Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash? – A preliminary RCT

Differential changes in muscle composition exist in traumatic and nontraumatic neck pain

STUDY DESIGN

A population based cross-sectional study.

OBJECTIVE

To clarify relative constituents of viable muscle in 2-dimensional cross-sectional area (CSA) measures of ventral and dorsal cervical muscles in patients with chronic whiplash-associated disorders (WAD), idiopathic neck pain, and healthy controls.

SUMMARY OF BACKGROUND DATA

Previous data using T1-weighted magnetic resonance image demonstrated large amounts of neck muscle fat infiltration and increased neck muscle CSA in patients with chronic WAD but not in idiopathic neck pain or healthy controls.

METHODS

Magnetic resonance images were obtained for 14 cervical muscle regions in 136 females, including 79 with chronic whiplash, 23 with chronic idiopathic neck pain, and 34 healthy controls.

RESULTS

Without fat removed, relative CSA of 7 of 14 muscle regions in the participants with chronic WAD was larger, 3 of 14 smaller and 4 of 14 similar to healthy individuals. When T1-weighted signal representing the lipid content of these muscles was removed, 8 of 14 relative muscle CSA in patients with whiplash were similar, 5 of 14 were smaller and only 1 of 14 was larger than those observed in healthy controls. Removal of fat from the relative CSA measurement did not alter findings between participants with idiopathic neck pain and healthy controls.

CONCLUSION

These findings clarify that previous reports of increased relative CSA in patients with chronic whiplash represent cervical muscle pseudohypertrophy. Relative muscle CSA measures reveal atrophy in several muscles in both patients with WAD and idiopathic neck pain, which supports inclusion of muscle conditioning in the total management of these patients.

LEVEL OF EVIDENCE

3.

A comparison of physical and psychological features of responders and non-responders to cervical facet blocks in chronic whiplash

Background

Cervical facet block (FB) procedures are often used as a diagnostic precursor to radiofrequency neurotomies (RFN) in the management of chronic whiplash associated disorders (WAD). Some individuals will respond to the FB procedures and others will not respond. Such responders and non-responders provided a sample of convenience to question whether there were differences in their physical and psychological features. This information may inform future predictive studies and ultimately the clinical selection of patients for FB procedures.

Methods

This cross-sectional study involved 58 individuals with chronic WAD who responded to cervical FB procedures (WAD_R); 32 who did not respond (WAD_NR) and 30 Healthy Controls (HC)s. Measures included: quantitative sensory tests (pressure; thermal pain thresholds; brachial plexus provocation test); nociceptive flexion reflex (NFR); motor function (cervical range of movement (ROM); activity of the superficial neck flexors during the cranio-cervical flexion test (CCFT). Self-reported measures were gained from the following questionnaires: neuropathic pain (s-LANSS); psychological distress (General Health Questionnaire-28), post-traumatic stress (PDS) and pain catastrophization (PCS). Individuals with chronic whiplash attended the laboratory once the effects of the blocks had abated and symptoms had returned.

Results

Following FB procedures, both WAD groups demonstrated generalized hypersensitivity to all sensory tests, decreased neck ROM and increased superficial muscle activity with the CCFT compared to controls (p < 0.05). There were no significant differences between WAD groups (all p > 0.05). Both WAD groups demonstrated psychological distress (GHQ-28; p < 0.05), moderate post-traumatic stress symptoms and pain catastrophization. The WAD_NR group also demonstrated increased medication intake and elevated PCS scores compared to the WAD_R group (p < 0.05).

Conclusions

Chronic WAD responders and non-responders to FB procedures demonstrate a similar presentation of sensory disturbance, motor dysfunction and psychological distress. Higher levels of pain catastrophization and greater medication intake were the only factors found to differentiate these groups.

Effects of neck-specific exercise with or without a behavioural approach in addition to prescribed physical activity for individuals with chronic whiplash-associated disorders: a prospective randomised study

BACKGROUND

Up to 50% of chronic whiplash associated disorders (WAD) patients experience considerable pain and disability and remain on sick-leave. No evidence supports the use of physiotherapy treatment of chronic WAD, although exercise is recommended. Previous randomised controlled studies did not evaluate the value of adding a behavioural therapy intervention to neck-specific exercises, nor did they compare these treatments to prescription of general physical activity. Few exercise studies focus on patients with chronic WAD, and few have looked at patients' ability to return to work and the cost-effectiveness of treatments. Thus, there is a great need to develop successful evidence-based rehabilitation models. The study aim is to investigate whether neck-specific exercise with or without a behavioural approach (facilitated by a single caregiver per patient) improves functioning compared to prescription of general physical activity for individuals with chronic WAD.

METHODS/DESIGN

The study is a prospective, randomised, controlled, multi-centre study with a 2-year follow-up that includes 216 patients with chronic WAD (> 6 months and < 3 years). The patients (aged 18 to 63) must be classified as WAD grade 2 or 3. Eligibility will be determined with a questionnaire, telephone interview and clinical examination. The participants will be randomised into one of three treatments: (A) neck-specific exercise followed by prescription of physical activity; (B) neck-specific exercise with a behavioural approach followed by prescription of physical activity; or (C) prescription of physical activity alone without neck-specific exercises. Treatments will be performed for 3 months. We will examine physical and psychological function, pain intensity, health care consumption, the ability to resume work and economic health benefits. An independent, blinded investigator will perform the measurements at baseline and 3, 6, 12 and 24 months after inclusion. The main study outcome will be improvement in neck-specific disability as measured with the Neck Disability Index. All treatments will be recorded in treatment diaries and medical records.

DISCUSSION

The study findings will help improve the treatment of patients with chronic WAD.

TRIALS REGISTRATION

ClinicalTrials.gov identifier: NCT01528579.

Psychological Care, Patient Education, Orthotics, Ergonomics and Prevention Strategies for Neck Pain: An Systematic Overview Update as Part of the ICON Project

OBJECTIVES

To conduct an overview on psychological interventions, orthoses, patient education, ergonomics, and 1⁰/2⁰ neck pain prevention for adults with acute-chronic neck pain.

SEARCH STRATEGY

Computerized databases and grey literature were searched (2006-2012).

SELECTION CRITERIA

Systematic reviews of randomized controlled trials (RCTs) on pain, function/disability, global perceived effect, quality-of-life and patient satisfaction were retrieved.

DATA COLLECTION & ANALYSIS

Two independent authors selected articles, assessed risk of bias using AMSTAR tool and extracted data. The GRADE tool was used to evaluate the body of evidence and an external panel to provide critical review.

