Pain Provocation Research Articles

Value of Preoperative Cervical Discography

Purpose: The aim of this study was to describe the method and the value of cervical discography as correlated with the MR findings. Materials and Methods: Twenty-one discs in 11 consecutive patients who underwent cervical discography were analyzed. MR and CT discography (CTD) were performed in all patients. Discography was performed after swallowing barium for visualizing the pharynx and the esophagus to prevent penetration. We also analyzed the preceding causes of the subjects'cervical pain. The results of the pain provocation test were classified into concordant pain, discordant pain and a negative test. MRI was analyzed according to the T2-signal intensity (SI) of the disc, disc height, annular bulging and disc herniation. The CTD was analyzed for degeneration or radial tear of the disc, epidural leakage of the contrast agent and pooling of the contrast agent at the periphery of the disc. The pain provocation tests were correlated with the MR and CTD findings. We used the chi-square test to analyze the results. Results: Concordant pain was observed in 14 cases, discordant pain in 3 cases and there were negative tests in 4 cases. There were no complications related to the procedure. Four patients had undergone anterior cervical fusion and four patients had pain that developed after traffic injuries. The decreased T2-SI and annular bulging on MRI, disc degeneration and peripheral pooling of the contrast agent on CT were significantly correlated with pain provocation. Conclusion: When the diagnosis of disc disease is difficult with performing MRI, cervical discography with using swallowed barium solution to reduce the penetration of the esophagus or hypopharynx may play be helpful. The decreased T2-SI and annular bulging on MRI correlated significantly with a positive result on the pain provocation test.

Pain provocation tests for diagnosis of sacroiliac joint pain

Pain provocation tests for diagnosis of sacroiliac joint pain

A Multitest Regimen of Pain Provocation Tests as an Aid to Reduce Unnecessary Minimally Invasive Sacroiliac Joint Procedures

van der Wurff P, Buijs EJ, Groen GJ. A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Objective To compare the diagnostic accuracy of a multitest regimen of 5 sacroiliac joint (SIJ) pain provocation tests with fluoroscopically controlled double SIJ blocks using a short- and long-acting local anesthetic in order to reduce the exposure of patients to unnecessary invasive SIJ procedures. Design Prospective, observational study. Setting Hospital setting. Participants Sixty patients with chronic low back pain. Interventions Not applicable. Main Outcome Measures Visual analog scale score and receiver operating characteristic (ROC) curve. Results Twenty-seven patients responded positively to the blocks, of whom 23 were found positive after the multitest regimen and 4 were negative. For the nonresponders (n=33), these figures were 7 positive and 26 negative. The calculated sensitivity and specificity were .85 (95% confidence interval [CI], .72–.99) and .79 (95% CI, .65–.93), respectively. Positive and negative predictive values were .77 (95% CI, .62–.92) and .87 (95% CI, .74–.99), respectively. The positive likelihood ratio was 4.02 (95% CI, 2.04–7.89); the negative likelihood ratio was .19 (95% CI, .07–.47). The area under the ROC curve was .799. Conclusions The test regimen with 3 or more positive tests is indicative of SIJ pain. It can be used in early clinical decision making to reduce the number of unnecessary minimally invasive diagnostic SIJ procedures.

Back and neck extensor loading and back pain provocation in urban bus drivers with and without low back pain

This study assessed low back and trapezius muscle activity in bus drivers, with or without recurrent low back pain (LBP), during the long term driving. In addition, low back and neck–shoulder pain intensities and fatigue were measured and the effect of low back support was observed. Also the possible source of LBP was attempted to assess by vibration pain provocation test and lumbar MRI. Forty bus drivers (recurrent LBP n = 25) participated in this study. Low back and neck–shoulder pain and subjective fatigue intensity was assessed by visual analogue scales (VAS) before and after driving. Lumbar paraspinal and trapezius muscle activation during driving was measured by surface EMG. Vibration pain provocation test was applied for all subjects. Average paraspinal myoelectric activity during driving was approximately 1% of MVC in both groups. Average trapezius myoelectric activity during driving was from 2 to 4% of MVC. Trapezius muscle activity was higher in back healthy drivers than in those with LBP. The low back support had no effect either on paraspinal or trapezius EMG activity. Low back and neck–shoulder fatigue increased during driving in both groups especially in those subjects with positive vibration pain provocation. The neck–shoulder pain and fatigue were more severe in drivers suffering from LBP. Low back support had no effect on low back and neck–shoulder subjective fatigue and neck–shoulder pain but tended to limit the LBP increase during driving. Paraspinal muscle loading in urban bus drivers was very limited and either LBP or ergonomic low back support had no effect on it. Trapezius muscle seemed to be less active in drivers suffering from recurrent LBP. Internal disc disruptions may expose to pain and fatigability during driving.

