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Background:

Vitamin D deficiency-induced osteomalacia remains underexplored, despite the substantial migration to northern sun-deprived latitudes. In women, osteomalacia may impair smooth and striated muscle function and disrupt the birth canal. This study aimed to investigate the associations and effect estimates of biochemical osteomalacia on perinatal outcomes.

Methods:

A prospective cohort study was conducted to examine 71 Swedish and 52 Somali women during pregnancy and breastfeeding, addressing the heightened risk of severe vitamin D deficiency among Somali women. The baseline data comprised blood samples, questionnaires and clinical examination. Two years later, outcome variables were collected and comprised diagnostic codes for delivery methods. Women with miscarriage, stillbirth, or relocation from the region were excluded. Biochemical osteomalacia reaffirmed by signs and symptoms was diagnosed based on a non-invasive, non-radiation protocol. Associations between biochemical osteomalacia and delivery outcomes were analyzed using multinomial logistic regression, adjusted for a minimal set of confounders.

Results:

In the cohort 20 women, 19 Somali and one Swedish, were diagnosed with biochemical osteomalacia. Among women with biochemical osteomalacia, the adjusted odds ratio (aOR) for instrumental-assisted delivery was 4.92 (95 % CI 1.30-18.65) and the aOR for vacuum extractions was 16.16 (95 % CI 1.20-217.55).

Conclusions:

Biochemical osteomalacia was associated with a higher incidence of emergency instrumental delivery procedures, including an increased likelihood of vacuum-assisted delivery and emergency Caesarean sections. Primary healthcare staff play a vital role in screening for vitamin D deficiency during pregnancy and breastfeeding period, as well as initiating supplementation to mitigate the risk of adverse perinatal outcomes.

Introduction: This project aimed to develop a Person-Centred Co-ordinated Care (P3C) pathway for low back pain (LBP). Description: A national working group was formed consisting of representatives from all regional healthcare organisations in Sweden and included all relevant healthcare professions, academia, and patient organisations. A mixed method iterative design and consensus approach was applied in the development of the P3C pathway. Discussion: As a foundation, patient interviews along with a review of literature were conducted investigating the evidence base for healthcare interventions, earlier regional care programs/pathways and guidelines in Sweden as well as patient experiences and challenges with healthcare for LBP. Updated evidence-based clinical recommendations, tools supporting the practical use of the national P3C pathway and national healthcare data registry-based quality outcome indicators were then developed. Thereafter, an open consultation period provided review and feedback for final revisions and consensus. Conclusions: Essential factors for integrating best praxis according to scientific evidence and patient and healthcare professional perspectives were identified to establish a Swedish national P3C pathway for LBP. This provides a novel and innovative example of feasible methodology applicable in the international context. Future research will evaluate potential improvements in healthcare quality outcomes and effectiveness of dissemination and implementation strategies.

Introduction: The workload in orthopedic outpatient departments is increasing while the available medical resources are often limited. Research questions: Can reorganizing the outpatient work routines for referred patients with spinal disorders improve cost-effectiveness and patient's experience of care (PEC) without negatively affecting the waiting time required for the healthcare guarantee? Material and methods: We compared our standard routine (control group) to a new routine (study group) for evaluating referrals of patients with spinal complaints. In the control group, the referral was first evaluated by a spinal surgeon, and when deemed indicated, a visit to a spinal surgeon was booked. In the study group, a spinal surgeon first evaluated all referral notes and either assigned a spinal surgeon or a physiotherapist to meet the patient, depending on certain criteria. If considered eligible for surgical intervention, the patient is appointed for a follow-up visit to the spinal surgeon. For both groups, calculations were made for the number of waiting days and visits, as well as the cost. Also, we compared the PEC between the two groups through telephone interviews. Results: The number of waiting days and visits, as well as the cost, were significantly reduced (p < 0.01) in the study group. Also, the study group showed slightly higher mean values for the PEC components, with significant differences related to the waiting time, treatment with respect, and taking account of patient knowledge. Discussion and conclusions: Reorganizing outpatient work routines could eliminate the need for locum doctors while maintaining patient satisfaction and reducing costs.