MAIN RESULTS

We retrieved 30 reviews (5-9 AMSTAR score) reporting on 75 RCTs with the following moderate GRADE evidence. For acute whiplash associated disorder (WAD), an education video in emergency rooms (1RCT, 405participants] favoured pain reduction at long-term follow-up thus helping 1 in 23 people [Standard Mean Difference: -0.44(95%CI: -0.66 to -0.23)). Use of a soft collar (2RCTs, 1278participants) was not beneficial in the long-term. For chronic neck pain, a mind-body intervention (2RCTs, 1 meta-analysis, 191participants) improved short-term pain/function in 1 of 4 or 6 participants. In workers, 2-minutes of daily scapula-thoracic endurance training (1RCT, 127participants) over 10 weeks was beneficial in 1 of 4 participants. A number of psychosocial interventions, workplace interventions, collar use and self-management educational strategies were not beneficial.

REVIEWERS' CONCLUSIONS

Moderate evidence exists for quantifying beneficial and non-beneficial effects of a limited number of interventions for acute WAD and chronic neck pain. Larger trials with more rigorous controls need to target promising interventions.

Pain treatment for patients with osteoarthritis and central sensitization

Osteoarthritis is one of the most frequent, disabling, and costly pathologies of modern society. Among the main aims of osteoarthritis management are pain control and functional ability improvement. The exact cause of osteoarthritis pain remains unclear. In addition to the pathological changes in articular structures, changes in central pain processing or central sensitization appear to be involved in osteoarthritis pain. The latter calls for a broader approach to the management of patients with osteoarthritis. Yet, the scientific literature offers scant information addressing the treatment of central sensitization, specifically in patients with osteoarthritis. Interventions such as cognitive-behavioral therapy and neuroscience education potentially target cognitive-emotional sensitization (and descending facilitation), and centrally acting drugs and exercise therapy can improve endogenous analgesia (descending inhibition) in patients with osteoarthritis. Future studies should assess these new treatment avenues.

Relationship between quantitative sensory testing and pain or disability in people with spinal pain-a systematic review and meta-analysis

Sensitization of the nervous system can present as pain hypersensitivity that may contribute to clinical pain. In spinal pain, however, the relationship between sensory hypersensitivity and clinical pain remains unclear. This systematic review examined the relationship between pain sensitivity measured via quantitative sensory testing (QST) and self-reported pain or pain-related disability in people with spinal pain. Electronic databases and reference lists were searched. Correlation coefficients for the relationship between QST and pain intensity or disability were pooled using random effects models. Subgroup analyses and mixed effects meta-regression were used to assess whether the strength of the relationship was moderated by variables related to the QST method or pain condition. One hundred and forty-five effect sizes from 40 studies were included in the meta-analysis. Pooled estimates for the correlation between pain threshold and pain intensity were -0.15 (95% confidence interval [CI]: -0.18 to -0.11) and for disability -0.16 (95% CI: -0.22 to -0.10). Subgroup analyses and meta-regression did not provide evidence that these relationships were moderated by the QST testing site (primary pain/remote), pain condition (back/neck pain), pain type (acute/chronic), or type of pain induction stimulus (eg, mechanical/thermal). Fair correlations were found for the relationship between pain intensity and thermal temporal summation (0.26, 95% CI: 0.09 to 0.42) or pain tolerance (-0.30, 95% CI: -0.45 to -0.13), but only a few studies were available. Our study indicates either that pain threshold is a poor marker of central sensitization or that sensitization does not play a major role in patients' reporting of pain and disability. Future research prospects are discussed.

Effectiveness of an 8-week exercise programme on pain and specificity of neck muscle activity in patients with chronic neck pain: a randomized controlled study

BACKGROUND

Although exercise can be effective for relief of neck pain, little is known about the effect of exercise on the neural control of neck muscles.

METHODS

A randomized controlled trial was conducted on 46 women with chronic neck pain to investigate the immediate effectiveness of an 8-week exercise programme on pain and directional specificity of neck muscle activity. At baseline, the patients completed questionnaires including the neck disability index (NDI) and performed a circular contraction of their head in the horizontal plane at 15 N force, with continuous change in force direction in the range 0-360°. Electromyography (EMG) was recorded from the sternocleidomastoid (SCM) and splenius capitis (SCap) muscles. Tuning curves of the EMG amplitude were computed, which depicts muscle activity over a range of force directions. The mean point of the tuning curves defined a directional vector, which determined the specificity of muscle activity. Patients were randomly assigned either to a training or control group.

RESULTS

A significant between-group difference in the change in NDI was observed. A reduction in NDI was observed following training (pre: 18.2 ± 7.4; post: 14.1 ± 6.5; p < 0.01) but not for the control group (pre: 17.5 ± 6.3; post: 16.6 ± 7.4). The training group showed higher specificity of muscle activity post-intervention (pre: 18.6 ± 9.8%, post: 24.7 ± 14.3%; p < 0.05), whereas no change occurred for the control group (pre: 19.4 ± 11.9%, post: 18.2 ± 10.1%).

CONCLUSION

An exercise programme that aims to enhance motor control of the cervical spine improves the specificity of neck muscle activity and reduces pain and disability in patients with neck pain.

Evidence of Physiotherapy Interventions for Patients with Chronic Neck Pain: A Systematic Review of Randomised Controlled Trials

Chronic neck pain (CNP) is common and costly, and the effect of physiotherapeutic interventions on the condition is unclear. We reviewed the literature for evidence of effect of physiotherapy interventions on patients with CNP. Five bibliographic databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, and PEDro) were systematically searched. Randomised, placebo and active-treatment-controlled trials including physiotherapy interventions for adults with CNP were selected. Data were extracted primary outcome was pain. Risk of bias was appraised. Effect of an intervention was assessed, weighted to risk of bias. 42 trials reporting on randomised comparisons of various physiotherapy interventions and control conditions were eligible for inclusion involving 3919 patients with CNP. Out of these, 23 were unclear or at high risk of bias, and their results were considered moderate- or low-quality evidence. Nineteen were at low risk of bias, and here eight trials found effect on pain of a physiotherapy intervention. Only exercise therapy, focusing on strength and endurance training, and multimodal physiotherapy, cognitive-behavioural interventions, massage, manipulations, laser therapy, and to some extent also TNS appear to have an effect on CNP. However, sufficient evidence for application of a specific physiotherapy modality or aiming at a specific patient subgroup is not available.

A randomized controlled trial of cognitive-behavioral therapy for the treatment of PTSD in the context of chronic whiplash

OBJECTIVES

Whiplash-associated disorders (WAD) are common and involve both physical and psychological impairments. Research has shown that persistent posttraumatic stress symptoms are associated with poorer functional recovery and physical therapy outcomes. Trauma-focused cognitive-behavioral therapy (TF-CBT) has shown moderate effectiveness in chronic pain samples. However, to date, there have been no clinical trials within WAD. Thus, this study will report on the effectiveness of TF-CBT in individuals meeting the criteria for current chronic WAD and posttraumatic stress disorder (PTSD).

