A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfilment of the requirements for the degree of Master of Medicine in the branch of Psychiatry Johannesburg, 2012 / Background: Rheumatoid Arthritis (RA) is a chronic auto-immune musculoskeletal disorder of unknown aetiology that can result in physical disability, chronic pain and impaired quality of life. RA is associated with an increased prevalence of depression. The presence of depression in RA is reported to be associated with pain, functional disability, high disease activity and mortality. This study aims to determine the prevalence of depressive symptoms in a cohort of Black South African patients attending a Rheumatology outpatient clinic at a public health center. It also aims to determine the association and correlation between the presence of depressive symptoms and the sociodemographic profile and RA clinical characteristics of the study population. Methodology: The study was conducted in a Rheumatology out patient clinic. The study sample consisted of 100 systematically selected participants of Black race. The participants completed the disability questionnaire (HAQ-DI), Visual Analogue Scales (VAS) for pain, fatigue and disease activity; and the depression and tension subscales of the Arthritis Impact Measurement Scale (AIMS). The MADRS was then administered to assess depressive symptoms. Study participants were clinically assessed for disability, joint status and disease activity. Data was analyzed using the SAS version 9.1 statistical program. Results: The majority of the sample was female (85%) and unmarried (66%). The prevalence of current depression was 13.2%, although a further 22.2% of the sample was already stable on antidepressant treatment. The mean RA disease duration was 12.5 ± 9.2 years. No significant associations were found between the presence of depression and the sociodemographic variables. MADRS scores were significantly associated and correlated with disability (p = 0.002, r = 0.30); fatigue (p = <0.001, r = 0.43); disease activity (p = 0.001, r = 0.32); AIMS-D (p < 0.001, r = 0.40) and AIMS-T (p < 0.001, r = 0.35). Upon adjusting for age and clinical status, significant associations remained with MADRS scores and all five above-mentioned RA variables although correlations weakened slightly. Conclusions: Co morbid depression is prevalent in South African Black patients with RA. In order to improve clinical outcomes in RA, depression must be actively sought and effectively managed.

Atualmente observa-se que as queixas de afecção física mais comuns do aparelho locomotor na clínica médica e do esporte, entre adultos jovens e adolescentes ativos, estão relacionadas ao joelho, sendo o sintoma de dor femoropatelar, a mais freqüente. Porém, essa condição é uma incógnita, para os especialistas em joelho, quando se tenta definir uma causa específica e de consenso. Como forma de tentar contribuir na elucidação desse problema resolveu-se executar este trabalho investigativo, buscando-se encontrar diferenças clínicas e biomecânicas entre indivíduos do sexo feminino, com e sem o referido sintoma, com idade entre 15 e 20 anos. Foram avaliadas 23 jovens com dor femoropatelar bilateral, sem afecção conhecida presente e 20 sem sintoma (46 joelhos sintomáticos e 40 assintomáticos). Todas foram submetidas a exames radiográficos (incidências: antero-posterior, perfil e axial), onde se verificou o alinhamento femorotibial, a altura patelar, o ângulo do sulco, o ângulo de congruência, e o ângulo femoropatelar lateral. Também se mensurou a retração dos isquiotibiais e o ângulo Q em exame clínico e, os indivíduos da pesquisa ainda se submeteram a avaliação da força, por dinamometria isocinética, dos grupos musculares extensores e flexores do joelho e do quadril, além dos rotadores mediais e laterais e os adutores e abdutores do quadril. Após análise dos resultados, pode ser observado que as diferenças, estatisticamente significativas, entre os grupos estudados, foram quanto ao alinhamento do membro inferior, com o ângulo Q apresentando um p < 0,001, o ângulo femoropatelar lateral com um p = 0,006, o ângulo do sulco com o p < 0,001, o ângulo de congruência com o p = 0,027 e, o único parâmetro diferente