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Investigation of associations between recurrence of major depressive disorder and spinal posture alignment: A quantitative cross-sectional study
Gait & Posture 52 (2017) 258–264
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Investigation of associations between recurrence of major depressive disorder and spinal posture alignment: A quantitative cross-sectional study Janette Z. Canalesa,* , Juliana T. Fiquerb , Rodolfo N. Camposc , Márcio Gerhardt Soeiro-de-Souzaa , Ricardo Alberto Morenoa a Mood Disorders Unit (GRUDA), Department of Psychiatry, School of Medicine, University of São Paulo, R. Dr. Ovídio Pires de Campos 785, 05403-010 São Paulo, Brazil b Laboratory of Medical Investigation (LIM 23), Department of Psychiatry, School of Medicine, University of São Paulo, R. Dr. Ovídio Pires de Campos 785, 05403-010 São Paulo, Brazil c Department of Psychiatry, Federal University of Goiás, Primeira Avenida, Sem Número, Setor Universitário, 74000-000 Goiânia, Goiás, Brazil
A R T I C L E I N F O
Article history: Received 27 May 2016 Received in revised form 27 October 2016 Accepted 10 December 2016 Keywords: Posture Major depressive disorder Photogrammetry
A B S T R A C T
The aim of this study was to investigate associations between poor spinal posture and the recurrence of major depressive episodes and severity of symptoms in patients with major depressive disorder (MDD). This was a cross-sectional quantitative study of MDD patients. Outpatients were recruited from consecutive admissions at a mood disorders unit of a tertiary psychiatric hospital. Of 136 MDD patients, 72 (53 women, 19 men; mean age, 42.4 9.1 years) met all the criteria and completed the study. Fortyone patients were classified with a recurrent episode (RE) of MDD and 31 with a single episode (SE). Quantitative assessments of postural deviations were made using photogrammetry, including kyphosis, shoulder protraction, and head inclination. The severity of depressive episodes was assessed using the Hamilton Depression Rating Scale. The diagnosis and classification of patients were performed according to DSM-IV-TR and SCID criteria. Multivariate analysis of variance indicated that the RE group had greater anterior head inclination (35.39; SD: 1.57), greater scapular abduction (1.69; SD: 0.93), and worse thoracic kyphosis (139.38; SD: 1.19) than the SE group (p < 0.001 for all). Multivariate analysis of covariance showed an interaction between the severity of depressive symptoms and the degree of thoracic kyphosis (p = 0.002). Recurrence of depressive episodes is associated with measures of postural misalignment. © 2016 Elsevier B.V. All rights reserved.
1. Introduction Major depressive disorder (MDD) is a serious health problem and will be the second leading worldwide disease burden by 2030 [1]. According to the Diagnostic and Statistical Manual of Mental Disorders Edition IV-Text Revised (DSM-IV-TR), MDD comprises diminished interest in all/most activities, depressed mood for most of the day, insomnia or sleeping too much, psychomotor retardation, loss of energy, diminished concentration ability, and recurrent thoughts of death [2]. MDD is more common in women than men and is highly recurrent [3]. Individuals who suffer from a first depressive episode have a 40%–60% chance of experiencing a subsequent episode. Individuals
* Corresponding author. E-mail address: [email protected] (J.Z. Canales). http://dx.doi.org/10.1016/j.gaitpost.2016.12.011 0966-6362/© 2016 Elsevier B.V. All rights reserved.
with two previous episodes have approximately a 60% chance of a further episode, and for individuals with three episodes the risk is as high as 90% [4–6]. The physical symptoms of depression include psychomotor delay, fatigue, diminished energy, and pain. Depressed patients demonstrate alterations in their motor and cognitive functioning, which can affect adaptation to variations in the everyday environment. Motor retardation is a prominent clinical feature of major depression [7], and depressed individuals tend to have slower gait, slumped posture, and less steadiness when walking than normal individuals [8,9]. Correct upright posture is an important health marker [10]; some deviations in body posture can be unsightly and can adversely affect muscular efficiency [11]. Posture may be defined as the composition of the positioning of all body segments at a given point in time [12]. Intrinsic and extrinsic factors that can
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influence posture include heredity, socioeconomic level, and emotional factors [13]. Posture can reflect biomechanical aspects of the body such as misalignment, shortening, and pain, but also reflects emotional state through non-verbal communication [14,15]. When an individual cannot express their feelings using facial gestures, posture becomes an ideal vehicle for bodily expression. [16]. Postural assessment can be an important clinical diagnostic tool in therapeutic practice, useful for comparing and verifying the efficacy of interventions such as physical exercise [17]. Clinical use of postural assessment includes physiotherapeutic assessment of body posture and psychological and psychiatric assessment of body language. One study showed that reduced walking speed and slumped posture unambiguously characterized the gait patterns of sad and depressed individuals [9]. Static body posture is a reliable source of emotional information and can indicate how emotion is expressed through the body [16]. In addition to motor impairment and gait, poor posture is associated with MDD. Therefore, postural assessment is clinically relevant and may reflect both physical aspects and emotional expression [18]. One study of athletes and non-athletic male students found no relationship between depression and thoracic kyphosis [19]. In contrast, another study [20] reported a positive relationship between increased angle of curvature of kyphosis and depressive
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symptoms in students. A relationship between low self-esteem and elevated thoracic kyphosis has also been documented [21]. Rosário et al. [22] investigated the association between depression and body posture in 40 women, in the absence of neurological, psychiatric, or musculoskeletal disorders. Relationships were found between depression scores and the angle of Tales (a scoliosis marker); current depression and inclination of the head and shoulders; chronic depression and shoulder protraction. Evidence therefore suggests that depression and sadness may change posture. Previous studies have suffered from methodological limitations, such as the use of non-clinical samples and symptom scales, instead of DSM-IV-TR criteria [19,20,22]. A previous quantitative study by our group over a 10-week period assessed body posture in 34 MDD patients and compared it with that of 37 healthy controls. Posture was assessed during a depressive episode using digital photographs of the subjects. Postural changes during depressive episodes included significant increases in anterior head flexion, increased thoracic kyphosis, a trend toward pelvic retroversion, and an increase in scapular distance. All these interfere with the proper functioning of skeletal muscles. During symptom remission, the posture of the patients with depression was similar to the control group. In addition to consequences such as pain, tension, and shortness of breath, such posture alterations are often
Fig. 1. Flow of participants through the trial.
