EXPERIMENTAL AND THERAPEUTIC MEDICINE 21: 89, 2021
Predicting functional disability in patients
with spondyloarthritis using a CRP‑based
algorithm: A 3‑year prospective study
LILIANA CATAN1, MARIUS BOARIU2, ELENA AMARICAI1, DANIEL POPA1,3, GEORGE PUENEA1,
MIHAI DRĂGOI1,3, ȘTEFAN STRATUL4 and RĂZVAN GABRIEL DRĂGOI1,3
Departments of 1Balneology, Medical Rehabilitation and Rheumatology, and 2Endodontics,
‘Victor Babes’ University of Medicine and Pharmacy, 300041 Timisoara;
3
Rehabilitation and Rheumatology Department, City University and Emergency Hospital,
300020 Timisoara; 4Department of Periodontology, ‘Victor Babes’ University
of Medicine and Pharmacy, 300041 Timisoara, Romania
Received August 11, 2020; Accepted September 10, 2020
DOI: 10.3892/etm.2020.9521
Abstract. This prospective study explored the link between
values of C‑reactive protein (CRP) in patients with SpA
(ankylosing spondylitis, psoriatic arthritis, reactive arthritis,
or arthritis‑related inflammatory bowel disease) and func‑
tional disability in order to derive an algorithm that may
predict functional disability based on disease activity.
Patients diagnosed with Spa were classified into five groups
based on the type of therapy and they were followed up for
3 years. Group 1: Symptomatic medication alone; Group 2:
Disease‑modifying antirheumatic drugs (DMARDs); Group 3:
DMARDs and 30 rehabilitation sessions twice a year; Group 4:
Group 3 therapy and biologic anti‑tumor necrosis factor‑alpha
(anti‑TNF‑α) drugs; and Group 5: Group 4 therapy and, in
addition, a daily home‑adapted kinesiotherapy program. CRP,
modified Health Assessment Questionnaire (mHAQ‑S), Bath
Ankylosing Spondylitis Disease Activity Index (BASDAI),
and T‑score of the patients were recorded. Correlation and
multivariate regression analyses were conducted using
demographic data, CRP, and mHAQ‑S scores to derive the
CRP‑mHAQ‑S correlation algorithm. Statistical analysis
included the chi‑square, Mann‑Whitney, and multiple regres‑
sion tests and repeated measures analysis of variance. A total
of 144 patients were enrolled, all of whom completed the study.
The best predictive model (P<0.001) provided the algorithm
mHAQ‑S36=17.14+0.12xCRP0‑0.24xCRP12‑0.15xCRP36 (CRP0,
Correspondence to: Dr Marius Boariu, Department of Endo‑
dontics, ‘Victor Babes’ University of Medicine and Pharmacy,
9 Bulevardul Revolutiei din 1989, 300041 Timisoara, Romania
E‑mail: boarium@yahoo.com
Key words: C‑reactive protein, disease activity, functional disa‑
bility, HAQ‑S, quality of life, spondyloarthritis
CRP12, and CRP36 correspond to CRP levels at baseline, 12, and
36 months, respectively, and mHAQ‑S36 to mHAQ‑S score at
36 months). This derived algorithm based on objective CRP
assessment may have implications in the prediction of func‑
tional disability evolution in patients with SpA.
Introduction
Spondyloarthritis (SpA) is a group of chronic inflam‑
mator y rheumatic diseases compr ising an kylosing
spondylitis (AS), psoriatic arthritis (PsA), reactive arthritis
(ReA), arthritis‑related inflammatory bowel disease (IBD),
and a subgroup of juvenile idiopathic arthritis (1,2). In Europe,
the incidence of SpA is variable, ranging from 1.5 to 10.6 for
AS, 3.6 to 8 for PsA, and 9.3 to 28 for ReA per 100,000 popu‑
lation (3). Because delay in treatment could have important
medical (4,5) and socioeconomic implications (1) that could
lead to severe disability, early diagnosis and treatment are
essential. Recommendations of the European League Against
Rheumatism (EULAR) advise that nonsteroidal anti‑inflam‑
matory drugs (NSAIDs) are the first‑line treatment for patients
with AS and PsA (6,7). Anti‑tumor necrosis factor‑alpha
(anti‑TNF‑α) drugs are recommended directly after failure
of conventional treatments in AS (6) but are third in line in
PsA treatment after the failure of synthetic disease‑modifying
antirheumatic drugs (DMARDs) (7). Physiotherapy and
kinesiotherapy are essential components of ReA treatment,
with NSAIDs and steroids as first‑ and second‑line therapies,
respectively (8,9). In contrast, NSAIDs are contraindicated in
the treatment of the arthritis component of arthritis‑related
IBD, where, DMARDs and biologic anti‑TNF‑ α drugs are
effective therapeutics (10,11).
