Axial spondyloarthritis

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Axial spondyloarthritis
Sacroiliac joint.svg
Sacroiliac joint

Axial spondyloarthritis (also often referred to as axSpA) is a chronic, immune-mediated disease predominantly affecting the axial skeleton (sacroiliac joints and spine). [1] The term itself is an umbrella term characterizing a diverse disease family united by shared clinical and genetic features, such as the involvement of the axial skeleton. [2] The 2009 introduced term axial spondyloarthritis is a preferred term nowadays and substitutes the old term ankylosing spondylitis. [3]

Contents

Classification

Along with peripheral spondyloarthritis, reactive arthritis, psoriatic arthritis and enteropathic arthritis (or inflammatory bowel disease-associated spondyloarthritis), axial spondyloarthritis belongs to the spondyloarthritis disease family, also known as the spondyloarthritides or spondyloarthropathies. [4] [5] [6] These arthritic conditions can sometimes overlap with one another. For example, psoriatic arthritis can cause both peripheral and axial symptoms. [7] Likewise, reactive arthritis can transform into chronic axial spondyloarthritis. [8] All are considered inflammatory rheumatic disorders because they involve immune system-mediated attacks on the joints, muscles, bones and organs. [9]

Axial spondyloarthritis can be differentiated from peripheral spondyloarthritis in terms of the areas of the body affected. The axial form of the disease primarily affects the spine, pelvis and thoracic cage, whereas the peripheral form mainly targets the arms and legs. [10]

Axial spondyloarthritis can be divided into two classes:

  1. Non-radiographic axial spondyloarthritis (nr-axSpA):
    This term encompasses both the early disease stage of ankylosing spondylitis, in which no radiographic changes are visible yet, as well as less severe forms of ankylosing spondylitis.
  2. Radiographic axial spondyloarthritis:
    Synonym for ankylosing spondylitis. This class is termed radiographic axial spondyloarthritis due to the unambiguous diagnosis through radiographic changes in the sacroiliac joints and/or spine.

Signs and symptoms

Axial spondyloarthritis is predominantly marked by inflammatory pain and/or stiffness affecting the lower back, hips and/or buttocks. [11] [12] The side affected may alternate. [11] Some may also experience symptoms in the eyes, rib cage, shoulders or cervical spine or neck as well. [12] [13] Inflammatory back pain tends to come on gradually, become worse at night or after periods of rest (such as in the morning after waking up) and improve after exercise or the use of anti-inflammatory medications such as ibuprofen. [11] [12] People with axial spondyloarthritis may experience alternating periods of remission and flare-ups. [14]

It is recommended that patients be formally evaluated for axial spondyloarthritis if they complain of inflammatory back pain and stiffness lasting at least three months, particularly if they are under the age of 45 and/or have a family history of the disease. [11]

Diagnosis

Patients being examined for axial spondyloarthritis may have x-rays, or radiographs, taken of their pelvis to check for signs of sacroilitis (often one of the first manifestations of the disease) and structural damage. [15] It can take several years from symptom onset for these changes to be visible, and some may never develop these changes at all. [16] [17] Their presence distinguishes radiographic axial spondyloarthritis from nr-axSpA.

Patients may also undergo an MRI in place of or in addition to radiography. MRI technology is sensitive to inflammatory changes such as enthesitis and synovitis and is more specific overall. [16] [18]

Blood work may also play a role in the diagnosis of axial spondyloarthritis. More than 80% of patients with the ankylosing spondylitis variant test positive for the HLA-B27 biomarker, but not everyone with this biomarker will develop disease. [19] Some people with axial spondyloarthritis may test positive for elevated C-reactive protein, or CRP, depending on their disease activity. [19] Spondyloarthritis is generally considered to be a seronegative disease, meaning tests for rheumatoid factor and other autoantibodies typically come back negative. [16] [20]

Depending on the results of the above tests, patients may be referred to a rheumatologist for confirmation and follow-up. [21]

