Authors: Farhad Adelmanesh, MD Ali Jalali, MD Seyed Mostafa Jazayeri Shooshtari, MD Gholam Reza Raissi, MD Seyed Mehdi Ketabchi, MD Yoram Shir, MD

Low Back Pain

ORIGINAL RESEARCH ARTICLE

Affiliations: From the The Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal, Quebec, Canada (FA, YS); Ear, Nose, Throat, Head and Neck Surgery Department and Research Center, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran (AJ); Department of Physical Medicine and Rehabilitation, Shiraz University of Medical Sciences, Shiraz, Iran (SMJS); Department of Physical Medicine and Rehabilitation, Iran University of Medical Sciences, Tehran, Iran (GRR); and International Neuroscience Institute, Hannover, Germany (SMK).

Correspondence: All correspondence and requests for reprints should be addressed to: Farhad Adelmanesh, MD, The Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal General Hospital, 1650 Cedar Ave, Room E19 133, Montreal QC, Canada H3G1A4.

Disclosures: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

Editor’s Note: Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this (www.ajpmr.com).

Is There an Association Between Lumbosacral Radiculopathy and Painful Gluteal Trigger Points? A Cross-sectional Study ABSTRACT Adelmanesh F, Jalali A, Jazayeri Shooshtari SM, Raissi GR, Ketabchi SM, Shir Y: Is there an association between lumbosacral radiculopathy and painful gluteal trigger points? A cross-sectional study. Am J Phys Med Rehabil 2015;94:784Y791.

Objective: The objective of this study was to compare the prevalence of gluteal trigger point in patients with lumbosacral radiculopathy with that in healthy volunteers.

Design: In a cross-sectional, multistage sampling method, patients with clinical, electromyographic, and magnetic resonance imaging findings consistent with lumbosacral radiculopathy were examined for the presence of gluteal trigger point. Age- and sex-matched clusters of healthy volunteers were selected as the control group. The primary outcome of the study was the presence or absence of gluteal trigger point in the gluteal region of the patients and the control group.

Results: Of 441 screened patients, 271 met all the inclusion criteria for lumbosacral radiculopathy and were included in the study. Gluteal trigger point was identified in 207 (76.4%) of the 271 patients with radiculopathy, compared with 3 (1.9%) of 152 healthy volunteers (P G 0.001). The location of gluteal trigger point matched the side of painful radiculopathy in 74.6% of patients with a unilateral radicular pain. There was a significant correlation between the side of the gluteal trigger point and the side of patients’ radicular pain (P G 0.001).

Conclusions: Although rare in the healthy volunteers, most of the patients with 0894-9115/15/9410-0784 American Journal of Physical Medicine & Rehabilitation Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.

lumbosacral radiculopathy had gluteal trigger point, located at the painful side. Further studies are required to test the hypothesis that specific gluteal trigger point therapy could be beneficial in these patients. Key Words:

Trigger Point, Back Pain, Lumbosacral Radiculopathy, Tender Point

DOI: 10.1097/PHM.0000000000000261

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L

ow back pain (LBP) is reported by almost 80% of people during their life time1 and is the main factor limiting regular activity in young adults younger than 45 yrs.2 Diagnosing the cause of LBP is a significant challenge for practitioners because it is frequently difficult, or even impossible, to find a pathologic or anatomical reason that explicitly explains the complaints. Moreover, LBP in most of the cases does not have a simple, solitary etiology.3 Intervertebral disk herniation can irritate nerve roots leading to lumbosacral radiculopathy, an important etiology of LBP. Painful gluteal trigger point (GTrP), one of the major hallmarks of lumbosacral myofascial pain syndrome, could imitate sciatic-like pain,4 with pain referred to the lateral thigh and the region below the knee.5 Differentiating between radicular pain due to intervertebral disk herniation and myofascial pain with GTrP is not always trivial. Still, differentiating between these two etiologies is important because different therapeutic approaches could be used to treat them.4,6 Although the clinical experience of the authors of this study indicates the frequent presence of GTrP in patients with lumbosacral radiculopathy, a routine GTrP evaluation in patients with symptoms and signs suggesting nerve root involvement is not a common practice. The primary aims of the present study were, therefore, to quantify GTrP in patients with lumbosacral radiculopathy and to examine a possible correlation between the two pathologies, compared with a control group of healthy volunteers of matching age and sex.

