Course and prognostic factors for neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders

Durable Effect of Acupuncture for Chronic Neck Pain: A Systematic Review and Meta-Analysis

OBJECTIVE

Chronic neck pain, a prevalent health concern characterized by frequent recurrence, requires exploration of treatment modalities that provide sustained relief. This systematic review and meta-analysis aimed to evaluate the durable effects of acupuncture on chronic neck pain.

METHODS

We conducted a literature search up to March 2024 in six databases, including PubMed, Embase, and the Cochrane Library, encompassing both English and Chinese language publications. The main focus of evaluation included pain severity, functional disability, and quality of life, assessed at least 3 months post-acupuncture treatment. The risk of bias assessment was conducted using the Cochrane Risk of Bias 2.0 tool, and meta-analyses were performed where applicable.

RESULTS

Eighteen randomized controlled trials were included in the analysis. Acupuncture as an adjunct therapy could provide sustained pain relief at three (SMD: - 0.79; 95% CI - 1.13 to - 0.46; p < 0.01) and six (MD: - 18.13; 95% CI - 30.18 to - 6.07; p < 0.01) months post-treatment. Compared to sham acupuncture, acupuncture did not show a statistically significant difference in pain alleviation (MD: - 0.12; 95% CI - 0.06 to 0.36; p = 0.63). However, it significantly improved functional outcomes as evidenced by Northwick Park Neck Pain Questionnaire scores 3 months post-treatment (MD: - 6.06; 95% CI - 8.20 to - 3.92; p < 0.01). Although nine studies reported an 8.5%-13.8% probability of adverse events, these were mild and transitory adverse events.

CONCLUSION

Acupuncture as an adjunct therapy may provide post-treatment pain relief lasting at least 3 months for patients with chronic neck pain, although it is not superior to sham acupuncture, shows sustained efficacy in improving functional impairment for over 3 months, with a good safety profile.

Effectiveness of Self-Care Education for Chronic Neck Pain: A Systematic Review and Meta-Analysis

Self-care programs for chronic neck pain are relevant to everyday life and can lead to long- term improvement. More studies on their effectiveness, key components and appropriate duration are needed. The aim of this study was to determine the effectiveness of self-care programs for patients with chronic neck pain. A systematic review and meta-analysis of randomized controlled trials was conducted according to the PRISMA guidelines. After searching in PubMed, Web of Science, Scopus and ScienceDirect, eleven studies met the inclusion criteria. Self-care education interventions typically consisted of education (i.e., pain neuro-science education or general educational concepts) accompanied by exercise or manual therapy. The most frequent components were addressing physical and psychological symptoms and engaging in self-care strategies. The least frequent ones were monitoring and recording symptoms and discussing with providers of medical care. The duration of the interventions ranged from three sessions to six months. Finally, individual and supervised modalities were the most frequent. After pooling the data, a meta-analysis was carried out according to four variables (i.e., pain, disability, kinesiophobia and catastrophization) and showed significant results (p < 0.05) in favor of self-care interventions. This systematic review and meta-analysis suggests that self-education interventions improve pain, psychological pain-related variables and disability in patients with chronic neck pain. The most frequently used components were addressing physical and psychological symptoms and engaging in self-care strategies. Future trials should focus on including other components, such as discussing symptoms with providers of medical care or self-monitoring symptoms. Additional areas of focus include more homogeneous doses and comparator treatments, as well as studies with better evidence to reach more solid conclusions.

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.

Are respiratory disorders risk factors for troublesome neck/shoulder pain? A study of a general population cohort in Sweden

PURPOSE

The etiology of neck/shoulder pain is complex. Our purpose was to investigate if respiratory disorders are risk factors for troublesome neck/shoulder pain in people with no or occasional neck/shoulder pain.

METHODS

This prospective cohort study was based on the Stockholm Public Health Cohorts (SPHC) 2006/2010 and the SPHC 2010/2014. We included adults who at baseline reported no or occasional neck/shoulder pain in the last six months, from the two subsamples (SPHC 06/10 n = 15 155: and SPHC 2010/14 n = 25 273). Exposures were self-reported asthma at baseline in SPHC 06/10 and Chronic Obstructive Pulmonary Disease (COPD) at baseline in SPHC 10/14. The outcome was having experienced at least one period of troublesome neck/shoulder pain which restricted work capacity or hindered daily activities to some or to a high degree during the past six months, asked for four years later. Binomial regression analyses were used to calculate risk ratios (RR) with 95% confidence intervals (95% CI).

RESULTS

Adjusted results indicate that those reporting to suffer from asthma at baseline had a higher risk of troublesome neck/shoulder pain at follow-up four years later (RR 1.48, 95% CI 1.10-2.01) as did those reporting to suffer from COPD (RR 2.12 95%CI 1.54-2.93).

CONCLUSION

Our findings indicate that those with no or occasional neck/shoulder pain and reporting to suffer from asthma or COPD increase the risk for troublesome neck/shoulder pain over time. This highlights the importance of taking a multi-morbidity perspective into consideration in health care. Future longitudinal studies are needed to confirm our findings.

Neck pain clinical practice guidelines: a systematic review of the quality and quantity of complementary and alternative medicine recommendations

BACKGROUND

Individuals with neck pain frequently turn to complementary and alternative medicine (CAM) to seek relief. However, conventional healthcare providers often lack adequate CAM therapy knowledge to deliver informed recommendations to patients. The purpose of this study was to identify mention of CAM in neck pain clinical practice guidelines (CPG) and assess the quality of CAM recommendations using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument.

METHODS

MEDLINE, EMBASE and CINAHL were systematically searched from 2009 to 2020 in addition to the Guidelines International Network and National Center for Complementary and Integrative Health websites. Eligible CPGs providing CAM recommendations were assessed twice with the AGREE II instrument, once to assess the overall CPG and then once to assess the CAM sections specifically.

RESULTS

From 643 unique search results, 15 CPGs on the treatment and/or management of neck pain were identified, and 8 made recommendations on CAM therapy. Regarding scaled domain percentages, the overall CPG scored higher than the CAM section for 5 of 6 domains (overall, CAM): (1) scope and purpose (93.4%, 93.1%), (2) stakeholder involvement (81.6%, 81.9%), (3) rigour of development (70.8%, 66.3%), (4) clarity of presentation (64.9%, 60.8%), (5) applicability (39.3%, 33.6%), and (6) editorial independence (47.9%, 45.3%).

CONCLUSIONS

Most neck pain CPGs made CAM recommendations. The quality of CAM recommendations is lower than overall recommendations across all domains with the exception of stakeholder involvement. This disparity highlights the need for CAM recommendations quality improvement. Although many patients with neck pain seek CAM therapies, few CPGs are available for healthcare providers and patients.

Immediate Effects of Adding Dry Needling to Thoracic Manipulation and Exercise in Cervical Range of Motion for Adults With Neck Pain: A Randomized Clinical Trial

OBJECTIVE

The purpose of this study was to determine the immediate effects of adding dry needling (DN) to thoracic spine manipulation and neck-specific exercise in individuals with neck pain.

METHODS

Forty-two participants with neck pain were randomized to either the true (n = 21) or sham (n = 21) DN groups, receiving treatment on the initial visit and 2 to 3 days later. Outcomes were assessed on day 1, both at baseline and immediately after the initial treatment, at the second treatment 2 to 3 days later, and at the final visit 5 to 7 days after visit 2. Primary outcomes were Neck Disability Index (NDI) (0-50) and current pain via numeric pain rating scale (0-10). Secondary outcomes were cervical range of motion, pain pressure threshold, and global rating of change.

RESULTS

Repeated measures analysis of covariance with baseline value as covariate revealed no significant difference in NDI scores at either follow-up time point with adjusted mean differences (95% confidence interval) of -0.11 (-2.70 to 2.48) and 0.31 (-1.96 to 2.57). There were no between-group differences in pain at any time point via Independent-Samples Median Test (P value range of .54-1.0). Secondary outcome measures were similarly not statistically different between groups except for immediate improvements in rotation to the side opposite of pain, which favored DN, with an adjusted mean difference (95% confidence interval) of 7.85 (3.54-12.15) degrees.

