New Anatomical Concepts regarding Pubic-Related Groin Pain: A Dissection Study.

OBJECTIVE: Pubis-related groin pain remains a difficult topic in orthopedic and sports medicine. A better understanding of the anatomy of the adductors and the pubic ligaments is necessary. The aim of this study is to map all the musculotendinous attachments to the pubic ligaments and to investigate in detail all the possible inter-adductor fusions. METHODS: The pubic symphyses were dissected in eight male and fourteen female embalmed cadavers (mean age 85 years), focusing on the fusion between the adductors, pubic ligaments, and musculotendinous attachments at the pubic ligaments. The 95% confidence intervals for the prevalence of the different conjoint tendons and tendon attachment to ligament were calculated. RESULTS: The presence of three types of conjoint tendons was found: adductor brevis and gracilis (AB/G) 90.9 [72.2 - 97.5]%; adductor brevis and adductor longus (AB/AL) 50.0 [30.7 - 69.3]%; adductor longus and gracilis (AL/G) 50.0 [30.7 - 69.3]%. The AL, AB and G were in every cadaver attached to the anterior pubic ligament (APL). 64% of the AB and 100% of the G were attached to the inferior pubic ligament (IPL). CONCLUSION: The proximal anatomy of the adductors is more complex than initially described. This study identified three possible conjoint tendons between the proximal adductors. The AB/G conjoint tendon was significantly more present than the AB/AL or AL/G conjoint tendon. The IPL has attachments only from the AB and G. Rectus Abdominis (RA) and AL were not attached to IPL. Mapping the musculotendinous attachments on the pubic ligaments creates more clarity on the pathophysiology of lesions in this area.

New insights into the musculotendinous and ligamentous attachments at the pubic symphysis: A systematic review.

OBJECTIVE: Collection and meta-analysis of all relevant anatomical studies related to the pubic symphysis to provide a state of the art review of its musculotendinous and ligamentous attachments from 2010 to date. METHODS: A systematic search of published literature databases (PubMed, Web of Science and Embase) was conducted according to the PRISMA guidelines from January 2010 up until now. All papers investigating the anatomy of the musculotendinous attachments of the pubis and the pubic ligaments were eligible. Methodological quality was assessed using the Quality Appraisal for Cadaveric Studies (QUACS scale). A narrative analysis approach was adopted to synthesize the findings. RESULTS: After screening and review of 1313 papers, a total of six studies investigating the anatomy of the pubic ligaments and tendons were included. Of the six articles included in this systematic review, five articles performed a macroscopic anatomical dissection, three articles performed a microscopic (histological) study, and one article combined microscopic examination with an MRI imaging examination. The anatomy of the pubic symphysis was examined in 76 anatomical cadavers (60 embalmed, 16 fresh frozen). In total 44 male cadavers (58%), 28 female cadavers (37%) and four cadavers whose gender was not stated were dissected. CONCLUSION: The age-old accepted concept of the fusion of the rectus abdominis with the adductor longus via the aponeurotic plate is outdated. New anatomical concepts like the pyramidalis-anterior pubic ligament-adductor longus complex (PLAC), recto-gracilis tendon, fusion of adductor brevis with gracilis, etc. are recently introduced. The awareness of anatomy and morphology of the pubic ligaments plays a significant role in understanding the diagnosis and treatment of groin pain.

The identification of preliminary prognostic indicators that predict treatment response for exercise therapy in patients with nonspecific chronic low back pain: A multiple-arm cohort study design.

BACKGROUND: For patients with nonspecific chronic low back pain (CLBP), exercise therapy is stated to be the most effective intervention strategy but it is unclear which kind of exercise therapy is most beneficial. OBJECTIVE: To identify preliminary prognostic indicators that predict outcome for exercise therapy in patients with nonspecific CLBP. METHODS: Patients were recruited in two hospitals and received 18 intervention sessions: stabilization therapy, isometric training therapy or a combination therapy. The primary outcome measure was the change in the Modified Low Back Pain Disability Questionnaire after nine weeks. RESULTS: A total of 59 patients completed the study which represents a statistical power of 90%. In total, 30 patients were categorized as having treatment success and 29 as treatment failure. After using regression analyses to determine the association between standardized examination variables and treatment response status, prognostic indicators were identified for predicting therapy success (positive likelihood ratio [LR], 3.8) and failure (negative LR, 0.19). CONCLUSIONS: The most important variables were the prone instability test, pelvic tilt test, straight leg raise, body weight, visual analogue scale and the short form 36 health survey.

