0008-3 194/2000/87-97/$2.00/©JCCA 2000

Ankylosing spondylitis presenting to a chiropractic office: a report of two cases Cameron McDermaid, DC* Silvano Mior, DC, FCCS(C)**

Ankylosing spondylitis (AS) is a seronegative spondyloarthropathy that predilects young men. It is difficult to diagnose in its early stages and challenging to manage, once detected. Two cases ofpatients with previously undiagnosed AS are presented. The role of the clinical history and examination, imaging, and paraclinical studies are discussed. Suggestions for management and outcome measures for patients with ankylosing spondylitis are presented. (JCCA 2000; 44(2):87-97)

La pelvispondylite rhumatismale (PR) est une spondylarthropathie se'ronegative qui touche surtout les jeunes hommes. C'est une maladie difficile a' diagnostiquer au debut, puis difficile a' traiter unefois decelee. Voici le cas de deux patients souifrant de PR non deja' diagnostique'e. Il sera question, dans le present article, du role de l'anamnese, des examens, de l'imagerie et des explorations paracliniques. Onfera egalement des suggestions concernant le traitement et les indicateurs de resultats chez les patients atteints de pelvispondylite rhumatismale. (JACC 2000; 44(2):87-97)

KEY WORDS: spondylitis, ankylosing, chiropractic.

M OTS C LE S: pelvispondylite, rhumatismale, chiropratique.

A small proportion of patients with low back pain may have an inflammatory condition such as ankylosing spondylitis (AS). The prevalence of AS is probably about 1-2/ 1000, but has been reported to be as high as 4% in specific ethnic groups.1 Identifying individuals with AS is important in order to avoid unnecessary investigation, ineffective treatment, and frustration for both the patient and the chiropractor. Once diagnosed, treatment plans can be individualized to address the patient's specific needs. This paper presents two cases of patients with AS and serves to illustrate the challenges that face the chiro-

practor, both with respect to diagnosis and management. The historical features, clinical exam, and the role of imaging and paraclinical studies are discussed. Management and outcome measures for patients with ankylosing spondylitis will be suggested.

Case 1 A 30-year-old gentleman was seen on referral from a chiropractor for a second opinion regarding his back pain. He had a six to eight month history of localized mid and lower thoracic pain of insidious onset. The pain was worse

Canadian Memorial Chiropractic College, Toronto, Ontario. In partial fulfilment for requirements for the College of Chiropractic Sciences Program. ** Dean of Graduate Studies and Research, Canadian Memorial Chiropractic College. Correspondence/reprints: Dr. Cam McDermaid, 1900 Bayview Avenue, Toronto, Ontario M4G 3E6, (416) 482-2340, ext. 267. e-mail: [email protected] C JCCA 2000. *

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in the morning and was accompanied by stiffness which lasted approximately one hour after arising. Less profound stiffness was always present during the day. Six to eight weeks after the onset of his complaint, he began experiencing a sharp pain in his mid-back with deep inspiration. His back complaint was aggravated by activities such as playing hockey, soccer, and running on hard surfaces (e.g. concrete) as well as prolonged flexion postures, such as doing the dishes. He obtained some relief by stretching. If he awoke in the night, he needed to stretch by hanging by his arms from a door frame before returning to bed. A systems review was remarkable for evening fatigue, tight hamstrings, and a history ofheartburn that was relieved by medication. He denied any bowel or bladder disturbance, fevers/chills or weight change. The patient felt he was generally an energetic person, but had progressively decreased the intensity of his activity and had given up some sports due to his back complaints. He reported a six year history of lower, mid back, and leg pain which was equivocally helped by chiropractic care. Past investigations included MRI, discogram, and nerve blocks. He reported having a medical exam done approximately one year ago. His immediate family history was significant for low back pain in his mother, brother, and sister, the latter two receiving surgery. On examination, he appeared healthy-looking and in no apparent distress. His posture was unremarkable and no deformities were noted. Lateral flexion of the lumbar spine was limited by stiffness to 1.5 cm on the right and 3 cm on the left in lateral flexion (Moll's test).* On inspection, flexion in the thoracic spine appeared limited although 10 cm of flexion was measured by Schober's test.** Chest expansion was measured at 3.5 cm with full inspiration (5 cm is considered normal).2 The mid-back pain was decreased by the examiner resisting rib excursion during inspiration. There was pain in the left groin with left FABER test. Straight leg-raising was limited by hamstring tightness to 70 degrees on the right and 60 degrees on the left. He was neurologically intact and no nerve root tension signs were elicited. Moll's test is done by measuring lateral flexion in the midaxillary line from the iliac crest 20 cm superiorly (2.5 cm or greater is considered normal2). ** Schober's test measures flexion using a tape measure placed along the spine from points 10 cm above and 5 cm below the top of the sacrum. Normal excursion is at least 4 cm.2 *