Prognosis

Some with more severe disease may experience fusion of their vertebrae, a condition referred to as bamboo spine. [22] Men are more likely to accrue radiographic joint damage, whereas women tend to experience comparatively worse quality of life and disease activity. [23]

Management

There is currently no cure for axial spondyloarthritis, but there are various disease management strategies. [24]

Traditional NSAIDs and COX-2 inhibitor NSAIDs are effective for treating axSpA. [25] The potential harms may not differ when compared to a placebo treatment in the short term. [25] Various NSAIDs are equally effective (e.g.: Cox2 NSAIDS and traditional NSAIDS). [25] Continuous NSAID use may reduce radiographic spinal progression, but this requires confirmation. [25]

Those who cannot tolerate these medications or who require more intensive treatment may be prescribed biologic medications such as a tumor necrosis factor-inhibitor in an attempt to alter the immune response driving the disease. [24]

Physical therapy and exercise have also been found to effectively address symptoms. [26]

In 2019 the American College of Rheumatology, Spondylitis Association of America and Spondyloarthritis Research and Treatment Network published updated recommendations for the treatment of the condition [27] based on updated literature reviews.

History

In 1984, a joint effort led to the definition of specific classification criteria for ankylosing spondylitis, called the "Modified New York criteria". [28] One of the central New York criteria was the existence of radiographically visible changes in the sacroiliac joints and/or spine, which have formed due to bone fusion, erosion and/or formation caused by the disease. [29] Even though these criteria helped to improve uniformly define ankylosing spondylitis, such radiologic changes often only manifested several years after the first disease symptoms appeared. [29] In order to be able to study also patients with early and less typical forms, new criteria were needed that could identify the disease already at an early stage. In 2009 the Modified New York criteria were extended by a broad set of new classification criteria that aimed to classify patients based on the presence of typical spondyloarthritis disease features. [2] These included inflammatory back pain, family history for axial spondyloarthritis, response to treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), history of or current inflammation in the joints (arthritis), tendon-bone attachment of the heel (enthesitis), or eyes (uveitis), bowel (inflammatory bowel disease), skin (psoriasis) or signs of elevated inflammation (C-reactive protein and erythrocyte sedimentation rate). [2] [30] Important parts of the ASAS axSpA criteria are the biomarker HLA-B27 and magnetic resonance imaging (MRI). [2] [30] The criteria can only be applied in people that have chronic back pain (at least 3 months duration) started before the age of 45 years and only in those patients that already have a diagnosis of axial SpA. Since the disease ankylosing spondylitis was still defined by the Modified New York criteria of 1984, there was the need to find a new disease term that would also include the less severe forms or early onset of ankylosing spondylitis. This expression was found in the umbrella term axial spondyloarthritis. The 2009 classification criteria are called the ASAS (Assessment of SpondyloArthritis international Society) classification criteria for axial spondyloarthritis. [31] [32]

Society and culture

Notable cases

Related Research Articles

<span class="mw-page-title-main">Rheumatoid arthritis</span> Type of autoimmune arthritis

Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and hands are involved, with the same joints typically involved on both sides of the body. The disease may also affect other parts of the body, including skin, eyes, lungs, heart, nerves, and blood. This may result in a low red blood cell count, inflammation around the lungs, and inflammation around the heart. Fever and low energy may also be present. Often, symptoms come on gradually over weeks to months.

<span class="mw-page-title-main">Ankylosing spondylitis</span> Type of arthritis of the spine

Ankylosing spondylitis (AS) is a type of arthritis characterized by long-term inflammation of the joints of the spine, typically where the spine joins the pelvis. With AS, eye, bowel problems and back pain may occur. Joint mobility in the affected areas sometimes worsens over time. Ankylosing spondylitis is believed to involve a combination of genetic and environmental factors. More than 85% of people affected in the UK have a specific human leukocyte antigen known as the HLA-B27 antigen. The underlying mechanism is believed to be autoimmune or autoinflammatory. Diagnosis is based on symptoms with support from medical imaging and blood tests. AS is a type of seronegative spondyloarthropathy, meaning that tests show no presence of rheumatoid factor (RF) antibodies.

