Diagnostic accuracy of patient interview items and clinical tests for cervical radiculopathy

(Cost-)effectiveness of personalised multimodal physiotherapy compared to surgery in patients with cervical radiculopathy: A systematic review

RATIONALE

Cervical radiculopathy is initially typically managed conservatively. Surgery is indicated when conservative management fails or with severe/progressive neurological signs. Personalised multimodal physiotherapy could be a promising conservative strategy. However, aggregated evidence on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with/without post-operative physiotherapy is lacking.

AIM/OBJECTIVES

To systematically summarise the literature on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with or without post-operative physiotherapy in patients with cervical radiculopathy.

METHODS

PubMed, Embase, CINAHL, PsycINFO and Web of Science were searched from inception to 1st of March 2023. Primary outcomes were effectiveness regarding costs, arm pain intensity and disability. Neck pain intensity, perceived recovery, quality of life, neurological symptoms, range-of-motion, return-to-work, medication use, (re)surgeries and adverse events were considered secondary outcomes. Randomised clinical trials comparing personalised multimodal physiotherapy versus surgical approaches with/without post-operative physiotherapy were included. Two independent reviewers performed study selection, data-extraction, and risk of bias assessment using the Cochrane RoB 2 and Consolidated Health Economic Evaluation Reporting Standards statement. Certainty of the evidence was determined using Grading of Recommendations, Assessment, Development and Evaluations.

RESULTS

From 2109 records, eight papers from two original trials, with 117 participants in total were included. Low certainty evidence showed there were no significant differences on arm pain intensity and disability, except for the subscale 'heavy work' related disability (12 months) and disability at 5-8 years. Cost-effectiveness was not assessed. There was low certainty evidence that physiotherapy improved significantly less on neck pain intensity, sensory loss and perceived recovery compared to surgery with/without physiotherapy. Low certainty evidence showed there were no significant differences on numbness, range of motion, medication use, and quality of life. No adverse events were reported.

CONCLUSION

Considering the clinical importance of accurate management recommendations and the current low level of certainty, high-quality cost-effectiveness studies are needed.

Rethinking neck-related arm pain: hypothetical clinical scenarios to differentiate the underlying IASP-defined pain mechanisms

Neck-related arm pain is frequently encountered in clinical settings, yet its underlying pain mechanisms remain elusive. While such pain radiating from the neck to the arm is often attributed to injuries or diseases of the nervous system (neuropathic pain), it can also arise from nociceptive (referred) or nociplastic sources. Regrettably, patients exhibiting this specific pain distribution are frequently diagnosed with varying terms, including 'cervicobrachialgia', 'cervicobrachial neuralgia', 'cervicobrachial pain syndrome', and 'cervical radiculopathy'. The ambiguity surrounding these diagnostic labels complicates the clinical reasoning process. It is imperative for clinicians to discern and comprehend the dominant pain mechanism. Three distinct hypothetical clinical scenarios depict patients with almost identical pain distribution but divergent dominant pain mechanisms. Within these scenarios, both subjective and objective examinations are employed to elucidate the dominant pain mechanism associated with neck-related arm pain: nociceptive, neuropathic, and nociplastic. Furthermore, clinicians must remain aware that the dominant pain mechanism can evolve over time.

Test procedures and positive diagnostic criteria of the upper limb tension tests differ: a systematic review of the DiTA database

BACKGROUND

The validity of the ULTT is unclear, due to heterogeneity of test procedures and variability in the definition of a positive test OBJECTIVE: To evaluate test procedures and positive diagnostic criteria for the upper limb tension test (ULTT) in diagnostic test accuracy studies.

METHODS

A systematic review of diagnostic accuracy studies was performed. We conducted a search of the DiTA (Diagnostic Test Accuracy) database and selected primary studies evaluating the diagnostic accuracy of the ULTT. We assessed risk of bias, performed data extraction on study characteristics, test procedures, and positive diagnostic criteria, and performed a descriptive analysis.