Diagnosis and classification of chronic low back pain disorders: Maladaptive movement and motor control impairments as underlying mechanism

Low back pain (LBP) is a very common but largely self-limiting condition. The problem arises however, when LBP disorders do not resolve beyond normal expected tissue healing time and become chronic. Eighty five percent of chronic low back pain (CLBP) disorders have no known diagnosis leading to a classification of ‘non-specific CLBP’ that leaves a diagnostic and management vacuum. Even when a specific radiological diagnosis is reached the underlying pain mechanism cannot always be assumed. It is now widely accepted that CLBP disorders are multi-factorial in nature. However the presence and dominance of the patho-anatomical, physical, neuro-physiological, psychological and social factors that can influence the disorder is different for each individual. Classification of CLBP pain disorders into sub-groups, based on the mechanism underlying the disorder, is considered critical to ensure appropriate management. It is proposed that three broad sub-groups of CLBP disorders exist. The first group of disorders present where underlying pathological processes drive the pain, and the patients’ motor responses in the disorder are adaptive. A second group of disorders present where psychological and/or social factors represent the primary mechanism underlying the disorder that centrally drives pain, and where the patient's coping and motor control strategies are mal-adaptive in nature. Finally it is proposed that there is a large group of CLBP disorders where patients present with either movement impairments (characterized by pain avoidance behaviour) or control impairments (characterized by pain provocation behaviour). These pain disorders are predominantly mechanically induced and patients typically present with mal-adaptive primary physical and secondary cognitive compensations for their disorders that become a mechanism for ongoing pain. These subjects present either with an excess or deficit in spinal stability, which underlies their pain disorder. For this group, physiotherapy interventions that are specifically directed and classification based, have the potential to impact on both the physical and cognitive drivers of pain leading to resolution of the disorder. Two case studies highlight the different mechanisms involved in patients with movement and control impairment disorder outlining distinct treatment approaches involved for management. Although growing evidence exists to support this approach, further research is required to fully validate it.

The Relation Between Annular Disruption on Computed Tomography Scan and Pressure-Controlled Diskography

Derby R, Kim BJ, Chen Y, Seo KS, Lee SH. The relation between annular disruption on computed tomography scan and pressure-controlled diskography. Objective To analyze the relation between annular disruption determined by computed tomography (CT) scan and diskographic findings using pressure-controlled manometric diskography. Design Cross-sectional using prospectively gathered data. Setting Ambulatory spine intervention unit. Specimens Two hundred seventy-nine disks from 86 patients (55 men, 31 women) who were referred for diskography of suspected chronic diskogenic low back pain. Interventions Not applicable. Main Outcome Measures The grade of annular disruption was rated using CT diskography and fluoroscopic imaging as follows: 0 (no disruption); 1 (extension into the inner third of the annulus); 2 (extension into the middle third of the annulus); 3 (extension into the outer third of the annulus); 4 (circumferential extension with a >30° arc at the disk center); and 5 (contrast media leakage into the outer space). Diskography was performed via a pressure-controlled manometric technique using an injection rate of .05mL/s and a restricted total volume of 3.5mL. Pain was rated on a 0 to10 numeric rating scale (NRS). Criteria for symptomatic disks included provocation of patient concordant pain (NRS score, ≥6/10) at 50psi or less above opening pressure, with 3.5mL or less of total volume. Symptomatic disks were classified as “low pressure sensitive” or “high pressure sensitive” based on the pressure level that evoked pain. Disks classified as low pressure sensitive required an NRS score of 6 out of 10 or higher at 15psi or less above opening pressure. Disks classified as high pressure sensitive required an NRS score of 6 out of 10 or higher at pressures within a range of 15 to 50psi. Results The numbers of disks at each annular disruption grade were 19 (6.8%) at grade 0, 29 (10.4%) at grade 1, 35 (12.5%) at grade 2, 42 (15.1%) at grade 3, 69 (24.7%) at grade 4, and 85 (30.5%) at grade 5. A total of 93 disks met the criteria for a symptomatic disk. The extent of annular disruption and the rate of symptomatic disks correlated significantly ( P<.001). The highest symptomatic disk rate was observed in grade 4 disks. Of 93 symptomatic disks, 88 (94.6%) showed annular disruption of grade 3 or greater. Disks with grades 0 to 2 and grades 3 to 5 annular disruption differed significantly when the mean NRS relative to intradiskal pressure was compared ( P<.001). Comparing the disk type of symptomatic disks at each annular disruption grade, there was a decreasing trend of low pressure sensitive disks relative to the extent of annular disruption (62.5% at grade 3, 39.4% at grade 4, 34.2% at grade 5). Conclusions Annular disruption reaching the outer annulus fibrosus is a key factor in pain generation. Disk morphology, including annular disruptions extending beyond the outer annulus, may permit increased diskography specificity.