Background: Lumbar spinal stenosis (LSS) is a common disorder in older people. Inactivity secondary to the disease state can further increase LSS symptoms. Initial care includes physiotherapy to relieve symptoms and optimize patient function and quality of life. It is currently unclear whether inactivity before surgery for LSS is associated with postoperative outcomes. Our aim was to investigate associations between self-reported exercise before LSS surgery and self-reported outcomes at 1 -year follow-up. Methods: Using a retrospective cohort study design, prospective data were collected from the National Swedish Register for Spine Surgery (Swespine) between September 2006 and December 2012: 11,956 patients diagnosed with LSS completed the 1 -year follow -up. The primary outcome measure was the Oswestry Disability Index (ODI). Secondary outcome measures were back and leg pain reported on a visual analog scale (VAS). The independent variable was dichotomized into no regular exercise (NRE) and regular exercise (RE). Adjusted analysis of covariance models were used to analyze differences in outcome improvement between the NRE and RE groups. Results: The mean improvement in the ODI was 15.9 (95% CI, 15.5-16.3) in the NRE group and 19.2 (95% CI, 18.5- 19.8) in the RE group (P < 0.001). Improvement in back pain (P < 0.001) and leg pain (P < 0.001) were also inferior in the NRE group compared to the RE group. The NRE group improved 21.8 (95% CI, 21.2-22.5) units in back pain and 28.8 (95% CI, 28.1-29.5) in leg pain on the VAS compared to 25.2 (95% CI, 24.2-26.3) units in back pain and 32.5 (95% CI, 31.3-33.6) in leg pain in the RE group. Conclusions: Inactivity defined as self-reported NRE before surgery for LSS is associated with worse outcomes 1 -year postsurgery compared to patients reporting RE. Clinical Relevance: This study is relevant to currently practicing spinal surgeons and spine physiotherapists. Level of Evidence: 3.

BackgroundPelvic girdle pain is a common problem during pregnancy. For most women, the symptoms cease within the first 3-6months of giving birth, but in some women the pain persists. In this study we investigate the sexuality and frequency of depressive symptoms in women with persistent pelvic girdle pain after childbirth and in healthy women.MethodsWe conducted a case-control study of women with persistent pelvic girdle pain after childbirth and a control group of healthy women. The frequency of depressive symptoms and sexuality were measured using the self-rating version of the Montgomery-Asberg Depression Rating Scale and the McCoy Female Sexuality Questionnaire.ResultsForty-six women with persistent pelvic girdle pain and thirty-nine healthy women were enrolled. The frequency of depressive symptoms and the total score on female sexuality did not differ between the groups. However, pain during intercourse was more frequent (P<0.001) in women with persistent pelvic girdle pain and caused them to avoid sexual intercourse frequently (P<0.001). In multiple linear regression a higher frequency of depressive symptoms was reversely correlated with a lower score on female sexuality (beta (=)-0,41, p<0,001 95% CI -0,6 - -0,22) This association remained after adjusting for obstetric variables and individual characteristics.ConclusionDepressive symptoms and female sexuality were similar between women with persistent pelvic girdle pain after childbirth and healthy controls. However, pain during intercourse and avoidance of sexual intercourse were more frequent among women with pelvic girdle pain.

Background: Chronic pelvic pain (CPP) affects 15-24% of women and can have a devastating impact on quality of life. Laparoscopy is often used in the investigation, although in one third of the examinations there is no visible pathology and the women may be dismissed without further investigation. Also, the contribution of skeletal, muscular, periosteal and ligamentous tissues to CPP remains to be further elucidated. The objective of the present study was to compare pain intensity provoked from anatomical landmarks of the intra-pelvic side-wall in women with pregnancy-related CPP after childbirth and women without such pain. Methods: This is a descriptive study of 36 non-randomly selected parous women with CPP after childbirth and 29 likewise selected parous women after childbirth without CPP. Pain was determined by questionnaire and clinical examination. The primary outcome measure was reported pain intensity provoked on 13 anatomical landmarks of the intra-pelvic side-wall. All women reported their perceived pain intensity for each anatomical landmark on Likert scales and an individual sum score was calculated. Results: Women with chronic pelvic pain were older than women without CPP. At several intra-pelvic landmarks high intensity pain was provoked in women with CPP compared with less intense pain provoked at fewer landmarks in women without low back or pelvic pain (p < 0.0001). The average sum of pain intensity scores was about 4 times higher in women with CPP (1.3) as compared with those without low back or pelvic pain (0.3), p < 0. 0001. This association remained when adjusting for the age difference between the pain groups in linear regression analysis. In addition, reported pain intensity at worst past week was independently associated with sum of pain intensity scores. The maximum individual sum of pain intensity scores among women without CPP was exceeded by that of 85% of the women with CPP. Conclusions: Parous women with CPP after childbirth had a heightened pain intensity over 13 anatomical landmarks during pelvic examination compared with parous women without CPP. These results need to be confirmed in a larger cohort with different types of CPP.

OBJECTIVES:

To describe referred pain patterns provoked from intra-pelvic structures in women with chronic pelvic pain (CPP) persisting after childbirth with the purpose to improve diagnostics and give implications for treatment.

