Sleep in ankylosing spondylitis and non-radiographic axial spondyloarthritis: associations with disease activity, gender and mood


The study aims were to assess the prevalence of good or poor sleep in a cohort of axial spondyloarthritis patients and to investigate its correlation with a range of objectively and subjectively measured variables in order to develop a model for distinguishing good from poor sleepers. Five hundred ninety-eight patients with ankylosing spondylitis and 61 with non-radiographic axial spondyloarthritis completed the Jenkins Sleep Evaluation Questionnaire. Measures of disease activity, mobility, function, mood, fatigue, quality of life, work productivity, night-time pain and general health were gathered. Patients with ankylosing spondylitis or non-radiographic axial spondyloarthritis were initially compared. With the exception of waking up tired less often and having lower mobility and functioning, the two groups were similar so were combined for subsequent analysis. Twenty-nine percent of all patients were classified as good sleepers and 19% as poor sleepers. Poor sleepers had higher disease activity and fatigue scores and more night-time back pain than good sleepers. They reported poorer quality of life, general health, mood and work-related measures. A model incorporating mood, gender, fatigue and objective and subjective judgements of disease activity correctly classified 87.3% of good and poor sleepers. Poor sleep was strongly associated with poor mood, female gender, greater fatigue, greater disease activity (specifically, spinal pain and stiffness) and better mobility; however, the direction of causality between poor sleep and markers of active disease was undetermined. This study also highlights the need to standardise the measurement of sleep disturbance in axSpA to facilitate comparisons between patient groups and interventions.

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  1. 1.

    Heiberg T, Lie E, van Der Heijde D, Kvien TK (2011) Sleep problems are of higher priority for improvement for patients with ankylosing spondylitis than for patients with other inflammatory arthropathies. Ann Rheum Dis 70(5):872–873.

    Article  PubMed  Google Scholar 

  2. 2.

    Ward MM (1999) Health-related quality of life in ankylosing spondylitis: a survey of 175 patients. Arthritis Care Res 12(4):247–255.<247::AID-ART3>3.0.CO;2-H

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Rudwaleit M, Gooch K, Michel B, Herold M, Thörner A, Wong R et al (2011) Adalimumab improves sleep and sleep quality in patients with active ankylosing spondylitis. J Rheumatol 38(1):79–86.

    Article  PubMed  Google Scholar 

  4. 4.

    Hultgren S, Broman J, Gudbjörnsson B, Hetta J, Lindqvist U (2000) Sleep disturbances in outpatients with ankylosing spondylitis a questionnaire study with gender implications. Scand J Rheumatol 29(6):365–369

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Aydin E, Bayraktar K, Turan Y, Kurt Omurlu I, Tastaban E, Sendur O (2015) Sleep quality in patients with ankylosing spondylitis. Rev Bras Reumatol 55(4):340–345.

    Article  PubMed  Google Scholar 

  6. 6.

    Batmaz I, Sariyildiz M, Dilek B, Bez Y, Karakoc M, Cevik R (2013) Sleep quality and associated factors in ankylosing spondylitis: relationship with disease parameters, psychological status and quality of life. Rheumatol Int 33(4):1039–1045.

    Article  PubMed  Google Scholar 

  7. 7.

    Dougados M, Tsai WC, Saaibi DL, Bonin R, Bukowski J, Pederson R et al (2015) Evaluation of health outcomes with Etanercept treatment in patients with early nonradiographic axial spondyloarthritis. J Rheumatol 42(10):1835–1841.

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Bedaiwi M, Sari I, Thavaneswaran A, Ayearst R, Haroon N, Inman RD (2015) Fatigue in ankylosing spondylitis and nonradiographic axial spondyloarthritis: analysis from a longitudinal observation cohort. J Rheumatol 42(12):2354–2360.

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Jiang Y, Yang M, Wu H, Song H, Zhan F, Liu S, Gao G, Liu Z, Hu Z, He P, Zhang S, Hu Z, Lin Z, Zhang Y, Li Y, Shen L, Huang A, Liao Z, Cao S, Wei Y, Li L, Li Q, Lv Q, Qi J, Huang J, Li T, Jin O, Pan Y, Gu J (2015) The relationship between disease activity measured by the BASDAI and psychological status, stressful life events, and sleep quality in ankylosing spondylitis. Clin Rheumatol 34(3):503–510.

    Article  PubMed  Google Scholar 

  10. 10.

    Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ (1989) The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res 28(2):193–213.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Spitzer KL, Hays RD. MOS sleep scale: a manual for use and scoring, version 1.0. Los Angeles, CA, RAND, 2003

  12. 12.

    Jenkins CD, Stanton BA, Niemcryk SJ, Rose RM (1988) A scale for the estimation of sleep problems in clinical research. J Clin Epidemiol 41(4):313–321.

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Hetta J, Almqvist M, Ågren H, Hambert G, Liljenberg B, Roos B-E (1985) Prevalence of sleep disturbances and related symptoms in a middle-aged Swedish population. In: Koella WP, Ruther E, Schulz H (eds) Sleep '84. Gustav Fischer Verlag, Stuttgart, pp 373–376

    Google Scholar 

  14. 14.

    Abdulaziez O, Asaad T (2012) Sleep problems in ankylosing spondylitis: polysomnographic pattern and disease related variables. Egyptian Rheumatologist 34(2):59–65.

    Article  Google Scholar 

  15. 15.

    Ananthakrishnan AN, Long MD, Martin CF, Sandler RS, Kappelman MD (2013) Sleep disturbance and risk of active disease in patients with Crohn's disease and ulcerative colitis. Clin Gastroenterol Hepatol 1:965–971

    Article  Google Scholar 

  16. 16.