88

X-rays of the lumbar spine and sacroiliac (SI) joint are shown in Figure 1. Bilateral sclerosis and erosion are seen in the SI joints (Figure la). Squaring of the vertebral bodies is evident throughout the lumbar spine (Figure Ib). A clinical diagnosis of seronegative spondyloarthropathy was made. Subsequent serology ordered by the patient's medical doctor was positive for HLA B27. The patient is currently managing his condition with Relefen (an NSAID) taken regularly, daily stretching, and Pilates exercise (a low impact exercise technique that emphasizes stretching and posture using body weight and a specialized exercise machine). He is able to play non-contact hockey and competitive soccer during the summer. He is not currently under chiropractic care because he feels it has equivocal benefit.

Case 2 A 21-year-old male was seen for an episode of debilitating right sacroiliac pain that had been present for 21/2 hours at the time of consultation. The pain was described as paralyzing, sharp, and stabbing. The patient was unable to lie on his back due to the pain. He denied any radiation of the pain. He could relate no specific aggravating factors and felt that the ice he was using was helping. He described a three year relapsing/remitting history of low back pain which started with a fall while playing soccer. After the fall he was unable to stand or walk. This first episode resolved after one week, but a few months later he had another episode of back pain. He reported that the x-rays taken shortly after the second episode were unremarkable. Anti-inflammatory medication seemed to decrease the pain of his prior episodes. He had been treated by a chiropractor and felt this had helped his condition, although he said that it had taken 6 to 7 months to show improvement. He reported being in good health, but over the past month he had noticed feeling stiff and sore in the mornings. He attributed this stiffness to his school work. He reported significant morning stiffness that lasted at least 11/2 hours and decreased over the course of the day. Aggressive stretching provided some relief, but a low level of stiffness and soreness was always present. A systems review was unremarkable. His father had arthritis, but the patient was unsure what type it was. He was in a great deal of discomfort due to his back pain at physical examination. Forward flexion was markedly limited by low back pain, with extension and extensionJ Can Chiropr Assoc 2000; 44(2)

C McDermaid, S Mior

Figure la Case 1 AP pelvis x-ray. Note the erosive changes and marked sclerosis in the sacroiliac joints bilaterally (white arrows).

rotation less limited. Moll's test for lateral flexion mobility was 7 cm bilaterally and Schober' s test could not be done due to back pain. Straight leg raising was limited to 70 degrees bilaterally by hamstring tightness. On the right, it elicited low back pain at 30 degrees of hip flexion. Gaenslen' s and Yeoman's tests on the left reproduced the right SI joint pain. The right SI joint was extremely tender to touch. The neurological exam was unremarkable. A working diagnosis of sacroiliitis with a high index of suspicion of ankylosing spondylitis was made. He was treated with soft-tissue therapy to the lumbar spine and gluteal musculature and referred to his general practitioner for NSAID's and serology. On subsequent x-ray, the SI J Can Chiropr Assoc 2000; 44(2)

Figure lb Case 1 lateral lumbar x-rays. Note the vertebral squaring at L3 and L4.

joints appeared normal (Figure 2a), but the vertebrae appeared slightly squared (Figure 2b). NSAID's obtained from his family doctor gave marked relief. Subsequent serology was positive for HLA B27. After the patient was diagnosed he discovered that the arthritis his father had was ankylosing spondylitis. Currently, the patient is symptom free and manages his condition with a self-directed exercise program. He is not taking medication. He feels that soccer is a specific aggravating activity, although if he stretches and maintains his exercise program, he can still play occasionally. He feels that swimming gives him the most benefit if he is in pain. He reports being stiff and sore if he does not exercise regularly. 89

Ankylosing spondylitis

.e. . s.

..i

Figure 2a Case 2 Hibbs view x-ray of the sacroiliac joint. The joints 8appear normal.

