Available online http://arthritis-research.

com/content/11/6/R182

Research article Open Access

Vol 11 No 6

Psychological correlates of self-reported functional limitation in

patients with ankylosing spondylitis
Tamar F Brionez1*, Shervin Assassi1*, John D Reveille1, Thomas J Learch2, Laura Diekman1,
Michael M Ward3, John C Davis Jr4, Michael H Weisman2 and Perry Nicassio5

1Department of Medicine, Division of Rheumatology, University of Texas-Houston, 6431 Fannin, Houston, Texas 77030, USA
2Department of Medicine, Division of Rheumatology, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, California 90048, USA
3Department of Medicine, Division of Rheumatology, NIAMS-NIH, 1 AIMS Circle, Bethesda, Maryland 20892, USA
4Department of Medicine, Division of Rheumatology, University of California-San Francisco, 505 Parnassus Avenue, San Francisco, California 94122,

USA
5Department of Psychiatry, University of California-Los Angeles, 300 Medical Plaza, Los Angeles, California 90095, USA

* Contributed equally

Corresponding author: Shervin Assassi, [email protected]

Received: 5 Aug 2009 Revisions requested: 21 Sep 2009 Revisions received: 29 Oct 2009 Accepted: 7 Dec 2009 Published: 7 Dec 2009

Arthritis Research & Therapy 2009, 11:R182 (doi:10.1186/ar2874)

This article is online at: http://arthritis-research.com/content/11/6/R182
© 2009 Brionez et al.; licensee BioMed Central Ltd.
This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Introduction Functional status is an integral component of Results In the multivariate regression analysis, the
health-related quality of life in patients with ankylosing psychological variables contributed significantly to the variance
spondylitis (AS). The purpose of this study was to investigate in BASFI scores, adding an additional 24% to the overall R-
the role of psychological variables in self-reported functional square beyond that accounted by demographic and medical
limitation in patients with AS, while controlling for demographic variables (R-square 32%), resulting in a final R-square of 56%.
and medical variables. Specifically, arthritis helplessness, depression and passive
coping beside age, ESR and the Bath AS Radiograph Index
Methods 294 AS patients meeting modified New York Criteria accounted for a significant portion of the variance in BASFI
completed psychological measures evaluating depression, scores in the final model.
resilience, active and passive coping, internality and Conclusions Arthritis helplessness, depression, and passive
helplessness at the baseline visit. Demographic, clinical, and coping accounted for significant variability in self-reported
radiologic data were also collected. Univariate and multivariate functional limitation beyond demographic and clinical variables
analyses were completed to determine the strength of in patients with AS. Psychological health should be examined
correlation of psychological variables with functional limitation, and accounted for when assessing functional status in the AS
as measured by the Bath AS Functional Index (BASFI). patients.

Introduction body of research examining the major determinants of func-

With the improvement in prognosis due to advances in treat- tional limitations in the AS population.
ment, there is greater focus now on the patient's perspective
on disease activity and quality of life [1-3]. Functional status is Markers of disease activity (erythrocyte sedimentation rate
an integral component of health-related quality of life, and is (ESR), C-reactive protein, radiograph severity, disease dura-
important to patients with ankylosing spondylitis (AS) [4]. Poor tion) and socio-demographic variables do not fully account for
functional status is correlated with work disability and the variability in patients' functional limitations, suggesting that
increased medical costs in AS [4-8], lending to the increasing additional factors, such as psychosocial variables, might play
an important role [9]. Radiographic severity, higher disease

AHI: Arthritis Helplessness Index; AS: ankylosing spondylitis; BASDAI: Bath AS Disease Activity Index; BASFI: Bath AS Functional Index; BASRI:
Bath AS Radiographic Index; BRSC: Brief Resilient Coping Scale; ESR: erythrocyte sedimentation rate; NSAID: non-steroidal anti-inflammatory drug;
PHQ-9: Patient Health Questionnaire-9; PSOAS: Prospective Study of Outcomes in Ankylosing Spondylitis; RA: rheumatoid arthritis; VAS: visual
analogue scale; VPMI: Vanderbilt Pain Management Inventory.