Provocative cervical discography symptom mapping

Background context In a small prospective study assessing 10 symptomatic and 10 asymptomatic subjects, Schellhas et al. compared cervical discography to magnetic resonance imaging. Within that study he reported on the distribution of pain for the C3–C4 to C6–C7 levels. Four years later, Grubb and Ellis reported retrospective data from his 12-year experience using cervical discography from C2–C3 to C7–T1 in 173 patients. To date, no large prospective study defining pain referral patterns for each cervical disc has been performed. Purpose To conduct a prospective visual and statistical descriptive study of pain provocation of a cohort of subjects undergoing cervical discography. Study design/setting Prospective multicenter descriptive study. Methods Pain referral maps were generated for each disc level from patients undergoing cervical discography with at least two levels assessed. If concordant pain was reproduced in a morphologically abnormal disc, the subject immediately completed a pain diagram. An independent observer interviewed the subject and recorded the location of provoked symptoms. Visual data were compiled using a body sector bit map, which consisted of 48 clinically relevant body regions. Visual maps with graduated color codes and frequencies of symptom location at each cervical disc level were generated. Results A total of 101 symptom provocation maps were recorded during cervical discography on 41 subjects. There were10 at C2–C3, 19 at C3–C4, 27 at C4–C5, 27 at C5–C6, 16 at C6–C7 and 2 at C7–T1. Predominantly unilateral symptoms were provoked just as often as bilateral symptoms. The C2–C3 disc referred pain to the neck, subocciput and face. The C3–C4 disc referred pain to the neck, subocciput, trapezius, anterior neck, face, shoulder, interscapular and limb. The C4–C5 disc referred pain to the neck, shoulder, interscapular, trapezius, extremity, face, chest and subocciput. The C5–C6 disc referred pain to the neck, trapezius, interscapular, suboccipital, anterior neck, chest and face. The C6–C7 disc referred pain to the neck, interscapular, trapezius, shoulder, extremity and subocciput. At C7–T1 we produced neck and interscapular pain. Visual maps with graduated color codes and frequencies of symptom location at each cervical disc level were generated. Conclusions In conclusion, these results confirm the observations of prior investigators that cervical internal disc disruption can elicit axial and peripheral symptoms. The particular patterns of pain generation allow the discographer to preprocedurally anticipate disc levels to assess. With these data, the number of disc punctures that are required can be limited rather than routinely assessing all cervical discs.