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observed in MDD, and characterize a “depressive posture.” The findings demonstrated both emotional and physical negative impacts of depression [18]. Findings on body posture and depression are promising but sparse. There is a shortage of investigations into the effects of recurrent depressive episodes and symptom severity on static body posture in MDD patients. MDD involves a range of physical symptoms, such as psychomotor retardation and pain; therefore, it is relevant to assess postural misalignment and its consequences. The purpose of this study was to identify associations between recurrent episodes of MDD, severity of depressive symptoms, and spinal posture alignment. 2. Methods 2.1. Patient sample Of 136 consecutive MDD outpatients presenting at the Mood Disorders Unit (PROGRUDA) of the Institute and Department of Psychiatry of Clinics Hospital of the University of São Paulo Medical School (IPq-HC-FMUSP), 72 patients (53 women, 19 men; mean age, 42.4 9.1 years; range: 18–60 years) met all the criteria and were recruited to the study. 2.2. Inclusion and exclusion criteria Adult participants (men and women, aged 18–65 years) had to fulfill the DSM-IV-TR [2] and Structured Clinical Interview for DSM-IV-TR (SCID) [23] criteria for single or recurrent episodes of MDD. Participants were excluded if they had a history of other psychiatric, neuromuscular, musculoskeletal, respiratory, or neurological disorders; a fracture; any previous limitation to movement; or if they trained in physical exercise more than twice a week. 2.3. Recruitment of study participants Participants who registered on the study website PROGRUDA (www.progruda.com) between January 2013 and August 2014 were contacted. A telephone pre-screening was performed to confirm eligibility criteria. Those meeting all eligibility criteria were included in the study (Fig. 1). 2.4. Assessment methods A trained psychiatrist (RNC) made the MDD diagnoses using the DSM-IV-TR [2] and SCID [23]. For the recurrent depression group, the number of recurrent episodes was analyzed using the SCID [23]. The severity of depressive episodes was assessed using the 17-item Hamilton Depression Rating Scale (HDRS; severe episode: 25, moderate: 18; mild: 7) [24]. Spinal postural alignment was assessed by a trained physiotherapist (JZC) blind to the diagnosis and severity of depressive symptoms, and was conducted using photogrammetry. This evaluation was made during the morning (8:00 A.M.–12:00 P. M.), which we assumed would minimize the effects of natural intraindividual postural changes that may occur throughout the day. Patients from both groups were evaluated once during the depressive episode by the same physiotherapist, who assessed all the postural procedures (reference points, photograph, and photograph analysis). The photogrammetry technique involves quantitatively evaluating postural deviations using a photograph [11,25], and allows measurement of angles and distances between anatomical
reference points, joints, planes, and axes. It is a reliable, noninvasive measure of posture and its deviations [25,26] that is relatively time- and cost-effective, portable, and accessible for most clinicians [27]. Patients were photographed in a standing position in anterior, posterior, sagittal left, and sagittal right views [28]. As the left and right side views showed no appreciable difference, values from the left side were used for analysis. Patients were asked to wear swimsuits to permit marking of anatomical points (reference points). To prevent individuals modifying their position during assessment, patients were told “You will be standing when the picture is taken; try to stand naturally. How do you feel now?”. The reference points were the lateral malleolus; head of the fibula; greater trochanter of the femur; posterior and anterior iliac spine; spinous processes of the cervical vertebra (C7), thoracic (T3, T6, T9, T12) and lumbar (L3, L5) regions; and the inferior angle of the scapula [13]. Reference points were assessed using a tutorial [25], which established identification by palpation of the external limits of the bones. Points were marked using adhesive tape. The iliac spine (posterior and anterior), spinous processes (T3, T6, T9, T12, L3, L5, C7), and acromion were assessed on the sagittal plane by marking with polystyrene spheres (15 mm) to achieve a raised effect [25,29] (Fig. 2). After marking the points, patients were placed in front of a posture assessment grid (2 1-m board printed with 10 10-cm squares) mounted on a wooden base support (40 40 cm). The grid board and base unit incorporated a bubble spirit level to indicate floor slant [25,29]. The tripod for the camera was placed at a distance of 2.7 m from the grid board and set at a height of 1 m above floor level. The resultant photographs were analyzed in CorelDraw1 v.12 (Corel Corporation, Ottawa, Canada) using the anatomical points and reference lines of the grid board. Table 1 shows the measurements between anatomical points (degrees and distances) and postural variables. The interpretation of postural misalignments were as follows: head posture (down): low values represented more anterior inclination (looking down); shoulder posture: high values represented more shoulder protraction; scapular posture: high values represented greater abduction (distance) between the scapulae; thoracic kyphosis: low values represented more kyphosis (curvature); lumbar lordosis: high values represented less lordosis; pelvic inclination: high values represented more lordosis; knee posture: high values represented hyperextension; ankle posture: high values represented pronation of the ankle. We could find no indication of the normal population ranges of these postural variables in the literature. Postural alignment studies usually use normal controls for comparisons. 2.5. Data analysis Statistical analysis was performed using SPSS Version 22 (IBM Corp., Armonk, NY, USA). First, the sample was tested for homogeneity. For descriptive purposes, participants were classified into single episode (SE) and recurrent episode (RE) groups. The results are presented as mean, standard deviation (SD), and 95% confidence interval (CI) for quantitative variables, and as number (n) and percentage for qualitative variables. To test the interaction between depression severity and the recurrence of depressive disorder (RE vs. SE) in postural alignment, we used two-way multivariate analysis of variance, corrected for age, sex, and body mass index (BMI). To assess the impact of depressive symptoms on body posture, multivariate analysis of covariance was performed with postural variables as dependent variables and age, sex, BMI, and depression
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Fig. 2. Postural sagittal left plane (A) single episode; (B) recurrent episode. Head posture (1); shoulder posture (2); thoracic kyphosis (3); lumbar lordosis (4); pelvic inclination (5); knee posture (6). Graus = degrees.
