The role of diet in the pathogenesis and management of irritable bowel syndrome (Review).

Most patients with irritable bowel syndrome (IBS) believe that diet plays a significant role in inducing IBS symptoms and desire to know what foods to avoid. It has been found that the intake of calories, carbohydrates, proteins and fat by IBS patients does not differ from that of the background population. IBS patients were found to avoid certain food items that are rich in fermentable oligo-, di- and monosacharides and polyols (FODMAPs), but they did have a high consumption of many other FODMAP-rich food items. The diet of IBS patients was found to consist of a low calcium, magnesium, phosphorus, vitamin B2 and vitamin A content. There is no consistent evidence that IBS patients suffer from food allergy, nor is there documented evidence that food intolerance plays a role in IBS symptoms. Abnormalities in gut hormones have been reported in IBS patients. As gut hormones control and regulate gastrointestinal motility and sensation, this may explain the abnormal gastrointestinal motility and visceral hypersensitivity reported in these patients. Guidance concerning food management which includes individually based restrictions of FODMAP-rich food items and individual evaluation of the effects of protein-, fat- and carbohydrate-rich/poor diets may reduce IBS symptoms.

Low densities of serotonin and peptide YY cells in the colon of patients with irritable bowel syndrome.

BACKGROUND: The gut hormones are important in regulating gastrointestinal motility. Disturbances in gastrointestinal motility have been reported in patients with irritable bowel syndrome (IBS). Reduced endocrine cell density, as revealed by chromogranin A, has been reported in the colon of IBS patients. AIMS: To investigate a possible abnormality in the colonic endocrine cells of IBS patients. METHODS: A total of 41 patients with IBS according to Rome Criteria III and 20 controls were included in the study. Biopsies from the right and left colon were obtained from both patients and controls during colonoscopy. The biopsies were immunostained for serotonin, peptide YY (PYY), pancreatic polypeptide (PP), entroglucagon, and somatostatin cells. Cell densities were quantified by computerized image analysis. RESULTS: Serotonin and PYY cell densities were reduced in the colon of IBS patients. PP, entroglucagon, and somatostatin-immunoreactive cells were too few to enable reliable quantification. CONCLUSION: The cause of these observations could be primary genetic defect(s), secondary to altered serotonin and/or PYY signaling systems and/or subclinical inflammation. Serotonin activates the submucosal sensory branch of the enteric nervous system and controls gastrointestinal motility and chloride secretion via interneurons and motor neurons. PYY stimulates absorption of water and electrolytes, and inhibits prostaglandin (PG) E2, and vasoactive intestinal peptide, which stimulates intestinal fluid secretion and is a major regulator of the "ileal brake". Although the cause and effect relationship of these findings is difficult to elucidate, the abnormalities reported here might contribute to the symptoms associated with IBS.

Acupuncture as an adjunct to standard treatment for pelvic girdle pain in pregnant women: randomised double-blinded controlled trial comparing acupuncture with non-penetrating sham acupuncture.

OBJECTIVE: To investigate whether acupuncture has a greater treatment effect than non-penetrating sham acupuncture in women with pelvic girdle pain (PGP) during pregnancy. DESIGN: Randomised double-blinded controlled trial. SETTING: East Hospital, Gothenburg, and 25 antenatal primary care units in the region of Västra Götaland, Sweden. POPULATION: A total of 115 pregnant women with a clinical diagnosis of PGP who scored > or =50 on a 100-mm visual analogue scale (VAS). METHOD: Women were randomly allocated to standard treatment plus acupuncture or to standard treatment plus non-penetrating sham acupuncture for 8 weeks. MAIN OUTCOME MEASURES: Main outcome measure was pain. Secondary outcomes were frequency of sick leave, functional status, discomfort of PGP, health-related quality of life and recovery of severity of PGP as assessed by the independent examiner. RESULTS: After treatment, median pain decreased from 66 to 36 in the acupuncture group and from 69 to 41 in the non-penetrating sham group (P = 0.493) as assessed on a VAS. Women in the acupuncture group were in regular work to a higher extent than women in the sham group (n = 28/57 versus 16/57, P = 0.041). The acupuncture group had superior ability to perform daily activities measured with the disability rating index (DRI) (44 versus 55, P = 0.001). There were no significant differences in quality of life, discomfort of PGP and recovery from severity of PGP between the groups. CONCLUSIONS: Acupuncture had no significant effect on pain or on the degree of sick leave compared with non-penetrating sham acupuncture. There was some improvement in performing daily activities according to DRI. The data imply that needle penetration contributes to a limited extent to the previously reported beneficial effects of acupuncture.

