Pain Provocation Research Articles

P184. Can Discogram Identify Pain Generator in Degenerative Low Back Pain?

BACKGROUND CONTEXT: Discogram has been debated as a poor tool to identify pain generator because it may provoke non-specific pain in asymptomatic subjects. In contrast, in symptomatic subjects with degenerative back pain, its role in separating painful from painless disc degeneration has not been critically appraised. The present study compares relationship between pain provocation with discography to MRI signal intensity to assess the role of discogram to identify pain generator.

Painful Disc Lesion: Can Modern Biplanar Magnetic Resonance Imaging Replace Discography?

A new magnetic resonance imaging (MRI) classification of disc degeneration was correlated with discography. It was also studied for intraobserver and interobserver variability in interpreting disc abnormality and for the capability in predicting symptomatic disc. To correlate the results of discography with a new MRI classification for disc degeneration and the presence of the vertebral endplate changes and the high intensity zone (HIZ). MRI and discography have been compared in numerous studies as methods for detecting disc degeneration. The results were conflicting and the role of MRI in assessing discogenic pain remains ambiguous. One hundred thirty-one discs in 55 patients were studied with pain provocation discography and MRI. A new MRI classification was correlated to discography and assessed together with the presence of end plate changes and HIZ, by the sensitivity and specificity in predicting a painful disc. MRI classification had a good intra and interobserver agreement and a significant correlation with discographic findings. The sensitivity and specificity of MRI in predicting painful disc was 94% and 77%. The sensitivities and specificity of HIZs was 27% and 87% and for end plate changes was 32% and 98%, respectively. Although MRI is an excellent investigation for assessing disc morphology it should be interpreted along with discography findings before planning fusion surgery. The proposed MRI classification is a useful aid in predicting painful degenerative disc. The utility of HIZs and end plate changes is limited due to low sensitivity.

Spinal Palpation for Lumbar Segmental Mobility and Pain Provocation: An Interexaminer Reliability Study

Objective This study determined the degree of interexaminer reliability using 2 experienced clinicians performing 3 palpation procedures over the lumbar facet joints and sacroiliac joints. Methods The sample consisted of 39 patients with low back pain who had a recent history of low back pain. Two doctors of chiropractic independently examined each of these patients in the prone position with 3 different procedures: (1) springing palpation for pain provocation, (2) springing palpation for segmental mobility testing, and (3) the prone instability test. The doctors were blinded to each other's findings and the patient's clinical status, and performed the examinations on the same day. Standard and adjusted κ values were calculated for each test. Results The κ values for palpation of segmental motion restriction were poor (range, −.20 to .17) and in many cases less than chance observation (negative κ values). The prone instability test showed reasonable reliability ( κ = .54), and palpation for segmental pain provocation also showed fair to good reliability ( κ range, .21 to .73). Conclusions Palpation methods that are used to provoke pain responses are more reliable than palpation methods in which the clinician purports to find segmental motion restriction. The prone instability test shows good reliability.

Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint

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 specicity 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%. is 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 value of diskography in disk-related pain syndrome of the cervical spine for evaluation of indications for spondylodesis

In this study the postoperative results of patients with cervical spondylodesis for "discogenic pain syndrome" were evaluated. The diagnosis "discogenic pain syndrome" as well as the pathologic segments were confirmed by cervical discography. However interpretation of the discogram as "positive" was only considered reliable when typical pain provocation through discography correlated with pathologic disc pattern ("functional test"). 38 cervical segments have been found to fulfill these criteria and were fused in 29 operative procedures (21 unisegmental, 7 bisegmental, one trisegmental). The patients were evaluated postoperative for change of symptoms, pain character and intensity, neurological deficits, working and sporting disability and mobility of cervical spine. According to the criteria of Simmons and Segil 73% of the patients showed a good to excellent result. A fair result was found in 23.2% and an unsatisfactory result was seen in 3.8%. In the literature a good to excellent outcome is seen in 30 to 46% in similar patients groups after cervical fusion without preoperative assessment by discography.