RESULTS

We included nine studies (681 participants), four diagnosing people with cervical radiculopathy (CR), four diagnosing people with carpal tunnel syndrome (CTS), and one included both CR and CTS. The risk of bias varied between 2 and 6 out of 6 positive items. Eight studies reported on the ULTT1 (median nerve). Overall, all studies clearly described their test procedures and positive diagnostic criteria although the order of movements and the diagnostic criteria between studies varied. We suggest a more standardised test procedure for the ULTT1 to consist of: 1) stabilising the shoulder in abduction, 2) extending the wrist/fingers, 3) supinating the forearm, 4) externally rotating the shoulder, 5) extending the elbow, and finally 6) performed structural differentiation by side bending (lateral flexion) of the neck. This proposed test procedure should reproduce the symptoms and enables the clinician to evaluate whether symptoms increase/decrease when stressing or relaxing the nerves.

CONCLUSION

Based on our findings we proposed a more standardised test procedure for the ULTT1 with accompanying positive diagnostic criteria to facilitate homogeneity in future diagnostic accuracy studies of the ULTT.

Integrating jigsaw puzzle thinking into practice: the assessment of cervical spine radiculopathy

PURPOSE OF REVIEW

Cervical spine radiculopathy (CSR) presents a complex socioeconomic problem for patients, clinicians, families, employers and healthcare systems. Due to the heterogeneity of clinical presentation and underlying mechanisms, clinical assessment can be challenging. This review will examine the literature on the underlying pathophysiology and studies investigating the holistic assessment strategies for this disabling condition. The authors will focus particular attention on the psychological factors associated with CSR and the physical and imaging strategies to establish a diagnosis.

RECENT FINDINGS

Contemporary CSR assessment should identify the underlying pathomechanisms and how this may impact the somatosensory nervous system integrity and function. No physical assessment test in isolation will establish CSR diagnosis; therefore, clinicians should utilise a cluster of tests and recognise the potential limitations as part of a clinical reasoning framework. The assessment of the somatosensory nervous system can provide insights into particular subgroups of CSR presentation, which may provide interesting opportunities to continue to enhance individualised assessment and management strategies for CSR. The interplay between psychological factors can influence the diagnosis and recovery times for a person with CSR, and clinicians should continue to explore how these factors may influence a person's prognosis. The authors will discuss the opportunities for future research and limitations of contemporary approaches to assessment, underpinned by evidence, and how this supports a clinical assessment to establish CSR diagnosis.

SUMMARY

Research should continue to investigate how clinicians assess the interplay between physical and psychological factors to inform the establishment of CSR. Specifically, there is a need to investigate the validity and reliability of combining somatosensory, motor and imaging assessment findings to reach a diagnosis and inform onward management plans.

Diagnostic accuracy of the upper limb neurodynamic test with median bias (ULNT1) for cervical radiculopathy: a systematic review and meta-analysis

BACKGROUND

The upper limb neurodynamic test for median nerve (ULNT1) is commonly applied for assessment of cervical radiculopathy (CR). However, the diagnostic accuracy of ULNT1 in diagnosing CR remains unclear.

OBJECTIVE

This study aimed to examine the diagnostic accuracy of the ULNT1 for the CR.

DATA SOURCES

Four databases were searched for relevant studies published up to April 30, 2023.

STUDY SELECTION

Cross-sectional or cohort studies that assessed the diagnostic accuracy of ULNT1 for CR were included.

DATA SYNTHESIS

The methodological quality of studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) checklist. A bivariate random-effects regression model was used for the data synthesis. The overall quality of evidence was evaluated using the GRADE approach.

RESULTS

A total of 592 references were identified, and five studies with 465 patients met the inclusion criteria. The overall quality of the body of evidence was very low across studies. Heterogeneity of studies was high. The pooled sensitivity and specificity of the ULNT1 were 0.69 (95% CI 0.50-0.83) and 0.54 (95% CI 0.36-0.71), respectively. The summary receiver operating characteristic curve area was 0.65 (95% CI 0.61-0.69).

