Physical Inactivity Before Surgery for Lumbar Spinal Stenosis Is Associated With Inferior Outcomes at 1-Year Follow-Up: A Cohort Study.

BACKGROUND: Lumbar spinal stenosis (LSS) is a common disorder in older people. Inactivity secondary to the disease state can further increase LSS symptoms. Initial care includes physiotherapy to relieve symptoms and optimize patient function and quality of life. It is currently unclear whether inactivity before surgery for LSS is associated with postoperative outcomes. Our aim was to investigate associations between self-reported exercise before LSS surgery and self-reported outcomes at 1-year follow-up. METHODS: Using a retrospective cohort study design, prospective data were collected from the National Swedish Register for Spine Surgery (Swespine) between September 2006 and December 2012: 11,956 patients diagnosed with LSS completed the 1-year follow-up. The primary outcome measure was the Oswestry Disability Index (ODI). Secondary outcome measures were back and leg pain reported on a visual analog scale (VAS). The independent variable was dichotomized into no regular exercise (NRE) and regular exercise (RE). Adjusted analysis of covariance models were used to analyze differences in outcome improvement between the NRE and RE groups. RESULTS: The mean improvement in the ODI was 15.9 (95% CI, 15.5-16.3) in the NRE group and 19.2 (95% CI, 18.5-19.8) in the RE group (P < 0.001). Improvement in back pain (P < 0.001) and leg pain (P < 0.001) were also inferior in the NRE group compared to the RE group. The NRE group improved 21.8 (95% CI, 21.2-22.5) units in back pain and 28.8 (95% CI, 28.1-29.5) in leg pain on the VAS compared to 25.2 (95% CI, 24.2-26.3) units in back pain and 32.5 (95% CI, 31.3-33.6) in leg pain in the RE group. CONCLUSIONS: Inactivity defined as self-reported NRE before surgery for LSS is associated with worse outcomes 1-year postsurgery compared to patients reporting RE. CLINICAL RELEVANCE: This study is relevant to currently practicing spinal surgeons and spine physiotherapists.

Sexuality and mood changes in women with persistent pelvic girdle pain after childbirth: a case-control study.

BACKGROUND: Pelvic girdle pain is a common problem during pregnancy. For most women, the symptoms cease within the first 3-6 months of giving birth, but in some women the pain persists. In this study we investigate the sexuality and frequency of depressive symptoms in women with persistent pelvic girdle pain after childbirth and in healthy women. METHODS: We conducted a case-control study of women with persistent pelvic girdle pain after childbirth and a control group of healthy women. The frequency of depressive symptoms and sexuality were measured using the self-rating version of the Montgomery-Asberg Depression Rating Scale and the McCoy Female Sexuality Questionnaire. RESULTS: Forty-six women with persistent pelvic girdle pain and thirty-nine healthy women were enrolled. The frequency of depressive symptoms and the total score on female sexuality did not differ between the groups. However, pain during intercourse was more frequent (P < 0.001) in women with persistent pelvic girdle pain and caused them to avoid sexual intercourse frequently (P < 0.001). In multiple linear regression a higher frequency of depressive symptoms was reversely correlated with a lower score on female sexuality (ß = - 0,41, p < 0,001 95% CI -0,6 - -0,22) This association remained after adjusting for obstetric variables and individual characteristics. CONCLUSION: Depressive symptoms and female sexuality were similar between women with persistent pelvic girdle pain after childbirth and healthy controls. However, pain during intercourse and avoidance of sexual intercourse were more frequent among women with pelvic girdle pain.

Anatomical landmarks of the intra-pelvic side-wall as sources of pain in women with and without pregnancy-related chronic pelvic pain after childbirth: a descriptive study.

