Clinical reasoning for complex cervical spine conditions

Pre-manipulative cervical spine testing and sustained rotation do not influence intracranial hemodynamics: an observational study with transcranial Doppler ultrasound

INTRODUCTION

Manual joint mobilization and manipulation are recommended therapeutic interventions for people with neck pain. High-velocity thrust and sustained techniques have an uncertain association with serious arterial trauma. The validity of pre-manipulative tests of the cervical spine is often questioned, and the understanding of the effect of head/neck position on blood flow is still incomplete. Most of the evidence concerning hemodynamics in this area relates to extracranial flow (vertebral and carotid artery). Less is understood about the effects on intracranial flow while performing pre-manipulative tests and sustained positions like end of range cervical rotation mobilization. The aim of the study was to assess the influence of commonly used evaluation and treatment positions on intracranial hemodynamic parameters.

METHOD

A randomized, cross-over observational study using ultrasonography on healthy subjects (n = 19) was conducted to measure hemodynamic parameters (peak systolic velocity and end diastolic maximum) of intracranial arterial systems. Two test positions (sustained pre-manipulative thrust C0-1 and sustained cervical end of range rotation) were compared with a sham position for each test position.

RESULTS

:Neither the sequence of tests performed nor an independent variable (the two positions) had a significant effect (p < 0.05) on peak systolic velocity (PSV) or end diastolic maximum (EDM).

DISCUSSION

No effects from commonly used assessment and treatment of neck positions on hemodynamic parameters were found. This is consistent with previous studies. Further study is indicated on people with symptoms and known pathologies.

Sensorimotor performance in acute-subacute non-specific neck pain: a non-randomized prospective clinical trial with intervention

Background

The assessment of cervical spine kinematic axial rotation performance is of great importance in the context of the study of neck sensorimotor control. However, studies addressing the influence of the level of provocation of spinal pain and the potential benefit of passive manual therapy mobilizations in patients with acute-subacute non-specific neck pain are lacking.

Methods

A non-randomized prospective clinical trial with an intervention design was conducted. We investigated: (1) the test-retest reliability of kinematic variables during a fast axial head rotation task standardized with the DidRen laser test device in 42 Healthy pain-free Control Participants (HCP) (24.3 years ±6.8); (2) the differences in kinematic variables between HCP and 38 patients with Acute-subacute Non-Specific neck Pain (ANSP) assigned to two different groups according to whether their pain was localized in the upper or lower spine (46.2 years ±16.3); and (3) the effect of passive manual therapy mobilizations on kinematic variables of the neck during fast axial head rotation.

Results

(1) Intra-class correlation coefficients ranged from moderate (0.57 (0.06-0.80)) to excellent (0.96 (0.91-0.98)). (2) Kinematic performance during fast axial rotations of the head was significantly altered in ANSP compared to HCP (age-adjusted) for one variable: the time between peaks of acceleration and deceleration (p<0.019). No significant difference was observed between ANSP with upper vs lower spinal pain localization. (3) After the intervention, there was a significant effect on several kinematic variables, e.g., ANSP improved peak speed (p<0.007) and performance of the DidRen laser test (p<0.001), with effect sizes ranging from small to medium.

Conclusion

(1) The DidRen laser test is reliable. (2) A significant reduction in time between acceleration and deceleration peaks was observed in ANSP compared to HCP, but with no significant effect of spinal pain location on kinematic variables was found. (3) We found that neck pain decreased after passive manual therapy mobilizations with improvements of several kinematic variables.

Trial registration

Registration Number: NCT 04407637

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04876-4.

Experiences of responsiveness to exercise in people with chronic whiplash: A qualitative study

Exercise is recommended in clinical guidelines for the treatment of chronic whiplash associated disorders (WAD). However, randomised controlled trials have shown similar effects for comprehensive exercise programs and advice. To date, there is no clear understanding of why some individuals with WAD appear to respond to exercise whilst others do not. The aim of this study was to explore the experiences and self-reported characteristics of people with chronic whiplash identifying as 'responders' and 'non-responders' to exercise. Semi-structured interviews were conducted with 13 people with chronic whiplash (patients) and seven treating physiotherapists. Patients were asked whether they responded to the exercise program, and what contributed to this. Physiotherapists were asked to share their experiences about the characteristics of people that appear to respond to exercise, and those that do not. An interpretive descriptive approach was selected to facilitate the generation of discipline-specific knowledge. Four themes were generated from patient and physiotherapist interviews, including: (1) the therapeutic relationship, (2) exercise experiences and beliefs, (3) self-efficacy and acceptance, (4) physical and psychological determinants of responsiveness. Responsiveness to exercise is complex and multifaceted. Clinicians may seek to identify the presence of discrete physical impairment(s) (e.g., range of motion restriction), and where present, determine whether targeted exercise results in an immediate and positive response. Clinicians may also focus their efforts on developing aspects of the therapeutic relationship identified as important to patients, such as hope, partnership and rapport.

