Bernstein: Knowledge relations and professional identity

Approval was granted by the Research Ethics Committee of the Lagos State University Teaching Hospital (LASUTH) before the commencement of this study and informed consent was obtained from the study subjects (appendix 1 and 2)

(A) Clinical Assessment

The weight of all subjects was measured using a weight scale with the subject wearing light clothing. Measurement of height was done using a stadiometer with the subject unshod, feet together, arms by side in an erect posture. Body mass index was calculated using the formula, weight (kg)/height² (m).⁶⁶ Waist circumference was measured in horizontal plane midway between inferior margin of ribs and superior borders of iliac crest with the subject standing erect, arms by side, but away from the trunk, abdomen bare and breathing normally. Non stretchable tape measure graduated in cm was used for the measurement which was taken at the end of normal inspiration.

Blood pressure was measured in each arm using standard adult arm cuff of mercury- type sphygmomanometer with the subject’s arm supported and at least 10min after rest in sitting position. The measurement was repeated after 15 minutes. The average of the measurement in each arm was taken as the subject’s blood pressure.

Rheumatological examination included both the general and specific musculoskeletal examinations. General inspection of the subjects for abnormal gait, loss of function, joints deformities, subcutaneous nodules and joints swelling was carried out in all subjects. The joints and peri-articular structures were palpated for swelling, effusions, tenderness, crepitus and warmth while active range of motion of the joints was followed by passive joint mobilizations in subjects with limited active joints motion. Resisted active joints

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motion, provocative joints manoeuvres and some special tests such as Tinel’s and Phalen’s test for carpal tunnel syndrome, Finkelstein’s test for Dequervain’s tendinitis, prayer and table top tests for diabetics cheiroarthropathy, were carried out where applicable to identify specific MSS conditions.

(B) Laboratory and radiological assessments

Fasting and random whole blood glucose were measured for cases and controls, respectively, using a glucometer. In addition, two hour post prandial whole blood glucose measurement was carried out for diabetics cases while random venous blood sample was collected into EDTA for determination of ESR, PCV, and WBC in all subjects. The venous blood sample was also collected into lithium heparin bottles for determination of SUA and CRP in all subjects and for determination of HBAIC among the DM subjects. In addition, fasting venous blood sample was collected into lithium heparin bottles for determination of HDL cholesterol and triglycerides using precipitation⁶⁷ and enzyme hydrolysis methods⁶⁸, respectively, while RF and Anti-CCP were determined in two subjects to confirm diagnosis and exclude alternative diagnosis. Serum uric acid, WBC, and PCV were measured on a standard auto-analyzer. Anti-CCP and C-reactive protein were analyzed by ELISA methods.⁶⁹ RF and ESR were analyzed by nephelometry and Westergren’s methods, respectively, while SUA was analysed by spectrophotometry.

Plain radiographs of the affected joints were done for subjects requiring X-rays for definitive diagnosis and to exclude alternative diagnosis. Radiographs were reported by the researcher and the radiologists, whilst standard operational definitions were used to define type 1 and type 2 diabetic cases and poor glycemic control in all diabetic subjects.

It was also used to define obesity, abdominal obesity, anaemia, leucocytosis, elevated ESR, and elevated CRP in all subjects.

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Musculoskeletal conditions among the subjects were diagnosed using the validated criteria such as American College of Rheumatology (ACR) criteria, European Union League against Rheumatism criteria (EULAR), Southampton criteria and other well established rheumatic diseases classification criteria for different musculoskeletal conditions.

(A) Operational definitions adopted for all the subjects

(i) Abdominal obesity: waist circumference >102 cm in men and > 88cm in women⁷⁰

(ii) Alcohol history: intake of ≥3 standard drink per day (or >1 big beer bottle per day)⁷¹

(iii) Anemia: PCV <36% in women and <39% in men.⁷²

(iv) Co-morbidity: Presence of other chronic medical conditions excluding endocrine diseases, organ failures and hypertension

(v) Diabetes mellitus: Diabetes defines as fasting plasma glucose greater than or equal to 7.0 mmol/L (126 mg/dL) or symptoms of diabetes plus random blood glucose concentration greater than or equal to 11.1mmol/l (200mg/dl) or two-hour plasma glucose greater than or equal 11.1 mmol/L (200 mg/dL) during an oral glucose tolerance test or Hb A1C > 6.5%.⁷³

(vi) Diabetes type 2: Patients will be classified as having type 2 diabetes using clinical criteria such as present or prior history of use of oral hypoglycaemic agents or combination of insulin and oral hypoglycaemic agents.⁷⁴