    Kinnucan JA, Rubin DT, Ali T (2013) Sleep and inflammatory bowel disease: exploring the relationship between sleep disturbances and inflammation. Gastroenterol Hepatol (NY) 9:718–727

    Google Scholar 

  17. 17.

    Li Y, Zhang S, Zhu J, Du X, Huang F (2012) Sleep disturbances are associated with increased pain, disease activity, depression, and anxiety in ankylosing spondylitis: a case control study. Arthritis Res Ther 14(5):R215.

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Ohayon MM, Carskadon MA, Guilleminault C, Vitiello MV (2004) Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan. Sleep 27(7):1255–1273.

    Article  PubMed  Google Scholar 

  19. 19.

    Van Dongen HPA, Vitellaro KM, Dinges DF (2005) Individual differences in adult human sleep and wakefulness: leitmotif for a research agenda. Sleep 28(4):479–496.

    Article  PubMed  Google Scholar 

  20. 20.

    Altan L, Bingöl U, Aslan M, Yurtkuran M (2006) The effect of balneotherapy on patients with ankylosing spondylitis. Scand J Rheumatol 35(4):283–289.

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Deodhar A, Braun J, Inman R, Mack M, Parasuraman S, Buchanan J et al (2010) Golimumab reduces sleep disturbance in patients with active ankylosing spondylitis: results from a randomized, placebo-controlled trial. Arthritis Care Res 62(9):1266–1271.

    Article  Google Scholar 

  22. 22.

    Bao C, Huang F, Khan M, Fei K, Wu Z, Zhuang Y et al (2014) Safety and efficacy of golimumab in Chinese patients with active ankylosing spondylitis: 1-year results of a multicentre, randomized, double-blind, placebo-controlled phase III trial. Rheumatology 53(9):1654–1663.

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Sieper J, Kivitz A, Van Tubergen A, Deodhar A, Coteur G, Woltring F et al (2015) Impact of certolizumab pegol on patient-reported outcomes in patients with axial spondyloarthritis. Arthritis Care Res 67(10):1475–1480.

    CAS  Article  Google Scholar 

  24. 24.

    Garrett S, Jenkinson T, Kennedy LG, Whitelock H, Gaisford P, Calin A (1994) A new approach to defining disease status in ankylosing spondylitis: the Bath Ankylosing Spondylitis Disease Activity Index. J Rheumatol 21(12):2286–2291

    CAS  PubMed  Google Scholar 

  25. 25.

    Calin A, Garrett S, Whitelock H, Kennedy LG, O’Hea J, Mallone P et al (1994) A new approach to defining functional ability in ankylosing spondylitis: the development of the Bath Ankylosing Spondylitis Functional Index. J Rheumatol 21(12):2281–2285

    CAS  PubMed  Google Scholar 

  26. 26.

    Jenkinson TR, Mallorie PA, Whitelock HC, Kennedy LG, Garrett SL, Calin A (1994) Defining spinal mobility in ankylosing spondylitis (AS). The Bath AS Metrology Index. J Rheumatol 21(9):1694–1698

    CAS  PubMed  Google Scholar 

  27. 27.

    Webster K, Cella D, Yost K (2003) The Functional Assessment of Chronic Illness Therapy (FACIT) measurement system: properties, applications, and interpretation. Health Qual Life Outcomes 16:1–79

    Google Scholar 

  28. 28.

    Reynolds S, Doward LC, Spoorenberg A, Helliwell PS, McKenna SP, Tennant L, et al. The development of the ankylosing spondylitis quality of life questionnaire (ASQoL). Qual Life Res 1999;8:651

  29. 29.

    The EuroQol Group (1990) EuroQol - a new facility for the measurement of health-related quality of life. Health Policy 16:199–208

    Article  Google Scholar 

  30. 30.

    Reilly MC, Zbrozek AS, Dukes EM (1993) The validity and reproducibility of a work productivity and activity impairment instrument. PharmacoEconomics 4(5):353–365.

    CAS  Article  PubMed  Google Scholar 

  31. 31.

    Cohen J (1988) Statistical power analysis for the behavioural sciences, 2nd edn. Lawrence Erlbaum Associates, Hillsdale. NJ

    Google Scholar 

  32. 32.

    Wolf-Meyer M (2016) Can we ever know the sleep of our ancestors? Sleep Health 2(1):4–5.

    Article  PubMed  Google Scholar 

  33. 33.

    Wadeley A. Cognitive correlates of sleepiness and fatigue in sleep-disrupted mothers of children aged under five years. In: British Psychological Society Annual Conference, 7–9 2014, International Convention Centre, Birmingham, UK

  34. 34.

    Halperin D (2014) Environmental noise and sleep disturbances: a threat to health? Sleep Sci 7(4):209–212.

    Article  PubMed  PubMed Central  Google Scholar 

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Author information




AW is the main author of this paper and is responsible for data analysis. EC and SL reviewed and edited the manuscript. RS provided access to the data and reviewed and edited the manuscript.

Corresponding author

Correspondence to Alison Wadeley.

Ethics declarations

Bristol UK local research ethics committee (LREC) for National Health Service research approved the study, and all patients provided informed, written consent (the Bath Spondyloarthritis (SpA) Biobank; REC reference: 13/SW/0096).

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Wadeley, A., Clarke, E., Leverment, S. et al. Sleep in ankylosing spondylitis and non-radiographic axial spondyloarthritis: associations with disease activity, gender and mood. Clin Rheumatol 37, 1045–1052 (2018).

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  • Ankylosing spondylitis
  • Fatigue
  • Gender
  • Quality of life
  • Sleep