British Journal of Rheumatology 1990;29:354-357
A CLINICAL EPIDEMIOLOGICAL STUDY IN LOW BACK PAIN. DESCRIPTION OF TWO CLINICAL SYNDROMES BY G. COLLEE, B. A. C. DIJKMANS, J. P. VANDENBROUCKE*, P. M. ROZINGf AND A. CATS Departments of Rheumatology,
'Clinical Epidemiology and 10rthopaedic Surgery, University of Leiden, The Netherlands
KEY WORDS: LOW back pain, Regional pain syndromes, Greater trochanteric pain syndrome, Trochanteric bursitis, Iliac crest pain syndrome, Iliolumbar ligament syndrome.
Low back pain (LBP) is very common and affects more than half of all people during their lifetime and about 25% of the population at any given time [1,2]. LBP is usually transient and after 3 months only 5% of patients have persisting symptoms (chronic LBP) [1]. LBP is no diagnosis but a symptom. Only in 10-20% of the cases of acute LBP and in 10-45% of the chronic cases can a precise pathoanatomical lesion be recognized [3-6]. Thus, in the majority, the cause or diagnosis is unknown. The term non-specific LBP is preferred, because it underscores our lack of knowledge about this heterogeneous group of patients [7]. Most research on LBP is directed at epidemiological aspects, biomechanical models, technical investigations, invasive therapy, or psychosocial parameters. In contrast, a clinical approach is rarely employed and there is a striking lack of quantitative data concerning medical history and physical examination in nonselected groups of LBP patients. Furthermore, only a few studies have been directed at categorizing LBP in clinical syndromes [3, 4, 7, 8]. Until more data become available, non-specific LBP patients continue to be a clinically unclassifiable group, and this is a substantial obstacle for the study of therapy [9]. The purpose of the present investigation was to classify LBP by signs and symptoms.
of the out-patient clinics of rheumatology or orthopaedic surgery. At the end of the first visit, patients were invited to participate in the study. It was explained that the study was performed solely for the purpose of medical research and that the results would not affect evaluation, therapy or decisions pertaining to insurance or compensation. Within 1 week of the first visit, all patients were seen by one of us (G.C.) who was unaware of previous findings and diagnosis. He took a detailed medical history and performed an extensive physical examination according to a standardized protocol. History included patient characteristics, localization, characteristics and onset of pain and factors modifying the LBP. Examination included posture, range of movement, pain on movement, neurological findings, and systematic palpation for tenderness of the lumbar spine, paravertebral muscles, sacrum, iliac crests, gluteal muscles, trochanteric regions and iliotibial tracts. Typical local tenderness (TLT) was scored as positive if digital pressure not only revealed a point of maximum tenderness, but also reproduced the pain recognized by the patients as 'their own typical pain'. Student's /-test and x 2 " test were used where appropriate. RESULTS One hundred LBP patients (52 female) entered the study. The median age was 39 years (range 17-74); less than 10% of the patients were aged ^21 or >60 years. Forty-six (30 female) attended the rheumatology clinic and 54 (22 female) the orthopaedic department. No difference in clinical features was found between these two patient settings and analyses were done on the total group. The median duration of LBP was 36 months (range 1-360) and 96% of patients had chronic LBP of more than 3 months' duration. Of 67 patients with paid work for at least 20 h per week, 32 (48%) were unable to work (10/25 women and 22/42 men). This sickness
PATIENTS AND METHODS Consecutive new patients presenting with LBP at the out-patient clinics of rheumatology or orthopaedic surgery participated in the study. The criterion for entry was pain situated at some point between the lower ribs and the gluteal folds as the main complaint. Patients who had undergone lumbar surgery were excluded. All patients were assessed as usual by the physicians Submitted 21 November 1989; revised version accepted 10 March 1990. Correspondence to Dr G. Collee, Department of Rheumatology, University Hospital, Building 1, C2-Q, PO Box 9600, 2300 RC Leiden, The Netherlands. 354
Downloaded from http://rheumatology.oxfordjournals.org/ at Mount Royal University on June 14, 2015
SUMMARY In 100 patients with mainly chronic low back pain (LBP) signs and symptoms were evaluated prospectively and without preconceived expectation of particular findings. Two clinical syndromes were distinguished, both characterized by 'typical local tenderness' and associated with specific clinical features; these syndromes, described previously in the literature but receiving scant attention, were named the greater trochanteric pain syndrome (trochanteric bursitis) and the iliac crest pain syndrome (iliolumbar syndrome), and occurred in 35% and 43% of the patients, respectively. The recognition of these syndromes may enable us to study aetiology, prognosis, and therapy of LBP in more homogeneous groups of patients.
COLLfiE ETAL.: LOW BACK PAIN
355
TABLE I
TABLE II
TYPICAL LOCAL TENDERNESS IN 100 Low BACK PAIN PATIENTS
VARIABLES CORRELATED WITH GREATER TROCHANTERIC PAIN SYNDROME (GTPS) IN LOW BACK PAIN PATIENTS
Unilateral
Medial iliac crest Trochanteric region Iliotibial tract Insertion gluteus medius muscle
Total
Bilateral
right
left
43 35 47
13 8 21
19 17 14
11 10 12
15
4
8
3
DISCUSSION In this comprehensive and detailed study, more than half of the patients could be classified as GTPS or ICPS, two well-defined clinical syndromes. Our evaluation was prospective, encompassing
absent (n=65)
present ( )
Variables Night pain 38.5 Increase of pain during standing
A CLINICAL EPIDEMIOLOGICAL STUDY IN LOW BACK PAIN. DESCRIPTION OF TWO CLINICAL SYNDROMES BY G. COLLEE, B. A. C. DIJKMANS, J. P. VANDENBROUCKE*, P. M. ROZINGf AND A. CATS Departments of Rheumatology,
'Clinical Epidemiology and 10rthopaedic Surgery, University of Leiden, The Netherlands
KEY WORDS: LOW back pain, Regional pain syndromes, Greater trochanteric pain syndrome, Trochanteric bursitis, Iliac crest pain syndrome, Iliolumbar ligament syndrome.