METHOD

Twenty-six participants were randomly assigned to either TF-CBT or a waitlist control, and treatment effects were evaluated at posttreatment and 6-month follow-up using a structured clinical interview, self-report questionnaires, and measures of physiological arousal and sensory pain thresholds.

RESULTS

Clinically significant reductions in PTSD symptoms were found in the TF-CBT group compared with the waitlist at postassessment, with further gains noted at the follow-up. The treatment of PTSD was also associated with clinically significant improvements in neck disability, physical, emotional, and social functioning and physiological reactivity to trauma cues, whereas limited changes were found in sensory pain thresholds.

DISCUSSION

This study provides support for the effectiveness of TF-CBT to target PTSD symptoms within chronic WAD. The finding that treatment of PTSD resulted in improvements in neck disability and quality of life and changes in cold pain thresholds highlights the complex and interrelating mechanisms that underlie both WAD and PTSD. Clinical implications of the findings and future research directions are discussed.

Subgroups based on thermal and pressure pain thresholds in women with chronic whiplash display differences in clinical presentation - an explorative study

PURPOSE

To investigate the presence of subgroups in chronic whiplash-associated disorders (WAD) based on pain thresholds for pressure (PPT), cold (CPT), and heat (HPT) and to compare these subgroups with respect to symptomatology, disability, and health aspects.

METHODS

Two groups of female subjects - patients with chronic WAD (n = 28) and healthy controls (CON; n = 29) - were investigated. Quantitative sensory testing (QST) for thermal thresholds and algometry for PPT at four sites in the body (over the trapezius and tibialis anterior bilaterally) were determined. Habitual pain intensities, psychological strain, disability, and health aspects were registered using a questionnaire.

RESULTS

A CLUSTER ANALYSIS BASED ON PPT, CPT, AND HPT IDENTIFIED TWO SUBGROUPS OF CHRONIC WAD: one sensitive subgroup (s-WAD; n = 21), and one less sensitive subgroup (ls-WAD; n = 6). S-WAD displayed widespread hyperalgesia, whereas ls-WAD had localized hyperalgesia in the neck area, with tendencies to supernormal values in remote areas of the body. Generally, s-WAD had a significantly worse situation than the CON with respect to symptomatology, disability, and health aspects. The ls-WAD group was intermediary between s-WAD and CON in these aspects.

CONCLUSION

Different explanations, eg, severity of the pain condition per se, etiological factors, and pre-trauma differences in pain sensitivity, may exist for the differences in pain thresholds between the two subgroups. Future research should investigate the role of pain thresholds in the chronic stage to determine the efficacy of treatment interventions.

Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions

In recent years, increased knowledge of the pathogenesis of upper quadrant pain syndromes has translated to better management strategies. Recent studies have demonstrated evidence of peripheral and central sensitization mechanisms in different local pain syndromes of the upper quadrant such as idiopathic neck pain, lateral epicondylalgia, whiplash-associated disorders, shoulder impingement, and carpal tunnel syndrome. Therefore, a treatment-based classification approach where subjects receive matched interventions has been developed and, it has been found that these patients experience better outcomes than those receiving non-matched interventions. There is evidence suggesting that the cervical and thoracic spine is involved in upper quadrant pain. Spinal manipulation has been found to be effective for patients with elbow pain, neck pain, or cervicobrachial pain. Additionally, it is known that spinal manipulative therapy exerts neurophysiological effects that can activate pain modulation mechanisms. This paper exposes some manual therapies for upper quadrant pain syndromes, based on a nociceptive pain rationale for modulating central nervous system including trigger point therapy, dry needling, mobilization or manipulation, and cognitive pain approaches.

IFOMPT 2012: a rendez-vous of hands and minds

Since its founding in Montreal, Canada in 1974, the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) has been providing orthopaedic and manual therapists from around the world with the highest-quality learning opportunities through a conference held every 4 years. In 2012, IFOMPT is partnering with The International Private Practitioners Association (IPPA) to host this prestigious event in Quebec City, Canada. As more than 51% of the Canadian Physiotherapy Association membership is working in private practice, this adds even greater value to this quadrennial event. This conference emulates best-evidence practice in the marriage of research and clinical excellence by pulling together some of the best and brightest hands and minds in orthopaedic physiotherapy. Through a call for proposals that equally emphasized research, clinical excellence, and the knowledge translation link between the two, the IFOMPT mandate of clinical and academic excellence has been kept at the forefront of this year's conference. Included in this supplement are the IFOMPT 2012 keynote addresses, schedule, and abstracts.

Does acupuncture activate endogenous analgesia in chronic whiplash-associated disorders? A randomized crossover trial

BACKGROUND

Many patients with chronic pain, including those with chronic whiplash-associated disorders (WAD), show features of central sensitization. Randomized trials examining whether treatments are able to influence the process of central sensitization in patients with chronic WAD are emerging. Therefore, the present study aimed at examining whether acupuncture results in activation of endogenous analgesia and relief in symptoms in patients with chronic WAD.

METHODS

In this randomized crossover pilot trial with blinded assessors, each patient (n = 39) received two treatment sessions of identical duration, with acupuncture and relaxation therapy randomly crossed over in visit 2. Primary outcome measurement included immediate activation of endogenous analgesia i.e., pressure pain sensitivity and conditioned pain modulation. Secondary outcome measurements included pain relief and reduced disability level.

RESULTS

Local pressure pain sensitivity at baseline and during conditioned pain modulation decreased significantly more following acupuncture compared with relaxation (time × group interactions: p < 0.001), both in the neck and at a site distinct from the painful region. When comparing the effects of acupuncture versus relaxation, no differences were observed on conditioned pain modulation, temporal summation of pressure pain, neck disability or symptom severity (all p-values >0.05).

CONCLUSION

It was shown that one session of acupuncture treatment results in acute improvements in pressure pain sensitivity in the neck and calf of patients with chronic WAD. Acupuncture had no effect on conditioned pain modulation or temporal summation of pressure pain. Both acupuncture and relaxation appear to be well-tolerated treatments for people with chronic WAD. These findings suggest that acupuncture treatment activates endogenous analgesia in patients with chronic WAD.

Exercises for mechanical neck disorders

BACKGROUND

Neck disorders are common, disabling and costly. The effectiveness of exercise as a physiotherapy intervention remains unclear.

OBJECTIVES

To improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.

SEARCH METHODS

Computerized searches were conducted up to February 2012.

SELECTION CRITERIA

We included single therapeutic exercise randomized controlled trials for adults with neck pain with or without cervicogenic headache or radiculopathy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted selection, data extraction, 'Risk of bias' assessment, and clinical relevance. The quality of the body of evidence was assessed using GRADE. Relative risk and standardized mean differences (SMD) were calculated.  After judging clinical and statistical heterogeneity, we performed meta-analyses.

