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Before the introduction of tumour necrosis factor (TNF) blocking agents, the management of ankylosing spondylitis was mainly limited to physical exercise and the administration of non‐steroidal anti‐inflammatory drugs.1,2,3 To estimate the ankylosing spondylitis disease status in conventionally treated patients, we performed a community‐based cross‐sectional postal survey before TNF blocking agents became available in Austria.
Between January and April 2003, a questionnaire to assess ankylosing spondylitis disease activity, function and pain levels using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Functional Index (BASFI) and a Visual Analogue Scale (VAS) was distributed to all 1400 members of the Austrian ankylosing spondylitis patient's association treated in the community, to patients with ankylosing spondylitis treated in tertiary rheumatology centres and to consecutive sex‐matched controls with coronary artery disease, diabetes mellitus or goitre without signs of inflammatory rheumatic pain attending a general internal medicine outpatient clinic.
In all, 665 (47.6%) members of the ankylosing spondylitis patient's association (469 men and 196 women, mean (standard deviation (SD)) age 52 (12) years); 129 patients from rheumatology outpatient clinics (92 men and 37 women, mean (SD) age 40 (11) years); and 150 controls (89 men and 61 women, mean (SD) age 54 (14) years) returned an assessable questionnaire. Diagnosis of ankylosing spondylitis was confirmed in 97 of 100 randomly selected members of the ankylosing spondylitis patient's association by re‐evaluating their medical records. Disease activity evaluated by the BASDAI, and the percentage of patients with BASDAI 4 and >7 were equally high in patients in the community and in tertiary centres, but significantly lower in patients without inflammatory back pain (table 11).). No correlation was found between the BASDAI and the age of patients (r=0.03; p=0.42). Functional impairment measured by the BASFI was significantly lower in patients treated in tertiary centres than in patients in the community and was lowest in controls (table 11).). The BASFI increased significantly with age in all three groups and was highest in patients >60 years treated in tertiary centres (median (range) 7.6 (2.5–8.8)). The BASFI correlated with the BASDAI (r=0.67; p<0.01) and weakly with patient's age (r=0.23; p<0.01). The median pain score and the percentage of patients with a pain score >7 was equally high in patients treated in the community and in tertiary centres, but significantly lower in patients with non‐inflammatory back pain (table 11).). Pain levels correlated with the BASDAI (r=0.80; p<0.01) and the BASFI (r=0.61; p<0.01), but were independent of age (r=−0.07).
In summary, we have reported high disease activity, functional impairment and pain levels in 75% of conventionally treated patients with ankylosing spondylitis in the community, bearing in mind that the BASDAI may not be an appropriate measure to determine ankylosing spondylitis disease activity in a postal questionnaire. Conceivably, the population of organised patient's groups answering the questionnaire may be biased to report more severe disease than the total cohort of all patients with ankylosing spondylitis, but the disease status in our study was not different from a population of 246 patients with ankylosing spondylitis queried with a postal questionnaire between 2001 and 2003 in the UK.4
Competing interests: None declared.