Pain Provocation Tests Research Articles

Kinematic and kinetic changes in a single leg drop landing task following athletic groin pain rehabilitation

Background: Acute groin injuries are common, but there are no high quality studies on injury mechanisms, clinical and radiological findings. The objective of this study was to describe these parameters in a prospective cohort of athletes. Methods: Male athletes (age 18–40) presenting with acute groin pain within 7 days of injury onset were prospectively studied (Aug. 2012–Apr. 2014). All patients underwent a standardized history, clinical examination (pain-provocation tests including palpation, active isometric resistance and passive range of motion), and magnetic resonance imaging and/or ultra sound. A clinical entity approach was used to classify all injuries, and muscle injury distribution through radiology was specified and categorized to similar entities. Results: 109 athletes (age 25.6±4.7 yrs.) were included. Football and futsal players accounted for themajority of theparticipants (74%). The injuries occurred most frequently during kicking (32%), change of direction (20%), in stretch situations (17%), and during running/sprinting (15%). The clinical entities diagnosed were: adductor (66%, n=66), rectus femoris (26%, n=28), iliopsoas (23%, n=25), abdominal (10%, n=11), and sartorius (6%, n=7). Multiple clinical entities were found in 29% (n=32) of the cases, where a combination of adductor and iliopsoas injuries was most frequent (12, 38%). Radiological assessment was negative in 23% of the investigations. An acute adductor injury was present on imaging in 50% of the cases, and in 92% of these there was an injury in the adductor longus muscle. Iliopsoas injuries were found in 14% of cases, and 13% involved the rectus femoris. Findings in multiple entities were present in 8% of the cases, and the most frequent combination was adductor and abdominal (53%). In 47% of the cases, no radiological abnormalities were found in the location suspected clinically, and in 48% of those cases there were positive findings in a different location. Adductor injuries diagnosed clinically rarely had imaging findings in a different location (4%), whereas clinical iliopsoas and rectus femoris injuries had imaging findings in a different location in app. 40% of the cases. Discussion: Adductor-related injuries were the most common acute groin injury, and the kicking action was the most common injury situation. Negative radiological assessment was found in more than1outof 5acutegroin injuries. In1outof 4 cases radiology showed an injury in another location than the clinically examination, which highlights that acute groin injuries, especially iliopsoas and proximal rectus femoris injuries, can be difficult to diagnose.

Acute groin injuries in 109 athletes – Clinical and radiological findings

Background: Acute groin injuries are common, but there are no high quality studies on injury mechanisms, clinical and radiological findings. The objective of this study was to describe these parameters in a prospective cohort of athletes. Methods: Male athletes (age 18–40) presenting with acute groin pain within 7 days of injury onset were prospectively studied (Aug. 2012–Apr. 2014). All patients underwent a standardized history, clinical examination (pain-provocation tests including palpation, active isometric resistance and passive range of motion), and magnetic resonance imaging and/or ultra sound. A clinical entity approach was used to classify all injuries, and muscle injury distribution through radiology was specified and categorized to similar entities. Results: 109 athletes (age 25.6±4.7 yrs.) were included. Football and futsal players accounted for themajority of theparticipants (74%). The injuries occurred most frequently during kicking (32%), change of direction (20%), in stretch situations (17%), and during running/sprinting (15%). The clinical entities diagnosed were: adductor (66%, n=66), rectus femoris (26%, n=28), iliopsoas (23%, n=25), abdominal (10%, n=11), and sartorius (6%, n=7). Multiple clinical entities were found in 29% (n=32) of the cases, where a combination of adductor and iliopsoas injuries was most frequent (12, 38%). Radiological assessment was negative in 23% of the investigations. An acute adductor injury was present on imaging in 50% of the cases, and in 92% of these there was an injury in the adductor longus muscle. Iliopsoas injuries were found in 14% of cases, and 13% involved the rectus femoris. Findings in multiple entities were present in 8% of the cases, and the most frequent combination was adductor and abdominal (53%). In 47% of the cases, no radiological abnormalities were found in the location suspected clinically, and in 48% of those cases there were positive findings in a different location. Adductor injuries diagnosed clinically rarely had imaging findings in a different location (4%), whereas clinical iliopsoas and rectus femoris injuries had imaging findings in a different location in app. 40% of the cases. Discussion: Adductor-related injuries were the most common acute groin injury, and the kicking action was the most common injury situation. Negative radiological assessment was found in more than1outof 5acutegroin injuries. In1outof 4 cases radiology showed an injury in another location than the clinically examination, which highlights that acute groin injuries, especially iliopsoas and proximal rectus femoris injuries, can be difficult to diagnose.

