From: Curr Rheumatol Rep. 2009 Dec;11(6):433-436

Chronic widespread pain is very prevalent in the general population (5%-10%) and is characterized by pain in all four body quadrants, the neck, and back. Chronic widespread pain differs from localized pain not only in its distribution but also in the way it affects lives. Multiple pain sites are associated with higher pain intensity, longer pain duration, and greater disability. Anxiety and depression are more common in chronic widespread pain patients than among those with localized pain and pain-free controls. Fibromyalgia has been classified as chronic widespread pain of more than a 3 month duration, with mechanical hyperalgesia at greater than or equal to 11 tender point sites. Fibromyalgia has been found in 2% to 4% of community subjects and represents the extreme of chronic widespread pain. This article compares pain characteristics, quality of life, consequences for daily living, and psychosocial status between fibromyalgia patients and individuals with chronic widespread pain. Available evidence shows that fibromyalgia is associated with more severe symptoms and consequences for daily life and higher pain severity compared with chronic widespread pain.

Tags: chronic, widespread, pain,, localized, pain,, fibromyalgia

From: Exp Brain Res. 2009 Oct 10

Chronic neck pain has been associated with disturbances in the sensorimotor control system in both non traumatic and whiplash related neck pain, such as postural stability disturbances, head and eye movement disturbances, erratic and irregular cervical motion patterns and stiffer, less flexible movement patterns. This points to centrally mediated somatosensory alterations with neck pain that may contribute to ongoing symptoms. Some motor impairments seem to particularly associate with a traumatic origin of the pain. Greater deficits in tests of head and eye movement control and decreased postural stability seem to distinguish whiplash associated disorder patients. Some of these deficits appear in association with the complaint of dizziness and neck pain intensity.

Patients with whiplash associated disorders have shown less accuracy in trajectory head motion compared to asymptomatic controls, which comply with clinical observations. The aim of this study was to investigate whether a trajectory head movement task can differ between whiplash associated disorders patients, chronic non traumatic neck pain patients and asymptomatic controls. Study groups included subjects with whiplash associated disorders (n = 35) with persistent neck pain after a car accident, chronic non traumatic neck pain (n = 45), and asymptomatic controls (n = 48). Head motion was recorded from an unsupported standing position using a 3D Fastrak device. A laser pointer was attached to the head and by moving the head the subjects were asked to trace a figure of eight displayed on the wall at three different paces (slow, moderate and fast). The motion signal was decomposed into 1 Hz frequency bands and angular velocity (deg/s) within each frequency band was calculated. Significantly higher angular RMS velocity was found in the whiplash associated disorders group compared to the two other groups for the slow paced test (3-4 and 4-5 Hz frequency bands) and the moderate paced test (3-4 Hz frequency band) indicating irregular and uncoordinated movements. Angular RMS velocity was associated with pain and dizziness, but only with severe symptom levels. In conclusion, irregular head movements during a complex task were found in the whiplash associated disorders group, indicating altered central sensorimotor processing. The irregularities were found within frequency levels observable to clinicians.

Tags: whiplash,, neck, pain,, movement, patterns,, motor, control,, Fastrak

From: Clin Invest Med. 2009 Oct 1;32(5):E360-7

Chronic low back pain is one of the main causes of disability in the community. Although there have been studies suggesting an association between smoking and chronic low back pain, these studies were limited by the small numbers of patients, and they did not control for confounders. The objective of this study was to determine whether cigarette smoking is associated with an increased risk of chronic low back pain among adults.

Using Canadian Community Health Survey (cycle 3.1) data, 73,507 Canadians aged 20 to 59 yr were identified. Self-reported chronic low back pain status, smoking habits, sex, age, height, weight, level of activity and level of education were identified as well. Back pain secondary to fibromyalgia was excluded. Multivariate logistic regression analysis was used to detect effect modification and to adjust for covariates. Design effects associated with complex survey design were taken into consideration.

