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Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area
Abstract
The sacroiliac joint (SIJ) is often considered to be involved when people present for care with low back pain where the sacroiliac joint (SIJ) is located. However, determining why the pain has arisen can be challenging, especially in the absence of a specific cause such as pregnancy, disease, or trauma, where the SIJ may be identified as a source of symptoms with the help of manual clinical tests. Nonspecific SIJ-related pain is commonly suggested to be causally associated with movement problems in the sacroiliac joint(s); a diagnosis traditionally derived from manual assessment of movements of the SIJ complex. Management choices often consist of patient education, manual treatment, and exercise. Although some elements of management are consistent with guidelines, this perspective argues that the assumptions on which these diagnoses and treatments are based are problematic, particularly if they reinforce unhelpful, pathoanatomical beliefs. This article reviews the evidence regarding the clinical detection and diagnosis of SIJ movement dysfunction. In particular, it questions the continued use of assessing movement dysfunction despite mounting evidence undermining the biological plausibility and subsequent treatment paradigms based on such diagnoses. Clinicians are encouraged to align their assessment methods and explanatory models to contemporary science to reduce the risk of their diagnoses and choice of intervention negatively affecting clinical outcomes.
... Dans le cas contraire, le problème entre dans la catégorie des douleurs non spécifiques ou idiopathiques [10] . À ce jour, la douleur idiopathique de l'ASI reste cependant énigmatique et fait toujours l'objet de diverses théories [11][12][13] . Les modèles actuels tendent à considérer autant les facteurs psychosociaux, hormonaux et neurophysiologiques que biomécaniques pour expliquer les symptômes du patient [9,10,12,13] . ...
... À ce jour, la douleur idiopathique de l'ASI reste cependant énigmatique et fait toujours l'objet de diverses théories [11][12][13] . Les modèles actuels tendent à considérer autant les facteurs psychosociaux, hormonaux et neurophysiologiques que biomécaniques pour expliquer les symptômes du patient [9,10,12,13] . Ainsi, et plus particulièrement dans les cas de douleur chronique, l'ASI et ses tissus environnants ne sont plus les seuls générateurs de la douleur ; celle-ci pourrait être liée à des mécanismes de sensibilisation périphérique et centrale, eux-mêmes influencés par de nombreux facteurs biopsychosociaux [10] . ...
... Ces caractéristiques de forme et de force confèrent ainsi une très faible mobilité à l'ASI dans les six degrés de liberté de mouvement, avec une petite quantité de rotation et de translation [12,14] (Fig. 1). De fait, une étude utilisant l'analyse radiostéréométrique sur une population saine, méthode précise, fiable et appropriée pour évaluer la mobilité tridimensionnelle de petites amplitudes de mouvement articulaire, a obtenu comme résultats des valeurs moyennes (écart-type) de rotation de 0,2 • (0,5 • ) et de translation de 0,3 mm (0,2 mm) lors de tests en position debout (standing hip flexion test/Gillet test). ...
... While local tissue pathology can contribute to a person's experience of pain via peripheral nociception, according to , Holopainen (2021), Moseley and Butler (2017), and Palsson et al. (2019), the pain experience is more accurately viewed as a multidimensional, biopsychosocial experience that is associated with perceived bodily threat. In many situations, pain is beneficial as it alerts the individual that they may need to take action to protect their bodily integrity (Coninx & Stilwell, 2021). ...
... In addition to being an unreliable measure of tissue damage, pain may also lead to a vicious cycle of pain-related distress, pain-related fear, pain catastrophisation, unhelpful health behaviours (i.e., movement avoidance), and disability, which then can perpetuate or heighten a person's pain experience (Caneiro, Smith, et al., 2021;Palsson et al., 2019). Drawing on the common-sense model of illness representation, Caneiro, Smith, et al. (2021) and Palsson et al. (2019) argue that a person's beliefs about their pain can influence their health outcomes. ...
... In addition to being an unreliable measure of tissue damage, pain may also lead to a vicious cycle of pain-related distress, pain-related fear, pain catastrophisation, unhelpful health behaviours (i.e., movement avoidance), and disability, which then can perpetuate or heighten a person's pain experience (Caneiro, Smith, et al., 2021;Palsson et al., 2019). Drawing on the common-sense model of illness representation, Caneiro, Smith, et al. (2021) and Palsson et al. (2019) argue that a person's beliefs about their pain can influence their health outcomes. According to the model, a person experiencing pain attempts to make sense of their pain by creating a cognitive representation of it shaped by the person's existing beliefs about the identity, cause, consequences, timeline, and controllability of their pain (Caneiro, Smith, et al., 2021;Palsson et al., 2019). ...
The words spoken by clinicians can profoundly impact a person's perception of their body. Words may influence pain, as pain is a measure of perceived threat. Words such as tear, rupture, degeneration, instability, and damage may increase perceived threat. Similarly, pathologising 'abnormal' anatomical variation may leave people feeling vulnerable and fragile. This article aimed to explore the potential consequences of particular words and narratives commonly used to describe plantar heel pain and justify interventions used to treat plantar heel pain. Drawing on the existing body of pain-science research, the authors argue that some of the language and narratives used in the literature and practice may potentially be threat invoking/nocebic. In addition, we argue that justifying interventions such as orthoses by stating that they normalise foot function may leave patients feeling broken, deficient, and abnormal. In response, we provide several recommendations for clinicians to help them avoid invoking threat when describing plantar heel pain and justifying interventions for it. McGrath, R. L., Murray, A. W., Maw, R. A., & Searle, D. J. (2022). 'Collapsed arches', 'ripped plantar fasciae', and 'heel spurs': The painful language of plantar heel pain. New Zealand Journal of Physiotherapy, 50(2), 58–63. https://doi.org/10.15619/NZJP/50.2.02
... It has been assumed that pain located within the pelvis with mechanical causes is divided into three main categories: pregnancy-related pelvic pain, specific pathology pain, and pain of other origin [17][18][19]. Their common denominator is a disturbance in the function of the sacroiliac joints. Pelvic pain is obviously a highly complex phenomenon, and its causes are seen in structures other than the sacroiliac joints located within the pelvis itself, and it can be projected from the neighboring parts of the body [19][20][21]. ...
... In contrast to our study, these authors separately assessed the TPD with increasing and decreasing spacing of the caliper arms. The authors, for this test on the left healthy side, obtained a value of ICC = 0.74-0.82 in young people (aged [18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35] and ICC = 0.76-0.78 for older people (aged 36-65) for one examiner and ICC = 0.66-0.75 in young people and ICC = 0.72-0.78 in older people for two examiners. ...
Tactile acuity is typically measured by a two-point discrimination test (TPD) and a two-point estimation task (TPE). In the back area, they are only conducted in the lumbar and cervical regions of the spine. Considering that such measurements have not been conducted in the sacral regions, the purpose of this study was to assess the inter- and intra-examiner reliability of the TPD and TPE at the level of the S3 segment. The study included 30 pain-free subjects aged 20–30 years. Tests were performed with a pair of stainless hardened digital calipers. The TPD was measured in two locations: 5 and 15 cm from the midline; for TPE both, points were located inside the measured area. Session 1 involved assessments by two examiners in 10-min intervals. Session 2 was measured by one examiner, at analogous intervals between tests. The TPD inter-rater reliability was excellent for mean measurements (ICC3.2: 0.76–0.8; ICC3.3: 0.8–0.92); the intra-rater reliability was excellent for mean measurements (ICC2.2: 0.79–0.85; ICC2.3: 0.82–0.86). The TPE inter-rater reliability was good to excellent for mean measurements (ICC3.2: 0.65–0.92; ICC3.3: 0.73–0.94); the intra-rater reliability for all studies (ICC2.1, ICC2.2, ICC2.3) was excellent (0.85–0.89). Two measurements are sufficient to achieve good reliability (ICC ≥ 0.75), regardless of the assessed body side.
... Despite decades of extensive research, the exact causes of many cases of LBP remain elusive; therefore, the main diagnostic label often granted is nonspecific chronic low back pain (NSCLBP) [1]. In their attempts to elucidate the variability of NSCLBP presentations, some researchers have implicated the sacroiliac joints (SIJs) in the lumbosacral zone as possible culprits in the etiology of some cases of NSCLBP [3,4]. However, diagnostic investigations of SIJ-related nociceptive mechanisms in NSCLBP remain inconclusive [3,4]. ...
... In their attempts to elucidate the variability of NSCLBP presentations, some researchers have implicated the sacroiliac joints (SIJs) in the lumbosacral zone as possible culprits in the etiology of some cases of NSCLBP [3,4]. However, diagnostic investigations of SIJ-related nociceptive mechanisms in NSCLBP remain inconclusive [3,4]. ...
Objectives:
To compare the lumbosacral nerve distances (LNDs) and sacroiliac joint (SIJ) morphology in individuals with nonspecific chronic low back pain (NSCLBP) and control and examine their correlations with pain and dysfunction in the former.
Materials and methods:
The sample includes 200 adult patients (ranging from 20 to 50 years old) referred for computerized abdominal tomography (CT): 100 individuals with NSCLBP (50 males and 50 females) and 100 individuals without NSCLBP (50 males and 50 females). CT scans were assessed for LNDs, degenerative sacroiliac changes, and joint bridging. Those factors were correlated to the outcomes of three self-reported questionnaires about pain and function (Oswestry, Fear-Avoidance, and Numerical Pain Rating Scale) in the NSCLBP group.
Results:
Individuals with NSCLBP tend to have reduced LNDs from the sacral part of the SIJ compared to controls (males: right Δ = 5.8 mm, left Δ = 6.03 mm; females: right Δ = 7.9 mm, left Δ = 7.73 mm, two-way ANOVA, p < 0.01), with moderate significant negative correlations with all three questionnaires (-0.38 < Pearson's r < - 0.57, p < 0.02, i.e., reduced LNDs with greater disability and pain). The NSCLBP group had more significant SIJ degeneration severity that moderately correlated with two questionnaires (0.39 < Pearson's r < 0.66, p < 0.04, i.e., greater SIJ degeneration with greater disability and pain). In males, the existence of SIJ bridging strongly correlated with all three questionnaires (0.38 < Pearson's r < 0.78, p < 0.03), and in females, only the Fear-Avoidance Questionnaire and Numerical Pain Scale (0.29 < Pearson's r < 0.41, p < 0.04).
Conclusion:
Compared to controls, individuals with NSCLBP have reduced LNDs and worse SIJ degenerative changes that correlate with function and pain.
Key points:
• Individuals with nonspecific low back pain tend to have reduced lumbosacral nerve distances than healthy controls. This may be due to entrapments or inflammation of the nerves or surrounding tissues. • Individuals with nonspecific low back pain tend to have more severe degeneration of their sacroiliac joint than healthy controls. • The above findings significantly correlated with the scores of three self-reported questionnaires about pain and function, implicating that they may be of clinical significance.
... Indeed, while a manual technique can be effective in the short term, the narrative that guides it, which the practitioner presents when framing the patient and taking care of them, can have very significant consequences on the meaning that the patient gives and will give to their own disorder [30]. ...
... The same palpatory identification of the target structures proved to be poorly reproducible, with little agreement also as to the identification and pinpointing of anatomically evident elements such as the posterior superior and anterior superior iliac spines [30]. It is therefore not surprising that the assessment of any hypomobility or hypermobility of the selected segments shows low agreement values among different assessors [41,42] and that different therapists choose treat different joints [43]. ...