Vitamin D and central hypersensitivity in patients with chronic pain.

Low vitamin D is implicated in various chronic pain conditions with, however, inconclusive findings. Vitamin D might play an important role in mechanisms being involved in central processing of evoked pain stimuli but less so for spontaneous clinical pain. This study aims to examine the relation between low serum levels of 25-hydroxyvitamin D3 (25-OH D) and mechanical pain sensitivity. We studied 174 patients (mean age 48 years, 53% women) with chronic pain. A standardized pain provocation test was applied, and pain intensity was rated on a numerical analogue scale (0-10). The widespread pain index and symptom severity score (including fatigue, waking unrefreshed, and cognitive symptoms) following the 2010 American College of Rheumatology preliminary diagnostic criteria for fibromyalgia were also assessed. Serum 25-OH D levels were measured with a chemiluminescent immunoassay. Vitamin deficiency (25-OH D < 50 nmol/L) was present in 71% of chronic pain patients; another 21% had insufficient vitamin D (25-OH D < 75 nmol/L). After adjustment for demographic and clinical variables, there was a mean ± standard error of the mean increase in pain intensity of 0.61 ± 0.25 for each 25 nmol/L decrease in 25-OH D (P = 0.011). Lower 25-OH D levels were also related to greater symptom severity (r = -0.21, P = 0.008) but not to the widespread pain index (P = 0.83) and fibromyalgia (P = 0.51). The findings suggest a role of low vitamin D levels for heightened central sensitivity, particularly augmented pain processing upon mechanical stimulation in chronic pain patients. Vitamin D seems comparably less important for self-reports of spontaneous chronic pain.

Successful injection of the acromioclavicular joint with use of ultrasound: anatomy, technique, and follow-up

Injection into the acromioclavicular (AC) joint is often inaccurate (approximately 50%) even in experienced hands. In light of new anatomic observations, we evaluate accuracy of an innovative ultrasound-guided method and follow the clinical course of successful therapeutic injections. Relevant anatomy was investigated in 200 three-dimensional computed tomography scans, 100 magnetic resonance images, and 14 cadavers. Baseline measurements of joint depth and width were performed ultrasonically in 100 normal volunteers; 50 symptomatic patients were injected. Uniquely in a clinical ultrasound study, injection success was documented by arthrography. Outcomes after concomitant steroid instillation were observed for 6 months by visual analog scale (VAS) scores and pain provocation test results. Anatomic studies showed that the widest area for joint penetration was anterior superior. Injection success rate was 96%, overwhelmingly on the first needle pass. Shallow joint depth allowed access with a standard 3-cm needle. Joint width diminished with age but did not reduce injection success. Cadaveric joints admitted 1.2 ± 0.5 mL, but fluid ingress was initially blocked by soft tissues in one third of both cadaveric and clinical cases. Diligent follow-up after steroid injection showed sustained pain relief in the majority with isolated AC disease but significantly less in those with concomitant shoulder disorders. This high level of clinical injection success, irrefutably substantiated with arthrography, has not been previously demonstrated. The anterior superior aspect of the joint is the preferred place for entry. Initial intra-articular blockage to fluid inflow is common but can be surmounted. Encouraging 6-month results of steroid instillation in isolated AC disease do not apply to patients with coexisting shoulder pathologic processes.

