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PubMed1997

Gut pain reactions in man: an experimental investigation using short and long duration transmucosal electrical stimulation.

Visceral pain is a substantial, clinical problem but unfortunately few experimental models are available to study this phenomenon in man. In the present study we inserted a stimulation catheter 5-10 cm into the ileo-sigmoidostomy of nine patients. The catheter contained six small, flexible electrodes separated by 4 mm. The gut was stimulated by single burst, repeated burst (five stimuli delivered at 2 Hz), or continuous burst stimuli (4 Hz for 30, 60, 90, and 120 s). The sensation (ST), pain detection (PDT), and pain tolerance (PTT) thresholds to single/repeated burst stimuli were determined. The location/size/sensitivity of referred pain after repeated/continuous stimulation were characterized. The brain potentials to single burst stimuli and to increasing stimulus intensity were measured. ST to single burst stimuli was easy to determine (8 mA) and to reproduce. The patients found it difficult to determine the PDT and PTT to single burst stimuli, however both thresholds were easily determined for repeated burst stimuli. The pain thresholds to single burst stimuli were twice as high as the thresholds to repeated burst stimuli, indicating the importance of central temporal summation for visceral pain. Minor changes in the stimulus location resulted in changes of the referred pain projection site. The words most frequently selected (78%) from the McGill Pain Questionnaire to describe repeated burst stimulations were shooting, pricking, flashing, and boring. The amplitude of the brain potentials increased at increasing stimulus intensity. A stimulus intensity giving an initial pain rating of around 5 on a 0-10 visual analog scale (VAS) was used for continuous stimulation. A general increase of the pain intensity and the area of referred pain was found during this stimulation. It was concluded that electrical stimulation of the human gut provokes pain and especially long sequences of visceral stimuli are adequate to evoke referred pain mimicking pain profiles of pathologic origin.

Adult↗

PubMed2001

New pain following cordotomy: clinical features, mechanisms, and clinical importance.

OBJECT: The clinical features, possible causes, and contributing factors associated with novel spontaneous pain following unilateral cordotomy were investigated to clarify the mechanism and clinical importance of this pain. METHODS: Forty-five patients who underwent cordotomy for severe unilateral cancer pain were included in this study. New pain occurred in 33 (73.3%) of 45 patients. Pathological conditions of tissue demonstrated on imaging corresponded to new pain in eight patients, referred pain in five, and neither of these in 15 patients. New pain was centered opposite the site of the original pain in a mirror-image location in 28 patients and rostral to the original pain in five patients. It was temporary in seven patients, weaker than the original pain in 25, and as severe as the original pain in one patient. The incidence of moderate or severe pain was significantly higher in patients with confirmed tissue disease (six of eight patients) than in those without (six of 20 patients). An important contributing factor to the occurrence of new pain was the achievement of analgesia by performing the cordotomy. CONCLUSIONS: The present results indicate that new pain occurs frequently after unilateral cordotomy. Nonetheless, cordotomy may still be indicated for unilateral uncontrollable pain because new pain, when present, was weaker and more easily controlled than the original pain in nearly all cases. The authors speculate that new pain may represent a type of referred pain from the original painful area or may arise from sensitization of contralateral spinal nociceptive circuits due to metastasis or tumor infiltration, and that new pain is potentiated by the interruption of descending inhibitory pathways.

Adult↗

PubMedDate not supplied

Myofascial disorders in the trochlear region in unilateral migraine: a possible initiating or perpetuating factor.