<span class="mw-page-title-main">Disease-modifying antirheumatic drug</span> Category of drugs

Disease-modifying antirheumatic drugs (DMARDs) comprise a category of otherwise unrelated disease-modifying drugs defined by their use in rheumatoid arthritis to slow down disease progression. The term is often used in contrast to nonsteroidal anti-inflammatory drugs and steroids.

<span class="mw-page-title-main">HLA-B27</span> Type of antigen

Human leukocyte antigen (HLA) B27 is a class I surface molecule encoded by the B locus in the major histocompatibility complex (MHC) on chromosome 6 and presents antigenic peptides to T cells. HLA-B27 is strongly associated with ankylosing spondylitis and other associated inflammatory diseases, such as psoriatic arthritis, inflammatory bowel disease, and reactive arthritis.

Spondyloarthropathy or spondyloarthrosis refers to any joint disease of the vertebral column. As such, it is a class or category of diseases rather than a single, specific entity. It differs from spondylopathy, which is a disease of the vertebra itself, but many conditions involve both spondylopathy and spondyloarthropathy.

<span class="mw-page-title-main">Rheumatism</span> Medical conditions affecting the joints or connective tissue

Rheumatism or rheumatic disorders are conditions causing chronic, often intermittent pain affecting the joints or connective tissue. Rheumatism does not designate any specific disorder, but covers at least 200 different conditions, including arthritis and "non-articular rheumatism", also known as "regional pain syndrome" or "soft tissue rheumatism". There is a close overlap between the term soft tissue disorder and rheumatism. Sometimes the term "soft tissue rheumatic disorders" is used to describe these conditions.

<span class="mw-page-title-main">Calcium pyrophosphate dihydrate crystal deposition disease</span> Medical condition

Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease, also known as pseudogout and pyrophosphate arthropathy, is a rheumatologic disease which is thought to be secondary to abnormal accumulation of calcium pyrophosphate dihydrate crystals within joint soft tissues. The knee joint is most commonly affected. The disease is metabolic in origin and its treatment remains symptomatic.

<span class="mw-page-title-main">Reactive arthritis</span> Medical condition

Reactive arthritis, also known as Reiter's syndrome, is a form of inflammatory arthritis that develops in response to an infection in another part of the body (cross-reactivity). Coming into contact with bacteria and developing an infection can trigger the disease. By the time the patient presents with symptoms, often the "trigger" infection has been cured or is in remission in chronic cases, thus making determination of the initial cause difficult.

<span class="mw-page-title-main">Sacroiliitis</span> Medical condition

Sacroiliitis is inflammation within the sacroiliac joint. It is a feature of spondyloarthropathies, such as axial spondyloarthritis, psoriatic arthritis, reactive arthritis or arthritis related to inflammatory bowel diseases, including ulcerative colitis or Crohn's disease. It is also the most common presentation of arthritis from brucellosis.

<span class="mw-page-title-main">Certolizumab pegol</span> Pharmaceutical drug

Certolizumab pegol, sold under the brand name Cimzia, is a biopharmaceutical medication for the treatment of Crohn's disease, rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. It is a fragment of a monoclonal antibody specific to tumor necrosis factor alpha (TNF-α) and is manufactured by UCB.

The BASDAI or Bath Ankylosing Spondylitis Disease Activity Index is a validated diagnostic test which allows a physician, usually a rheumatologist, to determine the effectiveness of a current drug therapy, or the need to institute a new drug therapy for the treatment of Ankylosing spondylitis (AS). The BASDAI is one of a group of classification criteria for spondyloarthropathies.

Biological response modifiers (BRMs) are substances that modify immune responses. They can be endogenous or exogenous, and they can either enhance an immune response or suppress it. Some of these substances arouse the body's response to an infection, and others can keep the response from becoming excessive. Thus they serve as immunomodulators in immunotherapy, which can be helpful in treating cancer and in treating autoimmune diseases, such as some kinds of arthritis and dermatitis. Most BRMs are biopharmaceuticals (biologics), including monoclonal antibodies, interleukin 2, interferons, and various types of colony-stimulating factors. "Immunotherapy makes use of BRMs to enhance the activity of the immune system to increase the body's natural defense mechanisms against cancer", whereas BRMs for rheumatoid arthritis aim to reduce inflammation.