CONCLUSION

There is low certainty of evidence that the ULNT1 has only fair accuracy in diagnosing CR. The ULNT1 was recommended as an add-on test after the existing diagnostic pathway to enhance diagnostic accuracy further. High-quality studies which follow the Standards for Reporting of Diagnostic Accuracy and the QUADAS-2; a revised tool for the quality assessment of diagnostic accuracy, are needed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO: CRD42021255686 CONTRIBUTION OF THE PAPER.

2. Cervical radicular pain

INTRODUCTION

Cervical radicular pain is pain perceived in the upper limb, caused by irritation or compression of a cervical spine nerve, the roots of the nerve, or both.

METHODS

The literature on the diagnosis and treatment of cervical radicular pain was retrieved and summarized.

RESULTS

The diagnosis is made by combining elements from the patient's history, physical examination, and supplementary tests. The Spurling and shoulder abduction tests are the two most common examinations used to identify cervical radicular pain. MRI without contrast, CT scanning, and in some cases plain radiography can all be appropriate imaging techniques for nontraumatic cervical radiculopathy. MRI is recommended prior to interventional treatments. Exercise with or without other treatments can be beneficial. There is scant evidence for the use of paracetamol, nonsteroidal anti-inflammatory drugs, and neuropathic pain medications such as gabapentin, pregabalin, tricyclic antidepressants, and anticonvulsants for the treatment of radicular pain. Acute and subacute cervical radicular pain may respond well to epidural corticosteroid administration, preferentially using an interlaminar approach. By contrast, for chronic cervical radicular pain, the efficacy of epidural corticosteroid administration is limited. In these patients, pulsed radiofrequency treatment adjacent to the dorsal root ganglion may be considered.

CONCLUSIONS

There is currently no gold standard for the diagnosis of cervical radicular pain. There is scant evidence for the use of medication. Epidural corticosteroid injection and pulsed radiofrequency adjacent to the dorsal root ganglion may be considered. [Correction added on 12 June 2023, after first online publication: The preceding sentence was corrected.].

Eligibility Criteria of Participants in Randomized Controlled Trials Assessing Conservative Management of Cervical Radiculopathy: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

The aim of this study was to evaluate the inclusion and exclusion criteria for participants in randomized control trials (RCTs) assessing conservative management for cervical radiculopathy (CR), to determine if any consensus exists within the literature.

SUMMARY OF BACKGROUND DATA

A 2012 systematic review identified a lack of uniformity for the eligibility criteria of participants in RCTs evaluating conservative interventions for CR. Since then, a large number of RCTs have been published, signaling the need for an updated evaluation of this topic.

MATERIALS AND METHODS

We electronically searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022, to identify RCTs assessing conservative management of CR. Information extracted was analyzed to determine the level of homogeneity and/or heterogeneity of the inclusion and exclusion criteria across studies.

RESULTS

Seventy-six RCTs met our inclusion criteria with 68 distinct trials identified. The inclusion of arm pain with or without another symptom ( i.e. numbness, paresthesia, or weakness) was required in 69.12% of trials, 50% of trials required participants to exhibit neck symptoms, and 73.53% of studies required some form of clinical examination findings, but inconsistencies existed for the number and type of tests used. Furthermore, 41.18% of trials included imaging, with 33.82% of trials requiring magnetic resonance imaging findings. The most common exclusion criteria included were the presence of red flags and cervical myelopathy in 66.18% and 58.82% of trials, respectively.

CONCLUSIONS

Overall, there is still a lack of uniformity for the inclusion/exclusion criteria of trials assessing the conservative management of CR, with some improvements noted compared with the 2012 review. Based on the current literature assessing the diagnostic utility of clinical symptoms and confirmatory tests, we proposed inclusion criteria for trials assessing conservative interventions. Future research should aim to develop standardized classification criteria to improve consistency among studies.

