Classification and Treatment of Chronic Neck Pain: A Longitudinal Cohort Study

Lumbar transforaminal epidural steroid injections with particulate vs. nonparticulate steroid: an evidence-informed review on shifting gear to a personalized medicine paradigm

PURPOSE OF REVIEW

To provide an evidence-informed review weighing the pros and cons of particulate vs. nonparticulate steroids for lumbar transforaminal epidural steroid injections (TFESI).

RECENT FINDINGS

The relative use of nonparticulate vs. particulate steroids for lumbar TFESI has risen recently in light of catastrophic consequences reported for the latter during cervical TFESI. Among various causes of spinal cord infarct, an exceedingly rare event in the lower lumbar spine, embolization of particulate steroid is among the least likely. Case reports have documented cases of spinal cord infarct during lower lumbar TFESI with both particulate and nonparticulate steroids, with database reviews finding no difference in complication rates. There is some evidence for superiority of particulate over nonparticulate steroids in well-designed studies, which could lead to increase steroid exposure (i.e. more injections) and treatment failure resulting in surgical and/or opioid management when nonparticulate steroids are utilized.

SUMMARY

Similar to a paradigm shift in medicine, a personalized approach based on a shared decision model and the consequences of treatment failure, should be utilized in deciding which steroid to utilize. Alternatives to ESI include high-volume injections with nonsteroid solutions, and the use of hypertonic saline, which possesses anti-inflammatory properties and has been shown to be superior to isotonic saline in preliminary clinical studies.

Integrating mechanistic-based and classification-based concepts into perioperative pain management: an educational guide for acute pain physicians

Chronic pain begins with acute pain. Physicians tend to classify pain by duration (acute vs chronic) and mechanism (nociceptive, neuropathic and nociplastic). Although this taxonomy may facilitate diagnosis and documentation, such categories are to some degree arbitrary constructs, with significant overlap in terms of mechanisms and treatments. In clinical practice, there are myriad different definitions for chronic pain and a substantial portion of chronic pain involves mixed phenotypes. Classification of pain based on acuity and mechanisms informs management at all levels and constitutes a critical part of guidelines and treatment for chronic pain care. Yet specialty care is often siloed, with advances in understanding lagging years behind in some areas in which these developments should be at the forefront of clinical practice. For example, in perioperative pain management, enhanced recovery protocols are not standardized and tend to drive treatment without consideration of mechanisms, which in many cases may be incongruent with personalized medicine and mechanism-based treatment. In this educational document, we discuss mechanisms and classification of pain as it pertains to commonly performed surgical procedures. Our goal is to provide a clinical reference for the acute pain physician to facilitate pain management decision-making (both diagnosis and therapy) in the perioperative period.

Effects of chronic neck pain on grip strength and psychomotor skills in adults

BACKGROUND

It can be challenging to perform activities of daily living in patients with chronic neck pain. As the severity of the pain increases, the quality of the movements decreases. Not only the neck, but also the shoulder, elbow, grip strength and psychomotor skills are affected by these pains.

OBJECTIVE

In this study, it was aimed to investigate the effect of neck pain on grip strength and psychomotor skills in adults diagnosed with chronic neck pain.

METHODS

A cross-sectional study was conducted to examine the effect of pain on grip strength and psychomotor skills in patients with chronic neck pain. This study was planned to be carried out between October 2019 and May 2020 at the Private Yaşam Medical Center in Adana, with the official permission of the institution manager, but this period was carried out between October 2019 and November 2020 due to the fact that sufficient number of patients could not be reached due to the COVID-19 global epidemic. A total of 80 individuals, including 40 control and 40 patients, were included in the study. Forty adult patients who applied to the clinic with a diagnosis of chronic neck pain and 40 healthy adults without a diagnosis of chronic neck pain were included in the study. Conducted with 80 adults between the age of 19 and 74 years old. Individuals were divided into Group 1-control group (n = 40) and Group 2-patient group (n = 40). Information such as age, height, body weight and occupation of the groups were noted. Visual analogue scale and Neck Disability Index were applied to both the groups; hand grip strength with a Jamar hydraulic hand dynamometer, finger lateral grip strength with a pinchmeter and psychomotor skills with the Purdue Pegboard test were evaluated.

RESULTS

In the study, hand grip strength (p < .05), finger lateral grip strength (p < .05), psychomotor skills (p < .01) showed a statistically significant decrease in the patient group compared to the control group.

CONCLUSION

It is thought that in addition to the routine treatments for neck pain in the treatment plan of patients with chronic neck pain, exercises to improve the functionality and psychomotor skills in daily living activities can be included in the direction of increasing the grip strength and will guide future studies.

