Building a Collaborative Model of Sacroiliac Joint Dysfunction and Pelvic Girdle Pain to Understand the Diverse Perspectives of Experts.

BACKGROUND: Pelvic girdle pain (PGP) and sacroiliac joint (SIJ) dysfunction/pain are considered frequent contributors to low back pain (LBP). Like other persistent pain conditions, PGP is increasingly recognized as a multifactorial problem involving biological, psychological, and social factors. Perspectives differ between experts and a diversity of treatments (with variable degrees of evidence) have been utilized. OBJECTIVE: To develop a collaborative model of PGP that represents the collective view of a group of experts. Specific goals were to analyze structure and composition of conceptual models contributed by participants, to aggregate them into a metamodel, to analyze the metamodel's composition, and to consider predicted efficacy of treatments. DESIGN: To develop a collaborative model of PGP, models were generated by invited individuals to represent their understanding of PGP using fuzzy cognitive mapping (FCM). FCMs involved proposal of components related to causes, outcomes, and treatments for pain, disability, and quality of life, and their connections. Components were classified into thematic categories. Weighting of connections was summed for components to judge their relative importance. FCMs were aggregated into a metamodel for analysis of the collective opinion it represented and to evaluate expected efficacy of treatments. RESULTS: From 21 potential contributors, 14 (67%) agreed to participate (representing six disciplines and seven countries). Participants' models included a mean (SD) of 22 (5) components each. FCMs were refined to combine similar terms, leaving 89 components in 10 categories. Biomechanical factors were the most important in individual FCMs. The collective opinion from the metamodel predicted greatest efficacy for injection, exercise therapy, and surgery for pain relief. CONCLUSIONS: The collaborative model of PGP showed a bias toward biomechanical factors. Most efficacious treatments predicted by the model have modest to no evidence from clinical trials, suggesting a mismatch between opinion and evidence. The model enables integration and communication of the collection of opinions on PGP.

Benchmarking of a Simple Scintigraphic Test for Gastro-oesophageal Reflux Disease That Assesses Oesophageal Disease and Its Pulmonary Complications

Objectives: Gastro-oesophageal reflux disease (GORD) is both common and troubling with a prevalence of 20-40%. We assessed the utility of a scintigraphic reflux study to evaluate the oesophageal and extra-oesophageal manifestation of disease compared to the standard tests such as pH monitoring and manometry. Methods: Patients were recruited into a prospective database of referrals to a tertiary referral center for either resistance to maximal medical therapy or extra-oesophageal symptoms of GORD. Data included 2 channel 24-hour pH monitoring and manometry results, as well as scintigraphic reflux data with late images assessing pulmonary aspiration of refluxate. Results: Study population included 250 patients (155 F, 95 M) with an average age of 60 years. Patients were clinically classified as either GORD (n=72) or laryngopharyngeal reflux (LPR) (n=178). Pulmonary aspiration of the refluxate was detected significantly more commonly in LPR patients (58/178 compared with GORD 10/72). Strong correlations were found between the scintigraphic time-activity curves in the upper oesophagus and pharynx, and ineffective oesophageal motility and pulmonary aspiration. pH studies correlated with the scintigraphic studies but did not predict aspiration similar to other modalities when evaluated by ROC analysis. Conclusion: Scintigraphic reflux studies offer a viable alternative test for GORD and extra-oesophageal manifestations of reflux disease. Strong correlations were found between measurable scintigraphic parameters and oesophageal motility and lung aspiration of refluxate. This may provide a more confident decision analysis in patients being considered for fundoplication for troubling extra-oesophageal symptoms.

What's Old Is New Again: The Sacroiliac Joint as a Cause of Lateralizing Low Back Pain.

It has not been easy to identify mechanical failure of the sacroiliac joint (SIJ) with traditional imaging. The integrated model of function (Lee and Vleeming, 1998) suggests that under normal circumstances, form and force closure combined contribute to sacral nutation and "locking" the SIJ for optimal load transfer. This model is supported by clinical evidence and scintigraphic findings that contribute to successful therapy in 80% of cases. Single-photon emission computed tomography and x-ray computed tomography (SPECT-CT), a hybrid device, was used in a study of 1200 patients (64% female and 36% male patients with an average age of 42 years; range, 15-78 years) with a clinical diagnosis of SIJ incompetence (pelvic girdle pain syndrome). Standard clinical testing and an alternate series of tests were used as a reference standard for imaging. Symptoms were present for a mean of 43 months. Imaging finding were of increased uptake in the upper SIJ (S1-S2), with extension into the dorsal interosseous ligament and measurable by count profile. Associated findings of tendon enthesopathy reflected altered biomechanics around the pelvis. Ipsilateral adductor enthesopathy was found in 70% and contralateral hamstring enthesopathy in 60% of patients. SPECT-CT criteria for the diagnosis of SIJ incompetence were developed and validated. SPECT-CT is a valid and reproducible technique for the diagnosis of SIJ incompetence with high concordance and specificity compared to the reference standards. Findings are supportive of the integrated model of SIJ function proposed by Lee and Vleeming.

Low Back Pain and sport; what role the pelvic ring? / Dolor lumbar y deporte: ¿cuál es el papel del anillo pélvico?

No disponible

Metabolic disturbances identified by SPECT-CT in patients with a clinical diagnosis of sacroiliac joint incompetence.

PURPOSE: To establish the sensitivity and specificity of cross-sectional scintigraphy [single photon emission computed tomography (SPECT)] combined with computed X-ray tomography (CT) in the detection of sacroiliac joint (SIJ) mechanical dysfunction and evaluate reproducibility of reporting. METHODS: Patients with pelvic girdle pain either on the basis of peri-partum SIJ dysfunction or trauma were included. These patients were imaged with bone scintigraphy with hybrid imaging with SPECT/CT. RESULTS: The study group comprised 100 patients (72 females, 28 males). Trauma accounted for 52% and the remainder were patients with peri-partum pain. Average age was 43 years and average length of history was >2 years. The major finding was increased uptake in the upper SIJ and posterior soft-tissues/ligaments. Hybrid imaging had a sensitivity of 95% and specificity of 99%. Positive predictive value was 99% and negative predictive value 94%. Power of the test was 1.0. Reproducibility of the test was good with kappa values of 0.85. CONCLUSION: Hybrid imaging with SPECT/CT reproducibly demonstrates metabolic alterations around the SIJ in patients with SIJ dysfunction, which we have termed SIJ incompetence. The condition is more common than previously recognised and frequently occurs after trauma, which has not been reported previously.

Drummer's fracture of the third metatarsal bone.

A 14-year-old girl presented with a painful right foot. She was an elite water-polo player and could recall no history of specific trauma to the foot. On close and persistent questioning, she admitted to having taken up playing the drums recently, with practice sessions of up to 4 h/d. She used the foot drum with her right foot and had noticed that this was becoming increasingly painful and prevented her playing the instrument for the last 2 days. Plain films of the foot were originally reported as normal, but revised to abnormal after the scintigraphic study. Bone scintigraphy confirmed a stress fracture of the right 3rd metatarsal bone. Stress fractures of the 3rd metatarsal bone are rare with only 2 previous reports in the literature.