Pain Provocation Research Articles

Modulation Of Experimental Prolonged Pain and Sensitization Using High-Definition Transcranial Direct Current Stimulation: A Double-Blind, Sham-Controlled Study

High definition transcranial direct current stimulation (HD-tDCS) targeting brain areas involved in pain processing has shown analgesic effects in some chronic pain conditions, but less modulatory effect on mechanical and thermal pain thresholds in asymptomatic subjects. This double-blinded study assessed the HD-tDCS effects on experimental pain and hyperalgesia maintained for several days in healthy participants. Hyperalgesia and pain were assessed during three consecutive days following provocation of experimental pain (nerve growth factor injected into the right-hand muscle) and daily HD-tDCS sessions (20-minutes). Forty subjects were randomly assigned to Active-tDCS targeting primary motor cortex and dorsolateral prefrontal cortex simultaneously or Sham-tDCS. Tactile and pressure pain sensitivity were assessed before and after each HD-tDCS session, as well as the experimentally-induced pain intensity scored on a numerical rating scale (NRS). Subjects were effectively blinded to the type of HD-tDCS protocol. The Active-tDCS did not significantly reduce the NGF-induced NRS pain score (3.5±2.4) compared to Sham-tDCS (3.9±2.0, P > .05) on day 3 and both groups showed similarly NGF-decreased pressure pain threshold in the right hand (P < .001). Comparing Active-tDCS with Sham-tDCS, the manifestation of pressure hyperalgesia was delayed on day 1, and an immediate (pre-HD-tDCS to post-HD-tDCS) reduction in pressure hyperalgesia was found across all days (P < .05). PerspectiveThe non-significant differences between Active-tDCS and Sham-tDCS on experimental prolonged pain and hyperalgesia suggest that HD-tDCS has no effect on moderate persistent experimental pain. The intervention may still have a positive effect in more severe pain conditions, with increased intensity, more widespread distribution, or increased duration and/or involving stronger affective components.

Posterior Ankle Impingement Syndrome Clinical Features Are Not Associated With Imaging Findings in Elite Ballet Dancers and Athletes.

To assess the association between clinical features and magnetic resonance imaging (MRI) findings in posterior ankle impingement syndrome (PAIS) and to compare the prevalence of imaging findings between participants with and without a clinical diagnosis of PAIS. Case-control study. Elite ballet and sport. Eighty-two male (54%) and female participants comprising ballet dancers (n = 43), cricket fast bowlers (n = 24), and football (soccer) players (n = 15). Clinical: posterior ankle pain on body chart, passive plantarflexion pain provocation test. Patient-reported outcome measures: Oslo Sports Trauma Research Center Overuse Injury Questionnaire, Foot and Ankle Ability Measure Sports subscale. Imaging findings including posterior ankle bone marrow edema, os trigonum (± bone marrow edema, and increased signal at synchondrosis), Stieda process (± bone marrow edema), talocrural and subtalar joint effusion-synovitis size, flexor hallucis longus tendinopathy, and tenosynovitis identified as present or absent on 3.0-Tesla MRI. Imaging findings were not associated with posterior ankle pain or a positive ankle plantarflexion pain provocation test. Imaging findings were not associated with patient-reported outcome measures. Imaging findings did not differ between PAIS-positive and PAIS-negative groups. Os trigonum and Stieda process were prevalent despite clinical status. The lack of association between imaging findings and clinical features questions the role of imaging in PAIS. Clinicians should rely primarily on clinical assessment in the diagnosis and management of patients with PAIS.

Usefulness of the additional contrast agents to identify offending nerve root in selective nerve root block.

