Jan Mens

Efficacy of epidural steroid injections for low-back pain and sciatica: a systematic review of randomized clinical trials

&NA; The purpose of the study was to assess the efficacy of epidural steroid injections for low‐back pain. Data was obtained using computer‐aided search of published randomized clinical trials and assessment of the methods of the studies. Twelve randomized clinical trials evaluating epidural steroid injections were identified. Data was extracted based on scores for quality of the methods, using 4 categories (study population, interventions, effect measurement, and data presentation and analysis) and the conclusion of the author(s) with regard to the efficacy of epidural steroid injections. Method scores of the trials ranged from 17 to 72 points (maximum 100 points). Eight trials showed method scores of 50 points or more. Of the 4 best studies (> 60 points), 2 reported positive outcomes and 2 reported negative results. Overall, 6 studies indicated that the epidural steroid injection was more effective than the reference treatment and 6 reported it to be no better or worse than the reference treatment. There appeared to be no relationship between the methodological quality of the trials and the reported outcomes. In conclusion, there are flaws in the design of most studies. The best studies showed incosistent results of epidural steroid injections. The efficacy of epidural steroid injections has not yet been established. The benefits of epidural steroid injections, if any, seem to be of short duration only. Future research efforts are warranted, but more attention should be paid to the methods of the trials.

Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy.

Study Design. A cross-sectional analysis was performed in a group of women meeting strict criteria for posterior pelvic pain since pregnancy (PPPP). The scores on the Active Straight Leg Raise Test (ASLR test) were compared with the scores of healthy controls. Objectives. To develop a new diagnostic instrument for use in patients with PPPP. The objectives of the present study were to assess the validity and reliability of the ASLR test. Summary of Background Data. Various diagnostic tools are used to diagnose PPPP, but there is still a need for simple tests with high reliability, sensitivity, and specificity. Methods. Reliability of the ASLR test was assessed in a group of 50 women with lumbopelvic pain of various etiologies and various degrees of severity. Sensitivity was assessed in 200 patients with PPPP and specificity in 50 healthy women. Sensitivity and specificity of the ASLR test were compared with the posterior pelvic pain provocation test (PPPP test). Results. The test–retest reliability measured with Pearson’s correlation coefficient between the two ASLR scores 1 week apart was 0.87. The intraclass correlation coefficient (ICC) was 0.83. Pearson’s correlation coefficient between the scores of the patient and the scores of a blinded assessor was 0.78; the ICC was 0.77. In the patient group, the ASLR score ranged from 0–10; in the control group it ranged from 0–2. The best balance between specificity and sensitivity was found when scores 1–10 are designated as positive and zero as negative. With this cut-off point sensitivity of the test was 0.87 and specificity was 0.94. The sensitivity of the ASLR test is higher than the sensitivity of the PPPP test; an advantage of the ASLR test is the simplicity of measuring the score. Conclusion. The ASLR test is a suitable diagnostic instrument to discriminate between patients who are disabled by PPPP and healthy subjects. The test is easy to perform; reliability, sensitivity, and specificity are high. It seems that the integrity of the function to transfer loads between the lumbosacral spine and legs is tested by the ASLR test.

The active straight leg raising test and mobility of the pelvic joints.

Abstract Objective signs to assess impairment in patients who are disabled by peripartum pelvic girdle pain hardly exist. The purpose of this study was to develop a clinical test to quantify and qualify disability in these patients. The study examined the relationship between impaired active straight leg raising (ASLR) and mobility of pelvic joints in patients with peripartum pelvic girdle pain, focusing on (1) the reduction of impairment of ASLR when the patient was wearing a pelvic belt, and (2) motions between the pubic bones measured by X-ray examination when the patient was standing on one leg, alternating left and right. Twenty-one non-pregnant patients with peripartum pelvic girdle pain in whom pain and impairment of ASLR were mainly located on one side were selected. ASLR was performed in the supine position, first without a pelvic belt and then with a belt. The influence of the belt on the ability to actively raise the leg was assessed by the patient. Mobility of the pelvic joints was radiographically visualized by means of the Chamberlain method. Assessment was blinded. Ability to perform ASLR was improved by a pelvic belt in 20 of the 21 patients (binomial two-tailed P = 0.0000). When the patient was standing on one leg, alternating the symptomatic side and the reference side, a significant difference between the two sides was observed with respect to the size of the radiographically visualized steps between the pubic bones (binomial two-tailed P = 0.01). The step at the symptomatic side was on average larger when the leg at that side was hanging down than when the patient was standing on the leg at that side. Impairment of ASLR correlates strongly with mobility of the pelvic joints in patients with peripartum pelvic girdle pain. The ASLR test could be a suitable instrument to quantify and qualify disability in diseases related to mobility of the pelvic joints. Further studies are needed to assess the relationship with clinical parameters, sensitivity, specificity and responsiveness in various categories of patients. In contrast with the opinion of Chamberlain, that a radiographically visualized step between the pubic bones is caused by cranial shift of the pubic bone at the side of the standing leg, it is concluded that the step is caused by caudal shift of the pubic bone at the side of the leg hanging down. The caudal shift is caused by an anterior rotation of the hip bone about a horizontal axis near the sacroiliac joint.