The prevalence of chronic low back pain was 23.3% in daily smokers and only 15.7% in non smokers. Age and sex were found to be effect modifiers, and the relationship between smoking and chronic low back pain risk was dependent on sex and age. The association between daily smoking and the risk of chronic low back pain was stronger among younger individuals. Occasional smoking slightly increased the odds of having chronic low back pain.

Daily smoking increases the risk of chronic low back pain among young adults, and this effect seems to be dose dependent. Back pain treatment programs may benefit from integrating smoking habit modification. Further research is required to develop effective prevention strategies.

From: Pain. 2008 Oct 31;139(3):588-93

Trapezius myalgia – chronic pain from the upper trapezius muscle – is frequent in female employees in monotonous stressful jobs, potentially due to chronic overload of type I muscle fibers. In this study, the authors investigated the intra-individual distribution of trapezius muscle fiber size, and hypothesized that females with myalgia compared with matched healthy controls have a higher percentage of grossly hypertrophied type I fibers with poor capillarization.

Forty-two female office workers with trapezius myalgia and 20 healthy matched controls participated in the study. Standard histochemical methods were used to determine fiber size, fiber type, and capillarization. Type I megafiber were defined as at least twice the size of the median type I fiber size of each individual. The main finding was that trapezius myalgia had a significantly higher proportion of type I megafibers than healthy matched controls, in spite of no significant difference in overall type I fiber size. In trapezius myalgia and healthy matched controls type I megafibers were located in 46% and 11% of the females, respectively. Capillarization of the overall type I fiber pool was not different between healthy matched controls and trapezius myalgia, but was significantly lower in type I megafibers of both groups. The percentage of megafibers was positively related to age and weekly working hours, indicating an effect of long-term exposure. In conclusion, this study shows that trapezius myalgia is associated with a significantly higher percentage of grossly hypertrophied type I muscle fibers with poor capillarization – type I megafibers.

From: J Manipulative Physiol Ther. 2009 Sep;32(7):521-6

Low back pain is one of the leading causes of disability, contributing to 40% of all workdays lost in the United States of America. Because of the cost associated with work-related low back pain disabilities, most published studies have focused on the working-aged population. However, back pain and neck pain are also common musculoskeletal disorders affecting, each month, approximately one third of adults older than 70 years. The annual prevalence of chronic low back pain ranges from 44% to 84% in adults older than 65 years. In Canada, chronic low back pain is the third and fourth most important chronic health problem in women and men, respectively, older than 65 years. Women with severe chronic low back pain are 3 to 4 times more likely than other women to have difficulty with light housework tasks and 2 times more likely to encounter problems with mobility tasks, such as climbing stairs, walking, or lifting. In Canada, it is estimated that approximately 25% of the population will be older than 65 years by 2031. Anticipating the growing impact of the ageing population, a better understanding of chronic low back pain’s impact on physical capabilities in elderly people is important.

In working aged adults, chronic low back pain has been associated with increased fatigability of the lumbopelvic extensor muscles, as demonstrated by shorter back endurance test duration. In all back endurance protocols reported in the literature, isometric testing procedures with the trunk positioned in a weight-dependent position, such as the Sorensen test, may be most suitable in clinical settings. Weight dependent position tests of muscle endurance are cost-effective, easy to perform in a clinical context, and require no special equipment. The Sorensen test is conducted with subjects lying prone, the upper body unsupported in a horizontal position relative to the ground, and the lower limbs fixed by straps. This procedure has been found to be a reliable measure of position-holding time and can discriminate between subjects with and without low back pain.

Ageing has been related to changes in the neuromuscular system. Among these changes, loss of muscle force generation capacity, a slower firing rate of motor units, and a reduction in motor unit and muscle fiber number have been observed. Together with the loss of muscle fibers, a selective decrease in fast twitch fibers has been demonstrated with advancing age, leading to alteration of muscle fiber type proportion. This shift in fiber-type proportion appears to contribute to changes in muscle fatigability in healthy elderly individuals.