OBJECTIVE: Some patients with trochlear disorders have been found to suffer from concurrent migraine. However, a trochlear examination is not systematically done in patients with migraine. Moreover, a search for myofascial trigger points in the superior oblique muscle has never been reported in these patients. METHODS: The trochlear region was examined in 20 participants with strictly unilateral migraine without side-shift and in 20 controls. Referred pain elicited by different maneuvers during manual palpation (ie, maintained pressure, active muscle contraction, and stretching of the superior oblique muscle) was assessed with a visual analog scale. All participants were headache free on the day of evaluation. RESULTS: Sixteen participants with migraine (80%) perceived referred pain on examination of the trochlear area. It was described as a tightening sensation in the retro-orbital region, sometimes extending to the supraorbital region and the homolateral forehead. In 15 participants with migraine, both the active contraction and the stretching of the muscle increased the referred pain, which was consistent with definite myofascial trigger points. All the definite trigger points were ipsilateral to the side of the headache. Conversely, only 5 controls (20%) had referred pain. None of them had definite myofascial trigger points because muscle stretching did not increase the intensity of pain. The intensity of referred pain at each stage of the trochlear examination was greater in subjects with migraine than in controls (P<0.001). CONCLUSION: Patients with unilateral migraine commonly perceive referred pain from the trochlear area that probably comes from the myofascial trigger points. Myofascial disorders in the trochlear region might contribute to the perpetuation of concomitant migraine.

Adult↗

PubMed1999

Analysis by sex of low back pain among workers from small companies in the Paris area: severity and occupational consequences.

OBJECTIVES: To describe workers with low back symptoms, to identify risk factors and to assess the occupational consequences separately in men and women. METHODS: A descriptive study was conducted between 1 October 1996 and 31 December 1996 in a sample of workers selected at random from all types of small companies in the Paris area. A group of 202 occupational physicians interviewed 7129 workers with a standardised questionnaire including the Nordic questionnaire. Data analysis was performed by sex in the two groups: with low back pain and without low back pain over the previous 12 months. The group with low back pain was then divided into four subgroups: mild cases (without referred pain), moderate cases (with referred pain above the knee), serious cases (with referred pain below the knee), and low back pain with occupational consequences. RESULTS: 7010 questionnaires were able to be evaluated. The sample consisted of 54.8% of men (3842) and 45.2% of women (3168), with a mean age of 37.8 and 37.0 years, respectively (p < 0.05). The following risk factors occurred significantly more often in men: high weight, height, body mass index (BMI), smoking, number of children, increased driving time and work time, material handling tasks, uncomfortable working positions. Most women were clerks (53%). Non-conditional logistic regression applied to the whole sample identified female sex as a risk factor (odds ratio (OR) = 1.85, 95% confidence interval (95% CI) 1.58 to 2.13). The following risk factors were common to both sexes: lifting weights > 10 kg, in women (OR 1.69, 95% CI 1.27 to 2.25) and in men (OR 1.27, 95% CI 1.06 to 1.53), uncomfortable working positions (OR 2.04, 95% CI 1.58 to 2.17 and OR 1.85, 95% CI 1.69 to 2.43), and absence of means to achieve good quality work (OR 1.39, 95% CI 1.19 to 1.63 and OR 1.38, 95% CI 1.15 to 1.65), respectively. Driving was a risk factor only in men and its importance increased with driving time (driving > 4 hours a day (OR 1.61, 95% CI 1.24 to 2.09)). Severe low back pain was linked to female sex (10.2% of women v 6.6% of men), high BMI, aging, and uncomfortable working positions. Low back pain with occupational consequences (n = 258) was not linked to sex, but only to aging and severity. CONCLUSIONS: The incidence and severity of low back pain were higher in women, although they seemed to be less exposed to known occupational risk factors. However, our results indicate a preponderance of these risk factors among female workers. Particular attention must therefore be paid to lifting of weights and uncomfortable working positions in female jobs (clerk, trading, health care staff).

Adult↗

PubMed2003

Central sensitization in fibromyalgia and other musculoskeletal disorders.