Understanding peripartum pelvic pain. Implications of a patient survey.

Study Design. An analysis was made of the self‐reported medical histories of patients with peripartum pelvic pain. Objectives. To compile an inventory of the disabilities of patients with peripartum pelvic pain, analyze factors associated with the risk for development of the disease, and to formulate a hypothesis on pathogenesis and specific preventive and therapeutic measures. Summary of Background Data. Pregnancy is an important risk factor for development of chronic low back pain. Understanding the pathogenesis of pelvic and low back pain during pregnancy and delivery could be useful in understanding and managing nonspecific low back pain. Methods. By means of a questionnaire, background data were collected among patients of the Dutch Association for Patients With Pelvic Complaints in Relation to Symphysiolysis. Results were compared with the general population. Subgroups were compared with each other. Results. Peripartum pelvic pain seriously interferes with many activities of daily living such us standing, walking, sitting, and all other activities in which the pelvis is involved. Most patients experience a relapse around menstruation and during a subsequent pregnancy. Occurrence of peripartum pelvic pain was associated with twin pregnancy, first pregnancy, higher age at first pregnancy, larger weight of the baby, forceps or vacuum extraction, fundus expression, and a flexed position of the woman during childbirth; a negative association was observed with cesarean section. Conclusions. It is hypothesized that peripartum pelvic pain is caused by strain of ligaments in the pelvis and lower spine resulting from a combination of damage to ligaments (recently or in the past), hormonal effects, muscle weakness, and the weight of the fetus.

The function of the long dorsal sacroiliac ligament: Its implication for understanding low back pain

Study Design In embalmed human bodies the tension of the long dorsal sacroiliac ligament was measured during incremental loading of anatomical structures that are biomechanically relevant. Objectives To assess the function of the long dorsal sacroiliac ligament. Summary of Background Data In many patients with aspecific low back pain or peripartum pelvic pain, pain is experienced in the region in which the long dorsal sacroiliac ligament is located. It is not well known that the ligament can be easily palpated in the area directly caudal to the posterior superior iliac spine. Data on the functional and clinical importance of this ligament are lacking. Methods A dissection study was performed on the sacral and lumbar regions. The tension of the long dorsal sacroiliac ligament (n = 12) was tested under loading. Tension was measured with a buckle transducer. Several structures, including the erector spinae muscle, the posterior layer of the thoracolumbar fascia, the sacrotuberous ligament, and the sacrum, were incrementally loaded (with forces of 0‐50 newtons). The sacrum was loaded in two directions, causing nutation (ventral rotation of the sacrum relative to the iliac bones) and counternutation (the reverse). Results Forced nutation in the sacroiliac joints diminished the tension and forced counternutation increased the tension. Tension in the long dorsal sacroiliac ligament increased during loading of the ipsilateral sacrotuberous ligament and erector spinae muscle. The tension decreased during traction to the gluteus maximus muscle. Tension also decreased during traction to the ipsilateral and contralateral posterior layer of the thoracolumbar fascia in a direction simulating contraction of the latissimus dorsi muscle. Conclusions The long dorsal sacroiliac ligament has close anatomical relations with the erector spinae muscle, the posterior layer of the thoracolumbar fascia, and a specific part of the sacrotuberous ligament (tuberoiliac ligament). Functionally, it is an important link between legs, spine, and arms. The ligament is tensed when the sacroiliac joints are counternutated and slackened when nutated. The reverse holds for the sacrotuberous ligament. Slackening of the long dorsal sacroiliac ligament can be counterbalanced by both the sacrotuberous ligament and the erector muscle. Pain localized within the boundaries of the long ligament could indicate among other things a spinal condition with sustained counternutation of the sacroiliac joints. In diagnosing patients with aspecific low back pain or peripartum pelvic pain, the long dorsal sacroiliac ligament should not be neglected. Even in cases of arthrodesis of the sacroiliac joints, tension in the long ligament can still be altered by different structures.

Validity of the active straight leg raise test for measuring disease severity in patients with posterior pelvic pain after pregnancy

Study Design. A cross-sectional analysis was performed with a group of women meeting strict criteria for posterior pelvic pain after pregnancy. The active straight leg raise test and common severity measurement scales of lumbopelvic pain were scored. Objective. To assess the validity of the active straight leg raise test as a disease severity scale for patients with posterior pelvic pain after pregnancy. Summary of Background Data. Various diagnostic tools are used to measure disease severity in patients with posterior pelvic pain after pregnancy, but simple tests with high reliability and validity still are needed. Methods. The investigation was performed with 200 women who had posterior pelvic pain after pregnancy. The validity of the active straight leg raise test as a severity scale was investigated by comparing the test score with the medical history, scores on self-reported disability scales, pain and tiredness, and pain provocation tests. The usefulness of the active straight leg raise test as a severity scale was compared with that of the Québec Back Pain Disability Scale. The influence of several demographic and anthropometric variables on the active straight leg raise score was investigated. Results. The active straight leg raise score ranged from 0 to 10 and correlated as expected with all severity scales. The correlation between the scores on the active straight leg raise test and the Québec Back Pain Disability Scale was 0.70. No association was found between the active straight leg raise score and age, parity, duration of the postpartum period, height, or weight. Conclusion. The active straight leg raise test can be recommended as a disease severity scale for patients with posterior pelvic pain after pregnancy.