MAIN RESULTS

Six of the 21 selected trials had low risk of bias. Moderate quality evidence shows that combined cervical, scapulothoracic stretching and strengthening are beneficial for pain relief post treatment (pooled SMD -0.35, 95% confidence interval (CI): -0.60, -0.10) and at intermediate follow-up (pooled SMD -0.31, 95% CI: -0.57, -0.06), and improved function short term and intermediate term (pooled SMD -0.45, 95% CI: -0.72, -0.18) for chronic neck pain. Moderate quality evidence demonstrates patients are very satisfied with their care when treated with therapeutic exercise. Low quality evidence shows exercise is of benefit for pain in the short term and for function up to long-term follow-up for chronic neck pain. Low to moderate quality evidence shows that chronic neck pain does not respond to upper extremity stretching and strengthening or a general exercise program.Low to moderate quality evidence supports self-mobilization, craniocervical endurance and low load cervical-scapular endurance exercises in reducing pain, improving function and global perceived effect in the long term for subacute/chronic cervicogenic headache. Low quality evidence supports neck strengthening exercise in acute cervical radiculopathy for pain relief in the short term.

AUTHORS' CONCLUSIONS

Low to moderate quality evidence supports the use of specific cervical and scapular stretching and strengthening exercise for chronic neck pain immediately post treatment and intermediate term, and cervicogenic headaches in the long term. Low to moderate evidence suggests no benefit for some upper extremity stretching and strengthening exercises or a general exercise program.  Future trials should consider using an exercise classification system to establish similarity between protocols and adequate sample sizes. Factorial trials would help determine the active treatment agent within a treatment regimen where a standardized representation of dosage is essential. Standardized reporting of adverse events is needed for balancing the likelihood of treatment benefits over potential harms.

What is different about spinal pain?

BACKGROUND

The mechanisms subserving deep spinal pain have not been studied as well as those related to the skin and to deep pain in peripheral limb structures. The clinical phenomenology of deep spinal pain presents unique features which call for investigations which can explain these at a mechanistic level.

METHODS

Targeted searches of the literature were conducted and the relevant materials reviewed for applicability to the thesis that deep spinal pain is distinctive from deep pain in the peripheral limb structures. Topics related to the neuroanatomy and neurophysiology of deep spinal pain were organized in a hierarchical format for content review.

RESULTS

Since the 1980's the innervation characteristics of the spinal joints and deep muscles have been elucidated. Afferent connections subserving pain have been identified in a distinctive somatotopic organization within the spinal cord whereby afferents from deep spinal tissues terminate primarily in the lateral dorsal horn while those from deep peripheral tissues terminate primarily in the medial dorsal horn. Mechanisms underlying the clinical phenomena of referred pain from the spine, poor localization of spinal pain and chronicity of spine pain have emerged from the literature and are reviewed here, especially emphasizing the somatotopic organization and hyperconvergence of dorsal horn "low back (spinal) neurons". Taken together, these findings provide preliminary support for the hypothesis that deep spine pain is different from deep pain arising from peripheral limb structures.

CONCLUSIONS

This thesis addressed the question "what is different about spine pain?" Neuroanatomic and neurophysiologic findings from studies in the last twenty years provide preliminary support for the thesis that deep spine pain is different from deep pain arising from peripheral limb structures.

Patient education for neck pain

BACKGROUND

Neck disorders are common, disabling, and costly. The effectiveness of patient education strategies is unclear.

OBJECTIVES

To assess the short- to long-term effects of therapeutic patient education (TPE) strategies on pain, function, disability, quality of life, global perceived effect, patient satisfaction, knowledge transfer, or behaviour change in adults with neck pain associated with whiplash or non-specific and specific mechanical neck pain with or without radiculopathy or cervicogenic headache.

SEARCH METHODS

We searched computerised bibliographic databases (inception to 11 July 2010).

SELECTION CRITERIA

Eligible studies were randomised controlled trials (RCT) investigating the effectiveness of TPE for acute to chronic neck pain.

DATA COLLECTION AND ANALYSIS

Paired independent review authors conducted selection, data abstraction, and 'Risk of bias' assessment. We calculated risk ratio (RR) and standardised mean differences (SMD). Heterogeneity was assessed; no studies were pooled.

MAIN RESULTS

Of the 15 selected trials, three were rated low risk of bias. Three TPE themes emerged.Advice focusing on activation: There is moderate quality evidence (one trial, 348 participants) that an educational video of advice focusing on activation was more beneficial for acute whiplash-related pain when compared with no treatment at intermediate-term [RR 0.79 (95% confidence interval (CI) 0.59 to 1.06)] but not long-term follow-up [0.89 (95% CI, 0.65 to 1.21)]. There is low quality evidence (one trial, 102 participants) that a whiplash pamphlet on advice focusing on activation is less beneficial for pain reduction, or no different in improving function and global perceived improvement from generic information given out in emergency care (control) for acute whiplash at short- or intermediate-term follow-up. Low to very low quality evidence (nine trials using diverse educational approaches) showed either no evidence of benefit or difference for varied outcomes. Advice focusing on pain & stress coping skills and workplace ergonomics: Very low quality evidence (three trials, 243 participants) favoured other treatment or showed no difference spanning numerous follow-up periods and disorder subtypes.  Low quality evidence (one trial, 192 participants) favoured specific exercise training for chronic neck pain at short-term follow-up.Self-care strategies: Very low quality evidence (one trial, 58 participants) indicated that self-care strategies did not relieve pain for acute to chronic neck pain at short-term follow-up.

AUTHORS' CONCLUSIONS

With the exception of one trial, this review has not shown effectiveness for educational interventions, including advice to activate, advice on stress-coping skills, workplace ergonomics and self-care strategies. Future research should be founded on sound adult learning theory and learning skill acquisition.

Can a functional postural exercise improve performance in the cranio-cervical flexion test?--a preliminary study

Deep cervical flexor (DCF) muscle impairment is common in patients with neck pain. Retraining function is often commenced with a motor relearning approach, requiring the patient to practice and hold a cranio-cervical flexion position in supine lying. Motor relearning requires multiple repetitions which is difficult to achieve if only exercising in supine. This preliminary study investigated the effects of training the DCF with a functional exercise: assumption of an upright lumbo-pelvic and spinal postural position, adding a neck lengthening manoeuvre. The exercise effect was evaluated by changes in sternocleidomastoid (SCM) muscle activity in the cranio-cervical flexion test (CCFT). Twenty subjects with neck pain were randomly assigned to an exercise or control group. The exercise group trained for two weeks. Pre and post-intervention, electromyographic (EMG) signals were recorded from the SCM muscles during the five stages of the CCFT. Results indicated that the exercise improved performance. SCM EMG signal amplitudes decreased across all CCFT stages, albeit significant only at the first and third stages of the test; 22 mmHg (p = 0.043) and 26 mmHg (p = 0.003). No differences were evident in the control group (all p > 0.05). There was no difference between groups for pain and disability measures. This initial study indicates that a postural exercise, convenient to perform during the working day, improves the pattern of SCM muscle activity in the CCFT. Whilst further research is necessary, these observations suggest the worth of such an exercise to augment other training in the rehabilitation of patients with neck pain.