It is hypothesized that if it is confirmed that the pain caused by the injection needle coincides with the lower leg radiating pain(LLRP) that the patient mainly complains of, then the contrast agents may be used less. This study aims to understand if the identification of lancinating identical pain in the procedure could replace the use of contrast agents that causes additional pain provocation using control arm of randomized clinical trial.This retrospective study included 165 patients who met exclusion criteria from among patients who underwent Selective nerve root block for the treatment of LLRP. With the identical and lancinating pain confirmed in the same site of the patient, consistent with that of the original symptom, the subjects were divided into 2 groups: 1 without contrast injection (Non-Dye [ND] group; 57 patients) and the other with contrast injection (Dye [D] group; 108 patients). The degree of LLRP in the 2 groups was evaluated using visual analog scale (VAS) before injection, 2, 6, and 12 weeks after injection. Functional outcomes were measured using Owestry Disability Index and Rolland-Morris Disability Questionnair, whereas quality of life was measured using Physical component score and Mental component score of Short Form 36 (SF-36) before injection and 3 months after injection.There was no statistically significant difference in the LLRP severity in both groups at all times and no statistical difference in the degree of VAS improvement relative to the before-injection VAS value between the 2 groups at 2 and 6 weeks after injection (all P > .05). At 12 weeks after injection, there was a statistically significant difference, but they were below Minimum Clinical Important Difference, bearing little clinical implications. There was no statistically significant difference between the 2 groups in Owestry Disability Index, Rolland-Morris Disability Questionnair, SF-36 Physical component score, and SF-36 Mental component score at every interval (all P > .05).Instead of contrast agent injections that have been used for accurate nerve root identification during Selective Nerve Root Block, the method of merely checking if the needle-induced pain under fluoroscopic imaging is consistent with the LLRP that the patient predominantly experiences shows the same effect in the patient's pain control and functional outcome.

Investigation of the efficacy and safety of ultrasoundstandardized autologous blood injection as treatment for lateral epicondylitis.

BackgroundThere are various conservative treatment options for lateral epicondylitis (LE). The aim is to evaluate pain, daily functioning, and complications after ultrasound-standardized autologous blood injections in patients with LE.MethodsFor this prospective cohort study, consecutive patients (>18 years) diagnosed with LE were included. Autologous blood was injected using a medical device containing an injection disposable with 12 small needles (Instant Tennis Elbow Cure [ITEC]) device. Patient-Rated Tennis Elbow Evaluation (PRTEE), subjective elbow score (SES), palpation and provocation pain, satisfaction, and complications of treatment were measured at baseline and two months after treatment. Paired t-tests and Fisher’s exact tests were used for calculating the difference between pre- and post-treatment outcomes.ResultsFifty-five elbows were analyzed. Mean time between pre- and post-treatment was 11.1 weeks (standard deviation [SD], 8.9 weeks). The mean PRTEE score decreased from 68.2 (SD, 15.7) before surgery to 53.2 (SD, 25.9; p<0.001) after. The mean SES improved from 36.9 (SD, 20.8) to 51.7 (SD, 27.4; p<0.001). Despite this improvement, only 44.7% of patients showed relevant clinical improvement in PRTEE, and 37.3% showed significant clinical improvement based on SES. Four patients reported a complication and the injection disposable failed three times.ConclusionsUltrasound-standardized autologous blood injection using the ITEC device is not an effective tool in reducing symptoms related to LE. This study showed that only half of all patients experienced a positive effect. In this heterogeneous cohort of patients, we showed no added value of ultrasound standardization.

Greek physiotherapists’ contemporary knowledge and practice for lateral elbow tendinopathy: An online survey

ObjectivesTo investigate physiotherapists' current knowledge and practice in the management of patients with lateral elbow tendinopathy, to explore associations between the participants’ education and management preferences and to identify potential evidence-to-practice gaps by making comparisons with recent research recommendations. DesignAn on-line cross-sectional survey. SubjectsRegistered physiotherapists working in Greece with previous experience in the management of lateral elbow tendinopathy. ResultsThree hundred and seventy eight responses met the inclusion criteria. Most responders (70.4%–91.5%) use pain provocation tests for the diagnosis of the condition, while a limited proportion uses patient rated outcome measures (6.9%–13%). Supervised exercise is the mainstay of rehabilitation (92.6%), followed by adjunctive research recommended treatment techniques such as manual therapy (72%) and advice (59.5%). Up to 83.6% of participants use adjunctive treatment techniques that are not recommended or without research recommendation (such as electrophysical agents, ice etc.). Physiotherapists with post-graduate education in musculoskeletal physiotherapy are almost three times more likely to choose only research recommended treatment approaches. There is a lack of consensus in an optimal exercise programme (type, volume, duration etc.) in patients with lateral elbow tendinopathy. ConclusionDespite research recommendations a limited use of patient rated outcome measures in lateral elbow tendinopathy is recorded. Supervised exercise is the first line treatment option for most physiotherapists, although the optimal application is still unclear. A large proportion of physiotherapists apply adjunctive treatment techniques that are either ineffective or poorly researched suggesting a substantial evidence-to-practice gap. Better access to knowledge, organisational and peer-support can potentially help to bridge this gap.