METHODS The study was approved by the ethical committee of the university. All participants signed an informed consent before joining. It was a crosssectional study of eligible patients with a history of low back and radicular pain visiting the pain clinic in the Department of Physical Medicine and Rehabilitation. Initial eligibility was determined if the patient’s medical history suggested spinal nerve root involvement, as determined by the presence of any of the following conditions: history of LBP radiating to posterior/lateral thigh, leg, or foot; dermatomal leg numbness and/or paresthesia; or weakness of the lower limb muscles. Excluded were patients with a history of lumbar vertebral surgery, history of back trauma, active rheumatologic diseases, or fibromyalgia syndrome, as well as patients deemed to be too frail to participate in the study. Study patients were matched and compared with a control group of www.ajpmr.com

healthy volunteers from the hospital staff who agreed to participate in the study. Candidates for the control group were excluded if reporting one of the following: back and/or radicular pain in the last 6 mos, rheumatologic disease, previous spine trauma or surgery, peripheral neuropathy of any etiology, or peripheral vascular disease. The control group population was divided into two main cohorts, women and men, and then subdivided into age cohorts of 10 yrs each. Age matching was acceptable if the volunteer was born in the same decade as an individual patient of the same sex. Medical history of all participants, that is, the patients and control group subjects, was taken and recorded by a study member who was not involved later in their physical examination or magnetic resonance imaging (MRI) or electromyographic interpretations (see below).

Study Flow Chart Patients’ eligibility was determined in a multistage sampling method (Fig. 1). After each stage, a panel of experts, blinded to the GTrP findings, evaluated the results and decided whether patients will proceed with the next step or be excluded from the study.

Stage 1 Eligible patients and volunteers were randomly evaluated for the existence of GTrP at the superiorlateral gluteal areas. To avoid bias, the evaluator first met the patient or the healthy control subject when already lying in a prone position on the examination table. The presence or absence of GTrP was determined using the flat palpation technique. In this technique, taut bands and trigger points located at the superior-lateral part of the gluteal area are compressed between the thumb and the index finger against the underlying tissue or bone.7 Positive diagnosis of GTrP was made only when the following three criteria were fulfilled: severe tenderness to palpation, pain recognition (i.e., the elicited pain was recognized by the patient as her/his usual pain),8 and the presence of a taut band.9 Local twitch response, referred pain, and jump sign were evaluated as well, but their existence was not essential for the diagnosis of GTrP.9 Once a GTrP was identified, its sensitivity to controlled pressure was determined using a hand-held digital algometer (Pain Test; Wagner) that was attached to a force gauge and was equipped with a rubber disc head with a surface area of 1 cm2. Once the disc head was placed perpendicularly to the GTrP, the examiner constantly increased the pressure at a rate of 1 kg/cm2 per second. The subject was instructed to say Bnow[ when slight pain was experienced. The pressure shown by the algometer at that Gluteal Trigger Point and Radiculopathy

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FIGURE 1 Study flow chart. moment was recorded as pressure pain threshold of the patient. An upper pressure limit below 9 kg/cm2 was used to prevent false-positive results. The location and pressure pain threshold of each GTrP were recorded. If GTrP were identified bilaterally, both points were considered positive. Algometry was not done in examined individuals without GTrP.

Stage 2 Once the absence or existence of GTrP was recorded and quantified, the examiner verified the identity of the examined individual. The control group volunteers finished their participation at this stage and were discharged.

Stage 3 The patients then underwent a thorough neurologic and musculoskeletal examination. Patients whose findings in the physical examination were compatible with one of the following diagnoses were excluded from the study: sacroiliac or hip joints abnormalities, piriformis syndrome, and facet syndrome (see Appendix 1 for the detailed diagnostic tests; http://links.lww.com/PHM/A92).

Stage 4 Patients with history and physical examination indicative of radicular pain underwent MRI of the lumbosacral spine. The MRI was performed to determine the existence of herniated lumbosacral disk

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of any severity (bulged, protruded, or extruded). Scans of MRI were evaluated by two experienced researchers who were blinded to the patients’ history and the results of the physical examination. Patients with MRI findings indicative of spondylotic spinal canal stenosis or spondylolisthesis were excluded from further participation in the study, regardless of other MRI findings. Only patients whose MRI findings were in agreement with their pain history and physical findings indicative of radiculopathy were qualified for the final staging process.

Stage 5 Patients fulfilling all the previously mentioned criteria underwent electrophysiological studies to evaluate spinal nerve root/s involvement at levels agreeing with the clinical and MRI findings. A standard 6-point method, including paraspinal muscles evaluation, was used.10,11 Only patients with signs of acute or chronic/active nerve root involvement, detected at least in two muscles, were qualified to be included in the study. Patients with signs of peripheral neuropathy were excluded, and their results were not included in the final analysis.