(vii) Diabetes type 1:This refers to patients who are presently on insulin and have been insulin requiring since diagnosis.⁷⁴

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(viii) Duration of DM: long term (DM ≥10 year duration), medium term (DM 5-9.9year duration), short term (DM <5 year duration).⁷⁴

(ix) Elevated CRP: Serum CRP >3mg/l.⁷⁵

(x) Elevated ESR: ESR > 15mm/hr in men and > 20mmhr in women for subjects

<50yrs, corrected ESR for subjects above 50years (n+10/2 for female, n/2 for male, n= age of subjects).⁷⁵

(xi) Hypertension: known hypertensive or on anti-hypertensive drugs or SBP ≥140 or DBP ≥90 on ≥2 occasions 2 hours apart.⁷⁶

(xii) Hyperuricemia: Serum uric acid >6mg/dl for women, and >7mg/dl for men⁷⁷ (xiii) Leucocytosis: WBC count >11,000/mm³.⁷⁸

(xiv) Metabolic syndrome: defines by presence of 3 of any of the following; 1) waist circumference (WC) greater than 102 cm in men and 88 cm in women; 2) serum triglycerides (TG) level of at least 150 mg/dl (1.69 mmol/L); 3) high density lipoprotein cholesterol (HDL-C) level of less than 40 mg/dl (1.04 mmol/L) in men and 50 mg/dl (1.29 mmol/L) in women; 4) blood pressure of at least 130/85 mm Hg.⁷⁹

(xv) Obesity: BMI ≥30kg/m². ⁶⁷

(xvi) Poor glycaemic control: HBA1C greater than 7%.⁷³

(xvii) Smoking history: currently smoke cigarette or ever smoked cigarette.⁸⁰

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(B) Operational definitions and validated criteria for diagnosis of MSS conditions, (i) Adhesive capsulitis(frozen shoulder): History of pain in the deltoid area and

equal restriction of active and passive glenohumeral movement with capsular pattern (external rotation > abduction >internal rotation).³⁸

(ii) Bicipital tendinitis: History of anterior shoulder pain and pain on resisted active flexion or supination of forearm.³⁸

(iii) Carpal tunnel syndrome: Pain or paraesthesia or sensory loss in the median nerve distribution and one of: Tinel's test positive, Phalen's test positive, nocturnal exacerbation of symptoms, motor loss with wasting of abductor pollicis brevis, abnormal nerve conduction time.³⁸

Tinel’s test is positive when numbness or paraesthesia is elicited in the distribution of median nerve following tap over the transverse carpal ligament at the level of the proximal wrist flexion crease. ³⁸

Phalen’s test is positive when there is reproduction of numbness in the distribution of the median nerve in the hand following full passive flexion of the wrist over 15-16 seconds. ³⁸

(iv) Dequervain’s tendinitis: Pain over the radial styloid and tender swelling of first extensor compartment and either pain reproduced by resisted thumb extension or positive Finkelstein's test.³⁸

Finkelstein’s test is positive when there is reproduction of pain in the radial styloid process when the wrist is moved into ulnar deviation along with adduction of the thumb.³⁸

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(v) Dupuytren’s contracture: Patients having pitting and thickening of the palmar skin with a firm, painless nodule, fixed to the skin and deep fascia with

contracture of the ring and little finger.

(vi) Fibromyalgia: Entry criteria include history of widespread pain, present in all of the following sites: left and right sides of the body; above and below the waist; axial pain and the presence of pain in 11 of the following 18 bilateral tender points on digital palpation (approximate force of 4 kg; must elicit the subjective sensation of pain); (1) occiput (insertion of sub-occipital muscles) ; (2) lower cervical (anterior aspects of inter- transverse spaces C5); (3) midpoint of upper border of trapezius origin of supraspinatus (above and near medial border of spine of scapula); (4) second costo-chondral junctions 2 cm distal to lateral epicondyles (elbow); (5) upper outer quadrant of gluteal muscles (buttock); (6) in anterior fold of muscle posterior to the prominence of the greater trochanter medial fat pad of knee (proximal to joint line).⁸¹

(vii) Flexor tenosynovitis (trigger fingers): Patients having a palpable nodule, usually in the area overlying the MCP joints, and thickening along the affected flexor tendon sheath on the palmar aspect of the finger and hand. The locking phenomenon may be reproduced with either active or passive finger flexion.¹

(viii) Generalised Osteoarthritis: Osteoarthritis involving 3 or more joints with or without Heberden’s and Bouchard’s nodes.⁸²

(IX) Gouty arthritis: clinical criteria include; (1) More than one attack of acute arthritis;

(2) Maximum inflammation developed within 1 day; (3) Oligoarthritis attack; (4).