Very few studies have assessed back muscle endurance in elderly subjects. The current investigation aims to evaluate back extensor muscle fatigability in healthy elderly adults by quantifying endurance time during a clinical isometric back endurance test and the posttest decrease of lumbopelvic extensor maximal force. We hypothesized that elderly subjects will experience greater fatigability of lumbopelvic extensor muscles than young subjects.

The endurance time of back extensor muscles has become an important outcome in clinical decision making to guide exercise therapy interventions, particularly in chronic low back pain patients. Indeed, reduced back muscle endurance has been identified as a potential personal risk factor for developing low back pain. However, identifying endurance deficits requires normative values and an understanding of related psychophysical mechanisms. Very few databases on back muscle endurance time in elderly subjects are available. Furthermore, there is very limited information regarding the psychophysical aspects of performance during isometric back extensor testing in young adults and the elderly.

The experimental data provided in this study support the Sorensen test to evaluate back and hip extensor muscle endurance in elderly subjects. All the elderly participants in our study were able to perform the Sorensen test until exhaustion. One could consider that they had not achieved their endurance time limit to exhaustion because they may have underestimated their physical capabilities or have altered perceptive physical exertion. We tried to account for this with other measures, such as force reduction occurring with fatigue and effort perception on the Borg scale. Force was decreased after prolonged exertion and was an indicator of muscle fatigue. Both the elderly and young adult groups presented a significant decline of maximal isometric lifting force values after the Sorensen protocol. In addition, our results demonstrated that the amount of postfatigue reduction of isometric lifting force was similar between young adults and elderly subjects. The perceived exertion during the Sorensen test increased similarly in the elderly subjects and young adults, and we did not find any difference in Borg scores during the Sorenson test. All these results support the hypothesis that the elderly subjects achieved their endurance time limit during the Sorensen test.

The authors initially hypothesized that lumbopelvic extensor muscle endurance in the elderly subjects would be decreased during the weight-dependent isometric test due to age-associated muscle strength reduction. Although strength diminution was observed with age, we did not see a significant age effect on performance during the Sorensen test. McGill et al argued that age could impact the endurance time of torso muscles. Indeed, this study sample was composed of community-dwelling, nonsymptomatic, physically active elderly subjects that could have contributed to decrease the between-group difference. Maximal isometric lifting force was associated with back extensor endurance time in the young subjects, but no such relationship was clearly established for the elderly study participants. Thus, factors other than back muscle strength may have modulated endurance time for the elderly subjects during the fatiguing protocol in our study. Yassierli et al also found lower correlations between torso extension torque and back endurance time in elderly subjects compared to young adults, using a dynamometer in an upright position. Age-related adaptations, such as decreased muscle mass and increased type I muscle fiber proportion in elderly subjects, may limit maximal force-generation capacity in elderly subjects. These neurophysiologic factors may cause a reduction of the force-endurance relationship. In the study by Yassierli et al, back extension torque explained 74% to 78% and 46% to 63% of the endurance time variance in young and elderly subjects, respectively. In the present investigation, much lower correlation values between maximal isometric lift force and endurance time were obtained during the Sorenson test. The isometric lift task involves synergistic muscle activation of knee extensor muscles and lumbopelvic extensor muscles. Motor control strategies of multiple joints and muscles during isometric lifting may also explain the low correlation observed in elderly subjects.

This study is the first to assess lumbopelvic extensor muscle endurance in a clinical isometric back extension test in elderly subjects. Lumbopelvic extensor muscle endurance seems to be modulated by different neurophysiologic or mechanical factors with age, and in light of the present findings, normative data gathered from young adults should be interpreted with caution in elderly subjects. Future studies will be needed to assess lumbopelvic extensor muscle endurance in elderly male and female subjects with or without low back pain.