<span class="mw-page-title-main">Golimumab</span> Pharmaceutical drug

Golimumab, sold under the brand name Simponi, is a human monoclonal antibody which is used as an immunosuppressive medication. Golimumab targets tumor necrosis factor alpha (TNF-alpha), a pro-inflammatory molecule and hence is a TNF inhibitor. Profound reduction in C-reactive protein (CRP) levels, interleukin (IL)-6, intercellaular adhesion molecules (ICAM)-1, matrix metalloproteinase (MMP)-3, and vascular endothelial growth factor (VEGF) demonstrates golimumab as an effective modulator of inflammatory markers and bone metabolism. Golimumab is given via subcutaneous injection.

<span class="mw-page-title-main">Enteropathic arthropathy</span> Medical condition

Enteropathic arthropathy commonly referred to as enteropathic arthritis, is a type of arthritis linked to Crohn's disease, ulcerative colitis, and chronic inflammatory bowel diseases.

<span class="mw-page-title-main">Secukinumab</span> Monoclonal antibody against IL-17

Secukinumab, sold under the brand name Cosentyx among others, is a human IgG1κ monoclonal antibody used for the treatment of psoriasis, ankylosing spondylitis, and psoriatic arthritis. It binds to the protein interleukin (IL)-17A and is marketed by Novartis.

Sarilumab, sold under the brand name Kevzara, is a human monoclonal antibody medication against the interleukin-6 receptor. Regeneron Pharmaceuticals and Sanofi developed the drug for the treatment of rheumatoid arthritis (RA), for which it received US FDA approval on 22 May 2017 and European Medicines Agency approval on 23 June 2017.

The Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire is a patient-reported outcome (PRO) measure which assesses the quality of life of patients with ankylosing spondylitis. The ASQoL is based on the needs-based quality of life model. It is a self-administered questionnaire which contains 18 items and takes up to four minutes to complete.

Interleukin-38 (IL-38) is a member of the interleukin-1 (IL-1) family and the interleukin-36 (IL-36) subfamily. It is important for the inflammation and host defense. This cytokine is named IL-1F10 in humans and has similar three dimensional structure as IL-1 receptor antagonist (IL-1Ra). The organisation of IL-1F10 gene is conserved with other members of IL-1 family within chromosome 2q13. IL-38 is produced by mammalian cells may bind the IL-1 receptor type I. It is expressed in basal epithelia of skin, in proliferating B cells of the tonsil, in spleen and other tissues. This cytokine is playing important role in regulation of innate and adaptive immunity.

In radiology, a Romanus lesion is the erosion of the anterior and posterior vertebral endplates in patients with an inflammatory spondyloarthropathy – such as ankylosing spondylitis or an enteropathic arthropathy. The anterior erosion in particular causes a loss of anterior vertebral body concavity, causing the vertebra to display a squared contour or even a barrel-shape. Healing of the erosion results in a sclerotic increase in density causing what is known as a shiny corner sign, which can later result in syndesmophyte formation. It is most easily diagnosed using MRI, compared to conventional radiography.

Diagnostic delay is the time interval between the onset of symptoms and confirmed diagnosis of a disease. For a variety of reasons, including the mitigation of disease severity and financial expense, it is desirable for this delay to be minimized.

