Academic literature on the topic 'Pain provocation test'

Background: Even though the prevalence of thoracic pain has been reported to be 15% of the general population and up to 22% of the population in interventional pain management settings, the role of thoracic discs as a cause of chronic thoracic and extrathoracic pain has not been well researched. The intervertebral discs, zygapophysial or facet joints, and other structures including the costovertebral and costotransverse joints have been identified as a source of thoracic pain. Objective: To systematically assess the quality of clinical studies evaluating the diagnostic accuracy of provocation thoracic discography. Study Design: A systematic review of provocation thoracic discography. Methods: A systematic review of the literature was performed to assess the diagnostic accuracy of thoracic discography with respect to chronic, function limiting, thoracic or extrathoracic pain. Studies meeting the Agency for Healthcare Research and Quality (AHRQ) methodologic quality criteria with scores of 50 or higher were included for the assessment of the level of evidence. Level of evidence was based on the United States Preventive Services Task Force (USPSTF) criteria for the assessment of accuracy of diagnostic studies. Based on the level of evidence, recommendations were made according to Guyatt et al’s criteria. Results: The clinical value of thoracic provocation discography is limited (Level II-3) with 2C/weak recommendation derived from low quality or very low quality evidence indicating that other alternatives may be equally reasonable. Conclusion: Based on the available evidence for this systematic review, thoracic provocation discography is provided with a weak recommendation for the diagnosis of discogenic pain in the thoracic spine, if conservative management has failed. This is qualified by the need to appropriately evaluate and diagnose other causes of chronic thoracic pain including pain originating from thoracic facet joints. Key words: Thoracic pain, chest wall pain, intervertebral disc, thoracic intervertebral disc, facet joint, thoracic disc herniation, discogenic pain, lumbar provocation discography, cervical provocation discography, thoracic provocation discography, false-positive response, diagnostic accuracy

Introduction: Sacroiliac joint (SIJ) can be a nociceptive source of the pain in lower back. Clinical diagnosis of SIJ pain remains yet problematic. The cause of SIJ pain is multifactorial. The pain may be a result of an inflammatory disease, arthrosis, traumatic injury, infectious process or overload. The potential role in SIJ examination have pain provocation tests. Objective: To review and further discuss the validity of some of the mostly used clinical provocation tests such as Distraction test, Thigh Thrust test, Compression test, Sacral Thrust test, Patrick’s (FABER), Gaenslen’s test, Standing Flexion Test, Gillet Test and Shimpi Prone test. Method: A literature search was conducted using PubMed. Reviewed were studies between 2005 and 2020 in English, Slovak and Czech with keywords: sacroiliac joint, sacroiliac assessment, provocation tests. The methodology of studies was not considered. Discussion: It is challenging to determine whether SIJ is the actual source of the pain by using only one of the provocation tests. Therefore, it is beneficial to combine more compression tests, what will also increase the validity of testing. Other widely used SIJ tests are palpation test, however their validity is poor.

