Chronic neck pain patients with traumatic or non-traumatic onset: Differences in characteristics. A cross-sectional study

Differences in physical examination findings between those who present with or without headache soon after a whiplash injury: a cross-sectional study

AIM

To determine differences in physical examination findings between people with acute whiplash-associated disorders (WAD) with and without headache.

METHODS

In this cross-sectional study, participants with acute WAD were evaluated to assess differences in the presence of physical impairments. The following were assessed: pain intensity on manual palpation the over spinous process of C1-C3, zygapophyseal joints of C0-C4, and trapezius, sternocleidomastoid, suboccipitalis, masseter and temporalis muscles; cervical range of motion (ROM); flexion-rotation test (FRT); forward head posture; cranio-cervical flexion test (CCFT); neck flexor and extensor endurance; pressure-pain thresholds (PPT) over neural structures and upper limb neural tests (ULNT) in addition to median UNLT + CCF. Correlation analyses were performed to assess the association between examination findings and headache intensity. Logistic regression and discriminant analyses were also performed.

RESULTS

Forty-seven participants (26 men and 21 women; mean age = 38.9 years old) were included in the study. 60% of the participants presented with headache. Several examination findings were significantly different between groups. A group of examination findings composed of neck endurance, manual palpation over cervical and muscular structures, PPT, CCFT, ROM and FRT could discriminate between groups with a sensitivity of 86.7% and specificity of 90%.

CONCLUSIONS

Several neuromusculoskeletal features are different between people with acute WAD with or without headache. A combination of features could distinguish between groups with high levels of sensitivity and specificity.

Results of neck-specific exercise for altered postural sway in individuals with chronic whiplash-associated disorders: a longitudinal case-control study

Postural sway has not been investigated before or after a neck exercise intervention in individuals with chronic whiplash-associated disorders (WAD). The aim of the study was to investigate postural sway in individuals with chronic WAD grades 2 and 3: (a) compared with healthy matched controls at baseline; (b) after three months of neck-specific exercise and (c) to investigate the correlation between postural sway with self-reported dizziness during motion and balance problems/unsteadiness. This is a longitudinal prospective experimental case-control intervention study. Individuals with WAD (n = 30) and age- and gender-matched healthy volunteers (n = 30) participated. Postural sway was assessed using an iPhone application. Measurements were carried out at baseline, and for those with WAD a second measurement was performed at the three-month follow-up when neck-specific exercise intervention ended. The WAD group performed significantly worse than the healthy group in both pathway and ellipse area double stance eyes closed at baseline (main outcome), but not at the three-month follow-up. The WAD group significantly improved after rehabilitation in both pathway double stance eyes closed and pathway single stance eyes open. The correlation between postural sway and self-rated dizziness during motion and balance problems was low to moderate. One may conclude that postural sway was improved after a neck-specific exercise programme. The study results strengthen earlier findings that individuals with WAD have worse balance outcome when they have to rely on neck proprioception (eyes closed). The study results may be important for the development of improved rehabilitation methods for WAD.

High level of post-traumatic stress symptoms in patients with chronic neck pain is associated with poor mental health but does not moderate the outcome of a multimodal physiotherapy programme

INTRODUCTION

Chronic traumatic neck pain has a high prevalence of post-traumatic stress symptoms (PTSS). However, whether PTSS moderates treatment effects is unknown. This study investigated: 1) whether PTSS was associated with patient-reported outcomes and clinical test results at baseline; 2) whether PTSS moderated the effect of a multimodal physiotherapy intervention of exercise therapy and patient education; and 3) whether adherence to the intervention differed across PTSS groups.

METHODS

Secondary data analysis from a randomized controlled trial on chronic neck pain with 12-month follow-up was conducted. Patients were divided into three groups (NT = non-traumatic, LT = traumatic low PTSS, HT = traumatic high PTSS) based on self-reported onset of pain and the Impact of Event Scale. The baseline data were used to analyze the association of PTSS with patient demographics and scores of physical and mental health-related quality of life, depression, neck-related disability, kinesiophobia, and clinical tests. Baseline, 4-month and 12-month follow-up data were analyzed to investigate possible moderating effects on outcomes. Data on adherence were collected at four months.

RESULTS

115 participants were included (NT n = 45; LT n = 46; HT n = 24). The HT group reported lower mental health scores and more depressive symptoms at baseline. PTSS did not significantly moderate the treatment effect on any outcomes. The HT group tended to have lower adherence to the multimodal physiotherapy intervention than the LT group.

CONCLUSION

For patients with traumatic neck pain, high levels of PTSS are associated with poorer psychological outcomes but do not affect the outcomes of multimodal physiotherapy intervention.

Exercise Therapy for Chronic Neck Pain: Tailoring Person-Centred Approaches within Contemporary Management

Exercise therapy is considered the best evidence-based approach for managing chronic neck pain. However, the implementation of exercise therapy presents several challenges. Systematic reviews indicate that it has modest effectiveness, while clinical practice guidelines offer limited guidance on the exercise parameters required to optimise clinical outcomes. Moreover, recommendations often fail to differentiate between different types of neck pain. This article addresses the challenges associated with the prescription of exercise for chronic neck pain and provides recommendations for exercise therapy specific to chronic nociceptive, neuropathic, and nociplastic neck pain. The goal of this article is to facilitate the implementation of high-value evidence-based exercise therapy for these distinct types of chronic neck pain with the aim to improve its outcomes and to reduce the related individual and societal burdens.

Objectively and subjectively measured physical activity levels in individuals with whiplash associated disorder and aged-matched healthy controls

BACKGROUND

Whiplash associated disorders (WAD) are the most common non-hospitalised injuries resulting from a motor vehicle crash. Half of individuals with WAD experience ongoing pain and disability. Furthermore, individuals with persistent WAD have lower levels of aerobic capacity and isometric strength compared with age-matched controls. It is not known whether these differences are associated with increased levels of pain and disability, or with reduced physical activity (PA) participation.

OBJECTIVE

Our primary aim was to compare PA levels in individuals with persistent WAD with healthy controls. Secondary aims were to: compare objective and subjective measurements of PA; explore factors that may influence PA; and describe proportions of these populations meeting World Health Organisation PA guidelines.

METHODS

Objective (ActiGraph accelerometer; seven days) and subjective (International Physical Activity Questionnaire (IPAQ)) PA data were collected for n = 53 age-matched participants (WAD n = 28; controls n = 25).