CONCLUSION

The addition of DN to thoracic spinal manipulation and neck-specific exercise did not affect improvements in NDI score or numeric pain rating scale but showed an increase in cervical range of motion.

Global, regional, and national neck pain burden in the general population, 1990–2019: An analysis of the global burden of disease study 2019

Background

This study describes the global epidemiology and trends associated with neck pain. Global Burden of Disease data collected between 1990 and 2019 were used to determine the global burden of neck pain in the general populations of 204 countries.

Methods

Global, regional, and national burdens of neck pain determined by prevalence, incidence, and years lived with a disability (YLD) from 1990 to 2019 were comprehensively analyzed according to age, gender, and socio-demographic index using the Global Burden of Disease Study 1990 and 2019 data provided by the Institute for Health Metrics and Evaluation.

Results

Globally, in 2019, the age-standardized rates for prevalence, incidence, and YLD of neck pain per 100,000 population was 2,696.5 (95% uncertainty interval [UI], 2,177.0 to 3,375.2), 579.1 (95% UI, 457.9 to 729.6), and 267.4 (95% UI, 175.5 to 383.5) per 100,000 population, respectively. Overall, there was no significant difference in prevalence, incidence, or YLD of neck pain between 1990 and 2019. The highest age-standardized YLD of neck pain per 100,000 population in 2019 was observed in high-income North America (479.1, 95% UI 323.0 to 677.6), Southeast Asia (416.1, 95% UI 273.7 to 596.5), and East Asia (356.4, 95% UI 233.2 to 513.2). High-income North America (17.0, 95% UI 9.0 to 25.4%) had the largest increases in YLD of neck pain per 100,000 population from 1990 to 2019. At the national level, the highest age-standardized YLD of neck pain was found in the Philippines (530.1, 95% UI 350.6 to 764.8) and the highest change age-standardized YLD between 1990 and 2019 was found in the United States (18.4, 95% UI 9.9 to 27.6%). Overall, the global burden of neck pain increased with age until the age of 70–74 years, and was higher in women than men. In general, positive associations between socio-demographic index and burden of neck pain were found.

Conclusions

Because neck pain is a major public health burden with a high prevalence, incidence, and YLD worldwide, it is important to update its epidemiological data and trends to cope with the future burden of neck pain.

Differences between spinal cord injury and cervical compressive myelopathy in intramedullary high-intensity lesions on T2-weighted magnetic resonance imaging: A retrospective study

Increases in aging populations have raised the number of patients with cervical spinal cord injury (SCI) without fractures due to compression of the cervical spinal cord. In such patients, it is necessary to clarify whether SCI or cervical compressive myelopathy (CCM) is the cause of disability after trauma. This study aimed to clarify the differences in magnetic resonance imaging (MRI) features between SCI and CCM. Overall, 60 SCI patients and 60 CCM patients with intramedullary high-intensity lesions on T2-weighted MRI were included in this study. The longitudinal lengths of the intramedullary T2 high-intensity lesions were measured using sagittal MRI sections. Snake-eye appearance on axial sections was assessed as a characteristic finding of CCM. The T2 values of the high-intensity lesions and normal spinal cords at the first thoracic vertebra level were measured, and the contrast ratio was calculated using these values. The longitudinal length of T2 high-intensity lesions was significantly longer in SCI patients than in CCM patients. Snake-eye appearance was found in 26 of the 60 CCM patients, but not in SCI patients. On both the sagittal and axial images, the contrast ratio was significantly higher in the SCI group than in the CCM group. Based on these results, a diagnostic scale was created. This scale made it possible to distinguish between SCI and CCM with approximately 90% accuracy.

Musculoskeletal mimics of cervical radiculopathy

Musculoskeletal mimics of cervical radiculopathy will be explored in this AANEM monograph. A review of the literature and textbooks was conducted. Musculoskeletal cervical radiculopathy mimics include: (1) head/neck pain, such as neck tension, cervicogenic headache, and temporomandibular disorder; (2) referred pain from shoulder pathology, such as rotator cuff tears/impingement; (3) elbow region abnormalities, including medial/lateral epicondylitis; (4) wrist/hand conditions, such as DeQuervain's tenosynovitis and intersection syndrome; (5) muscle connective tissue disorders, including myofascial trigger points; (6) conditions that have decreased range of motion, including frozen shoulder and rounded shoulders with tight pectoral/scalene muscles; (7) conditions with joint hyperlaxity and instability, as seen in post-stroke shoulder subluxation; (8) vascular conditions, such as thoracic outlet syndrome; and (9) autonomic controlled soft tissue changes associated with complex regional pain syndrome. Formulating a differential diagnosis and recognizing mimics of cervical radiculopathy can decrease the time between symptom onset and diagnosis/treatment plan.

Traditional Chinese Exercises on Pain and Disability in Middle-Aged and Elderly Patients With Neck Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

With the change of life and work style, more middle-aged and elderly individuals are suffering from neck pain. In China, traditional Chinese exercises (TCEs) are widely used in the management of neck pain, such as Tai Chi, Qigong, Yijinjing, Baduanjin, Liuzijue, and Five-animal exercises. However, the evidence of TCEs for neck pain maintains controversial. Therefore, the current systematic review was conducted to evaluate the effects of TCEs on pain and disability of middle-aged and elderly patients with neck pain.

METHODS

A comprehensive literature search was performed in six electronic databases from their inception to January 2022 for randomized controlled trials of TCEs for neck pain. The methodological quality of the included studies was assessed by PEDro scale. The subgroup analysis was conducted based on different TCEs. The I 2 statistic was applied to assess the heterogeneity.

RESULTS

Twenty-one studies were included in our review, which were conducted in China, United States, and Germany between 2003 and 2021. Most (86%) of them exceeded the cut off score 6. TCEs included Baduanjin, Yijinjing, Tai Chi, Qigong, and Five-animal exercises. The aggregated results indicated that TCEs showed positive complementary effects in relieving pain (SMD, 1.12; 95% CI, 0.78-1.45; p < 0.00001), especially Baduanjin exercises. Baduanjin exercises also showed beneficial complementary effects in improving flexion (SMD, 0.65; 95% CI, 0.28-1.03; p = 0.0006) and extension (SMD, 0.66; 95% CI, 0.12-1.19; p = 0.02) of the neck. In addition, the aggregated results indicated that TCEs alone showed beneficial effects in improving disability (SMD, 0.74; 95% CI, 0.40-1.08; p < 0.0001) and relieving pain (SMD, 0.81; 95% CI, 0.50-1.13; p < 0.00001) compared with waiting list. The follow-up effects of TCEs were still insufficient.

CONCLUSION

There was the positive evidence to support the clinical use of TCEs, as a complementary therapy, for middle-aged and elderly patients with neck pain, especially Baduanjin exercises. However, the evidence supporting the effects of TCEs alone for the middle-aged and elderly patients with neck pain was limited due to the small sample size.

SYSTEMATIC REVIEW REGISTRATION

https://inplasy.com/inplasy-2022-4-0083/, identifier INPLASY202240083.

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

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

Cervicothoracic spinal alignment and neck flexor muscle endurance in young and older adult females with and without neck and shoulder pain (Katakori in Japanese)

[Purpose] The characteristics of neck and shoulder pain (NSP) in different age populations have not been sufficiently examined. Therefore, the purpose of this study was to compare and verify the cervicothoracic spinal alignment and neck flexor muscle endurance of young and older adult females with and without NSP. [Participants and Methods] We assessed 72 female participants (39 young participants, 33 elderly participants, 43 NSP, 29 non-NSP) aged 18–82 years who were recruited for this study. Cervicothoracic spinal alignment measurements were obtained with forward head alignment (FHA) along with the upper thoracic angle. The neck flexor endurance test was performed. [Results] There were no significant age-by-group interactions for any of the assessment variables. However, the upper thoracic angle and neck flexor muscle endurance showed significant effects in the groups. Age also had significant effects on FHA and upper thoracic angle. [Conclusion] These results suggested that the neck flexor muscle endurance was more appropriate as an evaluation tool for older adult females with NSP. It was also suggested that the cervical flexor muscle endurance and upper thoracic angle were more appropriate as evaluation tools for young adult females with NSP.