Manual Therapy is one of the most widely used therapeutic solutions in the treatment of pain and musculoskeletal disorders. Its evolution began several centuries ago and culminated in the modern reference methods in the field of physiotherapy, osteopathy, and chiropractic, which mainly address the treatment of joint and myofascial tissues. The advent of evidence-based medicine and the ever-growing literature available in the field of Manual Therapy has led this therapeutic approach to be heavily criticized on the basis of studies that have shown its limitations with regard to manual and palpatory assessment techniques, the poor biomechanical validity of therapeutic methods, and the poor long-term results in the treatment of patients with musculoskeletal pain. A better understanding of the mechanisms underlying the effectiveness of Manual Therapy, as well as of the mediators of the medium- and long-term effectiveness of musculoskeletal rehabilitation processes, has made it possible to reconsider the role of Manual Therapy and the healthcare professionals specializing in manipulative therapy within the framework of the biopsychosocial model, which focuses on the patient and their functionality.
... The classification of these CAMs indicates that none have been subjected to rigorously designed and executed scientific studies that address essential questions such as their biological plausibility or clinical effectiveness. In contrast, when these therapies respond favorably to the scientific method, they are removed from the lists of CAMs and integrated into the repertoire of evidence-based techniques [22]. The importance of this discussion lies in the fact that in the best-case scenario, CAMs may not have a direct adverse effect. ...
The increasing interest in complementary and alternative medicines (CAMs) for musculoskeletal care has sparked significant debate, particularly regarding their biological plausibility and clinical effectiveness. This comprehensive review critically examines the use of two of the most widely utilized CAMs—osteopathy and chiropractic care—over the past 25 years, focusing on their biological plausibility, clinical effectiveness, and potential mechanisms of action. Our analysis of current research and clinical studies reveals that osteopathy and chiropractic are based on concepts such as “somatic dysfunction” and “vertebral subluxation”, which lack robust empirical validation. While these therapies are often presented as credible treatment options, studies evaluating their effectiveness frequently exhibit serious methodological flaws, providing insufficient empirical support for their recommendation as first-line treatments for musculoskeletal conditions. The effects and mechanisms underlying osteopathy and chiropractic remain poorly understood. However, placebo responses—mediated by the interaction of contextual, psychological, and non-specific factors—appear to play a significant role in observed outcomes. The integration of therapies with limited biological plausibility, whose effects may primarily rely on placebo effects, into healthcare systems raises important ethical dilemmas. This review highlights the need for rigorous adherence to scientific principles and calls for a more comprehensive investigation into biobehavioral, contextual, and psychosocial factors that interact with the specific effects of these interventions. Such efforts are essential to advancing our understanding of CAMs, enhancing clinical decision-making, promoting ethical practices, and guiding future research aimed at improving patient care in musculoskeletal disorders.
... Positive tests are interpreted as an indicator of increased SIJ sensitivity. [10] Three or more test positivity has a sensitivity of 85% and a specificity of 76-79% and is considered significant in terms of SIJD. [11][12][13] In this study, at least three positive tests were accepted as diagnostic for SIJD. ...
Background and Aim: Chronic lower extremity edema has been associated with postural impairment, sacroiliac joint dysfunction (SIJD), and abnormal gait. Lymphedema and lipedema are important chronic lower extremity causes. This study aimed to detect the presence of SIJD and postural disorders in patients with lower extremity edema and the relationship between them.
Methods: This is a comparative, prospective cohort study. Fifty-three patients with lower extremity edema and 53 healthy subjects were included in the study. Pain provocation tests were used to determine SIJD. Postural analysis was conducted with PostureScreen® Mobile 11.2 (PostureCo, Inc., Trinity, FL) software. The life quality of participants was determined by the Lymphedema Quality of Life (LYMQOL) scale. The functional status of the patients was determined by the Oswestry Disability Index and Lower Extremity Functional Scale.
Results: SIJD (18.9%) was more common in the edema group. There was a positive correlation between volume differences, percentages, and the development of SIJD. We found deviations in the head, shoulder, and hip angulations in the edema group. Q angle and lateral shoulder angulation were significantly higher in patients with SIJD in the edema group. In the edema group, LYMQOL-leg total score was higher in patients with SIJD.
Conclusion: Chronic lower extremity edema was found to be associated with postural deviations and SIJD. Besides edema control, postural disorders and SIJD should also be considered in these patients.
... Palsson refiere el dolor de articulaciones sacroiliacas y las engloba en tres etiologías principales: del embarazo, de enfermedad específica y dolor lumbar sacroiliaco no específico. 3 ...
... Recently, it was argued that in the management of SIJrelated pain clinicians should align their approach to a contemporary understanding of pain [5]. Such a perspective acknowledges pain as being a product of more than just local tissue nociception. ...
... For example, many practitioners continue to assess movement dysfunction when assessing the sacroiliac joint, suggesting to athletes their 'pelvis is off' or 'stuck', yet there is evidence undermining these assessments and treatment paradigms. 18 Once the athlete is sufficiently concerned, an intervention is proposed. It is clear that communication style and persuasion techniques during an athlete-clinician encounter can positively or negatively influence an athlete's 'buy-in' and subsequent expectations. ...
An athlete's body plays an important role in their performance and well-being. However, game-relevant skills are better determinants of success, compared with physical fitness, in technically-driven team sports. In the professional era, over utilization of resources, in pursuit of physical optimization, can detract from time spent on priorities. Athletes' non-strategic, time-demanding focus on physical preparation/treatments resembles avian 'avoidance preening', whereby stressful situations trigger birds to excessively preen in place of more productive activities. The purpose of this commentary is to explore the behaviors of resource-rich professional teams and the roles of staff dedicated to optimizing physical performance, including circumstances that foster avoidance behavior and create the potential for practitioners to encourage co-dependent relationships with athletes. To cultivate healthy/productive environments, the following is recommended: I) recognition of non-productive avoidance behaviors; II) eschewing unjustified, fear promoting, pathoanatomical language; III) fostering collaborative approaches; IV) encouraging utilization of psychology services; V) recognizing that optimal physical function and feeling good is rarely the primary goal in professional team sports.
Level of evidence:
5.
... Moreover, as spinal pain is currently considered an episodic condition [5], advice on self-management strategies to reduce or control future pain episodes should be included as first line treatment options [5]. In line with this, a four-step model was recently suggested [64] with the aim of guiding clinicians in the management of non-specific musculoskeletal pain conditions. Table 1 illustrates how this model is adapted to spinal pain in children/adolescents. Table 1. ...
Spinal pain in adults is a significant burden, from an individual and societal perspective. According to epidemiologic data, spinal pain is commonly found in children and adolescents, where evidence emerging over the past decade has demonstrated that spinal pain in adults can, in many cases, be traced back to childhood or adolescence. Nevertheless, very little focus has been on how to best manage spinal pain in younger age groups. The purpose of this article is to put the focus on spinal pain in children and adolescents and highlight how and where these problems emerge and how they are commonly dealt with. We will draw on findings from the relevant literature from adults to highlight potential common pathways that can be used in the management of spinal pain in children and adolescents. The overall focus is on how healthcare professionals can best support children and adolescents and their caregivers in making sense of spinal pain (when present) and support them in the self-management of the condition.
... A positive index test only indicates that mechanical hyperalgesia or allodynia is present in the scope of the provocation tests. 29 Modern understanding of pain is that it is multifactorial and not solely dependent on "input" from tissues. 3,45 Notably, there is an ambiguous link between nociception and pain and a disparity between reported pain and disability. 2 The multifactorial nature of pain is unlikely to be captured solely by a pain provocation test or by basing diag- ...
Objective:
To assess the diagnostic test accuracy of pain provocation tests for the sacroiliac joint.
Design:
Systematic review of diagnostic test accuracy.
Literature search:
Eight electronic databases and reference lists of included studies and previous reviews.
Study selection criteria:
Studies investigating the diagnostic accuracy of clusters of clinical tests for sacroiliac joint pain.
Data synthesis:
Bivariate random effects meta-analysis was employed. Risk of bias and applicability concerns were assessed using the QUADAS-2 tool and the GRADE tool to judge credibility of evidence.
Results:
From 2195 records identified in the search, five studies were included that assessed clusters of pain provocation tests for the sacroiliac joint. The estimated likelihood ratios (LLR) and diagnostic odds ratio (DOR) were positive LLR (2.13, 95%CI: 1.2, 3.9), negative LLR (0.33, 95% CI: 0.11, 0.72) and DOR (9.01, 95% CI: 1.72, 28.4). GRADE ratings for the outcomes were of very low certainty. Assuming a point prevalence of sacroiliac joint pain of 20%, we calculated positive posterior probability of 35% (95%CI: 32%, 46 37%) and negative posterior probability of 8% (95%CI: 6%, 10%).
Conclusions:
A positive result on a sacroiliac joint pain provocation test cluster gives the clinician 35% certainty of having correctly identified sacroiliac joint pain. Clusters of pain provocation tests for the sacroiliac joint do not provide sufficient diagnostic accuracy for ruling in the sacroiliac joint as the source of pain. Clinicians can rule out the sacroiliac joint as the source of pain with more confidence-the negative post-test probability indicates the clinician can conclude with 92% certainty that a negative test result is correct. J Orthop Sports Phys Ther, Epub 1 Jul 2021. doi:10.2519/jospt.2021.10469.
... Potential interpretations may include static joint 'malposition' with palpation, in addition to more dynamic constructs such as stiffness (k = F/δ), joint kinetics or joint kinematics. Further, the importance of several of these constructs has been questioned in the context of MT assessment and mechanisms of action [2,6,8,9]. Therefore, when considering biomechanical constructs in MT education, we should reevaluate those with questionable validity, reliability, biological plausibility, and clinical relevance (e.g. SIJ/ pelvic 'malalignment', vertebral and peripheral joint 'malposition/subluxation') and reconsider their inclusion as foundational concepts. ...
... A dominant biomechanical and structural view still pervades many management paradigms for the treatment of PGP, including sacroiliac joint (SIJ) pain (for example (Cibulka, 2002;Lee, 2015)). These management approaches lack validity (Bastiaanssen et al., 2005;Miles and Bishop, 2019;Palsson et al., 2019) (see Table 2 for a review of helpful facts about PGP). They may also negatively affect clinicians' confidence (Nolan, 2013) in their skills because of a self-perceived inability to 'feel intra-pelvic motion', observe 'displacements' and/or diagnose complex PGP disorders. ...
Introduction
Clinicians need support to effectively implement a biopsychosocial approach to people with pelvic girdle pain disorders.
Purpose
A practical clinical framework aligned with a contemporary biopsychosocial approach is provided to help guide clinician's management of pelvic girdle pain. This approach is consistent with current pain science which helps to explain potential mechanistic links with co/multi-morbid conditions related to pelvic girdle pain. Further, this approach also aligns with the Common-Sense Model of Illness and provides insight into how an individual's illness perceptions can influence their emotional and behavioural response to their pain disorder. Communication is critical to supporting recovery and facilitating behavior change within the biopsychosocial context and in this context, the patient interview is central to exploring the multidimensional nature of a persons' presentation. Focusing the biopsychosocial framework on targeted cognitive-functional therapy as a key component of care can help an individual with pelvic girdle pain make sense of their pain, build confidence and self-efficacy and facilitate positive behaviour and lifestyle change. There is growing evidence of the efficacy for this broader integrative approach, although large scale effectiveness trials are still needed. An in-depth case study provides guidance for clinicians, showing ‘how to’ implement these concepts into their own practice within a coherent practical framework.
Implications
This framework can give clinicians more confidence in understanding and managing pelvic girdle pain. The framework provides practical strategies to assist clinicians with implementation; assisting the transition from knowing to doing in an evidence-informed manner that resonates with real world practice.