The Diagnostic Value of Clinical Sacroiliac Joint Pain Provocation Tests for Detection of Sacroiliitis Identified by MRI in Sampled Iraqi Patients with Inflammatory Back Pain.

Background:Sacroiliitis has been considered as the keystone in the diagnosis of axial spondyloarthritis (SPA). The diagnosis can be challenging in early stages of sacroiliitis, as conventional radiographs may be normal. Pain provocative tests can be very helpful to give a clue whether sacroiliitis is present in suspected patient by reproducing the patient’s pain.Objective:To assess the validity of clinical sacroiliac joint pain provocation tests for sacroiliitis in comparison with magnetic resonance imaging (MRI).Patients and methods:A total of 65 patients were selected from cohort of patients with persistent inflammatory low back pain during their attendance to the Rheumatology Consultant Clinic at Baghdad Teaching Hospital. Data were collected using questionnaire and interview. Socio-demographic characteristics, disease duration and clinical data were recorded for all patients. Data from four different clinical examination tests (Flexion Abduction and External Rotation [FABER], direct compression, distraction, and lateral compression) with subsequent MRI findings of sacroiliac joint for each patient were analysed. Positive MRI findings were further subdivided into active and chronic lesions according to the new ASAS (association of spondyloarthritis international society) criteria of positive imaging in spondyloarthropathy.Results:A total of 65 patients were included in this study, age range 18–39 years, 69.2% were men. The prevalence of sacroiliitis in the study was 67.7% (43.1% bone marrow oedema, 18.5% erosions, 15.4% sclerosis, 6.2 % for each of effusion; ankyloses and capsulitis). In the whole study group, the highest association with sacroiliitis was for FABER test with sensitivity of 75% while the most specific one was the lateral compression test (71.4%). In men, sacroiliitis was associated with sacroiliac joint (SIJ) clinical tests assessed in multi-test regimens; significant association was found by combining direct compression and FABER test with sensitivity of 51% and specificity of 28.5%.Conclusion:This study identified the reliability of a number of clinical examination tests of SIJ, which increase as they are used in multi-test regimen rather than each one alone, this had a significant association for men only.

"Taking action" to reduce pain-Has interpretation of the motor adaptation to pain been too simplistic?

Movement adapts during acute pain. This is assumed to reduce nociceptive input, but the interpretation may not be straightforward. We investigated whether movement adaptation during pain reflects a purposeful search for a less painful solution. Three groups of participants performed two blocks (Baseline, Experimental) of wrist movements in the radial-ulnar direction. For the Control group (n = 10) both blocks were painfree. In two groups, painful electrical stimulation was applied at the elbow in Experimental conditions when the wrist crossed radial-ulnar neutral. Different stimulus intensities were given for specific wrist angles in a secondary direction (flexion-extension) as the wrist passed radial-ulnar neutral (Pain 5–1 group:painful stimulation at ~5 or ~1/10—n = 21; Pain 5–0 group:~5 or 0(no stimulation)/10—n = 6)). Participants were not informed about the less painful alternative and could use any strategy. We recorded the percentage of movements using the wrist flexion/extension alignment that evoked the lower intensity noxious stimulus, movement variability, and change in wrist/forearm alignment during pain. Participants adapted their strategy of wrist movement during pain provocation and reported less pain over time. Three adaptations of wrist movement were observed; (i) greater use of the wrist alignment with no/less noxious input (Pain 5–1, n = 8/21; Pain 5–0, n = 2/6); (ii) small (n = 9/21; n = 3/6) or (iii) large (n = 4/21; n = 1/6) change of wrist/forearm alignment to a region that was not allocated to provide an actual reduction in noxious stimulus. Pain reduction was achieved with “taking action” to relieve pain and did not depend on reduced noxious stimulus.