Chronic pain for rheumatological disorders: Pathophysiology, therapeutics and evidence

Pain is the leading reason people seek orthopedic and rheumatological care. By definition, most pain can be classified as nociceptive, or pain resulting from non-neural tissue injury or potential injury, with between 15% and 50% of individuals suffering from concomitant neuropathic pain or the newest category of pain, nociplastic pain, defined as "pain arising from altered nociception despite no clear evidence of actual or threatened tissue damage, or of a disease or lesion affecting the somatosensory system." Pain classification is important because it affects treatment decisions at all levels of care. Although several instruments can assist with classifying treatment, physician designation is the reference standard. The appropriate treatment of pain should ideally involve multidisciplinary care including physical therapy, psychotherapy and integrative therapies when appropriate, and pharmacotherapy with non-steroidal anti-inflammatory drugs for acute, mechanical pain, membrane stabilizers for neuropathic and nociplastic pain, and serotonin-norepinephrine reuptake inhibitors and tricyclic antidepressants for all types of pain. For nonsurgical interventions, there is evidence to support a small effect for epidural steroid injections for an intermediate-term duration, and conflicting evidence for radiofrequency ablation to provide at least 6months of benefit for facet joint pain, knee osteoarthritis, and sacroiliac joint pain. Since pain and disability represent the top reason for elective surgery, it should be reserved for patients who fail conservative interventions. Risk factors for procedural failure are the same as risk factors for conservative treatment failure and include greater disease burden, psychopathology, opioid use, central sensitization and multiple comorbid pain conditions, poorly controlled preoperative and postoperative pain, and secondary gain.

Effectiveness of neural mobilisation for the treatment of nerve-related cervicobrachial pain: a systematic review with subgroup meta-analysis

ABSTRACT

Neural mobilisations (NM) have been advocated for the treatment of nerve-related cervicobrachial pain; however, it is unclear what types of patients with nerve-related cervicobrachial pain (if any) may benefit. Medline, Web of Science, Scopus, PeDro, Cinahl, and Cochrane databases were searched from inception until December 2022. Randomised controlled trials were included if they assessed the effectiveness of NM in nerve-related cervicobrachial pain, and outcome measures were pain intensity and/or disability. Studies were classified according to their inclusion/exclusion criteria as radiculopathy , Wainner cluster , Hall , and Elvey cluster or other . Meta-analyses with subgroup analyses were performed. Risk of bias was assessed using Cochrane Rob2 tool. Twenty-seven studies were included. For pain and disability reduction, NM was found to be more effective than no treatment (pooled pain mean difference [MD] = -2.81, 95% confidence interval [CI] = -3.81 to -1.81; pooled disability standardized mean difference = -1.55, 95% CI = -2.72 to -0.37), increased the effectiveness of standard physiotherapy as an adjuvant when compared with standard physiotherapy alone (pooled pain MD = -1.44, 95% CI = -1.98 to -0.89; pooled disability MD = -11.07, 95% CI = -16.38 to -5.75) but was no more effective than cervical traction (pooled pain MD = -0.33, 95% CI = -1.35 to 0.68; pooled disability MD = -10.09, 95% CI = -21.89 to 1.81). For disability reduction, NM was found to be more effective than exercise (pooled MD = -18.27, 95% CI = -20.29 to -17.44). In most comparisons, there were significant differences in the effectiveness of NM between the subgroups. Neural mobilisations was consistently more effective than all alternative interventions (no treatment, traction, exercise, and standard physiotherapy alone) in 13 studies classified as Wainner cluster . PROSPERO registration: CRD42022376087.

Exercise-induced hypoalgesia in chronic neck pain: A narrative review

Chronic neck pain (CNP) is a worldwide health problem with several risk factors. One of the most widely used treatments for managing this condition is therapeutic exercise, which could generate a response called exercise-induced hypoalgesia (EIH). There is no consensus on the best exercise modality to induce hypoalgesia. Therefore, this review aims to analyze and synthesize the state-of-the-art about the hypoalgesic effect of exercise in subjects with CNP. We included articles on EIH and CNP in patients older than 18 years, with pain for more than three months, where the EIH response was measured. Articles that studied CNP associated with comorbidities or measured the response to treatments other than exercise were excluded. The studies reviewed reported variable results. Exercise in healthy subjects has been shown to reduce indicators of pain sensitivity; however, in people with chronic pain, the response is variable. Some investigations reported adverse effects with increased pain intensity and decreased pain sensitivity, others found no clinical response, and some even reported EIH with decreased pain and increased sensitivity. EIH is an identifiable, stimulable, and helpful therapeutic response in people with pain. More research is still needed on subjects with CNP to clarify the protocols and therapeutic variables that facilitate the EIH phenomenon. In addition, it is necessary to deepen the knowledge of the intrinsic and extrinsic factors that influence EIH in people with CNP.

Multicenter, Randomized, Placebo-controlled Crossover Trial Evaluating Topical Lidocaine for Mechanical Cervical Pain

BACKGROUND

There are few efficacious treatments for mechanical neck pain, with controlled trials suggesting efficacy for muscle relaxants and topical nonsteroidal anti-inflammatory drugs. Although studies evaluating topical lidocaine for back pain have been disappointing, the more superficial location of the cervical musculature suggests a possible role for topical local anesthetics.

METHODS

This study was a randomized, double-blind, placebo-controlled crossover trial performed at four U.S. military, Veterans Administration, academic, and private practice sites, in which 76 patients were randomized to receive either placebo followed by lidocaine patch for 4-week intervals (group 1) or a lidocaine-then-placebo patch sequence. The primary outcome measure was mean reduction in average neck pain, with a positive categorical outcome designated as a reduction of at least 2 points in average neck pain coupled with at least a 5-point score of 7 points on the Patient Global Impression of Change scale at the 4-week endpoint.