< Figure 2b Case 2 lateral lumbar x-ray. Note the suggestion of squaring at L3 (white arrow).

Discussion AS is challenging to diagnose in the early stages of the disease. The Rome criteria and its revised version, the modified New York criteria4 (Table 1) have been developed to help diagnose AS. These criteria require radiographic change for definitive diagnosis and may not be useful for diagnosis in day to day clinical practice.5 These criteria would not have allowed a diagnosis of AS in Case 2 because of the absence of definitive radiographic changes. The Amor criteria6 and the European Spondyloarthropathy Study Group (ESSG) criteria5 have been established for the diagnosis of spondyloarthropathy, but are not specific for AS.6 The Amor criteria for spondyloarthropathy includes HLA B27 and response to NSAIDS in the scoring system and would probably have facilitated a diagnosis of AS in Case 2. 90

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Table 1 Modified New York Criteria for ankylosing spondylitis.4 Reprinted with permission of Lippincott-Raven Publishers, New York.

Clinical features Historical features that appear to be most sensitive for ankylosing spondylitis include; stiffness in the morning, age of onset less than 35 years of age, over 3 months of low back pain, and no relief with lying down.7 Few elements of the physical examination appear to be particularly sensitive, although pain with compression of the sacroiliac joint, a Schober's test of less than 4 cm, and reduced lateral mobility have good specificity (> 0.80).7 The presence of these signs should raise the clinician's suspicion of AS, while their absence gives little information. The pre-radiological stages of AS are difficult to diagnose because bony changes can lag four to six years after J Can Chiropr Assoc 2000; 44(2)

the onset of symptoms. S5 The classic radiographic features of AS include osteoporosis, bony erosion, reactive

sclerosis, followed by bony ankylosis, with changes typically distributed bilaterally and symmetrically.8 The shoulder, hands, feet, hips and heels may also be involved. Objective changes in these sites was seen in approximately 50% of 92 cases after an average length of illness of 18 years.9 Pain, stiffness, and sleep disturbance correlate positively with increasing SI joint sclerosis as seen on CT and negatively with ankylosis.10 Computed tomography has a high false positive rate and often only confirms an indeterminate plain film.11 Quantitative scintigraphy is probably not useful in the routine investigation and management of AS patients.12 MRI is very sensitive for detecting early erosive changes in the sacroiliac joint, but is costly, time-consuming, and probably non-specific. 1I The patient in Case 1 had undergone numerous investigations. The diagnosis was ultimately made clinically and confirmed using plain film x-ray. Serial x-rays are probably of little value since the rate or nature of progression is unknown.'3 However, repeated x-rays may be useful for the chiropractor to assess bone quality prior to treatment. Compression fractures due to osteopenia, even in the absence of overt trauma, are not uncommon and may be unrecognised in patients with advanced AS.14 Serology for AS consists of the HLA-B27 histocompatability complex which appears in approximately 95% of Caucasian patients with AS and varies in other ethnic groups.1 This serology is most useful in the early stages of the disease5'15 when radiographic findings may not be definitive. Erythrocyte sedimentation rate has moderate sensitivity and specificity (0.66, 0.68),7 although elevated levels may only be present in 34-64% of patients with severe disease.16

Management Management of patients with AS focuses on symptom control and maintenance of function and mobility. This management may include exercise, manipulation, lifestyle modification and medication, all of which are tailored to suit the patient's need. An exercise and stretching program is recommended to assist in maintaining flexibility and function. Prospective trials of physiotherapy (which include exercise, stretching and modalities) have not consistently shown clinically significant benefits over controls. 17-20 The patients who ben91