A contemporary neuroscience approach compared to biomedically focused education combined with symptom-contingent exercise therapy in people with chronic whiplash associated disorders: a randomized controlled trial protocol

BACKGROUND

To address the need for a better treatment of chronic whiplash associated disorders (WAD), a contemporary neuroscience approach can be proposed.

OBJECTIVE

To examine the effectiveness of a contemporary neuroscience approach, comprising pain neuroscience education, stress management, and cognition-targeted exercise therapy versus conventional physical therapy for reducing disability (primary outcome measure) and improving quality of life and reducing pain, central sensitization, and psychological problems (secondary outcome measures) in people with chronic WAD.

METHODS

The study is a multi-center, two-arm randomized, controlled trial with 1-year follow-up and will be performed in two university-based and one regional hospital. People with chronic WAD (n=120) will be recruited. The experimental group will receive pain neuroscience education followed by cognition-targeted exercise therapy, and stress management. The control group will receive biomedically focused education followed by graded and active exercise therapy focusing on muscle endurance, strength, and flexibility, and ergonomic principles. The treatment will have a duration of 16 weeks. Functional status (Neck Disability Index) is the primary outcome measure. Secondary outcome measures include quality of life, pain, central sensitization, and psychological and socio-economic factors. In addition, electroencephalography will measure brain activity at rest and during a conditioned pain modulation paradigm. Assessments will take place at baseline, immediately post-treatment and at 6 and 12 months follow-up.

CONCLUSIONS

This study will examine whether a contemporary neuroscience approach is superior over conventional physical therapy for improving functioning, quality of life, and reducing pain, central sensitization, and psychological problems in people with chronic WAD.

Physical workload and increased frequency of musculoskeletal pain: a cohort study of employed men and women with baseline occasional pain

OBJECTIVES

Musculoskeletal pain (MSP) is prevalent among the workforce. This study investigates the long-term association between physical workload (PWL) and increased frequency of MSP among male and female employees with pre-existing occasional MSP.

METHODS

This study uses the Stockholm Public Health cohort survey data from the baseline 2006. The sample includes 5715 employees with baseline occasional MSP (no more than a few days per month). Eight PWL exposures and overall PWL were estimated using a job-exposure matrix (JEM). The JEM was assigned to occupational titles from a national register in 2006. Follow-up survey data on frequent MSP (a few or more times a week) were collected from 2010. Logistic regressions produced sex-specific ORs with 95% CIs and were adjusted for education, health conditions, psychological distress, smoking, BMI, leisure-time physical activity and decision authority.

RESULTS

Associations were observed between several aspects of heavy PWL and frequent MSP for men (eg, OR 1.57, 95% CI 1.13 to 2.20, among those in the highest exposure quartile compared with those in the lowest quartile for heavy lifting) and women (eg, OR 1.76, 95% CI 1.35 to 2.29, among those in the highest exposure quartile compared with those in the the lowest quartile for physically strenuous work). Small changes were observed in the OR after adjustment, but most of the ORs for PWL exposures among the men were no longer statistically significantly increased.

CONCLUSION

A high level of exposure to heavy PWL was associated with increased frequency of MSP 4 years later for men and women with baseline occasional pain.

Revisiting Risk-stratified Whiplash-exposed Patients 12 to 14 Years After Injury

OBJECTIVE

The objective of this study was to evaluate the long-term predictive value of the Danish Whiplash Group Risk Assessment Score (DWGRAS) with 7 risk strata.

DESIGN

E-questionnaire-based follow-up study (n=927) combining 2 cohorts of whiplash-injured patients, 1 observational (n=187) and 1 interventional randomized controlled trial (n=740).

METHODS

Nine hundred twenty-seven previously healthy persons exposed to acute whiplash injury during motor vehicle collision were sent letter by postal service asking the addressee if they would respond to an E-questionnaire. Outcome measures were: whiplash-related disability, pain, use of medication/nonmedical treatment, work capacity.

RESULTS

The response rate was 37%. Fifty-five percent reported whiplash-related disability. Fourteen percent reported daily symptoms. A strong relationship was found between risk strata and impact of event and between risk strata and disabling symptoms.

CONCLUSIONS

Internal and long-term validation of DWGRAS was performed, but a low response rate indicates that results should be interpreted with caution. Furthermore, external validation needs to be done in long-term studies. An receiver operating characteristics curve of 0.73 (95% confidence interval 0.67; 0.79) predicting daily or weekly whiplash-related disability after 12 to 14 years was found using the DWGRAS risk score.

Ultrasound shear wave elastography measurement of the deep posterior cervical muscles: Reliability and ability to differentiate between muscle contraction states

The deep posterior cervical muscles (DPCM), specifically the semispinalis cervicis and cervical multifidus, are often impaired in patients with neck disorders and have been assessed by several imaging techniques. Prior ultrasound shear wave elastography (SWE) imaging and reliability assessments of the DPCM were performed utilizing similar positioning as assessments for the more superficial cervical extensors. Our objectives were to describe an SWE imaging technique for the DPCM, establish intra-rater reliability of DPCM SWE, and compare DPCM shear modulus during rest and submaximal contraction in both prone and seated positions in individuals without spinal pain. In sixteen participants, the DPCM was located using B-mode ultrasound, then muscle shear modulus was assessed via SWE at both rest and with contraction against a 2-kg resistance applied at the C2 spinous process. Within-day intra-rater reliability was moderate to good (ICC = 0.70-0.88). The DPCM were stiffer during contraction than at rest in the prone position (p = 0.002), and at rest in sitting versus at rest in prone (p = 0.003). Further research is needed to assess DPCM-specific SWE in symptomatic individuals and compare DPCM shear modulus to electromyography across contraction intensities.

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.

Cross-cultural adaptation and validation of the Dutch language version of the Pictorial Fear of Activity Scale - Cervical

Background

The Pictorial Fear of Activity Scale-Cervical (PFActS-C) is a reliable and valid instrument to assess fear of movement in people with whiplash associated disorders. It is not available in Dutch and has not been evaluated in other neck pain populations. This study aimed to systematically translate the PFActS-C into Dutch and evaluate the psychometric properties of this Dutch Language Version (DLV) in people with non-specific neck pain.

Methods

The PFActS-C was translated according to international guidelines. Internal consistency, test-retest reliability, floor and ceiling effects, face validity and construct validity (convergent and discriminant validity by hypotheses testing and structural validity by confirmatory and exploratory factor-analyses) of the PFActS-C-DLV were tested in 125 people with non-specific neck pain.

Results

The PFActS-C-DLV showed good to excellent internal consistency (Cronbach’s alpha: 0.98) and stability over time (ICC: 0.90 [95%CI: 0.82–0.93). Four out of five a priori formulated hypotheses regarding related (convergent validity) and unrelated (discriminant validity) constructs were confirmed. However, the confirmatory factor analysis could not confirm the expected 1-factor solution. Furthermore, the exploratory factor analyses revealed that also a higher factor solution would not lead to a good fit of the model.

Conclusions

The PFActS-C-DLV is a reliable region-specific instrument for people with non-specific neck pain. The construct validity was supported, based on hypotheses testing. However, factor analyses could not confirm a 1-factor solution, so the underlying construct of the PFActS-C-DLV remains unclear. Given the PFActS-C’s photographic format, we believe these findings also have relevance for the original English version.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12891-020-03724-1.

Brain Network Disruption in Whiplash

BACKGROUND AND PURPOSE

Whiplash-associated disorders frequently develop following motor vehicle collisions and often involve a range of cognitive and affective symptoms, though the neural correlates of the disorder are largely unknown. In this study, a sample of participants with chronic whiplash injuries were scanned by using resting-state fMRI to assess brain network changes associated with long-term outcome metrics.