References

  1. ↑ Sieper, Joachim; Poddubnyy, Denis (July 2017). "Axial spondyloarthritis". The Lancet. 390 (10089): 73–84. doi:10.1016/S0140-6736(16)31591-4.
  2. 1 2 3 4 Rudwaleit M, van der Heijde D, Landewé R, Listing J, Akkoc N, Brandt J, et al. (June 2009). "The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection". Annals of the Rheumatic Diseases. 68 (6): 777–83. doi: 10.1136/ard.2009.108233 . PMID   19297344.
  3. ↑ van der Heijde, Désirée; Molto, Anna; Ramiro, Sofia; Braun, Jürgen; Dougados, Maxime; van Gaalen, Floris A; Gensler, Lianne S; Inman, Robert D; Landewé, Robert B M; Marzo-Ortega, Helena; Navarro-Compán, Victoria; Phoka, Andri; Poddubnyy, Denis; Protopopov, Mikhail; Reveille, John (2023-12-08). "Goodbye to the term 'ankylosing spondylitis', hello 'axial spondyloarthritis': time to embrace the ASAS-defined nomenclature". Annals of the Rheumatic Diseases: ard–2023–225185. doi:10.1136/ard-2023-225185. ISSN   0003-4967.
  4. ↑ Kocatürk, Begüm; Balık, Zeynep; Pişiren, Gaye; Kalyoncu, Umut; Özmen, Füsun; Özen, Seza (2022). "Spondyloarthritides: Theories and beyond". Frontiers in Pediatrics. 10. doi: 10.3389/fped.2022.1074239 . ISSN   2296-2360. PMC   9816396 . PMID   36619518.
  5. ↑ "Spondyloarthritis". rheumatology.org. Retrieved 2023-04-23.
  6. ↑ Zochling, J.; Brandt, J.; Braun, J. (2005-08-09). "The current concept of spondyloarthritis with special emphasis on undifferentiated spondyloarthritis". Rheumatology. 44 (12): 1483–1491. doi: 10.1093/rheumatology/kei047 . ISSN   1462-0332. PMID   16091395.
  7. ↑ Schoels, M. M.; Braun, J.; Dougados, M.; Emery, P.; Fitzgerald, O.; Kavanaugh, A.; Kvien, T. K.; Landewé, R.; Luger, T.; Mease, P.; Olivieri, I.; Reveille, J.; Ritchlin, C.; Rudwaleit, M.; Sieper, J. (2014-01-01). "Treating axial and peripheral spondyloarthritis, including psoriatic arthritis, to target: results of a systematic literature search to support an international treat-to-target recommendation in spondyloarthritis". Annals of the Rheumatic Diseases. 73 (1): 238–242. doi:10.1136/annrheumdis-2013-203860. ISSN   0003-4967. PMC   3888585 . PMID   23740234.
  8. ↑ Inman, Robert D. (2021-04-01). "Axial Spondyloarthritis: Current Advances, Future Challenges". Journal of Rheumatic Diseases. 28 (2): 55–59. doi:10.4078/jrd.2021.28.2.55. PMC   10324891 . PMID   37476012. S2CID   233561575.
  9. ↑ Joseph, Amy; Brasington, Richard; Kahl, Leslie; Ranganathan, Prabha; Cheng, Tammy P.; Atkinson, John (2010-02-01). "Immunologic rheumatic disorders". Journal of Allergy and Clinical Immunology. 2010 Primer on Allergic and Immunologic Diseases. 125 (2, Supplement 2): S204–S215. doi: 10.1016/j.jaci.2009.10.067 . ISSN   0091-6749. PMID   20176259.
  10. ↑ Taurog, Joel D.; Chhabra, Avneesh; Colbert, Robert A. (2016-06-30). Longo, Dan L. (ed.). "Ankylosing Spondylitis and Axial Spondyloarthritis". New England Journal of Medicine. 374 (26): 2563–2574. doi:10.1056/NEJMra1406182. ISSN   0028-4793. PMID   27355535.
  11. 1 2 3 4 Braun, Juergen; Inman, Robert (2010-07-01). "Clinical significance of inflammatory back pain for diagnosis and screening of patients with axial spondyloarthritis". Annals of the Rheumatic Diseases. 69 (7): 1264–1268. doi:10.1136/ard.2010.130559. ISSN   0003-4967. PMID   20566619. S2CID   12571711.