... Mittlerweile weiß man, dass die Ursachen, die zu Beschwerden im ISG führen können, vielfältig sind [4,19,20,37]. Neben spezifischen Ursachen wie Trauma, Schwangerschaft, entzündliche Arthropathien, degenerative Veränderungen der angrenzenden Gelenke, der Implantation von Hüftendoprothesen oder nach Operationen der Lendenwirbelsäule, wird ein Zusammenhang des Schmerzes zu einer fehlerhaften Position oder Bewegung im ISG diskutiert. Neben dem grundlegenden Verständnis der funktionellen Anatomie sollte das biopsychosoziale Krankheitsmodell in die klinische Arbeit miteinbezogen werden, um patientenbezogen die Ursachen der jeweiligen Beschwerden zu identifizieren und die richtige Therapieentscheidungen zu treffen. ...
Background
The sacroiliac joint is a common cause of low back pain. Due to variable symptoms, the diagnosis is often very difficult. For diagnosis, systemic disease, as well as pathologies in the hips and lumbar spine must be excluded.
Objectives
To describe anatomy and function of the joint and underlying pathologies. To present the evidence of actual diagnostic and therapeutic options.
Materials and methods
An extensive literature research was carried out on PubMed.
Results
The sacroiliac joint is an important and biomechanically complex joint. There are many controversial diagnostic tests to identify the sacroiliac joint as a source of pain. The cause of the dysfunction must be identified in order to treat it correctly and to prevent a chronification of the pain. The gold standard is conservative care.
Conclusion
The sacroiliac joint must be included in the differential diagnosis in patients with low back pain. Diagnostic tests are often insufficient for the diagnosis of sacroiliac joint pain. Many of the current diagnostic and therapeutic options present weak evidence.
The sacroiliac joint (SIJ), a synovial joint with irregular surfaces, is crucial for stabilizing the body and facilitating daily activities. However, recent studies have reported that 15–30% of lower back pain can be attributed to instability in the SIJ, a condition collectively referred to as sacroiliac joint dysfunction (SIJD). The aim of this study is to investigate how the morphological characteristics of the auricular surface may influence the SIJ range of motion (ROM) and to examine differences in SIJ ROM between females and males, thereby contributing to the enhancement of SIJD diagnosis and treatment.
We measured SIJ ROM using motion-analysis cameras in 24 fresh cadavers of Korean adults (13 males and 11 females). Using three-dimensional renderings of the measured auricular surface, we investigated the correlations between the morphological characteristics of the auricular surface and the ROM of the SIJ.
The SIJ ROM was between 0.2° and 6.7° and was significantly greater in females (3.58° ± 1.49) compared with males (1.38° ± 1.00). Dividing the participants into high-motion (3.87° ± 1.19) and low-motion (1.13° ± 0.62) groups based on the mean ROM (2.39°) showed no significant differences in any measurements. Additionally, bone defects around the SIJ were identified using computed tomography of the high-motion group. In the low-motion group, calcification between auricular surfaces and bone bridges was observed.
This suggests that the SIJ ROM is influenced more by the anatomical structures around the SIJ than by the morphological characteristics of the auricular surface.
Common etiologies of low back pain include degenerative arthrosis and inflammatory arthropathy of the sacroiliac joints. The diagnostic workup revolves around identifying and confirming the sacroiliac joints as a pain generator. Diagnostic sacroiliac joint injections often serve as functional additions to the diagnostic workup through eliciting a pain response that tests the hypothesis that the sacroiliac joints do or do not contribute to the patient’s pain syndrome. Therapeutic sacroiliac joint injections aim to provide medium- to long-term relief of symptoms and reduce inflammatory activity and, ultimately, irreversible structural damage. Ultrasonography, fluoroscopy, computed tomography, and magnetic resonance imaging (MRI) may be used to guide sacroiliac joint injections. The populations that may benefit most from MRI-guided sacroiliac joint procedures include children, adolescents, adults of childbearing age, and patients receiving serial injections due to the ability of interventional MRI to avoid radiation exposure. Most clinical wide-bore MRI systems can be used for MRI-guided sacroiliac joint injections. Turbo spin echo pulse sequences optimized for interventional needle display visualize the needle tip with an error margin of < 1 mm or less. Published success rates of intra-articular sacroiliac joint drug delivery with MRI guidance range between 87 and 100%. The time required for MR-guided sacroiliac joint injections in adults range between 23–35 min and 40 min in children. In this article, we describe techniques for MRI-guided sacroiliac joint injections, share our practice of incorporating interventional MRI in the care of patients with sacroiliac joint mediated pain, discuss the rationales, benefits, and limitations of interventional MRI, and conclude with future developments.
RÉSUMÉ - La douleur pelvienne chronique est un problème en pelvi-périnéologie, qui semble toucher la femme plus que l´homme. Elle est définie par «The American College of Obstetricians and Gynecologists» comme une douleur localisée au niveau de l'abdomen au-dessous de l'ombilic, ainsi que dans les régions pelvienne, lombo-sacrale et fessière, durant depuis au moins 6 mois, qui n'est ni cyclique, ni associée à une lésion organique.
Les diagnostics souvent posés sont l'endométriose, le syndrome vésical douloureux (cystite interstitielle), la prostatite chronique, ainsi que les syndromes du muscle élévateur de l'anus et du colon, ou de l'intestin irritable.
Le syndrome myofascial pelvien douloureux est caractérisé par une hypertonie musculaire associée à des cordons myalgiques et à des points trigger myofasciaux et se manifeste par une douleur des muscles du plancher pelvien, du périnée et des fascias pelviens voisins.
Les points trigger myofasciaux peuvent se développer dans tous les muscles du corps humain, y compris au niveau de la région pelvienne. Ils semblent ici engendrer des sensations référées au niveau de la vessie, de la prostate, du vagin, du rectum, du coccyx, du sacrum, de toute la région pelvienne, du bas du dos, du bas de l'abdomen et de la région postérieure de la cuisse. ABSTRACT - Chronic pelvic pain is a problem in perineology, which seems to affect women more than men. It is defined by "The American College of Obstetricians and Gynecologists" as pain localized in the abdomen below the umbilicus, as well as in the pelvic, lumbosacral, and gluteal regions, lasting for at least 6 months, which is neither cyclic nor associated with an organic lesion.
Common diagnoses include endometriosis, painful bladder syndrome (interstitial cystitis), chronic prostatitis, and anal and colonic elevator muscle or irritable bowel syndromes.
Painful pelvic myofascial syndrome is characterized by muscle hypertonicity associated with myalgic cords and myofascial trigger points and manifests as pain in the pelvic floor muscles, perineum, and surrounding pelvic fascias.
Myofascial trigger points can develop in all muscles of the human body, including the pelvic region. Here they appear to generate referred sensations in the bladder, prostate, vagina, rectum, coccyx, sacrum, entire pelvic region, lower back, lower abdomen, and posterior thigh region.
Background
Most people experience low back pain (LBP), and it is often ongoing or recurrent. Contemporary research knowledge indicates individual’s pain beliefs have a strong effect on their pain experience and management. This study’s primary aim was to determine the discourses (patterns of thinking) underlying people’s beliefs about what causes their LBP to persist. The secondary aim was to investigate what they believed was the source of this thinking.
Methods
We used a primarily qualitative survey design: 130 participants answered questions about what caused their LBP to persist, and where they learned about these causes. We analysed responses about what caused their LBP using discourse analysis (primary aim), and mixed methods involving content analysis and descriptive statistics to analyse responses indicating where participants learnt these beliefs (secondary aim).
Results
We found that individuals discussed persistent LBP as 1) due to the body being like a ‘broken machine’, 2) permanent/immutable, 3) complex, and 4) very negative. Most participants indicated that they learnt these beliefs from health professionals (116, 89%).
Conclusions
We concluded that despite continuing attempts to shift pain beliefs to more complex biopsychosocial factors, most people with LBP adhere to the traditional biomedical perspective of anatomical/biomechanical causes. Relatedly, they often see their condition as very negative. Contrary to current “best practice” guidelines for LBP management, a potential consequence of such beliefs is an avoidance of physical activities, which is likely to result in increased morbidity. That health professionals may be the most pervasive source of this thinking is a cause for concern. A small number of people attributed non-physical, unknown or complex causes to their persistent LBP – indicating that other options are possible.
Background: As mortality rates decline, life expectancy increases, and populations age, non-fatal outcomes of diseases and injuries are becoming a larger component of the global burden of disease. The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of prevalence, incidence, and years lived with disability (YLDs) for 328 causes in 195 countries and territories from 1990 to 2016.
Methods: We estimated prevalence and incidence for 328 diseases and injuries and 2982 sequelae, their non-fatal consequences. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between incidence, prevalence, remission, and cause of death rates for each condition. For some causes, we used alternative modelling strategies if incidence or prevalence needed to be derived from other data. YLDs were estimated as the product of prevalence and a disability weight for all mutually exclusive sequelae, corrected for comorbidity and aggregated to cause level. We updated the Socio-demographic Index (SDI), a summary indicator of income per capita, years of schooling, and total fertility rate. GBD 2016 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).
Findings: Globally, low back pain, migraine, age-related and other hearing loss, iron-deficiency anaemia, and major depressive disorder were the five leading causes of YLDs in 2016, contributing 57·6 million (95% uncertainty interval [UI] 40·8–75·9 million [7·2%, 6·0–8·3]), 45·1 million (29·0–62·8 million [5·6%, 4·0–7·2]), 36·3 million (25·3–50·9 million [4·5%, 3·8–5·3]), 34·7 million (23·0–49·6 million [4·3%, 3·5–5·2]), and 34·1 million (23·5–46·0 million [4·2%, 3·2–5·3]) of total YLDs, respectively. Age-standardised rates of YLDs for all causes combined decreased between 1990 and 2016 by 2·7% (95% UI 2·3–3·1). Despite mostly stagnant age-standardised rates, the absolute number of YLDs from non-communicable diseases has been growing rapidly across all SDI quintiles, partly because of population growth, but also the ageing of populations. The largest absolute increases in total numbers of YLDs globally were between the ages of 40 and 69 years. Age-standardised YLD rates for all conditions combined were 10·4% (95% UI 9·0–11·8) higher in women than in men. Iron-deficiency anaemia, migraine, Alzheimer's disease and other dementias, major depressive disorder, anxiety, and all musculoskeletal disorders apart from gout were the main conditions contributing to higher YLD rates in women. Men had higher age-standardised rates of substance use disorders, diabetes, cardiovascular diseases, cancers, and all injuries apart from sexual violence. Globally, we noted much less geographical variation in disability than has been documented for premature mortality. In 2016, there was a less than two times difference in age-standardised YLD rates for all causes between the location with the lowest rate (China, 9201 YLDs per 100 000, 95% UI 6862–11943) and highest rate (Yemen, 14 774 YLDs per 100 000, 11 018–19 228).
Interpretation: The decrease in death rates since 1990 for most causes has not been matched by a similar decline in age-standardised YLD rates. For many large causes, YLD rates have either been stagnant or have increased for some causes, such as diabetes. As populations are ageing, and the prevalence of disabling disease generally increases steeply with age, health systems will face increasing demand for services that are generally costlier than the interventions that have led to declines in mortality in childhood or for the major causes of mortality in adults. Up-to-date information about the trends of disease and how this varies between countries is essential to plan for an adequate health-system response.
Importance
Radiofrequency denervation is a commonly used treatment for chronic low back pain, but high-quality evidence for its effectiveness is lacking.
