Posterior pelvic pain provocation test is negative in patients with lumbar herniated discs

The classification of pelvic girdle pain can only be reached after lumbar causes have been excluded by a clinical examination. During clinical examination, the posterior pelvic pain provocation test is a well-established method for verifying pelvic girdle pain. However, a criticism of pelvic pain provocation tests is that they may have an effect on lumbar structures, thus yielding false-positive results. The posterior pelvic pain provocation test was performed with four groups of patients: patients with computed tomography-verified disc herniations (1) on the waiting list for surgery (14 women; 9 men); (2) 6 weeks after disc surgery (18 women, 12 men); (3) pregnant women seeking care for pelvic girdle pain (n = 25); and (4) women with persistent pelvic girdle pain after delivery (n = 32). The sensitivity of the posterior pelvic pain provocation test was 0.88 and the specificity was 0.89. The positive predictive value was 0.89 and the negative predictive value was 0.87. Analysis of only women showed similar results. In our study, the posterior pelvic pain provocation test was negative in patients with a well-defined lumbar diagnosis of lumbar disc herniation, both before and after disc surgery. Our results are an important step toward the more accurate classification of lumbopelvic pain.     

Lumbar back and posterior pelvic pain during pregnancy: a 3-year follow-up

This study is a prospective, consecutive, 3-year cohort study of women with back pain in an index pregnancy. The aim was to describe the physical status and disability among women with back pain 3 years after delivery. Pain was identified as lumbar back pain, posterior pelvic pain or combined lumbar as well as posterior pelvic pain. Previous studies have established that all three types of pain can be reduced by structured physiotherapy during pregnancy, and the beneficial effect may last for several years. Though it is known that some women have residual pain for a long time, the relative incidence of the three pain types and their degree of disability associated with each have never been reported. Neither has any study presented findings of a physical examination of women 3 years post partum with a focus on the type of pain. All women who were registered as having experienced back pain during an index pregnancy were interviewed by mail 3 years post partum. Women who had residual back pain filled in an additional questionnaire and were physically examined. Out of 799 pregnant women, 231 had some type of back pain during the index pregnancy, and 41 women had pain 3 years later. Women with combined lumbar and posterior pelvic pain were significantly more disabled ( P<0.05) and had significantly lower endurance in the lumbar back and hip abduction muscles ( P<0.01). Some 5% of all pregnant women, or 20% of all women with back pain during pregnancy, had pain 3 years later. The key problem may be poor muscle function in the back and pelvis.     

Patient-oriented assessment of back pain in pregnancy

Back pain is a common symptom in women during the last period of pregnancy. Only a few studies using validated patient-oriented tools have been undertaken on this topic. We report on a multicenter study on back pain in women during the last period of pregnancy, which involved seven Italian institutions. Seventy-six women in their 8th and 9th months were studied using the Italian validated version of the Roland questionnaire -- a disease-specific patient-oriented tool for low back pain. Sixty-two percent of the women had gone through at least one previous pregnancy, and clinical data concerning both the period before all pregnancies and the period before the current pregnancy were acquired. The study found that 31% of the women had no back pain symptoms (Roland score 0), 40% scored from 1 to 4, 21% scored from 5 to 10, and 8% scored more than 10. With regard to the predictive factor, history of back pain and sciatica before the pregnancy were found to be associated with occurrence of back pain symptoms during pregnancy. Unexpectedly, our results showed that male sex of the fetus seems to be related to occurrence of back pain symptoms during pregnancy. However, back pain was not associated with having gone through previous pregnancies, nor was the Roland score related to the weight before pregnancy or to increment of weight during pregnancy. Evaluation of the patient's perspective made it possible to identify predictive factors for occurrence of back pain, thereby furnishing important information for the clinical approach to pregnancy.     