Clinical management of SpA is based on assessment of
disease activity (determined by clinical signs and symptoms
and levels of acute phase reactants), structural changes,
functional impairment, extra‑articular manifestations,
comorbidities, and treatment risks, with specific assessments
that differ based on the type of SpA (12). Various objective,
2
CATAN et al: FUNCTIONAL DISABILITY IN SPONDYLOARTHRITIS
subjective, and composite indices are used to assess disease
activity and functional disability of different types of SpA.
The merits of some of these indices have been described
previously (9,11,13,14). The acute‑phase reactant C‑reactive
protein (CRP) is an established measure of disease activity
in AS (13), PsA (14), and ReA (15) and is included in several
composite indices to increase sensitivity (16,17).
The Health Assessment Questionnaire Modified for
Spondyloarthropathies (HAQ‑S) can be used to assess func‑
tional disability in AS, PsA, ReA, as well as arthritis‑related
IBD (18‑20). The HAQ‑S, modified from the original HAQ
instrument includes spinal mobility for SpA (21), being a
patient‑reported outcome (PRO) based on the assessment
of disability, pain, medication effects, costs of care, and
mortality (22). Such a multifaceted analysis of functional
disability is part of the quality of life (QoL) assessment (23),
which involves assessment of the overall perception of QoL
(global measures) and specific physical, psychological, social,
and functional issues that reflect or contribute to QoL (subscale
item measures) (24).
The present study aimed to determine the association
between the disease activity assessment tool (BASDAI),
CRP and the functional disability assessment tool mHAQ‑S
(HAQ‑S with a modified scoring system) in patients with SpA.
Patients and methods
Study design. This prospective study was conducted from
January 2015 to May 2018 in the Department of Balneology,
Rehabilitation, and Rheumatology of the City University and
Emergency Hospital. The study was designed, implemented,
and reported in accordance with the International Conference
on Harmonisation (ICH) Harmonized Tripartite Guidelines for
Good Clinical Practice and the ethical principles stated in the
Declaration of Helsinki, as approved by the Ethics Committee
of the ‘Victor Babeș’ University of Medicine and Pharmacy,
Timisoara, Romania. Patients were invited to participate in
the study at one of the routine visits in the outpatient/inpa‑
tient clinic. All patients provided written informed consent
for participation and use of the data collected by the research
team.
Participants. Patients aged ≥18 years of both sexes and diag‑
nosed with SpA, including AS, PsA, ReA, or arthritis‑related
IBD, were included in the study. Patients who had received
prior therapy with immunomodulating agents, steroids, or
NSAIDs, those who discontinued immunomodulator treat‑
ment due to side effects or absence of therapeutic response,
and treatment‑naïve patients were included in the study and
randomized into study groups accordingly.
Patients were excluded if they had severe cardiac (heart
failure, unstable angina, uncontrolled hypertension, heart
attack, or coronary bypass 3 months prior to inclusion
in the study), metabolic (uncontrolled diabetes mellitus,
uncontrolled thyroid or suprarenal disorders, or cachexia),
respiratory (uncontrolled asthma or chronic obstructive
pulmonary disease), hematologic (leukemia or blood coagu‑
lation disorders), or psychiatric disorders, malignant tumors,
infectious diseases (tuberculosis, hepatitis, or acquired
immunodeficiency syndrome), febrile syndrome, acute
thrombophlebitis, alcohol dependency, participated in other
concomitant clinical trials, or required surgical procedures.
Pregnant and lactating women were also excluded.