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activity scores, smoking [10], advanced age, lower education Study design
level, longer disease duration, presence of co-morbid medical Baseline assessments completed at each academic study site
conditions, and female gender are all associated with greater included medical history, socio-demographic information, psy-
limitation; however, few studies have investigated the contri- chological status, as well as radiographs of the pelvis, lumbar
bution of psychological factors to functional impairment in AS, spine, and cervical spine. The majority of radiographs (58%)
and none have weighed the relative impact of psychological were completed at the time of the cross-sectional survey at the
variables compared with these other factors [11-14]. enrollment; the time between enrollment and radiographic
examination was generally short (mean: 63 days).
Two prior studies, examining the role of psychological factors
in AS functional limitation, found functional disability, meas- Primary outcome
ured by the Bath AS Functional Index (BASFI), to be associ- The primary outcome used was the BASFI, with a score range
ated with higher depression scores and lower internality of 0 mm to 100 mm. The BASFI is a self-report 10-item ques-
scores in a UK AS population, and depression to be highly cor- tionnaire developed by a team of medical professionals and
related with work disability and unemployment in an Argen- patients. The first eight questions cover function in AS, while
tinean AS population [15,16]. However, these studies the final two explore the patient's ability to cope with the hap-
examined only a limited number of potential variables and did penings of everyday life. Each question is answered on a 100
not use multivariate analyses to account for the confounding mm visual analogue scale (VAS), from none (0 mm) to very
effect of multiple baseline variables when they are examined severe (100 mm), and the average determines the final BASFI
simultaneously. score (0 to 100). Lower scores indicate a better functional sta-
tus [21].
As emotional problems are present in approximately one-third
of patients with inflammatory rheumatic conditions, ranging Independent variables
from 20% to 31% of patients with AS, and the correlation of Our database includes variables from the following domains:
functional limitation and depression is well documented in socioeconomic-demographic, immunologic, genetic, psycho-
chronic arthritides such as rheumatoid arthritis (RA), it is logical, and clinical. We only describe the variables included in
important to investigate the contribution of psychological fac- the final analyses below.
tors to functional limitation in patients with AS [13,17-19].
Socio-demographic information included age (at cross-sec-
The purpose of this study is to investigate the correlation of tional study baseline), education level (≤ 12 years, 13 to 15
psychological variables, independent of important demo- years, 16 years, and > 16 years), ethnicity (white vs. other),
graphic and biologic factors, on functional limitation, as meas- current employment and student status as binary variables.
ured by the BASFI, in a large AS cohort.
Medical variables consisted of an inflammatory marker (ESR),
Materials and methods current tobacco use, number of co-morbid medical conditions
Patients (0 to 4 or greater), current non-steroidal anti-inflammatory drug
Study participants were enrolled in the Prospective Study of (NSAID) use and biologic therapy (yes vs. no), disease dura-
Outcomes in Ankylosing Spondylitis (PSOAS), a longitudinal tion (at time of cross-sectional survey), and radiographic
study of AS patients recruited from four US study sites: score. We also investigated the relation between exercise
Cedars-Sinai Medical Center, Los Angeles, CA; the National habits and BASFI. For this purpose, the frequency of general
Institutes of Health, Bethesda, MD; the University of Texas exercise per week, performance of back stretching or
Health Science Center at Houston, Houston, TX; and the Uni- strengthening exercises (yes vs. no) and physical therapy for
versity of California, San Francisco, CA. Recruitment occurred treatment of AS in the past four months (yes vs. no) were
via three avenues: academic rheumatology clinics at the above investigated as independent variables. Each participant also
US study sites, internet advertisements, and patients enrolled had baseline radiographs of the pelvis (anterior-posterior),
in prior clinical studies at the above sites were invited to par- lumbar spine (anterior-posterior and lateral) and cervical spine
ticipate. All patients met the Modified New York Criteria for AS (lateral), which were scored using the Bath AS Radiographic
[15,20]. All the 294 enrolled patients in the longitudinal Index Global (BASRI-global) by a single musculoskeletal radi-
PSOAS study were included in the current study. This study ologist (TJL) at study entry. The BASRI-global is a validated
was conducted in compliance with the Helsinki Declaration to method to score radiographic severity in patients with AS,
protect human subjects and was approved by the Institutional including both hip and spine scores, with a score range of 1.5
Review Boards of the participating sites. All participating to 16 [22].
patients gave written informed consent according to the Insti-
tutional Review Boards specifications. We have observed in a previous study that the self-reported
disease activity in AS, as measured by the Bath AS Disease
Activity Index (BASDAI) [23], highly correlates with the psy-