Lower-dose diclofenac capsules developed using solumatrix fine particle technology result in clinically meaningful improvements in pain in a phase 3 study of patients with osteoarthritis

Lower-dose diclofenac capsules developed using solumatrix fine particle technology result in clinically meaningful improvements in pain in a phase 3 study of patients with osteoarthritis

Pain referral and regional deep tissue hyperalgesia in experimental human hip pain models

Hip disorder patients typically present with extensive pain referral and hyperalgesia. To better understand underlying mechanisms, an experimental hip pain model was established in which pain referrals and hyperalgesia could be studied under standardized conditions. In 16 healthy subjects, pain was induced by hypertonic saline injection into the gluteus medius tendon (GMT), adductor longus tendon (ALT), or gluteus medius muscle (GMM). Isotonic saline was injected contralaterally as control. Pain intensity was assessed on a visual analogue scale (VAS), and subjects mapped the pain distribution. Before, during, and after injections, passive hip joint pain provocation tests were completed, together with quantitative sensory testing as follows: pressure pain thresholds (PPTs), cuff algometry pain thresholds (cuff PPTs), cutaneous pin-prick sensitivity, and thermal pain thresholds. Hypertonic saline injected into the GMT resulted in higher VAS scores than hypertonic injections into the ALT and GMM (P<.05). Referred pain areas spread to larger parts of the leg after GMT and GMM injections compared with more regionalized pain pattern after ALT injections (P<.05). PPTs at the injection site were decreased after hypertonic saline injections into GMT and GMM compared with baseline, ALT injections, and isotonic saline. Cuff PPTs from the thigh were decreased after hypertonic saline injections into the ALT compared with baseline, GMT injections, and isotonic saline (P<.05). More subjects had positive joint pain provocation tests after hypertonic compared with isotonic saline injections (P<.05), indicating that this provocation test also assessed hyperalgesia in extra-articular soft tissues. The experimental models may open for better understanding of pain mechanisms associated with painful hip disorders.

Intertester Agreement and Validity of Identifying Lumbar Pain Provocative Movement Patterns Using Active and Passive Accessory Movement Tests

ObjectiveThe purpose of this study was to evaluate the interexaminer agreement and validity of active and passive pain provocation tests in the lumbar spine. MethodsTwo blinded raters examined 36 participants, 18 of whom were asymptomatic and 18 reported subacute nonspecific low back pain (LBP). Two types of pain provocation tests were performed: (1) physiological movements in single (flexion/extension) and, when necessary, combined planes and (2) passive accessory intervertebral movement tests of each lumbar vertebra in prone with the lumbar spine in neutral, flexion, and extension position. ResultsThe interobserver agreement in both groups was good to excellent for the identification of flexion (κ = 0.87-1) or extension (κ = 0.65-0.74) as the most painful pattern of spinal movement. In healthy participants, 0% was identified as having a flexion provocative pattern and 8.8% were identified as having an extension provocative pattern. In the LBP group, 20% were identified as having a flexion provocative pattern vs 60% with an extension provocative pattern. The average interexaminer agreement for passive accessory intervertebral movement tests in both groups was moderate to excellent (κ = 0.42-0.83). The examiners showed good sensitivity (0.67-0.87) and specificity (0.82-0.85) to distinguish participants with LBP using this combined examination procedure. ConclusionThe use of a combination of pain provocative tests was found to have acceptable interexaminer reliability and good validity in identifying the main pain provocative movement pattern and the lumbar segmental level of involvement. These pain provocation tests were able to distinguish participants with LBP from asymptomatic participants and may help clinicians in directing manual therapy treatment.

Does This Patient With Shoulder Pain Have Rotator Cuff Disease?