severity as cofactors. Normality was checked using a Kolmogorov– Smirnov test. Values of p < 0.006 indicated statistical significance corrected for multiple comparisons. 3. Results Of the 72 patients, 41 were diagnosed with a recurrent MDD episode and assigned to the RE group, and 31 were diagnosed with a single MDD episode and assigned to the SE group. No betweengroup difference was observed for BMI, age, age at onset, and sex (Table 2). Depression severity was more severe in the RE group than in the SE group. Table 2 shows the number of recurrences in the RE group.
Of the 41 RE subjects, 21 were diagnosed with severe depressive episodes, 17 with moderate, and 3 with mild episodes. Of the 31 SE patients, 19 had severe episodes, 10 had moderate, and 2 had mild episodes. There was no significant between-group difference in episode severity (p = 0.070). The associations between postural variables and RE and SE groups revealed statistically significant between-group differences for head posture (down) (p < 0.001 for both), scapular posture (p < 0.001 for both), and thoracic kyphosis (p < 0.001 for both). The RE group showed greater postural misalignment (Table 3). The severity of depression had an impact on thoracic kyphosis (p = 0.002 for both left and right sides).
Table 1 Postural variables and the assessment procedure. Variable
Plane Anatomical points used for measurements
Head posture Thoracic kyphosis Lumbar lordosis Pelvic inclination Knee posture Scapula posture Shoulder posture Ankle posture
S S S S S P S P
Angle between horizontal lines at C7 and external auditory meatus. Angle between points of greatest concavity of cervical and lumbar spines, taking point of greatest thoracic convexity as the vertex. Angle between points of greatest convexity of thoracic spine and gluteus region and point of greatest thoracic concavity of lumbar spine. Angles between horizontal lines at levels of anterior superior and posterior superior iliac spines. Angles between lateral malleolus lines, head of fibula, and greater trochanter of femur. Distance in centimeters from the inferior angle to the corresponding spinous apophysis. Distance in centimeters from acromion to C7 spinous process. Angles between the vertical lines passing through the Achilles tendon and the mid-vertical line of the leg to the midpoint of the heel bone
Abbreviations: S: sagittal plane; P: posterior plane; C7: 7th cervical vertebra.
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Table 2 Numeric and categorical variables of the subject groups. Variable Sex
Male (%) Female (%) Age (years)a BMI (kg/m2)a HDRS a Age at onset (years)a Recurrences (n)a
p-valuec
MDD Group
b
RE (n = 41) 10 (52.6) 31 (58.5) 39.3 (9.5) 25.8 (5.6) 24.0 (5.3) 21.4 (21.4) 3.0 (0.9)
SE (n = 31) 9 (47.4) 22 (47.5) 37.3 (9.4) 25.5 (4.4) 21.6 (4.0) 22.58 (3.6) –
0.79d
0.36 0.85 0.033* 0.16e –
Abbreviations: RE: recurrent episode; SE: single episode; BMI: body mass index; HDRS: Hamilton Depression Rating Scale; MDD: major depressive disorder; *Significant differences were detected between groups (p < 0.05). a Mean (standard deviation). b Number of participants (%). c Independent samples t-test. d Chi-square test. e Mann–Whitney U test.