Benefits and Disadvantages of Electronic Patient-reported Outcome Measures: Systematic Review.

BACKGROUND: Patient-reported outcome measures (PROMs) are important in clinical practice and research. The growth of electronic health technologies provides unprecedented opportunities to systematically collect information via PROMs. OBJECTIVE: The aim of this study was to provide an objective and comprehensive overview of the benefits, barriers, and disadvantages of the digital collection of qualitative electronic patient-reported outcome measures (ePROMs). METHODS: We performed a systematic review of articles retrieved from PubMED and Web of Science. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed during all stages. The search strategy yielded a total of 2333 records, from which 32 met the predefined inclusion and exclusion criteria. The relevant ePROM-related information was extracted from each study. RESULTS: Results were clustered as benefits and disadvantages. Reported benefits of ePROMs were greater patient preference and acceptability, lower costs, similar or faster completion time, higher data quality and response rates, and facilitated symptom management and patient-clinician communication. Tablets were the most used ePROM modality (14/32, 44%), and, as a platform, Web-based systems were used the most (26/32, 81%). Potential disadvantages of ePROMs include privacy protection, a possible large initial financial investment, and exclusion of certain populations or the "digital divide." CONCLUSIONS: In conclusion, ePROMs offer many advantages over paper-based collection of patient-reported outcomes. Overall, ePROMs are preferred over paper-based methods, improve data quality, result in similar or faster completion time, decrease costs, and facilitate clinical decision making and symptom management. Disadvantages regarding ePROMs have been outlined, and suggestions are provided to overcome the barriers. We provide a path forward for researchers and clinicians interested in implementing ePROMs. TRIAL REGISTRATION: PROSPERO CRD42018094795; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=94795.

Convergent validity of clinical tests which are hypothesized to be associated with physical functioning in patients with nonspecific chronic low back pain.

BACKGROUND: Up until now, assessment of physical functioning in patients with low back pain is mostly completed with the use of patient reported outcome measurements (PROMs). There are however limitations to the use of these measurements such as inaccuracies due to recall bias, social desirability bias and errors in self-observation. A recent review indicated seven clinical tests as having good test retest reliability. These tests can now be further investigated for their validity. OBJECTIVES: To investigate the convergent validity of seven clinical tests (extensor endurance, flexor endurance, 5 minute walking, 50 foot walking, shuttle walk, sit to stand and the loaded forward reach test) in patients with nonspecific chronic low back pain (CLBP). METHODS: Patients filled in a series of PROMs and performed all included clinical tests during a specific test moment. Convergent validity was firstly investigated by assessing Pearson correlations between the seven included clinical tests and secondly by assessing the correlations between the predefined PROMs and the clinical tests. RESULTS: Twenty-five patients were included in this study representing a power of 84%. The best overall evidence for convergent validity could be identified for the extensor endurance, sit to stand and the loaded forward reach test. However, when all study results were combined, evidence for convergent validity was found for all included clinical tests except for the shuttle walk test. CONCLUSION: The current study was able to provide evidence that multimethod and multidimensional approaches should be used as a more comprehensive assessment of physical function in patients with nonspecific CLBP.

