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Postural Stability and the Relationship with Enthesitis in Ankylosing Spondylitis: a Cross-Sectional Study

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Postural Stability and the Relationship with Enthesitis in Ankylosing Spondylitis: a Cross-Sectional Study Available online at www.medicinescience.org Medicine Science ORIGINAL RESEARCH International Medical Journal Medicine Science 2019;8(3):613-9 Postural stability and the relationship with enthesitis in ankylosing spondylitis: A cross-sectional study Sena Tolu1, Aylin Rezvani1, Nurbanu Hindioglu1, Ibrahim Ethem Kirez1, Merve Calkin Korkmaz2 1Medipol University Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Istanbul, Turkey 2Alsancak Nevvar Salih Isgoren State Hospital, Department of Physical Medicine and Rehabilitation, Izmir, Turkey Received 19 January 2019; Accepted 10 March 2019 Available online 04.04.2019 with doi:10.5455/medscience.2019.08.9030 Copyright © 2019 by authors and Medicine Science Publishing Inc. Abstract This study aims to investigate the static and dynamic postural stability in ankylosing spondylitis (AS), and to evaluate their relationships with clinical parameters, postural measurements, and enthesitis. Sixty-four patients with AS (37 males, 27 females; mean age 41.06±8.89 years) and 42 healthy individuals (23 males, 19 females; mean age 38.45±8.46 years) were involved in the study. The static and dynamic postural stability of all participants were assessed using the Biodex Balance System. Patients’ posture was evaluated using chest expansion, tragus-wall distance, and the modified Schober’s test. The disease activity (Bath Ankylosing Spondylitis Disease Activity Index: BASDAI), functional status (Bath Ankylosing Spondylitis Functional Index: BASFI), spinal mobility (Bath Ankylosing Spondylitis Metrology Index: BASMI), enthesitis score (Maastricht Ankylosing Spondylitis Enthesitis Score: MASES), pain (Visual Analogue Scale: VAS), quality of life (Ankylosing Spondylitis Quality of Life: ASQoL) and depression (Beck Depression Inventory: BDI) of all patients were evaluated. Similar demographic data were found in both groups. Significant differences were acquired between the patient and control groups regarding all postural stability tests (p<0.05). The BASDAI, BASMI, BASFI, MASES, VAS pain, modified Schober’s test, ASQoL, and BDI were associated with sway velocity on a firm surface with eyes closed. There was a significant correlation between MASES and all tests of sway velocity. Dynamic postural stability in the sagittal plane and whole tests (except on foam surface eyes closed test) of sway velocity were affected negatively in patients with Achilles enthesitis. Static and dynamic postural stability impairments are seen in AS. Enthesitis significantly impaired static postural stability and increased postural sway. Keywords: Ankylosing spondylitis, enthesitis, postural stability, sensory integration and balance, postural deformity Introduction retroversion, hip extension, knee flexion, and ankle plantar flexion develop to maintain erect posture and align the head and eyes to Ankylosing spondylitis (AS) is an axial spondyloarthritis which a horizontal position [3,5,6]. With the progression of AS, balance primarily affects the axial skeleton. Peripheral joints and entheses is impaired and postural control strategies become inadequate to are frequently affected. It is common among young people, cope with poor balance. [3-5]. especially in males, who generally present at ages younger than 30 years. AS is characterized by spinal stiffness and loss of spinal Balance is the capability to maintain the body’s center of mass mobility, which is explained by spinal inflammation, structural within the base of support with minimal postural sway. Balance is damage or both [1]. As the disease progresses, postural changes affected by postural changes and the displaced center of gravity. become more marked. Chronic structural changes occur with The cooperation of sensory (vestibular, visual, and somatosensory new bone formation and progression to fusion (ankyloses) in the inputs) and musculoskeletal systems maintain postural stability [5]. inflamed sacroiliac joints, spinal and peripheral joints, which cause In patients with AS, the musculoskeletal system is the prominently a reduction in the range of motion, mobility, and flexibility [2]. affected system. Thoracic kyphotic deformity in patients with AS causes forward Enthesitis, a central feature of spondyloarthritis, is the inflammation and downward displacement of the center of gravity of the body in of tendinous or ligamentous insertions onto the bone. Enthesitis the sagittal plane [3-5]. A series of compensations, including pelvic most commonly affects the Achilles tendon site and also may affect joint structures in AS [7]. Components in the spine, like ligaments, intervertebral discs, facet joints, interspinous