Since the days of when people living with what is now known to be Axial Spondyloarthropathy (Axial SpA) being put into plaster casts (1950’s) to now; there has been a vast evolution in the knowledge and care both medically and within the world of physiotherapy for this condition. Having used the Bath AS Metrology Index (BASMI) with my patients over a number of years from the pre biologic days until now, I wonder if the BASMI is still serving a purpose for both clinicians and of course people living with Axial SpA?
This blog looks at some of my own thoughts which led to the survey we devised on the current use of the BASMI in the UK which will hopefully act as a springboard for discussion and future research.
The BASMI was devised by a group of physiotherapists, rheumatologists and people with lived experience to specifically look at the areas where reduction of movement occurs with AxSpA (Jenkinson et al 1994). Those who are familiar with it will know it measures 5 key movements: tragus to wall, lateral spinal side flexion, lumbar flexion, cervical rotation and hip abduction. It has excellent inter and intra-rater observer reliability (Martindale et al 2012) It is also used widely in clinical research trials as an outcome measure.
Elements of the BASMI are described by the Spondylitis International Society (ASAS) Sieper et al 2009.) And in 2016 an update of the ASAS-EULAR management recommendations for axial spondyloarthritis stated that monitoring should include a broad variety of assessments and cited the ASAS core set being still “guiding” whilst not using the acronym BASMI it did use the words “spinal mobility”. The latest NICE guidelines, 2017 for spondyloarthritis in over 16’s; diagnosis and management do not include any objective outcome measures looking at the range of movement.
One criticism stated over the years according to Braun et al 2014 is that it is not a pure spinal measure given that hip abduction is measured and not chest expansion. They suggest there is room for development of the BASMI to include other features. Other suggestions have been made such as measuring occiput to wall and also adapting the scoring system such as the 2-point score, Van Der Heijde et al 2008.
The BASMI was designed to be used in conjunction with the other BATH indices which are subjective questionnaires notably the BASDAI and BASFI. The BASMI now tends to be used in isolation which was not ithe original purpose and in some centres, it is not used at all. Gregory et al in 2017 looking at services in the North West for people living with spondyloarthritis found: “across our regional forum of physiotherapists there is a wide variation in how physiotherapy-led spondyloarthritis assessment is provided”. Also, in collaboration with the NASS a survey of rheumatology departments in 2018 found only 65% of the 83 respondents said their departments carried out the BASMI. Derakhshan et al 2018.
Another point I would like to make is that over the years thankfully with improved medication the deformities that we used to see are less frequent. A study by Rodriguez et al 2019 has shown “our findings indicate that long-term anti-TNF therapy decelerates the progression of structural damage in the SI joints”. They looked at the radiographic progression of early AxSpA with the use of anti-TNF for up to 6 years in patients. The BASMI is amongst other things measuring the progression of the disease but if this is being slowed by anti-TNF then does it still have a purpose?
Currently in my own practice as part of an assessment of a person with a new diagnosis of AxSpA the BASMI is completed to give a baseline measure of movement. This occurs in combination with subjective questioning and other objective findings such as functional movements. Clinical reasoning informs a management plan often advising on specific stretches and exercises for which the BASMI is a useful guide as to where movement is restricted.
It is also useful depending on the person to look at the scoring table and explain where they sit with regard to their individual movements. A study in 2013 by Chilton-Mitchell et al looked at the BASMI on healthy individuals. They suggest that “The generation of normative values has the potential to inform clinical assessment of spinal mobility and assist patients in understanding how their spinal mobility compares with that of a healthy age-matched population” They found that it is unusual for this group (normal population) to score zero. It can be helpful for some people and reassuring that their movements are ok. Also, it can act as an incentive to advise people to stretch if they are stiffening and moving further up the table with worsening scores.
