1. INternational Spondyloarthritis Inter- observer Reliability Exercise – the INSPIRE study. Gladman DD, Inman RD, Cook R, Maksymowych W, van der Heijde D, Lendewé R, Braun J, Davis J, Mease P Brandt J, Burgos-Vargas R, Chandran V, Helliwell P, Kavanaugh A, Khan MA, O’Shea B, Pipitone N, Rahman P, Reveille JD, Stone M, Taylor W, Veale D, Supported by SPARCC, the Arthritis Society (Canada), Abbott Canada, Amgen/Wyeth Canada, Pfizer Canada, Schering Canada, Wyeth Global,

2. The INSPIRE Study u Several measures have been used in the assessment of ankylosing spondylitis (AS). u It has not yet been determined whether these measurements are reproducible. u It has not been determined whether these measures are applicable in psoriatic arthritis (PsA) with axial involvement. Background

3. The INSPIRE study To determine whether the axial measures used in primary AS were reproducible for both AS and PsA with axial disease Objective

4. The INSPIRE Study u Assessors: 20 rheumatologists from 11 countries with expertise in spondyloarthritis (SpA) –10 experts in AS; 10 experts in PsA u Patients: –10 patients with PsA with axial involvement –9 AS patients u Design: A Latin Square design that enabled assessment of patient, assessor and order effect was used. u Measures: occiput to wall, tragus to wall, cervical rotation, chest expansion, lateral spinal bending, modified Schober, and hip mobility. u Analysis: Intra Class Correlations (ICC) adjusted for order of measurements. Methods

5. The INSPIRE Study Patient Characteristics GroupASPsA Females/Males7 / 29 / 1 Mean Age (yrs)3852 Disease Duration (yrs)1716

6. The INSPIRE Study MeasurementASPsA with axial disease Occiput to wall Tragus to wall Cervical rotation Chest expansion Xiphisternum 4 th intercostal Modified Schober Lateral spinal bending BASMI Domjan Modified Domjan Intermalleolar distance Internal Hip rotation 0.81 (0.64,0.94) 0.80 (0.63,0.94) 0.66 (0.43,0.88) 0.57 (0.33,0.84) 0.24 (0.07,0.59) 0.85 (0.70,0.95) 0.83 (0.67,0.95) 0.91 (0.82,0.98) 0.92 (0.83,0.98) 0.78 (0.60,0.93) 0.92 (0.82,0.98) 0.82 (0.66,0.94) 0.67 (0.46,0.88) 0.94 (0.87,0.98) 0.64 (0.42,0.87) 0.70 (0.50,0.89) 0.65 (0.43,0.87) 0.82 (0.66,0.94) 0.85 (0.71,0.95) 0.77 (0.58,0.92) 0.96 (0.91,0.99) 0.92 (0.83,0.97) Spinal Measurements ICC

7. The INSPIRE Study % total variance due to MeasurePatientAssessorOrder Occiput to wall Tragus to wall 81.8 (<0.001) 79.8 (<0.001) 8.0 (0.003) 3.7 (0.66) 0.1 (0.98) 1.9 (0.13) Cervical rotation68.1 (<0.001)14.3 (0.003)0.1 (0.98) Chest expansion Xiph* Chest expansion 4IC* 58.5 (<0.001) 29.3 (<0.001) 26.2 (<0.001) 40.1 (<0.001) 2.5 (0.06) 1.5 (0.56) Modified Schober84.9 (<0.001)5.3 (0.04)0.7 (0.38) LLB* – BASMI LLB – DOMJAN LLB – INSPIRE 83.3 (<0.001) 91.4 (<0.001) 91.5 (<0.001) 3.9 (0.43) 2.3 (0.24) 1.6 (0.56) 0.4 (0.73) 0.5 (0.30) 1.0 (0.07) Intermalleolar Internal Hip rotation 78.4 (<0.001) 91.5 (<0.001) 5.9 (0.19) 2.0 (0.34) 1.2 (0.31) 0.6 (0.24) Variation in Patients with AS *LLB=lateral lumbar bending; Xiph=xiphisternum; 4IC=4 th intercostal space

8. The INSPIRE Study % total variance due to MeasurePatientAssessorOrder Occiput to wall Tragus to wall 83.0 (<0.001) 68.0 (<0.001) 7.7 (0.001) 10.0 (0.04) 0.1 (0.97) 1.7 (0.24) Cervical rotation94.0 (<0.001)2.8 (0.001)0.3 (0.20) Chest expansion Xiph* Chest expansion 4IC* 66.2 (<0.001) 72.1 (<0.001) 17.3 (<0.001) 15.7 (<0.001) 2.2 (0.10) 0.2 (0.87) Modified Schober67.1 (<0.001)18.3 (<0.001)1.0 (0.36) LLB* – BASMI LLB – DOMJAN LLB – INSPIRE 82.0 (<0.001) 84.4 (<0.001) 75.8 (<0.001) 2.6 (0.82) 5.1 (0.01) 4.5 (0.46) 1.1 (0.27) 1.4 (0.04) 2.7 (0.04) Intermalleolar Internal Hip rotation 95.3 (<0.001) 91.3 (<0.001) 1.2 (0.04) 2.2 (0.15) 0.9 (<0.001) 0.8 (0.08) Variation in Patients with PsA *LLB=lateral lumbar bending; Xiph=xiphisternum; 4IC=4 th intercostal space

9. The INSPIRE Study u Substantial to Excellent reliability was noted for: –Occiput-to-wall, cervical rotation, lateral bending, hip mobility, modified Schober’s for both AS and PsA –Chest expansion at xiphisternum for PsA u The majority of the variation was due to patients u Assessor effect was noted for: –Occiput-to-wall, cervical rotation and chest expansion for both AS and PsA, and modified Schober’s for PsA u Order effect was noted only for intermalleolar distance in PsA. Summary

10. The INSPIRE Study u Measures of spinal mobility are reliable for AS. u Measures of spinal mobility that have been applied to primary AS perform well with respect to inter-observer reliability when applied to PsA patients with axial involvement. u These measures now need to be used in clinical trials and longitudinal cohort studies in PsA to confirm sensitivity to change. Conclusions