Hilde Stendal Robinson

Pelvic girdle pain in pregnancy: The impact on function

Background. The aim of this study was to determine the prevalence of self‐reported pelvic girdle pain in pregnancy and study the impact on function, the use of crutches, and waking up at night, according to location of pain. Methods. A population‐based questionnaire study was performed among all women 18–40 years in two communities in Norway in 1998–99. A total of 1,817 women with a prior delivery constituted the study sample. Pelvic girdle pain was grouped into five categories: pain in anterior pelvis, in posterior pelvis, in anterior and unilateral posterior pelvis, in anterior and bilateral posterior pelvis (a complete pelvic girdle syndrome), and pelvic pain with no information on location. Results. A total of 46% (843/1,817) reported pelvic girdle pain in pregnancy at one location or more. Nineteen percent reported pain in anterior pelvis only, 14% in posterior pelvis only, 4% in anterior and unilateral posterior pelvis, and 5% reported a complete pelvic girdle syndrome. A total of 7% of all pregnant women used crutches during pregnancy and 15% reported waking up at night frequently due to pelvic girdle pain. A complete pelvic girdle syndrome, as compared to pain in the anterior pelvis only, was strongly associated with the use of crutches (adjusted odds ratio (OR) 4.3; 95% confidence interval (CI) 2.5–7.4) and with waking up at night due to pain (OR 4.6; 95% CI 2.7–7.2). Conclusion. Pain related to the pelvic joints is common among pregnant women in Norway and may cause serious functional problems.

Reliability and validity of a palpation technique for identifying the spinous processes of C7 and L5

The objective was to examine inter-tester reliability and validity of two therapists identifying the spinous processes (SP) of C7 and L5, using one predefined surface palpation procedure for each level. One identification method made it possible to examine the reliability and the validity of the procedure itself. Two manual therapists examined 49 patients (29 women). Aged between 26 and 79 years, 18 were cervical and 31 lumbar patients. An invisible marking pen and ultraviolet light were used, and the findings were compared. X-rays were taken as an objective measure of the correct spinal level. Percentage agreement and kappa statistics were used to evaluate reliability and validity. The best inter-therapist agreement was found for the skin marks. Percentage agreement within 10mm and 20mm was 67% and 85%, respectively. The inter-tester reliability for identifying a radiological nominated SP by palpation was found to be poor for C7 and moderate for L5, with kappa of 0.18 and 0.48, respectively. The results indicated acceptable inter-therapist surface palpation agreement, but the chosen procedures did not identify the correct SP. This indicates that the procedures are not precise enough. Future reliability studies should test other non-invasive palpation procedures, both individually and in combination, and compare these with radiological investigation.

Pelvic girdle pain, clinical tests and disability in late pregnancy

The objective of this cross-sectional study was to explore the associations between pain locations, responses to the posterior pelvic pain provocation (P4) test, responses to the active straight leg raise (ASLR) test and disability in late pregnancy. 283 women in gestation week 30 (mean age 31.3 years; 59% nullipara) completed a questionnaire (including pain drawing and Disability Rating Index, DRI). A physiotherapist blinded for the questionnaire data assessed responses to the P4 and ASLR tests. The pain drawing was used to: 1) distinguish between Pelvic girdle pain (PGP) and low back pain (LBP); 2) discriminate between pain locations within the pelvic area. A large variation was found in DRI within each pain location group. Women with PGP were more afflicted than the women with LBP and those without PGP. Highest DRI score was reported by women having combined symphysis pain and bilateral posterior pain. The multivariate analyses showed that results from P4 and ASLR contributed independently to DRI. Taken together, pain location combined with responses to P4 and ASLR tests are relevant when evaluating affliction in pregnant women with possible PGP.

Pelvic girdle pain: potential risk factors in pregnancy in relation to disability and pain intensity three months postpartum.

The objective of this prospective cohort study was to examine how results of clinical tests on women with pelvic girdle pain (PGP) in late pregnancy were associated with disability and pain intensity 12 weeks postpartum controlling for socio-demographical and psychological factors. Out of the 283 women clinically examined in gestation week 30, 179 were considered afflicted from PGP and constituted the study sample. Potential risk factors were assessed by questionnaires (at inclusion and in gestation week 30) and clinical examination in gestation week 30. The clinical examination included pain provocation tests for the pelvis as well as the active straight leg raise test. We used pain intensity and disability (disability rating index, DRI) as response variables, derived from questionnaires 12 weeks postpartum. Using multivariable linear regression analyses, sum of pain provocation tests and pre-pregnancy low back pain (LBP) were significantly associated with DRI 12 weeks postpartum. Furthermore, sum of pain provocation tests and number of pain sites were significantly associated with pain intensity. In conclusion, we found that when including results of clinical tests as risk factors together with socio-demographical and psychological factors in multivariable regression models, the clinical risk factors are the ones that remain significant. These results are of clinical importance because they seem to have the potential to identify women with a poor prognosis.