Statistical Analysis The following data were recorded: patients’ demographic information, complaint characteristics,

Am. J. Phys. Med. Rehabil. & Vol. 94, No. 10, October 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

presence or absence of the GTrP, pressure algometry, as well as MRI and electrodiagnostic results. The onesample Kolmogorov-Smirnov was acquired to determine normal distribution for numeric variables such as age, pain duration, and algometry scores. Mode and median were reported instead of mean and standard deviation in numeric variables if they did not have a normal distribution. Nominal variables such as sex, chief complaint for referral, as well as electromyographic and MRI data were reported by prevalence. Fisher’s exact probability test was used to compare the prevalence of GTrP of the patients vs. that of the control group in a two-way table (patients/controls vs. presence/absence of the GTrP). The W2 test was used to assess the relationship between the painful side and the existence of GTrP in the resulting two-way cross tab. To evaluate patients with bilateral GTrP, each patient was considered to present two cases: one with right- and the other with left-sided symptoms. The Monte Carlo test was done to assess possible association between row and columns in the four-way cross tab. In addition, the Cramer V and phi were calculated to show strength of the possible association. The IBM SPSS Statistics v. 17 was used as statistical assistance.

RESULTS Of the 176 screened volunteers, 152 were included in the control group (59.8% women; mean age, 43.63 T 12.48 yrs). Twenty-four potential participants were excluded because no suitable age and sex matching patients were identified. Four hundred forty-one patients were initially screened for the study. Of them, 271 patients (61.4%) including 154 women (56.8%) and 117 men (43.2%) with a mean age of 45.7 T 14.2 yrs met all the inclusion criteria for lumbosacral radiculopathy and

were included in the statistical analysis. The reasons for exclusion are detailed in Table 1. Pain duration ranged from 1 to 52 mos, with a mode of 3 mos and median pain duration of 6 mos. Low back and leg pain was reported by 241 (88.9%) of the 271 patients; leg pain only, by 16 patients (5.9%); and lower limb paresthesia and/or weakness without leg or back pain, by 14 patients (5.2%). Rightsided symptoms (pain, paresthesia, or weakness) were reported by 113 participants (41.7%); left-sided symptoms, by 96 patients (35.4%); and bilateral pain and/or paresthesia, by 62 patients (22.9%). Intervertebral disk bulging, protrusion, and extrusion were detected by MRI in 26.1%, 39.1%, and 34.7% of the patients, respectively. The electromyogram identified L5 and/or S1 nerve roots involvement in 242 (89.3%) of the 271 patients. The other roots involved were mainly L4 and, rarely, L3 and L2 roots in 29 (10.7%) patients. Bilateral root involvement was identified in 125 patients, whereas only right or only left side was involved in 77 and 69 patients, respectively.

Gluteal Trigger Point Findings Gluteal trigger points were identified in 3 (1.9%) healthy volunteers and in 207 (76.4%) of the patients (P G 0.001; Fisher’s exact probability test). The mean pressure pain threshold of GTrP in these 207 patients was 3.90 T 1.26 kg/cm2 (range, 2.1Y8.4 kg/cm2). Ninety-six patients had right-sided GTrP, 83 had left-sided GTrP, and 28 patients had bilateral GTrP (Table 2). Of the patients with right-sided complaints, 76.1% had right-sided GTrP. Similarly, 72.9% of the patients with left-sided complaints were found to have left-sided GTrP. Of the 62 patients with bilateral complaints, 24 patients (38.7%) were found to have bilateral GTrPs (Table 3). Only

TABLE 1 Reasons for excluding patients Cause

No. Patients

Normal electromyography Unwilling to participate Spondylotic spinal canal stenosis Facet joint pain Fibromyalgia History of spinal trauma/surgery Other rheumatologic disease Spondylolisthesis Sacroiliac joint pain History of peripheral neuropathy Signs of peripheral neuropathy in electrodiagnostic test Normal MRI Patients deemed to be too frail to participate

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31 28 25 17 15 14 11 8 7 5 4 3 2

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TABLE 2 Prevalence of the GTrPs in patients with radicular pain Total No. Patients

Patients’ Complaint Weakness/paresthesia Bilateral Right side Left side Leg pain with or without paresthesia Bilateral Right side Left side Low back and leg pain Bilateral Right side Left side Total

Bilateral GTrP

Right-Sided GTrP

Left-Sided GTrP

No GTrP Found

14 9 3 2

9 2 2

1

16 3 7 6

1

50 103 88

23 3

2 4 3

3 2

1

241

271

5 82 3 96

28

one of the 14 patients with leg weakness and paresthesia without pain had positive GTrP. Of the 241 patients with both low back and leg pain, 103 patients had right-sided pain and 88 patients had left-sided pain. Gluteal trigger points were present in 85 (82.5%) of 103 patients with right-sided pain and in 70 (79.5%) of 88 patients with left-sided pain (Table 2). Sixty-three patients with MRI and electromyographic findings that were compatible with bilateral nerve compression reported a unilateral leg pain. Of these, 44 patients (69.8%) presented solely with GTrP ipsilateral to the painful side. A significant correlation was found between the side of the GTrP and the side of patients’ complaints (P G 0.001; Monte Carlo test; Cramer V = 0.681; phi = 0.694), indicating a high probability to find ipsilateral GTrP on the painful side of patients with radicular pain.