MATERIALS AND METHODS

Resting-state fMRI was collected for 23 participants and used to calculate network modularity, a quantitative measure of the functional segregation of brain region communities. This was analyzed for associations with whiplash-associated disorder outcome metrics, including scales of neck disability, traumatic distress, depression, and pain. In addition to these clinical scales, cervical muscle fat infiltration was quantified by using Dixon fat-water imaging, which has shown promise as a biomarker for assessing disorder severity and predicting recovery in chronic whiplash.

RESULTS

An association was found between brain network structure and muscle fat infiltration, wherein lower network modularity was associated with larger amounts of cervical muscle fat infiltration after controlling for age, sex, body mass index, and scan motion (t = -4.02, partial R ²  = 0.49, P < .001).

CONCLUSIONS

This work contributes to the existing whiplash literature by examining a sample of participants with whiplash-associated disorder by using resting-state fMRI. Less modular brain networks were found to be associated with greater amounts of cervical muscle fat infiltration suggesting a connection between disorder severity and neurologic changes, and a potential role for neuroimaging in understanding the pathophysiology of chronic whiplash-associated disorders.

Relationships Between Context, Process, and Outcome Indicators to Assess Quality of Physiotherapy Care in Patients with Whiplash-Associated Disorders: Applying Donabedian's Model of Care

BACKGROUND

Quality indicators (QIs) are measurable elements of practice performance and may relate to context, process, outcome and structure. A valid set of QIs have been developed, reflecting the clinical reasoning used in primary care physiotherapy for patients with whiplash-associated disorders (WAD). Donabedian's model postulates relationships between the constructs of quality of care, acting in a virtuous circle.

AIM

To explore the relative strengths of the relationships between context, process, and outcome indicators in the assessment of primary care physiotherapy in patients with WAD.

MATERIALS AND METHODS

Data on WAD patients (N=810) were collected over a period of 16 years in primary care physiotherapy practices by means of patients records. This routinely collected dataset (RCD-WAD) was classified in context, process, and outcome variables and analyzed retrospectively. Clinically relevant variables were selected based on expert consensus. Associations were expressed, using zero-order, as Spearman rank correlation coefficients (criterion: rs >0.25 [minimum: fair]; α-value = 0.05).

RESULTS

In round 1, 62 of 85 (72.9%) variables were selected by an expert panel as relevant for clinical reasoning; in round 2, 34 of 62 (54.8%) (context variables 9 of 18 [50.0%]; process variables 18 of 34 [52.9]; outcome variables 8 of 10 [90.0%]) as highly relevant. Associations between the selected context and process variables ranged from 0.27 to 0.53 (p≤0.00), between selected context and outcome variables from 0.26 to 0.55 (p≤0.00), and between selected process and outcome variables from 0.29 to 0.59 (p≤0.00). Moderate associations (rs >0.50; p≤0.00) were found between "pain coping" and "fear avoidance" as process variables, and "pain intensity" and "functioning" as outcome variables.

CONCLUSION

The identified associations between selected context, process, and outcome variables were fair to moderate. Ongoing work may clarify some of these associations and provide guidance to physiotherapists on how best to improve the quality of clinical reasoning in terms of relationships between context, process, and outcome in the management of patients with WAD.

Effectiveness of deep tissue massage therapy, and supervised strengthening and stretching exercises for subacute or persistent disabling neck pain. The Stockholm Neck (STONE) randomized controlled trial

OBJECTIVE

To compare the effectiveness of deep tissue massage, supervised strengthening and stretching exercises, and a combined therapy (exercise followed by massage) (index groups), with advice to stay active (control group).

METHODS

Randomized controlled trial of 619 adults with subacute or persistent neck pain allocated to massage (n = 145), exercise (n = 160), combined therapy (n = 169) or advice (n = 147). Primary outcomes were minimal clinically important improvements in neck pain intensity and pain-related disability based on adapted questions from the Chronic Pain Questionnaire. Secondary outcomes were perceived recovery and sickness absence. Outcomes were measured at seven, 12, 26 and 52 weeks.

RESULTS

We found improvement in pain intensity favouring massage and combined therapy compared to advice; at seven weeks (RR = 1.36; 95%CI:1.04-1.77) and 26 weeks (RR = 1.23; 95%CI:0.97-1.56); and seven (RR = 1.39; 95%CI:1.08-1.81) and 12 weeks (RR = 1.28; 95%CI:1.02-1.60) respectively, but not at later follow-ups. Exercise showed higher improvement of pain intensity at 26 weeks (RR = 1.31; 95%CI:1.04-1.65). Perceived recovery was higher in the index groups than in the advice group at all follow-ups. We found no consistent differences in pain related disability or sickness absence.

CONCLUSIONS

In this study, at 12-months follow-up, none of the index therapies were more effective than advice in terms of pain intensity in the long term or in terms of pain-related disability in the short or long term. However, the index therapies led to higher incidence of improvement in pain intensity in the short term, and higher incidence of favorable perceived recovery in the short and in the long term than advice.

TRIAL REGISTRATION

ISRCTN01453590. Registered 3 July 2014.

Clinical Characteristics and Patient-Reported Outcomes of Primary Care Physiotherapy in Patients with Whiplash-Associated Disorders: A Longitudinal Observational Study

BACKGROUND

Whiplash-associated disorders (WADs) constitute a state of health characterized by a wide diversity of symptoms as a result of impairments of functions, activity limitations, and participation restrictions. Patient-reported outcome measurements (PROMs) and patient-reported outcomes (PROs) seem appropriate when describing and evaluating the health status of patients with WAD.

AIM

To measure the use of PROMs and PROs as quality indicators in clinical reasoning, and to analyze and evaluate pre- and post-treatment 'pain intensity' and 'functioning', and for 'perceived improvement' in patients with WAD in primary care physiotherapy practice by year of referral, with the phase after accident and prognostic health profile embedded in the clinical reasoning process.

MATERIALS AND METHODS

Data were collected over a period of 10 years. Pain intensity, functioning, and perceived improvement were measured using the Visual Analogue Scale for Pain (VAS-P), the Neck Disability Index (NDI) and the Global Perceived Effect scale (GPE). Pre- and post-treatment mean differences were tested for statistical significance and compared to minimal clinically important differences (MCID). Effect sizes were expressed as Cohen's d. Multivariable regression analysis was performed to explore independent associations of year of referral, phase after the accident, and the patient's prognostic health profile with post-treatment pain intensity and functioning.

RESULTS

A consecutive sample of 523 patients was included. Pre- and post-treatment mean differences on VAS-P and NDI were statistically significant (P<0.000) and clinically relevant, with 'large' effect sizes for pain intensity and functioning. MCIDs were achieved by 80% for VAS-P and for 60% for NDI. Year of referral and phase after the accident were independently associated with worse post-treatment functioning. About half of the patients (n=241 [46.1%]) perceived themselves as improved.

CONCLUSION

The PROMs and PROs pain intensity, functioning and perceived improvement were integrated as quality indicators in the physiotherapy clinical reasoning process for patients with WAD. Significant differences in pain intensity and functioning were found but were unrelated to year of referral, phase after whiplash-related injury or prognostic health profile. The MCID VAS-P scores did not differ depending on experienced pain.

Healthy lifestyle behaviour and risk of long-duration troublesome neck pain among men and women with occasional neck pain: results from the Stockholm public health cohort

OBJECTIVES

The effect of a healthy lifestyle on the prognosis of neck pain is unknown. This study aimed to investigate if a healthy lifestyle behaviour influences the risk of long-duration troublesome neck pain among men and women with occasional neck pain.

DESIGN

Longitudinal cohort study.

SETTINGS

General population, and a subsample of the working population, in Stockholm County, Sweden.

PARTICIPANTS

This study involved 5342 men and 7298 women, age 18 to 84, from the Stockholm Public Health Cohort, reporting occasional neck pain at baseline in 2006.

MEASURES

Baseline information about leisure physical activity, smoking, alcohol consumption and consumption of fruits and vegetables were dichotomised into recommendations for healthy/not healthy behaviour. The exposure, a healthy lifestyle behaviour, was categorised into four levels according to the number of healthy behaviours (HB) met. Generalised linear models were applied to assess the exposure on the outcome long-duration troublesome neck pain (activity-limiting neck pain ≥2 days/week during the past 6 months), at follow-up in 2010.