Background: The intervertebral disc has been implicated as an etiology of chronic lumbar spine pain based on clinical, basic science, and epidemiological research. However, there is lack of consensus regarding the diagnosis and treatment of intervertebral disc disorders. Based on controlled evaluations, the lumbar intervertebral discs have been shown to be sources of chronic back pain without disc herniation in 26% to 39%. Lumbar provocation discography, which includes disc stimulation and morphological evaluation, is often used to distinguish a painful disc from other potential sources of pain. Despite the extensive literature, controversy continues about provocation lumbar discography. Study Design: A systematic review of the lumbar provocation discography literature. Objectives: To systematically assess the diagnostic accuracy of lumbar discography. Methods: A systematic review of the literature was performed to assess the diagnostic accuracy of lumbar discography with respect to chronic low back pain. Study inclusion/exclusion criteria were based on International Association for the Study of Pain (IASP) standards with pain provocation and determination of controlled discs. Selected studies were then subjected to a rating instrument for diagnostic accuracy studies. Specific data were then culled from these studies and tabulated. Quality of evidence was assessed using modified Agency for Healthcare Research and Quality (AHRQ) diagnostic accuracy evaluation. Studies meeting methodologic quality criteria scores of 50 or higher were included in the assessment of the level of evidence. Qualitative analysis was conducted using 5 levels of evidence, ranging from Level I to III, with 3 subcategories in Level II. The rating scheme was modified to evaluate the diagnostic accuracy. Results: Based on a modified U.S. Preventive Services Task Force (USPSTF) level of evidence criteria, this systematic review indicates the strength of evidence as Level II-2 for the diagnostic accuracy of lumbar provocation discography utilizing IASP criteria. Limitations: Limitations include a paucity of literature, poor methodologic quality, and very few studies performed utilizing IASP criteria. Conclusion: Based on the current systematic review, lumbar provocation discography performed according to the IASP criteria with control disc (s) with minimum pain intensity of 7 of 10, or at least 70% reproduction of worst pain (i.e. worst spontaneous pain of 7 = 7 x 70% = 5) may be a useful tool for evaluating chronic lumbar discogenic pain. Discography is an important imaging and pain evaluation tool in identifying a subset of patients with chronic low back pain secondary to intervertebral disc disorders. Key words: Chronic low back pain, lumbar intervertebral disc, lumbar discography, provocation discography, pain generator, false-positives, diagnostic accuracy, sensitivity, specificity

Background—The cholecystokinin provocation test (CCKPT) has been claimed to predict a better symptomatic result after cholecystectomy in patients with acalculous biliary pain.Aims—To examine the predictive value of the CCKPT for symptom relief after cholecystectomy in both CCKPT positive and negative patients.Patients and methods—Fifty eight patients with acalculous biliary pain underwent CCKPT with serial ultrasound gall bladder volumetry. CCKPT positive patients were offered cholecystectomy; negative patients were reassessed and were offered a cholecystectomy if symptoms persisted. Six months after cholecystectomy, the CCKPT was repeated.Results—Of 32 CCKPT positive patients, 27 underwent cholecystectomy and of these, 18 (67%) became symptom-free. Postoperatively, 20 of 25 patients converted to CCKPT negative but five remained CCKPT positive and were symptomatic. Of the 26 CCKPT negative patients, nine became symptom-free without cholecystectomy; six of 14 (42.8%) patients undergoing cholecystectomy became asymptomatic and remained CCKPT negative. Cholecystectomy seemed to reduce symptoms in both groups, but there was no significant difference in the symptomatic outcome between preoperative CCKPT positive and negative patients.Conclusions—In this study, cholecystokinin provocation testing did not predict symptomatic benefit from cholecystectomy and we suggest it should no longer be used in the evaluation of patients with acalculous biliary pain.

Background: Even though the prevalence of thoracic pain has been reported to be 13% of the general population and up to 22% of the population in interventional pain management settings, the role of thoracic discs as a cause of chronic thoracic and extrathoracic pain has not been well studied. The intervertebral discs, zygapophysial or facet joints, and other structures including the costovertebral and costotransverse joints have been identified as a source of thoracic pain. Study Design: A systematic review of provocation thoracic discography. Objective: To systematically assess and update the quality of clinical studies evaluating the diagnostic accuracy of provocation thoracic discography. Methods: A systematic review of the literature was performed to assess the diagnostic accuracy of thoracic discography with respect to chronic, function limiting, thoracic or extrathoracic pain. The available literature on thoracic discography was reviewed. A methodological quality assessment of included studies was performed using Quality Appraisal of Reliability Studies (QAREL). The level of evidence was classified as good, fair, and limited (or poor) based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to June 2012, and manual searches of the bibliographies of known primary and review articles. Results: The evidence and clinical value of thoracic provocation discography is limited (poor) with a paucity of evidence, with only 2 studies meeting inclusion criteria. Limitations: The limitation of this study continues to be the paucity of literature. Conclusion: Based on the available evidence for this systematic review, due to limited evidence, thoracic provocation discography is rarely recommended for the diagnosis of discogenic pain in the thoracic spine, if conservative management has failed and facet joint pain has been excluded. Key words: Thoracic pain, chest wall pain, intervertebral disc, thoracic intervertebral disc, thoracic disc herniation, discogenic pain, thoracic provocation discography, falsepositive response, diagnostic accuracy