Sensorimotor performance in acute-subacute non-specific neck pain: a non-randomized prospective clinical trial with intervention

BackgroundThe assessment of cervical spine kinematic axial rotation performance is of great importance in the context of the study of neck sensorimotor control. However, studies addressing the influence of the level of provocation of spinal pain and the potential benefit of passive manual therapy mobilizations in patients with acute-subacute non-specific neck pain are lacking.MethodsA non-randomized prospective clinical trial with an intervention design was conducted. We investigated: (1) the test-retest reliability of kinematic variables during a fast axial head rotation task standardized with the DidRen laser test device in 42 Healthy pain-free Control Participants (HCP) (24.3 years ±6.8); (2) the differences in kinematic variables between HCP and 38 patients with Acute-subacute Non-Specific neck Pain (ANSP) assigned to two different groups according to whether their pain was localized in the upper or lower spine (46.2 years ±16.3); and (3) the effect of passive manual therapy mobilizations on kinematic variables of the neck during fast axial head rotation.Results(1) Intra-class correlation coefficients ranged from moderate (0.57 (0.06-0.80)) to excellent (0.96 (0.91-0.98)). (2) Kinematic performance during fast axial rotations of the head was significantly altered in ANSP compared to HCP (age-adjusted) for one variable: the time between peaks of acceleration and deceleration (p<0.019). No significant difference was observed between ANSP with upper vs lower spinal pain localization. (3) After the intervention, there was a significant effect on several kinematic variables, e.g., ANSP improved peak speed (p<0.007) and performance of the DidRen laser test (p<0.001), with effect sizes ranging from small to medium.Conclusion(1) The DidRen laser test is reliable. (2) A significant reduction in time between acceleration and deceleration peaks was observed in ANSP compared to HCP, but with no significant effect of spinal pain location on kinematic variables was found. (3) We found that neck pain decreased after passive manual therapy mobilizations with improvements of several kinematic variables.Trial registrationRegistration Number: NCT 04407637

The 45-second anterior knee pain provocation test: A quick test of knee pain and sporting function in 10–14-year-old adolescents with patellofemoral pain

ObjectiveTo test 1) if the 45-second Anterior Knee Pain Provocation Test (AKPP-test) could differentiate between adolescents with patellofemoral pain (PFP) and pain-free controls and; 2) whether improvements in the AKPP-test over 12 weeks were associated with improvements in self-reported knee function and pain. DesignProspective cohort. Patients151 with PFP and 50 pain-free controls (age 10–14 years). OutcomesThe AKPP-test was performed at baseline, 4- and 12-week follow-up. Pain and function were collected using Knee Injury and Osteoarthritis Outcome Score (KOOS). ResultsAt baseline, the AKPP-test provoked pain to a median of 5 points (IQR: 3–7) on the 0–10 Numeric Pain Rating Scale in adolescents with PFP, compared to 0 (IQR 0-0) in controls. Higher pain during the AKPP-test was associated with worse KOOS-Sport/Rec (r = −0.33, P < 0.001), worse KOOS-Pain (r = −0.47, P < 0.001), and pain intensity (worst pain last 24 hours) (r = −0.39, P < 0.001) at baseline. Improvements in the AKPP-test over 12 weeks were associated with improvements in KOOS Pain (r = 0.48, P < 0.001) and KOOS Sport/Rec (r = 0.40, P < 0.001). ConclusionsImprovements in the AKPP-test were associated with improvements in self-report knee pain and limitations in sports, suggesting the AKPP-test may be a clinically responsive test of knee pain and sporting function in adolescents with PFP.

Thermography evaluation of low back pain in pregnant women: Cross-sectional study

BackgroundLow back pain during pregnancy is very common and thermography seems to be a promising method of evaluation for pregnant women, because it is painless and safe. The aim of the present study was to evaluate low back pain, during pregnancy, using thermography together with artificial intelligence. MethodsA cross-sectional study was carried out with pregnant women recruited from a university hospital. The following data were collected: (a) clinical data; (b) physical assessment with mobility and low back pain provocation tests; and (c) thermograms acquisitions, in a controlled environment. Artificial intelligence and the statistical tests were used to compare the groups’ mean: with low back pain (LBP) and without low back pain (WLBP). ResultsThirty pregnant women took part, with fifteen in each group. The mean ± Standard Deviation temperature of the lumbar region in both groups were 32.7 ± 1.05 °C and 32.6 ± 1.01 °C for LBP and WLBP, respectively. There was not any difference in temperature between the groups; however, the artificial intelligence software found thermogram differences between groups; furthermore, the correlation between pain intensity and functionality was found. ConclusionThermography associated with artificial intelligence analyses demonstrated to be a promising method as an adjunct to clinical evaluation.