The Modified Low Back Pain Disability Questionnaire: Reliability, Validity, and Responsiveness of a Dutch Language Version.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: The goal of this study is to translate the English version of the Modified Low Back Pain Disability Questionnaire (MDQ) into a Dutch version and investigate its clinimetric properties for patients with nonspecific chronic low back pain (CLBP). SUMMARY OF BACKGROUND DATA: Fritz et al (2001) developed a modified version of the Oswestry Disability Questionnaire (ODI) to assess functional status and named it the MDQ. In this version, a question regarding employment and homemaking ability was substituted for the question related to sex life. Good clinimetric properties for the MDQ were identified but up until now it is not clear whether the clinimetric properties of the MDQ would change if it was translated into a Dutch version. METHODS: Translation of the MDQ into Dutch was done in 4 steps. Test-retest reliability was investigated using the intraclass correlation coefficient (ICC) model. Validity was calculated using Pearson correlations and a 2-way analysis of variance for repeated measures. Finally, responsiveness was calculated with the area under the curve (AUC), minimal detectable change (MDC), and the standardized response mean (SRM). RESULTS: A total of 80 completed questionnaires were collected in 3 different hospitals and a total of 43 patients finished a 9 weeks intervention period, completing the retest. Test-retest reliability was excellent with an ICC of 0.89 (95% confidence interval [CI], 0.74-0.95). To confirm the convergent validity, the MDQ answered all predefined hypothesises (r = -0.65-0.69/P = 0.01-0.00) and good results for construct validity were found (P = 0.02). The MDQ had an AUC of 0.64 (95% confidence interval [CI], 0.47-0.81), an MDC of 8.80 points, and a SRM of 0.65. CONCLUSION: The Dutch version of the MDQ shows good clinimetric properties and is shown to be usable in the assessment of the functional status of Dutch-speaking patients with nonspecific CLBP. LEVEL OF EVIDENCE: 3.

Reliability of physical functioning tests in patients with low back pain: a systematic review.

PURPOSE: The aim of this study was to provide a comprehensive overview of physical functioning tests in patients with low back pain (LBP) and to investigate their reliability. DATA SOURCES: A systematic computerized search was finalized in four different databases on June 24, 2017: PubMed, Web of Science, Embase, and MEDLINE. STUDY SELECTION: Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed during all stages of this review. Clinical studies that investigate the reliability of physical functioning tests in patients with LBP were eligible. The methodological quality of the included studies was assessed with the use of the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist. To come to final conclusions on the reliability of the identified clinical tests, the current review assessed three factors, namely, outcome assessment, methodological quality, and consistency of description. DATA SYNTHESIS: A total of 20 studies were found eligible and 38 clinical tests were identified. Good overall test-retest reliability was concluded for the extensor endurance test (intraclass correlation coefficient [ICC]=0.93-0.97), the flexor endurance test (ICC=0.90-0.97), the 5-minute walking test (ICC=0.89-0.99), the 50-ft walking test (ICC=0.76-0.96), the shuttle walk test (ICC=0.92-0.99), the sit-to-stand test (ICC=0.91-0.99), and the loaded forward reach test (ICC=0.74-0.98). For inter-rater reliability, only one test, namely, the Biering-Sörensen test (ICC=0.88-0.99), could be concluded to have an overall good inter-rater reliability. None of the identified clinical tests could be concluded to have a good intrarater reliability. CONCLUSIONS: Further investigation should focus on a better overall study methodology and the use of identical protocols for the description of clinical tests. The assessment of reliability is only a first step in the recommendation process for the use of clinical tests. In future research, the identified clinical tests in the current review should be further investigated for validity. Only when these clinimetric properties of a clinical test have been thoroughly investigated can a final conclusion regarding the clinical and scientific use of the identified tests be made.

Inter- and Intrarater Reliability of Clinical Tests Associated With Functional Lumbar Segmental Instability and Motor Control Impairment in Patients With Low Back Pain: A Systematic Review.

OBJECTIVES: To provide a comprehensive overview of clinical tests associated with functional lumbar segmental instability and motor control impairment in patients with low back pain (LBP), and to investigate their intrarater reliability, interrater reliability, or both. DATA SOURCES: A systematic computerized search was conducted on December 1, 2015, in 4 different databases (starting search year is indicated in parentheses, with articles included from that year until December 1, 2015): PubMed (1972-), Web of Science (1955-), Embase (1947-), and MEDLINE (1946-). STUDY SELECTION: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed during design, search, and reporting stages of this review. The included population comprised patients with primary LBP. DATA EXTRACTION: Data were extracted as follows: (1) description and scoring of the clinical tests; (2) population characteristics; (3) inclusion and exclusion criteria; (4) description of the used procedures; (5) results for both intra- and interrater reliability; and eventually (6) notification on used statistical method. The risk of bias of the included articles was assessed with the use of the COnsensus-based Standards for the selection of health Measurement INstruments checklist. DATA SYNTHESIS: A total of 16 records were eligible, and 30 clinical tests were identified. All included studies investigated interrater reliability, and 3 studies investigated intrarater reliability. The identified interrater reliability scores ranged from poor to very good (κ=-.09 to .89; intraclass correlation coefficient, .72-.96), and the intrarater reliability scores ranged from fair to very good (κ=.51-.86). CONCLUSIONS: Three clinical tests (aberrant movement pattern, prone instability test, Beighton Scale) could be identified as having an adequate interrater reliability. No conclusions could be made for intrarater reliability. However, further research should focus on better study designs, provide an overall agreement for uniformity and interpretation of clinical tests, and should implement research regarding validity.