RESULTS

Independent sample t-tests showed no significant difference in objectively measured PA (p>0.05) between WAD and controls. For the subjective measure (IPAQ), controls reported more overall weekly PA (t = 0.219, p<0.05), while WAD participants reported more weekly walking minutes (t = -0.712, p<0.05). Linear regression showed mental health quality-of-life predicted objectively measured moderate intensity PA (R2 = 0.225, F (2, 44) = 6.379, p<0.004) and subjectively reported overall PA (R2 = 0.132, F (1, 41) = 6.226, p<0.017). Bland-Altman analyses indicated that subjects over-reported MVPA and under-reported sedentary time using the IPAQ.

CONCLUSIONS

Individuals with WAD had levels of physical and mental health quality-of-life significantly lower than controls and below population norms yet participated in similar levels of PA. Given that increased perceptions of mental health quality-of-life were positively associated with objectively measured MVPA and subjectively reported overall PA, strategies to help people with WAD achieve adequate doses of MVPA may be beneficial. ActiGraph-measured and IPAQ-reported PA were discordant. Hence, IPAQ may not be a reliable measure of habitual PA in WAD.

Recommendations for a core outcome measurement set for clinical trials in whiplash associated disorders

ABSTRACT

Inconsistent reporting of outcomes in clinical trials of treatments for whiplash associated disorders (WAD) hinders effective data pooling and conclusions about treatment effectiveness. A multidisciplinary International Steering Committee recently recommended 6 core outcome domains: Physical Functioning, Perceived Recovery, Work and Social Functioning, Psychological Functioning, Quality of Life and Pain. This study aimed to reach consensus and recommend a core outcome set (COS) representing each of the 6 domains. Forty-three patient-reported outcome measures (PROMs) were identified for Physical Functioning, 2 for perceived recovery, 37 for psychological functioning, 17 for quality of life, and 2 for pain intensity. They were appraised in 5 systematic reviews following COSMIN methodology. No PROMs of Work and Social Functioning in WAD were identified. No PROMs had undergone evaluation of content validity in patients with WAD, but some had moderate-to-high-quality evidence for sufficient internal structure. Based on these results, the International Steering Committee reached 100% consensus to recommend the following COS: Neck Disability Index or Whiplash Disability Questionnaire (Physical Functioning), the Global Rating of Change Scale (Perceived Recovery), one of the Pictorial Fear of Activity Scale-Cervical, Pain Self-Efficacy Questionnaire, Pain Catastrophizing Scale, Harvard Trauma Questionnaire, or Posttraumatic Diagnostic Scale (Psychological Functioning), EQ-5D-3L or SF-6D (Quality of Life), numeric pain rating scale or visual analogue scale (Pain), and single-item questions pertaining to current work status and percent of usual work (Work and Social Functioning). These recommendations reflect the current status of research of PROMs of the 6 core outcome domains and may be modified as evidence grows.

Effectiveness of psychological interventions delivered by physiotherapists in the management of neck pain: a systematic review with meta-analysis

Physiotherapists are increasingly using psychological treatments for musculoskeletal conditions. We assessed the effects of physiotherapist-delivered psychological interventions on pain, disability, and quality of life in neck pain. We evaluated quality of intervention reporting. We searched databases for randomized controlled trials (RCTs) comprising individuals with acute or chronic whiplash-associated disorder (WAD) or nontraumatic neck pain (NTNP), comparing physiotherapist-delivered psychological interventions to standard care or no treatment. Data were extracted regarding study characteristics and outcomes. Standardised mean difference (SMD) was calculated by random-effects meta-analysis. We evaluated certainty of evidence using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) and intervention reporting using TIDieR. Fourteen RCTs (18 articles-4 detail additional outcome/follow-up data) were included comprising 2028 patients, examining acute WAD (n = 4), subacute/mixed NTNP (n = 3), chronic WAD (n = 2), and chronic NTNP (n = 5). Treatment effects on pain favoured psychological interventions in chronic NTNP at short-term (SMD -0.40 [95% CI -0.73, -0.07]), medium-term (SMD -0.29 [95% CI -0.57, 0.00]), and long-term (SMD -0.32 [95% CI -0.60, -0.05]) follow-up. For disability, effects favoured psychological interventions in acute WAD at short-term follow-up (SMD -0.39 [95% CI -0.72, -0.07]) and chronic NTNP at short-term (SMD -0.53 [95% CI -0.91, -0.15]), medium-term (SMD -0.49 [95% CI -0.77, -0.21]), and long-term (SMD -0.60 [95% CI -0.94, -0.26]) follow-up. GRADE ratings were typically moderate, and intervention reporting often lacked provision of trial materials and procedural descriptions. Psychological interventions delivered by physiotherapists were more effective than standard physiotherapy for chronic NTNP (small-to-medium effects) and, in the short term, acute WAD.

Physical testing in patients with acute whiplash-associated disorders: A within session test-retest reliability study

BACKGROUND

People with whiplash-associated disorders (WAD) commonly present with a variety of physical impairments. However, the reliability of physical tests has not been established for patients with acute WAD.

OBJECTIVE

To assess test-retest reliability of different physical tests in acute WAD.

DESIGN

Intra-rater test-retest reliability.

METHODS

Patients with acute WAD were recruited. Physical tests were used to evaluate articular, muscular and neural systems in two blocks of measurements separated by 10 min. Bland-Altman plots were performed to assess intrarater agreement, which included calculation of the mean difference (d) between rates, the 95% CI for d, the standard deviation of the differences and the 95% limits of agreement. Reliability was calculated via the standard error of measurement, the minimal detectable change, percent of agreement, the intraclass-correlation coefficient, and kappa coefficient.

RESULTS

47 patients participated. Test-retest reliability was excellent or good for almost all measures, except for extension ROM, ULTT for the radial nerve, and active cervical extension and upper cervical rotation performed in 4-point kneeling, which presented moderate reliability. Systematic bias was found in cervical ROM in flexion, left and right lateral-flexion, left and right rotation; left ULTT for radial nerve; right trapezius, suboccipitalis and temporalis muscles, left temporalis; C3, both sides of C1-C2, left C3-C4.

CONCLUSION

The majority of physical tests achieved good or excellent test-retest intra-rater reliability when tested in patients with acute WAD. Findings must be considered with caution for those tests which demonstrated systematic bias. Additional research is warranted to evaluate inter-rater reliability.

A study protocol for the validation of a prognostic model with an emphasis on modifiable factors to predict chronic pain after a new episode of acute- or subacute nonspecific idiopathic, non-traumatic neck pain presenting in primary care

BACKGROUND

The primary objective of this study is to identify which modifiable and non-modifiable factors are independent predictors of the development of chronic pain in patients with acute- or subacute nonspecific idiopathic, non-traumatic neck pain, and secondly, to combine these to develop and internally validate a prognostic prediction model.