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chometric variables (manuscript in review). Therefore, we did functional limitation independently of demographic and medi-
not include BASDAI as one of the independent variables in our cal variables. Subsequently, a final model was established
analysis and relied more on objective surrogates of disease using a forward hierarchical variable selection strategy. This
activity such as ESR because the inclusion of perceived dis- approach was chosen to decrease the effect of multicolinear-
ease activity might have masked the relation between the psy- ity in our analysis. Initially we entered all variables into the
chometric factors and the self-reported disease disability. model. Then, the number of independent variables was
reduced to those that changed the R square of the entire
Six psychological variables were measured: active and pas- model by 2% or more. Those variables were entered into the
sive coping, depression, resilience coping, helplessness and final model (Table 4).
internality. The Vanderbilt Pain Management Inventory (VPMI)
is an 18-item self-report questionnaire that assesses the fre- Results
quency of utilization of coping strategies in patients with Sample characteristics
chronic pain when their pain is at a moderate level of intensity A total of 294 patients were included in the study. Table 1
or greater. The VPMI has two validated subscales: active cop- shows patient demographics, medical, and psychological test-
ing and passive coping [24]. The Patient Health Questionnaire ing scores. The mean (standard deviation) age of the sample
(PHQ-9) is a brief, valid, nine-item self-report instrument that was 45.1 (± 14.40) years, 68% of the cohort was male, and
has primarily been designed for detecting depressive disor- 82% of the sample was white. The mean disease duration at
ders in primary care settings. An advantage of the PHQ-9 is study baseline was 21.23 (± 13.85) years, and less than half
that its items are based on the actual criteria upon which the of the sample was taking NSAIDs (47%) and/or biologic
diagnosis of Diagnostic and Statistical Manual of Mental Dis- agents (45%). The majority of patients (64%) were performing
orders-IV depressive diagnosis is made [25-27] and do not back exercise while only a small portion of patients (9%) was
overlap with medical symptoms as extensively as many other undergoing physical therapy for treatment of AS. Participants
depression measures. Score can range from 0 to 27, as each reported a high level of resilient coping (mean score 16.09 ±
of the nine items can be scored from 0 (not at all) to 3 (nearly 3.33) and relatively low depression scores (mean score 5.14
every day). The Brief Resilient Coping Scale (BRCS) is a four- ± 5.01). The mean score for arthritis internality was 25.66 (±
item self-report measure that measures patients' ability to feel 5.94), for helplessness was 12.42 (± 4.41), for active coping
challenged by, and cope adaptively, with adversity. BRCS was 22.74 (± 5.52), and for passive coping was 25.59 (±
scores can range from 0 to 20, with higher scores indicating 7.45). The latter scores are all within one standard deviation of
higher resilience [28]. The Arthritis Helplessness Index (AHI) mean scores obtained from samples of patients with RA
is a 15-item self-report questionnaire designed to measure [24,30] on these measures.
patient's perceptions of loss of control in association with their
chronic arthritis [29]. We used the two subscales, internality Univariate analyses
(seven items) and helplessness (five items), which reflect sep- The univariate regression analysis found the following varia-
arate constructs and have been found to have greater reliabil- bles to be significantly associated with higher BASFI scores
ity and validity than the total AHI score [30]. Arthritis internality (more functional limitation): older age, tobacco use, number of
assesses patients' beliefs that their own behavior can control medical co-morbidities, higher ESR, disease duration at base-
their arthritis, while arthritis helplessness assesses patients' line visit, higher BASRI scores (more radiographic disease
perceptions of helplessness in coping with their chronic damage), high passive coping, high helplessness, and high
arthritic condition. The two subscales are inversely related to depression scores. Low education level, unemployment, low
each other, but reflect largely independent beliefs about the resilience coping and low internality also significantly corre-
controllability of arthritis [30]. lated with higher BASFI scores while performance of back
strengthening or stretching exercise was associated with
Statistical analysis lower BASFI scores The other variables examined, including
We conducted the data analysis in four steps. First, descrip- gender, ethnicity, marital and student status, current use of
tive statistics were computed on our study cohort (Table 1). biologic therapy and NSAIDs, frequency of exercise, treatment
Second, we completed univariate linear regression analyses to by physical therapy and active coping did not significantly cor-
evaluate which variables were associated with the BASFI relate with BASFI scores (Table 2).
(Table 2). Then, we examined the association of demographic,
medical, and psychological factors with the BASFI using hier- Hierarchical modeling with successive conceptual
archal regression modeling (Table 3). In order to analyze the blocks
contribution of these groups of variables to BASFI, we entered In order to evaluate the factors contributing variance to BASFI
the variables in successive conceptual blocks: (1) demo- scores, the independent variables were added into the analy-
graphic variables, (2) medical variables, (3) psychological sis in the following successive conceptual blocks: socio-
measures. This order of entry tested the proposition that psy- demographic variables; medical variables; and psychological
chological factors would contribute unique variance to AS variables. First, the demographic variables were entered. The