estatisticamente na dinamometria isocinética, foi o ângulo do pico de torque da extensão do quadril, com um p = 0,03. De acordo com os resultados da comparação entre o grupo sintomático e o assintomático, observa-se que há uma relação importante do mau alinhamento da articulação do joelho com a sintomatologia estudada, porém não pode ser apontado um ou outro ângulo como o mais importante para o surgimento da dor, ou talvez ainda possa ser dito que estes desalinhamentos predispõem o joelho ao sintoma, mas talvez não sejam as causas primárias da afecção. Ficou demonstrado que o aumento do ângulo Q e o encurtamento dos isquiotibiais não são causas de dor femoropatelar. Foi verificado que indivíduos com e sem o sintoma não apresentam diferença quanto a força muscular de músculos envolvidos na ação do quadril e do joelho. O ângulo femoropatelar lateral apresentou média maior no grupo assintomático, enquanto que a média do ângulo do sulco, no mesmo grupo, foi menor. Já o ângulo de congruência apresentou média positiva no grupo assintomático e negativa no grupo com dor, mostrando que a patela do grupo com dor, tem seu ápice mais medializado que a do grupo controle / Presently it has been observed that the most common physical affection in the locomotor system in medical and sportive clinic, among active young adults and adolescents are related to the knee, being femoropatellar pain symptom the most frequent. Although, this condition is unknown for those who are specialists in knee when they try to identify a specific cause and an agreement. As a way of trying to contribute for the elucidation of this problem, it has been decided to execute this investigative study trying to find clinic, radiographic and isokinetic differences among female individuals, with and without the above mentioned symptom, between 15 and 20 years old. 23 young females with bilateral femoropatellar pain were analyzed, with unknown affection, and 20 without symptoms (46 symptomatic knees and 40 asymptomatic). All of them were submitted to radiographic exams (anteroposterior, profile and axial incidences), were it was verified the femorotibial alignment, the patellar height, the groove angle, the congruence angle and the femoropatellar lateral angle. It was also measured the hamstring shortness and Q angle in clinic exam and, the individuals of this study were submitted to strength evaluation, by isokinetic dynamometry of the extensor and flexor muscles of knees and hips, besides hip medial and lateral rotators and the adducts and abducts. After analyzing the results, it can be observed that the statistically significant differences among studied groups were related to the inferior member alignment, with the Q angle presenting p value < 0,001, the femoropatellar lateral angle p value = 0,006, the groove angle p value < 0,001, the congruence angle p value = 0,027 and, the only one statistically different parameter in isokinetic dynamometry was the torque peak angle of hip extension with p value = 0,03. According to the results of comparison between symptomatic and asymptomatic groups there is an important relationship between bad alignment of the knee joint with the studied symptomatology, but it cannot be appointed one or another as the most important for the appearing of the pain, or maybe it still can be said that these disarrangements can predispose the knee to the symptom, but maybe they are not the primary causes of the affection. It was shown that the raise of the Q angle and the hamstring shortness are not the causes of femoropatellar pain. It was verified that individuals with or without the symptom do not show difference in relation to the muscular strength of the involved muscles in movement of the hip and knee. The femoropatellar lateral angle presented higher average in the asymptomatic group, while the average of the groove angle, in the same group, was smaller. Yet the congruence angle presented a positive average in the asymptomatic group and a negative average in the group with pain, showing that the patella in the group with pain has its apex more medially than the control group

