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Residual disease in axial spondyloarthritis. Facts and issues
Wendling Daniel1, Goupille Philippe2, Verhoeven Frank1
1Rheumatology Department, CHU de Besançon, University of Franche-Comté, boulevard Fleming, 25030 Besançon cedex, France.
Abstract:
Residual disease in axial spondyloarthritis (axSpA) is defined by the persistence of signs, symptoms, or disease burden despite active treatment. Magnetic resonance imaging (MRI) inflammation may still be present in up to one-third of patients in clinical remission. Moreover, residual symptoms are frequently reported in patients with low disease activity (LDA), with 20-40% of patients experiencing pain or fatigue scores greater than 4 out of 10 on a visual analogue scale. Nociplastic pain (central sensitization) and neuropathic pain components are commonly associated with residual symptoms, as is female gender. Other contributing factors may include psycho-behavioral disorders, low physical activity, sarcopenia, sleep disturbances, and comorbidities. This residual disease is a key feature of difficult-to-manage (D2M) axSpA. A comprehensive assessment of the patient's context and a thorough evaluation of pain mechanisms are essential first steps in the management of these patients. Non-pharmacological strategies should be prioritized and reinforced in this setting, while certain targeted disease-modifying anti-rheumatic drugs (DMARDs) may have a specific effect on pain independently of their anti-inflammatory properties. There is a pressing need for new biomarkers that more specifically reflect the inflammatory process in spondyloarthritis, as therapeutic response is currently assessed primarily through patient-reported outcomes (PROs). Although no consensus definition exists to date, the recognition of residual disease and its associated factors is crucial in axSpA - particularly in a condition where objective signs of inflammation may be absent - to prevent overtreatment.
Insights
Residual disease in axial spondyloarthritis (axSpA) persists despite treatment, often involving pain and fatigue. Understanding contributing factors like central sensitization is key for managing difficult-to-treat axSpA effectively.
Area of Science:
- Rheumatology
- Immunology
- Pain Medicine
Background:
- Residual disease in axial spondyloarthritis (axSpA) is defined as persistent signs, symptoms, or disease burden despite active treatment.
- Magnetic resonance imaging (MRI) may show inflammation in up to one-third of patients in clinical remission.
- Residual symptoms like pain and fatigue are common in low disease activity (LDA) axSpA, affecting 20-40% of patients.
Purpose of the Study:
- To define residual disease in axSpA and identify associated factors.
- To highlight the importance of comprehensive patient assessment and pain mechanism evaluation.
- To emphasize the need for tailored management strategies for difficult-to-manage (D2M) axSpA.
Main Methods:
- Review of current literature and clinical definitions of residual disease in axSpA.
- Analysis of contributing factors including nociplastic pain, neuropathic pain, female gender, psycho-behavioral disorders, physical activity, sarcopenia, sleep disturbances, and comorbidities.
- Evaluation of current management strategies, including non-pharmacological approaches and disease-modifying anti-rheumatic drugs (DMARDs).
Main Results:
- Residual symptoms are frequently linked to nociplastic pain (central sensitization) and neuropathic pain components.
- Factors such as female gender, psycho-behavioral disorders, low physical activity, sarcopenia, sleep disturbances, and comorbidities contribute to residual disease.
- Certain DMARDs may impact pain independently of anti-inflammatory effects.
Conclusions:
- Recognizing residual disease and its multifaceted contributors is crucial for managing axSpA, especially when objective inflammation is absent.
- Comprehensive patient assessment and understanding pain mechanisms are essential for effective management.
- There is a need for novel biomarkers to better assess inflammatory processes and therapeutic response in axSpA.
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