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Table 1

Sample characteristics

Demographic variables:

Mean age, SD, years 45.1 (14.40)

Education level
≤12 years, n, % 34 (11.6%)
13-15 years, n, % 81 (27.6%)
16 years, n, % 77 (26.2%)
> 16 years, n, % 102 (34.7%)
Gender, n, male, % 197 (68.2)
Ethnicity, n, white, % 241 (82.0)
Number employed, % 192 (65.5)
Number student, % 26 (8.9)
Married, n, yes, % 153 (55.8)

Medical variables:

Current tobacco use, n, % 32 (11.0)

Mean number of medical co-morbidities (0-4), SD 2.0 (1.34)
Current NSAID use, n, % 136 (46.6)
Current biologic therapy, n, % 132 (45.2)
Mean erythrocyte sedimentation rate mm/hr, SD 14.9 (16.0)
Mean disease duration, SD, years 21.2 (13.85)
Mean Bath AS Radiographic Index (BASRI) score (1.5-16), SD 6.5 (4.27)
Mean frequency of exercise/week, SD 3.12 (2.34)
Performance of back stretching or strengthening exercises, n, % 188 (63.9)
Physical therapy in the past 4 months, n, % 25 (8.5)

Psychological variables:

Mean resilience coping (BRCS) score (0-20), SD 16.1 (3.33)

Mean arthritis internality score (6-36), SD 25.7 (5.94)
Mean arthritis helplessness score (5-25), SD 12.4 (4.41)
Mean sepression (PHQ-9) score (0-27), SD 5.1 (5.01)
Mean active coping score (7-35), SD 22.7 (5.22)
Mean passive coping score (11-55), SD 25.6 (7.45)

n = 294. PHQ = Patient Health Questionnaire; SD = standard deviation.

contribution of these variables accounted for an overall R- exercise, performance of back exercises and treatment by
square of 0.21 (P < 0.001. Advanced age (P < 0.001), unem- physical therapy resulted in an R-square of 0.32 (P < 0.001).
ployment (P < 0.001), and low education level (P = 0.001) However ESR (P = 0.001), NSAID use (P = 0.021), frequency
contributed independent variability to BASFI scores. The addi- of exercise (P = 0.036) and treatment by physical therapy (P
tion of the medical variables, including current tobacco use, = 0.024) were significantly related to BASFI scores after cor-
current NSAID and/or biologic therapy, BASRI scores, medi- rection for other demographic and clinical factors. The other
cal co-morbidities, ESR, and disease duration, frequency of variables, including current tobacco use, biologic therapy, dis-

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Table 2

Univariate analyses of demographic, medical and psychological variables in relationship to BASFI

Independent variable Mean difference in BASFI 95% confidence interval P value

Age (at baseline visit) 0.48 0.28-0.68 < 0.001

Education -3.07 -5.36--0.78 0.009
Gender (male) -3.18 -9.48-3.12 0.322
Ethnicity (white) -1.17 -8.73-6.39 0.761
Employment (yes) -16.41 -22.27--10.54 < 0.001
Student (yes) 0.75 -9.49-10.99 0.885
Married (yes) 3.31 -2.76-9.38 0.284
Current tobacco use (yes) 9.64 0.48-18.81 0.039
Number of medical co-morbidities 3.48 1.32-5.64 0.002
NSAIDs (yes) 2.37 -3.49-8.23 0.427
Biologics (yes) -2.46 -8.33-3.40 0.409
Erythrocyte sedimentation rate 0.41 0.23-0.59 < 0.001
Disease duration 0.37 0.15-0.58 < 0.001
BASRI 1.74 0.97-2.50 < 0.001
Frequency of exercise/week -0.19 -1.44-1.06 0.766
Back exercise (yes) -7 -13.11--0.893 0.025
Physical therapy (yes) 8.75 -1.63-19.13 0.098
Resilience coping (BRCS) -1.42 -2.30--0.55 0.002
Arthritis internality -1.34 -1.81--0.87 < 0.001
Arthritis helplessness 2.76 2.18-3.34 < 0.001
Depression (PHQ-9) 2.40 1.90-2.91 < 0.001
Active coping -0.49 -1.04-0.07 0.086
Passive coping 1.39 1.04-1.75 < 0.001