Ankylosing spondylitis

efit the most appear to be those who exercise intensely.'7 Most of these studies have been hampered by small numbers of subjects and poor long-term follow-up. The chiropractor should be aware of the potential for extra-spinal joint involvement such as in the hips or shoulders and reports of fatigue when recommending exercise. Fatigue is a common and often ignored symptom in patients with AS.2' Exercise seems to have an equivocal effect in either preventing or decreasing fatigue, but can exacerbate it in those patients who describe fatigue as a major symptom.21 Swimming may assist in maintaining relative extension during exercise which may be beneficial. Despite maintaining activity, a small loss in mobility will occur as the disease progresses.'7 Due to the apparent link of gut inflammation and AS, dietary intervention for patients with AS has been attempted.22'23 Patients have reported subjective improvement of their symptoms and decrease NSAID use after six weeks on a dairy-free diet.22 However, no confirmatory reintroduction of the dairy products was attempted. Ebringer23 found that a "low starch diet" led to a reduction in serum IgA as well as decreases in inflammation and symptoms in AS patients. Other lifestyle modification, such as sleeping prone, have not undergone rigorous study, but may be beneficial. The effectiveness of manipulation or chiropractic treatment for AS is generally based on anecdotal reports24 or individual clinical experience. Guidelines to chiropractic practice suggest that manipulation is contraindicated in the acute inflammatory stages, but not in the subacute or chronic stages.25 Manipulation of a joint in an acute inflammatory phase may prolong the symptoms and delay healing.26 Our clinical experience is that manipulation of inflamed joints may provide short term benefit, but typically symptoms are exacerbated hours later. Manipulation appears to have had an equivocal effect on the patients in our cases. Both patients reported occasional exacerbations from treatment, which may have occurred during a period of increased disease activity. Alternative methods to reduce pain and improve flexibility should be employed in these periods and the role of manipulation should be critically examined in each case. X-rays may be indicated to identify sites of fusion and assess bone quality, due to the possibility of pathological fracture secondary to osteopenia and increased rigidity. There is at least one case report of a patient injured after 92

being treated by a chiropractor who apparently missed a pathological fracture caused by a fall in a patient with

AS.27 Assisted stretching and mobilization of the hip joints, hamstrings and low back may be beneficial. Fibrotic changes in paraspinal musculature that exceed that which would be expected from disuse atrophy may be a specific pathological component of AS and of particular importance in early stages of the disease.28 Medical management consists of NSAIDs for pain control during the inflammatory stages of AS. Patients tend to respond well symptomatically, but there is no consistent evidence that NSAIDs have a beneficial effect on axial skeleton mobility.29 A low percentage of patients with spondyloarthropathy have disease activity that will require second line medication such as sulfasalazine.30 Patients with AS who maintain good function in the early stages of the disease tend to have a relatively good prognosis. Gran3' found that 80 percent of a sample of 100 patients with AS still had pain and stiffness but showed that the majority of loss of function occurred in the first 10 years of the disease. This loss of function was higher in those with peripheral arthritis, spinal changes, and development of a bamboo spine. In a long term follow-up of 142 patients with AS, 81 % of those with severe spinal restriction at thirty year follow-up had demonstrated severe restriction in the first 10 years of the disease.32 The authors felt that less than 20% of those patients with adult onset AS will progress to significant disability and that early peripheral joint involvement is a poor prognostic sign.

Assessing outcome of care Assessing treatment efficacy in patients with AS is difficult because patients demonstrate a great deal of individual variability.33 Useful outcome measures have traditionally been difficult to determine. Clinically important differences were defined in only a few of the trials of exercise intervention and, in many cases, primary outcomes were based simply on changes in spinal mobility. Metrology such as spinal flexion, chest expansion, finger-to-floor distance, and occiput-to-wall distance are measures of disease severity or deformity rather than disease activity.'0 Measures such as finger-to-floor distance may have limited use in the entire spectrum of AS because such measures would have little use in a patient with a fused spine.34 As well, metrology does not tend to improve J Can Chiropr Assoc 2000; 44(2)

C McDernaid, S Mior

Table 2 Bath Ankylosing Spondylitis Disease Activity Index. Reprinted with permission36

BASDAI The Bath Ankylosing Spondylitis Disease Activity Index PLEASE PLACE A MARK ON EACH LINE BELOW TO INDICATE YOUR ANSWER TO EACH QUESTION, RELATING TO THE PAST WEEK (1) How would you describe the overall level of fatigue/tiredness you have experienced?

NONE

VERY SEVERE

(2) How would you describe the overall level of AS neck, back or hip pain you have had? VERY SEVERE

NONE

(3) How would you describe the overall level of pain/swelling in joints other than neck, back or hips you have had?

NONE

VERY SEVERE

(4) How would you describe the overall level of discomfort you have had from any areas tender to touch or pressure? VERY SEVERE

NONE

(5) How would you describe the overall level of morning stiffness you have had from the time you wake up?