RESULTS

The adjusted risk of long-duration troublesome neck pain decreased with increasing adherence to a healthy lifestyle behaviour among both men and women (trend test: p<0.05). Compared with the reference category, none or one HB, the risk decreased by 24% (risk ratio 0.76, 95% CI 0.58 to 0.98) among men and by 34% (0.66, 0.54 to 0.81) among women, with three or four HBs. The same comparison showed an absolute reduction of the outcome by 3% in men (risk difference -0.03, 95% CI -0.05 to -0.01) and 5% in women (-0.05,-0.08 to -0.03). Similar results were found in the working population subsample.

CONCLUSION

Adhering to a healthy lifestyle behaviour decreased the risk of long-duration troublesome neck pain among men and women with occasional neck pain. The results add to previous research and supports the importance of promoting a healthy lifestyle behaviour.

Prediction of 2-year work participation in sickness absentees with neck or shoulder pain: the contribution of demographic, patient-reported, clinical and imaging information

Background

In cases of neck and shoulder pain, the responsibility for assessing work prognosis is held by clinicians with access to different domains of information. One of these domains is magnetic resonance imaging (MRI), and although MRI is increasingly used, it is unknown which domains of information contribute the most to the prediction of work prognosis. This retrospective cohort study explored the contribution of demographic, patient-reported, clinical, and MRI information to the prediction of work participation in sickness absentees with neck or shoulder pain.

Methods

From a secondary care setting, 168 sickness absentees with neck or shoulder pain were included. Based on registry data, a successful work outcome was defined as ≥50% work participation score (WPS) from Weeks 1 to 104 after enrolment. Prognostic variables were categorized into four domains (demographic, patient-reported, clinical, and MRI) resembling the order of information obtained in a clinical setting. Crude logistic regression analyses were used to identify prognostic variables for each domain (p < 0.2). This was followed by multivariable analyses including the identified variables in a domain-wise order. For each added domain, the probability of successful WPS was dichotomized leaving two possible classifications: ≥ 50% chance of successful WPS or not. In cross-tabulations of chance and the actual WPS outcome, positive and negative predictive values (PPV and NPV), sensitivity, specificity and area under the curve (AUC) were calculated.

Results

The combination of demographic and patient-reported variables yielded an NPV of 0.72 and a PPV of 0.67, while specificity was 0.82, sensitivity 0.54 and AUC 0.77. None of these values improved notably by adding clinical and MRI variables as predictors of successful WPS.

Conclusions

These results suggest that - among sickness absentees with neck or shoulder pain – clinical and MRI variables provide no additional information for the prediction of work participation compared with only demographic and patient-reported information.

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.

Beyond symptom resolution: insurance case manager's perspective on predicting recovery after motor vehicle crash

PURPOSE

Insurance company case managers can play a critical role in the rehabilitation process of people with musculoskeletal disorders sustained following minor motor vehicle crash injury due to their interaction with multiple stakeholders and their role in approving various services. This study aimed to identify factors that case managers perceive as predictive of recovery in people with musculoskeletal disorders after minor motor vehicle crash injury.

MATERIALS AND METHODS

To explore the perspectives of cases managers in Australia and the United States, semi-structured interviews explored factors that case managers thought provided an early indication of likely recovery outcomes in people with musculoskeletal disorders after minor motor vehicle crash injury. A framework analysis was applied and factors were displayed within the ICF-framework.

RESULTS

Case managers (n = 40) demonstrated a broad, detailed understanding of biopsychosocial and contextual issues influencing recovery. They emphasized the importance of the injured worker's expressed affect and motivation, style of communication, the role of lawyers, the worker's family and friends, as well as cultural and geographic influences. The overarching themes perceived as having a major influence on recovery outcomes were general health, pain processing and response, work situation, and compensation entitlement.

CONCLUSIONS

Case managers' broad and detailed perceptions about recovery may provide additional, valuable perspectives for professionals involved in the rehabilitation process of people with musculoskeletal disorders after minor motor vehicle crash injury. Further research needs to be conducted to explore the effects of case manager involvement in the process of recovery.Implications for rehabilitationInsurance Case Managers identified multiple factors including affect and motivation, style of communication, the role of lawyers, family and friends, cultural and geographic variation provide opportunities for more effective treatment of people with musculoskeletal disorders related to minor motor vehicle collisions. These managers' perceptions about recovery may be informative to and provide opportunities for health professionals involved in the rehabilitation of people with musculoskeletal disorders related to minor motor vehicle collisions.While the Insurance Case Managers involved in this research did not use formalized assessment techniques, tools and assessment protocols could be developed jointly between for the needs of Insurance Case Managers and other stakeholders to tackle recovery of people with musculoskeletal disorders related to minor motor vehicle collision.

Predictive models for short-term and long-term improvement in women under physiotherapy for chronic disabling neck pain: a longitudinal cohort study

OBJECTIVES

To develop predictive models for short-term and long-term clinically important improvement in women with non-specific chronic disabling neck pain during the clinical course of physiotherapy.

DESIGN

Longitudinal cohort study based on data from a randomised controlled trial evaluating short-term and long-term effects on sensorimotor function over 11 weeks of physiotherapy.

PARTICIPANTS AND SETTINGS

Eighty-nine women aged 31-65 years with non-specific chronic disabling neck pain from Gävle, Sweden.

MEASURES

The outcome, clinically important improvement, was measured with the Patient Global Impression of Change Scale (PGICS) and the Neck Disability Index (NDI), assessed by self-administered questionnaires at 3, 9 and 15 months from the start of the interventions (baseline). Twelve baseline prognostic factors were considered in the analyses. The predictive models were built using random-effects logistic regression. The predictive ability of the models was measured by the area under the receiver operating characteristic curve (AUC). Internal validity was assessed with cross-validation using the bootstrap resampling technique.

RESULTS

Factors included in the final PGICS model were neck disability and age, and in the NDI model, neck disability, depression and catastrophising. In both models, the odds for short-term and long-term improvement increased with higher baseline neck disability, while the odds decreased with increasing age (PGICS model), and with increasing level of depression (NDI model). In the NDI model, higher baseline levels of catastrophising indicated increased odds for short-term improvement and decreased odds for long-term improvement. Both models showed acceptable predictive validity with an AUC of 0.64 (95% CI 0.55 to 0.73) and 0.67 (95% CI 0.59 to 0.75), respectively.

CONCLUSION

Age, neck disability and psychological factors seem to be important predictors of improvement, and may inform clinical decisions about physiotherapy in women with chronic neck pain. Before using the developed predictive models in clinical practice, however, they should be validated in other populations and tested in clinical settings.

Widespread Pressure Pain Hypersensitivity, Health History, and Trigger Points in Patients with Chronic Neck Pain: A Preliminary Study

Background

Pain sensitivity in chronic neck pain patients may be influenced by health conditions related to higher levels of widespread pressure pain hypersensitivity (sensitization). Trigger points have also been reported to play a role in the sensitization process.

Objectives

To investigate the association between pressure pain thresholds, trigger points, and health conditions in patients with chronic neck pain.

Design

Original research, preliminary study.

Setting

A private clinic.

Subjects

Thirty-four chronic mechanical neck pain patients and 34 chronic whiplash-associated neck pain patients, giving a final sample of 68 chronic neck pain patients.

Methods

Patients underwent an assessment of pressure pain thresholds over the upper trapezius, extensor carpi radialis longus, and tibialis anterior muscles and were screened for the presence of trigger points in the upper trapezius muscle. Further, information about health history conditions was obtained and collected in a form.

Results

Significantly negative correlations between all pressure pain thresholds and duration of health history conditions were found (all P &lt; 0.02). Significantly lower pressure pain thresholds (all P &lt; 0.01) were found in patients with active trigger points as compared with those with latent trigger points.