The traumatised chronic pain patient—Prevalence of posttraumatic stress disorder - PTSD and pain sensitisation in two Scandinavian samples referred for pain rehabilitation

Introduction

Correctly identifying chronic pain patients with posttraumatic stress disorder (PTSD) is important because the comorbidity of a chronic pain condition and PTSD is found to compromise treatment success. In addition, the existence of PTSD is associated with pain sensitisation, elevated levels of pain, and disability. Furthermore, the diagnostic criteria for PTSD has changed dramatically in the last two decades which has had a profound impact on the reported prevalence rates of PTSD in chronic pain samples. To our knowledge, no study has employed the DSM-IV criteria for estimating the prevalence of PTSD in chronic pain patients referred consecutively for multidisciplinary pain rehabilitation.

Aim

The aim of the present study was to assess the prevalence of significant traumatic stressors and PTSD in chronic pain patients referred consecutively to multidisciplinary pain rehabilitation. We wanted to investigate whether specific pain diagnoses were more related to PTSD than others. Moreover, we investigated the possible association of altered sensory processing (hypersensitivity or hyposensitivity) and PTSD.

Methods

Data were collected from two Scandinavian multidisciplinary pain centres (Denmark and Finland). All patients referred consecutively were assessed for PTSD and sensitisation at admission. A total of 432 patients were assessed, of which 304 (DK, N =220, female n = 144; FIN, N=84, female n = 44) were admitted and consented to participate. All patients had to be diagnosed with a non-malign chronic pain condition lasting for at least 6 months (median = 6.0 years). The Harvard Trauma Questionnaire was employed to measure PTSD symptoms, using the DSM-IV criteria. To measure altered sensory processing, anaesthetists performed quantitative sensory testing on admission. Patients were asked to report if cold, brush, and pinprick mechanical stimulation resulted in decreased or increased sensation or pain.

Results

stimulation resulted in decreased or increased sensation or pain. Results: A high prevalence of PTSD was found in both consecutive samples. Using the DSM-IV criteria, 23% fulfilled the criteria for a possible PTSD diagnosis. There were no gender differences in PTSD. The three most reported traumatic events: traffic accidents, serious illness personally or in the family, and the actual loss of someone, were reported as the primary traumatic events by almost 50% of those with PTSD. No particular pain diagnosis was significantly related to PTSD. However, hypersensitivity to cold and hyposensitivity to brush were significantly associated with PTSD.

Discussion

The prevalence of PTSD in the present study was 23%. Earlier studies finding a lower prevalence rate of PTSD may reflect the use of older diagnostic criteria for PTSD or other estimates, for instance PTSD symptom cut-off scores.

Conclusion

The study emphasised the importance of screening all chronic pain patients for PTSD at admission for pain rehabilitation, using up to date diagnostic tools.

Implications

Untreated PTSD may exacerbate or maintain the pain condition and negatively affect outcome of pain rehabilitation.

Neck exercises, physical and cognitive behavioural-graded activity as a treatment for adult whiplash patients with chronic neck pain: design of a randomised controlled trial

BACKGROUND

Many patients suffer from chronic neck pain following a whiplash injury. A combination of cognitive, behavioural therapy with physiotherapy interventions has been indicated to be effective in the management of patients with chronic whiplash-associated disorders. The objective is to present the design of a randomised controlled trial (RCT) aimed at evaluating the effectiveness of a combined individual physical and cognitive behavioural-graded activity program on self-reported general physical function, in addition to neck function, pain, disability and quality of life in patients with chronic neck pain following whiplash injury compared with a matched control group measured at baseline and 4 and 12 months after baseline.

METHODS/DESIGN

The design is a two-centre, RCT-study with a parallel group design. Included are whiplash patients with chronic neck pain for more than 6 months, recruited from physiotherapy clinics and an out-patient hospital department in Denmark. Patients will be randomised to either a pain management (control) group or a combined pain management and training (intervention)group. The control group will receive four educational sessions on pain management, whereas the intervention group will receive the same educational sessions on pain management plus 8 individual training sessions for 4 months, including guidance in specific neck exercises and an aerobic training programme. Patients and physiotherapists are aware of the allocation and the treatment, while outcome assessors and data analysts are blinded. The primary outcome measures will be Medical Outcomes Study Short Form 36 (SF36), Physical Component Summary (PCS). Secondary outcomes will be Global Perceived Effect (-5 to +5), Neck Disability Index (0-50), Patient Specific Functioning Scale (0-10), numeric rating scale for pain bothersomeness (0-10), SF-36 Mental Component Summary (MCS), TAMPA scale of Kinesiophobia (17-68), Impact of Event Scale (0-45), EuroQol (0-1), craniocervical flexion test (22 mmHg - 30 mmHg), joint position error test and cervical range of movement. The SF36 scales are scored using norm-based methods with PCS and MCS having a mean score of 50 with a standard deviation of 10.

DISCUSSION

The perspectives of this study are discussed, in addition to the strengths and weaknesses.

TRIAL REGISTRATION

The study is registered in http://www.ClinicalTrials.gov identifier NCT01431261.

Traumatic injury and traumatic stress

STUDY DESIGN

To review findings from recent research in consideration of relevant theoretical models between post-traumatic stress disorder (PTSD) and pain, and to review emerging interventions and prevention options for PTSD in individuals with whiplash.

OBJECTIVE

A traumatic accident may lead to whiplash injury, but can also frequently lead to post-traumatic stress. There is concern that this occurrence is more problematic than each disorder separately. Furthermore, it is unclear why this might occur. This review addresses two mechanisms that might explain this, specifically arousal and pain.

SUMMARY OF BACKGROUND DATA

There is a growing body of research revealing relationships between injury, pain and psychological trauma with important implications for the prevention and management of chronic pain and post-traumatic reactions. Intervention for PTSD in the context of whiplash has been shown to be effective, and seems to have a beneficial effect on the whiplash injury. The intervention for traumatic stress in acute whiplash presents further challenges.

METHODS

This chapter will review findings from recent research in consideration of relevant theoretical models between PTSD and pain in general and more specifically in the case of pain resulting from whiplash injury. A review of emerging interventions and prevention options for PTSD in individuals with whiplash will also be discussed to provide a basis for treatment of individuals and future research.

RESULTS

Recent work in this area suggests that stress, pain and arousal interact through the effects of tissue injury and the distress in response to perceived threat. Post-traumatic stress plays an important role in a significant proportion of whiplash sufferers as its presence seems to deleteriously impact recovery.

CONCLUSION

Intervention for PTSD in the context of whiplash has been shown to be effective, and seems to have a beneficial effect on the whiplash injury. The intervention for traumatic stress in acute whiplash presents further challenges.