Patient classification and assessment. Eligible patients were
provided standard‑of‑care treatment and were classified into
5 groups based on the type of therapy. Group 1 comprised
patients receiving symptomatic treatment (e.g., oral NSAIDs
with or without gastric protection) based on their clinical and
functional status and associated pathology. Group 2 included
patients receiving the same treatment as Group 1 and addi‑
tional DMARDs. Group 3 comprised patients receiving the
same treatment as Group 2 along with a rehabilitation program
of 30 sessions twice a year, including physical therapy with
manual massage, electrotherapy, phototherapy, thermotherapy,
aquatic therapy, and kinesiotherapy based on the pathology
and clinical stage of the disease (active or chronic) and disease
activity. Group 4 comprised patients receiving the same treat‑
ment as Group 3 in addition to biologic therapy (anti‑TNF‑α
drugs). Group 5 comprised patients receiving the same
treatment as Group 4 along with a daily home‑adapted kine‑
siotherapy program administered by a rehabilitation specialist.
Patients were evaluated at the beginning of the study
(baseline), then monthly for the first 3 months, every 3 months
thereafter until the end of the first year, and every 6 months
thereafter until the end of the third year. Assessments included
CRP, Bath Ankylosing Spondylitis Disease Activity Index
(BASDAI), mHAQ‑S, and T‑score (measured by Dual Energy
X‑ray Absorption [DEXA] to assess bone mineral density). CRP
levels of <5 mg/l were considered normal (25). The scores for
BASDAI, a PRO for disease activity, ranged from 0 (no disease
activity) to 10 (maximal disease activity). The mHAQ‑S scale
was modified from the original instrument (18) from 0‑3 to
0‑30, to increase the resolution and hence sensitivity, of the
scoring system. In this system, higher scores indicated a better
QoL to accommodate patients' mindset of giving higher scores
to better conditions. T‑scores >‑1 were considered normal (26).
Statistical analysis. Correlation and multivariate regression
analyses were used to determine the best predictive model
that defined the relationship between CRP and mHAQ‑S.
The model included demographic variables, including age,
sex, and residential area (urban or rural), as well as CRP and
mHAQ‑S assessments at baseline. Repeated measures analysis
of variance (ANOVA) was used to determine treatment effi‑
cacy among the groups, in terms of change from baseline in
the BASDAI, CRP and mHAQ‑S scores. Other statistical
tests included the chi‑square, Mann‑Whitney, and multiple
regression analyses. All P‑values were two‑sided with a
significant level of 0.05. Demographic and baseline character‑
istics were summarized using descriptive statistics. Statistical
analyses were conducted using the Statistics software program
(IBM‑SPSS, version 18, 2010).
Results
Patient characteristics. Of the 1,170 patients screened, 144
met the eligibility criteria [AS (n=78), PsA (n=44), ReA (n=12),
arthritis‑related IBD (n=10)] and completed the study (Table I).
Data collected was statistically analyzed and interpreted. The
3
EXPERIMENTAL AND THERAPEUTIC MEDICINE 21: 89, 2021
Table I. Demographics and baseline characteristics.
Characteristics
1 (n=48)
2 (n=24)
3 (n=24)
4 (n=24)
5 (n=24)
Total n=144
46.27 (13.27)
47.21 (14.23)
49.25 (14.62)
46.96 (15.39)
49.08 (10.49)
47.51 (13.50)
Sex, n (%)
Men
Women
27 (56.25)
21 (43.75)
12 (50.00)
12 (50.00)
11 (45.83)
13 (54.17)
14 (58.33)
10 (41.67)
13 (54.16)
11 (45.83)
77 (53.5)
67 (46.5)
Disease, n (%)
AS
PsA
ReA
IBD
26 (18.1)
16 (11.1)
4 (2.8)
2 (1.4)
13 (9.0)
8 (5.6)
2 (1.4)
1 (0.7)
13 (9.0)
8 (5.6)
2 (1.4)
1 (0.7)
13 (9.0)
6 (4.2)
2 (1.4)
3 (2.1)
13 (9.0)
6 (4.2)
2 (1.4)
3 (2.1)
78 (54.2)
44 (30.6)
12 (8.3)
10 (6.9)
Mean age, years (SD)
CRP, mg/l, mean (SD)
33.51 (8.69)
36.55 (12.74)
28.23 (7.76)
35.94 (12.24)
34.80 (10.97)
33.73 (10.50)
mHAQ‑S, mean (SD)
7.15 (1.60)
6.75 (1.03)
8.38 (2.18)
6.83 (1.52)
7.46 (1.67)
7.28 (1.70)
T‑Score, mean (SD)
‑2.68 (0.59)
‑2.77 (0.54)
‑1.90 (0.95)
‑2.24 (0.73)
‑2.41 (0.73)
‑2.42 (0.73)
BASDAI, mean (SD)
6.72 (0.90)
6.75 (0.85)
5.91 (1.06)
7.09 (0.98)
6.70 (1.08)
6.65 (1.02)
AS, ankylosing spondylitis; BASDAI0, Bath Ankylosing Spondylitis Disease Activity Index at baseline; IBD, arthritis‑related IBD;
CRP, C‑reactive protein; mHAQ‑S: modified Health Assessment Questionnaire Modified for Spondyloarthropathies; PsA: psoriatic arthritis;
n, number of patients; ReA, reactive arthritis; and SD, standard deviation.
