Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders

Immediate efficacy of acupuncture combined with active exercise as 10 min rapid therapy for pain and movement disorders in patients suffering from acute stiff neck: protocol for a randomised controlled trial

INTRODUCTION

Stiff neck is a condition mainly characterised by persistent pain and limited neck movement, which can substantially impact patients' daily lives during acute episodes. Accordingly, rapid pain relief and restoration of normal activities are the main needs of patients during doctor visits. This study aims to assess the immediate efficacy of acupuncture combined with active exercises in rapidly relieving pain and improving movement disorders within 10 min in patients with acute stiff neck (ASN).

METHODS AND ANALYSIS

This randomised controlled clinical trial is being conducted at a single centre in China. 120 participants diagnosed with ASN will randomly be assigned in a 1:1:1 ratio to one of three groups: the acupuncture combined with active exercise group (group A), sham acupuncture combined with active exercise group (group B) and active exercise only group (group C). Each participant will undergo a single 10 min session. The primary outcome is the effective rate at 10 min of treatment. Secondary outcomes include the effective rate at other time points (0-1, 2, 4, 6 and 8 min), Visual Analogue Scale score and cervical range of motion. The intention-to-treat analysis will include all randomised participants.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of the Second Affiliated Hospital of Yunnan University of Chinese Medicine (2022-009). Written informed consent will be obtained from all participants before randomisation. The findings of this study will be disseminated through publication in a peer-reviewed journal and presentation at conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2200066997.

Comparative Efficacy of Mind-Body Exercise for Treating Chronic Non-Specific Neck Pain: A Systematic Review and Network Meta-Analysis

PURPOSE OF REVIEW

This systematic review and network meta-analysis aims to compare the efficacy of different mind-body exercise (MBE) interventions, including Yoga, Pilates, Qigong, and Tai Chi, in managing chronic non-specific neck pain (CNNP). We searched randomized controlled trials in PubMed, Embase, Web of Science and Cochrane Library. After screening eligible studies and extracting relevant data, risk of bias of included studies was assessed by the Cochrane Risk of Bias assessment tool, and network meta-analysis was performed by the Stata software version 16.0.

RECENT FINDINGS

Of the 1019 studies retrieved, 18 studies with 1442 subjects were included. Fourteen studies were graded as high quality. Yoga plus hot sand fomentation was the most effective in reducing pain intensity and functional disability, and improving the quality of physical life in patients with CNNP. Yoga achieved the most improvement in cervical mobility. And Pilates was the best MBE intervention for improving the quality of mental life. Overall, Yoga, Pilates, Qigong, and Tai Chi demonstrated considerable effectiveness in improving pain intensity, functional disability, cervical mobility, and quality of life in patients with CNNP. Yoga or Yoga plus heat therapy was the most effective method for patients with CNNP. Additional high-quality, large-scale, multi-center, long-term follow-up studies are necessary to fully understand the comparative effectiveness of different MBE interventions for CNNP, and to recognize the potential benefits of each MBE intervention and the need for individualized treatment approaches.

Association between clinical biomechanical metrics of cervical spine function and pain or disability in people with neuromusculoskeletal neck pain: Protocol for a systematic review and planned meta-analysis

INTRODUCTION/BACKGROUND

Neck pain is a burdensome condition associated with pain, disability, and economic cost. Neck pain has been associated with observable changes in neuromuscular function and biomechanics. Prior research shows impairments in kinematic control, including reduced mobility, velocity, and smoothness of cervical motion. However, the strength of association between these impairments and patient-reported pain and disability is unclear rendering development of novel and relevant rehabilitation strategies difficult. The aim of this systematic review is to synthesize existing evidence on the strength of association between clinical biomechanical metrics of neck function (ROM, strength, acceleration, accuracy, smoothness, etc.) and patient-reported neck pain and disability.

METHODS/ANALYSIS

This protocol follows Cochrane guidelines and adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). MEDLINE, EMBASE, CINAHL, SPORTDiscus, Web of Science and Scopus will be searched, along with the gray literature, up to 20 November 2023, using terms and keywords derived from initial scoping searches. Observational studies, including cohorts and cross-sectional studies, that explore associations between clinical biomechanics of the neck and patient-reported outcomes of neck pain or disability will be included. Two reviewers will independently perform study selection, data extraction, and risk of bias assessment (National Institute of Health tool). Data will be synthesized using either a random effects meta-analytic approach or qualitatively using a modified Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, dependent on the homogeneity of data available.

DISCUSSION AND RELEVANCE

This review addresses a gap in the literature by systematically synthesizing findings on the relationship between neck function impairments and patient-reported outcomes. It will identify priorities for neck pain rehabilitation and gaps in current knowledge.

DISSEMINATION

The results of this review will be disseminated through a peer-reviewed publication, conference presentation, and lay language summaries posted on an open-access website.

TRIAL REGISTRATION

PROSPERO Registration number: CRD42023417317. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023417317.

