379 Do Depressive Symptoms Mediate the Association Between Insomnia and Physical Activity?

Abstract Introduction Insomnia and depression are highly comorbid and have been shown to be independently associated with lower levels of physical activity. It is not clear, however, if being less physically active is a risk factor for or consequence of depression and insomnia. The factors that explain the associations between insomnia, depression, and physical activity are likely complex and overlapping. For example, insomnia may predict inactivity by impacting one’s energy levels, leaving them too tired to exercise. Insomnia may also interfere with one’s motivation to exercise due to low mood, as insomnia is associated with the development of depressive symptoms. The purpose of the present study was to explore whether depression mediated the link between insomnia and low levels of physical activity. Methods A national online survey was conducted from April-June 2020. Participants completed surveys to assess demographics, mood, sleep, and physical activity. Depressive symptoms were estimated with the Center for Epidemiologic Studies Depression Scale (CES-D). Insomnia symptoms were estimated with the Insomnia Severity Index (ISI). Physical activity levels were estimated with the International Physical Activity Questionnaire (IPAQ). Analyses were conducted using multiple linear regression, with separate models for depression, insomnia, and the combination of the two, on levels of physical activity. Results 3,952 adults (Mage = 46.9 years) completed the survey. According to the unadjusted models, greater insomnia symptoms were associated with greater depressive symptoms (b = 0.4523, SE = 0.019593, p < .001), and lower levels of physical activity (b = -38.741, SE = 18.236, p = 0.0337). The relationship between insomnia and physical activity was no longer significant, however, when controlling for depression (b = -6.140, SE = 19.274, p = 0.75). According to the mediation analyses, there was an indirect effect of insomnia on physical activity that was explained by differences in depressive symptoms (Sobel Test = -4.895, SE = 6.518, p < .001). Conclusion Our findings support previous research indicating associations between symptoms of insomnia and depression and physical activity. Future research should examine if these same results hold using a longitudinal design. Support (if any) Vargas: K23HL141581

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Changes in Physical Activity Pre-, During and Post-lockdown COVID-19 Restrictions in New Zealand and the Explanatory Role of Daily Hassles

Frontiers in Psychology ◽

10.3389/fpsyg.2021.642954 ◽

2021 ◽

Vol 12 ◽

Author(s):

Elaine A. Hargreaves ◽

Craig Lee ◽

Matthew Jenkins ◽

Jessica R. Calverley ◽

Ken Hodge ◽

...

Keyword(s):

Physical Activity ◽

Online Survey ◽

Longitudinal Design ◽

Short Form ◽

Daily Hassles ◽

Moderate Intensity ◽

Future Research ◽

Activity Levels ◽

Explanatory Role ◽

Convenience Sample

Covid-19 lockdown restrictions constitute a population-wide “life-change event” disrupting normal daily routines. It was proposed that as a result of these lockdown restrictions, physical activity levels would likely decline. However, it could also be argued that lifestyle disruption may result in the formation of increased physical activity habits. Using a longitudinal design, the purpose of this study was to investigate changes in physical activity of different intensities, across individuals who differed in activity levels prior to lockdown restrictions being imposed, and across three time periods: pre-, during- and post-lockdown. This study also examined the extent to which the experience of daily hassles explained any changes in physical activity. A convenience sample (N = 759) recruited through social media, provided data from an online survey administered during weeks 2–3 of a 5-week lockdown and 231 participants provided complete data again 6 weeks post-lockdown (72% female, M age = 43 years). Participants completed the International Physical Activity Questionnaire–Short Form and the Daily Hassles Scale. Results showed that vigorous and moderate intensity PA were significantly lower during- and post-lockdown compared to pre-lockdown in those individuals who had been highly active pre-lockdown. In contrast, for moderately active individuals pre-lockdown, vigorous and moderate intensity PA was significantly higher during-lockdown compared to pre-lockdown, and these increased levels of vigorous PA were maintained post-lockdown. Participants experienced daily hassles due to inner concerns, time pressures, family, and financial concerns to the same extent during- and post-lockdown. Those daily hassles had a small negative (Standardized β = −0.11; p < 0.05) predictive effect on post-lockdown PA. It appears that to understand the effect of COVID-19 restrictions on PA, the activity status of individuals pre-lockdown needs to be taken into account. The daily hassles appeared to play a role in post-lockdown PA behavior, but future research should investigate why these results occurred.