RESULTS

For the primary outcome, the median reduction in average neck pain score was -1.0 (interquartile range, -2.0, 0.0) for the lidocaine phase versus -0.5 (interquartile range, -2.0, 0.0) for placebo treatment (P = 0.17). During lidocaine treatment, 27.7% of patients experienced a positive outcome versus 14.9% during the placebo phase (P = 0.073). There were no significant differences between treatments for secondary outcomes, although a carryover effect on pain pressure threshold was observed for the lidocaine phase (P = 0.015). A total of 27.5% of patients in the lidocaine group and 20.5% in the placebo group experienced minor reactions, the most common of which was pruritis (P = 0.36).

CONCLUSIONS

The differences favoring lidocaine were small and nonsignificant, but the trend toward superiority of lidocaine suggests more aggressive phenotyping and applying formulations with greater penetrance may provide clinically meaningful benefit.

EDITOR’S PERSPECTIVE

Inter- and intra-rater-reliability of a clinical framework for spine-related neck-arm pain

OBJECTIVE

A mechanism-based clinical framework for spine-related pain differentiates (i) somatic referred pain, ii) heightened nerve mechanosensitivity, iii) radicular pain, iv) radiculopathy and mixed-pain. This study aimed to determine the reliability of proposed framework.

METHOD

Fifty-one people with unilateral spine-related neck-arm pain were assessed and categorized by examiner-1. The classifications were compared to those made by two other examiners, based on written documentation of examiner-1. Cohens kappa was calculated between examiner-pairs; Fleiss Kappa among all examiners to assess agreement in classifying subgroups and entire framework.

RESULT

Inter-rater-reliability showed moderate to almost perfect reliability (somatic: no variation, mechanosensitivity: 0.96 (95% CI 0.87-1.0) to 1.0 (95% CI: 1.0-1.0), radicular pain: 0.46 (95% CI: 0.19-0.69) to 0.62 (95% CI: 0.42-0.81), radiculopathy: 0.65 (95% CI: 0.43-0.84) to 0.80 (95% CI: 0.63-0.96) mixed-pain: 0.54 (95% CI: 0.21-0.81) to 0.75 (95% CI: 0.48-0.94). There was almost perfect to moderate reliability among all examiners (somatic: no variation, mechanosensitivity: 0.97 (95% CI: 0.82-1.0), radicular pain: 0.56 (95% CI: 0.40-0.71), radiculopathy: 0.74 (95% CI: 0.58-0.90), mixed-pain: 0.63 (95% CI: 0.47-0.79), entire framework: 0.64 (95% CI: 0.57-0.71)). Intra-rater-reliability showed substantial to almost perfect reliability (somatic: no variation, mechanosensitivity: 0.96 (95% CI: 0.87-1.0), radicular pain: 0.76 (95% CI: 0.57-0.92), radiculopathy: 0.84 (95% CI: 0.67-0.96), mixed-pain: 0.83 (95% CI: 0.60-1.0), entire framework: 0.80 (95% CI: 0.61-0.92).

CONCLUSION

Moderate to almost perfect reliability in subgrouping people with spine-related neck-arm pain and substantial reliability for entire framework support this classification's reliability.

Association of Cervical Spine Magnetic Resonance Imaging Abnormalities with Chronic Neck Pain in Southern Nigeria

Objective

This study was done to evaluate the relationship between cervical spine magnetic resonance imaging (MRI) findings and clinical features in adults with chronic neck pain (NP) at our tertiary hospital.

Materials and Methods

This was a prospective cross-sectional study of the cervical spine MRI of 90 adult patients with chronic NP. The clinical history, biodata, and cervical spine MRI findings were analysed. Statistical tests were considered significant at P ≤ 0.05.

Results

The mean age of the participants was 54.72 (13.51) years (range = 28-79 years). There were 52 (58%) males and 38 (42%) females. Cervical disc desiccation and disc herniation were the most prevalent MRI findings. C4/C5 and C5/C6 disc levels were most commonly affected. Disc height reduction correlated with shoulder pain (r = 0.23, P = 0.030), unsteady gait (r = 0.27, P = 0.010), and lower limb weakness (r = 0.23, P = 0.029). Vertebral collapse correlated with shoulder pain (r = 0.22, P = 0.036), upper limbs burning sensation (r = 0.33, P = 0.001), and loss of dexterity (r = 0.22, P = 0.037). Spondylolisthesis correlated significantly with unsteady gait (r = 0.34, P = 0.001), dizziness/vertigo (r = 0.29, P = 0.005), painful neck movement (r = 0.32, P = 0.002), loss of dexterity (r = 0.37, P < 0.001) and sphincteric dysfunction (r = 0.23, P = 0.031). Modic changes correlated with loss of dexterity (r = 0.39, P < 0.001) and upper limbs burning sensation (r = 0.21, P = 0.048). Cervical canal stenosis did not correlate significantly with any symptom.

Conclusion

Cervical disc disease (C4/C5 and C5/C6 levels) was the most prevalent finding on MRI. Disc height reduction, vertebral collapse, spondylolisthesis, and Modic changes correlated with various clinical symptoms.

Nonorganic (Behavioral) Signs and Their Association With Epidural Corticosteroid Injection Treatment Outcomes and Psychiatric Comorbidity in Cervical Radiculopathy: A Multicenter Study

OBJECTIVE

To determine the association between cervical nonorganic pain signs and epidural corticosteroid injection outcomes and coexisting pain and psychiatric conditions.