Muscle hyperalgesia and referred pain play an important role in chronic musculoskeletal pain. New knowledge on the involved basic mechanisms and better methods to assess muscle pain in the clinic are needed to revise and optimize treatment regimens. Increased muscle sensitivity is manifested as pain evoked by a normally non-nociceptive stimulus (allodynia), increased pain intensity evoked by nociceptive stimuli (hyperalgesia), or increased referred pain areas with associated somatosensory changes. Some manifestations of sensitization, such as expanded referred muscle pain areas in patients with chronic musculoskeletal pain, can be explained from animal experiments showing extrasegmental spread of sensitization. An important part of the pain manifestations (eg, tenderness and referred pain) related to chronic musculoskeletal disorders may result from peripheral and central sensitization, which may play a role in the transition from acute to chronic pain.

Fibromyalgia↗

PubMed1994

Referred knee pain in a young athlete: a case study.

Parapatellar pain is a common complaint in the active adolescent patient population. Patello-femoral pain syndrome, Osgood-Schlatter disease, Sinding-Larsen-Johansson syndrome, patellar tendinitis, and other stress failure conditions are the primary causes of these parapatellar symptoms. Not all cases of knee discomfort are related to knee pathology. This case study discusses hip pathology as a source of referred knee pain in an 8-year-old male athlete. Care must be taken to evaluate all possible sources of both primary and referred pain in all cases.

Bone Transplantation↗

PubMed1996

Prevalence of esophageal disorders in patients with chest pain newly referred to the cardiologist.

STUDY OBJECTIVE: The prevalence of esophageal disorders (dysmotility and/or gastroesophageal reflux) in patients with chest pain newly referred to a cardiologic clinic is unknown. The aims of our study were to investigate the prevalence of esophageal abnormalities in these patients and to assess the value of medical history in predicting the origin of the patient's chest pain. DESIGN: We evaluated 28 consecutive patients who were newly referred to the cardiologist because of angina-like chest pain. Patients with evidence of severe myocardial ischemia were excluded. Cardiologic evaluation included medical history, physical examination, ECG, and exercise testing; further cardiologic workup was carried out only when considered necessary. Gastroenterologic evaluation consisted of medical history, esophageal manometry, endoscopy, and 24-h ambulatory monitoring of esophageal pH and pressure. MEASUREMENTS AND RESULTS: In five patients a diagnosis of ischemic coronary artery disease was made. In only two of these five patients, the cardiologic history strongly suggested a cardiac origin of the pain. Twelve patients had a pathologic 24-h pH profile, four of whom also had reflux esophagitis. Ten patients had symptomatic reflux. In only three of these ten patients, the history was judged to be indicative of an esophageal origin of the chest pain. No motility disorders were found. CONCLUSIONS: Thirty-six percent of the patients with chest pain newly referred to a cardiologic out-patient clinic have symptomatic gastroesophageal reflux. Neither cardiologic nor gastroenterologic history data have a high predictive value with respect to the origin of the chest pain.

Adult↗

PubMed2002

Medial branch neurotomy in management of chronic spinal pain: systematic review of the evidence.

Zygapophysial or facet joints have been implicated as cause of low back, mid back, upper back and neck pain with referred pain. Cervical, thoracic and lumbar facet joints are innervated by the medial branches of the dorsal rami. Zygapophysial (facet) joints have been implicated as the source of chronic pain in 15% to 45% of the patients with chronic low back pain, 54% to 60% of the patients with chronic neck pain and 48% of the patients with thoracic pain. A systematic review of the evidence of effectiveness of radiofrequency denervation in the management of chronic spinal pain was undertaken. This review included randomized clinical trials, as well as non-randomized or observational studies in the analysis. Literature search included MEDLINE, EMBASE, systematic reviews, narrative reviews, cross-references to the reviews and various published trials; and peer reviewed abstracts from scientific meetings during the past two years. An algorithmic approach was followed in study evaluation with a description of inclusion and exclusion criteria. A set of high-performing scales or checklists pertaining to randomized clinical trials and observational trials derived from the Agency for Healthcare Research and Quality (AHRQ) was utilized; Systems to Rate the Strength of Scientific Evidence. Qualitative analysis was conducted, using five levels of evidence for effectiveness of medial branch neurotomy. Our search strategy identified over 1,000 citations as the result of electronic and manual screening. A total of 7 randomized trials of radiofrequency neurotomy for spinal pain were identified. However, only 4 related to medial branch neurotomy. Two of the four met the inclusion criteria. Among the multiple observational studies considered for inclusion, 4 prospective evaluations were included in the systematic review. In addition, 3 retrospective evaluations were also included. Two randomized trials comprised of 27 patients receiving active treatment. The first study consisted of cervical facet joint pain and the second consisted of lumbar facet joint pain. Both studies showed positive results. Similar to randomized trials, prospective, as well as retrospective evaluations showed positive evidence, both in short-term and long-term. The results of this systematic review of 2 well-designed randomized trials, 4 prospective well-designed trials without randomization and 3 retrospective evaluations provided strong evidence that radiofrequency denervation offers short-term relief and moderate evidence of long-term pain relief of facet joint origin.