The value of sacroiliac pain provocation tests in early active sacroiliitis

Detection of preradiographic sacroiliitis is important for early diagnosis of ankylosing spondylitis (AS) and related spondyloarthropathies. Magnetic resonance imaging (MRI) is a valuable tool for the diagnosis of sacroiliitis in the early and active stages. The aim of this study is to assess the value of pain provocation tests in detecting early active sacroiliitis. Chronic low-back pain (LBP) patients were recruited and examined by blinded assessors for pain provocation tests: compression, distraction, Gaenslen, Mennel, Patrick, thigh thrust and sacral thrust tests. Patients underwent lumbar and sacroiliac MRI. The percentage of agreement for each pain provocation tests was between 72-95%, and the inter-rater reliability was from moderate to good (kappa, 0.43-0.87). Kappa values ranged from 0.43 to 0.60 with an agreement of 80-95% for clusters of pain provocation tests. As separately evaluated, pain provocation tests did not have favorable accuracy. When evaluated in clusters (out of three and five provocation tests) four positive over five tests on the left side reached an area under the curve 0.693 (95% CI 0.489-0.897), and two positive over three tests reached an AUC 0.697 (95% CI 0.484-0.910). Sacroiliac pain provocation tests had acceptable reliability in early active sacroiliitis; however, the discriminating capacity of these tests is poor. A multi-test regimen of three or five sacroiliac pain provocation tests may improve the accuracy of these tests discriminating sacroiliitis from LBP of mechanical origin. Four out of five selected tests or any of the two out of three selected tests have the highest predictive value.

Perceptions and use of passive intervertebral motion assessment of the spine: A survey among physiotherapists specializing in manual therapy

Manual therapists commonly use passive intervertebral motion (PIVM) assessment within physical examination. Data describing the use and interpretation of this manual diagnostic procedure, as well as therapists' perception of related importance and confidence, are lacking. A survey was conducted among Dutch physiotherapists specializing in manual therapy (MT) using a 13-item, self-administered, structured questionnaire. Three hundred and sixty-seven questionnaires were analysed. Response rate from the postal part of the survey was 56%. Dutch manual therapists most frequently apply passive segmental motion assessment to the cervical region and they prefer three-dimensionally coupled motions. They consider end-feel or, to a lesser extent, provocation of patient's pain as decisive for diagnostic conclusions. Respondents believe that these spinal motion tests are important for treatment decisions and are confident in their conclusions drawn from it. These perceptions were largely stable across subgroups of therapists with different gender, age, experience, and educational background. Weekly amount of work related to spinal disorders was positively associated with perceived importance and confidence. Reported use and interpretation of PIVM assessment and related perceptions could only partly be substantiated by evidence. Results from this survey will help researchers design studies better reflecting daily practice in MT.

Inter- and intra-examiner reliability of single and composites of selected motion palpation and pain provocation tests for sacroiliac joint

The sacroiliac joint (SIJ) has been implicated as a potential source of low back and buttock pain. Several types of motion palpation and provocation tests are used to examine the SIJ. It has been suggested that use of a cluster of motion palpation or provocation tests is a more acceptable method than single test to assess SIJ. This study examined the inter- and intra-examiner reliability of single and composites of the motion palpation and provocation tests together. Twenty-five patients between the ages of 20 and 65 years participated. Four motion palpation and three provocation tests were examined three times on both sides (left, right) by two examiners. Kappa coefficient and prevalence-adjusted and bias-adjusted kappa (PABAK) were calculated to evaluate the reliability. PABAK for intra- and inter-examiner reliability of individual tests ranged from 0.36 to 0.84 (95% CI: −0.22 to 1.12) and 0.52 to 0.84 (95% CI: −0.18 to 1.08) which is considered fair to substantial. PABAK for intra- and inter-examiner reliability for clusters of motion palpation or provocation tests ranged from 0.44 to 0.92 (95% CI: −0.36 to 1.2) which is considered moderate to excellent reliability. PABAK for intra- and inter-examiner reliability of composites of motion palpation and provocation tests ranged from 0.44 to 1.00 (95% CI: −0.22 to 1.12) and 0.52 to 0.92 (95% CI: −0.02 to 1.32) which is considered substantial to excellent. It seems that composites of motion palpation and provocation tests together have reliability sufficiently high for use in clinical assessment of the SIJ.