BACKGROUND: Chronic pelvic pain (CPP) affects 15-24% of women and can have a devastating impact on quality of life. Laparoscopy is often used in the investigation, although in one third of the examinations there is no visible pathology and the women may be dismissed without further investigation. Also, the contribution of skeletal, muscular, periosteal and ligamentous tissues to CPP remains to be further elucidated. The objective of the present study was to compare pain intensity provoked from anatomical landmarks of the intra-pelvic side-wall in women with pregnancy-related CPP after childbirth and women without such pain. METHODS: This is a descriptive study of 36 non-randomly selected parous women with CPP after childbirth and 29 likewise selected parous women after childbirth without CPP. Pain was determined by questionnaire and clinical examination. The primary outcome measure was reported pain intensity provoked on 13 anatomical landmarks of the intra-pelvic side-wall. All women reported their perceived pain intensity for each anatomical landmark on Likert scales and an individual sum score was calculated. RESULTS: Women with chronic pelvic pain were older than women without CPP. At several intra-pelvic landmarks high intensity pain was provoked in women with CPP compared with less intense pain provoked at fewer landmarks in women without low back or pelvic pain (p < 0.0001). The average sum of pain intensity scores was about 4 times higher in women with CPP (1.3) as compared with those without low back or pelvic pain (0.3), p < 0.0001. This association remained when adjusting for the age difference between the pain groups in linear regression analysis. In addition, reported pain intensity at worst past week was independently associated with sum of pain intensity scores. The maximum individual sum of pain intensity scores among women without CPP was exceeded by that of 85% of the women with CPP. CONCLUSIONS: Parous women with CPP after childbirth had a heightened pain intensity over 13 anatomical landmarks during pelvic examination compared with parous women without CPP. These results need to be confirmed in a larger cohort with different types of CPP.

[New routines in orthopedics department yielded more efficient care and more satisfied patients. Physiotherapist and team make the first assessment in new visits to the spine surgeon]. / Nya rutiner på ortopeden gav effektivare vård och nöjdare patienter - Sjukgymnast och team gör första bedömning vid nybesök till ryggkirurg.

There is a shortage of spine surgeons in Sweden. To guarantee the legal right to healthcare, many counties must hire doctors, with increasing costs. In our new out-patient department routine, the majority of the patients are examined by a physiotherapist at their first visit. History taking and clinical and radiographic examinations are discussed in a team conference, and possible candidates for spine surgery are selected for an appointment with a spine surgeon. Furthermore, the patients were more satisfied with the new routine and management plan.

Referred pain patterns provoked on intra-pelvic structures among women with and without chronic pelvic pain: a descriptive study.

OBJECTIVES: To describe referred pain patterns provoked from intra-pelvic structures in women with chronic pelvic pain (CPP) persisting after childbirth with the purpose to improve diagnostics and give implications for treatment. MATERIALS AND METHODS: In this descriptive and comparative study 36 parous women with CPP were recruited from a physiotherapy department waiting list and by advertisements in newspapers. A control group of 29 parous women without CPP was consecutively assessed for eligibility from a midwifery surgery. Inclusion criterion for CPP was: moderate pain in the sacral region persisting at least six months after childbirth confirmed by pelvic pain provocation tests. Exclusion criteria in groups with and without CPP were: persistent back or pelvic pain with onset prior to pregnancy, previous back surgery and positive neurological signs. Pain was provoked by palpation of 13 predetermined intra-pelvic anatomical landmarks. The referred pain distribution was expressed in pain drawings and described in pain maps and calculated referred pain areas. RESULTS: Pain provoked by palpation of the posterior intra-pelvic landmarks was mostly referred to the sacral region and pain provoked by palpation of the ischial and pubic bones was mostly referred to the groin and pubic regions, with or without pain referred down the ipsilateral leg. The average pain distribution area provoked by palpation of all 13 anatomical landmarks was 30.3 mm² (19.2 to 53.7) in women with CPP as compared to 3.2 mm² (1.0 to 5.1) in women without CPP, p< 0.0001. CONCLUSIONS: Referred pain patterns provoked from intra-pelvic landmarks in women with CPP are consistent with sclerotomal sensory innervation. Magnification of referred pain patterns indicates allodynia and central sensitization. The results suggest that pain mapping can be used to evaluate and confirm the pain experience among women with CPP and contribute to diagnosis.

Improved function in women with persistent pregnancy-related pelvic pain after a single corticosteroid injection to the ischiadic spine: a randomized double-blind controlled trial.