4. Discussion The main study purpose was to identify associations between recurrent episodes of MDD, depression severity, and spinal posture alignment. We observed that the recurrence of depressive episodes is associated with postural misalignment. Canales et al. [18] showed that patients with MDD presented with postural misalignment during a depressive episode (e.g., marked head flexion, scapular abduction, pelvic retroversion, greater thoracic kyphosis), which improved during symptom remission. In agreement with this earlier study, our findings demonstrated that recurrence of depressive episodes had a negative influence on postural alignment, mainly concerning the anterior inclination of the head, scapular abduction, and increased kyphosis. The observed head posture (higher anterior inclination/looking down) among recurrent depressed patients may lead to increased anterior tensile forces and posterior compressive forces [30]. This accords with evidence suggesting that an individual’s emotional state is reflected in the contraction of facial muscles [31] and body posture [16]. Patients with recurrent depression showed greater distance between the scapulae. This indicates abduction of the scapula to the side of the body, a finding not previously documented. This position suggests possible weakness of the major and minor rhomboid muscles. The scapula is important for normal movement of the upper extremities and scapular functions are greatly affected by the actions of surrounding muscles [32]. Scapular muscles maintain balance with each other and provide stability and mobility to the scapula [33]. If the position of the scapula hinders its ability to provide stability to the shoulder joint, dysfunction and pain in the shoulder and upper extremity are likely to occur [32]. In this study, the increase in scapula abduction may have been
associated with hyperkyphosis, but more studies are needed to confirm this. Thoracic kyphosis refers to forward curvature of the thoracic spine in the sagittal plane. Exaggerated thoracic kyphosis, or hyperkyphosis (as observed in our study), is associated with functional physical limitations [34], increased fall risk [35], and reduced spinal mobility [36]. In this study, we found a direct relationship between the severity of depressive symptoms and kyphosis. Hence, thoracic kyphosis is affected not only by the severity of depressive symptoms, but also by the recurrence of depressive episodes. Hyperkyphosis is also associated with poor self-esteem [21], sadness [37], and depressive symptoms in non-clinical subjects [22]. Therefore, recurrent depressed patients show postural alterations associated with both negative emotional states and motor dysfunction. These postural alterations may impact adjustment and recovery. These findings also corroborate the argument that emotional and bodily factors interact reciprocally to express non-verbal emotions [9]. Embodiment theories offer one interpretation of the reciprocal relationship between postural variation and emotional state [38–40]. They assume that emotional experience affects somatovisceral and motor systems (and vice versa) and hypothesize that both bodily and cognitive feedback loops can become established; these “lock” subsystems into a self-perpetuating configuration that maintains depression. Studies using ethological techniques have also shown that depressed patients’ body posture and movements, such as shrugging and looking with the head down, may non-verbally communicate ambivalent or negative feelings, and these may contribute towards interpersonal problems and the persistence of depressive states [41–43]. Our findings corroborate both embodiment theories and ethological observations, showing an interaction between recurrent negative emotional states and bodily factors. The postural alterations (anterior inclination of head, abduction of scapulae, and hyperkyphosis) in our patients with recurrent depressive episodes are common in elderly people [35,44]. Postural misalignment can indicate age-related changes and problems with emotional state [16,44]. Thus, our data suggest that the postures of depressive patients with recurrent episodes can resemble those of elderly people [44]. As we corrected all statistical analyses for age, sex, BMI, and depression severity, the finding of postural misalignment in patients with recurrent symptoms suggests independence from the intensity of depressive symptoms. Hence, postural misalignment may be a specific indicator of recurrent depressive episodes in later life, independently of current symptom levels. Little is known about the neurophysiological mechanisms underlying postural changes in depressed individuals, but it is known that motor disturbance in depression may indicate an underlying neuropathology and could be relevant to therapeutic
Table 3 Comparison of postural variables between recurrent and single episode MDD groups during a depressive episode. Measurements are taken from the sagittal plane and are corrected for age, gender, BMI, and HDRS. Postural Variables
MDD episode RE (n = 41)
Head posture ( ) Scapular posture (cm) Thoracic kyphosis ( )
p-valuea
SE (n = 31)
mean (SD)
95%CI
mean (SD)
95%CI
35.39 (1.57) 1.69 (0.93) 139.38 (1.19)
32.2–38.5 1.5–1.8 136.9–141.7
46.37 (1.79) 1.69 (0.53) 147.13 (1.35)
42.7–49.9 1.4.5–1.8 144.4–149.8
<0.001* <0.001* <0.001*
Abbreviations: MDD: major depressive disorder; RE: recurrent episode; SE: single episode; SD: standard deviation; R: right; L: left; CI: confidence interval. For thoracic kyphosis, the lower value represents a more kyphotic measure. *Significant difference between recurrent and single episode MDD, p < 0.05. a MANCOVA.
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interventions [45]. Some studies show that alterations in psychomotor performance in MDD may involve dysfunction in dopamine-rich regions of the basal ganglia, including the dorsal striatum [46,47]. Physical exercise can benefit MDD by increasing the functional activity of mood-related monoamines (e.g., dopamine, epinephrine/norepinephrine, serotonin) [48]. We suggest that, in addition to pharmacotherapeutic and psychological interventions, an exercise program for MDD patients would be an effective intervention for improving postural alignment. Thus, postural assessment in clinical screening could be used as an index of the effectiveness of exercise programs recommended to depressed people. Physical exercises focusing on postural alignment, in association with medical and psychological treatments, may help to improve symptoms in recurrent depressed patients. It is also possible that postural misalignments are caused by psychomotor and postural control alterations; however, this requires further investigation. To the best of our knowledge, this is the first study evaluating the association between recurrent episodes of MDD, depression severity, and spinal posture alignment. Evaluations were made on a clinical sample using postural alignment measurements based on photogrammetry. Future studies are needed to confirm our findings and to investigate whether postural misalignments are caused by alterations in motor and postural control. 5. Limitations One study limitation was the small sample size. A further limitation was locating the anatomical points for placement of markers. However, a tutorial on point location was carefully followed to avert possible placement errors [25]. Although the same appraiser evaluated the posture during the morning, which we assumed would minimize the effects of natural intraindividual postural changes that occur throughout the day, body posture does vary throughout the day; therefore, this was a limitation. In addition, we did not re-evaluate our results to assess their reliability. A final limitation was the lack of a healthy control population to act as a reference for posture. 6. Conclusion This study revealed associations between recurrent episodes of MDD, depression severity, and spinal posture alignment. Recurrent depressive patients had greater postural misalignment than single MDD episode patients, and severity of depressive symptoms was associated with kyphosis. These findings demonstrate that depression is a multifactorial disorder, which affects motor and gait patterns and body posture. Conflict of interest The authors have no conflicts of interest to report. Ethical approval Ethical approval was granted by the Ethics Committee of the Clinical Hospital, School of Medicine of the University of Sao Paulo, Brazil (process: 1127/05) and procedures were conducted according to the Declaration of Helsinki. All participants signed an informed consent form. Funding The authors report that there was no direct source of funding for the study.