Rotator cuff disease (RCD) is the most common cause of shoulder pain seen by physicians. To perform a meta-analysis to identify the most accurate clinical examination findings for RCD. Structured search in MEDLINE, EMBASE, and CINAHL from their inception through May 2013. For inclusion, a study must have met the following criteria: (1) description of history taking, physical examination, or clinical tests concerning RCD; (2) detailing of sensitivity and specificity; (3) use of a reference standard with diagnostic criteria prespecified; (4) presentation of original data, or original data could be obtained from the authors; and (5) publication in a language mastered by one of the authors (Danish, Dutch, English, French, German, Norwegian, Spanish, Swedish). Likelihood ratios (LRs) of symptoms and signs of RCD or of a tear, compared with an acceptable reference standard; quality scores assigned using the Rational Clinical Examination score and bias evaluated with the Quality Assessment of Diagnostic Accuracy Studies tool. Twenty-eight studies assessed the examination of referred patients by specialists. Only 5 studies reached Rational Clinical Examination quality scores of level 1-2. The studies with quality scores of level 1-2 included 30 to 203 shoulders with the prevalence of RCD ranging from 33% to 81%. Among pain provocation tests, a positive painful arc test result was the only finding with a positive LR greater than 2.0 for RCD (3.7 [95% CI, 1.9-7.0]), and a normal painful arc test result had the lowest negative LR (0.36 [95% CI, 0.23-0.54]). Among strength tests, a positive external rotation lag test (LR, 7.2 [95% CI, 1.7-31]) and internal rotation lag test (LR, 5.6 [95% CI, 2.6-12]) were the most accurate findings for full-thickness tears. A positive drop arm test result (LR, 3.3 [95% CI, 1.0-11]) might help identify patients with RCD. A normal internal rotation lag test result was most accurate for identifying patients without a full-thickness tear (LR, 0.04 [95% CI, 0.0-0.58]). Because specialists performed all the clinical maneuvers for RCD in each of the included studies with no finding evaluated in more than 3 studies, the generalizability of the results to a nonreferred population is unknown. A positive painful arc test result and a positive external rotation resistance test result were the most accurate findings for detecting RCD, whereas the presence of a positive lag test (external or internal rotation) result was most accurate for diagnosis of a full-thickness rotator cuff tear.

Pelvic girdle pain in Indian postpartum women: a cross-sectional study

During pregnancy or postpartum period many women will experience some degree of pelvic girdle pain (PGP). In India, there is no information about the PGP prevalence and its associated factors evaluated during postpartum period. Purpose: To reveal the prevalence of PGP postpartum in Indian women and identify associated factors with PGP postpartum. Methods: In this cross-sectional study, 284 postpartum women completed a questionnaire and underwent clinical examinations. The clinical examination included pain provocation tests for the pelvic as well as the active straight leg raise (ASLR) test. Possible associating factors were studied by using nonparametric tests and logistic regression analysis. Results: A total of 116 postpartum women (41%) had reported PGP at the time of the examination. A stepwise logistic regression analysis was performed to reveal associated factors. In the final model, factors such as (1) Caesarean delivery (adjusted OR, 2.0; 95% CI, 1.3–4.9); (2) ASLR test score ≥4 (adjusted OR, 2.3; 95% CI, 1.2–3.3); (3) Unilateral P4 test (adjusted OR, 1.8; 95% CI, 1.1–3.0); and (4) Sitting position during feeding (adjusted OR, 1.5; 95% CI, 0.9–2.8) were associated with the PGP. Conclusion: We found a high prevalence of PGP in Indian women during the first three months of postpartum period. Our finding suggests that unilateral posterior pelvic pain provocation test (P4), ASLR test score ≥4, caesarean section delivery and sitting in breast-feeding posture were associated with increased risk of PGP during postpartum.

Pelvic girdle pain after childbirth: The impact of mode of delivery

During pregnancy or postpartum period, several women experience some degree of pelvic girdle pain (PGP). In India, information is lacking about the prevalence and possible risk factors of PGP evaluated during postpartum period. This study aims to determine the prevalence of PGP in postpartum women who underwent vaginal or caesarean mode of delivery and to estimate possible associated factors with or without PGP in both modes of deliveries. In this cross-sectional study, 284 postpartum women answered questionnaires and underwent clinical examinations. Clinical examination included pain provocation tests for the pelvis as well as the active straight leg raise (ASLR) test. Probable associated factors were studied using non-parametric tests and logistic regression analysis. In this study of 284 women, 41% reported pain in the pelvic girdle during postpartum period. Overall, 33% of the women experienced PGP after caesarean delivery as compared with 8.3% of women after vaginal delivery. Low back pain (LBP) before pregnancy, parity, active straight leg raise test score ≥ 4, bilateral P4 test, and sitting position during breast-feeding were significantly associated with vaginal delivery group and caesarean delivery group during postpartum period. In both modes of delivery, the association of PGP with these common factors remained after adjustment for other study factors. We found high prevalence of PGP in women who had caesarean delivery than those who had a vaginal delivery. Our finding suggests that, during postpartum period, LBP before pregnancy, parity, ASLR test score ≥ 4, bilateral P4 test, and sitting position during breast-feeding were significantly associated with increased risk of PGP in both vaginal and caesarean modes of deliveries, but further studies are needed for definitive conclusions.