Atualmente observa-se que as queixas de afecção física mais comuns do aparelho locomotor na clínica médica e do esporte, entre adultos jovens e adolescentes ativos, estão relacionadas ao joelho, sendo o sintoma de dor femoropatelar, a mais freqüente. Porém, essa condição é uma incógnita, para os especialistas em joelho, quando se tenta definir uma causa específica e de consenso. Como forma de tentar contribuir na elucidação desse problema resolveu-se executar este trabalho investigativo, buscando-se encontrar diferenças clínicas e biomecânicas entre indivíduos do sexo feminino, com e sem o referido sintoma, com idade entre 15 e 20 anos. Foram avaliadas 23 jovens com dor femoropatelar bilateral, sem afecção conhecida presente e 20 sem sintoma (46 joelhos sintomáticos e 40 assintomáticos). Todas foram submetidas a exames radiográficos (incidências: antero-posterior, perfil e axial), onde se verificou o alinhamento femorotibial, a altura patelar, o ângulo do sulco, o ângulo de congruência, e o ângulo femoropatelar lateral. Também se mensurou a retração dos isquiotibiais e o ângulo Q em exame clínico e, os indivíduos da pesquisa ainda se submeteram a avaliação da força, por dinamometria isocinética, dos grupos musculares extensores e flexores do joelho e do quadril, além dos rotadores mediais e laterais e os adutores e abdutores do quadril. Após análise dos resultados, pode ser observado que as diferenças, estatisticamente significativas, entre os grupos estudados, foram quanto ao alinhamento do membro inferior, com o ângulo Q apresentando um p < 0,001, o ângulo femoropatelar lateral com um p = 0,006, o ângulo do sulco com o p < 0,001, o ângulo de congruência com o p = 0,027 e, o único parâmetro diferente estatisticamente na dinamometria isocinética, foi o ângulo do pico de torque da extensão do quadril, com um p = 0,03. De acordo com os resultados da comparação entre o grupo sintomático e o assintomático, observa-se que há uma relação importante do mau alinhamento da articulação do joelho com a sintomatologia estudada, porém não pode ser apontado um ou outro ângulo como o mais importante para o surgimento da dor, ou talvez ainda possa ser dito que estes desalinhamentos predispõem o joelho ao sintoma, mas talvez não sejam as causas primárias da afecção. Ficou demonstrado que o aumento do ângulo Q e o encurtamento dos isquiotibiais não são causas de dor femoropatelar. Foi verificado que indivíduos com e sem o sintoma não apresentam diferença quanto a força muscular de músculos envolvidos na ação do quadril e do joelho. O ângulo femoropatelar lateral apresentou média maior no grupo assintomático, enquanto que a média do ângulo do sulco, no mesmo grupo, foi menor. Já o ângulo de congruência apresentou média positiva no grupo assintomático e negativa no grupo com dor, mostrando que a patela do grupo com dor, tem seu ápice mais medializado que a do grupo controle / Presently it has been observed that the most common physical affection in the locomotor system in medical and sportive clinic, among active young adults and adolescents are related to the knee, being femoropatellar pain symptom the most frequent. Although, this condition is unknown for those who are specialists in knee when they try to identify a specific cause and an agreement. As a way of trying to contribute for the elucidation of this problem, it has been decided to execute this investigative study trying to find clinic, radiographic and isokinetic differences among female individuals, with and without the above mentioned symptom, between 15 and 20 years old. 23 young females with bilateral femoropatellar pain were analyzed, with unknown affection, and 20 without symptoms (46 symptomatic knees and 40 asymptomatic). All of them were submitted to radiographic exams (anteroposterior, profile and axial incidences), were it was verified the femorotibial alignment, the patellar height, the groove angle, the congruence angle and the femoropatellar lateral angle. It was also measured the hamstring shortness and Q angle in clinic exam and, the individuals of this study were submitted to strength evaluation, by isokinetic dynamometry of the extensor and flexor muscles of knees and hips, besides hip medial and lateral rotators and the adducts and abducts. After analyzing the results, it can be observed that the statistically significant