average age [± standard deviation (SD)] was 47.5 (±13.5) years
and 53.3% were men, of whom 68.1% living in urban areas.
Group 1 comprised 48 patients, while the rest of the groups
(2, 3, 4 and 5) comprised 24 patients each.
Physical disability as a function of disease activity. A math‑
ematic model was developed using correlation and regression
analyses to objectively determine the functional disability in
patients with SpA during a 3‑year treatment period as follows:
mHAQ‑S36=17.14+0.12xCRP0 ‑0.24xCRP12‑0.15xCRP36
where CRP 0, CRP12, and CRP36 correspond to CRP levels at
baseline, 12, and 36 months, respectively, and mHAQ‑S36 to
mHAQ‑S score at 36 months [F (7, 136)=36.25; P<0.001].
mHAQ‑S scores at baseline did not significantly influence
the model. CRP at baseline and 12 and 36 months showed
β equivalent to 0.12, ‑0.24, and ‑0.15, respectively, and the
standardized β equivalent to 0.14, ‑0.43, and ‑0.38, respec‑
tively, which significantly influenced the model (Table II).
When β increased by 1 unit, the mHAQ‑S score increased by
0.043 units at baseline and decreased by 0.24 and 0.15 units
at 12 and 36 months, respectively. Preliminary analyses were
conducted to test the hypotheses of normality, linearity, and
multicollinearity. The CRP levels at 24 months and BASDAI
scores were excluded because they were collinear.
Efficacy analysis. Analysis of BASDAI, CRP, and mHAQ‑S
scores revealed significant between‑treatment differences in effi‑
cacy. The scores were higher in Group 2 and 3 than in Group 1,
whereas the scores in Group 4 and 5 were higher than in both
Groups 1, 2 and 3; CRP: F [2,141]=171.54, P<0.001; BASDAI: F
[2,141]=178.16, P<0.001; mHAQ‑S: F [2,141]=745.50, P<0.001;
total T‑score: F [2,141]=8.69, P<0.001). Table III depicts a
Table II. Correlation and regression analysis of HAQ‑S36
values.
Model
Unstandardized
coefficients
‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑
B
SE
Standardized
coefficients
‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑
Beta
T
1
Age
Sex
Environmenta
0.002
‑0.281
1.487
0.056
1.474
1.629
0.003
‑0.016
0.080
0.038
‑0.191
0.913
0.969
0.849
0.363
2
Age
Sex
Environmenta
CRP0
CRP12
CRP36
0.011
‑0.353
0.813
0.107
‑0.245
‑0.151
0.034
0.896
0.978
0.043
0.067
0.047
0.018
‑0.020
0.044
0.130
‑0.440
‑0.388
0.340
‑0.394
0.831
2.484
3.639
‑3.232
0.734
0.694
0.408
0.014
0.000
0.002
3
Age
Sex
Environmenta
CRP0
CRP12
CRP36
mHAQ‑S0
0.013
‑0.342
0.804
0.123
‑0.243
‑0.152
0.139
0.034
0.900
0.982
0.059
0.068
0.047
0.368
0.021
‑0.020
0.043
0.149
‑0.437
‑0.389
0.027
0.387
‑0.380
0.819
2.065
‑3.588
‑3.232
0.377
0.699
0.704
0.414
0.041
0.000
0.002
0.707
Sig.