PATIENTS AND METHODS

Seventy-eight patients with cervical radiculopathy who received epidural corticosteroid injection were observed to determine the effects that nonorganic signs have on treatment outcome. A positive outcome was a decrease of 2 or more points in average arm pain, coupled with a score of 5 on a 7-point Patient Global Impression of Change scale 4 weeks after treatment. Nine tests in 5 categories (abnormal tenderness, regional disturbances deviating from normal anatomy, overreaction, discrepancies in examination findings with distraction, and pain during sham stimulation) were modified from previous studies and standardized. Other variables examined for their association with nonorganic signs and outcomes included disease burden, psychopathology, coexisting pain conditions, and somatization.

RESULTS

Of the 78 patients, 29% (n=23) had no nonorganic signs, 21% (n=16) had signs in 1 category, 10% (n=8) had signs in 2 categories, 21% (n=16) had signs in 3 categories, 10% (n=8) had signs in 4 categories, and 9% (n=7) had signs in 5 categories. The most common nonorganic sign was superficial tenderness (44%; n=34). Mean number of positive nonorganic categories was higher in individuals with negative treatment outcomes (2.5±1.8; 95% CI, 2.0 to 3.1) compared with those with positive outcomes (1.1±1.3; 95% CI, 0.7 to 1.5; P=.0002). Negative treatment outcomes were most strongly associated with regional disturbances and overreaction. Positive associations were noted between nonorganic signs and multiple pain (P=.011) and multiple psychiatric (P=.028) conditions.

CONCLUSION

Cervical nonorganic signs correlate with treatment outcome, pain, and psychiatric comorbidities. Screening for these signs and psychiatric symptoms may improve treatment outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04320836.

Predictors of Quality of Life in Patients With Degenerative Cervical Myelopathy Receiving Nonsurgical Management Due to Chronic Pain

BACKGROUND

Most patients with degenerative cervical myelopathy (DCM) experience pain, and their quality of life (QoL) is poor.

AIMS

This study aimed to identify predictors of QoL, including demographic, clinical, physical, and psychosocial characteristics, in chronic pain patients with DCM receiving non-surgical management.

DESIGN

A descriptive study design was used.

SETTING

Participants were recruited at the pain clinic at a university hospital in Seoul, South Korea.

PARTICIPANTS/SUBJECTS

The subjects included 157 inpatients and outpatients with DCM receiving non-surgical management.

METHODS

We administered a written, structured, self-reported questionnaire, which included standard validated measures for the main variables of interest.

RESULTS

The median number of pain sites was two, and the average and most pain severities were 4.63 ± 2.35 and 5.71 ± 2.32 out of 10 within one month, respectively. Stepwise multiple regression analysis revealed that depression, education level, and headache were factors influencing physical QoL. Depression, education level, and marital status were factors influencing psychological QoL, whereas depression and education level were factors influencing social relationships QoL. Finally, the factors influencing environmental QoL were depression, educational level, and marital status.

CONCLUSIONS

Demographic characteristics, including educational level and marital status, clinical characteristics, including pain site, and psychological characteristics, including depression, were identified as factors influencing QoL in chronic pain patients with DCM receiving non-surgical management.

CLINICAL IMPLICATIONS

Healthcare professionals should consider demographic, clinical, and psychological characteristics when evaluating patients... QoL. In addition, it is necessary to pay attention to the QoL of participants who are single and have lower levels of education, headache pain, and high levels of depression. These patients are likely to have low QoL and strategies to improve their QoL should be developed.

Clinical and Psychological Variables in Female Patients with Cervical Syndromes: A Cross-Sectional and Correlational Study

Background: The objectives of this study were: (1) to compare the pain intensity, cervical range of motion (ROM), psychological distress and kinesiophobia in patients with cervicogenic dizziness (CGD), tension-type headache (TTH), and mechanical chronic neck pain (MCNP); and (2) to investigate the relationships between pain intensity and cervical ROM and between psychological distress and kinesiophobia. Methods: a cross-sectional and correlational study was designed. In total, 109 patients (32 patients with CGD, 33 with TTH and 44 with MCNP) were included. Pain intensity, cervical ROM, psychological distress and kinesiophobia were assessed. Results: Statistically significant differences were found between the groups in pain intensity, psychological distress and kinesiophobia. The patients with MCNP showed higher pain intensity compared to the other groups (p < 0.001). The patients with CGD showed higher depression and kinesiophobia values compared to the MCNP and TTH groups (p < 0.05). No differences were found for cervical flexion, extension, lateral flexion, or rotation ROM (p > 0.05). The CGD and MCNP groups found a moderate positive correlation between psychological distress and kinesiophobia (p < 0.05). The patients with TTH and MCNP showed a moderate positive correlation between pain intensity, psychological distress and kinesiophobia (p < 0.05). Conclusion: Pain intensity, psychological distress and kinesiophobia should be considered in the three groups. Psychological distress was correlated with kinesiophobia in the CGD and MCNP groups. The MCNP group showed a correlation between pain intensity, psychological distress and kinesiophobia.