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660 Chronotype Associations with Insomnia, Depressive Symptoms, and Changes in Sleep and Health Behaviors during the COVID-19 Pandemic

SLEEP ◽

10.1093/sleep/zsab072.658 ◽

2021 ◽

Vol 44 (Supplement_2) ◽

pp. A258-A258

Author(s):

Megan Petrov ◽

Matthew Buman ◽

Dana Epstein ◽

Shawn Youngstedt ◽

Nicole Hoffmann ◽

...

Keyword(s):

Physical Activity ◽

Depressive Symptoms ◽

Health Behaviors ◽

Screen Time ◽

Online Survey ◽

Light Exposure ◽

Multinomial Logistic Regression ◽

Depression Scale ◽

Time In Bed ◽

Significant Difference

Abstract Introduction Evening chronotype (i.e., night owl preference) is associated with worse insomnia and depressive symptoms, and poorer health behaviors. The aim of this study was to examine the association between chronotype and these symptoms and health behaviors during COVID-19 pandemic quarantine. Methods An online survey, distributed internationally via social media from 5/21/2020–7/1/2020, asked adults to report sociodemographic/economic information, changes in sleep (midpoint, total sleep time, sleep efficiency, time-in-bed), and health behaviors (i.e., physical activity, sedentary screen time, and outdoor light exposure patterns) from prior to during the pandemic, chronotype preference (definitely morning [DM], rather more morning [RM], rather more evening [RE], or definitely evening [DE]), and complete the Insomnia Severity Index (ISI) and the 10-item Center for Epidemiologic Studies Depression scale (CES-D-10). Multinomial logistic regression and ANCOVA models, adjusting for age and sex, examined associations of chronotype with COVID-19 pandemic related impacts on sleep, depressive symptoms, and health behaviors. Results A subsample of 579 participants (M age: 39y, range: 18–80; 73.6% female), currently under quarantine and neither pregnant nor performing shift work, represented each chronotype evenly (~25%). Participants delayed their sleep midpoint by 72.0min (SD=111.5) during the pandemic. DE chronotypes had a greater delay than morning types (M±SD DE: 91.0±9.0 vs. RM: 55.9±9.2 & DM: 66.1±9.3; p=0.046) with no significant change in other sleep patterns relative to other chronotypes. However, DE and RE chronotypes had greater odds of reporting that their new sleep/wake schedule was still not consistent with their “body clock” preference relative to morning types (Χ2[15]=54.8, p<0.001), reported greater ISI (F[3,503]=5.3, p=.001) and CES-D-10 scores (F[3,492]=7.9, p<.001), and had greater odds for increased or consistently moderate-to-high sedentary screen time (Χ2[12]=22.7, p=0.03) and decreased physical activity (Χ2[12]=22.5, p=0.03) than DM chronotype. There was no significant difference in change in outdoor light exposure by chronotype (Χ2[12]=12.1, p=0.43). Conclusion In an international online sample of adults under COVID-19 pandemic quarantine, evening chronotypes, despite taking the opportunity to delay sleep to match biological clock preference, reported their sleep/wake schedules were still inconsistent with personal preference, and reported greater insomnia and depressive symptoms, and odds of engaging in poorer health behaviors than morning chronotypes. Support (if any):

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Factors That Shape Women’s Physical Activity: Development of the Reasons to Participate in Physical Activity Scale (RPPAS)

Healthcare ◽

10.3390/healthcare10010094 ◽

2022 ◽

Vol 10 (1) ◽

pp. 94

Author(s):

Zhaohui Su ◽

Dean McDonnell ◽

Ali Cheshmehzangi ◽

Jing Zhu ◽

Junaid Ahmad ◽

...