Physical Characteristics of Women With Severe Pelvic Girdle Pain After Pregnancy

Descriptive cohort study. This study aims to further elucidate the differences in physical characteristics of women with severe pregnancy-related pelvic girdle pain (PGP). There is increasing interest in pelvic girdle pain (PGP). To our knowledge, this is the first study on a large population of patients with severe PGP, after pregnancy, based on high cutoff scores on diagnostic PGP tests. Two hundred five patients were selected from the outpatient clinic of a rehabilitation center. Patients were divided in 3 inclusion groups based on the total number of positive scores on 5 diagnostic tests; i.e., active straight leg raise test, posterior pelvic pain provocation test, long dorsal sacroiliac ligament test, and hip abduction and adduction strength tests. These inclusion groups were related to the data on trunk strength test, general provocation tests, Quebec Back Pain Disability Scale (QBPDS) and activities of daily living. A typical pattern of PGP emerges from this study. The mean group score on the active straight leg raise, posterior pelvic pain provocation, and long dorsal sacroiliac ligament tests became higher when more than 3 inclusion tests were positive. Hip abduction and adduction strength became lower with more positive tests. The QBPDS score was overall high and significantly higher for 5 positive tests compared with 3 and 4 positive tests. This shows that the number of positive tests, the individual score on the diagnostic tests, and the QBPDS could all be an indicator for severity of PGP. Among the general pain provocation tests, both the passive hip flexion test and the upper and middle sacral thrust test scored high. The maximal isometric strength of trunk muscles was below the 10th percentile compared with women without complaints and was even less for 5 positive inclusion tests. It is confirmed that there is a typical order for difficulties with daily activities for PGP patients as follows (most difficult first): standing still, cycling, walking, sitting, and lying. The study shows that the level of severity in PGP can be adequately assessed by a combination of specific tests.

European guidelines for the diagnosis and treatment of pelvic girdle pain.

A guideline on pelvic girdle pain (PGP) was developed by "Working Group 4" within the framework of the COST ACTION B13 "Low back pain: guidelines for its management", issued by the European Commission, Research Directorate-General, Department of Policy, Coordination and Strategy. To ensure an evidence-based approach, three subgroups were formed to explore: (a) basic information, (b) diagnostics and epidemiology, and (c) therapeutical interventions. The progress of the subgroups was discussed at each meeting and the final report is based on group consensus. A grading system was used to denote the strength of the evidence, based on the AHCPR Guidelines (1994) and levels of evidence recommended in the method guidelines of the Cochrane Back Review group. It is concluded that PGP is a specific form of low back pain (LBP) that can occur separately or in conjunction with LBP. PGP generally arises in relation to pregnancy, trauma, arthritis and/or osteoarthritis. Uniform definitions are proposed for PGP as well as for joint stability. The point prevalence of pregnant women suffering from PGP is about 20%. Risk factors for developing PGP during pregnancy are most probably a history of previous LBP, and previous trauma to the pelvis. There is agreement that non risk factors are: contraceptive pills, time interval since last pregnancy, height, weight, smoking, and most probably age. PGP can be diagnosed by pain provocation tests (P4/thigh thrust, Patrick's Faber, Gaenslen's test, and modified Trendelenburg's test) and pain palpation tests (long dorsal ligament test and palpation of the symphysis). As a functional test, the active straight leg raise (ASLR) test is recommended. Mobility (palpation) tests, X-rays, CT, scintigraphy, diagnostic injections and diagnostic external pelvic fixation are not recommended. MRI may be used to exclude ankylosing spondylitis and in the case of positive red flags. The recommended treatment includes adequate information and reassurance of the patient, individualized exercises for pregnant women and an individualized multifactorial treatment program for other patients. We recommend medication (excluding pregnant women), if necessary, for pain relief. Recommendations are made for future research on PGP.

Intradiscal Electrothermal Therapy (IDET) Provides Effective Symptom Relief in Patients With Discogenic Low Back Pain

Single-arm, prospective clinical trial. To evaluate back pain severity, physical function, and quality of life outcomes in highly selected patients with lumbar discogenic pain treated with intradiscal electrothermal therapy (IDET). Degeneration and disruption of the intervertebral disc can be the source of severe low back pain and the associated physical dysfunction. IDET is a minimally invasive treatment option in the continuum of care between conservative nonoperative management and spinal surgery. Using magnetic resonance imaging, pressure-controlled discography, and postdiscogram computed tomography findings, 56 patients with lumbar discogenic pain were identified, underwent IDET treatment and followed for 20.5+/-4.4 months, on average. Outcomes included assessments of back pain severity by visual analog scale, sitting, standing, and walking tolerances, and health-related quality of life using the SF-36. Mean pain severity scores (visual analog scale) improved from 6.1+/-1.8 pretreatment to 2.4+/-2.6 at final follow-up (P=0.0001). Mean tolerance times (minutes) improved from 40.9+/-40.6 to 84.5+/-54.4, 46.8+/-42.9 to 84.4+/-54.2, and 39.2+/-39.6 to 77.9+/-50.8 between baseline and final follow-up for sitting, standing, and walking, respectively (P=0.0001 for all comparisons). Seven of 8 quality of life domains showed significant (P=0.0001 for all comparisons) improvement over baseline. Forty-two patients (75%) were classified as a treatment success by virtue of a >or=2-point improvement in pain severity or a >or=10-point improvement in either the physical functioning or bodily pain domain of the SF-36. The findings of this study suggest that durable clinical improvements can be realized after IDET in highly selected patients with mild disc degeneration, confirmatory imaging evidence of annular disruption, and concordant pain provocation by low pressure discography.