BASFI = Bath Ankylosing Spondylitis Functional Index; BASRI = Bath Ankylosing Spondylitis Radiographic Index; BRCS = Brief Resilient Coping
Scale; PHQ = Patient Health Questionnaire.

ease duration, number of medical co-morbidities, performance Final model

of back exercises and radiographic damage scores did not The hierarchical forward model found that higher helplessness
reach statistical significance in the hierarchal model. Finally, (P < 0.001), depression (PHQ-9; P < 0.001), passive coping
the entry of arthritis internality, helplessness, resilient coping, (P = 0.003), ESR (P < 0.001), radiographic severity scores
depression, active coping, and passive coping resulted in an (BASRI) (P < 0.001), and older age at baseline visit (P =
R-square of 0.56 (P < 0.001). Higher depression (P = 0.013), 0.002) were significantly associated with higher BASFI scores
helplessness (P = 0.004), passive coping (P = 0.006), and (Table 4). These variables explained 49% of variance in BASFI
lower internality (P = 0.048) had significant, independent scores. More specifically, each numerical increase (range of
associations with BASFI scores, while the contribution of scores 0 to 27, with higher numbers equaling more depres-
active coping (P = 0.703), and resilience coping (P = 0.507) sion) in depression resulted in an increase of 1.20 in the
were not significant. As an aggregate, the psychological varia- BASFI score (scale score 0 to 100 mm), and each numerical
bles contributed significantly to the overall variance, adding an increase in the arthritis helplessness score (range of scores 5
additional 24% variance above that accounted for by demo- to 25, with higher scores indicating more helpless behavior),
graphic and medical variables (Table 3). resulted in an increase of 1.31 in the BASFI score. Although
age, radiographic severity scores, and ESR were significant in
the final model, the remaining demographic and medical fac-
tors, including number of medical co-morbidities, use of

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Table 3

Hierarchical multivariate analysis of demographic, medical and psychological variables in relation to BASFI

Step Independent variable Mean difference R-square (%)* P value+

1 Demographic variables 21.0 * < 0.001+

Age 0.54 < 0.001

Employment -13.58 < 0.001
Gender -4.68 0.122
Marital 2.15 0.491
Education -3.80 0.001
Student 2.75 0.669
Ethnicity -4.38 0.259

2 Medical variables 32.0* < 0.001+

Current tobacco use 9.12 0.099

NSAID therapy 6.56 0.021
BASRI (range 1.5 -- 16) 0.75 0.134
Biologic therapy 4.96 0.052
Number of medical co-morbidities 2.08 0.19
Erythrocyte sedimentation rate 0.36 0.001
Disease duration 0.00 0.86
Days of general exercise per week -1.5 0.036
Back exercise -6.35 0.08
Physical therapy 12.65 0.024

3 Psychological variables 56.3* < 0.001+

Arthritis internality (6-36) -0.54 0.048

Arthritis helplessness (5-25) 1.14 0.004
Resilience coping (BRCS) (0-20) 0.32 0.507
Depression (PHQ-9) (0-27) 0.90 0.013
Active coping (7-35) -0.12 0.703
Passive coping (11-55) 0.68 0.006

*Overall R-square (%) after the addition of each conceptual block. +Overall P value after the addition of each block. BASFI = Bath Ankylosing
Spondylitis Functional Index; BASRI = Bath Ankylosing Spondylitis Radiographic Index; BRCS = Brief Resilient Coping Scale; PHQ = Patient
Health Questionnaire.

NSAID and biologic therapy, exercise habits and disease dura- (BASRI), and older age correlated significantly with more func-
tion, failed to explain a significant portion of the variance of tional limitations in our cohort.
BASFI scores in the final model. Inspection of the variance
inflation factor did not suggest multicollinearity among predic- Although prior studies have demonstrated an association
tors in the final model. between systemic inflammation, radiographic severity, older
age and functional limitation, this is the first study to investi-
Discussion gate the role of psychological factors beyond the demo-
Six variables, higher arthritis helplessness, depression, pas- graphic and clinical factors in a multivariate model. The results
sive coping scores, ESR and radiographic disease scores demonstrated a strong correlation of psychological variables
to AS functional limitations. Specifically, higher arthritis help-