Conclusion

Widespread pressure pain hypersensitivity was associated with duration of health history conditions, suggesting that long-lasting health complaints may act as a triggering/perpetuating factor, driving sensitization in individuals with chronic neck pain. Active trigger points may be associated with higher widespread pressure hypersensitivity.

Are trajectories of neck-shoulder pain associated with sick leave and work ability in workers? A 1-year prospective study

OBJECTIVES

The study aimed to determine the extent to which latent trajectories of neck-shoulder pain (NSP) are associated with self-reported sick leave and work ability based on frequent repeated measures over 1 year in an occupational population.

METHODS

This longitudinal study included 748 Danish workers (blue-collar, n=620; white collar, n=128). A questionnaire was administered to collect data on personal and occupational factors at baseline. Text messages were used for repeated measurements of NSP intensity (scale 0-10) over 1 year (14 waves in total). Simultaneously, self-reported sick leave (days/month) due to pain was assessed at 4-week intervals, while work ability (scale 0-10) was assessed using a single item (work ability index) at 12-week intervals over the year. Trajectories of NSP, distinguished by latent class growth analysis, were used as predictors of sick leave and work ability in generalised estimation equations with multiple adjustments.

RESULTS

Sick leave increased and work ability decreased across all NSP trajectory classes (low, moderate, strong fluctuating and severe persistent pain intensity). In the adjusted model, the estimated number of days on sick leave was 1.5 days/month for severe persistent NSP compared with 0.1 days/month for low NSP (relative risk=13.8, 95% CI 6.7 to 28.5). Similarly, work ability decreased markedly for severe persistent NSP (OR=12.9, 95% CI 8.5 to 19.7; median 7.1) compared with low NSP (median 9.5).

CONCLUSION

Severe persistent NSP was associated with sick leave and poor work ability over 1 year among workers. Preventive strategies aiming at reducing severe persistent NSP among working populations are needed.

A scoping review of biopsychosocial risk factors and co-morbidities for common spinal disorders

OBJECTIVE

The purpose of this review was to identify risk factors, prognostic factors, and comorbidities associated with common spinal disorders.

METHODS

A scoping review of the literature of common spinal disorders was performed through September 2016. To identify search terms, we developed 3 terminology groups for case definitions: 1) spinal pain of unknown origin, 2) spinal syndromes, and 3) spinal pathology. We used a comprehensive strategy to search PubMed for meta-analyses and systematic reviews of case-control studies, cohort studies, and randomized controlled trials for risk and prognostic factors and cross-sectional studies describing associations and comorbidities.

RESULTS

Of 3,453 candidate papers, 145 met study criteria and were included in this review. Risk factors were reported for group 1: non-specific low back pain (smoking, overweight/obesity, negative recovery expectations), non-specific neck pain (high job demands, monotonous work); group 2: degenerative spinal disease (workers' compensation claim, degenerative scoliosis), and group 3: spinal tuberculosis (age, imprisonment, previous history of tuberculosis), spinal cord injury (age, accidental injury), vertebral fracture from osteoporosis (type 1 diabetes, certain medications, smoking), and neural tube defects (folic acid deficit, anti-convulsant medications, chlorine, influenza, maternal obesity). A range of comorbidities was identified for spinal disorders.

CONCLUSION

Many associated factors for common spinal disorders identified in this study are modifiable. The most common spinal disorders are co-morbid with general health conditions, but there is a lack of clarity in the literature differentiating which conditions are merely comorbid versus ones that are risk factors. Modifiable risk factors present opportunities for policy, research, and public health prevention efforts on both the individual patient and community levels. Further research into prevention interventions for spinal disorders is needed to address this gap in the literature.

Impact of Workplace Exposure and Stress on Neck Pain and Disabilities in Women-A Longitudinal Follow-up After a Rehabilitation Intervention

Introduction

The aim was to evaluate if pain, disability, and work productivity are influenced by physical and psychosocial work exposures as well as by stress, up to 1 year after a randomized controlled trial treatment intervention, and to determine whether any such association differed between treatment and control groups.

Methods

Ninety-seven working women suffering non-specific neck pain (n = 67 treatment group, n = 30 control group) were followed from end of treatment intervention and at 9- and 15-month follow-ups, respectively. Physical and psychosocial exposures, as well as perceived stress, were assessed after the treatment intervention. Pain, neck disability, and work productivity were assessed at baseline, after intervention 3 months later and at 9- and 15-month follow-ups. Longitudinal assessment was conducted using the exposure level at 3 months as predictor of pain, disability, and work productivity at 3, 9, and 15 months, respectively. Mixed models were used to estimate longitudinal associations, accounting for within-individual correlation of repeated outcome measures by incorporation of a random intercept. Age and duration of neck pain were adjusted for in all models. To evaluate group differences, interactions between exposures and treatment groups were estimated.

Results

High perceived stress was associated with more neck pain, more neck disability, and decreased work productivity in both cross-sectional and longitudinal analyses. High 'control of decision' was associated with less neck pain, less neck disability, and higher work productivity in cross-sectional analyses but only to less disability and higher productivity in longitudinal analyses. Shoulder/arm load was the only physical exposure variable that was significantly associated with work productivity in the univariate analyses. Only small differences were observed between treatment and control groups.

Conclusion

High perceived stress and low 'control of decision' were associated with more neck pain, increased neck disability, and decreased work productivity. Treatment interventions for individuals with neck pain should take into account psychosocial workplace exposures and stress to improve intermediate and long-term results.

Modifiable individual and work-related factors associated with neck pain in 740 office workers: a cross-sectional study

BACKGROUND

Office workers have the highest incidence of neck pain of all occupations. However, the relationship between symptoms and the risk factors is unclear.

OBJECTIVE

To examine the relationship between self-reported neck pain with a comprehensive range of individual and work-related risk factors.

METHODS

This study utilised a cross-sectional study design. Office workers with and without neck pain (n=763) were recruited. Participants completed a survey which included a Pain Numerical Rating Scale (dependent variable), and measures of independent variables including demographic, individual, work-related factors, neck/shoulder muscle strength, endurance, and range of motion (ROM). The relationships between the independent and dependent variables were analysed in a logistic regression model.

RESULTS

Neck pain was significantly associated with more senior occupational categories, working more than six hours per day on the computer, female sex, greater fear avoidance beliefs for work, greater psychological distress, and reduced cervical flexion ROM. The low severity of neck pain of the participants in this study may limit a robust determination of their association with the risk factor variables, but the studied sample is a realistic representation of the office worker population.

CONCLUSION

Several potentially modifiable individual and work-related factors were identified to be associated with the presence of self-reported neck pain in office workers. Future studies will be needed to investigate whether strategies to alter these modifiable risk factors translate to changes in neck pain.

TRIAL REGISTRATION

ACTRN12612001154897 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363209).

Clinical Practice Guideline for Physical Therapy Assessment and Treatment in Patients With Nonspecific Neck Pain

The Royal Dutch Society for Physical Therapy (KNGF) issued a clinical practice guideline for physical therapists that addresses the assessment and treatment of patients with nonspecific neck pain, including cervical radiculopathy, in Dutch primary care. Recommendations were based on a review of published systematic reviews.During the intake, the patient is screened for serious pathologies and corresponding patterns. Patients with cervical radiculopathy can be included or excluded through corresponding signs and symptoms and possibly diagnostic tests (Spurling test, traction/distraction test, and Upper Limb Tension Test). History taking is done to gather information about patients' limitations, course of pain, and prognostic factors (eg, coping style) and answers to health-related questions.In case of a normal recovery (treatment profile A), management should be hands-off, and patients should receive advice from the physical therapist and possibly some simple exercises to supplement "acting as usual."In case of a delayed/deviant recovery (treatment profile B), the physical therapist is advised to use, in addition to the recommendations for treatment profile A, forms of mobilization and/or manipulation in combination with exercise therapy. Other interventions may also be considered. The physical therapist is advised not to use dry needling, low-level laser, electrotherapy, ultrasound, traction, and/or a cervical collar.In case of a delayed/deviant recovery with clear and/or dominant psychosocial prognostic factors (treatment profile C), these factors should first be addressed by the physical therapist, when possible, or the patient should be referred to a specialist, when necessary.In case of neck pain grade III (treatment profile D), the therapy resembles that for profile B, but the use of a cervical collar for pain reduction may be considered. The advice is to use it sparingly: only for a short period per day and only for a few weeks.