Neuropathic Pain Component in Patients with Cervical Radicular Pain: A Single-Center Retrospective Study

Background and Objectives: Evidence regarding the prevalence of neuropathic pain in patients with cervical radicular pain is limited. This study aimed to investigate the prevalence of neuropathic pain components in patients with cervical radicular pain using established screening tools and identify the relationship between neuropathic pain components and clinical factors. Materials and Methods: Data from 103 patients (aged ≥ 20 years) with cervical radicular pain who visited our pain clinic were analyzed retrospectively. Demographic characteristics, history of neck surgery, pain intensity using numeric rating score, dominant pain site, duration of symptoms, and neck disability index were assessed. The prevalence of neuropathic pain components was defined according to the Douleur Neuropathique 4 questions and painDETECT questionnaire tools. Patient characteristics were compared using the chi-square test or Fisher’s exact test for categorical variables and the independent t-test or Mann−Whitney U test for continuous variables. The correlation between neck disability index and other variables was analyzed using Pearson’s correlation coefficient. Results: Of the 103 patients, 29 (28.1%) had neuropathic pain components. The neck disability index was significantly higher (p < 0.001) for patients in the neuropathic pain group (23.79 ± 6.35) than that in the non- neuropathic pain group (18.43 ± 7.68). The Douleur Neuropathique 4 questions (r = 0.221, p < 0.025) and painDETECT questionnaire (r = 0.368, p < 0.001) scores positively correlated with the neck disability index score. Conclusions: The prevalence of neuropathic pain components in patients with cervical radicular pain was low. The patients in our study showed a strong correlation between functional deterioration and their neuropathic pain screening score. This study may be useful in understanding the characteristics of cervical radicular pain.

Different responses of cervical intervertebral disc caused by low and high virulence bacterial infection: a comparative study in rats

The aims of this study were to investigate the outcomes of low- and high-virulence bacterial cervical intervertebral discs (IVDs) infection and its association with cervical IVDs degeneration in rats. A total of 75 clean grade male rats were used to establish the corresponding animal models of low and high virulent bacterial cervical disc infection via an anterior cervical approach, with injection of Propionibacterium acnes (P. acnes) and Staphylococcus epidermidis (S. epidermidis) with a 29 G needle to cervical IVDs. Specimens were collected for evaluation of Blood routine (Blood-RT), histological staining, and gene expression assays after a magnetic resonance imaging (MRI) scan. There were no statistical differences in all groups in white blood cells (WBC) at 2 and 6 weeks postoperatively (P = 0.136). The highest percentage of neutrophils was found in the S. epidermidis group at 2 weeks postoperatively (P = 0.043). MRI and histology showed that at 6 weeks postoperatively, the puncture group and P. acnes group had similar disc degeneration. In the S. epidermidis group, the disc and subchondral bone structure had been destroyed and bony fusion had occurred after the discitis. The upregulation of pro-inflammatory factor expression had the strongest effect of S. epidermidis on the early stage, while the upregulation in the puncture and P. acnes groups was more persistent. P. acnes infection of the cervical IVDs can lead to degenerative changes, whereas S. epidermidis infection leads to the manifestation of septic discitis. The correlation between P. acnes infection and cervical IVDs degeneration found in clinical studies was confirmed.

Dry Needling in Physical Therapy Treatment of Chronic Neck Pain: Systematic Review

Chronic Neck Pain (CNP) is one of the main causes of disability worldwide, and it is necessary to promote new strategies of therapeutic approach in the treatment of chronic pain. Dry needling (DN) is defined as an invasive physiotherapy technique used in the treatment of neuromusculoskeletal disorders. The purpose of this review was to assess the effectiveness of invasive techniques in treatment of CNP. The search focused on randomized clinical trials, and according to the selection criteria, eight studies were obtained. In conclusion, DN can be an effective treatment option for CNP, positive outcomes were achieved in the short-term and in the follow-up performed between three and six months, and this technique may offer better outcomes than a placebo intervention based on the application of simulated DN.

Effectiveness of Neural Mobilisation Techniques in the Management of Musculoskeletal Neck Disorders with Nerve-Related Symptoms: A Systematic Review and Meta-Analysis with a Mapping Report

OBJECTIVE

The objective was to assess the effectiveness of neural mobilisation (NM) techniques in the management of musculoskeletal neck disorders with nerve-related symptoms (MND-NRS).

METHODS

We conducted a systematic review with meta-analysis, using pain intensity, disability, perceived function, cervical range of motion and mechanosensitivity as the main outcome measures.

RESULTS

The systematic review included 22 studies (n = 978). More favourable outcomes were observed for NM on pain intensity compared with control interventions (standardised mean differences (SMDs) -0.92; 95% CI - 1.66--0.18), but not compared with other treatments (OTs) (SMD 1.06; 95% CI - 0.02-2.15). Regarding neck pain intensity, no significant differences were found in favour of NM compared with OTs (SMD 0.37; 95% CI - 0.35-1.1). However, between-treatment differences were found in favour of OT on arm-pain intensity (SMD 0.57; 95% CI 0.08-1.05). In addition, the grouped MA did not show statistically significant differences between NM and OT outcomes on the cervical range of motion (SMD 0.16; 95% CI - 0.06-0.38). However, compared with no intervention, NM was associated with significantly improved outcomes in cervical rotation (SMD 0.91; 95% CI 0.61-1.22). Similar results were found regarding disability (SMD -0.08; 95% CI - 0.36--0.20, and SMD -1.44; 95% CI - 2.28--0.6, respectively). Finally, NM was associated with more favourable outcomes on mechanosensitivity compared with OT (SMD 0.79; 95% CI 0.15-1.42) and greater improvements in function compared with no intervention (SMD 0.89; 95% CI 0.16-1.62).