Regression of pelvic girdle pain after delivery: follow-up of a randomised single blind controlled trial with different treatment modalities.

OBJECTIVE: An earlier publication showed that acupuncture and stabilising exercises as an adjunct to standard treatment was effective for pelvic girdle pain during pregnancy, but the post-pregnancy effects of these treatment modalities are unknown. The aim of this follow-up study was to describe regression of pelvic girdle pain after delivery in these women. DESIGN: A randomised, single blind, controlled trial. SETTING: East Hospital and 27 maternity care centres in Göteborg, Sweden. POPULATION: Some 386 pregnant women with pelvic girdle pain. METHODS: Participants were randomly assigned to standard treatment plus acupuncture (n=125), standard treatment plus specific stabilising exercises (n=131) or to standard treatment alone (n=130). PRIMARY OUTCOME MEASURES: pain intensity (Visual Analogue Scale). SECONDARY OUTCOME MEASURE: assessment of the severity of pelvic girdle pain by an independent examiner 12 weeks after delivery. RESULTS: Approximately three-quarters of all the women were free of pain 3 weeks after delivery. There were no differences in recovery between the 3 treatment groups. According to the detailed physical examination, pelvic girdle pain had resolved in 99% of the women 12 weeks after delivery. CONCLUSIONS: This study shows that irrespective of treatment modality, regression of pelvic girdle pain occurs in the great majority of women within 12 weeks after delivery.

Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence.

Pregnancy-related lumbopelvic pain has puzzled medicine for a long time. The present systematic review focuses on terminology, clinical presentation, and prevalence. Numerous terms are used, as if they indicated one and the same entity. We propose "pregnancy-related pelvic girdle pain (PPP)", and "pregnancy-related low back pain (PLBP)", present evidence that the two add up to "lumbopelvic pain", and show that they are distinct entities (although underlying mechanisms may be similar). Average pain intensity during pregnancy is 50 mm on a visual analogue scale; postpartum, pain is less. During pregnancy, serious pain occurs in about 25%, and severe disability in about 8% of patients. After pregnancy, problems are serious in about 7%. The mechanisms behind disabilities remain unclear, and constitute an important research priority. Changes in muscle activity, unusual perceptions of the leg when moving it, and altered motor coordination were observed but remain poorly understood. Published prevalence for PPP and/or PLBP varies widely. Quantitative analysis was used to explain the differences. Overall, about 45% of all pregnant women and 25% of all women postpartum suffer from PPP and/or PLBP. These values decrease by about 20% if one excludes mild complaints. Strenuous work, previous low back pain, and previous PPP and/or PLBP are risk factors, and the inclusion/exclusion of high-risk subgroups influences prevalence. Of all patients, about one-half have PPP, one-third PLBP, and one-sixth both conditions combined. Overall, the literature reveals that PPP deserves serious attention from the clinical and research communities, at all times and in all countries.

Femoral alignment of the Charnley stem: a randomized trial comparing the original with the new instrumentation in 123 hips.

Deficient cement mantles are associated with aseptic loosening of the stem component of total hip replacement. In a former study of 206 Charnley stems, we found high frequencies of stem malalignment, especially on the lateral view, consequently resulting in a high percentage of low cement mantle grading. If the "true" lateral radiographic projection is not used, there is a risk that the frequency of mantle defects is underestimated. A logistic regression analysis showed a high correlation between low cement mantle grading and stem loosening after a mean follow-up of 10 years. The new Charnley instrumentation was introduced in 1994 and we started a randomized trial including 123 prostheses to determine whether the new instrumentation improved the position of the stem in both the AP and lateral planes. Postoperative radiographs revealed a significant change in AP positioning-i.e., from a high percentage of varus with the original method to valgus with the new instrumentation. However, there was no difference on the lateral view, with a persisting high frequency of stems with implant-inner cortex contact resulting in high percentages of low cement-mantle grading in both systems. If this deficiency, in a long-term perspective, is associated with aseptic loosening, as many authors have claimed, the manufacturers should address the problem.