Inertial flywheel vs heavy slow resistance training among athletes with patellar tendinopathy: A randomised trial

ObjectivesTo compare the efficacy of inertial flywheel and heavy slow resistance training in reducing pain and improving function in patellar tendinopathy. DesignRandomised clinical trial. MethodsFourty two participants (1 woman, 41 men) with longstanding (>3 months) patellar tendinopathy were randomised into inertial flywheel resistance (N = 21) or heavy slow resistance (N = 21) group. Both programmes consisted of three supervised inertial flywheel or heavy slow resistance exercise sessions per week in a fitness center during 12 weeks. Primary outcome was pain and function, assessed by the Spanish Victorian Institute of Sport Assessment for Patella (VISA-P) score at 6 and 12 weeks. Secondary outcomes were activity limitation using Patient Specific Functional Scale (PSFS), health status (EuroQol-5D), patient impression of change on pain and function, adherence, adverse events, pain provocation test for the patellar tendon (numerical rating score of pain between 0 and 10), physical test, patellar tendon thickness and doppler signal on ultrasound. Secondary outcomes were taken at 0 and 12 weeks. ResultsBoth groups showed significant improvements in VISA-P scores from 0 to 12 weeks but there was not statistically significant between-group difference (P = 0.506). No adverse events or side effects occurred in any of the groups during the intervention period. ConclusionsInertial flywheel resistance three times a week during 12 weeks resulted in similar pain and function benefit at 12 weeks compared with the heavy slow resistance training among people with patellar tendinopathy. Flywheel training is another exercise option for managing people with patellar tendinopathy. ClinicalTrials.gov RegistryNCT03917849.

The Dental stick test - Useful to reveal intra-articular conditions in persons with temporomandibular disorder?

BackgroundThere is a need for clinical tests that can reveal intra-articular conditions in the temporomandibular joint to be able to give proper treatment. The Dental stick test, where participants bite with their molars on a wooden stick, is a pain provocation test for the temporomandibular joint. ObjectiveThe purpose of this study was to explore if the Dental stick test can be used to reveal intra-articular conditions in the temporomandibular joint in persons with long-lasting painful disorders. DesignCross-sectional. Materials and methodsForty persons with pain in one or both temporomandibular areas were examined using the Dental stick test. The participants were between 18 and 70 years, and had 65 symptomatic joints. Sensitivity, specificity, false positive and false negative responses, and area under the curve were calculated for the Dental stick test with MRI and/or CT as reference standards. The phi-correlation coefficient (phi) was used to measure the correlation between the Dental stick test and intra-articular findings. ResultsThe sensitivity and specificity for the Dental stick test, revealing intra-articular findings, were 0.62 and1.0 respectively. False positive and false negative responses were 0 and 0.41 respectively, and the area under the curve 81% with p < 0.001. The correlation between a positive Dental stick test and intra-articular findings was not significant (phi = 0.60). ConclusionsWhen the Dental stick test is positive, intra-articular findings will most probably be present on MRI/CT, but the test alone cannot reveal intra-articular conditions in persons with long-lasting painful temporomandibular disorder.

Expression of Substance P and Nerve Growth Factor in Degenerative Long Head of Biceps Tendon in Patients with Painful Rotator Cuff Tear.