BMI, pain and hyper-mobility are determinants of long-term outcome for women with low back pain and pelvic pain during pregnancy

Low back pain and pelvic pain (LBPP) is common during pregnancy and up to 40% of women still have symptoms half a year after delivery. The aim of the study was to investigate determinants and the prevalence of persistent LBPP after pregnancy in a Swedish cohort. In a previous study 891 women had responded to a questionnaire on risk factors and prevalence of LBPP during pregnancy. Altogether 72% (n=639) of the women had reported LBPP during pregnancy. These respondents were sent a second questionnaire at approximately 6 months after delivery. The response rate was 72.6% (n=464). Independent t-test and Pearson’s chi-squared test were used to test the difference between the two groups. In response to the questionnaire, 43.1% of the women reported persistent LBPP 6 months after delivery. Women with persistent LBPP after pregnancy had had significantly earlier onset of pain during pregnancy, higher maternal age, higher body mass index (BMI), and assessed a higher level of pain due to LBPP during pregnancy and after pregnancy, and included a higher proportion of women with joint hyper-mobility. In summary, recurrent or continuous LBPP is prevalent after pregnancy. BMI as well as hyper-mobility are prominent determinants of persistent LBPP after pregnancy. Level and onset of pain during pregnancy were strong predictors of persistent LBPP.     

Back pain in pregnancy: 1-year follow-up of untreated cases

Back Pain (BP) is one of the most frequent symptoms during the last period of pregnancy, and high incidence has been described in several studies. Until now no wide, multicenter and prospective clinical studies on the natural course of BP after pregnancy have been available. We performed a multicenter follow-up study in a sample of pregnant women using the Italian validated version of the Roland questionnaire to assess the evolution of BP after pregnancy and identify prognostic factors. Each center had to re-evaluate at least 75% of the initially enrolled women, with latency of 1 year after delivery. At the follow-up, we acquired substantial clinical data concerning the post-delivery period. The evaluation of symptom evolution was based on the Roland questionnaire. At follow-up, 53% of re-evaluated women had no BP symptoms. Moreover, there was a significant improvement of patient-oriented assessment in women who suffered BP after delivery. With regard to the predictive factors, the presence of BP before pregnancy implied a 3.1-fold higher probability of improvement after delivery. In conclusion, women without history of BP before pregnancy and who complain of these symptoms during pregnancy require greater attention, because they have a lower possibility for improvement. Conversely, in women with a history of BP, pregnancy represents a transient period of worsening symptoms, probably due to the temporary para-physiological mechanical condition.This research was conducted in the Department of Neurology of Università Cattolica, Rome, Italy     

Relationship of pain drawings to invasive tests assessing intervertebral disc pathology

It has been found that the pain patterns in pain drawings are related to the presence of herniated disc identified by myelography. The purpose of this study was to determine whether the pattern of pain in the drawings or the type of pain indicated (aching, burning, numbness, pins and needles, stabbing) was related to the presence of symptomatic disc pathology identified by CT/discography. In a subgroup of patients who underwent myelography, the relationship of the drawings to myelographic findings was also investigated. Pain drawings were completed by 187 patients with low back and/or radicular pain who were undergoing CT/discography. The drawings were scored in two ways, first by the system described by Ransford and secondly by visual inspection. They were classified as being indicative, or not, of disc pathology. The CT/discograms were classified as disrupted, or not, and the pain responses were recorded upon injection of each disc, based on the similarity of the pain provoked to clinical symptoms. Among the 133 patients with discogenic pain confirmed by discography, 110 (82.7%) had pain drawings that were classified as indicative. Among the 45 patients without discogenic pain, 29 (64.4%) had pain drawings classified as non-indicative. Patients with discogenic pain used more symbols indicating burning pain and aching pain than did non-discogenic pain patients. Our results confirmed those reported earlier by Udén, who found a relationship between the pattern of pain in the drawings and myelographic findings. Pain drawings may be helpful in the diagnosis of symptomatic disc pathology. Received: 26 February 1998 Revised: 31 August 1998 Accepted: 26 October 1998     

脊柱旋转畸形与青年腰背痛

目的：探讨单纯性脊柱旋转畸形的发生率及其与青年腰背痛的关系。方法：对148例青年腰背痛患者进行临床脊柱前屈试验检查及X线像检查或CT扫描。结果：49例伴有脊柱旋转畸形,占30.2%,且脊柱旋转与腰背痛密切相关。结论：脊柱旋转畸形可单独存在,临床上并不少见。值得放射科及骨科医生予以关注。     

Interstitial cystitis in persistent posthysterectomy chronic pelvic pain.