Journal Article↗

PubMed1997

Experimental pain in the stomach: a model based on electrical stimulation guided by gastroscopy.

BACKGROUND: Abdominal pain is often variable in intensity and difficult to characterise due to its referred pain pattern. Clinical pain is furthermore confounded by various emotional and cognitive factors. AIMS: To develop and apply an experimental model to induce localised gastric pain. SUBJECTS: Twelve healthy male volunteers. METHODS: Stimulating electrodes were mounted on a biopsy forceps and electric stimuli were delivered during gastroscopy. Single, five repeated, and continuous stimuli were given at four locations in the stomach. Pain detection thresholds and pain intensities were assessed together with localisation of the referred pain area. RESULTS: Pain detection thresholds were higher in the prepyloric region compared with those obtained at the lesser and greater curvature. Increasing stimulus intensity resulted in augmented pain perception and repeated stimuli elicited pain at a lower stimulus intensity than single stimuli. Continuous stimuli evoked constant (33%), increasing (33%), or decreasing (33%) pain. The localisation of referred pain varied considerably in the subjects. CONCLUSIONS: The model seems relevant to study basic pain mechanisms elicited by localised stimuli in the stomach. The experimental data support the premise that a gastric focus should always be suspected in patients referred with different kinds of abdominal pain.

Abdominal Pain↗

PubMedDate not supplied

Provocative cervical discography symptom mapping.

BACKGROUND CONTEXT: In a small prospective study assessing 10 symptomatic and 10 asymptomatic subjects, Schellhas et al. compared cervical discography to magnetic resonance imaging. Within that study he reported on the distribution of pain for the C3-C4 to C6-C7 levels. Four years later, Grubb and Ellis reported retrospective data from his 12-year experience using cervical discography from C2-C3 to C7-T1 in 173 patients. To date, no large prospective study defining pain referral patterns for each cervical disc has been performed. PURPOSE: To conduct a prospective visual and statistical descriptive study of pain provocation of a cohort of subjects undergoing cervical discography. STUDY DESIGN/SETTING: Prospective multicenter descriptive study. METHODS: Pain referral maps were generated for each disc level from patients undergoing cervical discography with at least two levels assessed. If concordant pain was reproduced in a morphologically abnormal disc, the subject immediately completed a pain diagram. An independent observer interviewed the subject and recorded the location of provoked symptoms. Visual data were compiled using a body sector bit map, which consisted of 48 clinically relevant body regions. Visual maps with graduated color codes and frequencies of symptom location at each cervical disc level were generated. RESULTS: A total of 101 symptom provocation maps were recorded during cervical discography on 41 subjects. There were 10 at C2-C3, 19 at C3-C4, 27 at C4-C5, 27 at C5-C6, 16 at C6-C7 and 2 at C7-T1. Predominantly unilateral symptoms were provoked just as often as bilateral symptoms. The C2-C3 disc referred pain to the neck, subocciput and face. The C3-C4 disc referred pain to the neck, subocciput, trapezius, anterior neck, face, shoulder, interscapular and limb. The C4-C5 disc referred pain to the neck, shoulder, interscapular, trapezius, extremity, face, chest and subocciput. The C5-C6 disc referred pain to the neck, trapezius, interscapular, suboccipital, anterior neck, chest and face. The C6-C7 disc referred pain to the neck, interscapular, trapezius, shoulder, extremity and subocciput. At C7-T1 we produced neck and interscapular pain. Visual maps with graduated color codes and frequencies of symptom location at each cervical disc level were generated. CONCLUSIONS: In conclusion, these results confirm the observations of prior investigators that cervical internal disc disruption can elicit axial and peripheral symptoms. The particular patterns of pain generation allow the discographer to preprocedurally anticipate disc levels to assess. With these data, the number of disc punctures that are required can be limited rather than routinely assessing all cervical discs.