PurposeDegenerative long head of biceps tendon (LHBT) has been recognized as a notable pain source in patients with rotator cuff tear (RCT). Tenotomy or tenodesis of LHBT is frequently indicated together with arthroscopic rotator cuff repair (ARCR) aiming for complete pain relief; however, it has not been fully investigated whether resected LHBT is really a source of pain. The purpose of this study was to investigate expression levels of pain-associated mediators in LHBT and its association with preoperative pain profiles.MethodsTwenty-seven RCT patients who underwent ARCR with LHBT resection were included. Each LHBT was resected due to its abnormal arthroscopic findings including tenosynovitis, hypertrophy, and partial tear. Worst macroscopic lesion of the LHBT was obtained, and expression levels of substance P (SP) and nerve growth factor (NGF) were evaluated using enzyme-linked immunosorbent assay (ELISA). Ten healthy knee flexor tendons were analyzed as non-degenerative samples. Preoperatively, subjective shoulder pain VAS and pain duration were investigated. Conventional LHBT pain provocation tests (Speed, Yergason, O’Brien) were performed. Pressure pain threshold (PPT) of bilateral LHBT on the groove was recorded.ResultsLevels of SP and NGF expression were significantly higher compared with non-degenerative tendons (P<0.01). Shoulder pain VAS and pain duration were not directly associated with SP and NGF expression level. Patients with positive O’Brien test expressed greater SP than negative patients (P=0.001). Significant negative correlation between the PPT ratio (ipsilateral/contralateral) and SP expression level was observed (r=−0.453, P=0.034).ConclusionGreater expression of SP and NGF in degenerative LHBT supported our hypothesis that it would be a pain source in RCT patients. SP was likely to be expressed highly in patients with localized pressure pain hypersensitivity and positive O’Brien test (ie, altered mechanistic pain profile of LHBT), which may help when considering simultaneous LHBT resection during ARCR.Clinical RegistrationUMIN000023943.

Diagnostic Accuracy of Clusters of Pain Provocation Tests for Detecting Sacroiliac Joint Pain: Systematic Review With Meta-analysis.

To assess the diagnostic test accuracy of pain provocation tests for the sacroiliac joint. Systematic review of diagnostic test accuracy. Seven electronic databases and reference lists of included studies and previous reviews were searched. Studies investigating the diagnostic accuracy of clusters of clinical tests for sacroiliac joint pain were included. Bivariate random-effects meta-analysis was employed. Risk of bias and applicability concerns were assessed using the revised Quality Assessment of Diagnostic Accuracy Studies tool, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool was used to judge credibility of evidence. From 2195 records identified in the search, 5 studies were included that assessed clusters of pain provocation tests for the sacroiliac joint. The estimated positive likelihood ratio was 2.13 (95% confidence interval [CI]: 1.2, 3.9), the negative likelihood ratio was 0.33 (95% CI: 0.11, 0.72), and the diagnostic odds ratio was 9.01 (95% CI: 1.72, 28.4). The GRADE ratings for the outcomes were of very low certainty. Assuming a point prevalence of sacroiliac joint pain of 20%, we calculated a positive posterior probability of 35% (95% CI: 32%, 37%) and negative posterior probability of 8% (95% CI: 6%, 10%). A positive result on a sacroiliac joint pain provocation test cluster gives the clinician 35% certainty of having correctly identified sacroiliac joint pain. Clusters of pain provocation tests for the sacroiliac joint do not provide sufficient diagnostic accuracy for ruling in the sacroiliac joint as the source of pain. Clinicians can rule out the sacroiliac joint as the source of pain with more confidence: the negative posttest probability indicates that the clinician can conclude with 92% certainty that a negative test result is correct. J Orthop Sports Phys Ther 2021;51(9):422-431. Epub 1 Jul 2021. doi:10.2519/jospt.2021.10469.

Nearly 40% of adolescent athletes report anterior knee pain regardless of maturation status, age, sex or sport played

ObjectiveTo report point prevalence of anterior knee pain (AKP) in adolescent athletes by (1) maturation status, (2) chronological age, (3) sex, and (4) primary sport. DesignCross-sectional. MethodsMale and female participants aged 11–15 years were recruited from specialised sports programs for basketball, volleyball, Australian Rules Football and tennis. Standing height, sitting height, and body mass were measured and used to calculate maturity status. Past injury history, self-reported physical activity, and Victorian Institute of Sport Assessment Questionnaire Patellar Tendon (VISA-P) questionnaires were completed. Anterior knee pain was defined as any pain experienced on the anterior surface of the knee and recorded using a visual analogue scale (VAS). A single leg decline squat (SLDS) was performed for provocation of AKP. ResultsTwo hundred and seventeen male and female adolescent athletes participated in this study. Twenty participants were excluded from data analysis. Point prevalence of AKP was 39% (N = 76). Average self-reported physical activity/week was 7.9 ± 4.1 h of their specialised sport and 2.0 ± 2.0 h of other physical activity/week. Maturation status, chronological age, sex nor primary sporting program was statistically significant in explaining the presence or absence of AKP. ConclusionDue to the right-skewed maturation sample, the authors cannot state conclusively that maturation status was not associated with AKP. Nearly 40% of this cohort reported AKP during a pain provocation test. The presence of AKP was not explained by maturation status, age, sex or primary sport program. Given the chronic nature of AKP and future morbidity reported, this high prevalence provides rationale for intervention or prevention studies targeting younger athletes.