muscles, posterior *Coresponding Author: Sena Tolu, Medipol University Faculty of Medicine, annulus, and the posterior longitudinal ligament contribute to Department of Physical Medicine and Rehabilitation, Istanbul, Turkey proprioceptive control [8]. Previous studies have speculated that E-mail: [email protected] 613 doi: 10.5455/medscience.2019.08.9030 Med Science 2019;8(3):613-9 enthesopathy disturbs proprioception by damaging the afferent intermalleolar distance were measured, and the Bath Ankylosing nerve fibers in ligaments, tendons, and joint capsule system, and Spondylitis Metrology Index (BASMI) was calculated to assess this may contribute to balance impairment [5,6,9,10]. the mobility of the axial skeleton [15]. The clinical evaluation of enthesitis was performed using the Maastricht Ankylosing In AS, pain, stiffness, fatigue, reduced spinal mobility, and Spondylitis Enthesitis Score (MASES) [16]. Pain levels were restriction of the respiratory functions have impacts on different recorded using a 0-10–cm visual analog scale (VAS). Health- aspects of the patient’s physical disability [11]. Some studies related quality of life was assessed by The Ankylosing Spondylitis have shown the relationship between AS and balance and postural Quality of Life (ASQoL) questionnaire [17]. The severity of parameters, but no information exists regarding the association symptoms of depression was measured by the Beck Depression between enthesitis score and postural stability [3-5,8-10]. Inventory (BDI) [18]. Pain evaluation was performed by using the Visual analog scale (VAS). Posture was evaluated using tragus- In the present study, our first aim was to investigate the static and wall distance, modified Schober’s test, and chest expansion. dynamic postural stability in patients with AS and to disclose their relationships with clinical parameters, postural measurements, Postural Stability Assessment enthesitis score, quality of life and depression. The second purpose Postural stability tests were assessed using the Biodex Balance was to examine the effects of Achilles enthesopathy on static and System (BBS; Biodex Medical System Inc., Shirley, New York, dynamic postural stability. USA), which evaluates neuromuscular control and somatosensory input objectively. Two static tests and one dynamic postural Material and Methods stability test with different dynamic settings were evaluated. The postural stability test emphasized a patient’s ability to maintain Patient diagnosed with AS with using the 1984 modified New their center of gravity and balance on static or dynamic setting York Classification Criteria [12] and healthy subjects matched platforms [19]. All tests were performed under the supervision of for age, sex, and body mass index (BMI) were involved in the the third author. study. Hospital employees volunteered as healthy participants. Written informed consent from all participants was obtained 1. Static Postural Stability Test: before participating, and the study protocol was approved by After entering participants’ data, body height and the angle of Medipol University Human Research Ethics Board. This study settings for the right and left foot into the system, this test consists was conducted in accord with the ethical principles outlined in the of 3 trials performed while standing on a static platform for 20 s Declaration of Helsinki. per trial with eyes open. The mean score was calculated from the three trials. Three stability indexes were calculated as follows: The exclusion criteria for both groups were as follows: (1) unwillingness to participate in the study, (2) visual or vestibular - Anterior-Posterior Stability Index (APSI) assessed variation of disorders, (3) cognitive problems, (4) neurologic disorders that the platform displacement for sagittal plane movements expressed could result in balance problems or lower extremity motor paresis in degrees. (e.g., multiple sclerosis, cerebrovascular disease, polyneuropathy), (5) active lower extremity arthritis or orthopaedic problems - Medial-Lateral Stability Index (MLSI) indicated the variability of (contracture or range of motion limitations of low extremities, the platform position for frontal movements expressed in degrees. length difference between the legs of more than 1 cm, any surgical history of the lower extremities or vertebrae-related problems, - Overall Stability Index (OSI) reflected the variability of the scoliosis) affecting balance and posture, (6) cardiovascular platform position from the horizontal plane for all movements disorders, (7) psychiatric disorders that affected communication, performed in the test. (8) age under 20 years and above 65 years, and (9) pregnancy. 2. Dynamic Postural Stability Test Patients with AS were evaluated in the afternoon to rule out the This test consists of 3 trials while standing on a dynamic platform effects of morning stiffness.
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