From: BMC Musculoskelet Disord. 2009 Jul 7;10(1):82. [Epub ahead of print]

Among women, chronic pelvic pain is a highly prevalent (2% to 25%) clinical problem, with substantial costs as well as social and marital repercussions. Chronic pelvic pain is defined as continuous or recurrent pain in the lower abdomen or pelvis lasting at least six months, not related to pregnancy, and sufficiently severe to interfere with the habitual activities of the patient. Chronic pelvic pain excludes pain occurring exclusively in association with menstruation (dysmenorrhea) or during sexual intercourse (dyspareunia).

Although the etiology is often unknown, it may result from complex interactions among the gastrointestinal, urinary, gynecologic, musculoskeletal, neurologic and endocrine systems, as well as being influenced by psychological and sociocultural factors. To date, few therapeutic modalities have been effective in relieving the symptoms of chronic pelvic pain, particularly over the long term. An interdisciplinary approach has therefore been recommended, both to diagnose the presumed primary etiology, and to diagnose and control all the secondary factors associated with chronic pelvic pain.

In clinical practice, postural changes are frequently observed among women with chronic pelvic pain. Although this disease has been associated with musculoskeletal changes and particular postures, to date there have been no studies of the detailed postural evaluation of women with chronic pelvic pain, which can be performed by attending physicians, especially primary care physicians and gynecologists. Postural assessment can lead to early detection of uneven positions, shortenings, antalgic postures and tensions. Although these changes may not be the primary cause of the clinical condition, they can contribute significantly to the worsening of pain and tension. The authors therefore determined the frequency of postural changes in women with chronic pelvic pain, as assessed only by clinical examinations.

The authors observed statistically significant differences in the cervical spine and scapulae between women with chronic pelvic pain and control women. The authors believe that the changes observed in women with chronic pelvic pain resulted from a vicious cycle of pain and antalgic postures acquired over time. The mean duration of symptoms among women with chronic pelvic pain was about five years, and postural impairments over time can contribute significantly to the maintenance or worsening of pain. Nevertheless, the authors cannot conclude that women with chronic pelvic pain always show the same postural pattern. First, although the authors observed an association between chronic pelvic pain and postural changes, the control group, consisting of women who did not report any type of pain, also presented with several postural changes.

Additionally, the authors believe that postural changes among controls occurred because posture depends not only on pathologic condition, but on several other factors, including habits acquired by individuals throughout life, their work activities, and even their emotional and psychological states. Second, the authors study design did not allow them to determine whether postural changes were the cause or consequence of chronic pelvic pain. However, identifying postural changes is an important part of evaluating women with chronic pelvic pain because improvements in posture can contribute to improvement in chronic pelvic pain symptoms.

In this study, posture was assessed in a strictly clinical manner, with the examiners recording the static posture adopted by the women. This method of assessment was used because the authors wanted to determine the efficacy and reproducibility of this type of evaluation so that it might be incorporated into clinical practice in the evaluation of women with chronic pelvic pain. Because of its simplicity, this type of examination can be easily performed during ambulatory patient care at any level of assistance, thus minimizing factors that may worsen or perpetuate chronic pelvic pain and helping to refer these women to specialized services. However the authors recognize that, scientifically, more objective forms of postural assessment such as biophotogrammetry are necessary. However we believe that the method described here may be useful in assessing the effects of physiotherapy and/or advice to alleviate pain in women with chronic pelvic pain who have musculoskeletal changes.

The authors findings also support the importance of multidisciplinary care, involving physicians, physical therapists and psychologists, for women with chronic pelvic pain. In this series, musculoskeletal changes were associated with chronic pelvic pain in at least in 34% of the women in the chronic pelvic pain group, indicating that a more detailed assessment of women with chronic pelvic pain is necessary for better diagnosis and to provide more effective treatment for these women, including control of situations that may reduce the pain threshold.