Reduction of sick leave for lumbar back and posterior pelvic pain in pregnancy.

STUDY DESIGN: In this prospective, consecutive, controlled cohort study, the authors analyzed the impact of a differentiated, individual-based treatment program on sick leave during pregnancy for women experiencing lumbar back or posterior pelvic pain during pregnancy. OBJECTIVE: To identify patients with pain early in pregnancy and, by means of individual information and differentiated physiotherapy, reduce sick leave during pregnancy. SUMMARY OF BACKGROUND DATA: Sick leave for back pain during pregnancy is common, and treatment programs have been aimed at reducing pain, for that reason. In Sweden, the average sick leave due to back pain during pregnancy is 7 weeks. METHODS: All pregnant women who attended a specific antenatal clinic and experienced lumbar back or posterior pelvic pain were included in an intervention group, and results were compared with women in a control group from another antenatal clinic. RESULTS: The intervention group comprised 54 women, compared with 81 women in the control group. Thirty-three women were on sick leave for an average of 30 days in the intervention group versus 45 women for an average of 54 days in the control group (P < 0.001). The reduction in sick leave reduced insurance costs by approximately $53,000 U.S. CONCLUSIONS: Sick leave for lumbar back and posterior pelvic pain in the intervention group was significantly reduced with the program, and the program was cost effective.

Back pain in relation to pregnancy: a 6-year follow-up.

STUDY DESIGN: A prospective randomized controlled 6-year follow-up study of women with back pain during pregnancy. OBJECTIVES: To describe the long-term development of back pain in relation to pregnancy and to identify the effects of a physiotherapy and patient education program attended during pregnancy. SUMMARY OF BACKGROUND DATA: Pain incidence and intensity during pregnancy can be reduced by physiotherapy. No study has described the development of pain experienced for a period of years after delivery or the long-term effect of physiotherapy. METHODS: Pregnant women, registered consecutively, were randomly assigned to one control group and to two intervention groups and were observed throughout pregnancy, with follow-up after 3 months and 6 years. RESULTS: The first phase of the study was completed by 362 women. After 3 months, 351 and after 6 years, 303 women had been observed. Back pain among 18% of all women before pregnancy and among 71% during pregnancy declined to 16% after 6 years. Pain intensity was highest in Week 36 (visual analog score, 5.4) and declined markedly 6 years later (visual analog score, 2.5). Slow regression of pain after partus correlated with having a back pain history before pregnancy, (r = 0.30; P < 0.05), with high pain intensity during pregnancy (r = 0.45; P < 0.01), and with much residual pain 3 months after pregnancy (r = 0.41; P < 0.01). These correlations were not found in the intervention groups. Furthermore, frequency of back pain attacks at 6 years correlated with frequency of attacks during pregnancy (r = 0.41; P < 0.01) and with a vocational factor (r = -0.25; P < 0.01). Physiotherapy and patient education had no effects on back pain development among women without pain during pregnancy. CONCLUSIONS: Back pain during pregnancy regressed spontaneously soon after delivery and improved in few women later than 6 months post partum. Expected correlations between back pain in relation to pregnancy and back pain 6 years later were not present in the intervention groups who had attended a physiotherapy and education program during pregnancy. The program had no prophylactic effects on women without back or pelvic pain during pregnancy.

Regression of back and posterior pelvic pain after pregnancy.