Objective
To evaluate the effectiveness of radiofrequency denervation added to a standardized exercise program for patients with chronic low back pain.
Design, Setting, and Participants
Three pragmatic multicenter, nonblinded randomized clinical trials on the effectiveness of minimal interventional treatments for participants with chronic low back pain (Mint study) were conducted in 16 multidisciplinary pain clinics in the Netherlands. Eligible participants were included between January 1, 2013, and October 24, 2014, and had chronic low back pain, a positive diagnostic block at the facet joints (facet joint trial, 251 participants), sacroiliac joints (sacroiliac joint trial, 228 participants), or a combination of facet joints, sacroiliac joints, or intervertebral disks (combination trial, 202 participants) and were unresponsive to conservative care.
Interventions
All participants received a 3-month standardized exercise program and psychological support if needed. Participants in the intervention group received radiofrequency denervation as well. This is usually a 1-time procedure, but the maximum number of treatments in the trial was 3.
Main Outcomes and Measures
The primary outcome was pain intensity (numeric rating scale, 0-10; whereby 0 indicated no pain and 10 indicated worst pain imaginable) measured 3 months after the intervention. The prespecified minimal clinically important difference was defined as 2 points or more. Final follow-up was at 12 months, ending October 2015.
Results
Among 681 participants who were randomized (mean age, 52.2 years; 421 women [61.8%], mean baseline pain intensity, 7.1), 599 (88%) completed the 3-month follow-up, and 521 (77%) completed the 12-month follow-up. The mean difference in pain intensity between the radiofrequency denervation and control groups at 3 months was −0.18 (95% CI, −0.76 to 0.40) in the facet joint trial; −0.71 (95% CI, −1.35 to −0.06) in the sacroiliac joint trial; and −0.99 (95% CI, −1.73 to −0.25) in the combination trial.
Conclusions and Relevance
In 3 randomized clinical trials of participants with chronic low back pain originating in the facet joints, sacroiliac joints, or a combination of facet joints, sacroiliac joints, or intervertebral disks, radiofrequency denervation combined with a standardized exercise program resulted in either no improvement or no clinically important improvement in chronic low back pain compared with a standardized exercise program alone. The findings do not support the use of radiofrequency denervation to treat chronic low back pain from these sources.
Trial Registration
trialregister.nl Identifier: NTR3531
Purpose
To determine whether emotional distress reported at the initial consultation affects subsequent healthcare use either directly or indirectly via moderating the influence of symptoms.
Methods
Longitudinal observational study of 2891 participants consulting primary care for low back pain. Negative binomial regression models were constructed to estimate independent effects of emotional distress on healthcare use. Potential confounders were identified using directed acyclic graphs.
Results
After the initial consultation, participants had a mean (SD) of one (1.2) visit for back pain over 3 months, and nine (14) visits for back pain over 12 months. Higher reports of anxiety during the initial consultation led to increased short-term healthcare use (IRR 1.06, 95 % CI 1.01–1.11) and higher reports of depression led to increased long-term healthcare use (IRR 1.04, 95 % CI 1.02–1.07). The effect sizes suggest that a patient with a high anxiety score (8/10) would consult 50 % more frequently over 3 months, and a person with a high depression score (8/10) would consult 30 % more frequently over 12 months, compared to a patient with equivalent pain and disability and no reported anxiety or depression.
Conclusions
Emotional distress in the acute stage of low back pain increased subsequent consultation rates. Interventions that target emotional distress during the initial consultation are likely to reduce costly and potentially inappropriate future healthcare use for patients with non-specific low back pain.
Patient beliefs play an important role in the development of back pain and disability, as well as subsequent recovery. Community beliefs about the back and back pain which are inconsistent with current research evidence have been found in a number of developed countries. These beliefs negatively influence people's back-related behaviour in general, and these effects may be amplified when someone experiences an episode of back pain.In-depth qualitative research has helped to shed light on why people hold the beliefs which they do about the back, and how these have been influenced. Clinicians appear to have a strong influence on patients' beliefs. These data may be used by clinicians to inform exploration of unhelpful beliefs which patients hold, mitigate potential negative influences as a result of receiving health care, and subsequently influence beliefs in a positive manner.
Objectives The fear-avoidance model describes how the belief that pain is a sign of damage leads to pain-related fear and avoidance. But other beliefs may also trigger the fear and avoidance responses described by the model. Experts have called for the next generation of fear avoidance research to explore what beliefs underlie pain-related fear and how they evolve. We have previously described damage beliefs and suffering/functional loss beliefs underlying high pain-related fear in a sample of individuals with chronic back pain. The aim of this study is to identify common and differential factors associated with the beliefs in this sample.
Design A qualitative study employing semistructured interviews.
Setting Musculoskeletal clinics in Western Australia.
Participants 36 individuals with chronic back pain and high scores on the Tampa Scale (mean 47/68).
Results The overarching theme was a pain experience that did not make sense to the participants. The experience of pain as unpredictable, uncontrollable and intense made it threatening. Attempting to make sense of the threatening pain, participants with damage beliefs drew on past personal experiences of pain, societal beliefs, and sought diagnostic certainty. Met with diagnostic uncertainty, or diagnoses of an underlying pathology that could not be fixed, they were left fearful of damage and confused about how to ‘fix’ it. Participants with suffering/functional loss beliefs drew on past personal experiences of pain and sought help from healthcare professionals to control their pain. Failed treatments and the repeated failure to achieve functional goals left them unable to make ‘sensible’ decisions of what to do about their pain.
Conclusions The findings raise the suggestion that sense-making processes may be implicated in the fear-avoidance model. Future research is needed to explore whether fear reduction may be enhanced by considering beliefs underlying fear and providing targeted intervention to help individuals make sense of their pain.
Objective:
To determine whether land-based therapeutic exercise is beneficial for people with knee osteoarthritis (OA) in terms of reduced joint pain or improved physical function and quality of life.
Methods:
Five electronic databases were searched, up until May 2013. Randomised clinical trials comparing some form of land-based therapeutic exercise with a non-exercise control were selected. Three teams of two review authors independently extracted data and assessed risk of bias for each study. Standardised mean differences immediately after treatment and 2-6 months after cessation of formal treatment were separately pooled using a random effects model.
Results:
In total, 54 studies were identified. Overall, 19 (35%) studies reported adequate random sequence generation, allocation concealment and adequately accounted for incomplete outcome data. However, research results may be vulnerable to selection, attrition and detection bias. Pooled results from 44 trials indicated that exercise significantly reduced pain (12 points/100; 95% CI 10 to 15) and improved physical function (10 points/100; 95% CI 8 to 13) to a moderate degree immediately after treatment, while evidence from 13 studies revealed that exercise significantly improved quality of life immediately after treatment with small effect (4 points/100; 95% CI 2 to 5). In addition, 12 studies provided 2-month to 6-month post-treatment sustainability data which showed significantly reduced knee pain (6 points/100; 95% CI 3 to 9) and 10 studies which showed improved physical function (3 points/100; 95% CI 1 to 5).
Conclusions:
Among people with knee osteoarthritis, land-based therapeutic exercise provides short-term benefit that is sustained for at least 2-6 months after cessation of formal treatment.
Objective: To test the hypothesis that radiography of the lumbar spine in patients with low back pain is not associated with improved clinical outcomes or satisfaction with care.
Design: Randomised unblinded controlled trial.
Setting: 73 general practices in Nottingham, north Nottinghamshire, southern Derbyshire, north Lincolnshire, and north Leicestershire. 52 practices recruited participants to the trial.
Subjects: 421 patients with low back pain of a median duration of 10 weeks.
Intervention: Radiography of the lumbar spine.
Main outcome measures: Roland adaptation of the sickness impact profile, visual analogue scale for pain, health status, EuroQol, satisfaction with care, use of primary and secondary care services, and reporting of low back pain at three and nine months after randomisation.
Results: The intervention group were more likely to report low back pain at three months (relative risk 1.26, 95% confidence interval 1.00 to 1.60) and had a lower overall health status score and borderline higher Roland and pain scores. A higher proportion of participants consulted their doctor in the three months after radiography (1.62, 1.33 to 1.97). Satisfaction with care was greater in the group receiving radiography at nine but not three months after randomisation. Overall, 80% of participants in both groups at three and nine months would have radiography if the choice was available. An abnormal finding on radiography made no difference to the outcome, as measured by the Roland score.
Conclusions: Radiography of the lumbar spine in primary care patients with low back pain of at least six weeks' duration is not associated with improved patient functioning, severity of pain, or overall health status but is associated with an increase in doctor workload. Guidelines on the management of low back pain in primary care should be consistent about not recommending radiography of the lumbar spine in patients with low back pain in the absence of indicators for serious spinal disease, even if it has persisted for at least six weeks. Patients receiving radiography are more satisfied with the care they received. The challenge for primary care is to increase satisfaction without recourse to radiography.
The purpose of this study was to examine opioid and endocannabinoid mechanisms of exercise-induced hypoalgesia (EIH). Fifty-eight men and women (mean age = 21 yrs) completed three sessions. During the first session, participants were familiarized with the temporal summation of heat pain and pressure pain protocols. In the exercise sessions, following double-blind administration of either an opioid antagonist (50 mg naltrexone) or placebo, participants rated the intensity of heat pulses and indicated their pressure pain thresholds (PPT) and ratings (PPR) before and after 3 minutes of submaximal isometric exercise. Blood was drawn before and after exercise. Results indicated circulating concentrations of two endocannabinoids, N-arachidonylethanolamine (AEA) and 2-arachidonoylglycerol (2-AG) as well as related lipids oleoylethanolamide (OEA), palmitoylethanolamide (PEA), N-docsahexaenoylethanolamine (DHEA), and 2-oleoylglycerol (2-OG) increased significantly (p < 0.05) following exercise. PPT increased significantly (p < 0.05) while PPR decreased significantly (p < 0.05) following exercise. Also, temporal summation ratings were significantly lower (p < 0.05) following exercise. These changes in pain responses did not differ between placebo or naltrexone conditions (p > 0.05). A significant association was found between EIH and DHEA. These results suggest involvement of a non-opioid mechanism in EIH following isometric exercise.
Perspective
Currently, the mechanisms responsible for exercise-induced hypoalgesia (EIH) are unknown. This study provides support for a potential endocannabinoid mechanism of EIH following isometric exercise.
Objectives To explore the prevalence of attitudes and beliefs about back pain in New Zealand and compare certain beliefs based on back pain history or health professional exposure.
Design Population-based cross-sectional survey.
Setting Postal survey.
Participants New Zealand residents and citizens aged 18 years and above. 1000 participants were randomly selected from the New Zealand Electoral Roll. Participants listed on the Electoral Roll with an overseas postal address were excluded. 602 valid responses were received.
Measures Attitudes and beliefs about back pain were measured with the Back Pain Attitudes Questionnaire (Back-PAQ). The interaction between attitudes and beliefs and (1) back pain experience and (2) health professional exposure was investigated.
Results The lifetime prevalence of back pain was reported as 87% (95% CI 84% to 90%), and the point prevalence as 27% (95% CI 24% to 31%). Negative views about the back and back pain were prevalent, in particular the need to protect the back to prevent injury. People with current back pain had more negative overall scores, particularly related to back pain prognosis. There was uncertainty about links between pain and injury and appropriate physical activity levels during an episode of back pain. Respondents had more positive views about activity if they had consulted a health professional about back pain. The beliefs of New Zealanders appeared to be broadly similar to those of other Western populations.