Predicting Persistent Pregnancy-Related Low Back Pain

A cohort study. To examine the course of subtypes of low back pain (LBP) experienced [no LBP, pelvic girdle pain (PGP), lumbar pain, and combined PGP and lumbar pain (combined pain)] during gestational weeks 12 to 18 and 3 months postpartum, and to explore potential predictors for persistent PGP or combined pain postpartum. LBP is more prevalent in pregnant women (25%) than in the general population (6.3%). Persistent LBP postpartum (16%) is usually studied as a single entity. However, only one subgroup of LBP, pelvic girdle pain (PGP), is associated with pregnancy. Several studies have suggested an association between muscular dysfunction and pregnancy-related LBP, however, muscle dysfunction has not been evaluated as potential predictor of persistent LBP postpartum. Possible subgroup differences in the course and predictors of persistent LBP are unknown. Pregnant women (n = 308) were classified into LBP subgroups by mechanical assessment of the lumbar spine, pelvic pain provocation tests, standard history, and pain drawings. Trunk muscle endurance, hip muscle strength (dynamometer) and gait speed were evaluated. Multiple logistic regression was used to identify predictors from self-reports and clinical examination. Women with combined pain recovered to a lower degree 33% (17 of 51) than those with PGP 66% (56 of 85) or lumbar pain 72% (21 of 29). Predictors for having persistent PGP or combined pain after delivery were low endurance of back flexors, older age, combined pain in early pregnancy and work dissatisfaction (explained variance 30%). Women with combined pain were identified to be a target group since they had the most unfavorable course and since the classification of combined pain was found to be a predictor for persistent pain postpartum. Identification of women at risk for persistent pain postpartum seems possible in early pregnancy and requires physical examination and self-reports. Pregnancy had low impact on the course of lumbar pain.

Association between muscle function and low back pain in relation to pregnancy

To investigate the association of muscle function and subgroups of low back pain (no low back pain, pelvic girdle pain, lumbar pain and combined pelvic girdle pain and lumbar pain) in relation to pregnancy. Prospective cohort study. Consecutively enrolled pregnant women seen in gestational weeks 12-18 (n = 301) and 3 months postpartum (n = 262). Classification into subgroups by means of mechanical assessment of the lumbar spine, pelvic pain provocation tests, standard history and a pain drawing. Trunk muscle endurance, hip muscle strength (dynamometer) and gait speed were investigated. In pregnancy 116 women had no low back pain, 33% (n = 99) had pelvic girdle pain, 11% (n = 32) had lumbar pain and 18% (n = 54) had combined pelvic girdle pain and lumbar pain. The prevalence of pelvic girdle pain/combined pelvic girdle pain and lumbar pain decreased postpartum, whereas the prevalence of lumbar pain remained stable. Women with pelvic girdle pain and/or combined pelvic girdle pain and lumbar pain had lower values for trunk muscle endurance, hip extension and gait speed as compared to women without low back pain in pregnancy and postpartum (p < 0.001-0.04). Women with pelvic girdle pain throughout the study had lower values of back flexor endurance compared with women without low back pain. Muscle dysfunction was associated with pelvic girdle pain, which should be taken into consideration when developing treatment strategies and preventive measures.

Pain Provocation Test to Detect Posterior Capsular Tightness in Throwing Shoulder Injury

Pain Provocation Test to Detect Posterior Capsular Tightness in Throwing Shoulder Injury

Prevalence of cervicogenic headache: Vågå study of headache epidemiology

To describe the prevalence and various clinical characteristics of cervicogenic headache (CEH) in the population at large. CEH was searched for in Vågå, Norway, where 1838 18 to 65-year-old citizens, i.e. 88.6% of this age group, underwent an interview/clinical examination. The Cervicogenic Headache International Study Group criteria include: (I) unilaterality of head pain, (II) reduction, range of movement, neck, (III/IV) ipsilateral shoulder/arm discomfort, (V/VI) mechanical provocation of similar pain, objectively or subjectively. A prevalence of 4.1% was found. In 41 cases with the highest number of CEH criteria ('core' cases), there was a male preponderance (F/M: 0.71). While cervicogenic traits (mechanical precipitation etc.) were frequently present in CEH, 'migraine traits', like nausea, vomiting, and throbbing seemed to be rarely present. In 97% of the cases, pain exacerbations began in the neck/occipital region. CEH may be one of the three large, recurrent headaches. In this series, there was no female preponderance. Nuchal onset of pain is a characteristic trait.