STUDY DESIGN: A prospective, consecutive cohort analysis of the regression of the incidence and intensity of back and posterior pelvic pain after delivery in pregnant women was done. OBJECTIVE: To identify back and posterior pelvic pain from mid-pregnancy to 5 months after delivery and to illustrate differences between these two pain types. SUMMARY OF BACKGROUND DATA: Chronic back pain may start during a pregnancy, and regression of unspecified back pain after delivery may be slow and incomplete. Few studies have distinguished back pain from posterior pelvic pain in pregnancy, and no study has presented follow-up data after delivery with respect to pain types. METHODS: One hundred and sixty four of 368 pregnant women studied had back or posterior pelvic pain and were offered individual group physiotherapy and training. The women were observed until 5 months after delivery. Standardized clinical examination protocols and questionnaires were used. RESULTS: Posterior pelvic pain was experienced by 124 women, and back pain was experienced by 40 women during pregnancy. After delivery, however, back pain was more common. Pain intensity was higher among women with posterior pelvic pain during pregnancy, whereas after delivery pain intensity was higher among women with back pain. A correlation was found between the presence of high pain intensity during pregnancy and little regression of pain after delivery. CONCLUSIONS: One of every three pregnant women studied experienced posterior pelvic pain, and one of every nine women experienced back pain. Posterior pelvic pain was more intense during pregnancy, and back pain was more intense and more common after delivery. High pain intensity in pregnancy indicated a bad prognosis.

Assessment and treatment of low back pain in working pregnant women.

One of every two pregnant women experiences some type of back pain. This lowers the quality of life and causes absence from work for many women. Treatment is often unsuccessful because the problem is not well defined. There also is confusion concerning where these women should be treated. The authors define this problem and suggest a method for classification of back pain in pregnancy into two different pain types and provide a model for treating pregnant women with these pain types during and after pregnancy. Following these guidelines, back pain in pregnancy can be reduced in frequency and intensity, absence from work can be diminished, and persistent pain after delivery can be virtually extinguished. The program includes education of pregnant women in how to manage their specific pain type and contains no passive treatment. The cost-benefit relationship is very good. Team work among the obstetrician, midwife, and physiotherapist is important.

Reduction of back and posterior pelvic pain in pregnancy.

STUDY DESIGN: This study analyzed an education and training program concerning back and pelvic problems among pregnant women. OBJECTIVE: The program was aimed at reducing back and pelvic posterior pain during pregnancy. SUMMARY OF BACKGROUND DATA: Low back and posterior pelvic pain accounts for the majority of sick leave among pregnant women. No previous study has suggested any type of solution to this problem. METHODS: Four hundred and seven consecutive pregnant women were included in the study and randomly assigned into three groups. Group A served as controls while different degrees of interventions were made in groups B and C. RESULTS: Serious back or posterior pelvic pain developed in 47% of all women. Pain-related problems were reduced in groups B and C (P < 0.05), and sick-leave frequency was reduced in group C (P < 0.01). For some of the women in this group, pain intensity was also reduced 8 weeks post partum (P < 0.05). Weekly physical exercise before pregnancy reduced the risk for back pain problems in pregnancy (P < 0.05). A non-elastic sacro-iliac belt offered some pain relief to 82% of the women with posterior pelvic pain. CONCLUSIONS: An individually designed program reduced sick leave during pregnancy. Working with groups was less effective. Differentiation between low back and posterior pelvic pain was essential. Good physical fitness reduced the risk of back pain in a subsequent pregnancy. Reduction of posterior pelvic pain by a non-elastic pelvic support was experienced by 82% of the women with posterior pelvic pain.

The posterior pelvic pain provocation test in pregnant women.

This study was done to evaluate a new, simple, non-invasive pain provocation test as an acid to differentiate between low-back and posterior pelvic pain in pregnant women. The test was performed on 72 pregnant women at various stages of pregnancy with or without low-back or posterior pelvic pain. The study was conducted by two physiotherapists with special interest in back pain in pregnancy at a normal antenatal clinic. The test was easy to learn, perform and interpret and was applicable throughout pregnancy. There was a strong correlation between a positive test answer and a history of posterior pelvic pain (P < 0.01, chi-square). There were no side-effects. The test was highly specific and had a high positive prediction value for posterior pelvic pain and a high negative prediction value for low-back pain among pregnant women.

Influence of some biomechanical factors on low-back pain in pregnancy.