Logistic regression showed that the independent factors associated with chronic pelvic pain were postural changes in the cervical spine and scapulae. Musculoskeletal changes were associated with chronic pelvic pain in 34% of women. These findings suggest that a more detailed assessment of women with chronic pelvic pain is necessary for better diagnosis and for more effective treatment

From this study the authors conclude that postural changes are seen more frequently in women with chronic pelvic pain. However, it is not possible to confirm if these changes are causes or consequences of chronic pelvic pain. Thus, more detailed assessments are necessary to obtain better differential diagnosis and, consequently, more effective treatment for these women.

From: J Orthop Sports Phys Ther. 2009 May;39(5):400-17

Patient completed questionnaires are commonly used to measure clinical outcome in efficacy studies. Outcome questionnaires for neck pain should measure the effect of treatment on pain, motion, disability, activities of daily living, social function, and work function. The Neck Disability Index is a commonly used neck pain questionnaire. It is modeled after the Oswestry Back Disability questionnaire and includes 10 self-report items covering activities of daily living (7 items), concentration (1 item), and pain (2 items). Responses are on a 0-to-5 Likert scale with total score ranging from 0 (no pain or disability) to 50 (severe pain and disability). It has been studied in patients with whiplash associated symptoms and in groups with mixed causes for neck pain. It has excellent test-retest properties and good convergent validity when compared with the McGill Pain Questionnaire and a global improvement scale. Item analysis suggested that the Neck Disability Index measures a single domain.

Systematic review of clinical measurement to find and synthesize evidence on the psychometric properties and usefulness of the neck disability index. The neck disability index is the most commonly used outcome measure for neck pain, and a synthesis of knowledge should provide a deeper understanding of its use and limitations. Using a standard search strategy (1966 to September 2008) and 4 databases (Medline, CINAHL, Embase, and PsychInfo), a structured search was conducted and supplemented by web and hand searching. In total, 37 published primary studies, 3 reviews, and 1 in-press paper were analyzed. Pairs of raters conducted data extraction and critical appraisal using structured tools. Ranking of quality and descriptive synthesis were performed.

Horizon estimation suggested the potential for 1 missed paper. The agreement between raters on quality assessments was high(kappa = 0.82). Half of the studies reached a quality level greater than 70%. Failures to report clear psychometric objectives/hypotheses or to rationalize the sample size were the most common design flaws. Studies often focused on less clinically applicable properties, like construct validity or group reliability, than transferable data, like known group differences or absolute reliability (standard error of measurement or minimum detectable change. Most studies suggest that the neck disability index has acceptable reliability, although intraclass correlation coefficients range from 0.50 to 0.98. Longer test intervals and the definition of stable can influence reliability estimates. A number of high-quality published (Korean, Dutch, Spanish, French, Brazilian Portuguese) and commercially supported translations are available. The neck disability index is considered a 1-dimensional measure that can be interpreted as an interval scale. Some studies question these assumptions. The minimum detectable change is around 5/50 for uncomplicated neck pain and up to 10/50 for cervical radiculopathy. The reported clinically important difference is inconsistent across different studies ranging from 5/50 to 19/50. The neck disability index is strongly correlated to a number of similar indices and moderately related to both physical and mental aspects of general health.

The neck disability index has sufficient support and usefulness to retain its current status as the most commonly used self report measure for neck pain. More studies of clinically important difference in different clinical populations and the relationship to subjective/work/function categories are required.

From: Curr Opin Neurol. 2009 Mar 18. [Epub ahead of print]

This review discusses current data on nosological boundaries related to diagnosis, pathophysiology and therapeutic strategies in chronic tension type headache. Diagnostic criteria of chronic tension type headache should be adapted to improve its sensitivity against migraine. It seems that mechanical pain sensitivity is a consequence and not a causative factor of chronic tension type headache. Recent evidence is modifying previous knowledge about relationships between muscle tissues and chronic tension type headache, suggesting a potential role of muscle trigger points in the genesis of pain. An updated pain model suggests that headache perception can be explained by referred pain from trigger points in the craniocervical neck muscles, mediated through the spinal cord and the trigeminal nucleus caudalis rather than only tenderness of the neck muscles themselves.