Treatment of Pregnancy-Related Lumbar and Pelvic Girdle Pain by the Yoga Method: A Randomized Controlled Study

Pregnancy-related lumbopelvic pain is a major problem for the majority of pregnant women. Complementary medicine has been used to alleviate pain, and yoga is one of the most commonly chosen alternative methods. The objective of this study was to assess the effectiveness of Hatha yoga in the reduction of lumbopelvic pain in pregnancy. A randomized controlled trial with 60 pregnant women (age range, 14-40 years) who reported lumbopelvic pain at 12 to 32 weeks of gestation was conducted from June 2009 to June 2011. Pregnant women who had twin pregnancies, had medical restrictions for exercise, used analgesics, and participated in physical therapy were excluded from the study. Pregnant women were divided into two groups: the yoga group, practicing exercises guided by this method, and the postural orientation group, performing standardized posture orientation according to instructions provided in a pamphlet. Treatment in each group lasted 10 weeks. A visual analog scale (VAS) was used to measure pain intensity. Lumbar pain and posterior pelvic pain provocation tests were used to confirm the presence of pain. Statistical analysis included the Mann-Whitney test, the McNemar test, a paired Wilcoxon test, and analysis of covariance. The median pain score was lower in the yoga group (p<.0058) than the postural orientation group. Lumbar pain provocation tests showed a decreased response in relation to posterior pelvic pain provocation tests and a gradual reduction in pain intensity during 10 yoga sessions (p<.024). The yoga method was more effective at reducing lumbopelvic pain intensity compared with postural orientation.

Can Altering Motions, Postures, and Loads Provide Immediate Low Back Pain Relief

A quantitative biomechanical analysis of mechanism of pain alteration in 4 cases of low back pain. To investigate the contributions of a number of biomechanical factors associated with pain alteration. Some clinicians use mechanically based manual interventions in attempt to reduce low back pain. However, the mechanism of pain alteration remains unknown. A sample was formed with 4 patients with low back pain seeking consults for pain relief. All could produce "catches" of pain with movement. Manual interventions involving coached changes in motion and muscle activation attempted to reduce pain. Electromyographic and kinematic data were collected before and after intervention. These data were input to an anatomically detailed spine model that calculated muscle force, joint compression and shear, and spine stability. Using a clinically significant criterion of pain reduction of 2 or more, 3 of 4 subjects reduced pain immediately upon the intervention. Using a change of 10% as a criterion for biological significance for kinematic and kinetic variables, each subject demonstrated a different reaction. For example, subject 1 demonstrated increased stability, subject 2 increased mediolateral shear, subject 3 increased mediolateral shear and decreased spine flexion, and subject 4 increased stability. The pain-reducing interventions required to obtain these results were also different for each individual. Immediate pain reduction can be achieved by altering muscle-activation and movement patterns. However, the combination for optimal success seems to be different for every individual. Pain provocation tests help to "tune" the intervention. This also suggests that patient-classification schemes may need more refinement to address this heterogeneity.

Motor Control and Low Back Pain in Dancers

Professional dancers suffer a high incidence of injuries, especially to the spine and lower extremities. There is a lack of experimental research addressing low back pain (LBP) in dancers. The aim of this study is to compare lumbopelvic motor control, muscle extensibility and sacroiliac joint pain between dancers with and without a history of LBP. 40 pre-professional dancers (mean age of 20.3 years) underwent a clinical test battery, consisting of an evaluation of lumbopelvic motor control, muscle extensibility, generalized joint hypermobility, and sacroiliac joint pain provocation tests. Also self-reported measurements and standardized questionnaires were used. 41% of the dancers suffered from LBP during at least 2 consecutive days in the previous year. Only one dancer suffered from sacroiliac joint pain. Compared to dancers without a history of LBP, dancers with a history of LBP showed poorer lumbopelvic motor control (p<0.05). No differences in muscle extensibility or joint hypermobility were observed between dancers (p>0.05). Despite their young age, pre-professional dancers suffer from LBP frequently. Sacroiliac joint pain, generalized joint hypermobility or muscle extensibility appears unrelated to LBP in dancers. Motor control is decreased in those with a history of LBP. Further research should examine whether motor control is etiologically involved in LBP in dancers.