BACKGROUND: Low back pain is a common clinical complaint for young athletes. Making the diagnosis of sacroiliac (SI) pain is often challenging, as the clinical diagnosis is challenging with many non-specific physical examination findings. Previous research has attempted to identify the most accurate physical examination tests; however, the findings were limited in adult populations [1]. The most accurate physical examination test has not been established in pediatric, adolescent, and young adult patients with SI pain. Therefore, the purpose of this study was to identify the sensitivity and specificity of SI physical examination tests in order to diagnose more accurately SI joint pathology in pediatric, adolescent, young adult athletes. METHODS: A prospective study design was used. Pediatric, adolescent, and young adults presenting to the Sports Medicine clinic with low back pain underwent a series of physical examination tests for SI pathology. The physical examination tests for SI included: 1) pelvic distraction, 2) thigh thrust, 3) figure of four, 4) flexion-abduction-external rotation (FABER), 5) pelvic compression, 6) sacral torque, 7) sacral compression, 8) Gaenslen’s test, and 9) Stinchfield’s test. All study patients self-reported pain levels on a Visual Analog Scale (VAS) from 0 to 100 following each test. All study patients were then treated with, an ultrasound-guided injection of anesthetic and corticosteroid into the SI joint. To evaluate accuracy of each of the 9 provocation tests, two by two (2 x 2) contingency tables were developed by positive (+) or negative (-) response to SI special provocation test prior to SI injection and (+) or (-) response to anesthetic and corticosteroid following SI injection. Those who demonstrated 50% or greater pain alleviation immediately following injection were diagnosed with an SI pathology, and thus a (+) response. Based on the 2 x 2 contingency tables, sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratio, and accuracy of each provocation test were calculated. RESULTS: A total of 69 participants (age: 19.5 ± 5.5 years old, age range: 13 - 52, sex: 11 males and 58 females) were tested. There were 14 participants who had complaints of bilateral SI symptoms. Thus, right and left sides were treated separately, which resulted in a total of 83 data points. Table 1 summarizes the outcomes of each provocation test. The sacral torque maneuver was found to be the most sensitive (92.3%) and the most accurate (74.4%) in terms of diagnosing SI joint pathology. All maneuvers besides the Gaenslen test had over 50% sensitivity. However, accuracy of the distraction, Gaenslen, and Stinchfield maneuvers were under 50%. CONCLUSION/SIGNIFICANCE: In the pediatric, adolescent, and young adult populations, the leading three most sensitive clinical provocation tests for reproducing sacroiliac pain were the sacral torque, thigh thrust, and sacral compression tests. These three tests also demonstrate relatively high accuracy (>60%). These findings support the clinical utility of selected physical examination tests for accurately diagnosing SI joint pathology. Due to the relatively high number of false positives and false negatives, it is clear that more research are warranted to optimize these maneuvers before they can be considered as a standalone clinical tool. However, the implications of these results are encouraging and justify exploring the utility of provocative maneuvers of the SI joint in greater detail. [Table: see text]

The sacroiliac joint (SIJ) is a true source of pain commonly tested in osteopathic practice. This study investigated the inter examiner reliability and validity of pain provocation tests at the SIJ. Two examiners tested fifty participants, mean age 23. Sixteen participants were symptomatic for sacroiliac joint dysfunction. Examiners were blinded to participants inclusion criteria and examinations findings. Cohen's kappa and percentage agreement were used to evaluate inter examiner reliability. Validity was measured using sensitivity, specificity, positive and negative predictive values. Percentage agreement between examiners was 76% and Cohen's kappa findings included a kappa = 0.475 overall. Total validity findings included; sensitivity 0.34, specificity 0.93, positive predictive value 0.70 and negative predictive value 0.75. Investigation identified a poor level of validity of pain provocation tests at the SIJ and of inter examiner agreement using compression and gapping tests. A good level of inter examiner agreement occurred using the high thrust and Faber test (k=0.674 0.611 respectively). This minor thesis was written by a post-graduate student as part of the requirements of the Master of Health Science (Osteopathy) program.