Masterclass: A pragmatic approach to pain sensitivity in people with musculoskeletal disorders and implications for clinical management for musculoskeletal clinicians

INTRODUCTION

Research on musculoskeletal disorders indicates that pain sensitivity can be an important consideration for musculoskeletal clinicians in the holistic view of a patient presentation. However, diversity in research findings in this field can make this a difficult concept for clinicians to navigate. Limited integration of the concept of pain sensitivity into clinical practice for musculoskeletal clinicians has been noted.

PURPOSE

The purpose of this masterclass is to provide a framework for the consideration of pain sensitivity as a contributing factor in the presentation of people with musculoskeletal pain. It provides pragmatic synthesis of the literature related to pain sensitivity through a lens of how this information can inform clinical practice for musculoskeletal clinicians. Guidance is provided in a 'how to' format for integration of this knowledge into the clinical encounter to facilitate personalised care.

IMPLICATIONS

The relationship of pain sensitivity with pain and disability is not clear or linear. The real importance of pain sensitivity in a clinical presentation may be: (1) the potential for pain sensitivity to modify the effect of common treatments utilised by musculoskeletal clinicians, or (2) the effect of pain sensitivity on the prognosis/course of a disorder. Screening tools and subjective features have been highlighted to indicate when physical assessment of pain sensitivity should be prioritised in the physical examination. A pragmatic blueprint for specific assessment related to pain sensitivity has been outlined. A framework for integrating assessment findings into clinical reasoning to formulate management plans for the pain sensitive patient is provided.

Positive recovery for low-risk injuries screened by the short form - Örebro musculoskeletal pain screening questionnaire following road traffic injury: evidence from an inception cohort study in New South Wales, Australia

Background

Prognosis of musculoskeletal disorders following injury is essential in determining appropriate treatment and care. A generic validated prognostic tool to stratify risk of poor recovery for people with musculoskeletal injuries after road traffic crash is not available. This study aimed to examine differences in recovery, return to work and health related quality of life between low and high-risk of poor recovery people with musculoskeletal injuries stratified by the Short form - Örebro Musculoskeletal Pain Screening Questionnaire (SF-OMPSQ).

Methods

In an inception cohort study, participants with non-fracture musculoskeletal injury with the main site being the neck, lower back or lower limb were stratified into low (score ≤ 50) and high (score > 50) risk of poor recovery using the SF-OMPSQ score at baseline. We assessed the proportion of fully recovered participants (Global Perceived Effect scale ≥4), the proportion returning to work and changes in short form 12-item (SF-12) scores between baseline and 6-month follow-up in low and high-risk groups. Modified Poisson regression was used to estimate the adjusted risk ratio (RR) of being recovered and return to work in the low and high-risk groups. Paired t-test was used to compare changes in SF-12 physical and mental component summary scales, and chi-square test was used to assess the significance of the risk ratio of fully recovered between low and high-risk groups.

Results

The study included 498 participants (166 with neck, 78 with lower back and 254 with lower limb injuries). The proportion of being recovered was significantly higher in the low than the high-risk groups (Adjusted risk ratio: 2.96 [95% CI: 1.81 to 4.82]). Significantly more people in the low-risk group returned to work (91.0%) than the high-risk group (54.6%). People at low-risk had higher SF-12 scores at baseline and 6-month follow-up than those at high-risk. There were no differences between injury types for recovery and return to work at 6 months.

Conclusion

The SF-OMPSQ could be recommended as a generic prognostic tool to identify individuals with musculoskeletal injuries early after road traffic injury, who would have a higher or lower likelihood of recovering or returning fully to pre-injury work.

Trial registration

Australia New Zealand Clinical trial registry identification number - ACTRN12613000889752. Registered 09 August 2013.