Keyword(s):

Physical Activity ◽

Online Survey ◽

Future Research ◽

Psychological Resilience ◽

Activity Levels ◽

Women's Participation ◽

Physical Activity Levels ◽

Activity Scale ◽

And Performance ◽

Physical Activity Scale

(1) Background: Obesity could deepen women’s susceptibility to COVID-19 infections and deaths. While physical activity has the potential to improve women’s physical and psychological resilience to the pandemic, there is a dearth of research on factors that motivate women’s participation in physical activity. Thus, to bridge the research gap, this study aims to identify factors that motivate women’s participation in physical activity. (2) Methods: An online survey on motivations for physical activity was developed and distributed to the participants. A total of 108 women offered complete answers (N = 108, 18–33 years old, Mage = 20.34 ± 2.42 years). Participants selected factors that promote their physical activity from a list of 34 factors from the Reasons to Participate in Physical Activity Scale (RPPAS) developed in this study. (3) Results: Exploratory factor analysis revealed that factors that motivate women’s participation in physical activity are: enjoyment and gratification, consideration for other activities (i.e., exergaming), health benefits, networking opportunities, and appearance and performance. Multiple linear regression analyses indicate that only consideration for appearance and performance was significantly associated with participants’ physical activity levels after controlling for compounding factors. (4) Conclusions: The findings of this study underscore the importance of appearance and performance in shaping women’s participation in physical activity. Furthermore, the results also emphasize the need for a nuanced understanding of factors that influence women’s physical activity levels. Future research could investigate how to leverage these motivators in tailored health interventions that aim to improve women’s physical activity.

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Integrating Tracker Data Into Clinical Care (Preprint)

10.2196/preprints.11818 ◽

2018 ◽

Author(s):

Lisa Gualtieri ◽

Zoë Reinus ◽

Sandra Rosenbluth ◽

Jeffrey Phillips

Keyword(s):

Physical Activity ◽

Online Survey ◽

Clinical Care ◽

Future Research ◽

Activity Levels ◽

Objective Data ◽

Physical Activity Recommendations ◽

The Impact ◽

Tailored Advice ◽

Activity Recommendations

BACKGROUND Adding physical activity to a weekly routine has been shown to contribute to both delaying onset and improving management of existing chronic conditions. With physicians a highly trusted source of advice and care, the physical activity recommendations received from doctors may be adhered to more than other sources, especially when advice is tailored to patients’ specific physical conditions and limitations in increasing activity levels. Yet a survey by Smith et al found that fewer than 50% of clinicians were able to provide specific guidance on physical activity. This issue may stem from physicians rarely having objective physical activity data to inform their counseling. OBJECTIVE We aimed to understand physician perceptions of the potential benefits and challenges of integrating trackers in a clinical setting to provide tailored counseling to patients on increasing physical activity. METHODS Our study consisted of two phases: an online survey and in-depth, key-informant interviews. We recruited 60 clinicians to complete a 50-question survey and recruited fourteen primary and specialty care physicians for 15-20 minute in-person or phone interviews. Results from the survey were tabulated through Google Forms, while the interviews were recorded and then analyzed for emerging themes. RESULTS Fifty-seven percent of the fourteen interviewed physicians reported that objective data would be useful in counseling their patients on physical activity. Three-quarters (77%) believed that advice based on an objective data display would be actionable for the patients. Of the 60 clinicians who completed the online survey, only 14% believe their patients are adhering to their physical activity recommendations. More than half (57%) of respondents believe that objective data collected from a tracker would be useful in counseling patients. However, when asked how likely they would be to recommend a tracker to a patient, 43% replied they would recommend a tracker to help motivate patients to make a lifestyle change. From the interviews and the survey, the majority of physicians believed that their biggest barrier is limited time for reviewing data, yet they also expressed strong interest in well-designed displays with a small number of data points highlighting physical activity since the patients' last visit. CONCLUSIONS The majority of physicians in our study believed that integrating tracker data into clinical settings would improve their ability to make personalized recommendations to patients, but also noted that significant barriers exist, most notably time. Future research is needed to 1) create and test condensed tracker data displays to determine physician willingness to view and use them, 2) evaluate the impact of the displays on physicians' ability to provide tailored advice to patients, and 3) evaluate the impact of tailored advice on increases in patients' physical activity levels.