  12. 1 2 3 Harper, Brock E.; Reveille, John D. (January 2009). "Spondyloarthritis: Clinical Suspicion, Diagnosis, and Sports". Current Sports Medicine Reports. 8 (1): 29–34. doi:10.1249/JSR.0b013e3181967ac6. ISSN   1537-8918. PMC   2898732 . PMID   19142077.
  13. ↑ Schwartzman, Sergio; Ruderman, Eric M. (2022-01-01). "A Road Map of the Axial Spondyloarthritis Continuum". Mayo Clinic Proceedings. 97 (1): 134–145. doi: 10.1016/j.mayocp.2021.08.007 . ISSN   0025-6196. PMID   34801248. S2CID   244422146.
  14. ↑ Aouad, Krystel; Gossec, Laure (July 2022). "Defining and managing flares in axial spondyloarthritis". Current Opinion in Rheumatology. 34 (4): 195–202. doi:10.1097/BOR.0000000000000883. ISSN   1040-8711. PMID   35699318. S2CID   249645239.
  15. ↑ Navallas, María; Ares, Jesús; Beltrán, Brigitte; Lisbona, María Pilar; Maymó, Joan; Solano, Albert (June 2013). "Sacroiliitis Associated with Axial Spondyloarthropathy: New Concepts and Latest Trends". RadioGraphics. 33 (4): 933–956. doi:10.1148/rg.334125025. ISSN   0271-5333. PMID   23842966.
  16. 1 2 3 Canella, Clarissa; Schau, Bruno; Ribeiro, Elisio; Sbaffi, Bruna; Marchiori, Edson (January 2013). "MRI in Seronegative Spondyloarthritis: Imaging Features and Differential Diagnosis in the Spine and Sacroiliac Joints". American Journal of Roentgenology. 200 (1): 149–157. doi:10.2214/AJR.12.8858. ISSN   0361-803X. PMID   23255756.
  17. ↑ Rosenbaum, James T. (2016-07-03). "Evolving "Diagnostic" Criteria for Axial Spondyloarthritis in the Context of Anterior Uveitis". Ocular Immunology and Inflammation. 24 (4): 445–449. doi:10.3109/09273948.2016.1158277. ISSN   0927-3948. PMC   4993152 . PMID   27070270.
  18. ↑ Zochling, J.; Brandt, J.; Braun, J. (2005-12-01). "The current concept of spondyloarthritis with special emphasis on undifferentiated spondyloarthritis". Rheumatology. 44 (12): 1483–1491. doi: 10.1093/rheumatology/kei047 . ISSN   1462-0332. PMID   16091395.
  19. 1 2 Prajzlerová, Klára; Grobelná, Kristýna; Pavelka, Karel; Šenolt, Ladislav; Filková, Mária (2016-06-01). "An update on biomarkers in axial spondyloarthritis". Autoimmunity Reviews. 15 (6): 501–509. doi:10.1016/j.autrev.2016.02.002. ISSN   1568-9972. PMID   26851549.
  20. ↑ Joseph, Amy; Brasington, Richard; Kahl, Leslie; Ranganathan, Prabha; Cheng, Tammy P.; Atkinson, John (2010-02-01). "Immunologic rheumatic disorders". Journal of Allergy and Clinical Immunology. 2010 Primer on Allergic and Immunologic Diseases. 125 (2, Supplement 2): S204–S215. doi: 10.1016/j.jaci.2009.10.067 . ISSN   0091-6749. PMID   20176259.
  21. ↑ Poddubnyy, Denis; Tubergen, Astrid van; Landewé, Robert; Sieper, Joachim; Heijde, Désirée van der (2015-08-01). "Development of an ASAS-endorsed recommendation for the early referral of patients with a suspicion of axial spondyloarthritis". Annals of the Rheumatic Diseases. 74 (8): 1483–1487. doi:10.1136/annrheumdis-2014-207151. ISSN   0003-4967. PMID   25990288. S2CID   42585224.
  22. ↑ Schwartzman, Sergio; Ruderman, Eric M. (2022-01-01). "A Road Map of the Axial Spondyloarthritis Continuum". Mayo Clinic Proceedings. 97 (1): 134–145. doi: 10.1016/j.mayocp.2021.08.007 . ISSN   0025-6196. PMID   34801248.