Identification of Preliminary Prognostic Indicators for Back Rehabilitation in Patients With Nonspecific Chronic Low Back Pain: A Retrospective Cohort Study.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: Our aim was to identify prognostic indicators for success after a back rehabilitation program (BR) in patients with nonspecific chronic low back pain (CLBP). SUMMARY OF BACKGROUND DATA: Exercise therapy is recommended for patients with nonspecific CLBP. Consensus on the type of exercises is lacking, largely due to heterogeneity in the studied patient samples. The identification of subgroups through the identification of prognostic indicators is therefore needed. To our knowledge, no specific prognostic indicators for BR are described in the literature. METHODS: We retrospectively analyzed the patient files of 49 nonspecific CLBP patients who followed a BR. Patients were selected based on predefined in- and exclusion criteria. All underwent 43 therapy sessions, two times per week. Primary outcome measure and dependent variable was the change in Oswestry Disability Questionnaire (ODI) score. Potential predictive variables were tested for association with the primary outcome and consequently entered in a logistic regression model. RESULTS: In this study, the posthoc calculated power was 91%. Based on the change in ODI scores, 24 patients were considered as therapy success (eight points or 50% improvement on change in ODI score) and 25 as therapy failure. Univariate and multiple regression analysis revealed only one significant prognostic indicator: higher scores on the physical function subscale of the SF36 (PF-SF36) corresponded with high risk of therapy failure (odds ratio of 0.791 (95% CI =  .662-0.945); sensitivity of 0.79, and specificity of 0.68). CONCLUSION: Potentially, the preset exercises of the BR in this study design were not appropriate for the identified subgroup. The results of this study should be replicated in a RCT design that conforms to the necessary methodological steps in the identification of prognostic indicators and clinical prediction rules (CPRs).

Derivation and validation phase for the development of clinical prediction rules for rehabilitation in chronic nonspecific low back pain patients: study protocol for a randomized controlled trial.

BACKGROUND: There is a consensus that exercise therapy should be used as a therapeutic approach in chronic low back pain (CLBP) but little consensus has been reached about the preferential type of therapy. Due to the heterogeneity of the population no clear effect of specific therapy interventions are found. Probably a specific subgroup of the investigated population will benefit from the intervention and another subgroup will not benefit, looking at the total investigated population no significant effects can be found. Therefore there is a need for the development of clinical prediction rules (CPRs). Objectives for this trial are first, the derivation of CPRs to predict treatment response to three forms of exercise therapy for patients with nonspecific CLBP. Secondly, we aim to validate a CPR for the three forms of exercise therapy for patients with nonspecific CLBP. METHODS/DESIGN: The study design is a randomized controlled trial. Patients with nonspecific CLBP of more than three months duration are recruited at the Antwerp University Hospital (Belgium) and Apra Rehabilitation Hospital. After examination, patients are randomly assigned to one of three intervention groups: motor control therapy, general active exercise therapy and isometric training therapy. All patients will undergo 18 treatment sessions during nine weeks. Measurements will be taken at baseline, nine weeks, six months and at one year. The primary outcome used is the Modified Oswestry Disability Questionnaire score. For each type of exercise therapy a CPR will be derived and validated. For validation, the CPR will be applied to divide each treatment group into two subgroups (matched and unmatched therapy) using the baseline measurements. We predict a better therapeutic effect for matched therapy. DISCUSSION: A randomized controlled trial has not previously been performed for the development of a CPR for exercise therapy in CLBP patients. Only one CPR was described in a single-arm design for motor control therapy in sub-acute non-radicular LBP patients. In this study, a sufficiently large sample will be included in both the derivation and validation phase. TRIAL REGISTRATION: This trial was registered with Clinicaltrials.gov on 10 February 2014, registration number: NCT02063503.