Possible role of the long dorsal sacroiliac ligament in women with peripartum pelvic pain

Background.  To enhance the understanding of the pathophysiology of women with peripartum pelvic pain, it is necessary to couple anatomical insights with relevant clinical research. In this context, the long dorsal sacroiliac ligament is especially of interest because it was noticed that women diagnosed with peripartum pelvic pain frequently experience pain within the boundaries of this ligament.

Efficacy of non-steroidal anti-inflammatory drugs for low back pain: a systematic review of randomised clinical trials

PURPOSE To assess the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) for low back pain. DATA SOURCES Computer aided search of published randomised clinical trials and assessment of the methods of the studies. STUDY SELECTION 26 randomised clinical trials evaluating NSAIDs for low back pain were identified. DATA EXTRACTION Score for quality (maximum = 100 points) of the methods based on four categories: study population; interventions; effect measurement; data presentation and analysis. Determination of success rate per study group and evaluation of different contrasts. Statistical pooling of placebo controlled trials in similar patient groups and using similar outcome measures. RESULTS The methods scores of the trials ranged from 27 to 83 points. NSAIDs were compared with placebo treatment in 10 studies. The pooled odds ratio in four trials comparing NSAIDs with placebo after one week was 0.53 (95% confidence intervals 0.32 to 0.89) using the fixed effect model, indicating a significant effect in favour of NSAIDs compared with placebo. In nine studies NSAIDs were compared with other (drug) therapies. Of these, only two studies reported better results of NSAIDs compared with paracetamol with and without dextropropoxyphene. In the other trials NSAIDs were not better than the reference treatment. In 11 studies different NSAIDs were compared, of which seven studies reported no differences in effect. CONCLUSIONS There are flaws in the design of most studies. The pooled odds ratio must be interpreted with caution because the trials at issue, including the high quality trials, did not use identical outcome measures. The results of the 26 randomised trials that have been carried out to date, suggest that NSAIDs might be effective for short-term symptomatic relief in patients with uncomplicated low back pain, but are less effective or ineffective in patients with low back pain with sciatica and patients with sciatica with nerve root symptoms.

A new view on adduction-related groin pain.

Objective:To evaluate the hypothesis that groin pain at isometric hip adduction may not be caused by adductor tendinitis. Design:Symptoms and signs in a cross-sectional analysis. Setting:Multicenter primary care institutes. Subjects:Athletes with pain in the groin(s), provoked by playing sports, with a duration of complaints for at least 1 month and pain provocation on isometric adduction of the hips. Interventions:Data on medical history and symptoms were collected. Pain provocation tests and strength measurements were performed. A pelvic belt was used to investigate its influence on pain provocation and strength. Main Outcome Measurements:Site of the pain, duration of the complaints, severity of the pain, hip adduction force, pain at isometric hip adduction, restriction to perform active straight leg raising, influence of a pelvic belt on pain and strength of isometric hip adduction and straight leg raising. Results:Groin pain was bilateral in 41%; pain was also located at the posterior aspect of the pelvis in 32%; Active Straight Leg Raise (ASLR) test was positive in 39%. When tested with a pelvic belt, the weakness of ASLR improved in all with a positive ASLR, hip adduction force increased significantly in 39% and pain at forceful isometric hip adduction decreased in 68%. Conclusions:Groin pain at isometric hip adduction may not be caused by adductor tendinitis in a large proportion of athletes with adduction-related groin pain. The results suggest that adduction-related groin pain with a positive belt test may be treated by stabilization of the pelvis.

Mobility of the pelvic joints in pregnancy-related lumbopelvic pain: a systematic review.

About 45% of all pregnant women and 25% of all women postpartum suffer from pelvic girdle pain and/or low back pain (PLPP). It has been suggested that increased motion of the three joints in the pelvic ring is one of the causes of PLPP. However, in spite of the availability of high technology the relation between enlarged motion of the pelvic joints and pain remains unclear. This article presents 14 studies on this topic, of which 8 are of sufficient quality to draw conclusions. The conclusion is that, during the last months of pregnancy and the first 3 weeks after delivery, motion of the pelvic girdle joints is 32–68% larger in patients with PLPP than in healthy controls. The overlap in the range of symphyseal motion between PLPP patients and healthy controls is too large to use motion as a diagnostic tool in individual cases. The findings support the idea that enlarged motion is one of the factors that causes PLPP and justifies treatment with measures to reduce this motion. Target Audience: Obstetricians & Gynecologists, Family Physicians Leaning Objectives: After completion of this article, the reader should be able to explain the presumptive mechanisms for pregnancy-related low back pain, identify the difficulties with literature regarding objective diagnostic criteria for pregnancy-related low back pain, and outline three possible treatment strategies for pregnancy-related low back pain.