Migraine without aura: comparison with cervicogenic headache. Vågå study of headache epidemiology

To study migraine without aura (MwoA) prevalence in the commune of Vågå, Norway; 1838 (18- to 65-year-old) individuals were included. A special search was made for cervicogenic characteristics in MwoA, as it has been claimed that such characteristics may frequently be present. A comparison with cervicogenic headache (CEH) was made. The MwoA and tension-type headache (T-TH) diagnosis was based on IHS criteria. CEH diagnosis was based on the principles of The Cervicogenic Headache International Study Group. There were 562 cases of MwoA; prevalence: 31%. There were 425 cases of 'pure' MwoA, i.e. without coexisting T-TH. These 'pure' cases were used for extracting MwoA symptoms. The female/male ratio was 1.69, the corresponding ratio in CEH being 0.71. Typical MwoA symptoms such as nausea/photophobia were most frequently found in migraine. This difference amounted to a factor of > or =2.6. On the other hand, typical CEH traits, like mechanical pain provocation and 'posterior' onset of exacerbations, occurred more frequently in CEH than in MwoA. The difference amounted to a factor of two or more. MwoA and CEH have clearly different characteristics. The differences between MwoA and CEH are staggering. It is unlikely that migraine and CEH are linked in a nosological sense.

The role of sacroiliac joint dysfunction in the genesis of low back pain: the obvious is not always right

It is a common practice to the link low back pain with protruding disc even when neurological signs are absent. Because pain caused by sacroiliac joint dysfunction can mimic discogenic or radicular low back pain, we assumed that the diagnosis of sacroiliac joint dysfunction is frequently overlooked. To assess the incidence of sacroiliac joint dysfunction in patients with low back pain and positive disc findings on CT scan or MRI, but without claudication or objective neurological deficits. Fifty patients with low back pain and disc herniation, without claudication or neurological abnormalities such as decreased motor strength, sensory alterations or sphincter incontinence and with positive pain provocation tests for sacroiliac joint dysfunction were submitted to fluoroscopic diagnostic sacroiliac joint infiltration. The mean baseline VAS pain score was 7.8 +/- 1.77 (range 5-10). Thirty minutes after infiltration, the mean VAS score was 1.3 +/- 1.76 (median 0.000E+00 with an average deviation from median = 1.30) (P = 0.0002). Forty-six patients had a VAS score ranging from 0 to 3, 8 weeks after the fluoroscopic guided infiltration. There were no serious complications after treatment. An unanticipated motor block that required hospitalization was seen in four patients, lasting from 12 to 36 h. Sacroiliac joint dysfunction should be considered strongly in the differential diagnosis of low back pain in this group of patients.

Psychophysical Measurements During Lumbar Discography

Prospective clinical data analysis. To determine if heart rate (HR) response correlates with positive discography results. Lumbar discography is a controversial tool for the diagnosis of discogenic low back pain. The subjective nature of discography can make data interpretation difficult, leading to false-positive and false-negative results. HR changes have been found in numerous studies to be a reliable and valid indicator of acute pain. To date, there is no study analyzing the HR response to discography-induced pain. The HR measurements were recorded immediately preceding and after contrast injection into the each disc, and statistically correlated with the provocation of concordant pain, nonconcordant pain, and nonpainful discs. Discography was performed in 26 subjects with low back pain. Among 75 discograms, 26 discs elicited concordant pain, 9 provoked nonconcordant pain, and 40 elicited no pain response. There was no significant change in HR during disc stimulation for negative [no pain response (P=0.19) and nonconcordant (P=0.26)] discograms, whereas positive discograms [concordant pain (numerical rating scale> or =6/10)] were associated with a statistically significant increase in HR (P=0.000002). Lumbar discography induces positive HR response only in positive discograms. Although there is no immediate practical application of these results, 2 implications may deserve future research: (a) correlation of HR response with surgical and intradiscal electrotherapy treatment outcomes; (b) evaluation of HR measurement in cases of false-positive results (concordant pain on discography but no HR response).

Facet joint injection in lower back pain–is its continued use justified?

Facet joint injection in lower back pain–is its continued use justified?

Facet joint injection in lower back pain--is its continued use justified?

Facet joint injection in lower back pain--is its continued use justified?