Redness observed over joints; (5). First MTP joint painful or swollen; (6) Unilateral first MTP joint attack; (7) Unilateral tarsal joint attack; (8) Tophus (suspected or

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proven); (9) Hyperuricaemia (more than 2 S.D. greater than the normal population average); (10) Asymmetric swelling within a joint on X-ray; (11) Subcortical cysts without erosions on X-ray; (12) Complete termination of an attack. Case definition: 6 of 12 clinical criteria required or presence of MSU crystals in synovial fluid or in tophus.⁵⁵

(x) Hand osteoarthritis: (1)Hand pain, aching, or stiffness for most days of prior month; (2) Hard tissue enlargement of ≥ 2 of 10 selected hand joints; (3) MCP

swelling in 1 or 2 joints; (4) Hard tissue enlargement of ≥ 2 DIP joints;

(5) Deformity of 1 or more of 10 selected hand joints. Classified as hand OA in the presence of 1plus 3 of the following: 2, 3, 4, 5.⁵⁰

(xi) Hip osteoarthritis: criteria include; (1) Hip pain for most days of the prior month;

(2) ESR < 20 mm/hr (laboratory); (3) Radiographic femoral and/or acetabular osteophytes; (4) Radiographic hip joint space narrowing. Classified as Hip OA: if 1, 2, 3 or 1, 2, 4 or 1, 3, 4.⁵¹

(xii) Knee osteoarthritis: criteria include; (1) Knee pain for most days of prior month;

(2) Crepitus on active joint motion; (3) Morning stiffness < 30 min in duration; (4) Age ≥ 50 years; (5) Bony enlargement of the knee on examination; (6) Bony tenderness; (7) No palpable warmth. Classified as Knee OA: if 1 plus 3 of the following: 2,3, 4, 5, 6, 7.⁵²

(xiii) Lateral epicondylitis: Epicondylar pain and epicondylar tenderness and pain on resisted extension of the wrist.^38.

(xiv) Limited joint mobility: will be diagnosed by presence of positive ‘Prayer sign’

and ‘Table top test’

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The “prayer sign,” which tests the ability to flatten the hands together as in prayer, facilitating recognition of contractures.¹¹

The “table top test,” which assesses the ability to flatten the palm against the surface of a table.¹¹

xv) Medial epicondylitis: Epicondylar pain and epicondylar tenderness and pain on resisted flexion of the wrist.³⁸

(xvi) Plantar fasciitis: Start up heel pain and or plantar heel pain at any time with either plantar heel tenderness or plantar heel pain on passive dorsiflexion of the foot.⁸³

(xvii) Polymyalgia rheumatic (PMR): The inclusion criteria are; age ≥ 50 years, bilateral aching shoulders, abnormal CRP, and or ESR with following features; (1) prolonged morning stiffness > 45minutes (score2); (2) hip pain or limited range of hip motion (score 1); (3) absence RF and anti-CCP(score 2) and; (4) absence of other joints involvement (score 1). Patient with score ≥4 is categorized as PMR.⁸⁴ (Xviii) Rotator cuff tendinitis: History of pain in the deltoid region and pain on resisted

active movement (abduction, supraspinatus; external rotation, infraspinatus;

internal rotation, subscapularis).³⁸

(xix) Subacromial bursitis: painful impingement tests on forced passive internal rotation, resisted external rotation and forced passive forward flexion.⁸⁵

(xx) Symptomatic cervical and lumbosacral degenerative disc diseases:

Mechanical neck or low back pain or stiffness greater than or equal to 3 months supported by typical radiographic features.⁸⁶

34 4.9 STATISTICAL ANALYSIS

Data obtained were analyzed using statistical package for social science (SPSS) version 19. All ccategorical variables were summarized and presented as frequency and percentages while all quantitative variables were expressed as mean and standard deviation (SD), as well as median and inter-quartile range, where applicable while the differences between the categorical variables were compared using Chi-square tests, the difference between the numerical variables were compared using independent t test. The Mann Whitney U test was used to compare non parametric numerical variables. Binary logistic regression analysis was performed to determine the categorical and numerical predictors of musculoskeletal conditions among the diabetic subjects, statistical significance was set at P value < 0.05.

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