The sacroiliac joint (SIJ) is a true source of pain commonly tested in osteopathic practice. This study investigated the inter examiner reliability and validity of pain provocation tests at the SIJ. Two examiners tested fifty participants, mean age 23. Sixteen participants were symptomatic for sacroiliac joint dysfunction. Examiners were blinded to participants inclusion criteria and examinations findings. Cohen's kappa and percentage agreement were used to evaluate inter examiner reliability. Validity was measured using sensitivity, specificity, positive and negative predictive values. Percentage agreement between examiners was 76% and Cohen's kappa findings included a kappa = 0.475 overall. Total validity findings included; sensitivity 0.34, specificity 0.93, positive predictive value 0.70 and negative predictive value 0.75. Investigation identified a poor level of validity of pain provocation tests at the SIJ and of inter examiner agreement using compression and gapping tests. A good level of inter examiner agreement occurred using the high thrust and Faber test (k=0.674 0.611 respectively). This minor thesis was written by a post-graduate student as part of the requirements of the Master of Health Science (Osteopathy) program.

Neurogenic thoracic outlet syndrome (NTOS) is an uncommon cause of chronic arm pain and numbness but should not be missed. It can lead to chronic pain and disability. Symptoms of NTOS are often aggravated by arm exertion and elevation and tend to occur after exercise rather than activity. A thorough diagnostic evaluation is key, which includes provocative tests, imaging, electromyography/nerve conduction study, and diagnostic injections. Electromyography/nerve conduction study (EMG/NCS) are recommended for NTOS as it is important to exclude an entrapment neuropathy or cervical radiculopathy that may be misdiagnosed as NTOS. EMG/NCS is usually normal in NTOS, however, in severe presentations, the EMG/NCS pattern is most consistent with a lower trunk plexopathy. Treatment options of NTOS are also described in this chapter.

This chapter discusses cervical radiculopathy, a common, painful condition from cervical root compression, irritation, or both. A thorough history and physical exam can often help in diagnosing the affected nerve root, without the need for reflexive imaging. A series of provocative tests can aid in the differential diagnosis. Most cases will be resolved with conservative management within several weeks of symptoms onset. Evidence-based conservative management includes physical therapy and oral NSAIDs. If symptoms indicate myelopathic changes or are refractory to 6 to 8 weeks of conservative management, advanced imaging such as MRI should be considered. Patients with imaging evidence of a compressive etiology and refractory to conservative therapy should have a surgical consultation. Either an MRI or CT should be obtained before surgical decompression. Both interventional and surgical treatments have had positive outcomes in the short term, but long-term outcomes appear comparable to those with conservative therapies. It is recommended that conservative treatment strategies be used for 6–8 weeks before pursuing procedural or surgical intervention.

Lars von Trier role as a provocateur, although well established, is central to his paratextuality. Approaching his performances in the film festival space as additional paratexts, the chapter shows how the director adds a transgressive capital to his films through these external acts. The chapter then instigates a detailed paratextual study of Antichrist. The chapter illustrates how Chelsea Films, a sub-branch of the larger Curzon conglomerate, adopts a generic horror schema for its paratextual presentation of Antichrist. Discussing the ramifications of the company’s decision to position a pair of bloody scissors on the film’s cover, the chapter concludes that the use of a horror narrative image simplifies the text and nullifies its arthouse credentials. Thereafter, the chapter explores Artificial Eye’s remediation, suggesting that the company are unsuccessful in their attempt to redefine the film within the parameters of art cinema. Finishing with an exploration of the film’s involvement in the Film4 Extreme Season, the chapter highlights the differences between the commercial representation of extremity on DVD and Television, showing the latter to be more flexible.