Provocative discography: current status

Low back pain is a common clinical problem that may be due to a variety of causes, including disc disease. Provocative discography is an imaging-guided procedure in which a contrast agent is injected into the nucleus pulposus of the disc. Despite its controversial history, it remains the only imaging technique that provides both anatomical and functional information about a diseased disc. Disc morphology is usually assessed on either radiographs or computed tomography (CT), or both. Functional evaluation of the disc consists of pain provocation and careful assessment of the patient's response to pain. As provocative discography is an invasive procedure, it should not be used as a screening study in patients with back pain. It should instead be reserved for carefully- selected patients whose painful symptoms cannot be explained by findings on non-invasive imaging modalities such as magnetic resonance imaging or CT, and who are not responsive to conservative measures. Discography is helpful in selection of patients and disc levels to be operated upon. Careful application of indications and meticulous technique are however required if a successful outcome is to be expected.

The relationship beween posture and back muscle endurance in industrial workers with flexion-related low back pain

This preliminary cross-sectional study was undertaken to determine if there were measurable relationships between posture, back muscle endurance and low back pain (LBP) in industrial workers with a reported history of flexion strain injury and flexion pain provocation. Clinical reports state that subjects with flexion pain disorders of the lumbar spine commonly adopt passive flexed postures such as slump sitting and present with associated dysfunction of the spinal postural stabilising musculature. However, to date there is little empirical evidence to support that patients with back pain, posture their spines differently than pain-free subjects. Subjects included 21 healthy industrial workers and 24 industrial workers with flexion-provoked LBP. Lifestyle information, lumbo-pelvic posture in sitting, standing and lifting, and back muscle endurance were measured. LBP subjects had significantly reduced back muscle endurance ( P < 0.01 ) . LBP subjects sat with less hip flexion, ( P = 0.05 ) , suggesting increased posterior pelvic tilt in sitting. LBP subjects postured their spines significantly closer to their end of range lumbar flexion in ‘usual’ sitting than the healthy controls ( P < 0.05 ) . Correlations between increased time spent sitting, physical inactivity and poorer back muscle endurance were also identified. There were no significant differences found between the groups for the standing and lifting posture measures. These preliminary results support that a relationship may exist between flexed spinal postures, reduced back muscle endurance, physical inactivity and LBP in subjects with a history of flexion injury and pain.

Botulinum toxin A injection for chronic tennis elbow — A potential new mode of treatment

AbstractChronic tennis elbow is not a serious disease but patients may suffer greatly. First studies with injection of Botulinum toxin A (Btx A) have shown promising results.In 18 patients a single dose of Btx A was injected into the origin of the forearm extensors. The site of injection was determined by local tenderness and pain provocation on finger and wrist extension. A significant clinical improvement was seen at two weeks following injection. The effect was noted up to the last follow-up at 14 weeks. Pain, as self-assessed on a visual analogue scale, was also significantly reduced. A significant decrease of muscle strength was only seen for the third finger two weeks after injection. It slowly returned to normal thereafter.A single injection of Btx A seems to be a promising therapy in chronic tennis elbow. It can be carried out in an outpatient setting, and allows the patients to continue working.

Time dependant differences in pain sensitivity during unilateral ischemic pain provocation in healthy volunteers

Plurisegmental endogenous pain inhibitory mechanisms related to diffuse noxious inhibitory controls (DNIC) were demonstrated in animal experiments to act on multireceptive neurons of the entire cord outside the conditioned segment without any side differences. Human experiments have demonstrated altered pain sensitivity to pressure, heat and electrical stimulation during heterotopic noxious conditioning stimulation (HNCS). The purpose of the study was to examine if side and/or time differences in pain thresholds and suprathreshold pain sensitivity for pressure and heat, respectively, could be detected during HNCS. Perception thresholds to pressure and heat pain as well as the sensitivity to suprathreshold pressure (SPP) and heat pain (SHP) were assessed in 18 healthy volunteers bilaterally at the thighs before, during and following ischemia-induced pain of the left forearm (HNCS). The assessments started with either the right (10 subjects) or the left thigh (8 subjects). During HNCS the pressure pain threshold increased significantly ( p < 0.001) on both sides alike. No significant difference in the magnitude of the altered pressure pain threshold was seen between sides for the first or the lastly assessed side. On the lastly assessed side only SPP and SHP increased significantly on both sides alike ( p < 0.02 and p < 0.03, respectively), without magnitude differences between sides. During unilateral HNCS of the left arm, a time factor was demonstrated only for alterations in suprathreshold pain sensitivity, without any differences in magnitude between sides. Therefore, the results have implications for future design of HNCS-related experimental and clinical studies.

Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests

Previous research indicates that physical examination cannot diagnose sacroiliac joint (SIJ) pathology. Earlier studies have not reported sensitivities and specificities of composites of provocation tests known to have acceptable inter-examiner reliability. This study examined the diagnostic power of pain provocation SIJ tests singly and in various combinations, in relation to an accepted criterion standard. In a blinded criterion-related validity design, 48 patients were examined by physiotherapists using pain provocation SIJ tests and received an injection of local anaesthetic into the SIJ. The tests were evaluated singly and in various combinations (composites) for diagnostic power. All patients with a positive response to diagnostic injection reported pain with at least one SIJ test. Sensitivity and specificity for three or more of six positive SIJ tests were 94% and 78%, respectively. Receiver operator characteristic curves and areas under the curve were constructed for various composites. The greatest area under the curve for any two of the best four tests was 0.842. In conclusion, composites of provocation SIJ tests are of value in clinical diagnosis of symptomatic SIJ. Three or more out of six tests or any two of four selected tests have the best predictive power in relation to results of intra-articular anaesthetic block injections. When all six provocation tests do not provoke familiar pain, the SIJ can be ruled out as a source of current LBP.

Description of pain provocation tests used for the diagnosis of sports‐related chronic groin pain: relationship of tests to defined clinical (pain and tenderness) and MRI (pubic bone marrow oedema) criteria

The clinical assessment of groin pain in athletes is difficult, with the lack of specific clinical tests being in part responsible. Three pain provocation tests used in the diagnosis of chronic groin pain are described and their relationship to defined clinical and MRI criteria has been assessed. Eighty-nine Australian Rules football players with and without groin symptoms underwent clinical examination followed by history. Three pain provocation tests were performed (named as the Single Adductor, Squeeze and Bilateral Adductor tests). All athletes subsequently underwent MRI of their groin region for the presence of significant pubic bone marrow oedema (BMO). Of the 89, 47 were defined as having chronic groin pain, and 46 had significant BMO with 37 having both chronic groin pain and BMO. The three pain provocation tests demonstrated only moderate sensitivity (range 30-65%). Positive predictive values were moderate to high (67-93%) depending upon the individual test. The Bilateral Adductor test was the most sensitive test with the highest positive predictive values. The high specificity (88-93%) demonstrated should be treated with caution due to the study methodology. Three pain provocation tests of potential value in assessing chronic groin pain in athletes are described. If positive, all three pain provocation tests demonstrated a high likelihood for the athlete having MR-detected parasymphyseal pubic BMO. Further research is required on assessing the clinical usefulness of these tests.

Therapie der chronischen Epicondylopathia humeri radialis mit Botulinumtoxin A

Chronic radial epicondylitis (tennis elbow) is not a serious disease but patients may suffer greatly. If standard conservative and possibly operative treatment modalities have not been effective, patients need further therapy. First trials with injection of Botulinum toxin A (Btx A) have shown promising results. The purpose of the study was to clarify if a single injection of Btx A could be an efficient therapy for chronic radial epicondylitis. In this study 16 patients received injections into the forearm extensors. The site of injection was determined by local tenderness and pain provocation on finger and wrist extension. A significant clinical improvement was already seen at 2 weeks following injection. The effect was noted up to the last follow-up at 2 years. Continuous and maximal pain during the last 48 h, as self-assessed on a visual analogue scale, was also significantly reduced. In a few cases a significant decrease of muscle strength was seen for the third finger two weeks after injection. It slowly returned thereafter. A single injection of Btx A was effective as therapy for chronic tennis elbow. It can be carried out in an out-patient setting, and allows the patient to continue working.