Comparison between two patient-reported outcome measures for patients with cervical radiculopathy: A think-aloud study

BACKGROUND

The Cervical Radiculopathy Impact Scale (CRIS) and Patient Specific Functional Scale 2.0 (PSFS 2.0) are patient-reported outcome measures (PROMs) used to assess activity limitations in patients with cervical radiculopathy (CR). This study a) compared the CRIS subscale 3 and the PSFS 2.0 in patients with CR with respect to completeness and patient preference, b) established the correlation between both PROMs in assessing the individual patient's level of functional limitations and c) assessed the frequency of reported functional limitations.

METHODS

Participants with CR participated in semi-structured, individual, face-to-face interviews as part of a "think-aloud" process; verbalising their thoughts while completing both PROMs. Sessions were digitally recorded and transcribed verbatim for analysis.

RESULTS

Twenty-two patients were recruited. The most frequently reported functional limitation on the CRIS was: 'working at a computer' (n = 17) and overhead activities' (n = 10) for the PSFS 2.0. There was significant moderate positive correlation between the scores on the PSFS 2.0 and the CRIS (Spearman's r = 0.55, n = 22 p = .008). Most patients (n = 18; 82%) preferred the ability to present their own individual functional limitations of the PSFS 2.0. Eleven participants (50%) preferred the 11-point scale of the PSFS 2.0 over the 5-point Likert scale scoring option of the CRIS.

CONCLUSION

Both easy to complete PROMs capture functional limitations in patients with CR. Most patients prefer the PSFS 2.0 over the CRIS. The wording and layout of both PROMs need refinement to enhance user-friendliness and avoid misinterpretation.

Digital physiotherapy assessment vs conventional face-to-face physiotherapy assessment of patients with musculoskeletal disorders: A systematic review

BACKGROUND

This systematic review aimed to assess the certainty of evidence for digital versus conventional, face-to-face physiotherapy assessment of musculoskeletal disorders, concerning validity, reliability, feasibility, patient satisfaction, physiotherapist satisfaction, adverse events, clinical management, and cost-effectiveness.

METHODS

Eligibility criteria: Original studies comparing digital physiotherapy assessment with face-to-face physiotherapy assessment of musculoskeletal disorders. Systematic database searches were performed in May 2021, and updated in May 2022, in Medline, Cochrane Library, Cinahl, AMED, and PEDro. Risk of bias and applicability of the included studies were appraised using the Quality Assessment of Diagnostic Accuracy Studies-2 tool and the Quality Appraisal of Reliability Studies tool. Included studies were synthesised narratively. Certainty of evidence was evaluated for each assessment component using GRADE.

RESULTS

Ten repeated-measures studies were included, involving 193 participants aged 23-62 years. Reported validity of digital physiotherapy assessment ranged from moderate/acceptable to almost perfect/excellent for clinical tests, range of motion, patient-reported outcome measures (PROMs), pain, neck posture, and management decisions. Reported validity for assessing spinal posture varied and was for clinical observations unacceptably low. Reported validity and reliability for digital diagnosis ranged from moderate to almost perfect for exact+similar agreement, but was considerably lower when constrained to exact agreement. Reported reliability was excellent for digital assessment of clinical tests, range of motion, pain, neck posture, and PROMs. Certainty of evidence varied from very low to high, with PROMs and pain assessment obtaining the highest certainty. Patients were satisfied with their digital assessment, but did not perceive it as good as face-to-face assessment.

DISCUSSION

Evidence ranging from very low to high certainty suggests that validity and reliability of digital physiotherapy assessments are acceptable to excellent for several assessment components. Digital physiotherapy assessment may be a viable alternative to face-to-face assessment for patients who are likely to benefit from the accessibility and convenience of remote access.

TRIAL REGISTRATION

The review was registered in the PROSPERO database, CRD42021277624.