Rural/urban environment. CRP0, CRP12, CRP36, C‑reactive
protein values at baseline, 12 months, and 36 months, respectively;
mHAQ‑S0, modified Health Assessment Questionnaire Modified for
Spondyloarthropathy values at baseline; and SE, standard error.
a
CATAN et al: FUNCTIONAL DISABILITY IN SPONDYLOARTHRITIS
4
Table III. Disease activity and functional disability outcomes
at 3‑year follow‑up.
Items
CRP, mg/l
BASDAI
mHAQ‑S
T‑score
Group
n
Mean (SD)
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
48
24
24
24
24
48
24
24
24
24
48
24
24
24
24
48
24
24
24
24
51.91 (16.72)
23.14 (7.54)
20.90 (5.61)
6.31 (2.10)
2.83 (1.19)
7.43 (0.68)
5.40 (0.82)
4.97 (0.88)
2.03 (0.52)
1.25 (0.50)
6.54 (1.03)
8.67 (1.01)
10.75 (1.92)
23.38 (1.66)
28.13 (1.39)
‑2.46 (0.59)
‑2.64 (0.62)
‑1.48 (1.05)
‑1.72 (0.74)
‑1.65 (0.61)
CRP, C‑reactive protein levels; BASDAI, Bath Ankylosing
Spondylitis Disease Activity Index; mHAQ‑S, modified Health
Assessment Questionnaire Modified for Spondyloarthropathy values;
n, number of patients; and SD, standard deviation.
comparison of the average values of the parameters at the end of
the study. No significant difference was observed in the average
CRP and BASDAI values at 36 months between Groups 2 and 3.
However, the average CRP and BASDAI values in Group 5 were
significantly lower than in Group 4 (Mann‑Whitney values:
U=17, z=‑5.59, P<0.001 and U=71, z=‑4.49, P<0.001, respec‑
tively). The average mHAQ‑S score at the final assessment was
significantly higher in Group 3 compared with Group 2 (U=74.5,
z=‑4.52, P<0.001) and in Group 5 compared with Group 4
(U=5.5, z=‑5.89, P<0.001; Table III). The total T‑score at the end
of the study was significantly higher in Group 3 compared with
Group 2 (U=94.5, z=‑3.99, P<0.001) and in Group 5 compared
with Group 4.
A mixed ANOVA was performed between the groups and
their serial determinations to determine the impact of specific
therapeutic approaches (differentiated group therapies) on the
average values of CRP, BASDAI, mHAQ‑S, and total T‑score
(at baseline and at 12, 24, and 36 months). A statistically signifi‑
cant association was observed between the type of therapy and
assessments at different evaluation time points (CRP, BASDAI,
mHAQ‑S, and total T‑score; all P‑values <0.001).
Discussion
Our study shows that CRP, an objective measure of disease
activity, can be used as a surrogate PRO of functional
disability, the HAQ‑S instrument, if a history of CRP values is
available. We propose an algorithm to measure the functional
disability associated QoL at 36 months using CRP levels at
baseline, 12, and 36 months. We believe that this algorithm
may have implications in the clinical management of SpA as it
would enable assessment of therapeutic efficacy and facilitate
longitudinal follow‑up, thereby promoting consistent treat‑
ment decisions. Even though updated information regarding
biomarkers/immune markers that sustain the heterogeneity and
complexity of psoriatic arthritis pathogenesis are studied, and
new immune proteomic or genomic biomarkers can enlarge
and identify new therapeutic targets (27), management of
clinical implications of the disease remain the main concern of
a clinician. Therefore, developing predictive models that serve
as a surrogate measure for PRO would be particularly helpful
in reducing the nonspecific effects observed in clinical trials,
which result from inherent bias in PROs. PROs may introduce
bias via the Hawthorne effect, wherein participants change
their behavior because they are being observed, or via the
Pygmalion effect, wherein participants augment their existing
impairment at study inclusion and minimize it at follow‑up to
meet the expectations of the clinician or the sponsor (28).