OBJECTIVES: Hysterectomies may be performed unnecessarily in women with chronic pelvic pain if the diagnosis of interstitial cystitis is not considered. The objectives of this study were to investigate the prevalence of interstitial cystitis in patients with posthysterectomy chronic pelvic pain and to evaluate the efficacy of various therapies for interstitial cystitis. METHODS: A study was performed of 111 patients with chronic pelvic pain whose pain persisted after hysterectomy. Patients were screened with the Pelvic Pain and Urgency/Frequency symptom scale, and underwent Potassium Sensitivity Testing. Patients were treated with dietary changes alone or in combination with cystoscopic hydrodistention or oral pentosan polysulfate, or both of these, for 3 to 6 months. RESULTS: Of the 111 patients enrolled, 79% (n=88) were diagnosed with bladder dysfunction consistent with interstitial cystitis. For patients treated with dietary modification alone (n=33), the mean score on the Pelvic Pain and Urgency/Frequency questionnaire improved 15.4%, from 13.18 at baseline to 11.15 at follow-up. For patients treated with pentosan polysulfate or cystoscopic hydrodistention, or both, plus diet changes (n=78), Pelvic Pain and Urgency/Frequency scores improved 34.2%, from 15.01 to 9.87. CONCLUSION: In this study, nonsurgical treatment for interstitial cystitis resulted in a marked improvement in symptoms that had not improved with surgery. Without determining the origin of bladder pain, gynecologists should not proceed to hysterectomy in patients with chronic pelvic pain.     

Does raloxifene treatment influence back pain and disability among postmenopausal women with osteoporosis?

Clinical studies have suggested that postmenopausal women on estrogen replacement treatment are more likely to experience back pain and related disability compared to women who do not take estrogens. Raloxifene, a selective estrogen receptor modulator has estrogen-like effects on bone tissue, and antagonize the action of estrogens on endometrium and breast tissue. It is unknown if the treatment of osteoporosis with raloxifene has estrogen-like or opposite effects on back pain and functional capacity among postmenopausal women with osteoporosis. A total of 120 postmenopausal women with osteoporosis and chronic back pain were randomized to receive raloxifene 60 mg with 1,000 mg calcium, and 800 IU vitamin D daily or 1,000 mg calcium and 800 IU vitamin D daily. Pain intensity and pain-related disability were measured before treatment at 6 months and after 1 year. Repeated measures of ANOVA, did not reveal statistically significant differences over time, on pain intensity and disability scores, between groups studied. There was a trend in pain intensity changes during the follow-up period, but the differences between the groups were not statistically significant. It seems that treatment with raloxifene does not influence back pain and disability among postmenopausal women with osteoporosis. Raloxifene may have estrogenic agonist effects on nociceptive processing in the central nervous system.     

Back pain in osteoporotic vertebral fractures

SUMMARY: This review article examines the epidemiology and pathogenesis of back pain and vertebral fractures in osteoporosis, reviewing the management of pain in patients with vertebral fractures and the direct and indirect effect of osteoporosis treatments on back pain. INTRODUCTION: The management of patients with vertebral fractures has largely concentrated on the prevention of further fractures by the treatment of underlying osteoporosis, with drug treatment for acute and chronic back pain and the non-pharmacological management of vertebral fractures receiving less attention. DISCUSSION: Emerging evidence suggests that, in addition to reducing the incidence of vertebral fractures, calcitonin, intravenous bisphosphonates and teriparatide may also have a direct effect on bone pain. Targeted analgesia, tailored to individual need is often required in both the acute and chronic phases following vertebral fracture. Vertebroplasty and kyphoplasty have also been approved for use in the management of vertebral fractures and may prove useful in selected patients unresponsive to conventional pain relief. There is some evidence to support the use of individualised tailored exercise programmes aimed at strengthening back muscles to maintain bone density and reduce further fracture incidence. In addition the use of specific orthoses may help to reduce kyphosis, improve mobility and reduce pain. CONCLUSION: Chronic back pain associated with vertebral fracture provides a great challenge to health care professionals and the patient. This demands a combination of options, including not only therapeutic interventions, but also physiotherapy, psychological support and patient education.     

Hernias as a cause of chronic pelvic pain in women.