Cervical Vertebrae↗

PubMed2005

Sensory and motor effects of experimental muscle pain in patients with lateral epicondylalgia and controls with delayed onset muscle soreness.

This study compares the effect of experimental muscle pain on deep tissue sensitivity and force attenuation in the wrist extensors of patients with lateral epicondylalgia (n=20), and healthy controls (n=20) with experimentally induced sensori-motor characteristics simulating lateral epicondylalgia. Delayed onset muscle soreness (DOMS) in wrist extensors of healthy controls was induced by eccentric exercise in one arm 24h prior to injection (Day 0). Saline-induced pain intensity (visual analogue scale, VAS), distribution, and quality were assessed quantitatively in both arms for both groups. Pressure pain thresholds (PPT) were assessed at three different sites in the wrist extensors. Maximal grip force and wrist extension force were recorded. In response to saline-induced pain in the extensor carpi radialis brevis, regardless of arm, the patient group demonstrated a significantly quicker pain onset (P<0.01), mapped larger pain areas and more referred pain areas, compared to healthy controls (P<0.03). Pain persisted significantly longer in the sore arm of the patient group, compared with all other arms (P<0.02). Patients demonstrated significant bilateral hyperalgesia at extensor carpi radialis brevis during and post saline-induced pain compared to pre-injection and healthy controls (P<0.04). The sore arm in patients and the DOMS arms in healthy subjects showed significantly reduced maximal force (P<0.0001), at all Day 1 times compared with the control arms. In patients, the bilateral increase in deep tissue sensitivity and enlarged referred pain areas during saline-induced pain might suggest involvement of central sensitisation.

Adult↗

PubMed1991

Sensory innervation of the canine esophagus, stomach, and duodenum.

The sensory innervation of the postpharyngeal foregut was investigated by injecting the enzyme horseradish peroxidase (HRP) into the walls of the esophagus, stomach, or duodenum. The transported HRP was identified histochemically, labeled neurons in the spinal and vagal ganglia were counted, and the results were plotted using an SAS statistical program. The spinal sensory fields of each viscus were defined using three determinations: craniocaudal extent, principal innervation field, and peak innervation field. The data revealed that innervation fields are craniocaudally extensive, the sensory field of each viscus overlaps significantly with its neighbor, yet each viscus can be characterized by a field of peak innervation density. Craniocaudal innervation of the esophagus spans as many as 22-23 paired spinal ganglia (C1-L2). There are two peak innervation fields for the cervical (C2-C6 and T2-T4) and for the thoracic (T2-T4 and T8-T12) sectors of the esophagus. The sensory innervation of the stomach extends craniocaudally over as many as 25 paired spinal ganglia (C2-L5). The peak innervation field of the stomach spans a large area comprising the cranial, middle, and the immediately adjoining caudal thoracic ganglia (T2-T10). The duodenum is innervated craniocaudally by as many as 15 paired thoracolumbar ganglia (T2-L3). Peak innervation originates in the middle and caudal thoracic ganglia and cranial lumbar (T6-L1) ganglia. There is a recognizable viscerotopic organization in the sensory innervation of the postpharyngeal foregut; successively more caudal sectors of this region of the alimentary canal are supplied with sensory fibers from successively more caudal spinal dorsal root ganglia. Vagal afferent innervation of the esophagus, stomach, and duodenum is bilateral and originates predominantly, but not exclusively, from vast numbers of neurons in the nodose (distal) ganglia. The esophagus is innervated bilaterally and more abundantly by jugular (proximal) ganglia neurons than is either the stomach or duodenum. The physiological significance of the findings are discussed in relation to the phenomena of visceral pain and referred pain.