METHODS

A prospective cohort study will be conducted by physiotherapists in 30 primary physiotherapy practices between January 26, 2020, and August 31, 2022, with a 6-month follow-up until March 17, 2023. Patients who consult a physiotherapist with a new episode of acute- (0 to 3 weeks) or subacute neck pain (4 to 12 weeks) will complete a baseline questionnaire. After their first appointment, candidate prognostic variables will be collected from participants regarding their neck pain symptoms, prior conditions, work-related factors, general factors, psychological and behavioral factors. Follow-up assessments will be conducted at six weeks, three months, and six months after the initial assessment. The primary outcome measure is the Numeric Pain Rating Scale (NPRS) to examine the presence of chronic pain. If the pain is present at six weeks, three months, and six months with a score of NPRS ≥3, it is classified as chronic pain. An initial exploratory analysis will use univariate logistic regression to assess the relationship between candidate prognostic factors at baseline and outcome. Multiple logistic regression analyses will be conducted. The discriminative ability of the prognostic model will be determined based on the Area Under the receiver operating characteristic Curve (AUC), calibration will be assessed using a calibration plot and formally tested using the Hosmer and Lemeshow goodness-of-fit test, and model fit will be quantified as Nagelkerke's R2. Internal validation will be performed using bootstrapping-resampling to yield a measure of overfitting and the optimism-corrected AUC.

DISCUSSION

The results of this study will improve the understanding of prognostic and potential protective factors, which will help clinicians guide their clinical decision making, develop an individualized treatment approach, and predict chronic neck pain more accurately.

Sensory Interaction Balance and Limits of Stability in Neck Pain: Comparison of Traumatic and Non-traumatic Patients

Background and Purpose: A variety of sensory-motor changes are reported in both the traumatic and non-traumatic neck pain. However, it is still unclear whether there is a significant difference between individuals with traumatic neck pain and those with non-traumatic in terms of postural control. The aim of this cross-sectional study was to investigate whether there was a difference between individuals with traumatic pain and non-traumatic neck pain in terms of postural control and disability. Methods: Ninety-two patients with chronic neck pain were grouped according to the onset of pain. Clinical test of sensory interaction balance (CTSIB) and limits of stability (LOS) test were used for postural control assessment. The Numeric Rating Scale and Neck Pain Disability Index (NPDI) were used to measure pain intensity and disability, respectively. Mann-Whitney U test was used to compare groups. Results: There were no significant differences between groups in terms of LOS, CTSIB and NPDI scores (p > 0.05). Conclusion: The results of this study suggest that postural control and disability do not differ between patients with traumatic and non-traumatic neck pain. Therefore, from a clinical perspective, postural control and disability should be evaluated without considering trauma history in patients with neck pain.

Evaluation of a physical activity promotion intervention for adults with whiplash associated disorders: a single-case experimental design study

PURPOSE

There is considerable variation in the physical and psychological presentations of people with whiplash-associated disorder (WAD). Optimal treatment continues to be a challenge. This research evaluated the efficacy of a community-located, theory-based intervention designed to promote physically active behaviour in people with persistent WAD, and thereby improve perceptions of pain interference and confidence completing activities in the presence of neck pain.

MATERIALS AND METHODS

A multiple-baseline, single-case experimental design was used to evaluate the 16-week intervention across six participants.

RESULTS

Weighted Tau-U showed significantly increased accelerometer-measured physical activity in three participants with large effect sizes (>0.5), with increased confidence in one participant (ES > 0.5), and reduced pain interference in another participant (ES > 0.7). Changes in other behaviours included clinically important improvements in quality of life for five participants and, in those participants with baseline symptom levels outside threshold levels, improvements in pain catastrophizing and pain self-efficacy.

CONCLUSIONS

Participation in a theory-based intervention resulted in significant improvements in physical and psychological health for five of six participants. Providing this type of community-located physical activity promotion strategy, to individuals with persistent WAD, may help address physical impairments and psychological distress commonly experienced in WAD. Trial registration: The trial was registered with the Australia and New Zealand Clinical Trials Registry (ACTRN: ACTRN12617001261303p) and ClinicalTrials.gov (Protocol Number: 2018000349/2017/743).Implications for rehabilitationRehabilitation professionals should consider recommending theory-based physical activity promotion strategies to reduce physical impairments and psychological distress in individuals with persistent WAD.Individually tailored physical activity promotion strategies may help individuals with persistent WAD become more physically active thereby reducing their risk of diseases associated with inactivity which may compound the effects of WADImprovements in physical and psychological health may occur independently of increasing habitual physical activity.Rehabilitation professionals may find that other community-located strategies which aim to promote physically active behaviour confer similar benefits for individuals with persistent WAD.

Effects of breathing reeducation on cervical and pulmonary outcomes in patients with non specific chronic neck pain: A double blind randomized controlled trial

OBJECTIVE

The purpose of this randomized controlled trial was to study effects of breathing reeducation in the treatment of patients with non specific chronic neck pain.

METHODS

A total of sixty eight eligible patients with chronic neck pain were randomly allocated to breathing reeducation (BR) group (n = 34) and routine physical therapy (RPT) group (n = 34). Clinical outcomes were neck pain measured through visual analogue score, cervical active range of motion through CROM device, strength of neck muscles through hand held dynamometer and endurance of neck muscles measured through craniocervical flexion test. The neck disability was measured through neck disability index (NDI) and pulmonary outcomes such as forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and FEV1/FVC ratio were measured through Spirolab 4. The outcomes were assessed at baseline and at 4 and at 8 weeks from baseline.

RESULTS

There were significant improvements in the BR group compared with the RPT group (P = 0.002) for cervical flexion, extension (P = 0.029), endurance (P = 0.042), strength of neck flexors (P <0.001), neck extensors (P = 0.034). Likewise there was a significant change in NDI (P = 0.011), FEV1 (P = 0.045), FVC (P <0.001), and FEV1/FVC ratio (P <0.001) in the BR group compared with the RPT group. The cervical side flexion and rotation showed no significant difference in breathing reeducation group with p > 0.05.

CONCLUSION

Breathing reeducation combined with routine physical therapy is an effective treatment in patients with non specific chronic neck pain.

TRIAL REGISTRATION

IRCT 20200226046623N1, https://www.irct.ir/trial/46240.

Oculomotor performance in patients with neck pain: Does it matter which angle of neck torsion is used in smooth pursuit eye movement test and is the agreement between angles dependent on target movement amplitude and velocity?