NONE

VERY SEVERE

(6) How long does your morning stiffness last from the time you wake up? NONE

VERY SEVERE

V 0 hrs J Can Chiropr Assoc 2000; 44(2)

½

'/2

1

1 1 1/2

2 or more hrs 93

Ankylosing spondylitis

Table 3 Bath Ankylosing Spondylitis Functional Activity Index. Reprinted with permission37

PLEASE DRAW A MARK ON EACH LINE BELOW TO INDICATE YOUR LEVEL OF ABILITY WITH EACH OF THE FOLLOWING ACTIVITIES DURING THE LAST WEEK.

N.B. An aid is a piece of equipment which helps you to perform an action of movement. Example IMPOSSIBLE

EASY 1) Putting on your socks or tights without help or aids (e.g. sock aid).

IMPOSSIBLE

EASY 2) Bending forward from the waist to pick up a pen from the floor without aid. EASY

IMPOSSIBLE

3) Reaching up to a high shelf without help or aids (e.g. helping hand).

EASY

IMPOSSIBLE

4) Getting up out of an armless dining room chair without using your hands or any other help.

EASY

IMPOSSIBLE

5) Getting up off the floor without help from lying on your back. EASY

IMPOSSIBLE

6) Standing unsupported for 10 minutes without discomfort. EASY

IMPOSSIBLE

7) Climbing 12-15 steps without using a handrail or walking aid. One foot on each step. EASY

IMPOSSIBLE

8) Looking over your shoulder without turning your body. EASY

IMPOSSIBLE

9) Doing physically demanding activities (e.g. physiotherapy exercises, gardening or sports). EASY

IMPOSSIBLE

10) Doing a full days activities whether it be at home or at work. EASY 94

IMPOSSIBLE J Can Chiropr Assoc 2000; 44(2)

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even though disease activity may subside. In 1993, Bakker34 identified the need to better assess the functional component of patients with AS. Since then, a number of attempts have been made to develop such instruments.35-39 Four indices have been developed by a group in Bath to measure disability, function, metrology and global status of patients with ankylosing spondylitis.3639 The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)36 and the Bath Ankylosing Spondylitis Functional Activity Index (BASFAI)37 are probably of most interest to chiropractors. The BASDAI may eventually be a useful tool to assess a patient's disease activity and helping guide clinical decision making regarding the prescription of exercise and the relative risk of spinal manipulation. The BASDAI (Table 2) takes approximately one minute to complete, has good test-retest-reliability, and scores in the testing of the instrument were well distributed over the range of the scale. Subsequent testing has shown good Cronbach alpha scores, indicating good internal consistency.40 Each analogue scale is scored from 0 to 10, questions 5 and 6 are averaged to determine an aggregate score for morning stiffness, and the total is divided by 5 to give a maximum possible score of 10. Mean scores at intake of an inpatient group was 5.31 (SD 1.74) and this had improved to 4.46 (SD 2.21) after 19 days of physiotherapy treatment.36 No longitudinal assessment of the BASDAI has been done to assess its responsiveness to fluctuations in disease activity in individual patients so it is premature to use this measure to help determine how physical treatment may be tolerated. The BASFAI (Table 3) has a similar format, with a mean of the ten scales being taken to give a maximum score out of 10. Reproducibility is good, and patient assessed function showed good agreement with function as assessed by an external observer. Improvement in function was seen in a group of 163 patients undergoing 18 days of physiotherapy who scored 4.82 (SD 2.04) at intake and 3.75 (SD 2.11) at day 8.37 Both the BASDAI and BASFAI were validated in a patient group with a mean disease duration of 25 years, so the response characteristics may vary in a younger population. Reference centile charts that use disease duration as the time dependant variable have recently been developed and may assist in assessing a patient's status relative to a reference population.4' J Can Chiropr Assoc 2000; 44(2)