Afferent Pathways↗

PubMed1996

Deep posterior knee pain caused by a ganglion of the popliteus tendon--a case report.

The most common causes of posterior and posterolateral knee pain (besides referred pain) are knee joint effusions, tendinitis of the hamstring tendons, Baker cyst (semi-membranous cyst), bursitis, meniscal pathologies such as tears and ganglions and lesions of the anterior cruciate ligament. Less common causes include popliteus and gastrocnemius tendinitis, arthrofibrosis after trauma, posterior cruciate ligament sprains, deep venous thrombosis and/or irritations of the common peroneal nerve. We present one patient with posterolateral knee pain after a minor contusion. Magnetic resonance imaging revealed a degenerated posterior horn of the lateral meniscus and a somewhat unclear polypoid structure in the intercondylar region. As the posterior component of the pain persisted even after an arthroscopic partial meniscectomy, an operative revision was performed. A small ganglion of the sheath of the popliteus tendon was found and excised. The patient was immediately relieved of his pain after this procedure. To our knowledge this is the first report concerning a ganglion of the sheath of the popliteus tendon causing posterior knee pain. A similar pathology of the popliteus tendon has been described earlier but at a different localisation (in the hiatus), simulating a parameniscal cyst.

Adult↗

PubMed2004

Simultaneous modulation of the exteroceptive suppression periods in the trapezius and temporalis muscles by experimental muscle pain.

OBJECTIVE: To investigate whether the exteroceptive suppression (ES) periods in the trapezius and temporalis muscles could be simultaneously modulated by either experimental trapezius muscle pain or temporalis muscle pain. METHODS: Fourteen healthy volunteers participated in two sessions with randomised injections of either hypertonic or isotonic saline into the right trapezius muscle or right temporalis muscle. The pain intensity was continuously scored on a 10 cm electronic visual analogue scale. During muscle contraction, the early (ES1) and late (ES2) reflex in the temporalis and late (ES2) reflex in the trapezius elicited by electrical stimulation of the right infraorbital nerve were recorded pre-, during-, and post-injection. RESULTS: Hypertonic saline injection induced local muscle pain and referred pain with the maximal pain intensity of 6.3+/-0.5 cm in the right trapezius and 6.7+/-0.6 cm in the right temporalis muscles. Injection of either hypertonic or isotonic saline into the right trapezius muscle was associated with significantly shortened ES2 duration and offset time in the injected right trapezius muscle. Only injection of hypertonic saline into the right trapezius muscle could significantly reduce the ES2 offset time and decrease the degree of suppression of ES2 in the right temporalis and left trapezius muscles. Injection of either hypertonic or isotonic saline into the right trapezius muscle evoked no changes in ES2 parameters in the left temporalis muscle. Injection of hypertonic saline, but not isotonic saline, into the right temporalis muscle caused a significantly shorter ES2 offset time and shorter ES2 duration bilaterally in the temporalis and trapezius muscles. CONCLUSIONS: The findings of the present study provide evidence for a bi-directional effects reflecting convergence of muscle afferents from the trigeminal and upper cervical neural systems in humans, which may partly underlie the manifestations of pain referral between these two areas.

Adult↗

PubMed2006

Mechanisms of neuropathic pain.