differences among studied groups were related to the inferior member alignment, with the Q angle presenting p value < 0,001, the femoropatellar lateral angle p value = 0,006, the groove angle p value < 0,001, the congruence angle p value = 0,027 and, the only one statistically different parameter in isokinetic dynamometry was the torque peak angle of hip extension with p value = 0,03. According to the results of comparison between symptomatic and asymptomatic groups there is an important relationship between bad alignment of the knee joint with the studied symptomatology, but it cannot be appointed one or another as the most important for the appearing of the pain, or maybe it still can be said that these disarrangements can predispose the knee to the symptom, but maybe they are not the primary causes of the affection. It was shown that the raise of the Q angle and the hamstring shortness are not the causes of femoropatellar pain. It was verified that individuals with or without the symptom do not show difference in relation to the muscular strength of the involved muscles in movement of the hip and knee. The femoropatellar lateral angle presented higher average in the asymptomatic group, while the average of the groove angle, in the same group, was smaller. Yet the congruence angle presented a positive average in the asymptomatic group and a negative average in the group with pain, showing that the patella in the group with pain has its apex more medially than the control group

Hipotrofía nos músculos que estabilizam a coluna tem sido identificada nos pacientes com lombalgia. Entretanto, não se sabe se a perda muscular é causa ou conseqüência desta disfunção, nem se ela é influenciada pelo tipo de alteração discal que o indivíduo apresenta. Este estudo testou a hipótese de que a hipotrofía dos pacientes com lombalgia seja dependente do tipo de alteração discal. Para avaliar a condição muscular em diferentes tipos de alteração discal, optou-se por um estudo retrospectivo e por uma seleção aleatória de 78 exames de ressonância magnética de indivíduos com lombalgia. Em cada exame foram realizadas medidas quantitativas da porcentagem de gordura na área de secção transversa dos mm. multífidus e psoas, nos três últimos níveis da coluna lombar. A alteração discal foi encontrada em 95% dos exames, sendo o abaulamento o achado de imagem mais freqüente, seguido pela protrusão discal. A porcentagem de gordura variou conforme o tipo de alteração discal. Nos níveis com abaulamento há em ambos os músculos estudados 6% a mais de tecido gorduroso do que nos níveis onde há protrusão e esta diferença foi estatisticamente significante. Músculos nos níveis onde há protrusão sem fissura no anel fibroso apresentaram maior substituição gordurosa do que aqueles onde há protrusão com fissura. A porcentagem de gordura foi influenciada por características anatômicas como músculo estudado e nível da coluna, e por características como idade e sexo dos sujeitos. Estes resultados indicam que a hipotrofía muscular em pacientes com lombalgia não é um processo uniforme e generalizado, mas sim correlacionado a diferentes variáveis, entre elas o tipo de alteração discal que o paciente apresenta. / Low back pain patients present atrophy on muscles responsible for spine stabilization. However, it is not clear if muscle waste is related to the cause or if it is a consequence of this disfunction. Nor it is clear if muscle athophy is affected by the type of disc pathology. This study tested the hypothesis that muscle waste in low back pain patients influenced by the type of disc derangement. Magnetic resonance scans of 78 low back pain patients were randomly analysed. Cross sectional area percentage of fat tissue in multifidi and psoas major muscles was measured on the lower levels of the lumbar spine. Disc pathology was found in 95% of the exams and disc bulge was the most frequent abnormality, followed by disc protrusion. Fat percentage varied according to disc pathology and this difference was statistically significant. Muscles on levels with disc bulge presented 6% more fat deposits than muscles on levels with disc protrusion. Muscles on levels with discs without anular tear present more fat infiltration than muscles on levels with anular tear. Fat percentage was also influenced by anatomic aspects such as evaluated muscle and spine level, and sample characteristics as age and sex. The results indicated that muscle atrophy in low back pain patients is not a uniform and generalized feature. It is correlated to different variables, such as type of disc pathology