Considerations in the physical rehabilitation of patients with whiplash-associated disorders

STUDY DESIGN

Review of research identifying physical impairments in the neuromuscular system in subjects with whiplash-associated disorders.

OBJECTIVE

Review the impairments in movement and neuromuscular function toward constructing research informed exercise programs.

SUMMARY OF BACKGROUND DATA

Pain and injury to the musculoskeletal system result in loss of motion and impaired neuromuscular function which impacts on functional activities, work and quality of life. Therapeutic exercise is a mainstay of rehabilitation, but the nature of the exercises prescribed are currently various and the effect sizes of current programs for patients with whiplash-associated disorders are modest at best.

METHODS

A review was undertaken of research investigating the changes in cervical motion and neuromuscular function to better inform exercise prescription and identify areas for future research. RESULTS.: Reduced range of movement as well as pathological movement patterns (reduced acceleration and velocity, reduced smoothness and irregular axes of neck movement) have been documented in subjects with whiplash-associated disorders. In relation to neuromuscular control, changes have been demonstrated in neck muscles' spatial and temporal relationships as well as in their strength and endurance. The presence or not and the extent of changes is highly variable between individuals and appears to have some relationship to pain intensity. It appears that there is a need for specificity in exercise prescription to address particular impairments rather than the use of generic programs. High pain intensity can modify effects of a therapeutic exercise program.

CONCLUSION

Pain and injury result in reorganization of the motor control strategies of neck muscles and movement. Further research is required to determine if outcomes after a whiplash injury can be improved by using research informed, individually prescribed exercise programs matched to the individual's presentation. Research into best methods of pain management is also required to facilitate physical rehabilitation.

Toward optimal early management after whiplash injury to lessen the rate of transition to chronicity: discussion paper 5

STUDY DESIGN

Expert debate and synthesis of research to inform future management approaches for acute whiplash disorders.

OBJECTIVE

To identify a research agenda toward improving outcomes for acute whiplash-injured individuals to lessen the incidence of transition to chronicity.

SUMMARY OF BACKGROUND DATA

International figures are concordant, estimating that 50% of individuals recover from pain and disability within 3 to 6 months of a whiplash injury. The remainder report continuing symptoms up to 1 to 2 years or longer postinjury. As no management approach to date has improved recovery rates, new clinical/research directions are required for early management of whiplash-injured patients.

METHODS

A group of multidisciplinary researchers critically debated evidence and current research concerning whiplash from biological, psychological, and social perspectives toward informing future research directions for management of acute whiplash.

RESULTS

It was recognized that effective treatments for acute whiplash are constrained by a limited understanding of causes of whiplash-associated disorders. Acute whiplash presentations are heterogeneous leading to the proposal that a research priority was development of a triage system based on modifiable prognostic indicators and clinical features to better inform individualized early management decisions. Other priorities identified included researching effective early pain management for individuals presenting with moderate to high levels of pain; development of best education/information for acute whiplash; testing the efficacy of stratified and individualized rehabilitation, researching modes of delivery considering psychosocial modulators of pain and disability; and the timing, nature, and mode of delivery of cognitive-behavioral therapies. Directions were highlighted for future biomechanical research into injury prevention.

CONCLUSION

The burden of whiplash injuries, the high rate of transition to chronicity, and evidence of limited effects of current management on transition rates demand new directions in evaluation and management. Several directions have been proposed for future research, which reflect the potential multifaceted dimensions of an acute whiplash disorder.

Diagnosis of altered central pain processing

STUDY DESIGN

Nonsystematic review.

OBJECTIVE

To review the current knowledge on detecting altered central pain processing in individual patients with chronic pain.

SUMMARY OF BACKGROUND DATA

Alterations in central pain processing are mainly characterized by hyperexcitability of the central nervous system and disturbances in endogenous pain modulation. Although these mechanisms are widely recognized as important determinants of pain and disability, there is need for translation of this knowledge into benefits for patients. To this purpose, the first step is the detection of abnormalities in pain processing in individual patients. Quantitative sensory tests (QST) explore aspects of nociception and pain perception, and are therefore potentially useful for diagnostic purposes.

METHODS

Nonsystematic review of the reliability, validity and reference values of QST for the assessment of altered central pain processing in chronic pain patients.

RESULTS

The reliability of QST is generally high. However, most studies have been performed on healthy volunteers, and few reliability data in patients are available. Furthermore, little is known on the reliability of measures of endogenous pain modulation. The face validity of QST is acceptable. The construct validity cannot be tested, because there is no gold standard for the detection of altered central pain processing in humans. Reference values of different types of QST for applications in neuropathic and musculoskeletal pain have been determined in large samples of pain-free subjects.

CONCLUSION

QST can be used in clinical practice to assess the presence of sensory abnormalities in individual patients. Because information on the reliability and validity of the tests is incomplete, the findings should be interpreted with caution. It is still unclear to what extent disturbances in central pain processing are relevant for the determination of symptoms in individual patients. Furthermore, the therapeutic consequences of these assessments remain undetermined. These are challenges of future translational research.

Dizziness, unsteadiness, visual disturbances, and postural control: implications for the transition to chronic symptoms after a whiplash trauma

STUDY DESIGN

Synthesis and application of research.

OBJECTIVE

To provide a framework to consider the role of signs and symptoms of postural control disturbance in the transition to chronicity after a whiplash trauma.

SUMMARY OF BACKGROUND DATA

Dizziness is one of the most frequent complaints in those with persistent pain after a whiplash trauma and is often associated with postural control disturbances.

METHODS

Focus paper to review the causes, management, onset, and relationships of such signs and symptoms after a whiplash trauma to explore the role they may have in the transition to chronicity.

RESULTS

Contemporary literature suggests these signs and symptoms are often, but not always, aligned with those with significant neck pain and disability and have been related to a poorer prognosis. There are obvious links between the cervical proprioceptors and the musculoskeletal system, but links to the autonomic nervous, vestibular, and visual systems and influence on pain modulation are important. Postural control may have potential to alter other systems and affect pain and should be considered as one of the processes that might influence the transition to chronicity after a whiplash trauma. Future research should monitor the effect that addressing abnormal cervical afferent input has on not just dizziness and postural control but other symptoms such as altered pain processing and psychological distress.

CONCLUSION

The causes of transition into chronicity after a whiplash trauma are present early and appear to be multifactorial. Pain sensitivity and psychosocial distress have recently been considered but postural deficits and the symptom of dizziness also appear to have a role.It is recommended that future research address these issues to further the understanding of the transition to chronicity after a whiplash trauma.