BACKGROUND: Chronic pelvic pain in women due to hernias may be misdiagnosed by practicing clinicians. These fascial defects, their symptoms, physical findings, and proper treatment must be known in order to help women experiencing this form of chronic pelvic pain. METHODS: All procedures were performed by the primary author using standard laparoscopic tension-free mesh techniques. RESULTS: The study included 264 patients referred to a chronic pelvic pain clinic, who underwent 386 laparoscopic surgical repairs of hernial defects. Ninety percent of the patients underwent concomitant procedures appropriate for their multiple pain generators. Length of follow-up is 1.53 years (range, 2 months to 5.5 years). Evaluation of patients' pain component from the repaired hernia was recorded. There have been no recurrences. One persistent ilioinguinal neuropathy from an inguinal hernia repair (.4%) has occurred. All other patients received relief of their hernia pain (99.6%). Four complications from concomitant surgeries (1.5%) are reported. CONCLUSIONS: Laparoscopic treatment of hernia pain in women is effective in relieving chronic pain and has a low recurrence and complication rate in the hands of experienced laparoscopists.     

Chronic pelvic pain in women: still a challenge

Chronic pelvic pain (CPP), a common condition particularly in reproductive-aged women, causes disability and distress, and significantly compromises quality of life and affects healthcare costs. The pathogenesis of CPP is still poorly understood and consequently poorly managed. Furthermore, the lack of a consensus on the definition of CPP greatly hinders epidemiological studies. Patients present with various associated problems, including bladder or bowel dysfunction, gynaecological pathologies or sexual dysfunction, and other systemic or constitutional symptoms. Other conditions, e.g. depression, anxiety and drug addiction, can also coexist. Effective management presupposes an integrated knowledge of all pelvic organs and other systems, including musculoskeletal, neurological and psychiatric systems. The key to treating CPP is to treat it as the complex disease it is. Treatment options range from conservative medical therapy to surgical intervention, and are primarily directed towards symptom relief. Unsatisfactory results of treatment render this condition a frustrating problem for both patients and physicians.     

Self-administered tests as a screening procedure for pregnancy-related pelvic girdle pain

The aim of this study was to investigate sensitivity and specificity of self-administrated tests aimed at pain provocation of posterior and/or anterior pelvis pain and to investigate pain intensity during and after palpation of the symphysis. A total of 175 women participated in the study, 100 pregnant women with and 25 pregnant women without lumbopelvic back pain and 50 non-pregnant women. Standard pain provocation tests were compared with self assessed tests. All women were asked to estimate pain during and after palpation of the symphysis. For posterior pelvic pain, the self-test of P4 and Bridging test had the highest sensitivity of 0.90 versus 0.97 and specificity of 0.92 and 0.87. Highest sensitivity for self-test for anterior pelvic pain was pulling a mat 0.85. Palpation of symphysis was painful and persistency of pain was the longest among women who fulfilled the criteria for symphyseal pain. There were overall significant differences between the groups concerning intensity and persistency of pain (P < 0.001). Our results indicate that pregnant women can perform a screening by provocation of posterior pelvic pain by self-tests with the new P4 self-test and the Bridging test. Palpation of the symphysis is painful and should only be used as a complement to history taking, pain drawing and pulling a MAT-test.     

An update on the management of chronic pelvic pain in women

Chronic pelvic pain represents a major public health problem for women and impacts significantly on their quality of life. Yet it is under-researched and a challenge to manage. Women who suffer from chronic pelvic pain frequently describe their healthcare journey as long, via a variety of specialists and frustrating, with their pain often dismissed. Aetiological factors and associations are best conceptualised using the ‘three P’s’ model of predisposing, precipitating and perpetuating factors. This integrates the numerous biological, psychological and social contributors to the complex, multifactorial nature of chronic pelvic pain. Overall management involves analgesia, hormonal therapies, physiotherapy, psychological approaches and lifestyle advice, which like other chronic pain conditions relies on a multidisciplinary team approach delivered by professionals experienced and trained in managing chronic pelvic pain.     