Inter-examinerreliability study of physical examination procedures to assess the cervical spine

ObjectiveThe objective of this study was to establish the level of inter-examiner reliability for six common cervical manual and physical examination procedures used to assess the cervical spine.Materials:Reliability study that used a convenience sample of 51 patients between the ages of 16–70 years presenting with a chief complaint of neck pain. Two physical therapists independently performed the same series of cervical physical examination procedures on each of the participant. The clinicians were blinded to each other’s findings and the clinical status of the patient. Kappa coefficients (κ) were calculated for levels of agreement between the clinicians for each procedure.ResultsWhen assessing for asymmetrical motion, excellent levels of reliability (κ range: 0.88–0.96) were observed for the Bilateral Modified Lateral Shear (asymmetry criterion), Bilateral C2 Spinous Kick (asymmetry criterion) and Flexion-Rotation Tests. When pain provocation was used as the indicator of a positive test during palpation of the cervical facet joints, moderate to substantial levels of reliability (κ range: 0.53–0.76) were observed. When patients were instructed not to provide feedback to the clinicians about pain provocation during facet joint palpation and clinicians relied solely on their qualitative assessment of segmental mobility, the level of reliability was lower (κ range: 0.45–0.53). Due to 100 % prevalence of negative findings, Kappa values could not be calculated for the Sharp-Purser test or the Unilateral C2 Spinous Kick Test.ConclusionsMost physical examination procedures examined in this study demonstrated moderate to excellent levels of inter-examiner reliability. Palpation for segmental mobility without pain provocation demonstrated a lower level of reliability compared to palpation for pain provocation. Correlation with clinical findings is necessary to establish validity and the applicability of these procedures in clinical practice.

Perspectiva de la práctica clínica de fisioterapeutas colombianos en el manejo de la disfunción de la articulación sacroilíaca. Estudio descriptivo

Background and aimSacroiliac joint dysfunction (SIJD) is characterized by hypermobility or hypomobility of the joint and could be present in 13%–30% of people with low back pain of idiopathic origin. Therefore, it was important to analyse the physiotherapeutic clinical approach for patients diagnosed with SIJD in Bucaramanga (Colombia). MethodsAn observational descriptive cross-sectional study was conducted. The information was collected through a 31-question web survey, with face and content validation. Sociodemographic data, data on the training of the therapists and evaluation and intervention procedures used in the consultation were included. Results147 physiotherapists participated, 86.4% were women, 22.5% with postgraduate training. Seventy point four percent recognized SIJD as cause of low back pain and 43.5% stated that they did not use a specific test to diagnose SIJD. The most reported treatment modalities were therapeutic exercise, electrotherapy, humid heat, and massage. ConclusionsMost of the participants recognize SIJD as a cause of low back pain. Pain provocation tests were not used by most of the participants. Neither was the use of lumbopelvic stabilization exercises reported, required in SIJD rehabilitation. These findings show there is a need for training for the physiotherapists who participated in the study in the diagnosis and treatment of people with SIJD, to improve the recovery and quality of life of this population.

Utility of Physical Examination Findings for Predicting Low-Back Pain in Adolescent Patients with Early-Stage Spondylolysis: A Retrospective Comparative Cohort Study.