Whiplash-associated disorder: musculoskeletal pain and related clinical findings

The aim of this paper was to review the physical and psychological processes associated with whiplash-associated disorders. There is now much scientific data available to indicate the presence of disturbed nociceptive processing, stress system responses, muscle and motor changes as well as psychological factors in both acute and chronic whiplash-associated disorders. Some of these factors seem to be associated with the transition from acute to chronic pain and have demonstrated prognostic capacity. Further investigation is required to determine if these processes can be modified and if modification will lead to improved outcomes for this condition. The burden of whiplash injuries, the high rate of transition to chronicity, and evidence of limited effects of current management on transition rates demand new directions in evaluation and management. The understanding of processes underlying this condition is improving and this lays the foundation for the development of more effective management approaches.

Objective assessment of mandibular motor control using a 'reach-and-hold' task

Mandibular motor function is well known to be impaired in the presence of temporomandibular disorders. However, while a vast literature is available concerning accuracy of motor control in limbs, quantitative and objective assessment of mandibular motor control has been seldom performed, also because of the lack of adequate investigative tools. Aim of this work is to present a technique for reliable evaluation of the motor performance of the mandible based on a kinesiography-monitored reach-and-hold task. Nineteen healthy subjects were engaged in a task in which they had to drive a cursor on a screen by corresponding movements of the mandible in the frontal plane and reach 30 random targets sequentially displayed on the screen. The whole task was repeated three times per session in two different days. The individual performance was assessed by different indices evaluating precision and steadiness of target matching. The performance progressively improved in the three trials of the first session, further improved and stabilised in the second session, with an average positioning error of 0·59 ± 038 mm and was slightly correlated with the horizontal dimension of the mandible border movement (r = 0·55). Intraclass correlation coefficient ranged between 0·76 and 0·94 for the different indices indicating good repeatability. The kinesiographic technique allowed for objective and reliable assessment of the voluntary control of the mandible position. Its potential applications include support to the characterisation of temporomandibular disorders and to motor training and progress monitoring in rehabilitation treatments.

Treatment of central sensitization in patients with 'unexplained' chronic pain: what options do we have?

INTRODUCTION

Central sensitization accounts for chronic 'unexplained' pain in a wide variety of disorders, including chronic whiplash-associated disorders, temporomandibular disorders, chronic low back pain, osteoarthritis, fibromyalgia, chronic fatigue syndrome and chronic tension-type headache among others. Given the increasing evidence supporting the clinical significance of central sensitization in those with unexplained chronic pain, the awareness is growing that central sensitization should be a treatment target in these patients.

AREAS COVERED

This article provides an overview of the treatment options available for desensitizing the CNS in patients with chronic pain due to central sensitization. It focuses on those strategies that specifically target pathophysiological mechanisms known to be involved in central sensitization. In addition, pharmacological options, rehabilitation and neurotechnology options are discussed.

EXPERT OPINION

Acetaminophen, serotonin-reuptake inhibitor drugs, selective and balanced serototin and norepinephrine-reuptake inhibitor drugs, the serotonin precursor tryptophan, opioids, N-methyl-d-aspartate (NMDA)-receptor antagonists, calcium-channel alpha(2)delta (a2δ) ligands, transcranial magnetic stimulation, transcutaneous electric nerve stimulation (TENS), manual therapy and stress management each target central pain processing mechanisms in animals that - theoretically - desensitize the CNS in humans. To provide a comprehensive treatment for 'unexplained' chronic pain disorders characterized by central sensitization, it is advocated to combine the best evidence available with treatment modalities known to target central sensitization.

Physiotherapy rehabilitation for whiplash associated disorder II: a systematic review and meta-analysis of randomised controlled trials

Objective To evaluate effectiveness of physiotherapy management in patients experiencing whiplash associated disorder II, on clinically relevant outcomes in the short and longer term. Design Systematic review and meta-analysis. Two reviewers independently searched information sources, assessed studies for inclusion, evaluated risk of bias and extracted data. A third reviewer mediated disagreement. Assessment of risk of bias was tabulated across included trials. Quantitative synthesis was conducted on comparable outcomes across trials with similar interventions. Meta-analyses compared effect sizes, with random effects as primary analyses. Data sources Predefined terms were employed to search electronic databases. Additional studies were identified from key journals, reference lists, authors and experts. Eligibility criteria for selecting studies Randomised controlled trials (RCTs) published in English before 31 December 2010 evaluating physiotherapy management of patients (>16 years), experiencing whiplash associated disorder II. Any physiotherapy intervention was included, when compared with other types of management, placebo/sham, or no intervention. Measurements reported on ≥1 outcome from the domains within the international classification of function, disability and health, were included. Results 21 RCTs (2126 participants, 9 countries) were included. Interventions were categorised as active physiotherapy or a specific physiotherapy intervention. 20/21 trials were evaluated as high risk of bias and one as unclear. 1395 participants were incorporated in the meta-analyses on 12 trials. In evaluating short term outcome in the acute/sub-acute stage, there was some evidence that active physiotherapy intervention reduces pain and improves range of movement, and that a specific physiotherapy intervention may reduce pain. However, moderate/considerable heterogeneity suggested that treatments may differ in nature or effect in different trial patients. Differences between participants, interventions and trial designs limited potential meta-analyses. Conclusions Inconclusive evidence exists for the effectiveness of physiotherapy management for whiplash associated disorder II. There is potential benefit for improving range of movement and pain short term through active physiotherapy, and for improving pain through a specific physiotherapy intervention.

A research synthesis of therapeutic interventions for whiplash-associated disorder: part 1 - overview and summary

Whiplash-associated disorder (WAD) represents a significant public health problem, resulting in a substantial socioeconomic burden throughout the industrialized world, wherever costs are documented. While many treatments have been advocated for patients with WAD, scientific evidence of their effectiveness is often lacking. A systematic review was conducted to evaluate the strength of evidence supporting various WAD therapies. Multiple databases (including Web of Science, EMBASE and PubMed) were searched to identify all studies published from January 1980 through March 2009 that evaluated the effectiveness of any clearly defined treatment for acute (less than two weeks), subacute (two to 12 weeks) or chronic (longer than 12 weeks) WAD. The present article, the first in a five-part series, provides an overview of the review methodology as well as a summary and discussion of the review's main findings. Eighty-three studies met the inclusion criteria, 40 of which were randomized controlled trials. The majority of studies (n=47) evaluated treatments initiated in the chronic stage of the disorder, while 23 evaluated treatments for acute WAD and 13 assessed therapies for subacute WAD. Exercise and mobilization programs for acute and chronic WAD had the strongest supporting evidence, although many questions remain regarding the relative effectiveness of various protocols. At present, there is insufficient evidence to support any treatment for subacute WAD. For patients with chronic WAD who do not respond to conventional treatments, it appears that radiofrequency neurotomy may be the most effective treatment option. The present review found a relatively weak but growing research base on which one could make recommendations for patients at any stage of the WAD continuum. Further research is needed to determine which treatments are most effective at reducing the disabling symptoms associated with WAD.