  23. ↑ Rusman, T.; van Vollenhoven, R. F.; van der Horst-Bruinsma, I. E. (2018-05-12). "Gender Differences in Axial Spondyloarthritis: Women Are Not So Lucky". Current Rheumatology Reports. 20 (6): 35. doi:10.1007/s11926-018-0744-2. ISSN   1534-6307. PMC   5949138 . PMID   29754330.
  24. 1 2 Lawson, Daeria O.; Eraso, Maria; Mbuagbaw, Lawrence; Joanes, Marianinha; Aves, Theresa; Leenus, Alvin; Omar, Ahmed; Inman, Robert D. (March 2020). "Tumor Necrosis Factor Inhibitor Dose Reduction for Axial Spondyloarthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials". Arthritis Care & Research. 73 (6): 861–872. doi:10.1002/acr.24184. ISSN   2151-464X. PMID   32166872. S2CID   212692973.
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  26. ↑ Perrotta, Fabio Massimo; Musto, Antonio; Lubrano, Ennio (2019-12-01). "New Insights in Physical Therapy and Rehabilitation in Axial Spondyloarthritis: A Review". Rheumatology and Therapy. 6 (4): 479–486. doi:10.1007/s40744-019-00170-x. ISSN   2198-6584. PMC   6858478 . PMID   31410786.
  27. ↑ Ward MM, Deodhar A, Gensler LS, Dubreuil M, Yu D, Khan MA, et al. (October 2019). "2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis". Arthritis & Rheumatology. 71 (10): 1599–1613. doi:10.1002/art.41042. PMC   6764882 . PMID   31436036.
  28. ↑ van der Linden S, Valkenburg HA, Cats A (April 1984). "Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria". Arthritis and Rheumatism (Submitted manuscript). 27 (4): 361–8. doi: 10.1002/art.1780270401 . PMID   6231933.
  29. 1 2 Taurog JD, Chhabra A, Colbert RA (June 2016). "Ankylosing Spondylitis and Axial Spondyloarthritis". The New England Journal of Medicine. 374 (26): 2563–74. doi:10.1056/NEJMra1406182. PMID   27355535.
  30. 1 2 Poddubnyy D, van Tubergen A, Landewé R, Sieper J, van der Heijde D (August 2015). "Development of an ASAS-endorsed recommendation for the early referral of patients with a suspicion of axial spondyloarthritis". Annals of the Rheumatic Diseases. 74 (8): 1483–7. doi:10.1136/annrheumdis-2014-207151. PMID   25990288. S2CID   42585224.
  31. ↑ Rudwaleit, M.; Landewé, R.; van der Heijde, D.; Listing, J.; Brandt, J.; Braun, J.; Burgos-Vargas, R.; Collantes-Estevez, E.; Davis, J.; Dijkmans, B.; Dougados, M.; Emery, P.; van der Horst-Bruinsma, I. E.; Inman, R.; Khan, M. A. (March 2009). "The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part I): classification of paper patients by expert opinion including uncertainty appraisal". Annals of the Rheumatic Diseases. 68 (6): 770–776. doi:10.1136/ard.2009.108217. ISSN   1468-2060. PMID   19297345. S2CID   34185040.
  32. ↑ Rudwaleit, M.; van der Heijde, D.; Landewé, R.; Listing, J.; Akkoc, N.; Brandt, J.; Braun, J.; Chou, C. T.; Collantes-Estevez, E.; Dougados, M.; Huang, F.; Gu, J.; Khan, M. A.; Kirazli, Y.; Maksymowych, W. P. (March 2009). "The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection". Annals of the Rheumatic Diseases. 68 (6): 777–783. doi: 10.1136/ard.2009.108233 . ISSN   1468-2060. PMID   19297344. S2CID   11515545.
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