Conclusions A large proportion of respondents believed that they needed to protect their back to prevent injury; we theorise that this belief may result in reduced confidence to use the back and contribute to fear avoidance. Uncertainty regarding what is a safe level of activity during an episode of back pain may limit participation. People experiencing back pain may benefit from more targeted information about the positive prognosis. The provision of clear guidance about levels of activity may enable confident participation in an active recovery.
Purpose:
The purpose of this study was to explore the formation and impact of attitudes and beliefs among people experiencing acute and chronic low back pain.
Methods:
Semistructured qualitative interviews were conducted with 12 participants with acute low back pain (less than 6 weeks' duration) and 11 participants with chronic low back pain (more than 3 months' duration) from 1 geographical region within New Zealand. Data were analyzed using an Interpretive Description framework.
Results:
Participants' underlying beliefs about low back pain were influenced by a range of sources. Participants experiencing acute low back pain faced considerable uncertainty and consequently sought more information and understanding. Although participants searched the Internet and looked to family and friends, health care professionals had the strongest influence upon their attitudes and beliefs. Clinicians influenced their patients' understanding of the source and meaning of symptoms, as well as their prognostic expectations. Such information and advice could continue to influence the beliefs of patients for many years. Many messages from clinicians were interpreted as meaning the back needed to be protected. These messages could result in increased vigilance, worry, guilt when adherence was inadequate, or frustration when protection strategies failed. Clinicians could also provide reassurance, which increased confidence, and advice, which positively influenced the approach to movement and activity.
Conclusions:
Health care professionals have a considerable and enduring influence upon the attitudes and beliefs of people with low back pain. It is important that this opportunity is used to positively influence attitudes and beliefs.
Psychological features have been related to trunk muscle activation patterns in low back pain (LBP). We hypothesised higher pain-related fear would relate to changes in trunk mechanical properties, such as higher trunk stiffness.
To evaluate the relationship between trunk mechanical properties and psychological features in people with recurrent LBP.
The relationship between pain-related fear (Tampa Scale for Kinesiophobia, TSK; Photograph Series of Daily Activities, PHODA-SeV; Fear Avoidance Beliefs Questionnaire, FABQ; Pain Catastrophizing Scale, PCS) and trunk mechanical properties (estimated from the response of the trunk to a sudden sagittal plane forwards or backwards perturbation by unpredictable release of a load) was explored in a case-controlled study of 14 LBP participants. Regression analysis (r (2)) tested the linear relationships between pain-related fear and trunk mechanical properties (trunk stiffness and damping). Mechanical properties were also compared with t-tests between groups based on stratification according to high/low scores based on median values for each psychological measure.
Fear of movement (TSK) was positively associated with trunk stiffness (but not damping) in response to a forward perturbation (r(2) = 0.33, P = 0.03), but not backward perturbation (r(2) = 0.22, P = 0.09). Other pain-related fear constructs (PHODA-SeV, FABQ, PCS) were not associated with trunk stiffness or damping. Trunk stiffness was greater for individuals with high kinesiophobia (TSK) for forward (P = 0.03) perturbations, and greater with forward perturbation for those with high fear avoidance scores (FABQ-W, P = 0.01).
Fear of movement is positively (but weakly) associated with trunk stiffness. This provides preliminary support an interaction between biological and psychological features of LBP, suggesting this condition may be best understood if these domains are not considered in isolation.
This paper argues that the biology of pain is never really straightforward, even when it appears to be. It is proposed that understanding what is currently known about the biology of pain requires a reconceptualisation of what pain actually is, and how it serves our livelihood. There are four key points: (i) that pain does not provide a measure of the state of the tissues; (ii) that pain is modulated by many factors from across somatic, psychological and social domains; (iii) that the relationship between pain and the state of the tissues becomes less predictable as pain persists; and (iv) that pain can be conceptualised as a conscious correlate of the implicit perception that tissue is in danger. These issues raise conceptual and clinical implications, which are discussed with particular relevance to persistent pain. Finally, this conceptualisation is used as a framework for one approach to understanding complex regional pain syndrome.
The extra-articular sacroiliac joint (SIJ) structure is a potential source for low back and pelvic pain. This study hypothesised that experimental pain induced in a superficial pelvic ligament causes (1) hyperalgesia to pressure, (2) distinct pain referral, and (3) an increased frequency of positive pain provocation tests of the SIJ complex. Thirty healthy subjects (15 females) participated in this study designed as a randomised crossover trial. Pain was induced in the long posterior sacroiliac ligament by injection of hypertonic saline, with the contralateral ligament injected with isotonic saline as control. Pain intensity was assessed on an electronic visual analogue scale (VAS). Pressure pain thresholds (PPTs) and pain provocation tests were assessed on 3 occasions: at baseline, after injection, and when pain had subsided. PPT sites were located bilaterally at the injection site, lateral to spinous processes of S2 and L5, and at the gluteus medius and gastrocnemius muscles. Hypertonic saline caused significantly higher VAS scores and more extended pain referral than isotonic saline (P<0.001). PPTs at the injection site and lateral to S2 were significantly reduced after hypertonic saline compared with baseline and isotonic saline (P<0.002). Significantly more subjects had positive pain provocation tests after hypertonic (67% of subjects) compared with isotonic saline (20%; P<0.001). These data demonstrate that the extra-articular SIJ structure accommodates nociceptors that are capable of inducing pain referral and regional hyperalgesia sensitive to manual pain provocation tests similar to what previously have been found in pelvic girdle pain patients.
Non-specific low back pain and peripartum pelvic pain have aetiologies that may feature the sacroiliac region. This region
possesses many potential pain-generating structures sharing common sensory innervation which makes clinical differentiation
of pathoanatomy difficult. This anatomical study explores the relationship between the long posterior sacroiliac ligament
(LPSL) and the lateral branches of the dorsal sacral nerve plexus. Twenty-five sides of the pelvis from 16 cadavers were studied,
three for histological analysis and 22 for gross anatomical dissection. We found that the LPSL is penetrated by the lateral
branches of the dorsal sacral rami of predominantly S2 (96%, 21/22) and S3 (100%, 22/22), variably of S4 (59%, 13/22) and
rarely of S1 (4%, 1/22). Some of the penetrating lateral branches give off nerve fibres that disappear within the ligament.
These findings provide an anatomical basis for the notion that the LPSL is a potential pain generator in the posterior sacroiliac
region.
Different techniques have been used to quantify the movement of sacroiliac (SI) joints. These include radiostereometric analysis (RSA), but the accuracy and precision of this method have not been properly evaluated and it is unclear how many markers are required and where they should be placed to achieve proper accuracy and precision.
The purpose of this study was to test accuracy and precision of RSA, applied to the SI joint, in a phantom model and in patients.
We used a plastic phantom attached to a micrometer to obtain a true value of the movement of the SI joint and compared this value with the measured value obtained by RSA; the difference represented the accuracy. The precision of the system was measured by double examination in the phantom and in six patients, and was expressed by a limit of significance (LOS). We analyzed different marker distributions to find optimal marker placement and number of markers needed.
The accuracy was high and we identified no systematic errors. The precision of the phantom was high with a LOS less than 0.25° and 0.16 mm for all directions, and in patients, the precision was less than 0.71° for rotations and 0.47 mm translations. No markers were needed in the pubic symphysis to obtain good precision.
The accuracy and precision are high when RSA is used to measure movement in the SI joint and support the use of RSA in research of SI joint motion.
The sacroiliac joint (SIJ) is identified as one of many possible sources of non-specific low back pain and may be a target for diagnostic palpation. Putative diagnostic palpation of joint motion, tissue texture changes and pain form a routine aspect of practice in manual healthcare. However, the tactile tradition of diagnostic palpation is beset with anatomical and sensory confounding that may establish an upper ceiling for sensitivity and specificity. For illustrative purposes, this is highlighted by a review of the anatomy of the sacroiliac joint (SIJ). Increasing critical awareness of the inherent limitations in the tactile tradition of diagnostic palpation may lead to the development of a standardised and technologically based approach.
We review recent advances in brain imaging in humans, concentrating on advances in our understanding of the human brain in clinical chronic pain. Understanding regarding anatomical and functional reorganization of the brain in chronic pain is emphasized. We conclude by proposing a brain model for the transition of the human from acute to chronic pain.
Sacroiliac joint pain is a challenging condition accounting for approximately 20% of cases of chronic low back pain. Currently, there are no effective long-term treatment options for sacroiliac joint pain.
A randomized placebo-controlled study was conducted in 28 patients with injection-diagnosed sacroiliac joint pain. Fourteen patients received L4-L5 primary dorsal rami and S1-S3 lateral branch radiofrequency denervation using cooling-probe technology after a local anesthetic block, and 14 patients received the local anesthetic block followed by placebo denervation. Patients who did not respond to placebo injections crossed over and were treated with radiofrequency denervation using conventional technology.
One, 3, and 6 months after the procedure, 11 (79%), 9 (64%), and 8 (57%) radiofrequency-treated patients experienced pain relief of 50% or greater and significant functional improvement. In contrast, only 2 patients (14%) in the placebo group experienced significant improvement at their 1-month follow-up, and none experienced benefit 3 months after the procedure. In the crossover group (n = 11), 7 (64%), 6 (55%), and 4 (36%) experienced improvement 1, 3, and 6 months after the procedure. One year after treatment, only 2 patients (14%) in the treatment group continued to demonstrate persistent pain relief.
These results provide preliminary evidence that L4 and L5 primary dorsal rami and S1-S3 lateral branch radiofrequency denervation may provide intermediate-term pain relief and functional benefit in selected patients with suspected sacroiliac joint pain. Larger studies are needed to confirm these results and to determine the optimal candidates and treatment parameters for this poorly understood disorder.
Content analysis of patient interviews, clinic letters, and radiology reports for patients with chronic low back pain of greater than 12 months duration.
To explore the language used by patients and healthcare professionals to describe low back pain and any potential effect on patient perceived prognosis.
Diagnostic explanations by healthcare professionals may influence patient coping and uptake of therapy by patients with chronic low back pain. Although the correlation between radiologic changes and chronic low back pain is weak, these investigations are often used by clinicians as an explanation of the underlying cause for the pain.
Patients were asked about their understanding of the mechanisms underlying their pain, flares, and future outcome. Notes from these interviews were transcribed, along with correspondence from primary care physicians, orthopedic surgeons and pain physicians, and lumbar spine radiology reports for these patients. Content analysis was performed to identify and group key terms.
Two major categories representing the predominant themes emerging from the content analysis were "Degeneration" and "Mechanical." Degenerative terms such as "wear and tear" and "disc space loss" indicated a progressive loss of structural integrity. Examples of phrases used by patients included "deterioration […] spine is crumbling" and "collapsing […] discs wearing out." The use of degenerative terms by patients was associated with a poor perceived prognosis (P < 0.01). Degenerative and mechanical terms were more commonly used by patients when they were documented in correspondence from secondary care specialists (P = 0.03 and 0.01, respectively).
A common language is shared between professionals and patients that may encourage unhelpful beliefs. The use of degenerative terms such as wear and tear by patients is associated with a poor perceived prognosis. The explanation of radiological findings to patients presents an opportunity to challenge unhelpful beliefs, thus facilitating uptake of active treatment strategies.
Objective:
To test the hypothesis that radiography of the lumbar spine in patients with low back pain is not associated with improved clinical outcomes or satisfaction with care.
Design:
Randomised unblinded controlled trial.
Setting:
73 general practices in Nottingham, north Nottinghamshire, southern Derbyshire, north Lincolnshire, and north Leicestershire. 52 practices recruited participants to the trial.
Subjects:
421 patients with low back pain of a median duration of 10 weeks.