Low back pain (LBP) is very common and affects more than half of all people during their lifetime and about 25% of the population at any given time [1,2]. LBP is usually transient and after 3 months only 5% of patients have persisting symptoms (chronic LBP) [1]. LBP is no diagnosis but a symptom. Only in 10-20% of the cases of acute LBP and in 10-45% of the chronic cases can a precise pathoanatomical lesion be recognized [3-6]. Thus, in the majority, the cause or diagnosis is unknown. The term non-specific LBP is preferred, because it underscores our lack of knowledge about this heterogeneous group of patients [7]. Most research on LBP is directed at epidemiological aspects, biomechanical models, technical investigations, invasive therapy, or psychosocial parameters. In contrast, a clinical approach is rarely employed and there is a striking lack of quantitative data concerning medical history and physical examination in nonselected groups of LBP patients. Furthermore, only a few studies have been directed at categorizing LBP in clinical syndromes [3, 4, 7, 8]. Until more data become available, non-specific LBP patients continue to be a clinically unclassifiable group, and this is a substantial obstacle for the study of therapy [9]. The purpose of the present investigation was to classify LBP by signs and symptoms.
of the out-patient clinics of rheumatology or orthopaedic surgery. At the end of the first visit, patients were invited to participate in the study. It was explained that the study was performed solely for the purpose of medical research and that the results would not affect evaluation, therapy or decisions pertaining to insurance or compensation. Within 1 week of the first visit, all patients were seen by one of us (G.C.) who was unaware of previous findings and diagnosis. He took a detailed medical history and performed an extensive physical examination according to a standardized protocol. History included patient characteristics, localization, characteristics and onset of pain and factors modifying the LBP. Examination included posture, range of movement, pain on movement, neurological findings, and systematic palpation for tenderness of the lumbar spine, paravertebral muscles, sacrum, iliac crests, gluteal muscles, trochanteric regions and iliotibial tracts. Typical local tenderness (TLT) was scored as positive if digital pressure not only revealed a point of maximum tenderness, but also reproduced the pain recognized by the patients as 'their own typical pain'. Student's /-test and x 2 " test were used where appropriate. RESULTS One hundred LBP patients (52 female) entered the study. The median age was 39 years (range 17-74); less than 10% of the patients were aged ^21 or >60 years. Forty-six (30 female) attended the rheumatology clinic and 54 (22 female) the orthopaedic department. No difference in clinical features was found between these two patient settings and analyses were done on the total group. The median duration of LBP was 36 months (range 1-360) and 96% of patients had chronic LBP of more than 3 months' duration. Of 67 patients with paid work for at least 20 h per week, 32 (48%) were unable to work (10/25 women and 22/42 men). This sickness
PATIENTS AND METHODS Consecutive new patients presenting with LBP at the out-patient clinics of rheumatology or orthopaedic surgery participated in the study. The criterion for entry was pain situated at some point between the lower ribs and the gluteal folds as the main complaint. Patients who had undergone lumbar surgery were excluded. All patients were assessed as usual by the physicians Submitted 21 November 1989; revised version accepted 10 March 1990. Correspondence to Dr G. Collee, Department of Rheumatology, University Hospital, Building 1, C2-Q, PO Box 9600, 2300 RC Leiden, The Netherlands. 354
Downloaded from http://rheumatology.oxfordjournals.org/ at Mount Royal University on June 14, 2015
SUMMARY In 100 patients with mainly chronic low back pain (LBP) signs and symptoms were evaluated prospectively and without preconceived expectation of particular findings. Two clinical syndromes were distinguished, both characterized by 'typical local tenderness' and associated with specific clinical features; these syndromes, described previously in the literature but receiving scant attention, were named the greater trochanteric pain syndrome (trochanteric bursitis) and the iliac crest pain syndrome (iliolumbar syndrome), and occurred in 35% and 43% of the patients, respectively. The recognition of these syndromes may enable us to study aetiology, prognosis, and therapy of LBP in more homogeneous groups of patients.
COLLfiE ETAL.: LOW BACK PAIN
355
TABLE I
TABLE II
TYPICAL LOCAL TENDERNESS IN 100 Low BACK PAIN PATIENTS
VARIABLES CORRELATED WITH GREATER TROCHANTERIC PAIN SYNDROME (GTPS) IN LOW BACK PAIN PATIENTS
Unilateral
Medial iliac crest Trochanteric region Iliotibial tract Insertion gluteus medius muscle
Total
Bilateral
right
left
43 35 47
13 8 21
19 17 14
11 10 12
15
4
8
3
DISCUSSION In this comprehensive and detailed study, more than half of the patients could be classified as GTPS or ICPS, two well-defined clinical syndromes. Our evaluation was prospective, encompassing
absent (n=65)
present ( )
Variables Night pain 38.5 Increase of pain during standing