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753 The role of circadian activity rhythms in depressive symptoms among female nursing students

SLEEP ◽

10.1093/sleep/zsab072.750 ◽

2021 ◽

Vol 44 (Supplement_2) ◽

pp. A293-A294

Author(s):

Xin Zhang ◽

Shih-Yu Lee

Keyword(s):

Nursing Education ◽

Depressive Symptoms ◽

Nursing Students ◽

Conceptual Model ◽

Depression Scale ◽

Psychological Problems ◽

Circadian Activity ◽

Activity Rhythms ◽

Wrist Actigraphy ◽

Insomnia Symptoms

Abstract Introduction Depression is prevalent among nursing students. Rumination and sleep-wake rhythms are associated to mental illness; however, no clear path has been found. This exploratory study aimed to examine the associations among circadian activity rhythms (CAR), rumination, and depressive symptoms in female nursing students; further, to test a hypothesized CAR conceptual model. Methods A total of 148 female nursing junior students in China completed a battery of questionnaires, including Athens Insomnia Scale (AIS), Ruminative Responses Scale (RRS), and Self-rating Depression Scale (SDS). Wrist actigraphy was used to collect total sleep time, CAR, and acrophase (time of the peak of the fitted activity curve). The path analysis was explored by using SPSS and AMOS. Results The mean age of the students was 20.64 years (SD = 0.86). About 58.8% of the participants were either mild or moderate depressed. About 93.9% of the students reported significant insomnia symptoms (AIS scores >6). Rumination was measured by the RRS (M= 2.01, SD = 0.54), and students scored higher in brooding than that of reflective pondering (2.07 vs. 1.95). The average of TST was 394.59 minutes (SD = 51.92). The CAR ranged from 0.40 to 0.98, with a mean of 0.75 (SD = 0.11). The acrophase ranged from 12:46 to 20:14 (median 16:30), with a later acrophase indicates of a more delayed circadian phase. The final model shows satisfactory fit (χ2= 2.238, p= .327); a better CAR can indirectly reduce depressive symptoms by directly reducing brooding (B = -1.149) and improving insomnia symptoms (B = -6.6443). Conclusion In order to prevent psychological problems of nursing students, ruminating and CAR should be part of health screening. The novel conceptual model provides a basis for reforming nursing education to prevent psychological problems. Support (if any) Chinese National Natural Science Foundation [71603279]

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Physical activity and depressive symptoms in community-dwelling elders from southern Brazil

Brazilian Journal of Psychiatry ◽

10.1590/s1516-44462011005000006 ◽

2011 ◽

Vol 33 (2) ◽

pp. 165-170 ◽

Cited By ~ 16

Author(s):

César L. Reichert ◽

César L. Diogo ◽

José L. Vieira ◽

Roberta R. Dalacorte

Keyword(s):

Physical Activity ◽

Depressive Symptoms ◽

Linear Trend ◽

Geriatric Depression Scale ◽

Depression Scale ◽

Population Based ◽

Community Dwelling ◽

Active Group ◽

Lower Prevalence ◽

Cross Sectional

OBJECTIVE: To determine the existence of a relationship between physical activity and depressive symptoms in community-dwelling elders. METHOD: This is a cross-sectional, population-based study, which included 379 community-dwelling elders from Novo Hamburgo, state of RS, Brazil. The level of physical activity was estimated using the International Physical Activity Questionnaire and depressive symptoms were diagnosed according to the Yesavage Geriatric Depression Scale. The association between the level of physical activity and depressive symptoms was analyzed by logistic regression. RESULTS: A tendency towards a lower prevalence of depressive symptoms was observed in individuals with higher levels of physical activity, both in the sample as a whole as well as among men, but not among women (p for linear trend 0.04, 0.03 and 0.36, respectively). The odds ratio of the presence of depressive symptoms in the very active group, as compared against that of the insufficiently active group was 0.32 (95% CI: 0.12-0.86) for men and 0.76 (95% CI: 0.39-1.46) for women. CONCLUSION: In this population of aged individuals, more intense physical activity is related to a lower prevalence of depressive symptoms. As shown by gender stratification, physical activity is inversely related to depressive symptoms in men, albeit not in women.

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Effectiveness of Attachment-Based Family Therapy compared to Treatment as Usual for Depressed Adolescents in Community Mental Health Clinics

10.21203/rs.3.rs-16225/v7 ◽

2021 ◽

Author(s):

Luxsiya Waraan ◽

Erling W. Rognli ◽

Nikolai Olavi Czajkowski ◽

Marianne Aalberg ◽

Lars Mehlum

Keyword(s):