DISCUSSION This study shows, for the first time, that painful, easily identifiable trigger points located at the gluteal area are found in the majority of patients with low

9 4 70 83

13 14 15 64

back and radicular pain. Seventy-six percent of the patients were found to have GTrP, whereas only 1.9% of the healthy, pain-free volunteers had GTrP. Moreover, in more than two-thirds of patients with radicular pain, the identified GTrPs were located on the painful side. Lastly, GTrPs were not found in patients with painless discogenic, nerve root-mediated neurogenic symptoms. Taken together, these findings support the clinical observation of the authors of this study that GTrPs are common among patients with radicular pain and that they are directly associated with this pain condition. A survey done a decade ago among members of the American Pain Society showed that 88.5% considered myofascial pain syndrome a valid clinical disorder.12 The concept of myofascial pain and trigger points was first described by Travell and Simons9 as well as by McPartland and Travell13 and later by Mense and Simons,14 hypothesizing that its key element is energy crisis. On the basis of this theory, an initiating event, such as marked increase

TABLE 3 Concordance between side of the GTrPs and patients’ complaint Side of GTrP Side of Complaint Healthy Right Left Bilateral

None

Right

Left

Bilateral

Total

149 (98%) 20 (17.7%) 20 (20.8%) 24 (38.7%)

0 (0%) 86 (76.1%) 5 (5.2%) 5 (8.1%)

1 (0.7%) 4 (3.5%) 70 (72.9%) 9 (14.5%)

2 (1.3%) 3 (2.7%) 1 (1.0%) 24 (38.7%)

152 (100.0%) 113 (100.0%) 96 (100.0%) 62 (100.0%)

Monte Carlo test indicates significant association between the side of the trigger point and the side of complaint (P G 0.001). The Cramer V = 0.681 and phi = 0.694 indicate moderate to high strength correlation between the side of trigger point and the side of complaint. Bold values indicate the association between the side of the GTrPs and patients’ complaints.

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in acetylcholine release from the end plate or a direct trauma, can result in excessive release of calcium from the sarcoplasmic reticulum. High calcium concentration can produce maximal contracture in the affected segment of the muscle, resulting in increased energy demand as well as in decreased muscle circulation and metabolites. Trigger points are therefore local muscle lesions,15 caused by sensitization or irritation of a part in muscle pain pathway that can be either peripheral or central.16 Others, however, believe in the structural lesion model of musculoskeletal pain,17 implying that myofascial pain is, in fact, a secondary phenomenon. Thus, muscular pain has been attributed to spinal disorders,18 neuropathies,19,20 and dyskinetic motor patterns.21 Accordingly, GTrP may be the consequence of poor posture and muscle fatigue. Accordingly, patients with radicular pain prefer to stay in particular postures that decrease tension from the involved nerve roots, leading to increased pressure and workload on a specific side, facilitating GTrP formation.17,22 The results of the present study support the second explanation: Firstly, approximately three-quarters of patients with unilateral radicular pain presented ipsilateral GTrP; secondly, the authors of this study found that patients with bilateral complaint had no preference to deviate to one side, possibly explaining why only one-third of patients with bilateral pain were found to have GTrP; thirdly, almost 70% of patients with MRI and electromyographic findings that were compatible with bilateral nerve compression but with a unilateral leg pain were found to have GTrP ipsilateral to the painful area. It has been shown that, in muscle pain, intact peripheral nerves pathway and spinal cord connections are mandatory for eliciting local twitch response that can be recorded by electromyography.21,23 In the current study, 13 of 14 patients who were diagnosed as having painless leg weakness, an indicator of severe nerve root involvement, did not present with painful GTrP. These findings corroborate the evidence for the dependence of muscular tenderness in intact muscle pain pathway and suggest that GTrPs could contribute to the pain complaint of patients with painful radiculopathy. Although not proven at present, this could also explain why some of the so-called recalcitrant radiculopathies do not respond to common treatments targeting the nerve root involved. Patients with both low back and painful radiculopathy were found to have more than 80% concordance between the painful side and the side of GTrP location. This finding could imply a causeand-effect relationship between the two phenomena. www.ajpmr.com