BACKGROUND

Neck torsion manoeuvre is thought to affect eye movement control via afferent sensory drive in neck pain disorders patients. Literature reports inconsistencies regarding the angle of neck torsion most commonly used across the studies.

OBJECTIVES

The goal of this study was to determine the level of agreement in oculomotor performance between two most commonly used neck torsion angles during smooth pursuit neck torsion test (SPNT).

DESIGN

A cross-sectional design was used in thirty-two neck pain patients and thirty-two healthy individuals.

METHOD

Gain and SPNT_diff were measured during SPNT test at 30° and 45° of neck torsion angle, at 30°, 40° and 50° of target movement amplitudes and three different target movement velocities (20°s^-1, 30°s^-1 and 40°s^-1) using eye tracking device. Bland-Altman plots and correlation analysis were used to study the agreement between the two angles.

RESULTS

Small to medium correlations and wide bias confidence intervals suggest medium level of agreement in gain or SPNT_diff between the two neck torsion angles for chronic neck pain patients, but higher in healthy individuals. Higher agreement in gain was observed at lager target movement amplitudes and at slower target movement velocities, however this trend was not observed for SPNT_diff.

CONCLUSION

Level of agreement between the two angles in SPNT test depends on the amplitude and velocity of the moving target. In cases when subjects within the same study are not able to perform 45° of neck torsion, 50° amplitude and 20°s^-1 velocity of target movement are more suitable to reach higher agreement between the angles.

Exercise therapy for whiplash-associated disorders: a systematic review and meta-analysis

OBJECTIVES

Acute as well as chronic pain syndromes are common after whiplash trauma and exercise therapy is proposed as one possible intervention strategy. The aim of the present systematic review was to evaluate the effect of exercise therapy in patients with Whiplash-Associated Disorders for the improvement of neck pain and neck disability, compared with other therapeutic interventions, placebo interventions, no treatment, or waiting list.

CONTENT

The review was registered in Prospero (CRD42017060356) and conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search in PubMed, Scopus and Cochrane from inception until January 13, 2020 was combined with a hand search to identify eligible randomized controlled studies. Abstract screening, full text assessment and risk of bias assessment (Cochrane RoB 2.0) were conducted by two independent reviewers.

SUMMARY

The search identified 4,103 articles. After removal of duplicates, screening of 2,921 abstracts and full text assessment of 100 articles, 27 articles that reported data for 2,127 patients were included. The included articles evaluated the effect of exercise therapy on neck pain, neck disability or other outcome measures and indicated some positive effects from exercise, but many studies lacked control groups not receiving active treatment. Studies on exercise that could be included in the random-effect meta-analysis showed significant short-term effects on neck pain and medium-term effects on neck disability.

OUTLOOK

Despite a large number of articles published in the area of exercise therapy and Whiplash-Associated Disorders, the current evidence base is weak. The results from the present review with meta-analysis suggests that exercise therapy may provide additional effect for improvement of neck pain and disability in patients with Whiplash-Associated Disorders.

Effects of breathing re-education on endurance, strength of deep neck flexors and pulmonary function in patients with chronic neck pain: A randomised controlled trial

Background

People with chronic neck pain show decreased endurance and strength of cervical muscles with compromised respiratory function. There is little evidence that improvement in breathing function of people with neck pain can help in enhancing cervical muscle strength and pulmonary function. The objective of this our clinical trial was to examine the effects of breathing re-education combined with physiotherapy on endurance and strength of deep neck flexors, and pulmonary function in patients with chronic neck pain.

Methods/design

In this double blind randomised clinical trial, 30 patients with chronic neck pain (25-50 years old) were randomly allocated to two groups. Group A, physiotherapy (n = 15), and Group B, breathing re-education (n = 15). The duration of intervention was eight weeks with treatment five days a week. The endurance was measured with the craniocervical flexion test, strength with a handheld dynamometer (Baseline USA) and pulmonary functions with the Spiro lab 4 (USA) at baseline, at week four and at week eight of the intervention.

Discussion

There was a significant between group improvement in the strength of deep neck flexors and forced vital capacity (FVC) in Group B p = 0.0001 and p = 0.0200 (p ˂ 0.05) respectively. Intergroup comparisons showed no significant differences for endurance, cervical extensor strength, Forced Expiratory Volume in one second (FEV1), and FEV1/FVC percentage.

Conclusion

Our study concluded that breathing re-education combined with other physiotherapy management is effective for improving the strength of neck flexors and increasing FVC in people with chronic neck pain.

Clinical implication

Breathing re-education may be part of physiotherapy management in patients with chronic neck pain.

Trial Registration

Iranian Registry of Clinical Trials, IRCT20200226046623N1, https://www.irct.ir/trial/46240.

Is Altered Oculomotor Control during Smooth Pursuit Neck Torsion Test Related to Subjective Visual Complaints in Patients with Neck Pain Disorders?

Subjective visual complaints are commonly reported in patients with neck pain, but their relation to objectively measured oculomotor functions during smooth pursuit neck torsion tests (SPNTs) has not yet been investigated. The aim of the study was to analyse classification accuracy of visual symptom intensity and frequency based on SPNT results. Forty-three patients with neck pain were referred by orthopaedic outpatient clinics where they were required to fill out 16-item proformas of visual complaints. Infrared video-oculography was used to measure smooth pursuit eye movements during neutral and neck torsion positions. Parameters of gain and SPNT difference (SPNTdiff) were taken into the Naïve Bayes model as classifiers, while intensity and frequency of visual symptoms were taken as predicted class. Intensity and, to a lesser degree, frequency of visual symptoms previously associated with neck pain or focal vision disorders (computer vision syndrome) showed better classification accuracy using gain at neck torsion position, indicating cervical driven visual disturbances. Moreover, SPNTdiff presented with slightly lower classification accuracy as compared to gain at neck torsion position. Our study confirmed the relationship between cervical driven oculomotor deficits and some visual complaints (concentrating to read, words moving on page, blurred vision, difficulty judging distance, sore eyes, heavy eyes, red eyes, and eyes strain).

Short-Term Changes in Chronic Neck Pain After the Use of Elastic Adhesive Tape

Objectives

The aim of the study was to examine the short-term changes of elastic adhesive tape application on pain intensity and the range of motion (ROM), cervical region proprioception sense, and cervical flexor endurance of patients with chronic neck pain.