Neuropathic pain refers to pain that originates from pathology of the nervous system. Diabetes, infection (herpes zoster), nerve compression, nerve trauma, "channelopathies," and autoimmune disease are examples of diseases that may cause neuropathic pain. The development of both animal models and newer pharmacological strategies has led to an explosion of interest in the underlying mechanisms. Neuropathic pain reflects both peripheral and central sensitization mechanisms. Abnormal signals arise not only from injured axons but also from the intact nociceptors that share the innervation territory of the injured nerve. This review focuses on how both human studies and animal models are helping to elucidate the mechanisms underlying these surprisingly common disorders. The rapid gain in knowledge about abnormal signaling promises breakthroughs in the treatment of these often debilitating disorders.

Animals↗

PubMedDate not supplied

[Management of adult abdominal pain in the Emergency Room].

Abdominal pain is a commonplace reason for surgical consultation in the emergency department and is the the most common symptom which the digestive surgeon on-call must evaluate. He must understand the pathophysiologic basis of visceral pain and referred pain in order to appreciate its diverse manifestations. Abdominal pain can stem from many causes intestinal and non-intestinal, medical and surgical. Evaluation and management in the emergency department must be rapid and pragmatic; clinical history and physical examination should define the gravity of the case, direct the first diagnostic procedures and complementary examinations, and guide the therapeutic direction. Ultrasonography is a quick and effective diagnostic procedure in the diagnosis of biliary, urologic, and gynecologic pathologies; it can be useful for other digestive problems as well. The new generation spiral CT scanner gives excellent definition of digestive and vascular pathologies. The initial evaluation and management of the acute abdomen may determine the prognosis of the patient; it should lead to prompt symptomatic relief and to a well-directed treatment appropriate to the diagnosis.

Abdominal Pain↗

PubMed2006

Phantom limb pain: a case of maladaptive CNS plasticity?

Phantom pain refers to pain in a body part that has been amputated or deafferented. It has often been viewed as a type of mental disorder or has been assumed to stem from pathological alterations in the region of the amputation stump. In the past decade, evidence has accumulated that phantom pain might be a phenomenon of the CNS that is related to plastic changes at several levels of the neuraxis and especially the cortex. Here, we discuss the evidence for putative pathophysiological mechanisms with an emphasis on central, and in particular cortical, changes. We cite both animal and human studies and derive suggestions for innovative interventions aimed at alleviating phantom pain.

Adaptation, Physiological↗

PubMed1996

A comparison of manual diagnosis with a diagnosis established by a uni-level lumbar spinal block procedure.

The study was designed to test if a manipulative therapist (MT) using manual examination techniques alone or when accompanied by a verbal response from the subject as to the pain produced, could diagnose the lumbar segmental level responsible for a subjects low back pain and referred pain. The study consisted of prospective and retrospective parts where the MTs manual diagnosis of the symptomatic lumbar segmental level was compared to a segmental level diagnosis attained by subsequent or previous spinal anaesthetic blocks. In the prospective part of the study the MT's manual diagnosis was 94.12% and 52.9% sensitive in detecting the symptomatic lumbar segmental level with verbal and non-verbal subject responses, respectively. In the retrospective part of the study the MTs manual diagnosis was found to be 60.86% and 47.82% sensitive in detecting the symptomatic lumbar segmental level with verbal and non-verbal subject responses, respectively. In the prospective study the MT's manual diagnosis showed 100% and 80% specificity in detecting subjects with no history of low back pain with verbal and non-verbal subject responses, respectively, and 100% and 75% specificity in the retrospective study with verbal and non-verbal subject responses, respectively. Inter-therapist reliability analysis for the recording of passive physiological intervertebral movements (PPIVMs), passive accessory intervertebral movements (PAIVMs) and 'tissue response' showed percentage agreement rates ranging from 55% to 99%; 74% to 100% and 43% to 100%, respectively, with weighted kappa values ranging from -0.11 to 0.32; -0.15 to 0.24 and kappa values ranging from -0.16 to 0.28, respectively. This study demonstrates that a MT's manual examination when accompanied by a verbal subject response, is highly accurate in detecting the lumbar segmental level responsible for a subjects complaint.

Journal Article↗