Amputation-related back pain: Prevalence, associated risk factors and correlation with functional disability

To determine the prevalence and associated risk factors for post-amputation back pain in lower limb amputees, and to evaluate post amputation back pain-related functional disability. Nested case control study included fifty three lower limb amputees who were more than one year post amputation and ambulatory with prosthesis. All studied lower limb amputees were underwent full history taking, measurement of intensity, frequency and duration of post amputation back pain and measurement of post amputation back pain - related functional disability by using of the revised Oswestry low back pain disability questionnaire [RODQ]. The prevalence of the reported back pain by the studied sample of the lower limb amputees was 64%. The mean of back pain intensity was 5.6 +/- 2.4. The majority of these with post amputation back pain [62%] described their back pain as intermittent and 38% described their back pain as constant. More than twenty three percent of lower limb amputees reported their average back pain intensity as mild [1-4], 50% reported their average back pain as moderate [5 or 6], and 26.5% reported their average back pain as severe [7-10]. As age increased, the odds of development of back pain increased. The prevalence of back pain in men was more than in women [OR =1.8, 95% CI = 1.2-2.3]. The odds of development of back pain in lower limb amputees who resided in an urban areas was higher than that in who resided in rural area [OR =3.8, 95% CI = 2.9 - 4.6]. The odds of development of back pain was higher in lower limb amputees with low education level than in those with high education level [OR = 2.6; 95% CI =1.6-2.9]. Diabetes mellitus as a reason of lower limb amputation associated with the highest risk of development of back pain in lower limb amputees [OR=3.4; 95% CI=2.9-5.1]. The transfemoral amputation associated with a higher risk of development of back pain than the transtibial amputation [OR=3.6; 95% CI=2.1-4.2]. As the time since amputation increased the risk of development of back pain increased [OR of > 2years = 3.2; 95% CI 2.8 -3.6]. The risk of development of back pain in lower limb amputees increased with increasing of duration of daily use of their prosthesis [OR of >/= 5 hours use =4.4; 95% CI= 3.1- 5.3]. As the number of co morbidities increased, the risk of development of back pain increased [OR of one sephantom limb pain was associated with a high risk of development of back pain [OR =2.4; 95% CI= 1.9-3], Also, presence of residual limb pain increased the risk of development of back pain in lower limb amputees [OR=2.6; 95% CI=1.7-3.2]. However, pain in non amputated limb was not associated with odds of development of back pain [OR=0.8; 95% CI=0.3-1.3]. A significant difference was found between the functional disability in lower limb amputees with post amputation back pain and those without back pain [t = 3.2, p< 0.05]. A significant positive correlation was found between the degree of intensity of back pain in the lower limb amputees and the level of back pain - related functional disability [r = + 0.7, p< 0.5]. The prevalence of back pain among the lower limb amputees is high. Identifying risk factors in this study helps to determine the characteristics of lower limb amputees toward whom to direct measures to prevent post amputation back pain. Measurement of back pain intensity is important to assess the back pain-related functional disability

Risk factors for anal sphincter injury during vaginal delivery

To determine the risk factors that may lead to occult injury of the anal sphincter or pudendal nerve during normal or assisted vaginal delivery. We compared the results of bowel function questionnaire, quantitative EMG changes, and anal endosonography in 70 pregnant women, before and 6-8 weeks after delivery. They were classified into 3 groups, Group I, 30 nullipara delivered vaginally [normal and assisted]; Group II, 30 multipara delivered vaginally [normal and assisted] and Group III, [control grroup] delivered by elective cesarean sections. Postpartum pudendal nerve terminal motor latency was measured in all women. In Group I, prolonged gestational age, duration of labor > 12 hours and oxytocin augmentation were associated with altered fecal continence, OR = 2.3, 95% CI = [1.3 - 4.1]; 2.8, [1.6 - 4.7] and 2.04, [1.52 - 6.25] respectively. But these factors were not associated with altered fecal continence in Group II, OR = 1.8, 95% CI = [0.91 - 1.66]; 0.8, [0.4-1.1] and 1.4, [0.3-5], respectively. Odds ratio of instrumental delivery in Group I, who complained of fecal incontinence was, OR = 16.6, 95% CI = [12.3-30], while in Group II, it was, OR = 9.94, 95% CI = [7.2-12.4], p < 0.001. Odds ratio of perineal tear in symptomatic nulliparous women was, OR = 11.3, 95% CI = [4.6-31.3], p < 0.001, while in symptomatic multipara it was, OR = 9.2, 95% CI = [7.1-12.2], p < 0.001. Postpartum QEMG changes of the external anal sphincter was observed in 5 [17%] in Group I, 3 [60%] of them had instrumental deliveries, OR = 7.3, 95% CI = [4.0 - 13.2], p < 0.001 and 2 [40%] of them had prolonged second stage of labor, OR = 2.55, 95% CI = [1.03 - 2.30], p < 0.001. In Group II, prolonged second stage was not associated with postpartum QEMG changes of the external anal sphincter. Perineal tears were found in 3 [60%] women in Group I, who had EMG changes, OR = 6.2, CI = [5 - 17], p < 0.001. Again, in Group II, 6 [20%] women, had postpartum QEMG changes recorded from their external anal sphincter, 2 [33%] of them had instrumental delivery, OR = 6.6, 95% CI = [5 - 17], p < 0.001 and 3 [50%] of them had perineal tear, OR = 5.5, 95% CI = [5-15], p < 0.001. There was a significant increase in the mean PNTML in the multiparous group as compared to the nulliparous or control groups p < 0.001. Postpartum anal endosonogaphic study in the control group showed that there was no defect in either external or internal anal sphinicters. But in Group I, 8 [26%] women had anal endosonographic defects and in Group II, 5 [16%] women had anal endosonographic defects Instrumental delivery and prolonged second stage of labor are the greatest risk factors for the development of anal sphincter injury and dysfunction after vaginal delivery. Electromyography [EMG], pudendal nerve terminal motor latency and anal endosonography are conclusive for the evaluation of subclinical patients with fecal incontinence