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Table 4

Final model of correlates of the BASFI

Independent variable Mean difference 95% confidence interval R2 (%) P value

Overall model 48.8 < 0.001

Age (at baseline visit, V0) 0.31 0.11-0.51 0.002
Depression (PHQ) (higher score = more depression, range 0-27) 1.20 0.58-1.82 < 0.001
Arthritis helplessness (higher score = more helpless behavior, range 5-25) 1.31 0.62-2.01 < 0.001
Passive coping (higher score = more passive coping, range 11-55) 0.69 0.24-1.13 0.003
BASRI (range 1.5-16) 1.28 0.61-1.95 < 0.001
Erythrocyte sedimentation rate 0.33 0.17-0.48 < 0.001

BASFI = Bath Ankylosing Spondylitis Functional Index; BASRI = Bath Ankylosing Spondylitis Radiographic Index; PHQ = Patient Health
Questionnaire.

lessness, depression and passive coping correlated signifi- mood disturbance which, in turn, could affect disability. Fur-
cantly with more functional limitation in the final model, ther research exploring mediational pathways underlying AS
mirroring findings in other chronic arthritic conditions disability would clarify such propositions.
[19,24,29,31-34]. Our findings are also consistent with a pre-
vious report linking helplessness to worse health-related qual- The independent relation between depression and functional
ity of life in AS [35]. In contrast to passive-coping, active limitations in AS is consistent with other literature in rheumatic
coping did not significantly correlate with loss of functional conditions showing that mood disturbance is a covariate of
abilities, a finding which has also been reported in other both disease activity and disability, particularly in RA [41,42].
arthritic conditions, such as RA [36,37]. Passive coping may Due to the cross-sectional design of the current study, it is not
be a more robust contributor to functional limitation due, in possible to discern whether depression is a cause of disability
part, to its association with depression and poor psychological in AS, a result of the impact of the disease, or a product of an
functioning, a result found in both rheumatic diseases and in underlying inflammatory process. Future research in AS could
traumatic injuries such as whiplash [38]. Coping researchers address these important questions and shed light on the issue
have theorized that successful coping is not solely the result of managing depression in affected patients.
of using adaptive coping strategies, but also the absence of
the frequent or continuous use of maladaptive strategies Both age and disease duration have been found to influence
[39,40]. In AS, while passive coping may be a common functional limitation in AS. However, as these variables tend to
response during acute disease flares, the more that patients be collinear, it is difficult to distinguish their individual effects.
rely on passive pain coping on a daily basis, the more difficulty Although age was significantly correlated with functional limi-
they may encounter in sustaining functioning and quality of life. tations in this study, disease duration was not, indicating that
age had an influence on functional limitation, apart from its
Interestingly, when psychological factors were included in the association with duration of disease. It could also be pre-
analysis, variables previously found to be significantly associ- sumed that the number of co-morbid medical conditions could
ated with functional limitation, including current tobacco use, influence the association of age with functional limitation.
education level, gender, and number of co-morbid medical However, in this analysis, age was significantly correlated with
conditions, performance of back exercises failed to show sig- functional limitation, while co-morbid medical conditions did
nificance. These findings indicate that psychological factors not achieve significance. The importance of age, independent
accounted for some of the variability in functioning that was of its association with disease duration or potential contribu-
originally contributed by these socio-demographic and medi- tion of co-morbid medical conditions, has been noted previ-
cal variables. Our data also indicate that psychometric varia- ously [43].
bles should be evaluated and accounted for when assessing
functional limitations of AS patients in observational or inter- The primary limitation of the present study was the cross-sec-
ventional studies. It also is possible that psychological varia- tional study design, which provided only correlational findings,
bles could mediate the effect of important socio-demographic precluding an understanding of directional relations among
and medical factors on functional limitations in patients with model variables. For example, it cannot be determined from
AS. For example, smoking, which has been shown to have a our data whether higher helplessness, depression, and pas-
strong association with the progression of functional limitation, sive coping scores caused a heightened perception of func-
could be a surrogate of a psychological health behavior or tional limitation or vice versa. Another point to consider is the

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possibility that patients with higher depression scores over- Morgan and Mr. Robert Sandoval for their assistance with data collec-
report functional limitation (i.e. reporting bias). A longitudinal tion and management.
study, in which patients' psychological status and functional
limitation are monitored over time, is needed to determine References
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