Methods

Thirty-four patients (male: 26, female: 8) between ages 20 and 55 with chronic neck pain having the complaints for at least 6 months were included in the study. Demographic information, pain intensity, cervical ROM, cervical flexor endurance, and cervical proprioception sense of the patients were evaluated. Results were examined 2 times. The first evaluation was conducted prior to elastic adhesive tape application and the second one was conducted 24 hours after the procedure.

Results

The mean age of the patients was 39.56 ± 17.09 years, average height was 165.65 ± 9.83 cm, average weight was 71.44 ± 15.79 kg, and average body mass index was 26.24 ± 6.62. A statistically significant difference was found between the measurement results of pain intensity, ROM of the joint in flexion, extension, right and left rotation, and cervical flexor endurance before and 24 hours after the application of elastic adhesive tape (P < .05). When the proprioception sense was examined, there was a significant difference between the results before elastic adhesive tape application and 24 hours after the same application in deviation angles except for right rotation (P < .05).

Conclusion

The results of this study revealed short-term changes following the use of elastic adhesive tape on cervical flexor endurance, pain, and cervical proprioception sense for patients with chronic pain.

EFFECTIVENESS OF CERVICAL MANUAL MOBILIZATION TECHNIQUES VERSUS STRETCHING EXERCISES FOR PAIN RELIEF IN THE MANAGEMENT OF NECK PAIN

Introduction. A huge literature is available regarding the efficacy of various physiotherapy techniques for neck pain (NP), however, comparative study is still in scarcity. Therefore, this study aimed to compare effectiveness of stretching exercises versus manual mobilization techniques in the management of NP. Material and method. A randomized controlled trial parallel-group design study was conducted on the patients suffering from NP. Participants with the history of NP, aged between 19 to 60 years, NP without radiculopathy, and no history of trauma were included in the study. Two outcome measures were used i.e., Numeric pain rating scale (NPRS) and neck pain disability index (NDI) questionnaire. Two groups were equally divided had twenty-five patients each. Group A received cervical stretching with strengthening exercises as home-treatment program and group B received manual mobilization with strengthening exercises as home-treatment program. Six sessions were given on alternate basis and assessed pre- and post-treatment information of all patients. Results and discussions. Independent sample t-test was run to compare the post difference between stretching exercises and manual mobilization at 95% confidence interval (p<0.05). The Post NPRS difference between the groups shows no significant improvement (p=0.32). Similarly no significant difference was found in post NDI Disability (p=0.57). Therefore, both the treatment strategies are equally effective in improving NP and disability. Conclusions. This clinical trial concluded that stretching or manual mobilization is equally effective to reduce pain and disability. Hence, improve the quality of life in neck pain survivors. Keywords: Manual Mobilization Technique, Neck Pain, , Neck Pain Disability Index Questionnaire, Numeric Pain Rating Scale, Range of Motion, Stretching Exercises,

Clinical characteristics differ between patients with non-traumatic neck pain, patients with whiplash-associated disorders, and pain-free individuals

BackgroundEvidence is lacking to what extent patients with Whiplash-Associated Disorders (WAD), those with non-traumatic neck pain (NTNP), and pain-free individuals differ regarding type and severity of impairments, disability, and psychological factors.Objective To compare clinical characteristics between patients with WAD, with NTNP, and pain-free individuals in primary care physiotherapy. Additionally, differences between patient groups for both acute and chronic symptoms were assessed.MethodA cross-sectional study was conducted including 168 patients with WAD, 336 matched patients with NTNP, and 336 pain-free individuals. Differences and prevalence rates were calculated for pain intensity, pain distribution, cervical range of motion, neck flexor muscle endurance, self-reported disability, and psychological factors.Results Patients with WAD had higher pain intensity (median 6/10 vs. 5/10 p<.01), had a wider distribution of their neck pain (p=.02), more restricted cervical flexion-extension (-11.9°) and rotation (-12.4°), less muscle endurance (-5.5 seconds), and more disability (+14.0%), compared to patients with NTNP. More patients with WAD reported low back pain (+9.5%) and headache (+12.2%) as musculoskeletal comorbidities. Regarding anxiety, depression, and stress, most patients (>83%) scored in the normal range. No significant differences between the patient groups were observed (p>.16). Both patient groups scored significantly worse than pain-free individuals on all characteristics. Patients with WAD and NTNP experienced different types of activity limitations and participation restrictions.ConclusionWAD is a more severe condition than NTNP and should be considered a separate subgroup. A different approach in clinical practice and research is required for WAD and NTNP.

Associates of Insomnia in People with Chronic Spinal Pain: A Systematic Review and Meta-Analysis

Insomnia is a major problem in the chronic spinal pain (CSP) population and has a negative impact on health and well-being. While insomnia is commonly reported, underlying mechanisms explaining the relation between sleep and pain are still not fully understood. Additionally, no reviews regarding the prevention of insomnia and/or associated factors in people with CSP are currently available. To gain a better understanding of the occurrence of insomnia and associated factors in this population, we conducted a systematic review of the literature exploring associates for insomnia in people with CSP in PubMed, Web of Science and Embase. Three independent reviewers extracted the data and performed the quality assessment. A meta-analysis was conducted for every potential associate presented in at least two studies. A total of 13 studies were found eligible, which together identified 25 different potential associates of insomnia in 24,817 people with CSP. Twelve studies had a cross-sectional design. Moderate-quality evidence showed a significantly higher rate for insomnia when one of the following factors was present: high pain intensity, anxiety and depression. Low-quality evidence showed increased odds for insomnia when one of the following factors was present: female sex, performing no professional activities and physical/musculoskeletal comorbidities. Higher healthcare use was also significantly related to the presence of insomnia. One study showed a strong association between high levels of pain catastrophizing and insomnia in people with chronic neck pain. Last, reduced odds for insomnia were found in physically active people with chronic low back pain compared to inactive people with chronic low back pain. This review provides an overview of the available literature regarding potential associates of insomnia in people with CSP. Several significant associates of insomnia were identified. These findings can be helpful to gain a better understanding of the characteristics and potential origin of insomnia in people witch CSP, to identify people with CSP who are (less) likely to have insomnia and to determine directions of future research in this area.

Changes in Muscle Morphology in Female Chronic Neck Pain Patients Using Magnetic Resonance Imaging

STUDY DESIGN

Population-based cross-sectional study.

OBJECTIVE

The aim of this study was to gain a better understanding of changes in muscle morphology in patients with chronic idiopathic neck pain (CINP) and chronic whiplash-associated disorder (CWAD).

SUMMARY OF BACKGROUND DATA

Worldwide, neck pain (NP) is a common health problem with high socioeconomic burden. A high percentage of these patients evolves toward chronic symptoms. Efficacy of treatments for these complaints remains variable. In current literature, changes in muscle morphology (muscle fat infiltration and cross-sectional area) have been reported in patients with NP, both CWAD and CINP. However, no strong conclusions could be made.