However, because it was a cross-sectional study, the authors of this study cannot prove that, indeed, painful radiculopathy is the initiating factor for the development of GTrP, that is, that the high prevalence of GTrP is a direct result of nerve root involvement. Few strengths of this study are worth mentioning: Firstly, clinical and ancillary evaluations of all patients and control subjects were done by evaluators who were blinded to the individual’s identity because the evaluators have first met the subject when already lying in a prone position. This approach enabled the evaluators to remain unbiased by subjects’ posture, gait, facial expression, or other signs extractable from inspection. In addition, the selection and evaluation of the control-group subjects and patients recruited to this study were meticulously done, using tests with high sensitivity and specificity.24Y29 Still, some questions could be raised pertaining to the methods used. It might be argued that more invasive diagnostic tools, such as selective nerve blocks or joint injections, should have been part of the diagnostic armamentarium of the authors of this study, confirming or refuting the diagnosis of radiculopathy. However, previous studies have shown that these interventions are associated with frequent false-positive outcome, making it difficult to interpret the results.1,24,30Y33 In addition, although the authors of this study have used meticulous selection criteria, the authors of this study cannot completely rule out that patients with sacroiliac joint pain, piriformis syndrome, or facet joint pain could have been included in the study group. However, tender points typifying these syndromes are usually found in anatomical locations differing from those of GTrP: Whereas GTrPs are located at the superior-lateral part of the gluteal area, tender points associated with sacroiliac disease are located inferior-medially to the posterior superior iliac spine,25,31,34 those associated with piriformis syndrome are located over the sciatic notch,35 and tender points accompanying a facet joint disease are usually located in the paravertebral muscles situated above the affected joint.36 We are not familiar with research trying to explain the different anatomical locations of TP on the basis of different etiology. However, it has been shown that concurrent source of pain from zygapophysial joints, the sacroiliac joint, or the intervertebral disks in LBP is rare.37,38 What are the possible clinical implications of the current study? Firstly, because the results suggest a clear relationship between lumbosacral radiculopathy and specifically located GTrP, it is plausible that the existence of GTrP could help diagnosing patients with radicular LBP. Secondly, Gluteal Trigger Point and Radiculopathy

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beyond the accepted therapies aimed at the injured nerve, the concordance between the side of the pain and GTrP may suggest that additional therapies in some patients, targeting the GTrP and not the injured nerve itself, could be a reasonable adjuvant treatment that might improve outcome. This hypothesis is speculative at present and should be tested in further prospective studies. In conclusion, a high prevalence of specifically located GTrP was found in patients with radicular pain. Because a direct correlation was found between the painful side and the side of the GTrP, these myofascial triggers could be another source of pain in patients with lumbosacral radiculopathy. Beyond their diagnostic significance, the therapeutic value of direct therapy of GTrP in these patients has yet to be determined.

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31. Maigne JY, Aivaliklis A, Pfefer F: Results of sacroiliac joint double block and value of sacroiliac provocation tests in 54 patients with low back pain. Spine 1996;21:1889Y92 32. Bernard TN, Kirrkadly-Willis WH: Recognizing specific characteristics of non-specific low back pain. Clin Orthop 1987;217:266Y80 33. Schwarzer AC, Aprill CN, Derby R, et al: The false positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain 1994;58: 195Y200 34. Forst SL, Wheeler MT, Fortin JD, et al: The sacroiliac joint: anatomy, physiology and clinical significance. Pain Physician 2006;9:61Y8

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35. Barr KP, Harrast MA : Low back pain. In: Braddom RL: Physical Medicine and Rehabilitation. Philadelphia, PA, Saunders, 2011, p. 904 36. Kleynhans AM, Terrett AG: The prevention of complications from spinal manipulative therapy. In: Glasgow EF, Twomey LT, Scull ER, et al, eds: Aspects of Manipulative Therapy. 2nd ed. New York, NY: Churchill Livingstone, 1985, pp 161Y75 37. Schwarzer AC, Aprill CN, Bogduk N: The sacroiliac joint in chronic low back pain. Spine 1995;20:31Y7 38. Schwarzer AC, Aprill CN, Derby R, et al: The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine 1995;20:1878Y83

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Is There an Association Between Lumbosacral Radiculopathy and Painful Gluteal Trigger Points?: A Cross-sectional Study.

The objective of this study was to compare the prevalence of gluteal trigger point in patients with lumbosacral radiculopathy with that in healthy vol...
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