CONCLUSIONS

NM appeared to be effective to improve overall pain intensity when embedded in a physiotherapy treatment in the management of MND-NRS. When compared with no intervention, it was effective to improve neck rotation, disability, and function. However, it was not superior to other types of treatments in improving overall pain intensity, neck pain intensity, arm pain intensity, cervical range of motion and disability, except for mechanosensitivity.

Chronic pain: an update on burden, best practices, and new advances

Chronic pain exerts an enormous personal and economic burden, affecting more than 30% of people worldwide according to some studies. Unlike acute pain, which carries survival value, chronic pain might be best considered to be a disease, with treatment (eg, to be active despite the pain) and psychological (eg, pain acceptance and optimism as goals) implications. Pain can be categorised as nociceptive (from tissue injury), neuropathic (from nerve injury), or nociplastic (from a sensitised nervous system), all of which affect work-up and treatment decisions at every level; however, in practice there is considerable overlap in the different types of pain mechanisms within and between patients, so many experts consider pain classification as a continuum. The biopsychosocial model of pain presents physical symptoms as the denouement of a dynamic interaction between biological, psychological, and social factors. Although it is widely known that pain can cause psychological distress and sleep problems, many medical practitioners do not realise that these associations are bidirectional. While predisposing factors and consequences of chronic pain are well known, the flipside is that factors promoting resilience, such as emotional support systems and good health, can promote healing and reduce pain chronification. Quality of life indicators and neuroplastic changes might also be reversible with adequate pain management. Clinical trials and guidelines typically recommend a personalised multimodal, interdisciplinary treatment approach, which might include pharmacotherapy, psychotherapy, integrative treatments, and invasive procedures.

Application and utility of a clinical framework for spinally referred neck-arm pain: A cross-sectional and longitudinal study protocol

BACKGROUND

The clinical presentation of neck-arm pain is heterogeneous with varying underlying pain types (nociceptive/neuropathic/mixed) and pain mechanisms (peripheral/central sensitization). A mechanism-based clinical framework for spinally referred pain has been proposed, which classifies into (1) somatic pain, (2) neural mechanosensitivity, (3) radicular pain, (4) radiculopathy and mixed pain presentations. This study aims to (i) investigate the application of the clinical framework in patients with neck-arm pain, (ii) determine their somatosensory, clinical and psychosocial profile and (iii) observe their clinical course over time.

METHOD

We describe a study protocol. Patients with unilateral neck-arm pain (n = 180) will undergo a clinical examination, after which they will be classified into subgroups according to the proposed clinical framework. Standardized quantitative sensory testing (QST) measurements will be taken in their main pain area and contralateral side. Participants will have to complete questionnaires to assess function (Neck Disability Index), psychosocial factors (Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale, Depression, anxiety and stress scale), neuropathic pain (Douleur Neuropathique 4 Questions, PainDETECT Questionnaire) and central sensitization features (Central Sensitization Inventory). Follow-ups at three, six and 12 months include the baseline questionnaires. The differences of QST data and questionnaire outcomes between and within groups will be analyzed using (M)AN(C)OVA and/or regression models. Repeated measurement analysis of variance or a linear mixed model will be used to calculate the differences between three, six, and 12 months outcomes. Multiple regression models will be used to analyze potential predictors for the clinical course.

CONCLUSION

The rationale for this study is to assess the usability and utility of the proposed clinical framework as well as to identify possible differing somatosensory and psychosocial phenotypes between the subgroups. This could increase our knowledge of the underlying pain mechanisms. The longitudinal analysis may help to assess possible predictors for pain persistency.

The Effects of Exercise Dosage on Neck-Related Pain and Disability: A Systematic Review With Meta-analysis

OBJECTIVE

To (1) evaluate whether exercise therapy is effective for managing neck pain, and (2) investigate the relationship between exercise therapy dosage and treatment effect.

DESIGN

Intervention systematic review with meta-analysis and meta-regression.

LITERATURE SEARCH

An electronic search of 6 databases was completed for trials assessing the effects of exercise therapy on neck pain.

STUDY SELECTION CRITERIA

We included randomized controlled trials that compared exercise therapy to a no-exercise therapy control for treating neck pain. Two reviewers screened and selected studies, extracted outcomes, assessed article risk of bias, and rated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

DATA SYNTHESIS

Data were pooled using random-effects meta-analysis. We used meta-regression to analyze the effect of exercise dosage on neck pain and disability.

RESULTS

Fourteen trials were included in the review. Seven trials were at high risk of bias, 4 were at unclear risk of bias, and 3 were at low risk of bias. Exercise therapy was superior to control for reducing pain (visual analog scale mean difference, -15.32 mm) and improving disability (Neck Disability Index mean difference, -3.64 points). Exercise dosage parameters did not predict pain or disability outcomes.

CONCLUSION

Exercise was beneficial for reducing pain and disability, regardless of exercise therapy dosage. Therefore, optimal exercise dosage recommendations remain unknown. We encourage clinicians to use exercise when managing mechanical neck pain. J Orthop Sports Phys Ther 2020;50(11):607-621. doi:10.2519/jospt.2020.9155.

Neck Muscle Stiffness Measured With Shear Wave Elastography in Women With Chronic Nonspecific Neck Pain

OBJECTIVE

Utilizing shear wave elastography, we compared the stiffness of the neck extensor muscles and the stiffness in muscle-specific regions between women with chronic nonspecific neck pain and asymptomatic controls.

DESIGN

Cross-sectional observational study.