METHODS

In this study, magnetic resonance imaging was used to obtain data on muscle morphology from 14 cervical flexor and extensor muscles in 117 female subjects with NP (CWAD = 37; CINP = 45) and healthy controls (HC = 35).

RESULTS

The CWAD group had a significantly larger muscle fat infiltration in some extensor (semispinalis and splenius capitis, trapezius, obliquus capitis inferior) and flexor (sternocleidomastoid) muscles compared to the CINP and/or HC group. A significantly larger (muscle) cross-sectional area was found in some extensor (levator scapulae, semispinalis capitis, trapezius) and flexor (longus colli, longus capitis, sternocleidomastoid) muscles in the HC group compared to the CINP and/or CWAD group. No clear associations were found between group differences and factors as pain duration, kinesiophobia, and disability.

CONCLUSION

The results in this study suggest changes in muscle morphology in both NP cohorts. These results show some similarities with earlier findings in this research domain. Further studies based on controlled longitudinal designs are needed to facilitate data compilation, to draw stronger conclusions, and to integrate them into the treatment of patients with chronic NP.Level of Evidence: 4.

Efficacy of Dry Needling and Acupuncture in the Treatment of Neck Pain

CONTEXT

Neck pain is a common phenomenon and affects a large segment of the population. Chronic neck pain, lasting more than 3 months, likely occurs in 10% - 30% of patients with acute neck pain and affects up to 288 million cases globally, carrying a significant cost in terms of quality of life, disability, and healthcare dollars. Here we review neck pain background, acupuncture and the evidence that exist to support acupuncture use in chronic neck pain.

RESULTS

Neck pain not only affects quality of life directly, but also contributes to depression, job dissatisfaction and reduced productivity. Unfortunately, neck pain is strongly linked to office and computer work and is likely to continue increasing in prevalence. Traditional treatments, such as analgesics, physical therapy, exercise, and non-invasive therapy bring some relief, and invasive therapy is indicated if anatomical pathologies exist. Acupuncture is a form of integrative medicine, originally described and practiced in traditional Chinese medicine and now expanded to include methods including acupressure, dry needling, and others. Traditionally, it focused on restoring the patient's flow of Qi by puncturing specific points along the meridians. It has previously been shown to be effective in other forms of chronic pain and disability. Clinical trials studying acupuncture for neck pain have shown significant reduction in both pain and associated symptoms. These therapies are reviewed in this text.

CONCLUSIONS

Neck pain is a common and significant global problem. Acupuncture, dry needling, and cupping were all shown to be effective in alleviating pain both immediately after treatment, as well as provide long-lasting relief. These treatments are generally safe and inexpensive and should be considered as part of a multimodal approach for the treatment of neck pain. More head-to-head studies will provide better data to support a choice of a specific treatment over another.

Enhanced amygdala-frontal operculum functional connectivity during rest in women with chronic neck pain: Associations with impaired conditioned pain modulation

BACKGROUND

Chronic neck pain is a leading cause of disability worldwide, affecting the lives of millions of people. Research investigating functional brain alterations in relation to somatosensory function is necessary to better understand mechanisms underlying pain development and maintenance in individuals with chronic neck pain, yet remains scarce. This case-control study aimed to examine resting-state functional connectivity alterations and associations with pain outcomes, self-reported central sensitization-related symptoms and quantitative sensory testing (QST) measures in patients with chronic non-traumatic (idiopathic/CINP) neck pain and chronic traumatic (whiplash associated/CWAD) neck pain compared to pain-free controls.

METHODS

Resting-state functional magnetic resonance images were acquired in 107 female participants (38 CINP, 37 CWAD, 32 healthy controls). After data pre-processing, seed-to-seed analyses were conducted focusing on resting-state functional connectivity involving pre-defined regions of interest that have previously been observed to be structurally or functionally altered and/or associated with pain-related measures in this patient population.

RESULTS

Findings demonstrate enhanced left amygdala functional coupling during rest with the left frontal operculum in women with CINP and CWAD compared to controls. This increased resting-state functional connectivity was associated with more self-reported symptoms related to central sensitization and decreased efficacy of conditioned pain modulation. Furthermore, enhanced connectivity between the left amygdala and left frontal orbital cortex, and between the left pallidum and the left frontal operculum was observed only in patients with CWAD compared to healthy controls. In patients, additional associations between local hyperalgesia and enhanced connectivity between the left superior parietal cortex and the left and right precentral gyrus were found.

CONCLUSIONS

In line with our hypotheses, patients with CWAD showed the most pronounced alterations in resting-state functional connectivity, encompassing subcortical limbic (amygdala) and basal ganglia (pallidum), and ventral frontal regions (frontal operculum, orbitofrontal cortex) when compared to CINP and controls. Findings are generally in line with the idea of a continuum, in absence of significant group differences across CINP and CWAD. Enhanced amygdala-frontal operculum functional connectivity was the most robust and only connectivity pair in the cluster that was associated with QST (i.e., dynamic QST; endogenous pain inhibition), and that was observed in both patient groups. In addition, independent of group differences, enhanced resting-state functional connectivity between superior parietal cortex (involved in attention) and primary motor cortex was associated with static QST (i.e., greater local hyperalgesia). Taken together, our findings show a key role for enhanced amygdala-ventral frontal circuitry in chronic neck pain, and its association with diminished endogenous pain inhibition further emphasizes the link between cognitive-affective and sensory modulations of pain in women with chronic non-traumatic and traumatic neck pain.

Tampa Scale for Kinesiophobia Short Form and Lower Extremity Specific Limitations

Background

We compared the amount of variation in Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) Computer Adaptive Test (CAT) accounted for by The Tampa Scale for Kinesiophobia (TSK) and its short form (TSK-4) independent of other factors. Questionnaire coverage, reliability, and validity were compared for both TSK and TSK-4 using mean scaled scores, internal consistency, floor and ceiling effects, interquestionnaire correlations, and collinearity with other measures as the Pain Catastrophizing Scale short form (PCS-4), PROMIS Depression CAT, and PROMIS Pain Interference (PROMIS PI) CAT.

Methods

One hundred forty eight consecutive new or return patients were enrolled. Patients were seen in an outpatient setting in several orthopaedic clinics in a large urban area. All patients completed the TSK, PROMIS PF CAT, PROMIS PI CAT, PROMIS Depression CAT, and PCS-4.