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Acknowledgments We would like to thank the members of Mood Disorders Unit (PROGRUDA) for their work, as well as the volunteers for their collaboration.
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Full length article
Investigation of associations between recurrence of major depressive disorder and spinal posture alignment: A quantitative cross-sectional study Janette Z. Canalesa,* , Juliana T. Fiquerb , Rodolfo N. Camposc , Márcio Gerhardt Soeiro-de-Souzaa , Ricardo Alberto Morenoa a Mood Disorders Unit (GRUDA), Department of Psychiatry, School of Medicine, University of São Paulo, R. Dr. Ovídio Pires de Campos 785, 05403-010 São Paulo, Brazil b Laboratory of Medical Investigation (LIM 23), Department of Psychiatry, School of Medicine, University of São Paulo, R. Dr. Ovídio Pires de Campos 785, 05403-010 São Paulo, Brazil c Department of Psychiatry, Federal University of Goiás, Primeira Avenida, Sem Número, Setor Universitário, 74000-000 Goiânia, Goiás, Brazil
A R T I C L E I N F O
Article history: Received 27 May 2016 Received in revised form 27 October 2016 Accepted 10 December 2016 Keywords: Posture Major depressive disorder Photogrammetry
A B S T R A C T
The aim of this study was to investigate associations between poor spinal posture and the recurrence of major depressive episodes and severity of symptoms in patients with major depressive disorder (MDD). This was a cross-sectional quantitative study of MDD patients. Outpatients were recruited from consecutive admissions at a mood disorders unit of a tertiary psychiatric hospital. Of 136 MDD patients, 72 (53 women, 19 men; mean age, 42.4 9.1 years) met all the criteria and completed the study. Fortyone patients were classified with a recurrent episode (RE) of MDD and 31 with a single episode (SE). Quantitative assessments of postural deviations were made using photogrammetry, including kyphosis, shoulder protraction, and head inclination. The severity of depressive episodes was assessed using the Hamilton Depression Rating Scale. The diagnosis and classification of patients were performed according to DSM-IV-TR and SCID criteria. Multivariate analysis of variance indicated that the RE group had greater anterior head inclination (35.39; SD: 1.57), greater scapular abduction (1.69; SD: 0.93), and worse thoracic kyphosis (139.38; SD: 1.19) than the SE group (p < 0.001 for all). Multivariate analysis of covariance showed an interaction between the severity of depressive symptoms and the degree of thoracic kyphosis (p = 0.002). Recurrence of depressive episodes is associated with measures of postural misalignment. © 2016 Elsevier B.V. All rights reserved.
1. Introduction Major depressive disorder (MDD) is a serious health problem and will be the second leading worldwide disease burden by 2030 [1]. According to the Diagnostic and Statistical Manual of Mental Disorders Edition IV-Text Revised (DSM-IV-TR), MDD comprises diminished interest in all/most activities, depressed mood for most of the day, insomnia or sleeping too much, psychomotor retardation, loss of energy, diminished concentration ability, and recurrent thoughts of death [2]. MDD is more common in women than men and is highly recurrent [3]. Individuals who suffer from a first depressive episode have a 40%–60% chance of experiencing a subsequent episode. Individuals
* Corresponding author. E-mail address: [email protected] (J.Z. Canales). http://dx.doi.org/10.1016/j.gaitpost.2016.12.011 0966-6362/© 2016 Elsevier B.V. All rights reserved.
with two previous episodes have approximately a 60% chance of a further episode, and for individuals with three episodes the risk is as high as 90% [4–6]. The physical symptoms of depression include psychomotor delay, fatigue, diminished energy, and pain. Depressed patients demonstrate alterations in their motor and cognitive functioning, which can affect adaptation to variations in the everyday environment. Motor retardation is a prominent clinical feature of major depression [7], and depressed individuals tend to have slower gait, slumped posture, and less steadiness when walking than normal individuals [8,9]. Correct upright posture is an important health marker [10]; some deviations in body posture can be unsightly and can adversely affect muscular efficiency [11]. Posture may be defined as the composition of the positioning of all body segments at a given point in time [12]. Intrinsic and extrinsic factors that can
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influence posture include heredity, socioeconomic level, and emotional factors [13]. Posture can reflect biomechanical aspects of the body such as misalignment, shortening, and pain, but also reflects emotional state through non-verbal communication [14,15]. When an individual cannot express their feelings using facial gestures, posture becomes an ideal vehicle for bodily expression. [16]. Postural assessment can be an important clinical diagnostic tool in therapeutic practice, useful for comparing and verifying the efficacy of interventions such as physical exercise [17]. Clinical use of postural assessment includes physiotherapeutic assessment of body posture and psychological and psychiatric assessment of body language. One study showed that reduced walking speed and slumped posture unambiguously characterized the gait patterns of sad and depressed individuals [9]. Static body posture is a reliable source of emotional information and can indicate how emotion is expressed through the body [16]. In addition to motor impairment and gait, poor posture is associated with MDD. Therefore, postural assessment is clinically relevant and may reflect both physical aspects and emotional expression [18]. One study of athletes and non-athletic male students found no relationship between depression and thoracic kyphosis [19]. In contrast, another study [20] reported a positive relationship between increased angle of curvature of kyphosis and depressive
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symptoms in students. A relationship between low self-esteem and elevated thoracic kyphosis has also been documented [21]. Rosário et al. [22] investigated the association between depression and body posture in 40 women, in the absence of neurological, psychiatric, or musculoskeletal disorders. Relationships were found between depression scores and the angle of Tales (a scoliosis marker); current depression and inclination of the head and shoulders; chronic depression and shoulder protraction. Evidence therefore suggests that depression and sadness may change posture. Previous studies have suffered from methodological limitations, such as the use of non-clinical samples and symptom scales, instead of DSM-IV-TR criteria [19,20,22]. A previous quantitative study by our group over a 10-week period assessed body posture in 34 MDD patients and compared it with that of 37 healthy controls. Posture was assessed during a depressive episode using digital photographs of the subjects. Postural changes during depressive episodes included significant increases in anterior head flexion, increased thoracic kyphosis, a trend toward pelvic retroversion, and an increase in scapular distance. All these interfere with the proper functioning of skeletal muscles. During symptom remission, the posture of the patients with depression was similar to the control group. In addition to consequences such as pain, tension, and shortness of breath, such posture alterations are often
Fig. 1. Flow of participants through the trial.