Hipotrofía nos músculos que estabilizam a coluna tem sido identificada nos pacientes com lombalgia. Entretanto, não se sabe se a perda muscular é causa ou conseqüência desta disfunção, nem se ela é influenciada pelo tipo de alteração discal que o indivíduo apresenta. Este estudo testou a hipótese de que a hipotrofía dos pacientes com lombalgia seja dependente do tipo de alteração discal. Para avaliar a condição muscular em diferentes tipos de alteração discal, optou-se por um estudo retrospectivo e por uma seleção aleatória de 78 exames de ressonância magnética de indivíduos com lombalgia. Em cada exame foram realizadas medidas quantitativas da porcentagem de gordura na área de secção transversa dos mm. multífidus e psoas, nos três últimos níveis da coluna lombar. A alteração discal foi encontrada em 95% dos exames, sendo o abaulamento o achado de imagem mais freqüente, seguido pela protrusão discal. A porcentagem de gordura variou conforme o tipo de alteração discal. Nos níveis com abaulamento há em ambos os músculos estudados 6% a mais de tecido gorduroso do que nos níveis onde há protrusão e esta diferença foi estatisticamente significante. Músculos nos níveis onde há protrusão sem fissura no anel fibroso apresentaram maior substituição gordurosa do que aqueles onde há protrusão com fissura. A porcentagem de gordura foi influenciada por características anatômicas como músculo estudado e nível da coluna, e por características como idade e sexo dos sujeitos. Estes resultados indicam que a hipotrofía muscular em pacientes com lombalgia não é um processo uniforme e generalizado, mas sim correlacionado a diferentes variáveis, entre elas o tipo de alteração discal que o paciente apresenta. / Low back pain patients present atrophy on muscles responsible for spine stabilization. However, it is not clear if muscle waste is related to the cause or if it is a consequence of this disfunction. Nor it is clear if muscle athophy is affected by the type of disc pathology. This study tested the hypothesis that muscle waste in low back pain patients influenced by the type of disc derangement. Magnetic resonance scans of 78 low back pain patients were randomly analysed. Cross sectional area percentage of fat tissue in multifidi and psoas major muscles was measured on the lower levels of the lumbar spine. Disc pathology was found in 95% of the exams and disc bulge was the most frequent abnormality, followed by disc protrusion. Fat percentage varied according to disc pathology and this difference was statistically significant. Muscles on levels with disc bulge presented 6% more fat deposits than muscles on levels with disc protrusion. Muscles on levels with discs without anular tear present more fat infiltration than muscles on levels with anular tear. Fat percentage was also influenced by anatomic aspects such as evaluated muscle and spine level, and sample characteristics as age and sex. The results indicated that muscle atrophy in low back pain patients is not a uniform and generalized feature. It is correlated to different variables, such as type of disc pathology

by Chan Kwai Foon May. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2000. / Includes bibliographical references (leaves 103-114). / Abstracts in English and Chinese. / Declaration --- p.2 / Abstract --- p.3 / Abstract in Chinese --- p.6 / Acknowledgements --- p.8 / Chapter Chapter 1. --- Introduction --- p.15 / Chapter Chapter 2. --- Osteoporosis : The relationship between aging and skeletal organization between men and women --- p.17 / Chapter 2.1. --- Skeletal organization --- p.17 / Chapter 2.1.1. --- Bone structure --- p.17 / Chapter 2.1.2. --- Bone metabolism --- p.17 / Chapter 2.1.3. --- Peak bone mass --- p.18 / Chapter 2.2. --- Bone loss between men and women --- p.20 / Chapter 2.2.1. --- Aging and bone loss --- p.20 / Chapter 2.2.2. --- Clinical aspects