The effect of psychosocial measures of resilience and self-efficacy in patients with neck and lower back pain

Background Context

Psychosocial risk factors may predispose to progression of back and neck pain to chronic pain or disability. Resilience (the ability to recover from stress) and pain self-efficacy (confidence that one can perform daily activities despite pain) are important psychometric properties shown to affect health and illness.

Is there a relationship between parity, pregnancy, back pain and incontinence?

The aims of this study were to compare prevalence of back pain in parous, nulliparous, pregnant and non-pregnant women and to determine whether there is an association between incontinence and back pain in pregnant women. Associations between back pain, pregnancy, parity and incontinence were assessed in 14,779 younger and 14,099 mid-age women using chi-squared analysis. The odds of back pain were modelled with multinomial logistic regression. Back pain was more frequent in parous than nulliparous (p < 0.001) and pregnant than non-pregnant (p < 0.001) younger women. However, no associations were seen for mid-aged women. Pregnant women who had incontinence had increased odds ratios for ‘often’ and ‘rarely or sometimes’ having back pain (8.5 and 3.8, respectively). This study suggests that pregnancy may lead to earlier development of back pain, without affecting long-term prevalence. Incontinence and back pain may be related because of contribution of the trunk muscles to continence and lumbopelvic control.     

Dilemmas in diagnosing pelvic pain: multiple pelvic surgeries common in women with interstitial cystitis

We determined the prevalence of pelvic surgeries in women with interstitial cystitis (IC) compared to community-based controls through responses to a survey from 215 women with IC and 823 controls. Women with IC had a statistically higher prevalence of hysterectomies (cases = 42.3%, controls = 21.4%), bladder suspensions (cases = 21.9%, controls = 5.7), pelvic or genital surgeries other than cystoscopy (cases = 26.5%, controls = 16.2%), and laparoscopic pelvic surgeries (cases = 22.8%, controls = 8.3%). Women with IC more commonly had been diagnosed with endometriosis (cases = 25.6%, controls = 9.8%) and fibroids (cases = 24.2%, controls = 16.3%). Of women with IC who had hysterectomies, 68% of the hysterectomies were done before their diagnosis of IC, and only 21% were done after their IC diagnosis. The diagnosis of IC occurred 1–5 years after hysterectomy in most cases. Women with IC have significantly more pelvic surgeries than controls. The majority of these surgeries were done before the diagnosis of IC and may be performed for pain related to undiagnosed IC.     

Intravesical potassium chloride sensitivity test in men with chronic pelvic pain syndrome

PURPOSE: Intravesical potassium chloride has been reported to cause pain in patients with interstitial cystitis and male chronic prostatitis (CP)/chronic pelvic pain syndrome (CPPS). We performed the potassium chloride sensitivity test (PST) in subjects with CP/CPPS and healthy men without pelvic pain. MATERIALS AND METHODS: We recruited 40 men with CP/CPPS and 63 healthy men. The National Institutes of Health CPPS symptom index was used to measure the severity of symptoms. We instilled 100 ml physiological saline (NaCl 0.9%) intravesically. The bladder was emptied and 100 ml potassium chloride solution (KCl 40 mEq) were instilled. The subjects were asked to score urgency (0 to 10) and pain (0 to 10) sensations after each instillation. A positive PST was defined by 5 different cut-off points as the difference in score between KCl and NaCl instillations. Logistic regression analyses and area under the receiver operating characteristics curve were used to determine the predictive power of PST in CP/CPPS. RESULTS: There was no difference in pain and urgency scores between the men with CP/CPPS and controls (p >0.05 for each). Men with CP/CPPS had higher pain and urgency scores with KCl than with NaCl (p = 0.011 and 0.033, respectively). The rates of positive PST were 50% and 36.5% in the CP/CPPS and control groups, respectively (p = 0.160). There was no significant correlation of potassium chloride sensitivity scores with National Institutes of Health symptom scores (p >0.05 for each). The sensitivity, specificity, and positive predictive and negative predictive values of PST were 50%, 63.5%, 46.5% and 66.7%, respectively. CONCLUSIONS: Although there was a significant increase in pain and urgency scores following KCl instillation in patients with CP/CPPS, these scores and the rate of positive PST were not statistically different from those of healthy subjects. Thus, PST does not have a good predictive value in the diagnosis of CP/CPPS.