Inter-rater reliability, discriminatory and predictive validity of neck movement control tests in office workers with headache and/or neck pain

BACKGROUND

Movement control tests (MCTs) are clinical tests to evaluate impairment of movement and associated neuromuscular control and are commonly used to evaluate people with neck pain or headache conditions. The aim of this study was to establish inter-rater reliability as well as discriminatory and predictive validity for seven MCTs of the upper (UCS) and lower cervical spine (LCS) in office workers with headache or neck pain.

METHODS

Seven MCTs of the UCS (3) and LCS (4) were performed at baseline on 140 office workers which were included in a cluster randomized controlled trial. The occurrences of headache and neck pain were established at baseline (discriminatory validity) and at a 15-month follow-up (predictive validity). Inter-rater-reliability was established in a separate cross-sectional study.

RESULTS

MCTs showed slight to almost perfect inter-rater reliability but limited discriminatory (baseline) and limited to small predictive validity (15-month follow up) for different subgroups of office workers with headache and/or neck pain. MCTs of the UCS showed limited discriminatory validity, especially for rotation in participants with headache and neck pain compared to those with headache only (Negative Likelihood-ratio: 0.82, 95% CI: 0.69-0.98). Participants with neck pain only and ≥1/4 positive MCTs for the sagittal plane had an increased risk for future neck pain (Relative risk: 3.33, 95% CI: 1.05-10.56).

DISCUSSION

MCTs of the UCS and LCS are reliable but have only limited to small validity to predict future headache events in office workers. Insufficient sagittal plane movement control may predict neck pain relapses in the future.

An open-label non-inferiority randomized trail comparing the effectiveness and safety of ultrasound-guided selective cervical nerve root block and fluoroscopy-guided cervical transforaminal epidural block for cervical radiculopathy

OBJECT

To compare therapeutic efficacy and safety of ultrasound (US)-guided selective nerve root block (SNRB) and fluoroscopy (FL)-guided transforaminal epidural steroid injection (TFESI) for cervical spine radiculopathy (CSR).

METHOD

156 patients with CSR randomly received US-guided SNRB verified by FL or FL-guided TFESI. We hypothesised that the accuracy rate of contrast dispersion into epidural or intervertebral foraminal space in the US group was not inferior to that in the FL group with a margin of clinical unimportance of -15%. Pain intensity assessed by Numeric Rating Scales (NRS) and functional disability estimated by neck disability index (NDI) were compared before treatment, at 1, 3 and 6 months after the intervention. Puncture time and complication frequencies were also reported.

RESULTS

88.7% and 90.3% accuracy ratings were respectively achieved in the US and FL groups with a treatment difference of -1.6% (95%CI: -9.7%, 6.6%) revealing that the lower limit was above the non-inferiority margin. Both NRS and NDI scores illustrated improvements at 1, 3 and 6 months after intervention with no statistically significant differences between the two groups (all p > .05). Additionally, shorter administration duration was observed in the US group (p < .001). No severe complications were observed in both group.

CONCLUSION

Compared with the FL group, the US group provided a non-inferior accuracy rate of epidural/foraminal contrast pattern. For the treatment of CSR, the US technique provided similar pain relief and functional improvements while facilitating distinguishing critical vessels adjacent to the foramen and requiring a shorter procedure duration without exposure to radiation. Therefore, it was an attractive alternative to the conventional FL method.Key messagesWe conducted a prospective, open-label, randomised and non-inferiority clinical trial to estimate a hypothesis that the precisely accurate delivery through ultrasound (US)-guided cervical selective nerve root block (SNRB) was non-inferior to that using FL-guided transforaminal epidural steroid injection. Additionally, US-guided SNRB was as effective as FL-guided TFESI in the treatment effect on pain relief and function improvements. Notably, the US technique might be an alternative to the conventional FL method due to the ability to prevent inadvertent vascular puncture (VP) and intravascular injection (IVI) with a shorter administration time and absence of radiation exposure.