Different therapeutic strategies for chronic tension type headache; pharmacological, physical therapy, psychological and acupuncture, are generally used. The therapeutic efficacy of nonsteroidal anti-inflammatory drugs remains incomplete. The tricyclic antidepressants are the most used first-line therapeutic agents for chronic tension type headache. Surprisingly, few controlled studies have been performed and not all of them have found an efficacy superior to placebo. Further, there is insufficient evidence to support or refute the efficacy of physical therapy in chronic tension type headache. Although there is an increasing scientific interest in chronic tension type headache, future studies incorporating subgroups of patients who will likely to benefit from a specific treatment (clinical prediction rules) should be conducted.

In Eur J Pain. 2007 May;11(4):475-82, it was noted that referred pain from trapezius muscle trigger points shares similar characteristics with chronic tension type headache. The results showed that manual exploration of trigger points in the upper trapezius muscle elicited referred pain patterns in both chronic tension type headache patients and healthy subjects. In chronic tension type headache patients, the evoked referred pain and its sensory characteristics shared similar patterns as their habitual headache pain, consistent with active trigger points.

In Pain Med. 2009 Jan;10(1):43-8, referred pain elicited by manual exploration of the lateral rectus muscle in chronic tension type headache. In some patients with chronic tension type headache, the manual examination of lateral rectus muscle trigger points elicits a referred pain that extends to the supraorbital region or the homolateral forehead. Nociceptive inputs from the extraocular muscles may sustain the activation of trigeminal neuron, thus sensitizing central pain pathways and exacerbating headache.

According to Headache. 2007 May;47(5):662-72, Active trigger points in the upper trapezius, sternocleidomastoid, and temporalis muscles were more common in tension headache subjects than in healthy controls, although trigger point activity was not related to any clinical variable concerning the intensity and the temporal profile of headache, tension headache patients showed greater forward head posture and lesser neck mobility than healthy controls, although both disorders were not correlated with headache parameters.

From: PLoS ONE. 2009;4(3):e4874. Epub 2009 Mar 16

General practitioners are often consulted for low back pain. The point prevalence of low back pain is reported to be about 15% to 30% in the Western world. For about 6% to 10% of patients, the disease may recur or become chronic and the demand on the health-care system is great and costly. These patients are also a cause of major disability and absence from work. Fewer than half of individuals disabled for longer than 6 months return to work, and after 2 years of absence from work, the return-to-work rate is close to zero. Moreover, back pain is the most common chronic illness in subjects younger than 65 years.

Early identification of risk factors for chronic low back pain is important in understanding and preventing the progression to chronic disease and disability.

Many studies in Western industrialized countries have attempted to identify risk factors for low back pain, with a good evidence of relation between chronic low back pain and history of low back pain (including pain severity, duration, disability, leg pain, related sick leave and history of spinal surgery), low level of job satisfaction and poor general health. Only moderate evidence exists for a relation between chronic low back pain and psychosocial factors such as employment status, amount of wages, workers’ compensation, and depression or physical factors such as lifting time per day and work posture.

The literature on risk factors for chronic low back pain is abundant with numerous prospective studies done on relatively small samples of patients assessing only a specific category of chronic low back pain risk factors. Moreover, the major drawback in prospective and cross-sectional studies of chronic low back pain risk factors is the use of simplistic methodological approach without considering the interrelations of the known risk factors. These studies do not allow for analyzing the structure of the existing relations between risk factors and discovering the underlying dimensions explaining the links between risk factors.

This study considered all the previously identified chronic low back pain risk factors and aimed to investigate their frequency and their interrelations with adapted multiple correspondence analysis in a French national sample of patients consulting their general practitioners for chronic low back pain.

This cross-sectional national study in a large sample of chronic low back pain patients in primary care confirmed a high frequency of previously identified risk factors, which suggests that our sample resembles those previously reported on this topic. The strength of this study is the variety of risk factors addressed and the use of multiple correspondence analysis, which allows for analyzing the interrelations among these risk factors by defining dimensions of risk factors for chronic low back pain and determining the contribution of each risk factor to the dimensions. Very few surveys examined the interrelation of identified chronic low back pain risk factors and evaluated the contribution of risk factors to professional, medical and psychological dimensions of chronic low back pain.