MATERIALS AND METHODS:

In this descriptive and comparative study 36 parous women with CPP were recruited from a physiotherapy department waiting list and by advertisements in newspapers. A control group of 29 parous women without CPP was consecutively assessed for eligibility from a midwifery surgery. Inclusion criterion for CPP was: moderate pain in the sacral region persisting at least six months after childbirth confirmed by pelvic pain provocation tests. Exclusion criteria in groups with and without CPP were: persistent back or pelvic pain with onset prior to pregnancy, previous back surgery and positive neurological signs. Pain was provoked by palpation of 13 predetermined intra-pelvic anatomical landmarks. The referred pain distribution was expressed in pain drawings and described in pain maps and calculated referred pain areas.

RESULTS:

Pain provoked by palpation of the posterior intra-pelvic landmarks was mostly referred to the sacral region and pain provoked by palpation of the ischial and pubic bones was mostly referred to the groin and pubic regions, with or without pain referred down the ipsilateral leg. The average pain distribution area provoked by palpation of all 13 anatomical landmarks was 30.3 mm² (19.2 to 53.7) in women with CPP as compared to 3.2 mm² (1.0 to 5.1) in women without CPP, p< 0.0001.

CONCLUSIONS:

Referred pain patterns provoked from intra-pelvic landmarks in women with CPP are consistent with sclerotomal sensory innervation. Magnification of referred pain patterns indicates allodynia and central sensitization. The results suggest that pain mapping can be used to evaluate and confirm the pain experience among women with CPP and contribute to diagnosis.

Objectives: To explore the pain mechanism and the origin of the pain and to evaluate a short-term pain relief treatment in women suffering from CPP persisting after childbirth in order to enable physiotherapeutic intervention.

Material and methods: Thirty-six parous women with chronic pelvic pain persisting after childbirth were recruited at the Department of Physiotherapy, SundsvallHospital and by advertisements in newspapers and 29 parous women without chronic pelvic pain were recruited from an organized gynaecological screening at a midwifery surgery. All women were provoked by intra-pelvic palpation of 13 predetermined intra-pelvic landmarks. The provoked pain distribution was expressed in pain drawings and the pain intensity verbally on a Likert scale.Also, in a randomised controlled trial the 36 women with chronic pelvic pain were allocated to bilateral injection treatment with either triamcinolone or saline solutions, given once on the ischial spine with follow-up after four weeks.

Results: Referred pain provoked on intra-pelvic landmarks follows a specific pattern. In general, pain provoked by palpation of the posterior intra-pelvic landmarks was mostly referred to the sacral region and pain provoked by palpation of the ischial and pubic bones was mostly referred to the groin and pubic regions. In women with chronic pelvic pain the provoked pain distribution area and pain intensity were magnified as compared to women without chronic pelvic pain.

In the clinical trial decreased pain intensity, decreased distribution of pain and improved physical function was achieved among the triamcinolone treatment group as compared to the saline treatment group. Also, a positive correlation was shown between reduced pain intensity and improved function.

Conclusions: Referred pain patterns provoked on intra-pelvic landmarks in women with chronic pelvic pain persisting after childbirth are consistent with sclerotomal sensory innervations and indicates allodynia and central sensitisation. This suggests that pain mapping can be used to evaluate and confirm the pain experience and contribute to diagnosis. Also, the pain intensity provoked by stimulation of the intra-pelvic landmarks is suggested to be useful to differentiate women with chronic pelvic pain from those without. Corticosteroid treatment to the ischial spine resulted in decreased pain and increased function.

Background: Pregnancy-related low back and pelvic pain is a worldwide problem. A large proportion of women still experience disabling daily back pain 2 years after childbirth, resulting in major changes in activities and general well-being. In spite of this, the source of pain and effective treatment are uncertain. Objective: To evaluate the short-term effects on function of a single corticosteroid injection treatment to the ischiadic spine in women with persistent pregnancy-related pelvic pain (PPPP). Methods: Thirty-six women were allocated to injection treatment with slow-release triamcinolone and lidocain or saline and lidocain, given once at the sacrospinous ligament insertion on the ischiadic spine bilaterally with follow-up at 4 weeks. Outcome measures were Disability Rating Index (DRI), self-rated functional health (SF-36), gait speed and endurance (6MWT), and strength and endurance of trunk muscles (isometric trunk extensor and flexor tests). Results: Women in the triamcinolone group showed significantly improved DRI (p  =  0.046), 6MWT (p  =  0.016), and isometric trunk extensor tests (p  =  0.004), as compared with the saline group. Close co-variation was shown between improved function and reduced pain intensity. Conclusions: Improved function was achieved among women with PPPP after a single injection treatment with slow-release corticosteroid. The effect was positively correlated to the reduced pain intensity.