Pelvic girdle pain - associations between risk factors in early pregnancy and disability or pain intensity in late pregnancy: a prospective cohort study

BackgroundRecent studies have shown high prevalence rates for pelvic girdle pain (PGP) in pregnancy. Some risk factors for developing PGP have been suggested, but the evidence is weak. Furthermore there is almost no data on how findings from clinical examinations are related to subsequent PGP. The main purpose for this study was to study the associations between socio-demographical, psychological and clinical factors measured at inclusion in early pregnancy and disability or pain intensity in gestation week 30.MethodsThis is a prospective cohort study following women from early to late pregnancy. Eligible women were recruited at their first attendance at the maternity care unit. 268 pregnant women answered questionnaires and underwent clinical examinations in early pregnancy and in gestation week 30. We used scores on disability and pain intensity in gestation week 30 as outcome measures to capture the affliction level of PGP. Multiple linear regression analysis was used to study the associations between potential risk factors measured in early pregnancy and disability or pain intensity in gestation week 30.ResultsSelf-reported pain locations in the pelvis, positive posterior pelvic pain provocation (P4) test and a sum of pain provocation tests in early pregnancy were significantly associated with disability and pain intensity in gestation week 30 in a multivariable statistic model. In addition, distress was significantly associated with disability. The functional active straight leg raise (ASLR) test, fear avoidance beliefs and the number of pain sites were not significantly associated with either disability or pain intensity.ConclusionsThe results suggest that a clinical examination, including a few tests, performed in early pregnancy may identify women at risk of a more severe PGP late in pregnancy. The identification of clinical risk factors may provide a foundation for development of targeted prevention strategies.

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

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

Assessments of lumbar flexion range of motion: intertester reliability and concurrent validity of 2 commonly used clinical tests.

Study Design. Cross-sectional. Objective. To compare intertester reliability and concurrent validity of 2 frequently used methods for assessing lumbar flexion range of motion: the fingertip-to-floor distance (FFD) test and the modified Schober (mSchober) test. Summary of Background Data. An assessment of lumbar flexion range of motion is often incorporated in the clinical evaluation of patients with low back pain, as well as in clinical studies when examining the effects of different therapies on these patients. In both cases, the validity and reliability of assessment methods are important. Methods. The FFD test and the mSchober test were used in a heterogeneous study sample (n = 98) including patients with low back pain, pelvic girdle pain, and individuals without pain in either of these areas. Each participant was examined by 2 of 3 randomly selected assessors on the same day. Intraclass correlation coefficient3,1, together with the Bland and Altman plot, were used to examine intertester reliability. Absolute reliability was calculated by the smallest detectable change. The relationship between the 2 tests was measured using Pearson correlation coefficient (r), which was used as the measure of concurrent validity. Results. The FFD test and the mSchober test showed an intraclass correlation coefficient of 0.93 and 0.77, and a smallest detectable change of 9.8 and 1.8 cm, respectively. There was a medium negative correlation between the 2 tests; an increase in the mSchober test resulted in a decrease in the FFD test (r = −0.47, P ⩽ 0.001). Conclusion. In our heterogeneous study sample, the FFD and the mSchober test showed excellent intertester reliability but with a relatively large smallest detectable change. However, the medium correlation between these 2 tests to measure lumbar flexion range of motion indicates that they do not fully assess the same phenomenon and hence should be used in combination when examining patients. Level of Evidence: 2

Fatigue in adults with Marfan syndrome, occurrence and associations to pain and other factors.

This study aims to investigate how fatigue affects adults with verified Marfan syndrome (MFS) in their daily lives, by examining fatigue levels and prevalence of severe fatigue compared to the general Norwegian population and individuals with other comparable chronic conditions. We investigated associations between socio‐demographic characteristics, Marfan‐related health problems, pain and fatigue. A cross‐sectional study was conducted, using a postal questionnaire including the Fatigue Severity Scale (FSS) and questions on socio‐demographic characteristics, Marfan‐related health problems and pain. One hundred seventeen persons with MFS were invited to participate, 73 answered (62%). Participants reported significantly higher FSS scores and prevalence of severe fatigue compared to the general Norwegian population and patients with rheumatoid arthritis (RA), but lower than for other chronic conditions. Participants with chronic pain reported higher fatigue scores than those without chronic pain. Participants on disability benefits reported higher fatigue scores than participants who were working or enrolled in higher education. Marfan‐related health problems like aortic dissection and use of blood pressure medication were not significantly associated with fatigue. In multivariable regression analyses chronic pain and employment status were significantly associated with fatigue. The final multivariable model explained 24% of the variance in fatigue scores. Our results show that fatigue is common in MFS patients and that it interferes with their daily lives. Chronic pain and employment status show significant associations to fatigue. This implies that fatigue is important to address when meeting MFS patients in clinical practice. There is need for more research on fatigue in Marfan syndrome.