If the stiffness we measure fits with their subjective experience this can also be powerful and by demonstrating this with the BASMI this can be an incentive to work on their specific stretches. For a new patient though I sometimes wonder is this scary for them to be measured and does it feed into negative thoughts about their bodies and concerns about deterioration of movement; hence my next train of thought…
Another reason for me to question the use of the BASMI in 2022 is in response to the narratives and discussions about non-specific low back pain. A clinical commentary paper by Bunzli et al 2017 is an interesting read talking about fear-related low back pain. I acknowledge this clinical presentation is very different to someone who has a diagnosis of Axial SpA which is a progressive autoimmune disease. However, I see two aspects here potentially at play. Firstly, does doing the BASMI and explaining the table to a newly diagnosed person feed into thoughts and concerns about losing range of movement in time and this escalates their worries and negative beliefs about their bodies feeding into pain mechanisms. Secondly, for established disease are we feeding into concerns at times looking at subtle changes when they could be age-related or from mechanical causes? This is potentially a controversial avenue of discussion as NSLBP and AxSpA are completely different presentations, but it is an important consideration I think to consider with our group.
This survey also seems timely to me given the recent “Rheumatology workforce: a crisis in numbers” British Society of rheumatology 2021. And the GIRFT report in rheumatology with their recommendations. Also, NHSE and NHS improvement in consultation with the BSR Clinical Affairs Committee published guidance on PIFU (patient-initiated follow-up) for adult rheumatology services. Plus, the NHS directive for more virtual consultations means overall, there is a real and necessary drive to make every appointment count. The AStretch team undertook a feasibility study in December 2020 looking at using a novel remote video-guided BASMI tool. They concluded that whilst it is unlikely to be a reliable and valid replacement they showed the feasibility and tolerability of this remote monitoring. This is encouraging given the research and development of app-based solutions for BASMI.
So, having discussed this with the AStretch committee we agreed that a UK-wide survey of the current use of the BASMI would act as a good springboard for us to start a conversation about current practice. This would in turn help us shape other questions we have in this area to guide future research questions and ultimately to advise on best practice. We hope then for example to devise and carry out surveys to ask questions of people living with AxSpA about their experiences of the BASMI. Firstly, we felt we need to establish what we are doing as clinicians in the UK.
The title: “A Survey of Current UK-wide use of the BASMI outcome measure in Axial Spondyloarthritis.” The survey was shared across multiple platforms and email professional distribution lists and was open from 2nd-12th October 2021. The aim was to find out when the BASMI was used, by whom, the reasons for it’s use and how the scores were recorded.
Having agreed on potential reasons for doing the BASMI we decided on a scale and then the survey platform was able to rank these statements which meant we could extrapolate the most important reasons (table 1). We felt some free text options were also important to capture reasons we hadn’t considered. We added in chest expansion and free text to add any other regular measured areas. We also asked about confidence in carrying out the BASMI and how frequently it is done.
Results: 74 UK healthcare professionals completed the survey; mostly it is physiotherapists who undertake the BASMI (69%), other clinicians also measure: nurses (10%), medics (9%), physiotherapy support workers (10%), healthcare support workers (2%). Confidence in performing the BASMI averaged at 3.5/5. Most respondents record the BASMI in the electronic record (73%), app-based solutions are developing (7%) and paper-only recording diminishing (20%). In terms of frequency most (73%) recorded “it depends” implying this is done on an individual patient basis. Table 1 presents data with regards to why the BASMI is undertaken, scored by participant ranking, and free text responses about reasons for use.