Description of Clinical Features and Diagnoses of 444 Cases with Neck-Shoulder-Upper Extremity Pain: A Single-Center Retrospective Review

PURPOSE

Neck-shoulder-upper extremity pain (NSUEP) is a frequently occurring clinical constellation of syndromes. However, its etiology is complicated, and the diagnosis is challenging. We aimed to present detailed clinical characteristics and diagnoses of NSUEP from a single center and heighten clinicians' understanding of this condition.

PATIENTS AND METHODS

Prospectively collected databases were used to retrospectively evaluate patients with NSUEP who underwent treatment at the multidisciplinary consultation center for neck, shoulder, and upper extremity pain at the China-Japan Union Hospital of Jilin University between April 2014 and July 2021. We performed descriptive statistics regarding demographic data, symptoms, findings of physical and radiographic examinations, and each patient's diagnosis.

RESULTS

Development of NSUEP was primarily observed in individuals aged between 51 and 60 years (n = 157, 35.4%). Patients were most commonly referred for upper extremity pain (n = 306, 68.9%). Patients with upper extremity pain presented with hypoesthesia (n = 139, 45.4%), muscle weakness (n = 93, 30.4%), muscle atrophy (n = 90, 29.4%), hyperesthesia (n = 39, 12.7%), and turgidity (n = 18, 5.9%). Among the 22 patients with upper extremity swelling, 8 (36.4%) were diagnosed with autoimmune rheumatic diseases. Among the 352 patients with a single diagnosis, 51 (14.5%) presented with thoracic outlet syndrome, 49 (13.9%) with cervical radiculopathy, 16 (4.5%) with carpal tunnel syndrome, and 16 (4.5%) with brachial plexus injury. Further, among the 92 patients with compound diagnosis, 18 patients (19.6%) were diagnosed with cervical radiculopathy.

CONCLUSION

Among the NSUEP patients in this study, older individuals were the largest group. Pain, numbness, weakness, and mobility limitation are common complaints accompanying NSUEP. The common etiologies of NSUEP include cervical spondylosis, thoracic outlet syndrome, carpal tunnel syndrome, and brachial plexus injury. In addition, autoimmune rheumatic diseases should be considered in patients with NSUEP and swelling.

Classification criteria for cervical radiculopathy: An international e-Delphi study

BACKGROUND

Establishing a set of uniform classification criteria (CC) for cervical radiculopathy (CR) is required to aid future recruitment of homogenous populations to clinical trials.

OBJECTIVES

To establish expert informed consensus on CC for CR.

DESIGN

A pre-defined four round e-Delphi study in accordance with the guidance on Conducting and Reporting Delphi Studies.

METHODS

Individuals with a background in physiotherapy who had authored two or more peer-reviewed publications on CR were invited to participate. The initial round asked opinions on CC for CR. Content analysis was performed on round one output and a list of discrete items were generated forming the round two survey. In rounds two to four, participants were asked to rate the level of importance of each item on a six-point Likert scale. Data were analysed descriptively using median, interquartile range and percentage agreement. Items reaching pre-defined consensus criteria were carried forward to the next round. Items remaining after the fourth round constituted expert consensus on CC for CR.

RESULTS

Twelve participants participated with one drop out. The final round identified one inclusion CC and 12 exclusion CC. The inclusion CC that remained achieved 82% agreement and was a cluster criterion consisting of radicular pain with arm pain worse than neck pain; paraesthesia or numbness and/or weakness and/or altered reflex; MRI confirmed nerve root compression compatible with clinical findings.

CONCLUSIONS

The CC identified can be used to inform eligibility criteria for future CR trials although caution should be practiced as consensus on measurement tools requires further investigation.

Clinical evaluation versus magnetic resonance imaging findings in patients with radicular arm pain—A pragmatic study

Objectives

Methods

Results

Conclusions