Intervention:
Radiography of the lumbar spine.
Main outcome measures:
Roland adaptation of the sickness impact profile, visual analogue scale for pain, health status, EuroQol, satisfaction with care, use of primary and secondary care services, and reporting of low back pain at three and nine months after randomisation.
Results:
The intervention group were more likely to report low back pain at three months (relative risk 1.26, 95% confidence interval 1.00 to 1.60) and had a lower overall health status score and borderline higher Roland and pain scores. A higher proportion of participants consulted their doctor in the three months after radiography (1.62, 1.33 to 1.97). Satisfaction with care was greater in the group receiving radiography at nine but not three months after randomisation. Overall, 80% of participants in both groups at three and nine months would have radiography if the choice was available. An abnormal finding on radiography made no difference to the outcome, as measured by the Roland score.
Conclusions:
Radiography of the lumbar spine in primary care patients with low back pain of at least six weeks' duration is not associated with improved patient functioning, severity of pain, or overall health status but is associated with an increase in doctor workload. Guidelines on the management of low back pain in primary care should be consistent about not recommending radiography of the lumbar spine in patients with low back pain in the absence of indicators for serious spinal disease, even if it has persisted for at least six weeks. Patients receiving radiography are more satisfied with the care they received. The challenge for primary care is to increase satisfaction without recourse to radiography.
Sacroiliac joint (SIJ) pain refers to the pain arising from the SIJ joint structures. SIJ dysfunction generally refers to aberrant position or movement of SIJ structures that may or may not result in pain. This paper aims to clarify the difference between these clinical concepts and present current available evidence regarding diagnosis and treatment of SIJ disorders. Tests for SIJ dysfunction generally have poor inter-examiner reliability. A reference standard for SIJ dysfunction is not readily available, so validity of the tests for this disorder is unknown. Tests that stress the SIJ in order to provoke familiar pain have acceptable inter-examiner reliability and have clinically useful validity against an acceptable reference standard. It is unknown if provocation tests can reliably identify extra-articular SIJ sources of pain. Three or more positive pain provocation SIJ tests have sensitivity and specificity of 91% and 78%, respectively. Specificity of three or more positive tests increases to 87% in patients whose symptoms cannot be made to move towards the spinal midline, i.e., centralize. In chronic back pain populations, patients who have three or more positive provocation SIJ tests and whose symptoms cannot be made to centralize have a probability of having SIJ pain of 77%, and in pregnant populations with back pain, a probability of 89%. This combination of test findings could be used in research to evaluate the efficacy of specific treatments for SIJ pain. Treatments most likely to be effective are specific lumbopelvic stabilization training and injections of corticosteroid into the intra-articular space.
The sacroiliac joint (SIJ) is a well‐known source of low back and pelvic pain, of increasing interest for both conservative and surgical treatment. Alterations in the kinematics of the pelvis have been hypothesized as a major cause of SIJ‐related pain. However, definitions of both the range and the extent of physiological movement are controversial, and there are no clear baseline data for pathological alterations. The present study combined a novel biomechanical setup allowing for physiological motion of the lumbosacral transition and pelvis without restricting the SIJ movement in vitro, combined with optical image correlation. Six fresh human pelvises (81 ± 10 years, three females, three males) were tested, with bodyweight‐adapted loading applied to the fifth lumbar vertebra and both acetabula. Deformation at the lumbopelvises was determined computationally from three‐dimensional image correlation data. Sacroiliac joint motion under the loading of 100% bodyweight primarily consisted of a z‐axis rotation (0.16°) and an inferior translation of the sacrum relative to the ilium (0.32 mm). Sacroiliac joint flexion‐extension rotations were minute (< 0.02°). Corresponding movements of the SIJ were found at the lumbosacral transition, with an anterior translation of L5 relative to the sacrum of −0.97 mm and an inferior translation of 0.11 mm, respectively. Moreover, a flexion of 1.82° was observed at the lumbosacral transition. Within the innominate bone and at the pubic symphysis, small complementary rotations were seen around a vertical axis, accounting for −0.10° and 0.11°, respectively. Other motions were minute and accompanied by large interindividual variation. The present study provides evidence of different SIJ motions than reported previously when exerted by physiological loading. Sacroiliac joint kinematics were in the sub‐degree and sub‐millimeter range, in line with previous in vivo and in vitro findings, largely limited to the sagittal rotation and an inferior translation of the sacrum relative to the ilium. This given physiological loading scenario underlines the relevance of the lumbosacral transition when considering the overall motion of the lumbopelvis, and how relatively little the other segments contribute to overall motion.
Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.
Synopsis
Pain-related fear is implicated in the transition from acute to chronic low back pain and the persistence of disabling low back pain, making it a key target for physical therapy intervention. The current understanding of pain-related fear is that it is a psychopathological problem, whereby people who catastrophize about the meaning of pain become trapped in a vicious cycle of avoidance behavior, pain, and disability, as recognized in the fear-avoidance model. However, there is evidence that pain-related fear can also be seen as a common-sense response to deal with low back pain, for example, when one is told that one's back is vulnerable, degenerating, or damaged. In this instance, avoidance is a common-sense response to protect a “damaged” back. While the fear-avoidance model proposes that when someone first develops low back pain, the confrontation of normal activity in the absence of catastrophizing leads to recovery, the pathway to recovery for individuals trapped in the fear-avoidance cycle is less clear. Understanding pain-related fear from a common-sense perspective enables physical therapists to offer individuals with low back pain and high fear a pathway to recovery by altering how they make sense of their pain. Drawing on a body of published work exploring the lived experience of pain-related fear in people with low back pain, this clinical commentary illustrates how Leventhal's common-sense model may assist physical therapists to understand the broader sense-making processes involved in the fear-avoidance cycle, and how they can be altered to facilitate fear reduction by applying strategies established in the behavioral medicine literature. J Orthop Sports Phys Ther 2017;47(9):628–636. Epub 13 Jul 2017. doi:10.2519/jospt.2017.7434
Background
The Active Straight Leg Raise is a functional test used in the assessment of pelvic girdle pain, and has shown to have good validity, reliability and responsiveness. The Active Straight Leg Raise is considered to examine the patients' ability to transfer load through the pelvis. It has been hypothesized that patients with pelvic girdle pain lack the ability to stabilize the pelvic girdle, probably due to instability or increased movement of the sacroiliac joint. This study examines the movement of the sacroiliac joints during the Active Straight Leg Raise in patients with pelvic girdle pain.
Methods
Tantalum markers were inserted in the dorsal sacrum and ilium of 12 patients with long-lasting pelvic girdle pain scheduled for sacroiliac joint fusion surgery. Two to three weeks later movement of the sacroiliac joints during the Active Straight Leg Raise was measured with radiosteriometric analysis.
Findings
Small movements were detected. There was larger movement of the sacroiliac joint of the rested leg's sacroiliac joint compared to the lifted leg's side. A mean backward rotation of 0.8° and inward tilt of 0.3° were seen in the rested leg's sacroiliac joint.
Interpretation
The movements of the sacroiliac joints during the Active Straight Leg Raise are small. There was a small backward rotation of the innominate bone relative to sacrum on the rested leg's side. Our findings contradict an earlier understanding that a forward rotation of the lifted leg's innominate occur while performing the Active Straight Leg Raise.
Objective:
The purpose of this study was to determine whether intraarticular sacroiliac joint injections provide greater immediate and short-term pain relief than periarticular sacroiliac joint injections do.
Materials and methods:
The records of all fluoroscopically guided sacroiliac joint injections performed over a 4-year period were identified. Patients who received an injection of 0.5 mL of bupivacaine and 0.5 mL (20 mg) of triamcinolone and who had preinjection, immediate, and 1-week postinjection pain scores (0-10 numeric scale) were included. Images from the procedures were retrospectively reviewed by two musculoskeletal radiologists to determine intraarticular or periarticular administration of the injection with discrepancies resolved by consensus.
Results:
One hundred thirteen injections in 99 patients (65 women, 34 men; mean age, 59.4 years) met the inclusion criteria. There were 55 intraarticular and 58 periarticular injections. The mean preinjection, immediate, and 1-week postinjection pain scores for the intraarticular injections were 6.0, 1.6, and 4.1 and for the periarticular injections were 6.1, 2.0, and 4.2. The mean immediate and 1-week postinjection pain reduction were statistically significant in both groups (p < 0.001). After adjustment for age, sex, preinjection pain score, time of year, and indication for injection, no significant difference in the preinjection to immediately postinjection change in pain between intraarticular and periarticular injections (mean change, 0.37; p = 0.319) or in the preinjection to 1-week postinjection change in pain (mean change, 0.06; p = 0.888) was noted. The mean fluoroscopy times were 42.4 seconds for intraarticular injections and 60.5 seconds for periarticular injections (p = 0.32).
Conclusion:
Although both intraarticular and periarticular sacroiliac joint injections provide statistically significant immediate and 1-week postinjection pain relief, no significant difference in the degree of pain relief achieved with intraarticular and periarticular injections was noted.
Unlabelled:
The pain field has been advocating for some time for the importance of teaching people how to live well with pain. Perhaps some, and maybe even for many, we might again consider the possibility that we can help people live well without pain. Explaining Pain (EP) refers to a range of educational interventions that aim to change one's understanding of the biological processes that are thought to underpin pain as a mechanism to reduce pain itself. It draws on educational psychology, in particular conceptual change strategies, to help patients understand current thought in pain biology. The core objective of the EP approach to treatment is to shift one's conceptualization of pain from that of a marker of tissue damage or disease to that of a marker of the perceived need to protect body tissue. Here, we describe the historical context and beginnings of EP, suggesting that it is a pragmatic application of the biopsychosocial model of pain, but differentiating it from cognitive behavioral therapy and educational components of early multidisciplinary pain management programs. We attempt to address common misconceptions of EP that have emerged over the last 15 years, highlighting that EP is not behavioral or cognitive advice, nor does it deny the potential contribution of peripheral nociceptive signals to pain. We contend that EP is grounded in strong theoretical frameworks, that its targeted effects are biologically plausible, and that available behavioral evidence is supportive. We update available meta-analyses with results of a systematic review of recent contributions to the field and propose future directions by which we might enhance the effects of EP as part of multimodal pain rehabilitation.
Perspective:
EP is a range of educational interventions. EP is grounded in conceptual change and instructional design theory. It increases knowledge of pain-related biology, decreases catastrophizing, and imparts short-term reductions in pain and disability. It presents the biological information that justifies a biopsychosocial approach to rehabilitation.
Qualitative interview studyObjective. Explore attitudes, beliefs, and perceptions related to low back pain (LBP), and analyze how these might influence the perceived threat associated with back pain.
Psychological factors which contribute to the perceived threat associated with LBP play an important role in back pain development and the progression to persistent pain and disability. Improved understanding of underlying beliefs may assist clinicians to investigate and assess these factors.
Semi-structured qualitative interviews were conducted with 12 participants with acute LBP (<6 weeks' duration) and 11 participants with chronic LBP (>3 months' duration). Data were analyzed thematically using the framework of Interpretive Description.
The back was viewed as being vulnerable to injury due to its design, the way in which it is used, and personal physical traits or previous injury. Consequently participants considered they needed to protect their back by resting, being careful with or avoiding dangerous activities, and strengthening muscles or controlling posture. Participants considered LBP to be special in its nature and impact, and they thought it difficult to understand without personal experience. The prognosis of LBP was considered uncertain by those with acute pain and poor by those with chronic pain. These beliefs combined to create a negative (mis)representation of the back.