of bone loss in men and women --- p.21 / Chapter Chapter 3. --- Vertebral deformity : Bone Mineral Density and Body Composition --- p.23 / Chapter 3.1. --- Bone mineral density --- p.23 / Chapter 3.1.1. --- Types of vertebral deformity --- p.23 / Chapter 3.1.2. --- Clinical diagnosis in vertebral deformity --- p.24 / Chapter 3.1.3. --- Bone mineral density measurements --- p.25 / Chapter 3.1.4. --- Vertebral deformity and bone mineral density --- p.28 / Chapter 3.2. --- Bone composition --- p.33 / Chapter Chapter 4. --- Literature Review on Health Consequences of Vertebral Deformity --- p.36 / Chapter 4.1. --- Back pain --- p.36 / Chapter 4.1.1. --- Back pain and vertebral deformity --- p.36 / Chapter 4.1.2. --- Back pain in men and women with vertebral deformity --- p.38 / Chapter 4.2. --- Morale and functional limitation and vertebral deformities --- p.39 / Chapter 4.2.1. --- Function evaluation : The Barthel Index --- p.40 / Chapter 4.2.2. --- Philadelphia Geriatric Morale Scale --- p.41 / Chapter Chapter 5. --- Objectives --- p.43 / Chapter Chapter 6. --- "Subjects and methods for phase I: anthropometric measurement, body composition and bone mineral density measurement in vertebral deformity patients and controls" --- p.44 / Chapter 6.1. --- Study subjects --- p.44 / Chapter 6.2. --- Radiology and digitization protocol for diagnosis vertebral deformity --- p.46 / Chapter 6.3. --- Diagnosis of vertebral deformity --- p.48 / Chapter 6.4. --- Body composition and bone mineral density measurements --- p.54 / Chapter 6.4.1. --- Body composition analysis --- p.54 / Chapter 6.4.2. --- Lumbar spine and hip bone mineral analysis --- p.54 / Chapter 6.5. --- Quality control --- p.56 / Chapter 6.5.1. --- Routine quality control of measurements --- p.56 / Chapter 6.5.2. --- Precision on patient repositioning --- p.56 / Chapter Chapter 7. --- Subjects and methods for phase II: health consequences of vertebral deformity patients and controls --- p.57 / Chapter 7.1. --- Questionnaire on health consequences --- p.57 / Chapter 7.1.1 --- Back pain and disability --- p.57 / Chapter 7.1.2 --- Activities of daily living --- p.59 / Chapter 7.1.3 --- Morale --- p.59 / Chapter 7.2. --- Statistical methods --- p.60 / Chapter 7.2.1. --- Bone mineral density and body composition --- p.60 / Chapter 7.2.2. --- Back pain and disability --- p.60 / Chapter 7.2.3. --- Activities of daily living and morale --- p.61 / Chapter Chapter 8. --- "Results for phase I: anthropometric measurement, body composition and bone mineral density measurement in vertebral deformity patients and controls" --- p.62 / Chapter 8.1. --- Demographic characteristics of study population --- p.62 / Chapter 8.2. --- Anthropometric measurements : Body composition and bone mineral density --- p.64 / Chapter Chapter 9. --- Results for phase II: Health Consequences of vertebral deformity patients and control --- p.76 / Chapter 9.1. --- Back pain --- p.76 / Chapter 9.2. --- Disability --- p.78 / Chapter 9.3. --- Activities of daily living --- p.81 / Chapter 9.4. --- Morale --- p.82 / Chapter Chapter 10. --- Discussion I --- p.83 / Chapter 10.1. --- Study Sample --- p.83 / Chapter 10.2. --- Digitization method and definition of vertebral deformity --- p.84 / Chapter 10.3. --- Methods for bone mineral density measurement --- p.87 / Chapter 10.4. --- Questionnaire validity --- p.88 / Chapter 10.4.1. --- Back pain and disability --- p.88 / Chapter 10.4.2. --- Barthel Index --- p.88 / Chapter 10.4.3. --- Philadelphia Geriatric Morale Scale --- p.89 / Chapter Chapter 11. --- Discussion II --- p.92 / Chapter 11.1 . --- Body composition and bone mineral density --- p.92 / Chapter 11.2. --- Differences of vertebral deformity between Chinese men and Caucasian men --- p.93 / Chapter 11.3. --- Health consequences in Chinese men --- p.96 / Chapter 11.4. --- Comparison of health consequences between Chinese men and Caucasian men --- p.98 / Chapter 11.5. --- Variation of health consequences between Chinese men and Chinese women --- p.101 / Chapter 11.5.1. --- Back pain and disability --- p.101 / Chapter 11.5.2. --- Morale --- p.102 / Chapter Chapter 12. --- Conclusion --- p.103 / Reference --- p.104 / Appendix I --- p.115 / Appendix II Publication