Christine Heron

Prevalence of anxiety and depression in osteoarthritis: use of the Hospital Anxiety and Depression Scale as a screening tool

The aims of this study are to ascertain the prevalence of anxiety and depressive disorders in an outpatient population with osteoarthritis (OA), examine the interrelationships between severity of OA, pain, disability, and depression, and evaluate the Hospital Anxiety and Depression Scale (HADS) as a screening tool for this population. Patients with lower limb OA were evaluated with the Short Form McGill Pain and Present Pain Index Questionnaires, and a visual analogue scale, WOMAC Osteoarthritis Index-section C, and the HADS. Participants underwent a structured clinical interview by a liaison psychiatrist (AB). X-rays of affected joints were rated for disease severity. Fifty-four patients (42 females; mean age 63.3) were investigated. The prevalence of clinically significant anxiety and/or depression was 40.7% (95% confidence interval (CI), 27.6–55.0%). HADS was a good predictor of anxiety and depression with a sensitivity and specificity of 88% (95%CI, 64% to 99%) and 81% (95%CI, 65% to 92%), respectively. Pain correlated with HADS anxiety and depression scores (e.g. Rank correlation coefficients (Kendall’s tau-b) between total HADS scores and Pain VAS scores 0.29; p = 0.003). Disability was greater in patients with depression and/or anxiety (e.g. total HADS score; Kendall’s rank correlation coefficient tau-b = 0.26, p = 0.007) OA severity as determined by radiological score was not a good predictor for anxiety nor depression and only weakly associated with disability. Anxiety and depression are very common in OA patients. HADS anxiety was a better predictor of diagnosed anxiety than HADS depression was of diagnosed depression. HADS is a valid and reliable screening instrument for detecting mood disorder, but not a diagnostic tool or a substitute for asking about symptoms of depression. The interrelationship between mental health, pain and disability is strong. We should therefore adopt a multidisciplinary approach to the management of OA.

Management of knee osteoarthritis in primary care: Pain and depression are the major obstacles☆

OBJECTIVES Osteoarthritis (OA) management is a challenge, as OA consists of a spectrum of pathologies requiring a multifaceted treatment approach. Patient education programmes (PEP) are attractive, as they may be cost effective and potentially efficacious. The goals of the study were to determine what may hinder the efficacy of a PEP for knee OA by determining the relevance of depression, pain, disease knowledge and physical ability in patients to their response to a PEP. METHODS Clinical and demographic data relating to 170 patients who completed a trial of a PEP were analysed to determine how they interrelate during patient management. RESULTS All patients showed a progressive decrease in mental health over the duration of the study (P<.001). Greater pain was associated with reduced coping, increased depression and reduced physical ability (P<.05). Women were more likely to experience disability (P<.05). Disability was associated with reduced ability to cope, increased depression and the experience of more pain (P<.05). Subjects with a Caucasian background were significantly (P<.05) more likely to possess knowledge of OA than other ethnic groups. The lowest knowledge group experienced more pain; the highest knowledge group was coping better and had less depression (P<.05). CONCLUSION A complex interrelationship between depression, pain, disease knowledge, and physical ability in patients with knee OA has been demonstrated. Specifically, the treatment of depression and pain may be paramount to the successful treatment of knee OA, and these factors should be considered in each patient and management priorities made.

The relation between composite ultrasound measures and the DAS28 score, its components and acute phase markers in adult RA

OBJECTIVES Ultrasound (US) provides measurements of synovial morphology and vascularity. However, on an individual joint basis in RA, US measures do not relate well to clinical signs. This study investigates the relationship between composite US measures and the 28-joint disease activity score (DAS28), its components and acute phase markers in adult RA. METHODS RA synovial disease activity was recorded in 50 patients by: (i) the DAS28 score; (ii) ESR and CRP; and (iii) US using Grey scale (GS) and power Doppler (PD) measures of PIP and MCP joints to derive composite US scores based on abnormal counts and severity. A total of 25 control subjects were studied to define normal US appearances. The relation between each measure of synovial disease was determined by Spearman correlation analysis. RESULTS There was a significant relation between the DAS28 and the GS joint count (GSJC, Spearmans r = 0.4; P = 0.004) and severity score (GSJS, r = 0.34; P = 0.016) and the PD joint count (PDJC, r = 0.32; P = 0.028). There was a significant relation between the ESR and PDJC (r = 0.37; P = 0.007) and PD joint severity score (PDJS, r = 0.38; P = 0.006) and between the CRP and PDJS (r = 0.29; P = 0.04). The remaining components of the DAS28 related poorly to all US measures, except the tender joint count, which related significantly to the GS but not the PD measures. CONCLUSIONS Composite US markers of synovial disease relate significantly to the DAS28 score and ESR/CRP in adult RA, but not as well with individual clinical joint counts and the patients global assessment.