Introduction This study aimed to elucidate low-back pain (LBP) characteristics, i.e., its qualities, extent, and location, in patients with early-stage spondylolysis (ESS). Methods We recruited patients (≤18 years old) who presented with acute LBP lasting up to 1 month. Patients were divided into ESS and nonspecific LBP (NS-LBP) groups based on their magnetic resonance imaging findings; patients showing no pathological findings that might explain the cause of LBP were classified as NS-LBP. All patients were evaluated using the following tests: hyperextension and hyperflexion (pain provocation tests in a standing position), pain quality (sharp/dull), pain extent (fingertip-sized area/palm-sized area), and pain location (left and/or right pain in side [side]/central pain [center]). We have also compared outcomes between the ESS and NS-LBP groups in terms of gender and physical symptoms. Results Of 101 patients, 53 were determined to have ESS (ESS group: mean age: 14.3 years old; 43 males/10 females), whereas 48 had no pathological findings explaining the LBP origin [NS-LBP group (mean age, 14.4 years old; 31 males/17 females)]. Chi-squared test has identified gender (male), a negative result on hyperflexion test, pain extent (fingertip-sized area), and pain location (side) to be significantly associated with ESS. Among these, regression analysis revealed that male gender and LBP located on the side were significantly associated with ESS (p<0.05). Conclusions Although the hyperextension test is generally considered useful for ESS, we demonstrated that its association is not deemed significant. Our results indicate that male gender, a negative result of the hyperflexion test, fingertip-sized pain area, and LBP on the side may be specific characteristics of ESS. Of these physical signs, male gender and LBP located on the side are characteristic factors suggesting ESS presence.

Validation of self-administered tests for screening for chronic pregnancy-related pelvic girdle pain

BackgroundMany women develop pelvic girdle pain (PGP) during pregnancy and about 10% have chronic pain several years after delivery. Self-administered pain provocation tests are one way to diagnose and evaluate this pain. Their validity in post-partum women is not yet studied.The purpose of this study was to evaluate the validity of self-administered test for assessment of chronic pregnancy-related PGP several years after delivery.MethodsWomen who previously have had PGP during pregnancy and who participated in one of three RCT studies were invited to a postal follow up of symptoms including performance of self-administered tests after two, 6 or 11 years later, respectively. In total, 289 women returned the questionnaire and the test-results. Of these, a sub-group of 44 women with current PGP underwent an in-person clinical examination. Comparisons were made between test results in women with versus without PGP but also, in the sub-group, between the self-administered tests and those performed during the clinical examination.ResultsFifty-one women reported PGP affecting daily life during the last 4 weeks, and 181 reported pain when performing at least one of the tests at home. Those with chronic PGP reported more positive tests (p < 0.001). There was no significant difference between diagnosis from the self-administered tests compared to tests performed during the in-person clinical examination (p = 0.305), either for anterior or posterior PGP. There were no significant differences of the results between the tests performed self-administered vs. during the clinical examination.ConclusionA battery of self-administered tests combined with for example additional specific questions or a pain-drawing can be used as a screening tool to diagnose chronic PGP years after delivery. However, the modified SLR test has limitations which makes its use questionable.

Best Practices for Clinical Evaluation of Sacroiliac Joint Pain: AnEvidence-to-Practice Review

Sacroiliac joint (SIJ) pain serves as an under-recognized source of chronic low back pain. Improvement in the accuracy SIJ pain diagnosis lends a higher likelihood of appropriate treatment measures, better patient outcomes and decreased out-of-pocket costs. Therefore, the overall purpose of the guiding paper was to systematically review and synthesize evidence associated with the clinical diagnosis of SIJ pain. Searches of 5 electronic databases revealed 758 studies, nonetheless only 6 studies met final inclusion criteria. Studies included in the guiding systematic review were assessed for methodological quality using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. Evidence suggests pain provocation tests including distraction, compression, thigh thrust, sacral thrust, and Gaenslen’s are useful individually at diagnosing sacroiliac joint pain. The thigh thrust test was most sensitive and the distraction test was most specific. Furthermore, the compression test carried the strongest positive likelihood ratio. The highest likelihood ratio was reported when three or more of the following pain provocation tests were positive: distraction, compression, thigh thrust, sacral thrust, and Gaenslen’s test for both the right and left sides. A comparable likelihood ratio was found when any two of the remaining four tests were positive after excluding the left and right-side applications of the Gaenslen’s test. Research suggests using the McKenzie evaluation to exclude pain of disc origin preceding the performance of pain provocation tests in an effort to further reduce false positives. Safe, effective, and efficient diagnostic evaluation techniques are essential to the provision of high-quality patient care.