Negative assumptions about the back made by those with LBP may affect information processing during an episode of pain. This may result in attentional bias toward information indicating the spine is vulnerable, an injury is serious, or the outcome will be poor. Approaching consultations with this understanding may assist clinicians to have a positive influence on beliefs.
Background:
Knee osteoarthritis (OA) is a major public health issue because it causes chronic pain, reduces physical function and diminishes quality of life. Ageing of the population and increased global prevalence of obesity are anticipated to dramatically increase the prevalence of knee OA and its associated impairments. No cure for knee OA is known, but exercise therapy is among the dominant non-pharmacological interventions recommended by international guidelines.
Objectives:
To determine whether land-based therapeutic exercise is beneficial for people with knee OA in terms of reduced joint pain or improved physical function and quality of life.
Search methods:
Five electronic databases were searched, up until May 2013.
Selection criteria:
All randomised controlled trials (RCTs) randomly assigning individuals and comparing groups treated with some form of land-based therapeutic exercise (as opposed to exercise conducted in the water) with a non-exercise group or a non-treatment control group.
Data collection and analysis:
Three teams of two review authors independently extracted data, assessed risk of bias for each study and assessed the quality of the body of evidence for each outcome using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. We conducted analyses on continuous outcomes (pain, physical function and quality of life) immediately after treatment and on dichotomous outcomes (proportion of study withdrawals) at the end of the study; we also conducted analyses on the sustained effects of exercise on pain and function (two to six months, and longer than six months).
Main results:
In total, we extracted data from 54 studies. Overall, 19 (20%) studies reported adequate random sequence generation and allocation concealment and adequately accounted for incomplete outcome data; we considered these studies to have an overall low risk of bias. Studies were largely free from selection bias, but research results may be vulnerable to performance and detection bias, as only four of the RCTs reported blinding of participants to treatment allocation, and, although most RCTs reported blinded outcome assessment, pain, physical function and quality of life were participant self-reported.High-quality evidence from 44 trials (3537 participants) indicates that exercise reduced pain (standardised mean difference (SMD) -0.49, 95% confidence interval (CI) -0.39 to -0.59) immediately after treatment. Pain was estimated at 44 points on a 0 to 100-point scale (0 indicated no pain) in the control group; exercise reduced pain by an equivalent of 12 points (95% CI 10 to 15 points). Moderate-quality evidence from 44 trials (3913 participants) showed that exercise improved physical function (SMD -0.52, 95% CI -0.39 to -0.64) immediately after treatment. Physical function was estimated at 38 points on a 0 to 100-point scale (0 indicated no loss of physical function) in the control group; exercise improved physical function by an equivalent of 10 points (95% CI 8 to 13 points). High-quality evidence from 13 studies (1073 participants) revealed that exercise improved quality of life (SMD 0.28, 95% CI 0.15 to 0.40) immediately after treatment. Quality of life was estimated at 43 points on a 0 to 100-point scale (100 indicated best quality of life) in the control group; exercise improved quality of life by an equivalent of 4 points (95% CI 2 to 5 points).High-quality evidence from 45 studies (4607 participants) showed a comparable likelihood of withdrawal from exercise allocation (event rate 14%) compared with the control group (event rate 15%), and this difference was not significant: odds ratio (OR) 0.93 (95% CI 0.75 to 1.15). Eight studies reported adverse events, all of which were related to increased knee or low back pain attributed to the exercise intervention provided. No study reported a serious adverse event.In addition, 12 included studies provided two to six-month post-treatment sustainability data on 1468 participants for knee pain and on 1279 (10 studies) participants for physical function. These studies indicated sustainability of treatment effect for pain (SMD -0.24, 95% CI -0.35 to -0.14), with an equivalent reduction of 6 (3 to 9) points on 0 to 100-point scale, and of physical function (SMD -0.15 95% CI -0.26 to -0.04), with an equivalent improvement of 3 (1 to 5) points on 0 to 100-point scale.Marked variability was noted across included studies among participants recruited, symptom duration, exercise interventions assessed and important aspects of study methodology. Individually delivered programmes tended to result in greater reductions in pain and improvements in physical function, compared to class-based exercise programmes or home-based programmes; however between-study heterogeneity was marked within the individually provided treatment delivery subgroup.
Authors' conclusions:
High-quality evidence indicates that land-based therapeutic exercise provides short-term benefit that is sustained for at least two to six months after cessation of formal treatment in terms of reduced knee pain, and moderate-quality evidence shows improvement in physical function among people with knee OA. The magnitude of the treatment effect would be considered moderate (immediate) to small (two to six months) but comparable with estimates reported for non-steroidal anti-inflammatory drugs. Confidence intervals around demonstrated pooled results for pain reduction and improvement in physical function do not exclude a minimal clinically important treatment effect. Since the participants in most trials were aware of their treatment, this may have contributed to their improvement. Despite the lack of blinding we did not downgrade the quality of evidence for risk of performance or detection bias. This reflects our belief that further research in this area is unlikely to change the findings of our review.
Objectives:
The Tampa Scale of Kinesiophobia (TSK) has been used to identify people with back pain who have high levels of "fear of movement" to direct them into fear reduction interventions. However, there is considerable debate as to what construct(s) the scale measures. Somatic Focus and Activity Avoidance subscales identified in factor analytic studies remain poorly defined. Using a mixed methods design, this study sought to understand the beliefs that underlie high scores on the TSK to better understand what construct(s) it measures.
Methods:
In-depth qualitative interviews with 36 adults with chronic nonspecific low back pain (average duration=7 y), scoring highly on the TSK (average score=47/68), were conducted. Following inductive analysis of transcripts, individuals were classified into groups on the basis of underlying beliefs. Associations between groups and itemized scores on the TSK and subscales were explored. Frequencies of response for each item were evaluated.
Findings:
Two main beliefs were identified: (1) The belief that painful activity will result in damage; and (2) The belief that painful activity will increase suffering and/or functional loss. The Somatic Focus subscale was able to discriminate between the 2 belief groups lending construct validity to the subscale. Ambiguous wording of the Activity Avoidance subscale may explain limitations in discriminate ability.
Discussion:
The TSK may be better described as a measure of the "beliefs that painful activity will result in damage and/or increased suffering and/or functional loss."
Objectives:
The active straight leg raise (ASLR) test is widely used clinically to assess severity of lumbopelvic pain due to decreased stability of the sacroiliac joint (SIJ). This study aimed to bypass the influence of decreased SIJ stability on the ASLR test by investigating the effect of experimental pelvic pain and hyperalgesia on the outcome of the ASLR test.
Methods:
Thirty-four healthy participants took part in this randomized crossover study. Pelvic pain was induced by injecting hypertonic saline into the long posterior sacroiliac ligament. Isotonic saline was injected on the contralateral side as control. Pain intensity was assessed on an electronic visual analogue scale. The Likert scores of difficulty performing the ASLR test and simultaneous electromyography of trunk and thigh muscles were recorded before, during, and postpain. Pressure pain thresholds were assessed bilaterally in the pelvic area and lower limb.
Results:
Compared with the control condition and baseline, hypertonic saline injections caused (P<0.05): (1) higher visual analogue scale scores of the pain intensity; (2) reduced pressure pain thresholds at the injection site and lateral to S2; (3) increased difficulty in performing the ASLR rated on the Likert scale; and (4) bilateral increase in the electromyography activity of stabilizing trunk and thigh muscles during pain.
Discussion:
These data demonstrate that pain and hyperalgesia in conditions unaffected by biomechanical SIJ impairments change the outcome of the ASLR test toward what is seen in clinical lumbopelvic pain. This may implicate pain-related changes in motor control strategies potentially relevant for the transition from acute into chronic pain.
Pelvic girdle pain (PGP) is frequently managed by physiotherapists. Little is known about current physiotherapy practice and beliefs in the management of PGP disorders. The primary aim of this study was to investigate current practice and beliefs in management of PGP among physiotherapists working in Norway and Australia. A secondary aim was to compare current practice with clinical guidelines. A questionnaire was developed and electronically distributed to physiotherapists in Norway (n=65) and Australia (n=77). Treatment and management were determined via responses to 2 case vignettes (during pregnancy, not related to pregnancy), with participants selecting their four primary preferences for treatment and management from a list of 33 possibilities. During pregnancy, ‘education around instability’ and ‘soft tissue treatment’ were selected amongst the most common interventions by physiotherapists in both countries. Norwegian physiotherapists selected ‘pelvic floor exercises’ more frequently, while Australian physiotherapists more commonly selected ‘correcting functional impairments’. In the other case, common responses from both countries were ‘hip strengthening in weight bearing’ and ‘correction of functional impairments’. Norwegian physiotherapists selected ‘general physical exercise’ and ‘general education’ more frequently, while Australian physiotherapists more commonly selected ‘hip strengthening in non-weight bearing’ and ‘muscular relaxation of the abdominal wall/pelvic floor’. Beliefs about PGP were generally positive in both groups while knowledge of and adherence to clinical guidelines were limited. The findings provide direction for future research related to the management and treatment of PGP, and targets for education of physiotherapists working in this area.
Chronic pain is an important public health problem that negatively impacts quality of life of affected individuals and exacts an enormous socio-economic cost. Currently available therapeutics provide inadequate management of pain in many patients. Acute pain states generally resolve in most patients. However, for reasons that are poorly understood, in some individuals, acute pain can transform to a chronic state. Our understanding of the risk factors that underlie the development of chronic pain is limited. Recent studies have suggested an important contribution of dysfunction in descending pain modulatory circuits to pain 'chronification'. Human studies provide insights into possible endogenous and exogenous factors that may promote the conversion of pain into a chronic condition.
Descending pain modulatory systems have been studied and characterized in animal models. Human brain imaging techniques, deep brain stimulation and the mechanisms of action of drugs that are effective in the treatment of pain confirm the clinical relevance of top-down pain modulatory circuits. Growing evidence supports the concept that chronic pain is associated with a dysregulation in descending pain modulation. Disruption of the balance of descending modulatory circuits to favour facilitation may promote and maintain chronic pain. Recent findings suggest that diminished descending inhibition is likely to be an important element in determining whether pain may become chronic. This view is consistent with the clinical success of drugs that enhance spinal noradrenergic activity, such as serotonin/norepinephrine reuptake inhibitors (SNRIs), in the treatment of chronic pain states. Consistent with this concept, a robust descending inhibitory system may be normally engaged to protect against the development of chronic pain. Imaging studies show that higher cortical and subcortical centres that govern emotional, motivational and cognitive processes communicate directly with descending pain modulatory circuits providing a mechanistic basis to explain how exogenous factors can influence the expression of chronic pain in a susceptible individual.
Preclinical studies coupled with clinical pharmacologic and neuroimaging investigations have advanced our understanding of brain circuits that modulate pain. Descending pain facilitatory and inhibitory circuits arising ultimately in the brainstem provide mechanisms that can be engaged to promote or protect against pain 'chronification'. These systems interact with higher centres, thus providing a means through which exogenous factors can influence the risk of pain chronification. A greater understanding of the role of descending pain modulation can lead to novel therapeutic directions aimed at normalizing aberrant processes that can lead to chronic pain.