| Table 1: Participant ranking score summation for “reason to use the BASMI” and free text “reasons for use of the BASMI” | ||
|---|---|---|
| Item | Overall Rank | Total Score * |
| For all newly diagnosed patients | 1 | 555 |
| To help us devise a bespoke exercise plan | 2 | 513 |
| To address poor movement or function | 3 | 498 |
| To address/encourage adherence with exercise/advice | 4 | 451 |
| It’s part of their on-going management | 5 | 391 |
| Delay to diagnosis affecting start of treatment and therefore movement restrictions apparent | 6 | 356 |
| Guidelines suggest yearly monitoring | 7 | 332 |
| As an outcome measure pre and post hydrotherapy | 8 | 295 |
| To address an increase in pain levels | 9 | 277 |
| For patient preference | 10 | 265 |
| Rheumatology team asked for it | 11 | 202 |
| For research purposes / as a part of a clinical trial | 12 | 155 |
| * Score is a weighted calculation. Items ranked first are valued higher than the following ranks, the score is a sum of all weighted rank counts. | ||
| Free text reasons for the use of the BASMI Helpful to patients to objectively understand their movement. Newly diagnosed-baseline score at initial assessment. Pre/post hydrotherapy. To encourage a home exercise programme. Most objective of PROMs for AxSpA. Provides an indication on posture and flexibility. Objective measure that we can compare over time. To monitor any subclinical restrictions creeping in over time. Started biologics – see if improving / new baseline. Pre commencing biologic. Provides the basis on which to base a specific exercise programme. Patient request. To support new patients in identifying issues. To assess the progression of the disease over time. Key objective measure of spinal movement. |
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Conclusions:
A large sample size for this survey implies a good level of interest to better understand the current application of the BASMI. It shows clinicians use the BASMI on newly diagnosed patients as a priority in their assessment and shared-decision making. Other aspects such as addressing poor movement and adherence to exercise are also ranked highly. The reported reasons for BASMI use are varied, and its application is not standardised across UK rheumatology teams. This might reflect the diverse trajectory of Axial SpA and the importance of seeing patients as individuals. How and why, we have undertaken physical outcome measures is crucial for consideration as we currently consider remote versus face-to-face consult pathways for our axSpA cohort as well as patient-initiated follow up’s. However, there is enough evidence here to recommend ongoing, regular application of the BASMI in a traditional face-to-face setting. Next steps will be to consider the patient perspective on this topic.
As a first venture out into the world of designing a survey for me this has been an invaluable experience with the support of the AStretch team. Being able to draw upon a wide variety of clinical backgrounds and experience helped to shape this project and we have a robust survey as a result. The use of Twitter and other networking platforms to disseminate the survey was invaluable and I’m proud to say the poster and abstracts were accepted and shown at both the BSR and BritSpA 2022 conferences.
Kate
NICE guideline [NG65]Published: 28 February 2017 Last updated: 02 June 2017: Spondyloarthritis in over 16s: diagnosis and management. Overview | Spondyloarthritis in over 16s: diagnosis and management | Guidance | NICE
Samantha Bunzli, Anne Smith, Robert Schutze. Making Sense of Low Back Pain and Pain-Related Fear. Journal of Orthopaedic & Sports physical therapy. September 2017, volume 47 no 9
Braun J, Kiltz U, baraliakos X, Van der Heijde D. Optimization of rheumatology assessments the actual situation in axial spondylarthritis including ankylosing spondylitis. Clinical and experimental rheumatology. 2014 Vol 32, No 5. Supp 85
Lucy Chilton-Mitchell, Jane Martindale, Anna Hart and Lynne Goodacre. Normative values for the Bath Ankylosing Spondylitis Metrology Index in a UK population. Rheumatology. 2013; 52. 2086-2090
Derakhshan MH, Pathak H, Cook D, Dickinson S, Siebert S, Gaffney K. Services for spondyloarthritis: a survey of patients and rheumatologists. Rheumatology (Oxford) 2018;57:987–96
Gregory, W, McCall G, Shaw K, Martindale J,. Audit and clinical evaluation of the North West Spondyloarthritis physiotherapy services. Rheumatology 2017: 6: Supplement 2; E03
Sieper J, Rudwaleit M, Baraliakos X, Brandt J, Braun J, Burgos-Vargas R, et al. The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis 2009;68 Suppl 2:ii1–44.
Van der Heijde D, Ramiro S, Landewé R, Baraliakos X, van den Bosch F, Sepriano A, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis 2017;76:978–9
Van Der Heijde et al 2008. Proposal of a linear definition of the Bath Ankylosing Spondylitis Metrology Index and comparison with the 2 step and 10 step definitions. Annals of rheumatology disease. 67: 489-493