The Global Spine Care Initiative: a summary of guidelines on invasive interventions for the management of persistent and disabling spinal pain in low- and middle-income communities

PURPOSE

The purpose of this study was to synthesize recommendations on the use of common elective surgical and interventional procedures for individuals with persistent and disabling non-radicular/axial with or without myelopathy, radicular back pain, cervical myelopathy, symptomatic spinal stenosis, and fractures due to osteoporosis. This review was to inform a clinical care pathway on the patient presentations where surgical interventions could reasonably be considered.

METHODS

We synthesized recommendations from six evidence-based clinical practice guidelines and one appropriate use criteria guidance for the surgical and interventional management of persistent and disabling spine pain.

RESULTS

Lower priority surgery/conditions include fusion for lumbar/non-radicular neck pain and higher priority surgery/conditions include discectomy/decompressive surgery for cervical or lumbar radiculopathy, cervical myelopathy, and lumbar spinal stenosis. Epidural steroid injections are less expensive than most surgeries with fewer harms; however, benefits are small and short lived. Vertebroplasty should be considered over kyphoplasty as an option for patients with severe pain and disability due to osteoporotic vertebral compression fracture.

CONCLUSION

Elective surgery and interventional procedures could be limited in medically underserved areas and low- and middle-income countries due to a lack of resources and surgeons and thus surgical and interventional procedures should be prioritized within these settings. There are non-invasive alternatives that produce similar outcomes and are a recommended option where surgical procedures are not available. These slides can be retrieved under Electronic Supplementary Material.

Magnetic Resonance Imaging-Based Prediction of the Relationship between Whiplash Injury and Temporomandibular Disorders

Purpose

Whiplash injury can cause internal derangement of the temporomandibular joint (TMJ) and lead to temporomandibular disorders (TMDs). Our aim was to evaluate whether the initial clinical findings in TMD patients with whiplash injury are correlated with their magnetic resonance imaging (MRI) characteristics.

Materials and methods

This case–control study involved 219 patients (135 women, 84 men; mean age: 37.84 years) who visited our orofacial pain clinic with TMD; TMD was diagnosed using the diagnostic criteria for TMD Axis I. Patients were categorized into three groups based on the presence and type of macrotrauma: in the “wTMD” group, patients had suffered whiplash injury; patients in the “pTMD” group had post-traumatic TMD; the “iTMD” group comprised patients who had presented with TMD symptoms and had sustained no macrotrauma. We investigated the presence of disk displacement, effusion, disk deformity, and condylar degeneration, and changes in the lateral pterygoid muscle (LPM). To evaluate the severity of TMD pain and objectively analyze symptoms, we used a visual analog scale (VAS), palpation index (PI), neck PI, dysfunction index, and craniomandibular index (CMI).

Results

The VAS scores, and the severity indexes of the TMD including PI, neck PI, and CMI were highest in the wTMD patients. Atrophy of the LPM was most commonly seen in the wTMD group, as was disk deformity. In wTMD patients only, VAS score was significantly correlated with stress; it was correlated with headache in wTMD and iTMD patients. The clinical symptoms of TMD were not correlated with MRI findings in the wTMD group. However, alterations in the LPM were strongly correlated with disk displacement.

Conclusion

If clinicians recognize alterations in the LPM and disk displacement in the TMJ, they will better understand the clinical symptoms and pathophysiology of TMD with whiplash injury. Whiplash injury may lead to TMD via different mechanisms from other macrotraumas.

Multidimensional features of pain in patients with chronic neck pain

Abstract Introduction: Chronic neck pain is associated with significant health costs and loss of productivity at work. Objective: to assess pain and disability in individuals with chronic neck pain. Methods: 31 volunteers with chronic neck pain, mean age 29, 65 years, were assessed using the McGill Pain Questionnaire in Brazilian version (Br-MPQ) and Neck Disability Index (NDI). The Br-MPQ analysis was performed based on the numerical values associated with the words selected to describe the experience of pain (Pain Rating Index - PRI), and present pain intensity (PPI). NDI was used to evaluate the influence of neck pain in performance of everyday tasks. Finally, we investigated the association between PPI and NDI. Results: PRI revealed that the most significant dimension was the sensory pain (70%), and the number of chosen words was 10 (2,62) out of 20 words. Mean PPI value was 1,23 (0,76) in five points; 40% of participants described pain intensity as moderate. NDI score was 9,77 (3,34), indicating mild disability. There was a positive association between disability and pain intensity (r = 0,36; p =0,046). Pain intensity and duration of pain were not associated. Conclusions: Findings of this study identified important information related to neck pain experienced by patients when suffering from chronic neck pain, moreover, the association between disability and pain intensity reinforces the importance of complementary investigation of these aspects to optimize function in them.

General Exercise Does Not Improve Long-Term Pain and Disability in Individuals With Whiplash-Associated Disorders: A Systematic Review

Study Design Systematic review of randomized controlled trials. Background General exercise, defined as purposeful physical activity involving repetitive exercises and incorporating multiple muscle groups, is frequently used in the management of whiplash-associated disorders (WADs). Evidence supporting its efficacy is not well established. Objectives To determine whether general exercise is effective in reducing pain and disability in people with WAD. Methods Studies published in English in peer-reviewed journals between January 1990 and May 2015 were eligible if they evaluated a general exercise intervention compared with a different intervention or control. Studies were required to evaluate pain and disability at medium-term (6-14 weeks) and long-term (52 weeks) follow-ups. The mean ± SD and sample size were recorded for follow-up scores and for change scores from baseline to follow-up. Results Of the 3 high-quality studies that were eligible for inclusion, none investigated general exercise alone. There were no clinically meaningful differences between comprehensive exercise programs, which included general exercise, and minimal intervention controls in the medium and long term. No studies directly compared general exercise with a no-treatment control. All included studies used different control interventions, preventing meta-analysis. Conclusion A lack of significant long-term improvements from general exercise interventions in individuals with WAD was identified. This finding differs from the positive benefits of general exercise for other musculoskeletal conditions. This may, in part, relate to the complexity of whiplash conditions. This may also reflect the challenge of exercise prescription in this population, where the need for sufficient intensity is balanced against the impact that exercise has on pain. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2017;47(7):472-480. Epub 16 Jun 2017. doi:10.2519/jospt.2017.7081.

Neck Pain: Revision 2017

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to neck pain. J Orthop Sports Phys Ther. 2017;47(7):A1-A83. doi:10.2519/jospt.2017.0302.

Factors associated with physical activity participation in adults with chronic cervical spine pain: a systematic review

OBJECTIVE

To determine the factors associated with physical activity participation in adults with chronic cervical spine pain.

METHODS

A systematic review was conducted including searches of PubMed (MEDLINE), EMBASE and CINAHL from inception to June 12th, 2016. Grey literature and reference checking was also undertaken. Quantitative studies including factors related to physical activity participation in adults with chronic cervical spine pain were included. Two independent authors conducted the searches, extracted data and completed methodological quality assessment.

RESULTS

A total of seven studies met the selection criteria, however, four papers were finally included in the final review. A modified Downs and Black criteria was used to assess methodological quality, each study included was classed as moderate quality. A total of six factors were assessed against physical activity participation for people with chronic neck pain. These included: pain, fear of movement, smoking habits, socioeconomic status, gender, leisure and work time habits. A significant relationship was demonstrated between pain, leisure and work time habits and physical activity. Subjects were less likely to participate in physical activity if they were in pain. Subjects with neck pain were less likely to participate in physical activity in their leisure and work time.

CONCLUSION

This review, based on a small number of heterogeneous studies demonstrated key factors that are likely to affect physical activity in people with chronic neck pain, most notably, pain levels, leisure and work habits. This review suggests that more in-depth, high quality studies are required to fully understand the impact of chronic pain on physical activity.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42015027970.