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observed in MDD, and characterize a “depressive posture.” The findings demonstrated both emotional and physical negative impacts of depression [18]. Findings on body posture and depression are promising but sparse. There is a shortage of investigations into the effects of recurrent depressive episodes and symptom severity on static body posture in MDD patients. MDD involves a range of physical symptoms, such as psychomotor retardation and pain; therefore, it is relevant to assess postural misalignment and its consequences. The purpose of this study was to identify associations between recurrent episodes of MDD, severity of depressive symptoms, and spinal posture alignment. 2. Methods 2.1. Patient sample Of 136 consecutive MDD outpatients presenting at the Mood Disorders Unit (PROGRUDA) of the Institute and Department of Psychiatry of Clinics Hospital of the University of São Paulo Medical School (IPq-HC-FMUSP), 72 patients (53 women, 19 men; mean age, 42.4 9.1 years; range: 18–60 years) met all the criteria and were recruited to the study. 2.2. Inclusion and exclusion criteria Adult participants (men and women, aged 18–65 years) had to fulfill the DSM-IV-TR [2] and Structured Clinical Interview for DSM-IV-TR (SCID) [23] criteria for single or recurrent episodes of MDD. Participants were excluded if they had a history of other psychiatric, neuromuscular, musculoskeletal, respiratory, or neurological disorders; a fracture; any previous limitation to movement; or if they trained in physical exercise more than twice a week. 2.3. Recruitment of study participants Participants who registered on the study website PROGRUDA (www.progruda.com) between January 2013 and August 2014 were contacted. A telephone pre-screening was performed to confirm eligibility criteria. Those meeting all eligibility criteria were included in the study (Fig. 1). 2.4. Assessment methods A trained psychiatrist (RNC) made the MDD diagnoses using the DSM-IV-TR [2] and SCID [23]. For the recurrent depression group, the number of recurrent episodes was analyzed using the SCID [23]. The severity of depressive episodes was assessed using the 17-item Hamilton Depression Rating Scale (HDRS; severe episode: 25, moderate: 18; mild: 7) [24]. Spinal postural alignment was assessed by a trained physiotherapist (JZC) blind to the diagnosis and severity of depressive symptoms, and was conducted using photogrammetry. This evaluation was made during the morning (8:00 A.M.–12:00 P. M.), which we assumed would minimize the effects of natural intraindividual postural changes that may occur throughout the day. Patients from both groups were evaluated once during the depressive episode by the same physiotherapist, who assessed all the postural procedures (reference points, photograph, and photograph analysis). The photogrammetry technique involves quantitatively evaluating postural deviations using a photograph [11,25], and allows measurement of angles and distances between anatomical
reference points, joints, planes, and axes. It is a reliable, noninvasive measure of posture and its deviations [25,26] that is relatively time- and cost-effective, portable, and accessible for most clinicians [27]. Patients were photographed in a standing position in anterior, posterior, sagittal left, and sagittal right views [28]. As the left and right side views showed no appreciable difference, values from the left side were used for analysis. Patients were asked to wear swimsuits to permit marking of anatomical points (reference points). To prevent individuals modifying their position during assessment, patients were told “You will be standing when the picture is taken; try to stand naturally. How do you feel now?”. The reference points were the lateral malleolus; head of the fibula; greater trochanter of the femur; posterior and anterior iliac spine; spinous processes of the cervical vertebra (C7), thoracic (T3, T6, T9, T12) and lumbar (L3, L5) regions; and the inferior angle of the scapula [13]. Reference points were assessed using a tutorial [25], which established identification by palpation of the external limits of the bones. Points were marked using adhesive tape. The iliac spine (posterior and anterior), spinous processes (T3, T6, T9, T12, L3, L5, C7), and acromion were assessed on the sagittal plane by marking with polystyrene spheres (15 mm) to achieve a raised effect [25,29] (Fig. 2). After marking the points, patients were placed in front of a posture assessment grid (2 1-m board printed with 10 10-cm squares) mounted on a wooden base support (40 40 cm). The grid board and base unit incorporated a bubble spirit level to indicate floor slant [25,29]. The tripod for the camera was placed at a distance of 2.7 m from the grid board and set at a height of 1 m above floor level. The resultant photographs were analyzed in CorelDraw1 v.12 (Corel Corporation, Ottawa, Canada) using the anatomical points and reference lines of the grid board. Table 1 shows the measurements between anatomical points (degrees and distances) and postural variables. The interpretation of postural misalignments were as follows: head posture (down): low values represented more anterior inclination (looking down); shoulder posture: high values represented more shoulder protraction; scapular posture: high values represented greater abduction (distance) between the scapulae; thoracic kyphosis: low values represented more kyphosis (curvature); lumbar lordosis: high values represented less lordosis; pelvic inclination: high values represented more lordosis; knee posture: high values represented hyperextension; ankle posture: high values represented pronation of the ankle. We could find no indication of the normal population ranges of these postural variables in the literature. Postural alignment studies usually use normal controls for comparisons. 2.5. Data analysis Statistical analysis was performed using SPSS Version 22 (IBM Corp., Armonk, NY, USA). First, the sample was tested for homogeneity. For descriptive purposes, participants were classified into single episode (SE) and recurrent episode (RE) groups. The results are presented as mean, standard deviation (SD), and 95% confidence interval (CI) for quantitative variables, and as number (n) and percentage for qualitative variables. To test the interaction between depression severity and the recurrence of depressive disorder (RE vs. SE) in postural alignment, we used two-way multivariate analysis of variance, corrected for age, sex, and body mass index (BMI). To assess the impact of depressive symptoms on body posture, multivariate analysis of covariance was performed with postural variables as dependent variables and age, sex, BMI, and depression
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Fig. 2. Postural sagittal left plane (A) single episode; (B) recurrent episode. Head posture (1); shoulder posture (2); thoracic kyphosis (3); lumbar lordosis (4); pelvic inclination (5); knee posture (6). Graus = degrees.