A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 4 - noninvasive interventions for chronic WAD

Whiplash-associated disorder (WAD) represents a significant public health problem, resulting in substantial social and economic costs throughout the industrialized world. While many treatments have been advocated for patients with WAD, scientific evidence supporting their effectiveness is often lacking. A systematic review was conducted to evaluate the strength of evidence for various WAD therapies. Multiple databases (including Web of Science, EMBASE and PubMed) were searched to identify all studies published from January 1980 through March 2009 that evaluated the effectiveness of any clearly defined treatment for acute (less than two weeks), subacute (two to 12 weeks) or chronic (longer than 12 weeks) WAD. The present article, the fourth in a five-part series, evaluates the evidence for noninvasive interventions initiated during the chronic phase of WAD. Twenty-two studies that met the inclusion criteria were identified, 12 of which were randomized controlled trials with 'good' overall methodological quality (median Physiotherapy Evidence Database score of 6). For the treatment of chronic WAD, there is evidence to suggest that exercise programs are effective in relieving whiplash-related pain, at least over the short term. While the majority of a subset of nine studies supported the effectiveness of interdisciplinary interventions, the two randomized controlled trials provided conflicting results. Finally, there was limited evidence, consisting of one supportive case series each, that both manual joint manipulation and myofeedback training may provide some benefit. Based on the available research, exercise programs were the most effective noninvasive treatment for patients with chronic WAD, although many questions remain regarding the relative effectiveness of various exercise regimens.

Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy

The aim of the current study was to identify whether hyperexcitability of the central nervous system is a prognostic factor for individuals with carpal tunnel syndrome (CTS) likely to experience rapid and clinical self-reported improvement following a physical therapy program including soft tissue mobilization and nerve slider neurodynamic interventions. Women presenting with clinical and electrophysiological findings of CTS were involved in a prospective single-arm trial. Participants underwent a standardized examination and then a physical therapy session. The physical therapy sessions included both soft tissue mobilization directed at the anatomical sites of potential median nerve entrapment and a passive nerve slider neurodynamic technique targeted to the median nerve. Pressure pain thresholds (PPT) over the median, radial and ulnar nerves, C5-C6 zygapophyseal joint, carpal tunnel and tibialis anterior muscle were assessed bilaterally. Additionally, thermal detection and pain thresholds were measured over the carpal tunnel and thenar eminence bilaterally to evaluate central nervous system excitability. Subjects were classified as responders (having achieved a successful outcome) or non-responders based on self-perceived recovery. Variables were entered into a stepwise logistic regression model to determine the most accurate variables for determining prognosis. Data from 72 women were included in the analysis, of which 35 experienced a successful outcome (48.6%). Three variables including PPT over the C5-C6 joint affected side <137 kPa, HPT carpal tunnel affected side <39.6º and general health >66 points were identified. If 2 out of 3 variables were present (LR + 14.8), the likelihood of success increased from 48.6 to 93.3%. We identified 3 factors that may be associated with a rapid clinical response to both soft tissue mobilization and nerve slider neurodynamic techniques targeted to the median nerve in women presenting with CTS. Our results support that widespread central sensitization may not be present in women with CTS who are likely to achieve a successful outcome with physical therapy. Future studies are now necessary to validate these findings.

Differential development of sensory hypersensitivity and a measure of spinal cord hyperexcitability following whiplash injury

Widespread sensory hypersensitivity is present in acute whiplash and is associated with poor recovery. Decreased nociceptive flexion reflex (NFR) thresholds (spinal cord hyperexcitability) are a feature of chronic whiplash but have not been investigated in the acute to chronic injury stage. This study compared the temporal development of sensory hypersensitivity and NFR responses from soon after injury to either recovery or to transition to chronicity. It also aimed to identify predictors of persistent spinal cord hyperexcitability. Pressure and cold pain thresholds, NFR responses (threshold and pain VAS) were prospectively measured in 62 participants at <3 weeks, 3 and 6 months post whiplash injury and in 22 healthy controls on two occasions a month apart. Pain levels and psychological distress (GHQ-28; IES) were measured at baseline. Whiplash participants were classified at 6 months post-injury using the Neck Disability Index: recovered (8%), mild pain and disability (10-28%) or moderate/severe pain and disability (30%). All whiplash groups demonstrated spinal cord hyperexcitability (lowered NFR thresholds) at 3 weeks post-injury. This hyperexcitability persisted in those with moderate/severe symptoms at 6 months but resolved in those who recovered or reported lesser symptoms at 6 months. In contrast generalized sensory hypersensitivity (pressure and cold) was only ever present in those with persistent moderate/severe symptoms and remained unchanged throughout the study period. This suggests different mechanisms underlie sensory hypersensitivity and NFR responses. In multivariate analyses only initial NDI scores (p=0.003) were a unique predictor of persistent spinal cord hyperexcitability indicating possible ongoing peripheral nociception following whiplash injury.

Manual therapy and exercise for neck pain: A systematic review

Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematic review update assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. Computerized searches were performed to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardized mean differences (pSMD) were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias. Low quality evidence suggests clinically important long-term improvements in pain (pSMD-0.87(95% CI:-1.69,-0.06)), function/disability, and global perceived effect when manual therapy and exercise are compared to no treatment. High quality evidence suggests greater short-term pain relief [pSMD-0.50(95% CI:-0.76,-0.24)] than exercise alone, but no long-term differences across multiple outcomes for (sub)acute/chronic neck pain with or without cervicogenic headache. Moderate quality evidence supports this treatment combination for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash. Evidence regarding radiculopathy was sparse. Specific research recommendations are made.

Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: a systematic review

Adverse events (AE) are a concern for practitioners utilizing cervical manipulation or mobilization. While efficacious, these techniques are associated with rare but serious adverse events. Five bibliographic databases (PubMed, CINAHL, PEDro, AMED, EMBASE) and the gray literature were searched from 1998 to 2009 for any AE associated with cervical manipulation or mobilization for neck pain. Randomized controlled trials (RCTs), prospective or cross-sectional observational studies were included. Two independent reviewers conducted study selection, method quality assessment and data abstraction. Pooled relative risks (RR) were calculated. Study quality was assessed using the Cochrane system, a modified Critical Appraisal Skills Program form and the McHarm scale to assess the reporting of harms. Seventeen of 76 identified citations resulted in no major AE. Two pooled estimates for minor AE found transient neurological symptoms [RR 1.96 (95% CI: 1.09-3.54) p < 0.05]; and increased neck pain [RR 1.23 (95% CI: 0.85-1.77) p > .05]. Forty-four studies (58%) were excluded for not reporting AE. No definitive conclusions can be made due to a small number of studies, weak association, moderate study quality, and notable ascertainment bias. Improved reporting of AE in manual therapy trials as recommended by the CONSORT statement extension on harms reporting is warranted.