The literature on risk factors for chronic low back pain is abundant, but numerous prospective studies assessed only a specific category of chronic low back pain risk factors (professional, psychological or medical). These studies give only limited information because they do not allow for 1) analyzing the structure of the existing relations between all the risk factors or 2) discovering the underlying dimensions explaining the interfactor links. For example, in the prospective study of Valat et al., which is methodologically valid, the authors selected explicit risk factors using only statistical criteria. Thus, they did not (wrongly) take into account an important clinical factor “satisfaction with professional activity” because it was not found to be statistically significant. Moreover, no psychological factor was studied to explain “chronicity”. This study, although methodologically valid, does not take into account several risk factors previously identified.

The strength of the multiple correspondence analysis was its ability to examine the relevant importance of work-related factors in the working population as compared with psychological and other social factors. Indeed, multiple correspondence analysis analysis revealed that the “work-related” dimension was the most important for patients with chronic low back pain. Poor job satisfaction and lack of recognition at work contributed largely to this dimension, which suggests that “social work-related” factors probably weigh more than “physical work-related” ones. Moreover, patients with more than 2 years’ duration of chronic low back pain tended to report dissatisfaction with their jobs more often than those with 2 years’ or less duration. Our results are in agreement with other studies showing poor job satisfaction and lack of recognition associated with chronic low back pain.

Among professional factors, beliefs about the harmfulness of posture and physical activities as being responsible for chronic low back pain were frequently cited and largely contributed to the “work-related” dimension. These results are in accordance with those from an increasing number of studies concerning the influence and consequences of pain-related fears and associated avoidance behavior in the development and maintenance of disabling low back pain. Self-reported feelings of disability and irrational and/or negative beliefs about pain such as kinesiophobia and fear avoidance have been associated with chronic evolution of low back pain. This the first report comparing the contribution of these risk factors with other risk factors.

As expected, a history of anxiety and depression largely contributed to the “psychological” dimension. Relationships with employers and co-workers, categorized as professional factors, also contributed to this dimension. Indeed, these variables could reflect more general behavioral attitudes with others than specific work-related attitudes.

The “health-related” dimension was the least important in this sample. This dimension concerned previously identified medical risk factors such as pain intensity or presence of sciatica at the onset of the current episode of low back pain, initial limitation of ADL, history of recurrent low back pain, absence from work due to low back pain before the current episode and history of lumbar spine surgery.

For the nonworking patients, multiple correspondence analysis revealed that general practitioners’ poor opinion of their patients’ general health status represents a dimension by itself. Poor general health status has already been reported as a risk factor of severity in several pathologic situations, but this is the first report to describe the contribution of this risk factor in terms of other risk factors. As was observed for working patients, for nonworking patients, the second and third dimensions were the “psychological” and “health-related” dimensions, with history of anxiety and depression largely contributing to the “psychological” dimension.”

The results shed light on the interrelation and respective contribution of several previously identified risk factors for chronic low back pain. They suggest that risk factors representing a “work-related” dimension are the most important risk factors for chronic low back pain in the working population. Among these factors, patients’ job satisfaction and job recognition largely contribute to this dimension and must be considered in prospective studies. Such feelings about professional conditions in low back pain patients should be systematically recorded and taken into account by professionals. As previously recommended by the European guidelines for the management of low back pain, educational and behavioral therapy programs on these topics should be proposed and evaluated in chronic low back pain.