Experimental pelvic pain facilitates pain provocation tests and causes regional hyperalgesia

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.

Conservative chiropractic management of urinary incontinence using applied kinesiology: a retrospective case-series report

ObjectiveThe purpose of this case series is to describe the chiropractic management of 21 patients with daily stress and occasional total urinary incontinence (UI). Clinical FeaturesTwenty-one case files of patients 13 to 90 years of age with UI from a chiropractic clinic were reviewed. The patients had a 4-month to 49-year history of UI and associated muscle dysfunction and low back and/or pelvic pain. Eighteen wore an incontinence pad throughout the day and night at the time of their appointments because of unpredictable UI. Intervention and OutcomePatients were evaluated for muscle impairments in the lumbar spine, pelvis, and pelvic floor and low back and/or hip pain. Positive manual muscle test results of the pelvis, lumbar spine muscles, and pelvic floor muscles were the most common findings. Lumbosacral dysfunction was found in 13 of the cases with pain provocation tests (applied kinesiology sensorimotor challenge); in 8 cases, this sensorimotor challenge was absent. Chiropractic manipulative therapy and soft tissue treatment addressed the soft tissue and articular dysfunctions. Chiropractic manipulative therapy involved high-velocity, low-amplitude manipulation; Cox flexion distraction manipulation; and/or use of a percussion instrument for the treatment of myofascial trigger points. Urinary incontinence symptoms resolved in 10 patients, considerably improved in 7 cases, and slightly improved in 4 cases. Periodic follow-up examinations for the past 6 years, and no less than 2 years, indicate that for each participant in this case-series report, the improvements of UI remained stable. ConclusionThe patients reported in this retrospective case series showed improvement in UI symptoms that persisted over time.

The Active Straight Leg Raise test in lumbopelvic pain during pregnancy

Although many properties of the Active Straight Leg Raise (ASLR) test as a diagnostic test in lumbopelvic pain (LPP) are well documented, various elements are lacking. A cross-sectional study was performed to compute sensitivity and specificity, to assess the advantages and disadvantages of various cutoff points, to analyze the relation between the ASLR test and the Posterior Pelvic Pain Provocation (PPPP) test, and to investigate the relation with confounders.Data of 110 women with LPP and 72 without LPP were available. The advantages and disadvantages of four cutoff points of ASLR, and combinations of the ASLR and PPPP, were investigated by comparing sensitivity, specificity and area under the curves (AUC) of receiver operating characteristic curves (ROC). The influence of the site of pain was analyzed by means of AUC. The relation with confounders was measured using Pearson correlation coefficients.Results show that for diagnostic use the best cutoff for the ASLR test in pregnancy is between score 0 and 1. Specificity of the ASLR test is good (88%). Sensitivity for all types of LPP during pregnancy is moderate (54%), and is larger in case of more pain and disability. When combined with the PPPP test, sensitivity of the ASLR test is larger (68%). Isolated symphyseal pain, isolated low back pain and isolated coccyx pain are not diagnosed by these two tests. The ASLR test is not influenced by age, number of previous deliveries, BMI, cause of LPP (pregnancy-related or not), the existence of urinary incontinence and/or level of fatigue.