Anxiety and depression predict musculoskeletal disorders in health care workers

Incidence of musculoskeletal disorders (MSDs) is high among health care workers (HCWs). To determine whether MSDs are associated with preexisting anxiety and/or depression, a case-control study was carried out in female HCWs (56 cases/55 controls). Cases were HCWs with a first-time clinical diagnosis of MSD within the previous 2 years. Occupation, workplace, work shift, direct patient assistance, and anxiety/depression scores (Goldberg scale) were assessed. Increased risk of incident MSDs (multivariate logistic regression) was found in workers with preexisting anxiety/depression compared to those without (OR 5.01; 95% CI 2.20-12.05; p < .01). Other significant risk factors were direct patient assistance (OR 2.59; 95% CI 1.03-6.92; p = .04) and morning work shift (OR 2.47; 95% CI 0.99-6.48; p = .05). Preexisting anxiety/depression was associated with incident MSDs in HCWs, adjusting for occupational exposure risk factors.

Neck Pain, Preoperative Opioids, and Functionality After Cervical Fusion

The use of opioids among patients with workers' compensation claims is associated with tremendous costs, especially for patients who undergo spinal surgery. This study compared return-to-work rates after single-level cervical fusion for degenerative disk disease between patients who received opioids before surgery and patients who underwent fusion with no previous opioid use. All study subjects qualified for workers' compensation benefits for injuries sustained at work between 1993 and 2011. The study population included 281 subjects who underwent single-level cervical fusion for degenerative disk disease with International Classification of Diseases, Ninth Revision, and Current Procedural Terminology code algorithms. The opioid group included 77 subjects who received opioids preoperatively. The control group included 204 subjects who had surgery with no previous opioid use. The primary outcome was meeting return-to-work criteria within 3 years of follow-up after fusion. Secondary outcome measures after surgery, surgical details, and presurgical characteristics for each cohort also were collected. In 36.4% of the opioid group, return-to-work criteria were met compared with 56.4% of the control group. Patients who took opioids were less likely to meet return-to-work criteria compared with the control group (odds ratio, 0.44; 95% confidence interval, 0.26-0.76; P=.0028). Return-to-work rates within the first year after fusion were 24.7% for the opioid group and 45.6% for the control group (P=.0014). Patients who used opioids were absent from work for 255 more days compared with the control group (P=.0001). The use of opioids for management of diskogenic neck pain, with the possibility of surgical intervention, is a negative predictor of successful return to work after fusion in a workers' compensation population. [Orthopedics. 2017; 40(1):25-32.].

Does structured patient education improve the recovery and clinical outcomes of patients with neck pain? A systematic review from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

BACKGROUND CONTEXT

In 2008, the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders recommended patient education for the management of neck pain. However, the effectiveness of education interventions has recently been challenged.

PURPOSE

To update the findings of the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders and evaluate the effectiveness of structured patient education for the management of patients with whiplash-associated disorders (WAD) or neck pain and associated disorders (NAD).

STUDY DESIGN/SETTING

Systematic review of the literature and best-evidence synthesis.

PATIENT SAMPLE

Randomized controlled trials that compared structured patient education with other conservative interventions.

OUTCOME MEASURES

Self-rated recovery, functional recovery (eg, disability, return to activities, work, or school), pain intensity, health-related quality of life, psychological outcomes such as depression or fear, or adverse effects.

METHODS

We systematically searched eight electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Central Register of Controlled Trials, DARE, PubMed, and ICL) from 2000 to 2012. Randomized controlled trials, cohort studies, and case-control studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Scientifically admissible studies were summarized in evidence tables and synthesized following best-evidence synthesis principles.

RESULTS

We retrieved 4,477 articles. Of those, nine were eligible for critical appraisal and six were scientifically admissible. Four admissible articles investigated patients with WAD and two targeted patients with NAD. All structured patient education interventions included advice on activation or exercises delivered orally combined with written information or as written information alone. Overall, as a therapeutic intervention, structured patient education was equal or less effective than other conservative treatments including massage, supervised exercise, and physiotherapy. However, structured patient education may provide small benefits when combined with physiotherapy. Either mode of delivery (ie, oral or written education) provides similar results in patients with recent WAD.

CONCLUSIONS

This review adds to the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders by defining more specifically the role of structured patient education in the management of WAD and NAD. Results suggest that structured patient education alone cannot be expected to yield large benefits in clinical effectiveness compared with other conservative interventions for patients with WAD or NAD. Moreover, structured patient education may be of benefit during the recovery of patients with WAD when used as an adjunct therapy to physiotherapy or emergency room care. These benefits are small and short lived.

Is multimodal care effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

BACKGROUND CONTEXT

Little is known about the effectiveness of multimodal care for individuals with whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD).

PURPOSE

To update findings of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders and evaluate the effectiveness of multimodal care for the management of patients with WAD or NAD.

STUDY DESIGN/SETTING

Systematic review and best-evidence synthesis.

PATIENT SAMPLE

We included randomized controlled trials (RCTs), cohort studies, and case-control studies.

OUTCOME MEASURES

Self-rated recovery, functional recovery (eg, disability, return to activities, work, or school), pain intensity, health-related quality of life, psychological outcomes (eg, depression, fear), or adverse events.

METHODS

We systematically searched five electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials) from 2000 to 2013. RCTs, cohort, and case-control studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Scientifically admissible studies were summarized using evidence tables and synthesized following best-evidence synthesis principles.

RESULTS

We retrieved 2,187 articles, and 23 articles were eligible for critical appraisal. Of those, 18 articles from 14 different RCTs were scientifically admissible. There were a total of 31 treatment arms, including 27 unique multimodal programs of care. Overall, the evidence suggests that multimodal care that includes manual therapy, education, and exercise may benefit patients with grades I and II WAD and NAD. General practitioner care that includes reassurance, advice to stay active, and resumption of regular activities may be an option for the early management of WAD grades I and II. Our synthesis suggests that patients receiving high-intensity health care tend to experience poorer outcomes than those who receive fewer treatments for WAD and NAD.

CONCLUSIONS

Multimodal care can benefit patients with WAD and NAD with early or persistent symptoms. The evidence does not indicate that one multimodal care package is superior to another. Clinicians should avoid high utilization of care for patients with WAD and NAD.

Are People With Whiplash-Associated Neck Pain Different From People With Nonspecific Neck Pain?

Study Design Secondary analysis of a prospective cohort study with cross-sectional and longitudinal analyses. Background The clinical importance of a history of whiplash-associated disorder (WAD) in people with neck pain remains uncertain. Objective To compare people with WAD to people with nonspecific neck pain, in terms of their baseline characteristics and pain and disability outcomes over 1 year. Methods Consecutive patients with neck pain who presented to a secondary-care spine center answered a comprehensive self-report questionnaire and underwent a physical examination. Patients were classified into a group of either those with WAD or those with nonspecific neck pain. We compared the outcomes of baseline characteristics of the 2 groups, as well as pain intensity and activity limitation at follow-ups of 6 and 12 months. Results A total of 2578 participants were included in the study. Of these, 488 (19%) were classified as having WAD. At presentation, patients with WAD were statistically different from patients without WAD for almost all characteristics investigated. While most differences were small (1.1 points on an 11-point pain-rating scale and 11 percentage points on the Neck Disability Index), others, including the presence of dizziness and memory difficulties, were substantial. The between-group differences in pain and disability increased significantly (P<.001) over 12 months. At 12-month follow-up, the patients with WAD had on average approximately 2 points more pain and 17 percentage points more disability than those with nonspecific neck pain. Conclusion People referred to secondary care with WAD typically had more self-reported pain and disability and experienced worse outcomes than those with nonspecific neck pain. Caution is required when interpreting the longitudinal outcomes due to lower-than-optimal follow-up rates. Level of Evidence Prognosis, level 2. J Orthop Sports Phys Ther 2016;46(10):894-901. Epub 3 Sep 2016. doi:10.2519/jospt.2016.6588.