BACKGROUND: Pregnancy-related low back and pelvic pain is a worldwide problem. A large proportion of women still experience disabling daily back pain 2 years after childbirth, resulting in major changes in activities and general well-being. In spite of this, the source of pain and effective treatment are uncertain. OBJECTIVE: To evaluate the short-term effects on function of a single corticosteroid injection treatment to the ischiadic spine in women with persistent pregnancy-related pelvic pain (PPPP). METHODS: Thirty-six women were allocated to injection treatment with slow-release triamcinolone and lidocain or saline and lidocain, given once at the sacrospinous ligament insertion on the ischiadic spine bilaterally with follow-up at 4 weeks. Outcome measures were Disability Rating Index (DRI), self-rated functional health (SF-36), gait speed and endurance (6MWT), and strength and endurance of trunk muscles (isometric trunk extensor and flexor tests). RESULTS: Women in the triamcinolone group showed significantly improved DRI (p = 0.046), 6MWT (p = 0.016), and isometric trunk extensor tests (p = 0.004), as compared with the saline group. Close co-variation was shown between improved function and reduced pain intensity. CONCLUSIONS: Improved function was achieved among women with PPPP after a single injection treatment with slow-release corticosteroid. The effect was positively correlated to the reduced pain intensity.

Corticosteroid injection treatment to the ischiadic spine reduced pain in women with long-lasting sacral low back pain with onset during pregnancy: a randomized, double blind, controlled trial.

STUDY DESIGN: Randomized double blind controlled clinical trial. OBJECTIVE: To evaluate the pain relief effect of locally injected corticosteroid treatment in women with long-lasting sacral low back pain with onset during pregnancy. SUMMARY OF BACKGROUND DATA: Pregnancy-related low back pain is a global problem. Almost 1 of 10 women still experienced disabling daily back pain 2 years after childbirth with high impact on the individual, family, and society. On spite of this, the sources of pain and effective treatment are uncertain. METHODS: Thirty-six women were allocated to injection treatment, with slow-release triamcinolone and lidocaine or saline and lidocaine, given at the sacrospinous ligament insertion on the ischiadic spine bilaterally with 4 weeks follow-up time. Primary outcome measure was reported pain intensity on visual analogue scale and secondary outcome measures number of pain-drawing locations and pain-provoking test results. RESULTS.: The triamcinolone treatment group had significantly reduced pain intensity, number of pain locations, and pain-provoking test results between baseline and follow-up as compared with the saline treatment group. The absolute median change of visual analogue scale score in the triamcinolone treatment group was -24 mm and in the saline group +4.5 mm (P < 0.05). A reduced number of pain drawing locations was reported by 16 of 18 women in the triamcinolone group as compared with 10 of 18 in the saline group (P < 0.05). In the triamcinolone treatment group, 17 of 18 women had an improved pain provocation test result as compared with 9 of 18 in the saline treatment group (P < 0.01). CONCLUSION: The anatomic region around the sacrospinous ligament insertion on the ischial spine is suggested to be one source of long-lasting sacral low back pain with onset during pregnancy. The pain was relieved by slow-release corticosteroid injection treatment to the ischial spine.

EMG biofeedback versus topical lidocaine gel: a randomized study for the treatment of women with vulvar vestibulitis.

BACKGROUND: To evaluate the efficacy of electromyographic biofeedback and topical lidocaine treatment for women with vulvar vestibulitis. METHODS: A prospective randomized study where 46 women with vulvar vestibulitis were randomized to receive either electromyographic biofeedback or topical lidocaine treatment for four months. Assessments with vulvar pressure pain thresholds and questionnaires regarding quality of life, psychosocial adjustments, and sexual functioning were made before treatment, after treatment, and at six- and 12-month follow-ups. Nonparametric statistical methods were used to analyze differences in outcomes. RESULTS: Nine women (9/46) dropped out during the treatment period. Both treatments showed significantly improved values for vestibular pressure pain thresholds, quality of life measurements, and sexual functioning at the 12-month follow-up. No differences were found between the two treatment groups. No severe side effects were reported. CONCLUSIONS: Four months' treatment with electromyographic biofeedback and topical lidocaine gave statistically significant improvements on vestibular pain measurements, sexual functioning, and psychosocial adjustments at the 12-month follow-up. No differences in outcome between the two treatments were observed but a larger sample may be needed to obtain significance. The treatments were well tolerated but the compliance to the electromyographic biofeedback training program was low. A combination of both treatments could potentially benefit many women with vulvar vestibulitis.