Conclusion Patients with ankylosing spondylitis may present undiagnosed to a chiropractor's office. Mild and moderate cases may be missed because AS is most often thought of in the classic context of spinal fusion and pathognomonic radiographic changes.42 Careful attention to the clinical history is the most useful tool available to the clinician. Suspected cases should have the appropriate x-ray studies performed and can be referred for serological testing if clinical suspicion is still high in the absence of radiographic change. Management should be directed at relieving pain and maintaining flexibility while avoiding manipulation of acutely inflamed joints. Providing patients with home exercises and attending to quality of life issues will help focus management upon the patient rather than the condition itself. This patient-centred approach is a necessity because patients demonstrate very individual patterns of exacerbation and remission33. The lack of information available regarding the use of manipulation in patients with AS reinforces the need for careful documentation of outcomes of care. References 1 Gran JT, Husby G. The epidemiology of ankylosing spondylitis. Semin Arthritis Rheum 1993; 22(5):319-334. 2 Merrit JL, McLean TJ, Erickson RP et al. Measurement of trunk flexibility in normal subjects: reproducibility of three clinical methods. Mayo Clin Proc 1986; 61(3):192-197. 3 Escalante A. Ankylosing spondylitis. A common cause of low back pain. Postgrad Med 1993; 94(l):153-166. 4 van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. Arthritis

Rheum 1984; 27:361-368. 5 Dougados M. Diagnostic features of ankylosing spondylitis. Br J Rheumatol 1995; 34:301-303. 6 Amor B, Dougados M, Mijiyawa M. Critere diagnostique des spondyloarthropathies. Rev Rhum Mal Osteoartic 1990; 57:85-89. 7 van den Hoogen HMM, Koes BW, van Eijk JTM, Bouter LM. On the accuracy of history, physical examination, and erythrocyte sedimentation rate in diagnosing low back pain in general practice. A criteria-based review of the literature. Spine 1995; 20(3):318-327. 8 Yochum T, Rowe L. Essentials of skeletal skeletal radiology. Baltimore: Williams and Wilkins. 1996 Vol II 2nd ed. p 880. 9 Kinsella TD, MacDonald FR, Johnson LG. Ankylosing spondylitis: a late re-evaluation of 92 cases. Can Med Assoc J 1966; 95:1-9. 95

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10 Taylor HG, Wardle T, Beswick EJ, Dawes PT. The relationship of clinical and laboratory measurements to radiological change in ankylosing spondylitis. Br J Rheumatol 991; 30:330-335. 11 Fenton P. Magnetic resonance imaging of the sacroiliac joints: Worth the cost? J Rheumatol 1996;

23(12):2020-2021. 12 Taylor HG, Gadd R, Beswick EJ, Venkatesaran M, Dawes PT. Quantitative radio-isotope scanning in ankylosing spondylitis: A clinical, laboratory and computerised tomographic study. Scand J Rheumatol 1991; 20:274-279. 13 Calin A. Ankylosing spondylitis: Defining disease status and the relationship between radiology, metrology, disease activity, function, and outcome. J Rheumatol 1995;

22(4):740-744. 14 Ralston SH, Urquhart GDK, Brzeski M, Sturrock RD. Prevalence of vertebral compression fractures due to osteoporosis in ankylosing spondylitis. Br Med J 1990; 300:563-565. 15 Olajos A, Suranyi P. The value of HLA-B27 typing in the diagnosis of early, oligosymptomatic spondyloarthropathies [letter]. Br J Rheumatol 1996; 35:192. 16 Tutuncu ZN, Bilgie A, Kennedy LG, Calin A. Interleukin-6, acute phase reactants and clinical status in ankylosing spondylitis. Ann Rheum Dis 1994; 53:425-426. 17 Russel P, Unsworth A, Haslock I. The effect of exercise on ankylosing spondylitis. A preliminary study. Br J Rheumatol 1993; 32:498-506. 18 Kraag G, Stokes B, Groh J, Helewa A, Goldsmith CH. The effects of comprehensive home physiotherapy and supervision on patients with ankylosing spondylitis. An 8 month follow up. J Rheumatol 1994; 21:261-263. 19 Helliwell PS, Abbott CA, Chamberlain MA. A randomised trial of three different physiotherapy regimes in ankylosing spondylitis. Physiotherapy 1996; 82(2):85-90. 20 Carbon RJ, Macey MG, McCarthy DA, Periera FP, Perry JD, Wade AJ. The effect of 30 min cycle ergometry on ankylosing spondylitis. Br J Rheumatol 1996; 35:167-177. 21 Jones SD, Koh WH, Steiner A, Garrett SL, Calin A. Fatigue in ankylosing spondylitis: Its prevalence and relation ship to disease activity, sleep, and other factors. J Rheumatol 1996; 23:487-490. 22 Appelboom T, Durez P. Effect of milk product deprivation on spondyloarthropathy. Ann Rheum Dis 1994;