Several biomechanical factors were recorded intermittently in 855 pregnant women from the 12th to the 36th week of gestation and were related to back pain occurrence during pregnancy. The three factors related to the development of back pain were abdominal sagittal diameter, which correlated with back pain, with a coefficient of 0.15 (P < 0.01); transverse diameter (r = 0.13, P < 0.01); and depth of the lumbar lordosis, which correlated with a coefficient of 0.11 (P < 0.01). In the group of women who were pregnant for their first time, there was a significantly lower peripheral joint laxity in the 12th week in those women who, later in pregnancy, developed back pain. These correlations suggest that back pain in pregnancy can not be explained primarily by biomechanical factors.

Postpartum low-back pain.

To determine the prevalence of back pain and its development over the first postpartum period, 817 women who had been followed through pregnancy were studied a minimum of 12 months after delivery. More than 67% of the women experienced back pain directly after delivery, whereas 37% said they had back pain at the follow-up examination. Most of the women who had recovered became pain-free within 6 months. Factors that correlated to persistent postpartum back pain were the presence of back pain before pregnancy, the presence of back pain during pregnancy, physically heavy work, and multipregnancy. Of these four factors, physically heavy work was found to have the strongest association with persistent back pain at 12 months.

Prevalence of back pain in pregnancy.

The prevalence of back pain was studied in 855 pregnant women who were followed from the 12th week of pregnancy, every 2nd week, until childbirth. The 9-month period prevalence was 49%, with a point prevalence of 22-28% from the 12th week until delivery. Because 22% of the women had back pain at the 12th week of the pregnancy, the 6-month incidence was 27%. Based on pain drawings, back pain was classified into three groups: In one group, pain was localized to the sacroiliac areas and increased as pregnancy progressed; in the other two groups, pain either decreased or did not change, respectively. True sciatica with a dermatomal distribution occurred in only 10 women (1%). Back problems before pregnancy increased the risk of back pain, as did young age, multiparity, and several physical and psychological work factors.

Previous back pain and risk of developing back pain in a future pregnancy.

Four hundred twenty-nine pregnant women who had back pain before pregnancy and 375 pregnant women with no previous back pain were followed at regular intervals from the 12th week of pregnancy until delivery; back-pain complaints were recorded. Overall , back pain occurred twice as often in the group with a back-pain history (period prevalence) (P less than 0.001). The point prevalence of back pain in weeks 12, 24, 30, and 36 was three times higher in the group who had had back pain before pregnancy indicating that pain was not only more prevalent but also lasted longer in that group. Women who had been pregnant previously tended to have an increased risk of back pain, and there was a statistically significant correlation between multiparity and longer periods of back pain (P less than 0.001). Young age increased the risk of back pain (P less than 0.001). Pain intensity was higher in the younger women during the first part of their pregnancies but not later on (P less than 0.05).

The impact of low back and pelvic pain in pregnancy on the pregnancy outcome.

The prevalence and characteristics of back pain were recorded in 855 women on nine occasions during pregnancy from the 12th to the 36th week of gestation. Data on delivery and pain relief were recorded. At 12 months post partum the women were reassessed regarding the presence of back pain. Women with a history of back pain had more intense pain (p less than 0.05). No correlation was observed between back pain (a) during pregnancy and (b) after pregnancy and delivery, nor between (a) the need for pain relief in labor and (b) birthweight, length and Apgar score. Back pain usually disappeared in the first 6 months post partum, except in women with recurrent back pain from previous pregnancies. Eighty-two percent of these women continued to have back pain at 18 months post partum, compared with 45% of all other multi-parous women (p less than 0.001).

Fixation of ankle fractures: power-driven staples compared with a routine method, a 3-year follow-up study.

A new method of internal fixation of ankle fractures with power-driven staples is presented. The results in 25 ankle fractures treated with this method were compared with those of 25 matched ankle fractures treated with Wiberg staples, cerclage, and Palmer pins. Reduction was exact in 22 fractures in the stapled group and in 23 in the routine group; all the fractures healed within 6 weeks. The only difference between the two groups was a gain of 20 min in operating time when using the power-driven staples (p less than 0.01). At follow-up observation 3 years later, no additional significant subjective, objective, or radiological differences appeared.