Association between the serum levels of relaxin and responses to the active straight leg raise test in pregnancy

There is a common belief that the laxity of pelvic joints increases in pregnancy. The hormone relaxin is suggested to be one of the most influential factors implementing this effect. Furthermore, increased laxity is assumed to induce pelvic girdle pain (PGP). The objectives were to examine the serum relaxin levels in pregnancy and to investigate whether relaxin levels relate to symptoms and clinical tests for PGP. Data from questionnaires, clinical tests and blood samples were collected once in pregnancy (gestation week 5–24) from 212 women. Serum from blood samples were analyzed by ELIZA to determine the concentration of relaxin. Self reported symptoms were assessed by Disability Rating Index (DRI) and pain intensity (VAS). Clinical examinations included Active Straight Leg Raise (ASLR) test and pain provocation tests. ANOVA was used to assess the effect of gestation age and multivariable statistics to examine the association between relaxin levels and the symptoms or responses to clinical tests.The serum levels of relaxin varied widely between individuals and were only marginally influenced by the gestation age. There was no association between gestation age and responses to clinical tests or pain intensity, but DRI increased with gestation age. Serum concentration of relaxin showed a significant association to positive score on the ASLR test, but no significant associations to responses to pain provocation tests, pain intensity or DRI.The results indicate that relaxin contributes to laxity of pelvic joints in pregnancy. Yet, no evidence of relaxin having an impact on symptoms or perceived disability was found.

Severity of signs and symptoms in lumbopelvic pain during pregnancy

Data on the severity of signs and symptoms of lumbopelvic pain (LPP) during pregnancy are scarce. Therefore, this cross-sectional study examines the severity of LPP and pain-related signs and symptoms.Women with an uncomplicated pregnancy of 20–30 weeks were invited to participate. They rated their pain and fatigue on a numerical rating scale, and pain location was indicated on a drawing. Disability was scored on the Quebec Back Pain Disability Scale (QBPDS) and urine incontinence on a Likert scale. Physical examination consisted of the Active Straight Leg Raise (ASLR) test, the Posterior Pelvic Pain Provocation (PPPP) test and pain score, and force during isometric bilateral hip adduction.Of all 182 participants, 60.4% reported LPP. Mean pain level was 3.6 (SD 2.2); in 20.0% of the women the score was >5. The mean score on the QBPDS was 27 (SD 16); in 20.9% the score was >40. Compared to women without LPP, women with LPP more frequently suffered back pain in the past (p<0.001), had a higher body mass index (p<0.01), more often had urinary incontinence (p<0.05), had less isometric hip adduction force (p<0.001), had more pain on isometric hip adduction (p<0.01), had a higher ASLR score (p<0.001) and more had often a positive PPPP test (p<0.001). Fatigue was not related to LPP during pregnancy.The main conclusion is that pain and disability of LPP during pregnancy can be interpreted as mild to moderate in most cases, and as severe in about 20%.

Reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy

BackgroundThe clinical assessment of chronic proximal hamstring tendinopathy (PHT) in athletes is a challenge to sports medicine. To be able to compare the results of research and treatments, the methods...

Pelvic Girdle Pain after Child Birth: The Impact of Mode of Delivery

Purpose: During pregnancy or postpartum period, several women experience some degree of pelvic girdle pain (PGP). In India, information is lacking about the prevalence and possible risk factors of PGP evaluated during postpartum period. This study aims to determine the prevalence of PGP in postpartum women who underwent vaginal or caesarean mode of delivery, and to estimate possible associated factors with or without PGP in both modes of deliveries. Methods: In this cross-sectional study, 284 postpartum women answered questionnaires and underwent clinical examinations. Clinical examination included pain provocation tests for the pelvis, as well as the active straight leg raise (ASLR) test. Probable associated factors were studied, using non-parametric tests and logistic regression analysis. Results: In this study of 234 women, 41% reported pain in the pelvic girdle during postpartum period. Overall, 33% of the women experienced PGP after caesarean delivery, as compared with 8.3% of women after vaginal delivery. Low back pain (LBP) before pregnancy, parity, active straight leg raise test score ≥ 4, bilateral P4 test, and sitting position during breast-feeding were significantly associated with vaginal delivery group and caesarean delivery group during postpartum period. In both modes of delivery, the association of PGP with these common factors remained after adjustment for other study factors. Conclusion: The results show high prevalence of PGP in women who had caesarean delivery than those who had a vaginal delivery. The finding suggests that during postpartum period, LBP before pregnancy, parity, ASLR test score ≥4, bilateral P4 test, and sitting position during breast-feeding were significantly associated with increased risk of PGP in both vaginal and caesarean modes of deliveries, but further studies are needed for definitive conclusions.