Medical School, Lancaster University
• ASSIGNw volunteers
• Our ‘normal’ participants!
• NIHR
References
1) Sengupta R, Stone M. The assessment of ankylosing spondylitis in clinical practice. Nat Clin Pract Rheumatol. 2007; 3(9):496-503
2) 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) Sieper J, Rudwaleit M, Baraliakos X, et al. The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis 2009;68:1-44
4) Jenkinson TR, Mallorie PA, Whitelock H, et al. Defining spinal mobility in ankylosing spondylitis: The Bath Ankylosing Spondylitis Metrology Index. J Rheumatol 1994;21:1694-1698
5) Jones SD, Porter J, Garrett SL, et al. A new scoring system for the Bath Ankylosing Spondylitis Metrology Index (BASMI). J Rheumatolo 1995;22:1609
6) Van der Heijde D, Landewe R, Feldtkeller E. Proposal of a linear definition of the Bath Ankylosing Spondylitis Metrology Index (BASMI) and comparison with the 2-step and 10-step definitions. Annals of the Rheumatic Diseases 2008; 67: 489-493
7) Martindale JH, Sutton CJ, Goodacre L. An exploration of the inter- and intra-rater reliability of the Bath Ankylosing Spondylitis Metrology Index. Clin Rheumatol 2012;31(11):1627-1631
8) Youdas JW, Garrett TR, Suman VJ, et al. Normal range of motion of the cervical spine: An initial goniometric study. Phys Ther 1992;72:770-780
9) Chen J, Solinger AB, Poncet JF, Lantz CA. Meta-analysis of normative cervical motion. Spine 1999;24:1571-157810) Finnsback C, Mannerkorpi K. Spinal and thoracic mobility – age-related reference values for healthy men and women.
Nordisk Fysioterapi 2005;9:136-143 11) Moll JM, Wright V. Normal range of spinal mobility. An objective clinical study. Ann Rheum Dis 1971;30:381-38612) Saidu IA, Maduagwu SM, Abbas AD, Adetunji OO, Jajere AM. Lumbar spinal mobility changes among adults with
advancing age. J Midlife Health 2011;2:65-7113) Einkauf DK, Gohdes ML, Jensen GM et al. Changes in spinal mobility with increasing age in women. Physical Therapy
1987; 67: 370-37514) Fitzgerald GK, Wynveen KJ, Rheault W et al. Objective assessment with establishment of normal values for lumbar
spinal range of motion. Physical Therapy 1983; 63: 1776-168115) Intolo P, Milosavljevic S, Baxter DG, Carman AB, Pal P. The effect of age on lumbar range of motion: A systematic
review. Man Ther 2009;14:596-60416) Royston P, Wright E M. A method for estimating age-specific reference intervals (‘normal ranges’) based on fractional
polynomials and exponential transformation. J.R. Statistic 1998; Soc. A; 161, Part 1, pp79-101.17) Ramiro S, van Tubergen A, Stolwijk C et al. Reference intervals of spinal mobility measures in normal individuals: the
mobility study. Annals of the Rheumatic Diseases. Published online 2014 doi: 10.1136/annrheumdis-2013-204953
Thank you for listening
Any Questions?
Chilton-Mitchell L, Martindale J, Hart A, Goodacre L. Normative values for the Bath Ankylosing Spondylitis Metrology Index in a UK population. Rheumatology 2013 52 (11)
2086-2090