Several studies have associated higher disease activity
with higher functional disability. Disease activity was iden‑
tified as one of the 2 independent determinants of physical
function impairment in AS in the study variables (29) and
was associated with reduced work efficiency in PsA (30), as
some pathogenic mechanism involved in the development of
psoriasis seems to produce disorders of the endogenous anti‑
oxidative systems (31). In addition, disease activity measured
by CRP correlated with functional disability measured by the
PRO Bath Ankylosing Spondylitis Functional Index (BASFI)
in patients with short‑term axial SpA treated with etaner‑
cept or adalimumab (32). The present study found a similar
correlation between CRP and mHAQ‑S. HAQ‑S as a part of
QoL assessment is one of the indicators of disease remission
along with laboratory biomarkers, radiologic findings, disease
activity, and functional markers. As such, HAQ‑S assess‑
ment can potentially reduce costs associated with expensive
investigations. A prospective study reported that remission
in patients with PsA receiving biologic therapy was strongly
associated with HAQ‑S rather than other parameters such as
global visual analog scores and early‑morning stiffness (33).
The combination of medical treatment with rehabilitation
and individualized daily home‑adapted kinesiotherapy programs
improved the disease activity as well as physical function, as
determined by BASDAI and mHAQ‑S scores, respectively. Our
results are consistent with those of previous studies reporting
improved QoL in patients with SpA who participated in physical
exercise programs (34‑36). In fact, physical exercise is an integral
part of non‑pharmacological AS treatment per 2010 EULAR
recommendations (6). The sustained, long‑term kinesiotherapy
programs in patients with SpA may play a role in immunomodu‑
lation by activating anti‑inflammatory and disease‑modifying
factors. If biomarkers that sustain the pathogenesis of SpA (24)
are available, new immune proteomic or genomic biomarkers
should be identified in order to evaluate the role of physical
exercise on the human body.
This study has some limitations, such as the relatively
small number of patients in each group and a 3‑year
EXPERIMENTAL AND THERAPEUTIC MEDICINE 21: 89, 2021
follow‑up period, which is considered short for a lifelong
chronic disease. In addition, our study did not characterize
disease duration. However, in PsA, increase in disease
duration reduces the influence of disease activity on HAQ
scores (37). Thus, in our study, differences in disease dura‑
tion among the patients may have influenced the strength
of the CRP‑mHAQ‑S association. The CRP‑mHAQ‑S
algorithm was partly based on patients with arthritis‑related
IBD; in this condition, CRP is not considered an adequate
measure of disease activity since it is also elevated in IBD
unrelated to arthritis (11). Nevertheless, the proportion of
patients with arthritis‑related IBD was low in the overall
patient population (6.9%), potentially mitigating the effect
to some extent.
Another limitation would be that a patient needs a history
of CRP values over time in order to apply the algorithm.
However, the algorithm can possibly be validated in an inde‑
pendent population, which may be undertaken in a future
study, so it could pave the way for a more comprehensive
understanding and use of it.
Acknowledgements
We thank Dr Costela Serban for her help in the statistical
analysis of the study results. The authors retained full control
of the manuscript content. All named authors meet the ICMJE
criteria for authorship for this manuscript, take responsibility
for the integrity of the work, and have given final approval for
the version to be published.
Funding
No funding was received.
Availability of data and materials
The datasets used/analyzed in the present study are available
from the corresponding author on reasonable request.
Authors' contributions
LC, EA, DP and GP participated in data acquisitions. MD, MB
and RGD participated in the study design. All authors drafted
the manuscript. SS and RGD critically revised the intellectual
content of the manuscript. All authors read and approved the
final version of the manuscript.
Ethics approval and consent to participate
The study was approved by the Ethics Committee of Timisoara
University of Medicine and Pharmacy, Romania. All proce‑
dures were followed in accordance with the ethical standards
of the responsible committee on human experimentation (insti‑
tutional and national) and with the Helsinki Declaration of
1975, as revised in 2000 and 2008. All patients gave informed
consent for participation.
Patient consent for publication
Not applicable.
5
Competing interests
The authors declare that they have no competing interests.
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