severity as cofactors. Normality was checked using a Kolmogorov– Smirnov test. Values of p < 0.006 indicated statistical significance corrected for multiple comparisons. 3. Results Of the 72 patients, 41 were diagnosed with a recurrent MDD episode and assigned to the RE group, and 31 were diagnosed with a single MDD episode and assigned to the SE group. No betweengroup difference was observed for BMI, age, age at onset, and sex (Table 2). Depression severity was more severe in the RE group than in the SE group. Table 2 shows the number of recurrences in the RE group.
Of the 41 RE subjects, 21 were diagnosed with severe depressive episodes, 17 with moderate, and 3 with mild episodes. Of the 31 SE patients, 19 had severe episodes, 10 had moderate, and 2 had mild episodes. There was no significant between-group difference in episode severity (p = 0.070). The associations between postural variables and RE and SE groups revealed statistically significant between-group differences for head posture (down) (p < 0.001 for both), scapular posture (p < 0.001 for both), and thoracic kyphosis (p < 0.001 for both). The RE group showed greater postural misalignment (Table 3). The severity of depression had an impact on thoracic kyphosis (p = 0.002 for both left and right sides).
Table 1 Postural variables and the assessment procedure. Variable
Plane Anatomical points used for measurements
Head posture Thoracic kyphosis Lumbar lordosis Pelvic inclination Knee posture Scapula posture Shoulder posture Ankle posture
S S S S S P S P
Angle between horizontal lines at C7 and external auditory meatus. Angle between points of greatest concavity of cervical and lumbar spines, taking point of greatest thoracic convexity as the vertex. Angle between points of greatest convexity of thoracic spine and gluteus region and point of greatest thoracic concavity of lumbar spine. Angles between horizontal lines at levels of anterior superior and posterior superior iliac spines. Angles between lateral malleolus lines, head of fibula, and greater trochanter of femur. Distance in centimeters from the inferior angle to the corresponding spinous apophysis. Distance in centimeters from acromion to C7 spinous process. Angles between the vertical lines passing through the Achilles tendon and the mid-vertical line of the leg to the midpoint of the heel bone
Abbreviations: S: sagittal plane; P: posterior plane; C7: 7th cervical vertebra.
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Table 2 Numeric and categorical variables of the subject groups. Variable Sex
Male (%) Female (%) Age (years)a BMI (kg/m2)a HDRS a Age at onset (years)a Recurrences (n)a
p-valuec
MDD Group
b
RE (n = 41) 10 (52.6) 31 (58.5) 39.3 (9.5) 25.8 (5.6) 24.0 (5.3) 21.4 (21.4) 3.0 (0.9)
SE (n = 31) 9 (47.4) 22 (47.5) 37.3 (9.4) 25.5 (4.4) 21.6 (4.0) 22.58 (3.6) –
0.79d
0.36 0.85 0.033* 0.16e –
Abbreviations: RE: recurrent episode; SE: single episode; BMI: body mass index; HDRS: Hamilton Depression Rating Scale; MDD: major depressive disorder; *Significant differences were detected between groups (p < 0.05). a Mean (standard deviation). b Number of participants (%). c Independent samples t-test. d Chi-square test. e Mann–Whitney U test.