Results

Greater fear of movement (higher TSK) was associated with worse physical function (lower PROMIS PF CAT) and the full TSK explained more variation in physical function than the short form (TSK-4). In contrast to prior studies PCS-4 was not independent of TSK. Flooring and ceiling effects were seen with TSK-4. Worse physical function was associated with older age, traumatic condition, and more symptoms of depression.

Conclusion

The short form of the Tampa Scale for Kinesiophobia can be used as a brief screening measure in patient care and research in order to identify an independent influence of kinesiophobia on lower extremity specific limitations. Additional study is needed to determine whether there is utility in screening for both TSK and PCS or if one or the other provides sufficient information about cognitive biases regarding pain to guide treatment with cognitive behavioral therapy and related techniques.

Association between cervical degeneration and self-perceived nonrecovery after whiplash injury

BACKGROUND CONTEXT

Pre-existing radiological degenerative changes have not previously been considered a risk factor for nonrecovery from neck pain due to motor vehicle accidents (MVA). Results from previous studies are however often based on assessment of plain radiography or MRI and little consideration has been given to facet joints. Furthermore, previous studies have often lacked a validated scoring system for degenerative changes.

PURPOSE

To investigate the association between cervical degeneration on computed tomography (CT) and nonrecovery after whiplash trauma.

STUDY DESIGN

Longitudinal cohort study.

PATIENT SAMPLE

One hundred twenty-one patients attending the Emergency Department because of neck pain after MVA, 2015-2017, with a valid CT-scan of the cervical spine and completion of follow up after 6 months.

OUTCOME MEASURES

The primary outcome measure was self-perceived nonrecovery (yes/no) after 6 months. A secondary outcome measure was self-reported pain level (Numeric Rating Scale).

METHODS

Baseline data regarding demographics and health factors were gathered through a web-based questionnaire. Degeneration of facet joints and intervertebral discs was assessed on CT-scans according to a validated scoring system. Binary logistic regression was used to study the association between cervical degeneration and nonrecovery.

RESULTS

Moderate facet joint degeneration was associated with nonrecovery. In the group with moderate degree of facet joint degeneration, 69.6% reported nonrecovery compared with 23.6% among patients without any signs of degeneration (adjusted odds ratio 6.7 [95% confidence interval: 1.9-24.3]). There was no association between disc degeneration and nonrecovery. Combined facet joint degeneration and disc degeneration were associated with nonrecovery (adjusted odds ratio 6.2 [2.0-19.0]).

CONCLUSIONS

These results suggest that cervical degeneration, especially facet joint degeneration, is a risk factor for nonrecovery after whiplash trauma. We hypothesize that whiplash trauma can be a trigger for painful manifestation of previously asymptomatic facet joint degeneration.

Best Evidence Rehabilitation for Chronic Pain Part 4: Neck Pain

Neck pain, whether from a traumatic event such as a motor vehicle crash or of a non-traumatic nature, is a leading cause of worldwide disability. This narrative review evaluated the evidence from systematic reviews, recent randomised controlled trials, clinical practice guidelines, and other relevant studies for the effects of rehabilitation approaches for chronic neck pain. Rehabilitation was defined as the aim to restore a person to health or normal life through training and therapy and as such, passive interventions applied in isolation were not considered. The results of this review found that the strongest treatment effects to date are those associated with exercise. Strengthening exercises of the neck and upper quadrant have a moderate effect on neck pain in the short-term. The evidence was of moderate quality at best, indicating that future research will likely change these conclusions. Lower quality evidence and smaller effects were found for other exercise approaches. Other treatments, including education/advice and psychological treatment, showed only very small to small effects, based on low to moderate quality evidence. The review also provided suggestions for promising future directions for clinical practice and research.

Prognostic factors for persistent pain after a first episode of nonspecific idiopathic, non-traumatic neck pain: A systematic review

BACKGROUND

Prognosis of acute idiopathic neck pain is poor. An overview of modifiable and non-modifiable prognostic factors for the development of chronic musculoskeletal neck pain after an episode of idiopathic, non-traumatic neck pain is needed.

OBJECTIVE

Identify prognostic factors for pain intensity and perceived non-recovery at three, six and 12 months after a first episode of idiopathic, non-traumatic neck pain.

STUDY DESIGN

Systematic review METHODS: Systematic literature search up to October 21, 2017 for prospective prognostic studies with main outcomes perceived non-recovery and pain intensity. The QUIPS was used for quality assessment.

RESULTS

Out of 2737 screened articles six prospective studies with high-risk-of-bias were identified, analyzing 47 and 43 factors for the outcome variables 'pain intensity' and 'perceived non-recovery', respectively. Based on univariate- and multivariate analyses we found moderate evidence for 'age> 40 years' and 'concomitant back pain' to be prognostic for 'pain intensity'. For the outcome 'perceived non-recovery' at 12 months, we found moderate evidence for both 'a previous period of neck pain' and 'accompanying headache' as prognostic variables for persistent pain, based on univariate analysis. No prognostic factor was found which was retained in more than one multivariate analysis for the outcome variable 'perceived non-recovery'. However, the quality of the evidence for these prognostic factors was low to very low.

CONCLUSION

This review identifies prognostic factors for neck pain, of which only a few are modifiable. Further research is needed before drawing definite conclusions about the prognostic value of these factors.

Reliability and validity of clinical tests to assess posture, pain location, and cervical spine mobility in adults with neck pain and its associated disorders: Part 4. A systematic review from the cervical assessment and diagnosis research evaluation (CADRE) collaboration

PURPOSE

To determine the reliability and validity of clinical tests to assess posture, pain location, and cervical spine mobility in adults with grades I-IV neck pain and associated disorders (NAD).

METHODS

We systematically searched electronic databases to update the systematic review of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Eligible reliability and validity studies were critically appraised using modified versions of the QAREL and QUADAS-2 instruments, respectively. Evidence from low risk of bias studies were synthesized following best evidence synthesis principles.

RESULTS

We screened 14302 articles, critically appraised 46 studies, and found 32 low risk of bias articles (14 reliability and 18 validity studies). We found preliminary evidence of: 1) reliability of visual inspection, aided with devices (CROM and digital caliper) to assess head posture; 2) reliability and validity of soft tissue palpation to locate tender/trigger points in muscles; 3) reliability and validity of joint motion palpation to assess stiffness and pain provocation in combination; and 4) range of motion tests using visual estimation (in cervical extension only) or devices (digital caliper, goniometer, inclinometer) to assess cervical mobility.