From: J Am Osteopath Assoc. 2008 Nov;108(11):629-30

Heel lifts are commonly recommended for patients to manage the pain and discomfort of leg length discrepancies. However, used inappropriately, orthotics can create additional pain instead of alleviating it. In the case described, a 79-year-old male physician used a recommended heel lift for a perceived leg length discrepancy after right hip arthroplasty. Six months postsurgery, chronic, intractable pain developed in his hip and groin. He underwent a battery of tests to locate the pain, but its source remained elusive. Osteopathic evaluation and radiographic examination revealed an absence of leg length discrepancy and the presence of chronic psoas syndrome. Osteopathic manipulative treatment was prescribed and heel lift therapy discontinued, and the patient reported complete remission from pain.

Leg length discrepancies contribute to myriad conditions in patients, including low back pain, knee pain, and abnormal gait. Such discrepancies, which can occur naturally or postsurgically, can often be resolved through the use of heel lifts. However, used inappropriately, these corrective devices can worsen—or even cause—leg length discrepancies, leading to somatic dysfunction. Although leg length discrepancies have not been reported previously in the medical literature as contributing to psoas syndrome, the current case illustrates the use of inappropriate heel lifts to be a plausible, underlying factor in the occurrence of this chronic condition.

Psoas syndrome can be defined as a muscular imbalance, strain, spasm, tendonitis, or flexion contracture of the iliopsoas muscle (consisting of the iliac and psoas major). This syndrome may result in a number of symptoms including:

• flexion deformity of the leg on the affected side
• increased pain when standing or walking
• lordosis when supine
• nonneutral somatic dysfunction of the lumbar vertebra 1 or 2 (L1 or L2)
• pain in the lower back, pain radiating anteriorly toward the groin, or both
• pelvic shift to the opposite side
• point tenderness medial to the ASIS or femoral triangle
• psoatic gait
• sacral dysfunction on an oblique axis
• spasm of the contralateral piriformis muscle

The most common causes of psoas syndrome are direct muscular dysfunctions arising from iliopsoas spasm or strain. Spasm of the iliopsoas often occurs after a position with a shortened psoas (eg, sitting, kneeling, crouching) has been maintained for an extended period of time. Strain of the iliopsoas can result from forceful contraction of these muscles when the thigh is in a fixed or extended position. For example, this forceful contraction may occur while running uphill, performing straight-legged sit-ups, stumbling with one leg extended, or kicking a ball. In iliopsoas strains, the pain begins as a sharp stab in the groin and increases with active resisted hip flexion or passive external rotation. In adolescents, the injury may produce avulsion of the lesser trochanter; in adults, the result may be a complete or partial tear at the muscle-tendon junction.

Other causes of psoas syndrome include irritation to the psoas muscle directly or through viscerosomatic reflexes. Organic causes of psoas syndrome, some of which may be serious or life-threatening, include abdominal aortic aneurysm, intra-abdominal abscess, appendicitis, diverticulitis, inguinal hernia, prostate or sigmoid colon cancer, prostatitis, salpingitis, ureteral calculi, and Crohn disease.

In the case described, the right sacral base unleveling and right anterior innominate rotation most likely resulted from compensating for the use of an inappropriate heel lift. The innominate rotation lengthened the resting length of the psoas muscle, placing it under constant strain. The onset of the psoas dysfunction probably began during a golf game, when the patient forcefully contracted the iliopsoas with the thigh in a fixed or extended position. This strain in the context of a chronically lengthened psoas initiated the chronic psoas syndrome. As illustrated in the current case, the long-term consequences of compensating for an inappropriate orthotic lift or of actual leg length discrepancy can become deleterious and even disabling.

The diagnosis of psoas syndrome may be elusive because the syndrome can masquerade as many different medical conditions that could distract a practitioner from making an accurate diagnosis. In addition, perceived leg length discrepancies should be carefully interrogated and managed properly. The long-term consequences of compensating for a leg length discrepancy or use of an improper lifting device can have serious, detrimental effects. Further research into leg length discrepancy as a cause of chronic psoas syndrome is recommended. Through conscientious appreciation of symptoms combined with an osteopathic structural examination and contemplating the whole person, the practitioner can facilitate proper diagnosis and treatment.