4. Discussion The main study purpose was to identify associations between recurrent episodes of MDD, depression severity, and spinal posture alignment. We observed that the recurrence of depressive episodes is associated with postural misalignment. Canales et al. [18] showed that patients with MDD presented with postural misalignment during a depressive episode (e.g., marked head flexion, scapular abduction, pelvic retroversion, greater thoracic kyphosis), which improved during symptom remission. In agreement with this earlier study, our findings demonstrated that recurrence of depressive episodes had a negative influence on postural alignment, mainly concerning the anterior inclination of the head, scapular abduction, and increased kyphosis. The observed head posture (higher anterior inclination/looking down) among recurrent depressed patients may lead to increased anterior tensile forces and posterior compressive forces [30]. This accords with evidence suggesting that an individual’s emotional state is reflected in the contraction of facial muscles [31] and body posture [16]. Patients with recurrent depression showed greater distance between the scapulae. This indicates abduction of the scapula to the side of the body, a finding not previously documented. This position suggests possible weakness of the major and minor rhomboid muscles. The scapula is important for normal movement of the upper extremities and scapular functions are greatly affected by the actions of surrounding muscles [32]. Scapular muscles maintain balance with each other and provide stability and mobility to the scapula [33]. If the position of the scapula hinders its ability to provide stability to the shoulder joint, dysfunction and pain in the shoulder and upper extremity are likely to occur [32]. In this study, the increase in scapula abduction may have been
associated with hyperkyphosis, but more studies are needed to confirm this. Thoracic kyphosis refers to forward curvature of the thoracic spine in the sagittal plane. Exaggerated thoracic kyphosis, or hyperkyphosis (as observed in our study), is associated with functional physical limitations [34], increased fall risk [35], and reduced spinal mobility [36]. In this study, we found a direct relationship between the severity of depressive symptoms and kyphosis. Hence, thoracic kyphosis is affected not only by the severity of depressive symptoms, but also by the recurrence of depressive episodes. Hyperkyphosis is also associated with poor self-esteem [21], sadness [37], and depressive symptoms in non-clinical subjects [22]. Therefore, recurrent depressed patients show postural alterations associated with both negative emotional states and motor dysfunction. These postural alterations may impact adjustment and recovery. These findings also corroborate the argument that emotional and bodily factors interact reciprocally to express non-verbal emotions [9]. Embodiment theories offer one interpretation of the reciprocal relationship between postural variation and emotional state [38–40]. They assume that emotional experience affects somatovisceral and motor systems (and vice versa) and hypothesize that both bodily and cognitive feedback loops can become established; these “lock” subsystems into a self-perpetuating configuration that maintains depression. Studies using ethological techniques have also shown that depressed patients’ body posture and movements, such as shrugging and looking with the head down, may non-verbally communicate ambivalent or negative feelings, and these may contribute towards interpersonal problems and the persistence of depressive states [41–43]. Our findings corroborate both embodiment theories and ethological observations, showing an interaction between recurrent negative emotional states and bodily factors. The postural alterations (anterior inclination of head, abduction of scapulae, and hyperkyphosis) in our patients with recurrent depressive episodes are common in elderly people [35,44]. Postural misalignment can indicate age-related changes and problems with emotional state [16,44]. Thus, our data suggest that the postures of depressive patients with recurrent episodes can resemble those of elderly people [44]. As we corrected all statistical analyses for age, sex, BMI, and depression severity, the finding of postural misalignment in patients with recurrent symptoms suggests independence from the intensity of depressive symptoms. Hence, postural misalignment may be a specific indicator of recurrent depressive episodes in later life, independently of current symptom levels. Little is known about the neurophysiological mechanisms underlying postural changes in depressed individuals, but it is known that motor disturbance in depression may indicate an underlying neuropathology and could be relevant to therapeutic
Table 3 Comparison of postural variables between recurrent and single episode MDD groups during a depressive episode. Measurements are taken from the sagittal plane and are corrected for age, gender, BMI, and HDRS. Postural Variables
MDD episode RE (n = 41)
Head posture ( ) Scapular posture (cm) Thoracic kyphosis ( )
p-valuea
SE (n = 31)
mean (SD)
95%CI
mean (SD)
95%CI
35.39 (1.57) 1.69 (0.93) 139.38 (1.19)
32.2–38.5 1.5–1.8 136.9–141.7
46.37 (1.79) 1.69 (0.53) 147.13 (1.35)
42.7–49.9 1.4.5–1.8 144.4–149.8
<0.001* <0.001* <0.001*
Abbreviations: MDD: major depressive disorder; RE: recurrent episode; SE: single episode; SD: standard deviation; R: right; L: left; CI: confidence interval. For thoracic kyphosis, the lower value represents a more kyphotic measure. *Significant difference between recurrent and single episode MDD, p < 0.05. a MANCOVA.
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interventions [45]. Some studies show that alterations in psychomotor performance in MDD may involve dysfunction in dopamine-rich regions of the basal ganglia, including the dorsal striatum [46,47]. Physical exercise can benefit MDD by increasing the functional activity of mood-related monoamines (e.g., dopamine, epinephrine/norepinephrine, serotonin) [48]. We suggest that, in addition to pharmacotherapeutic and psychological interventions, an exercise program for MDD patients would be an effective intervention for improving postural alignment. Thus, postural assessment in clinical screening could be used as an index of the effectiveness of exercise programs recommended to depressed people. Physical exercises focusing on postural alignment, in association with medical and psychological treatments, may help to improve symptoms in recurrent depressed patients. It is also possible that postural misalignments are caused by psychomotor and postural control alterations; however, this requires further investigation. To the best of our knowledge, this is the first study evaluating the association between recurrent episodes of MDD, depression severity, and spinal posture alignment. Evaluations were made on a clinical sample using postural alignment measurements based on photogrammetry. Future studies are needed to confirm our findings and to investigate whether postural misalignments are caused by alterations in motor and postural control. 5. Limitations One study limitation was the small sample size. A further limitation was locating the anatomical points for placement of markers. However, a tutorial on point location was carefully followed to avert possible placement errors [25]. Although the same appraiser evaluated the posture during the morning, which we assumed would minimize the effects of natural intraindividual postural changes that occur throughout the day, body posture does vary throughout the day; therefore, this was a limitation. In addition, we did not re-evaluate our results to assess their reliability. A final limitation was the lack of a healthy control population to act as a reference for posture. 6. Conclusion This study revealed associations between recurrent episodes of MDD, depression severity, and spinal posture alignment. Recurrent depressive patients had greater postural misalignment than single MDD episode patients, and severity of depressive symptoms was associated with kyphosis. These findings demonstrate that depression is a multifactorial disorder, which affects motor and gait patterns and body posture. Conflict of interest The authors have no conflicts of interest to report. Ethical approval Ethical approval was granted by the Ethics Committee of the Clinical Hospital, School of Medicine of the University of Sao Paulo, Brazil (process: 1127/05) and procedures were conducted according to the Declaration of Helsinki. All participants signed an informed consent form. Funding The authors report that there was no direct source of funding for the study.
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Acknowledgments We would like to thank the members of Mood Disorders Unit (PROGRUDA) for their work, as well as the volunteers for their collaboration.
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