Histopathologic Features of the Acetabular Labrum in Femoroacetabular Impingement

This paper summarizes clinical and histopathologic findings derived from 25 patients who had surgery for symptomatic femoroacetabular impingement. We explored if observed pathologic features were consistent with hypothesized mechanisms of injury, if severity of osteoarthritis and labral degeneration were associated, and if labral refixation would present an alternative. Clinically, all patients presented with limited range of motion at the hip attributable to pain and a positive impingement test. Magnetic resonance arthrography and surgical observations showed degenerated or ruptured labra or both in the anterior and/or superior regions of the acetabular rim (24 of 25 specimens) which correlated with pain provocation, limited range of motion, and anatomic deformities. Histologically, labra were mostly hyperplastic with disorganized cystic matrices. No inflammation was observed. Spatial distribution of degenerated labral matrices was not different for the two femoroacetabular impingement mechanisms. Labral degeneration and severity of osteoarthritis observed on radiographs did not correlate. In patients having only joint debridement, the labral matrix at the tip, near its vascular supply, was normal. Femoroacetabular impingement is a gentle chronic irritation of the labra located at the site of rupture that elicits a degenerative reaction. In early stages of the disease, the labral tip is not involved, providing the possibility of labral refixation after resection of the degenerated portion.

Piriformis syndrome: Correlation of muscle morphology with symptoms and signs

Broadhurst NA, Simmons DN, Bond MJ. Piriformis syndrome: correlation of muscle morphology with symptoms and signs. Objective To determine the relation of symptoms and pain provocation tests to abnormal piriformis morphology among people with chronic buttock pain. Design Each of 2 clinical symptoms and 2 clinical signs were compared with the abnormal morphology found on ultrasound. The pain-free side was used as an internal control. Setting A tertiary referral center. Participants A series of 27 consecutive patients (26 women, 1 man; average age, 48y) with chronic low lumbosacral or buttock pain, who presented to a musculoskeletal clinic over a 12-month period, underwent ultrasound assessment of piriformis muscle morphology. Four patients were excluded because their body mass index was in excess of 30kg/m 2. Intervention The symptomatic piriformis muscle was injected with bupivacaine after pain was assessed on a visual analog scale (VAS), using the resisted abduction test. Main outcome measure A 70% reduction of pain on the VAS was considered positive for pain in the piriformis muscle. Results Odds ratios (ORs) and 95% confidence intervals were calculated comparing each of the signs and symptoms with normal morphology. The highest ORs were found for pain on walking up inclines (10.8), referred pain (5.3), and pain on needling the piriformis muscle (6.0). Conclusions This study did not provide a criterion standard for the diagnosis of piriformis syndrome, but it did support the syndrome as a contributing factor in chronic buttock pain and very low back pain.

Does This Patient Have an Instability of the Shoulder or a Labrum Lesion?

History taking and clinical tests are commonly used to diagnose shoulder pain. Unclear is whether tests and history accurately diagnose instability or intra-articular pathology (IAP). To analyze the accuracy of clinical tests and history taking for shoulder instability or IAP. Relevant studies identified through PubMed, EMBASE, CINAHL, and bibliographies of known primary and review articles. Studies comparing the performance of history items or physical examination with a reference standard were included. Studies on fibromyalgia, fractures, or systemic disorders were excluded. Of 1449 articles, 35 were eligible, and 17 were selected. Data were extracted on study population, clinical tests, reference tests, and outcome. The studies' methodological quality (patient spectrum, verification, blinding, and replication) was assessed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) checklist. Six tests showed positive likelihood ratios (LRs) and confidence intervals (CIs). Tests favoring the diagnosis for establishing instability included: relocation (LR, 6.5; 95% CI, 3.0-14.0) and anterior release (LR, 8.3; 95% CI, 3.6-19). Tests showing promise for establishing labral lesions included: the biceps load I and II (LR, 29; 95% CI, 7.3-115.0 and LR, 26; 95% CI, 8.6-80.0), respectively, pain provocation of Mimori (LR, 7.2; 95% CI, 1.6-32.0), and internal rotation resistance strength (LR, 25; 95% CI, 8.1-76.0). The apprehension, clunk, release, load and shift, and sulcus sign tests proved less useful. Results should be cautiously interpreted because studies were completed in select populations in orthopedic practice, mostly assessed by the test designers, and evaluated in single studies only. No accuracy studies were found for history taking or for clinical tests in primary care. Shoulder complaints are frequently recurrent. Instability might cause some of these complaints. Best evidence supports the value of the relocation and anterior release tests. Symptoms related to IAP (labral tears) remain unclear. Most promising for establishing labral tears are currently the biceps load I and II, pain provocation of Mimori, and the internal rotation resistance strength tests.

Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature.

A systematic review. To determine the quality of the research and assess the interexaminer and intraexaminer reliability of spinal palpatory diagnostic procedures. Conflicting data have been reported over the past 35 years regarding the reliability of spinal palpatory tests. The authors used 13 electronic databases and manually searched the literature from January 1, 1966 to October 1, 2001. Forty-nine (6%) of 797 primary research articles met the inclusion criteria. Two blinded, independent reviewers scored each article. Consensus or a content expert reconciled discrepancies. The quality scores ranged from 25 to 79/100. Subject description, study design, and presentation of results were the weakest areas. The 12 highest quality articles found pain provocation, motion, and landmark location tests to have acceptable reliability (K = 0.40 or greater), but they were not always reproducible by other examiners under similar conditions. In those that used kappa statistics, a higher percentage of the pain provocation studies (64%) demonstrated acceptable reliability, followed by motion studies (58%), landmark (33%), and soft tissue studies (0%). Regional range of motion is more reliable than segmental range of motion, and intraexaminer reliability is better than interexaminer reliability. Overall, examiners' discipline, experience level, consensus on procedure used, training just before the study, or use of symptomatic subjects do not improve reliability. The quality of the research on interreliability and intrareliability of spinal palpatory diagnostic procedures needs to be improved. Pain provocation tests are most reliable. Soft tissue paraspinal palpatory diagnostic tests are not reliable.

Methods used by members of the Australian osteopathic profession to assess the sacroiliac joint

The range and frequency of clinical tests used by Australian osteopaths to detect sacroiliac joint dysfunction (SIJD) is unknown. The aim of this study was to determine what clinical tests are employed by Australian osteopaths to assess for SIJD, and determine whether a correlation existed between these tests and clinical experience. Surveys were mailed to all Australian osteopathic practice locations listed in the current phone directory. 168 osteopaths responded to the survey, with an estimated response rate of 30%. Most respondents reported they utilise asymmetry of bony landmarks, motion tests and pain provocation tests to detect SIJD. The PSIS (94%) was most frequently examined for asymmetry, sacral springing (prone) (73%) was the most frequently reported motion test, and the piriformis (80%) was most frequently examined for tenderness and/or tissue texture change. Only 14% of respondents completely abstained from using pain provocation testing. It appeared that many osteopaths used diagnostic procedures consistent with the model proposed by Mitchell, but supported them with other motion and pain provocation tests. The use of standard tests commonly advocated in the osteopathic literature declined with increasing practitioner experience, whereas the use of a wide range of idiosyncratic tests increased. It appeared that the majority of osteopaths use pain provocation tests, which are not advocated by osteopathic texts, but commonly referred to in the wider manual therapy literature.

Hydro-Galvanic and Rising - Temperature Bath Therapy For Chronic Elbow Epicondylitis: A comparative Study

The efficacy of two different regimens of physiotherapy for epicon-dylitis was compared. A combination treatment with hydrogalvanic four-cell bath and arm bath with rising temperature, which had showed good effects in treatmen of tennis elbow in an earlier observational study (Mucha 1987), was compared with the analgesic interference current treatment often recommended in the literature (Sadil and Sadil 1994, Noteboom et al 1994, Becker and Reuter 1982).For this study, 60 patients with epicondylitis that was resistant to conservative reatment were randomized into two groups for comparison. In group 1, interference currents were administered twicea day for six weeks and group 2 received combination treatment with the hydrogalvanic four-cell bath and risingt emperature arm bath once a day for six weeks.Criteria for inclusion, control and appraisal were laid down prospectively. Several parameters were used, recordedand statistically evaluated as outcome measures. These were active joint range of movement of the elbow, grip strength,pain provocation with muscle contraction, palpation pain and pain with functional activities. The results showed a significant superiority of combination treatment over therapy with interference current. It istherefore recommended that hydrogalvanic four-cell bath and arm bath with rising temperature should be carried outbefore considering surgical treatment for chronic epicondylitis.