53(7):481-482. 23 Ebringer A, Wilson C. The use of low starch diet in the treatment of patients suffering from ankylosing spondylitis. Clinical Rheumatology 1996; 15(Sl):62-66. 24 Gatterman MI. Disorders of the thoracic spine. In: Gatterman MI, editor. Chiropractic Management of SpinalRelated Disorders. Baltimore: Williams and Wilkins; 1990. p. 203- 204. 96

25 Clinical Guidelines for Chiropractic Practice in Canada. Proceedings of a Consensus Conference Commissioned by the Canadian Chiropractic Association; 1994 April 3-7;Mississauga Canada: JCCA 38(1) (Suppl); 143. 26 Dvorak J, Kranzlin P, Muhlemann D, Walchi. Musculoskeletal complications. In: Haldeman S, editor. Principles and Practice of Chiropractic. 2nd ed. Connecticut: Appleton and Lange; 1992. p. 554-555. 27 Schmidley J, Koch T. The noncerebrovascular complications of chiropractic manipulation. Neurology 1984; 34:684-685. 28 Cooper RG, Freemont AJ, Fitzmaurice R, Alani SM, Jayson MIV. Paraspinal muscle fibrosis: a specific pathological component in ankylosing spondylitis. Ann Rheum Dis 1991; 50:755-759. 29 Laurent MR, Buchanan WW, Bellamy N. Methods of assessment used in ankylosing spondylitis clinical trials: A review. Br J Rheumatol 1991; 30:326-329. 30 Amor B, Dougados M, Khan MA. Management of refractory ankylosing spondylitis and related spondyloarthropathies. Rheumatic Disease Clinics of North America 1995; 21(1):117-127. 31 Gran JT, Skomsvoll JF. The outcome of ankylosing spondylitis: A study of 100 patients. Br J Rheumatol 1997; 36:766-771. 32 Carrette S, Graham D, Little H, Rubenstein J, Rosen P. The natural disease course of ankylosing spondylitis. Arthritis Rheum 1983; 26(2):186-190. 33 Goodacre JA, Mander M, Dick WC. Patients with ankylosing spondylitis show individual patterns of variation in disease activity. Br J Rheumatol 1991; 30:336-338. 34 Bakker C, Boers M, van der Linden S. Measures to assess ankylosing spondylitis: Taxonomy, review and recommendations. J Rheumatol 1993; 20(2): 1724-1729. 35 Abbot CA, Helliwell PS, Chamberlain MA. Functional assessment in ankylosing spondylitis: Evaluation of a new self-administered questionnaire and correlation with anthropometric variables. Br J Rheumatol 1994;

33:1060-1066. 36 Garrett S, Jenkinson T, Kennedy LG, Whitelock H, Gaisford P, Calin A. A new approach to defining disease status in ankylosing spondylitis: The Bath Ankylosing Disease Activity Index. J Rheumatol 1994; 21:2286-2291. 37 Calin A, Garrett S, Whitelock H, Kennedy LG, O'Hea J, Mallorie P, Jenkinson T. 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. 38 Jenkinson TR, Mallorie PA, Whitelock HC, Kennedy LG, Garrett SL, Calin A. Defining spinal mobility in ankylosing spondylitis (AS). The Bath AS Metrology Index. J Rheumatol 1994; 21:1694-1698. J Can Chiropr Assoc 2000; 44(2)

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39 Jones SD, Steiner A, Garrett SL, Calin A. The Bath Ankylosing Spondylitis Patient Global Score (BAS-G). Br J Rheumatol 1996; 35:66-71. 40 Jones SD, Calin A, Steiner A. An update on the Bath Ankylosing Spondylitis Disease Activity and Functional Indices (BASDAI, BASFI): Excellent Cronbach's Alpha scores. J Rheumatol. 1996 Feb; 23(2):407.

41 Taylor AL, Balakrishnan C, Calin A. Reference centile charts for measures of disease activity, functional impairment, and metrology in ankylosing spondylitis. Arth Rheum 1998; 41(6):1119-1125. 42 Boyer GS, et al. A comparison of patients with spondyloarthropathy seen in specialy clinics with those identified in a community wide epidemiological study. Arch Intern Med 1997; 157:2111-2117.

Chiropractic Foundation for Spinal Research ~~~~~~~~~~~~~~~~~~~.....:

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97