MRI appearances of the asymptomatic patellar tendon on gradient echo imaging

Thickening of the patellar tendon and foci of increased signal intensity have been described as characteristic features of “jumpers knee” (chronic patellar tendinitis) on magnetic resonance imaging (MRI). It was our impression that such appearances may be seen in the patellar tendons of patients without symptoms referable to the anterior part of the knee when using gradient echo images. The appearances of the asymptomatic patellar tendon on three-dimensional gradient echo sequences were studied by retrospectively reviewing the images of 60 patients, none of whom had symptoms related to the anterior part of the knee. The anteroposterior width of the patellar tendon was measured at three levels (superior, middle and inferior) on the central sagittal image of a gradient echo sequence. The relative signal intensities at the same levels were recorded. In 97% of subjects the superior part of the tendon was wider than the midpoint, and in 97% the inferior part was wider than the midpoint. The range of widths was wide, and there was no significant difference between sexes. Focal increased signal intensity in the superior part was shown in 75%, and in the inferior part in 43%. The asymptomatic patellar tendon shows uniform thickness throughout most of its length, but there are focal expansions at the proximal and distal ends. It usually demonstrates low signal on MRI, but may contain foci of increased signal intensity at either or both ends when imaged on gradient-echo sequences.Thickening of the patellar tendon and foci of increased signal intensity have been described as characteristic features of “jumpers knee” (chronic patellar tendinitis) on magnetic resonance imaging (MRI). It was our impression that such appearances may be seen in the patellar tendons of patients without symptoms referable to the anterior part of the knee when using gradient echo images. The appearances of the asymptomatic patellar tendon on three-dimensional gradient echo sequences were studied by retrospectively reviewing the images of 60 patients, none of whom had symptoms related to the anterior part of the knee. The anteroposterior width of the patellar tendon was measured at three levels (superior, middle and inferior) on the central sagittal image of a gradient echo sequence. The relative signal intensities at the same levels were recorded. In 97% of subjects the superior part of the tendon was wider than the midpoint, and in 97% the inferior part was wider than the midpoint. The range of widths was wide, and there was no significant difference between sexes. Focal increased signal intensity in the superior part was shown in 75%, and in the inferior part in 43%. The asymptomatic patellar tendon shows uniform thickness throughout most of its length, but there are focal expansions at the proximal and distal ends. It usually demonstrates low signal on MRI, but may contain foci of increased signal intensity at either or both ends when imaged on gradient-echo sequences.

The prevalence of neovascularity in patients clinically diagnosed with rotator cuff tendinopathy

BackgroundShoulder dysfunction is common and pathology of the rotator cuff tendons and subacromial bursa are considered to be a major cause of pain and morbidity. Although many hypotheses exist there is no definitive understanding as to the origin of the pain arising from these structures. Research investigations from other tendons have placed intra-tendinous neovascularity as a potential mechanism of pain production. The prevalence of neovascularity in patients with a clinical diagnosis of rotator cuff tendinopathy is unknown. As such the primary aim of this pilot study was to investigate if neovascularity could be identified and to determine the prevalence of neovascularity in the rotator cuff tendons and subacromial bursa in subjects with unilateral shoulder pain clinically assessed to be rotator cuff tendinopathy. The secondary aims were to investigate the association between the presence of neovascularity and pain, duration of symptoms, and, neovascularity and shoulder function.MethodsPatients with a clinical diagnosis of unilateral rotator cuff tendinopathy referred for a routine diagnostic ultrasound (US) scan in a major London teaching hospital formed the study population. At referral patients were provided with an information document. On the day of the scan (on average, at least one week later) the patients agreeing to participate were taken through the consent process and underwent an additional clinical examination prior to undergoing a bilateral grey scale and colour Doppler US examination (symptomatic and asymptomatic shoulder) using a Philips HDI 5000 Sono CT US machine. The ultrasound scans were performed by one of two radiologists who recorded their findings and the final assessment was made by a third radiologist blinded both to the clinical examination and the ultrasound examination. The findings of the radiologists who performed the scans and the blinded radiologist were compared and any disagreements were resolved by consensus.ResultsTwenty-six patients agreed to participate and formed the study population. Of these, 6 subjects were not included in the final assessment following the pre-scan clinical investigation. This is because one subject had complete cessation of symptoms between the time of the referral and entry into the trial. Another five had developed bilateral shoulder pain during the same period. The mean age of the 20 subjects forming the study population was 50.2 (range 32-69) years (SD = 10.9) and the mean duration of symptoms was 22.6 (range .75 to 132) months (SD = 40.1). Of the 20 subjects included in the formal analysis, 13 subjects (65%) demonstrated neovascularity in the symptomatic shoulder and 5 subjects (25%) demonstrated neovascularity in the asymptomatic shoulder. The subject withdrawn due to complete cessation of symptoms was not found to have neovascularity in either shoulder and of the 5 withdrawn due to bilateral symptoms; two subjects were found to have signs of bilateral neovascularity, one subject demonstrated neovascularity in one shoulder and two subjects in neither shoulder.ConclusionsThis study demonstrated that neovascularity does occur in subjects with a clinical diagnosis of rotator cuff tendinopathy and to a lesser extent in asymptomatic shoulders. In addition, the findings of this investigation did not identify an association between the presence of neovascularity; and pain, duration of symptoms or shoulder function. Future research is required to determine the relevance of these findings.

Magnetic resonance imaging of the ankle and foot

Magnetic resonance imaging (MRI) is now established as a highly valuable imaging technique for the assessment of major joints. Extensive experience has confirmed the accuracy of MRI in the evaluation of the knee, shoulder and hip. The widespread application of MRI to the peripheral joints has occurred more slowly but the potential of MRI in areas such as the ankle and foot is equally great. Following recent technical refinements which enable the acquisition of images of high quality, MRI is assuming increasing importance in foot and ankle imaging. MRI is particularly advantageous in the assessment of musculoskeletal abnormalities because it enables direct depiction of tendons, ligaments, muscles, cartilage and bone without a requirement for intraarticular contrast. Ionising radiation is not employed and the multiplanar imaging capability of MRI is especially valuable in the foot and ankle.