CONCLUSIONS

We found little evidence to support the reliability and validity of clinical tests to assess head posture, pain location and cervical mobility in adults with NAD grades I-III. More advanced validity studies are needed to inform the clinical utility of tests used to evaluate patients with NAD.

The effect of three exercise approaches on health-related quality of life, and factors associated with its improvement in chronic whiplash-associated disorders: analysis of a randomized controlled trial

Purpose

The aim was to evaluate whether neck-specific exercise, with (NSEB) or without (NSE) a behavioural approach, improves health-related quality of life (HRQoL) compared to physical activity prescription (PPA) in chronic whiplash-associated disorders (WAD) grades 2 and 3. A secondary aim was to identify factors associated with HRQoL and HRQoL improvement following exercise interventions.

Methods

This is a secondary analysis of a multicentre randomized clinical trial. Participants (n = 216) with chronic WAD grades 2 and 3 were randomized to 12 weeks of PPA or physiotherapist-led NSE or NSEB. The EQ-5D 3L/EQ-VAS and SF-36v2 physical (PCS) and mental (MCS) component summaries were collected together with several neck-related and psychosocial outcomes at baseline, after 3, 6 and 12 months, and were analysed with linear mixed models (all time points) and multivariate linear regressions (baseline, 6 months).

Results

NSE/NSEB resulted in better outcomes than PPA (EQ-VAS and SF-36 PCS, both groups, p < 0.01) but not in a higher EQ-5D score. Improvement over time was seen in EQ-5D/EQ-VAS for the NSEB group (p < 0.01), and for NSE/NSEB as measured with the PCS (p < 0.01). Factors associated with baseline HRQoL and change to 6 months in HRQoL (R² = 0.38–0.59) were both neck-related and psychosocial (e.g. depression, work ability).

Conclusion

Neck-specific exercise, particularly with a behavioural approach, may have a more positive impact on HRQoL than physical activity prescription in chronic WAD grades 2 and 3. HRQoL is however complex, and other factors also need to be considered. Factors associated with HRQL and improvements in HRQoL following exercise are multidimensional.

Trial registration number: ClinicalTrials.gov, No. NCT01528579.

Electronic supplementary material

The online version of this article (10.1007/s11136-018-2004-3) contains supplementary material, which is available to authorized users.

Pain extent is more strongly associated with disability, psychological factors, and neck muscle function in people with non-traumatic versus traumatic chronic neck pain: a cross sectional study

BACKGROUND

Neck pain is presented with a variety of symptoms. Pain drawings are used in the clinical assessment of people with neck pain. Pain extent based upon pain drawings can be associated with different factors. However, the relation between pain extent and function limitations in people with neck pain is unknown.

AIM

The aim of this study was to explore the associations between pain extent extracted from pain drawings, and self-reported neck pain related disability, quality of life, depression, self-reported neck function, cervical muscle function, and range of motion in a chronic neck pain population and possible differences depending on the onset of pain being traumatic or not.

DESIGN

Observational cross-sectional study.

SETTING

Primary and secondary healthcare.

POPULATION

People with chronic neck pain (N.=200) of traumatic (N.=120) or non-traumatic (N.=80) origin.

METHODS

Outcome measures: Pain extent, Short Form 36 Health Survey Physical and Mental Component Summary (SF36-PCS/MCS), TAMPA Scale of Kinesiophobia (TSK), Beck Depression Inventory-II (BDI-II), Neck Disability Index (NDI), Craniocervical Flexion Test (CCFT), Cervical Extension Test (CE), and Cervical Range of Motion (ROM). Correlations were calculated using Spearman or Pearson correlation coefficients. Correlation between pain extent and outcomes were calculated for all participants collectively and then separately for those with a traumatic versus non-traumatic neck pain.

RESULTS

Overall, significant positive correlations were observed between pain extent and NDI (r=0.33; P<0.001), BDI-II (r=0.29; P<0.001), CCFT (r=-0.24; P=0.001) and CE (r=-0.19; P=0.006). No difference was observed in pain extent between patients with traumatic (mean: 7.6±6.7%) and non-traumatic onset (7.4±6.8%). Pain extent correlated moderately with NDI, BDI-II, TSK, CCFT and CE in those with non-traumatic onset, but weakly with NDI, BDI-II, CCFT and CE in those with trauma-induced chronic neck pain.

CONCLUSIONS

Pain extent is correlated with patient-reported neck function, depression and muscle test performance in people with chronic neck pain. These correlations were strongest in those with non-traumatic neck pain.

CLINICAL REHABILITATION IMPACT

Patients presenting with larger pain areas show poorer psychological and physical function. Pain drawings can therefore indicate a need for addressing these functions in management of a person with chronic neck pain.

Responsiveness of clinical tests for people with neck pain

BACKGROUND

Responsiveness of a clinical test is highly relevant in order to evaluate the effect of a given intervention. However, the responsiveness of clinical tests for people with neck pain has not been adequately evaluated. The objective of the present study was to examine the responsiveness of four clinical tests which are low cost and easy to perform in a clinical setting, including the craniocervical flexion test, cervical active range of movement, test for the cervical extensors and pressure pain threshold testing.

METHODS

This study is a secondary analysis of data collected in a previously published randomised controlled trial. Participants were randomized to either physical training, exercises and pain education combined or pain education only. Participants were tested on the clinical tests at baseline and at 4-month follow-up. An anchor-based approach using Receiver Operator Characteristics (ROC) curves was used to evaluate responsiveness of the clinical tests. The Neck Disability Index was used to discriminate between those who had improved and those who were unchanged at the 4-month follow-up. Minimum Clinically Important Difference (MCID), together with sensitivity, specificity, positive and negative predictive values, in addition to positive and negative likelihood ratios were calculated.

RESULTS

In total, 164 participants completed the 4 month follow up. One-hundred forty four participants were classified as unchanged whereas 20 patients were considered to be improved. Twenty-six participants didn't complete all of the clinical tests, leaving a total of 138 to be included for analyses. Area Under Curve (AUC) ranged from 0.50-0.62 for the clinical tests, and were all below an acceptable level. MCID was generally large, and the corresponding sensitivity and specificity was low with sensitivity ranging from 20 to 60%, and specificity from 54 to 86%. LR+ (0.8-2.07) and LR- (0.7-1.1) showed low diagnostic value for all variables, with PPV ranging from 12.1 to 26.1 and NPV ranging from 84.7 to 89.2.

CONCLUSION

Responsiveness of the included clinical tests was generally low when using change in NDI score as the anchor from baseline to the 4-month follow up. Further investigations of responsiveness are warranted, possibly using other anchors, which to a higher degree resemble similar dimensions as the clinical tests.