Mental Health ◽

Depressive Symptoms ◽

Family Therapy ◽

Depression Scale ◽

Small Sample ◽

Post Treatment ◽

Treatment Manual ◽

Future Research ◽

Hamilton Depression Scale ◽

Treatment As Usual

Abstract Background: Major Depressive Disorder (MDD) is a disabling mood disorder, profoundly affecting a large number of adolescent’s quality of life. To date, no obvious treatment of choice for MDD in adolescents is available and progress in the treatment of depressed adolescents will have important public health implications. Attachment-Based Family Therapy (ABFT), as the only empirically supported family therapy model designed to treat adolescent depression, aims to repair interpersonal ruptures and rebuild an emotionally protective parent-child relationship. Objective: To study the effectiveness of ABFT compared with treatment as usual (TAU) delivered within child- and adolescent mental health services (CAMHS) to adolescents with MDD.Method: Sixty adolescents (86.7% girls), aged 13-18 years (M = 14.9, SD = 1.35), with MDD referred to two CAMHS were randomized to 16 weeks of ABFT or TAU. ABFT consisted of weekly therapy sessions (family/individual or both) according to the treatment manual. TAU was not monitored. Primary outcomes were assessed by blinded evaluators at baseline and post-treatment with the Hamilton Depression Scale (HAMD). Self-reported (Beck Depression Inventory-II, BDI-II) depressive symptoms were assessed at baseline, and after 4, 6, 8, 10,12, 14, and 16 weeks. Analyses were performed according to intent-to-treat principles. Results: At post-treatment, clinician-rated remission rates on the HAMD (5 % in ABFT and 3.33% in TAU, p =1, OR=1.54, Fisher’s exact test) and self-reported symptoms of depression on the BDI-II did not differ significantly between groups (X2[2, N = 60] =0.06 , p = 0.97). In both treatment groups participants reported significantly reduced depressive symptoms, but the majority (63.3 %) of adolescents were still in the clinical range after 16 weeks of treatment. Conclusion: ABFT was not superior to TAU. Remission and response rates were low in both groups, suggesting none of the treatments were effective in treating MDD in adolescents. Findings must be viewed in the context of the study’s small sample size, missing data, and implementation challenges. Continued efforts to improve treatment for MDD in outpatient clinics are warranted . Future research should examine moderators of and mechanisms for individual differences to treatment response, as well as the feasibility and cost-effectiveness of implementing treatment models which may require extensive training and expertise to yield clinically meaningful improvements in non-research settings. Trial Registration: Clinicaltrials.gov identifier: NCT01830088 https://clinicaltrials.gov/ct2/show/NCT01830088?term=Villab%C3%B8&draw=2&rank=1 Date of registration: April 12, 2013

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The Relationship between Sleep Hygiene, Mood, and Insomnia Symptoms in Men with Prostate Cancer

10.21203/rs.3.rs-665325/v1 ◽

2021 ◽

Author(s):

Kathleen T. Galvin ◽

Sheila N. Garland ◽

Erik Wibowo

Keyword(s):

Prostate Cancer ◽

Depressive Symptoms ◽

Daytime Sleepiness ◽

Online Survey ◽

Psychological Symptoms ◽

Sleep Hygiene ◽

Psychological Conditions ◽

Mailing Lists ◽

Anxiety Depression ◽

Insomnia Symptoms

Abstract PurposeInsomnia symptoms are commonly experienced by men after prostate cancer (PCa) treatment. Here we explored how sleep hygiene behaviours and psychological symptoms are associated with insomnia symptoms in PCa patients.MethodsAn online survey was posted on social media and sent to mailing lists of PCa and general cancer organisations. The survey collected information on demographic, sleep hygiene and psychological symptoms using validated questionnaires. ResultsData from 142 participants were compared based on the absence (age = 68.3 ± 8.9 years) and presence (age = 66.6 ± 9.0 years) of insomnia symptoms. Participants with insomnia symptoms had significantly higher levels of anxiety, depression, fatigue, and daytime sleepiness as well as poorer sleep hygiene than those without insomnia symptoms. Control variables (age, comorbidities, ADT experience and BMI) accounted for 12.5% of the variance in insomnia symptoms. Adding sleepiness, fatigue, anxiety, depressive symptoms to the model explained an additional 45.1% of the variance in insomnia symptoms. Further, including the sleep hygiene item “I think, plan, or worry when I am in bed” and “I sleep in an uncomfortable bedroom” explained an additional 3.6% of the variance in insomnia symptoms. ConclusionsPoor sleep hygiene, fatigue, daytime sleepiness, anxiety, depressive symptoms were all associated with worse insomnia symptoms in PCa patients. Improving sleep hygiene and treating psychological conditions may potentially help prevent and/or alleviate insomnia symptoms in PCa patients.