Unpacking the process of interpretation in evidence-based decision making.

Evidence-based medicine (EBM) has promoted the conscientious and systematic use of the best available scientific evidence in clinical decision making [1]. From an EBM point of view, only experimental evidence, especially results from randomized controlled trials and meta-analyses of trial results, count as strong evidence. Experiential evidence based upon expert opinion is classified as weak and placed at the bottom of the evidence hierarchy. EBM is often contrasted with traditional clinical medicine which considered pathophysiological reasoning and expert knowledge as the principal sources of clinical decision making. In a recently published article in Journal of Evaluation in Clinical Practice, Jeannette Hofmeijer describes EBM as a revision of medical epistemology and points to the neglected role of expert opinion and the lack of focus on the principles of reasoning underpinning EMB [2]. More specifically, she shows how EBM involves important processes of interpretation. Hofmeijer is mainly concerned with the role of interpretation in the production of scientific knowledge within the EBM tradition, and she illustrates how the quest for evidence relies upon interpretation both in formulating a hypothesis and in accepting the accumulated evidence as sufficient. We will argue a related but still different perspective demonstrating the principles of reasoning involved in the integration of experimental and experiential knowledge in clinical decisions and the role of interpretation in this respect. The goal of EBM is, according to Sackett et al., the integration of (1) clinical experience and expertise; (2) scientific evidence; and (3) patient values and preferences to provide high-quality services [1]. However, a weakness of EBM is the lack of guidance on how to combine the main knowledge components of the model. The EBM literature says little about how to create a fruitful interaction between research, clinical expertise and patient preferences. Although the principal aim of EBM is to promote more conscientious and systematic clinical decision making, an important element of the model remains black boxed: the principles of reasoning according to which the different knowledge sources are combined. This paper aims to make explicit the often implicit interpretational work involved when scientific evidence, clinical expertise and patient preferences are combined. We believe that better awareness about this process of interpretation can promote better and more trustworthy decision making. Lack of individualization is a recurrent criticism against EBM [3,4]. Randomized clinical trials measure average effects and do not necessarily match the local and complex situation of the individual patient [5]. The need for a situated, practice-based reasoning has been argued, and concepts such as clinical intuition [6], tacit knowledge [7], wisdom [8] and collectively defined ‘mind lines’ [9] have been introduced to challenge a unilateral focus on implementing research evidence. More recently, the literature on patient-centred medicine and shared decision making has emphasized the importance of involving patients in medical decisions and suggested useful methods and approaches [10,11]. In spite of these attempts, the principles of reasoning according to which the knowledge sources are combined and applied are still poorly understood. There are few, if any, models and concepts available which make explicit the interpretational operations involved when combining and applying the knowledge components. We intend to throw light on this process by drawing on a four-step model of knowing developed by the Canadian philosopher Bernard Lonergan [12].

Clinical course of pelvic girdle pain postpartum – Impact of clinical findings in late pregnancy

The aims were to study: prevalence of pelvic girdle pain (PGP) one year postpartum; clinical course of PGP, physical functioning (PF) and bodily pain (BP) (from SF-36, 0 (worst) to 100 (best)) from gestation week (GW) 30 to one year postpartum; and whether findings at GW30 were associated with development of PF and BP from GW30 to one year postpartum. 215 pregnant women were followed from GW30 to one year postpartum. Clinical examination and questionnaire were used at GW30, questionnaire only were used at 12 weeks and one year postpartum. The women were categorised by GW30 clinical variables: self-reported PGP, pain locations in the pelvis and response to two clinical tests. Linear mixed models for repeated measures were used to study PF and BP during follow-up, within the categories of clinical variables. PGP prevalence remained unchanged from 12 weeks to one year postpartum (31-30%). PF and BP scores improved markedly from GW30 to 12 weeks postpartum, and marginally thereafter. Median PF scores were 70, 95 and 100 at GW30, 12 weeks and one year postpartum, respectively. Corresponding median BP scores were 52, 84 and 84. We found significant interactions between each clinical variable and time (P ≤ 0.01) for PF and BP. The most afflicted women at GW30 experienced largest improvement. Despite high PGP prevalence one year postpartum, most women recovered in terms of PF and BP scores. Unfavourable clinical course postpartum did not appear to depend on self-reported PGP, pain locations in the pelvis, or response to clinical tests at GW30.