METHODS

We measured the average muscle stiffness over multiple neck extensor muscles and in regions corresponding approximately to the trapezius, splenius capitis, semispinalis capitis, semispinalis cervicis, and multifidus muscles using ultrasound shear wave elastography in 20 women with chronic nonspecific neck pain and 18 asymptomatic women during multiple tasks. The measurements were automatically quality controlled and computer processed over the complete visible neck region or a large muscle-specific region.

RESULTS

Pooled over all tasks, neck muscle stiffness was not significantly different between those with neck pain and asymptomatic controls (neck pain median, 11.6 kPa; interquartile range, 8.9 kPa and control median, 13.3 kPa; interquartile range, 8.6 kPa; P = .175). The measure of neck muscle stiffness was not correlated with the intensity of neck pain or perceived disability.

CONCLUSION

Shear wave elastography revealed similar muscle stiffness in people with and without chronic neck pain, despite the sensation of increased neck stiffness in those with chronic neck pain. Therapeutic interventions aiming to reduce neck muscle tone are often based on the assumption that perceived neck stiffness corresponds to objective muscle stiffness. The current results question this assumption. J Orthop Sports Phys Ther 2020;50(4):179-188. Epub 6 Jan 2020. doi:10.2519/jospt.2020.8821.

A Cost-Effectiveness Analysis Of Pregabalin For The Treatment Of Patients With Chronic Cervical Pain With A Neuropathic Component In Japan

Purpose

To evaluate the cost-effectiveness of pregabalin versus other analgesics among patients with chronic cervical pain with neuropathic components during routine clinical practice in Japan.

Patients and methods

The analysis considered patients with chronic cervical pain with a neuropathic pain component (radiating pain to the upper limb) and who were treated with pregabalin with or without other analgesics (pregabalin-containing treatments) or other analgesics alone (usual care) for 8 weeks. Other analgesics included non-steroidal anti-inflammatory drugs (NSAIDs), weak opioids, antidepressants, and antiepileptic drugs. A Markov cohort simulation model was constructed to estimate costs and effectiveness (in terms of quality-adjusted life-years, QALYs) of each treatment over a 12-month time horizon. In the model, patients transitioned among three states of pain severity (no/mild, moderate, and severe). Data were derived from a previous observational study (pregabalin-containing treatments, n = 138; usual care, n = 211). Cost inputs included medical costs and productivity losses. QALYs were calculated using the EuroQol five-dimensional, five-level questionnaire. The cost-effectiveness was evaluated using incremental cost-effectiveness ratios (ICERs). Sensitivity analyses were conducted to assess the robustness of results.

Results

From the payer's perspective, pregabalin-containing treatments were more costly (JPY 61,779 versus JPY 26,428) but also more effective (0.763 QALYs versus 0.727 QALYs) than the usual care, with an ICER of JPY 970,314 per QALY gained. From the societal perspective, which also included productivity losses, the ICER reduced to JPY 458,307 per QALY gained. One-way sensitivity analyses demonstrated the robustness of the results. Given a hypothetical threshold value of one additional QALY of JPY 5,000,000, the probability of pregabalin-containing treatments being cost-effective was 100%.

Conclusion

Compared with using other analgesics alone, the use of pregabalin, alone or in addition to other analgesics, was cost-effective for the treatment of chronic cervical pain with a neuropathic pain component in Japan.

Mesotherapy in the treatment of musculoskeletal pain in rehabilitation: the state of the art

Background

Mesotherapy can be included as an ancillary treatment in the management of localized pain in rehabilitation, but there are no definitive treatment protocols for this approach.

Objectives

The purpose of this review was to examine new indications for more standard protocols of mesotherapy in rehabilitation.

Materials and methods

This systematic review was performed using the following resources: PubMed, Cochrane, PEDro, Scopus, and Google Scholar. The following algorithm was developed, based on the PICO acronym, to evaluate the effects of mesotherapy, with pain as the primary outcome (MESH terms): [mesotherapy AND pain], [mesotherapy AND musculoskeletal], [mesotherapy AND musculoskeletal disorder], [intradermal therapy AND pain], and [intradermal therapy AND musculoskeletal disorder].

Results

Seven articles (N=7) satisfied the inclusion criteria and were considered in the review: two of them treated osteoarthritis of the knee (3 sessions) and pes anserine (9 sessions) emphasizing a good efficacy of mesotherapy. Five studies analyzed spine diseases (specifically, two was about chronic and nonspecific neck pain, two about acute low back pain and one about chronic spinal pain): the results of mesotherapy treatment are encouraging both for the resolution of acute and chronic musculoskeletal vertebral pain from one to five sessions.

Conclusion

Mesotherapy showed a good effect to reduce acute and chronic musculoskeletal pain and, also, it is a well-tolerated treatment. Nonetheless future randomized controlled trials should be desirable for more uniform treatment protocols.

Tapentadol for neuropathic pain: a review of clinical studies

Neuropathic pain (NP) is an enormous burden for patients, caregivers and society. NP is a pain state that may develop after injury of the peripheral or central nervous system because of a wide range of diseases and traumas. A NP symptom component can be found also in several types of chronic pain. Many NP patients are substantially disabled for years. Due to its chronicity, severity and unpredictability, NP is difficult to treat. Tapentadol is a central-acting oral analgesic with combined opioid and noradrenergic properties, which make it potentially suitable for a wide range of pain conditions, particularly whenever a NP component is present or cannot be excluded. In randomized controlled trials, tapentadol has proved to be effective in relieving NP in diabetic peripheral neuropathy and in chronic low back pain. In observational studies, tapentadol reduced NP in chemotherapy-induced peripheral neuropathies, blood and solid cancers, and the NP component in neck pain and Parkinson's disease. This narrative review aims to provide clinicians with a broad overview of tapentadol effects on NP.

Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists

BACKGROUND

Over the past 2 decades, the use of intravenous ketamine infusions as a treatment for chronic pain has increased dramatically, with wide variation in patient selection, dosing, and monitoring. This has led to a chorus of calls from various sources for the development of consensus guidelines.

METHODS

In November 2016, the charge for developing consensus guidelines was approved by the boards of directors of the American Society of Regional Anesthesia and Pain Medicine and, shortly thereafter, the American Academy of Pain Medicine. In late 2017, the completed document was sent to the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters, after which additional modifications were made. Panel members were selected by the committee chair and both boards of directors based on their expertise in evaluating clinical trials, past research experience, and clinical experience in developing protocols and treating patients with ketamine. Questions were developed and refined by the committee, and the groups responsible for addressing each question consisted of modules composed of 3 to 5 panel members in addition to the committee chair. Once a preliminary consensus was achieved, sections were sent to the entire panel, and further revisions were made. In addition to consensus guidelines, a comprehensive narrative review was performed, which formed part of the basis for guidelines.

RESULTS

Guidelines were prepared for the following areas: indications; contraindications; whether there was evidence for a dose-response relationship, or a minimum or therapeutic dose range; whether oral ketamine or another N-methyl-D-aspartate receptor antagonist was a reasonable treatment option as a follow-up to infusions; preinfusion testing requirements; settings and personnel necessary to administer and monitor treatment; the use of preemptive and rescue medications to address adverse effects; and what constitutes a positive treatment response. The group was able to reach consensus on all questions.

CONCLUSIONS

Evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range. Most studies evaluating the efficacy of ketamine were small and uncontrolled and were either unblinded or ineffectively blinded. Adverse effects were few and the rate of serious adverse effects was similar to placebo in most studies, with higher dosages and more frequent infusions associated with greater risks. Larger studies, evaluating a wider variety of conditions, are needed to better quantify efficacy, improve patient selection, refine the therapeutic dose range, determine the effectiveness of nonintravenous ketamine alternatives, and develop a greater understanding of the long-term risks of repeated treatments.

The clinical reasoning process in randomized clinical trials with patients with non-specific neck pain is incomplete: A systematic review

OBJECTIVE

Primarily to evaluate the completeness of the description of the clinical reasoning process in RCTs with patients with non-specific neck pain with an argued or diagnosed cause i.e. an impairment or activity limitation. Secondly, to determine the association between the completeness of the clinical reasoning process and the degree of risk of bias.

DATA SOURCES

Pubmed, Cinahl and PEDro were systematically searched from inception to July 2016.

STUDY SELECTION

RCTs (n = 122) with patients with non-specific neck pain receiving physiotherapy treatment published in English were included.

DATA EXTRACTION

Data extraction included study characteristics and important features of the clinical reasoning process based on the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II)].

DATA SYNTHESIS

Thirty-seven studies (30%) had a complete clinical reasoning process of which 8 (6%) had a 'diagnosed cause' and 29 (24%) had an 'argued cause'. The Spearmans rho association between the extent of the clinical reasoning process and the risk of bias was -0.2.

CONCLUSIONS

In the majority of studies (70%) the described clinical reasoning process was incomplete. A very small proportion (6%) had a 'diagnosed cause'. Therefore, a better methodological quality does not necessarily imply a better described clinical reasoning process.

Cervical flexor muscle training reduces pain, anxiety, and depression levels in patients with chronic neck pain by a clinically important amount: A prospective cohort study

BACKGROUND AND PURPOSE

Neck pain is the fourth leading cause of disability in the United States and exerts an important socio-economic burden around the world. The aims of this study were to determine the effectiveness of deep and superficial flexor muscle training in addition to home-based exercises in reducing chronic neck pain and anxiety/depression levels.

METHODS

This was a prospective cohort study. Patients between 18 and 65 years old with chronic neck pain were eligible to participate if they had disability levels at least 5 out of 50 on the Neck Disability Index. Patients were divided into three groups: Group A received deep neck flexor and home-based exercises; Group B received superficial muscle and home-based exercises; and Group C received home-based exercises only. The Numeric Pain Rating Scale (NPRS), Neck Disability Index, and Hospital Anxiety and Depression Scale were administered at baseline and 7 weeks later.

RESULTS

The highest improvements in pain intensity levels were observed in Group A with 4.75 (1.74) NPRS points, and the lowest were in Group C with 1.00 (1.10). The highest reductions in anxiety and depression levels were noted in Group A (2.80) and Group B (1.65), respectively. The highest improvements in pain intensity levels were observed among Groups A versus C with 2.80 (0.52) NPRS. The highest reductions in anxiety and depression levels were noted among Groups A versus C with 1.75 (1.10) points and Groups B versus C with 1.60 (0.90) points, respectively.

CONCLUSIONS

Deep and superficial flexor muscle training along with home-based exercises is likely to reduce chronic neck pain and anxiety/depression levels by a clinically relevant amount. Future larger scaled randomized controlled trials are warranted to further support these findings.