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Parents’ and Early Childhood Educators’ Perceptions on Movement and Learning Program Implementation

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph182211913 ◽

2021 ◽

Vol 18 (22) ◽

pp. 11913

Author(s):

Myrto F. Mavilidi ◽

Sue Bennett ◽

Fred Paas ◽

Anthony D. Okely ◽

Spyridoula Vazou

Keyword(s):

Physical Activity ◽

Early Childhood ◽

Program Implementation ◽

Online Survey ◽

Early Childhood Educators ◽

Activity Levels ◽

Learning Program ◽

Home Based ◽

Potential Benefits ◽

Program Components

There is currently limited evidence on parents’ and early childhood educators’ perspectives on implementing programs that combine cognitive and motor tasks in early childhood. An online survey was distributed across Australia through social network platforms and emails at preschool centres, asking 65 parents of preschool children and early childhood educators about their preferences on program delivery, duration, and mode. Responses from the survey were evaluated in order to develop and pilot a 4 week home-based (n = 5 parents) and a 6 week school-based program (n = 5 educators) including cognitively engaging physical activity, requesting parents’ and educators’ perspectives, respectively, about the program components. Results from the online survey showed a preference for programs with online (e.g., video-based) compared to traditional delivery (e.g., books), emphasising the potential benefits on children’s physical activity levels, sleep, and cognitive function. However, after piloting the program, educators preferred to use the book version instead of the video. This program has the potential to become part of daily regular practice. Barriers reported include logistics issues (i.e., book size), connectivity issues with internet, and the need for varying activities.

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Mindsets Predict Physical Activity and Relate to Chosen Management Strategies in Individuals with Knee Osteoarthritis

10.1101/2021.03.31.21254737 ◽

2021 ◽

Author(s):

Melissa A. Boswell ◽

Kris M. Evans ◽

Sean R. Zion ◽

Danielle Z. Boles ◽

Jennifer L. Hicks ◽

...

Keyword(s):

Physical Activity ◽

Knee Osteoarthritis ◽

Online Survey ◽

Management Strategies ◽

The Elderly ◽

Activity Level ◽

Activity Levels ◽

Group A ◽

Test Retest Reliability ◽

The Relationship

Objectives. We compared mindsets about physical activity among those with and without knee osteoarthritis and investigated if these mindsets relate to physical activity level and symptom management. Methods. Participants with (n=150) and without (n=152) knee osteoarthritis completed an online survey at study enrollment (T1). Participants with knee osteoarthritis repeated the survey three weeks later (T2; n=62). The mindset questionnaire, scored from 1-4, assessed the extent to which individuals associate the process of exercising with less appeal-focused qualities (e.g., boring, painful, isolating, and depriving) vs. appeal-focused (e.g., fun, pleasurable, social, and indulgent) versus. Using linear regression, we examined the relationship between mindset and having knee osteoarthritis, and, in the subgroup of participants with knee osteoarthritis, the relationship between mindset at T1 and physical activity (via the Physical Activity Scale for the Elderly) at T2. We also compared mindsets between those who use medication for management and those who use exercise. Results. A less appeal-focused mindset regarding physical activity was marginally associated with having knee osteoarthritis (β=-0.125, P=0.096). Within the knee osteoarthritis group, a more appeal-focused mindset predicted higher future physical activity (β=20.68, P=0.039), controlling for current physical activity, demographics, and health. Individuals that used exercise with or without pain medication or injections had more appeal-focused process mindsets than those who used medication or injections without exercise (P<0.001). Further, the process mindset inventory demonstrated strong internal consistency (α=0.92 at T1 for n=150 and α=0.92 at T2 for n=62) and test-retest reliability (ICC>0.841, P<0.001) within the knee osteoarthritis population. Conclusion. In individuals with knee osteoarthritis, mindsets predict future physical activity levels and relate to an individual's management strategy. Mindsets are a reliable and malleable construct and may be a valuable target for increasing physical activity and improving adherence to rehabilitation strategies involving exercise among individuals with knee osteoarthritis.

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