Movement is changed in pain. This presents across a spectrum from subtle changes in the manner in which a task is completed to complete avoidance of a function and could be both a cause and effect of pain/nociceptive input and/or injury. Movement, in a variety of forms, is also recommended as a component of treatment to aid the recovery in many pain syndromes. Some argue it may not be sufficient to simply increase activity, whereas others defend a necessity to consider how a person moves. There is unlikely to be a simple relationship between pain and movement, as both too little and too much movement could be suboptimal for the health of the tissues. The interaction between pain, (re)injury and movement is surprisingly unclear. Traditional theories to explain adaptation in the motor system in pain are unable to account for the variability observed in laboratory and clinical practice. New theories are required. Treatments that focus on physical activity and exercise are the cornerstone of management of many pain conditions, but the effect sizes are modest. There is limited consensus when, if and how interventions may be individualized and combined. The aim of this narrative review was to present current understanding of the interaction between movement and pain; as a cause or effect of pain, and in terms of the role of movement (physical activity and exercise) in recovery of pain and restoration of function.
Objective
To investigate the intra-examiner and inter-examiner reliability of physical examination to identify asymmetry of selected anatomical landmarks indicative of pelvic somatic dysfunction in subjects with and without low back pain using experienced osteopaths and final year students of osteopathy.
Objective: To investigate the effect of training and standardisation of technique on the inter-examiner and intra-examiner reliability of static palpation of pelvic landmarks and the seated flexion test (SFT), which are commonly advocated for the detection of sacroiliac dysfunction. Methods: Two groups of final year osteopathic students (N = 10) examined 10 asymptomatic female subjects for symmetry of pelvic landmarks and the SFT. One group of examiners (n = 5) attended two training sessions in order to standardise their examination techniques, whereas those in the 'untrained' group (n = 5) did not. Three assessments of the symmetry of the anterior superior iliac spine (ASIS), posterior superior iliac spine (PSIS), medial malleoli (MM), sacral inferior lateral angle (SILA) and SFT were performed on every subject by all examiners. Examiner agreement was analysed using Cohen's weighted kappa (κ) statistic. Results: The trained group produced slightly higher intra-examiner reliability for three of the four landmarks and the SFT, and slightly higher inter-examiner reliability for two of the four landmarks and the SFT. Intra-examiner reliability was higher than inter-examiner reliability. The level of inter-examiner agreement in the trained group was fair for palpation of the MM (trained, κ = 0.31; untrained, κ = 0.28) and ASIS (trained, κ = 0.24; untrained, κ = -0.01), slight for the SFT (trained, κ = 0.14; untrained, κ = 0.07), PSIS (trained, κ = 0.08; untrained, κ = 0.15) and SILA (trained, κ = 0.04; untrained, κ = -0.01). Conclusions: Those examiners who attended training sessions achieved a marginal increase in intra-examiner and inter-examiner reliability, but concordance was still less than acceptable for a clinical test. The osteopathic profession should reconsider the use of these clinical tests purported to indicate sacroiliac dysfunction in view of their unestablished validity and poor inter-examiner reliability.
Purpose:
To compare the clinical features of patients with sacroiliac joint (SIJ)-related sciatica-like symptoms to those with sciatica from nerve root compression and to investigate the necessity to perform radiological imaging in patients with sciatica-like symptoms derived from the SIJ.
Methods:
Patients with pain radiating below the buttocks with a duration of 4 weeks to 1 year were included. After physical and radiological examinations, a diagnosis of SI joint-related pain, pain due to disk herniation, or a combination of these two causes was made.
Results:
Patients with SIJ-related leg pain (n = 77/186) were significantly more often female, had shorter statue, a shorter duration of symptoms, and had more often pain radiating to the groin and a history of a fall on the buttocks. Muscle weakness, corkscrew phenomenon, finger-floor distance ≥25 cm, lumbar scoliosis, positive Bragard or Kemp sign, and positive leg raising test were more often present when radiologic nerve root compression was present. Although these investigations may help, MRI of the spine is necessary to discriminate between the groups.
Conclusions:
Sciatica-like symptoms derived from the SIJ can clinically mimic a radiculopathy. We suggest to perform a thorough physical examination of the spine, SI joints, and hips with additional radiological tests to exclude other causes.
This article focuses on the (functional) anatomy and biomechanics of the pelvic girdle and specifically the sacroiliac joints (SIJs). The SIJs are essential for effective load transfer between the spine and legs. The sacrum, pelvis and spine, and the connections to the arms, legs and head, are functionally interrelated through muscular, fascial and ligamentous interconnections. A historical overview is presented on pelvic and especially SIJ research, followed by a general functional anatomical overview of the pelvis. In specific sections, the development and maturation of the SIJ is discussed, and a description of the bony anatomy and sexual morphism of the pelvis and SIJ is debated. The literature on the SIJ ligaments and innervation is discussed, followed by a section on the pathology of the SIJ. Pelvic movement studies are investigated and biomechanical models for SIJ stability analyzed, including examples of insufficient versus excessive sacroiliac force closure.
Chronic low back pain (CLBP) is a major clinical problem with a substantial socio-economical impact. Today, diagnosis and therapy are insufficient, and knowledge concerning interaction between musculoskeletal pain and motor performance is lacking. Most studies in this field have been performed under static conditions which may not represent CLBP patients' daily-life routines. A standardized way to study the sensory-motor interaction under controlled motor performance is to induce experimental muscle pain by i.m. injection of hypertonic saline. The aim of the present controlled study was to analyze and compare electromyographic (EMG) activity of and coordination between lumbar muscles (8 paraspinal recordings) during gait in 10 patients with CLBP and in 10 volunteers exposed to experimental back muscle pain induced by bolus injection of 5% hypertonic saline. When the results are compared to sex- and age-matched controls, the CLBP patients showed significantly increased EMG activity in the swing phase; a phase where the lumbar muscles are normally silent. These changes correlated significantly to the intensity of the back pain. Similar EMG patterns were found in the experimental study together with a reduced peak EMG activity in the period during double stance where the back muscles are normally active. Generally, these changes were localized ipsilaterally to the site of pain induction. The clinical and experimental findings indicate that musculoskeletal pain modulates motor performance during gait probably via reflex pathways. Initially, these EMG changes may be interpreted as a functional adaptation to muscle pain, but the consequences of chronic altered muscle performance are not known. New possibilities to monitor and investigate altered motor performance may help to develop more rational therapies for CLBP patients.
The objective of this study was to compare the efficacy of lateral branch neurotomy using cooled radiofrequency to a sham intervention for sacroiliac joint pain.
Fifty-one subjects were randomized on a 2:1 basis to lateral branch neurotomy and sham groups, respectively. Follow-ups were conducted at 1, 3, 6, and 9 months. Subjects and coordinators were blinded to randomization until 3 months. Sham subjects were allowed to crossover to lateral branch neurotomy after 3 months.
Subjects 18-88 years of age had chronic (>6 months) axial back pain and positive response to dual lateral branch blocks.
Lateral branch neurotomy involved the use of cooled radiofrequency electrodes to ablate the S1-S3 lateral branches and the L5 dorsal ramus. The sham procedure was identical to the active treatment, except that radiofrequency energy was not delivered.
The principal outcome measures were pain (numerical rating scale, SF-36BP), physical function (SF-36PF), disability (Oswestry disability index), quality of life (assessment of quality of life), and treatment success.
Statistically significant changes in pain, physical function, disability, and quality of life were found at 3-month follow-up, with all changes favoring the lateral branch neurotomy group. At 3-month follow-up, 47% of treated patients and 12% of sham subjects achieved treatment success. At 6 and 9 months, respectively, 38% and 59% of treated subjects achieved treatment success.
The treatment group showed significant improvements in pain, disability, physical function, and quality of life as compared with the sham group. The duration and magnitude of relief was consistent with previous studies, with current results showing benefits extending beyond 9 months.
The present study was performed to ascertain whether sacroiliac joint (SIJ) pain represents a potential source of pain in patients who have undergone lumbar or lumbosacral fusions.
Prospective cohort study. Patients and
Between June 2007 and June 2009, 130 patients who underwent lumbar or lumbosacral fusions were evaluated for SIJ pain. Fifty-two patients for whom positive findings were obtained on at least three of the provocating tests for SIJ pain were selected to receive dual diagnostic blocks.
A positive response was defined as characteristic pain reduction of 75% for 1-4 hours following the SIJ blocks. Predictive factors for a positive response to the SIJ blocks were also investigated.
Among the 52 patients, 21 were considered to have SIJ pain on the basis of two positive responses to diagnostic blocks. Univariate analysis revealed that the predictive factors related to positive responses were unilateral pain (P = 0.002), more than three positive responses to provocating maneuvers (P = 0.02), and postoperative pain with characteristics different from those of preoperative pain (P = 0.04).
SIJ pain is a potential source of pain after lumbar and lumbosacral fusion surgeries. Provocating SIJ maneuvers represent reliable tests for SIJ pain. The characteristics of postoperative SIJ pain frequently differ from those of preoperative pain.
The purpose of this article is to review current research investigating the reliability of bony anatomical landmark positional asymmetry assessment in the lumbar spine and pelvis, to determine the agreement on findings between authors, and to explore future directions in the area to address the significant issues. The databases MEDLINE, CINAHL, AMED, MANTIS, Academic Search Complete, and Web of Knowledge were searched. A total of 23 articles were identified and reviewed, 10 of which met the inclusion criteria. For these 10 articles, the average interexaminer reliability for bony anatomical landmark positional asymmetry assessment was slightly above chance for all landmarks except medial malleolus, which had fair reliability. Interexaminer reliability on average was less than intraexaminer reliability (anterior superior iliac spine, k = 0.128/0.414; posterior superior iliac spine, k = 0.092/0.371). All interexaminer reliability averages were below values of clinical significance. From the current literature review, bony anatomical landmark positional asymmetry assessment in the lumbar spine and pelvis has not been demonstrated to be a reliable assessment method. However, there are unexplored factors that, after standardization, may improve reliability and further the understanding of musculoskeletal palpatory examination.
The sacroiliac joint (SI joint) is a known source of low back pain. In the absence of validated physical signs and imaging studies, the diagnosis of SI joint pain can be secured by positive response to SI joint intra-articular infiltration with local anesthetics. The current anatomical and histological knowledge concerning intra-articular structures of the sacroiliac joint is insufficient to explain the efficacy of this infiltration. Consequently, this study was undertaken to detect the intra-articular presence of substance P and calcitonin gene-related peptide (CGRP) positive nerve fibers, providing indirect evidence of nociceptive innervation of the SI joint. Free-floating sections, obtained from iliac and sacral cartilage and subchondral bone of the SI joint and adjacent ligamentous tissue, of 10 human cadavers were studied immunohistochemically. Tissue of nine human cadavers showed the presence of substance P and CGRP immunoreactivity in the superficial layer of sacral and iliac cartilage, and the surrounding ligamentous structures. Subchondral bone reacted weakly to the antisera used. These findings support the view that the SI joint may be capable of intra-articular nociception and may explain the positive response to the intra-articular deposition of local anesthetic.
Current international treatment guidelines recommending therapeutic exercise for people with symptomatic hip OA report are based on expert opinion only.
To determine whether land-based therapeutic exercise is beneficial for people with hip OA in terms of reduced joint pain and/or improved physical function.
Five databases were searched from 1966 up until August 2008.
All randomised controlled trials (RCTs) recruiting people with hip OA and comparing some form of land-based therapeutic exercise (as opposed to exercises conducted in the water) with a non-exercise group.
Three reviewers independently extracted data and assessed methodological quality. All analyses were conducted on continuous outcomes.
Combining the results of the five included RCTs demonstrated a small treatment effect for pain, but no benefit in terms of improved self-reported physical function. Only one of these five RCTs exclusively recruited people with symptomatic hip OA.
The limited number and small sample size of the included RCTs restricts the confidence that can be attributed to these results. Adequately powered RCTs evaluating exercise programs specifically designed for people with symptomatic hip OA need to be conducted.