Effectiveness of Exercise Interventions for Preventing Neck Pain: A Systematic Review With Meta-analysis of Randomized Controlled Trials

OBJECTIVE: To update the evidence on the effectiveness of exercise interventions to prevent episodes of neck pain. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: MEDLINE, Embase, CENTRAL, CINAHL, SPORTDiscus, PEDro, and trial registries from inception to December 2, 2022. Forward and backward citation searches. STUDY SELECTION CRITERIA: Randomized controlled trials (RCTs) that enrolled adults without neck pain at baseline and compared exercise interventions to no intervention, placebo/sham, attention control, or minimal intervention. Military populations and astronauts were excluded. DATA SYNTHESIS: Random-effects meta-analysis. Risk of bias was assessed using the Cochrane RoB 2 tool. The certainty of evidence was judged according to the GRADE approach. RESULTS: Of 4703 records screened, 5 trials (1722 participants at baseline) were included and eligible for meta-analysis. Most (80%) participants were office workers. Risk of bias was rated as some concerns for 2 trials and high for 3 trials. There was moderate-certainty evidence that exercise interventions probably reduce the risk of a new episode of neck pain (OR, 0.49; 95% confidence interval: 0.31, 0.76) compared to no or minimal intervention in the short-term (≤12 months). The results were not robust to sensitivity analyses for missing outcome data. CONCLUSION: There was moderate-certainty evidence supporting exercise interventions for reducing the risk for an episode of neck pain in the next 12 months. The clinical significance of the effect is unclear. J Orthop Sports Phys Ther 2023;53(10):1-16. Epub: 8 September 2023. doi:10.2519/jospt.2023.12063.

Long-Term Survivorship of Cervical Spine Procedures; A Survivorship Meta-Analysis and Meta-Regression

STUDY DESIGN

Systematic Review.

OBJECTIVES

To conduct a meta-analysis on the survivorship of commonly performed cervical spine procedures to develop survival function curves for (i) second surgery at any cervical level, and (ii) adjacent level surgery.

METHODS

A systematic review of was conducted following PRISMA guidelines. Articles with cohorts of greater than 20 patients followed for a minimum of 36 months and with available survival data were included. Procedures included were anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty (ADR), laminoplasty (LAMP), and posterior laminectomy and fusion (PDIF). Reconstructed individual patient data were pooled across studies using parametric Bayesian survival meta-regression.

RESULTS

Of 1829 initial titles, 16 citations were included for analysis. 73 811 patients were included in the second surgery analysis and 2858 patients in the adjacent level surgery analysis. We fit a Log normal accelerated failure time model to the second surgery data and a Gompertz proportional hazards model to the adjacent level surgery data. Relative to ACDF, the risk of second surgery was higher with ADR and PDIF with acceleration factors 1.73 (95% CrI: 1.04, 2.80) and 1.35 (95% CrI: 1.25, 1.46) respectively. Relative to ACDF, the risk of second surgery was lower with LAMP with deceleration factor .06 (95% CrI: .05, .07). ADR decreased the risk of adjacent level surgery with hazard ratio .43 (95% CrI: .33, .55).

CONCLUSIONS

In cases of clinical equipoise between fusion procedures, our analysis suggests superior survivorship with anterior procedures. For all procedures, laminoplasty demonstrated superior survivorship.

Effects of gentle mechanical skin stimulation on subjective symptoms and joint range of motions in people with chronic neck and shoulder discomfort

This study aimed to examine the efficacy of a 2-week self-administered gentle mechanical skin stimulation on chronic neck and shoulder discomfort. In participants (n = 12) with chronic neck and shoulder discomfort, subjective measures of pain sensation, discomfort, and difficulty in moving using a visual analog scale (VAS, 0-10) and objective measures of 12 different joint range of motions (ROMs) for the cervical and shoulder regions, using a digital goniometer, were collected before and after self-care with contact acupuncture, called microcones. The self-care for 2 weeks significantly (p < 0.001) decreased all VAS scores to 2.2-2.3 from baseline values of 6.0-7.4. Of the 12 ROMs tested, 8 were significantly increased (p < 0.013). This open-label study suggests the use of self-care with microcones in improving subjective symptoms and joint ROMs in people suffering from chronic neck and shoulder discomfort. However, a randomized, double-blind, controlled clinical trial is needed to further investigate the efficacy and safety of microcones.

Conservative Management of Cervical Radiculopathy: A Systematic Review

OBJECTIVE

The purpose of this systematic review was to assess the effectiveness and safety of conservative interventions compared with other interventions, placebo/sham interventions, or no intervention on disability, pain, function, quality of life, and psychological impact in adults with cervical radiculopathy (CR).

METHODS

We searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022 to identify studies that were randomized controlled trials, had at least one conservative treatment arm, and diagnosed participants with CR through confirmatory clinical examination and/or diagnostic tests. Studies were appraised using the Cochrane Risk of Bias 2 tool and the quality of the evidence was rated using the Grades of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

Of the 2561 records identified, 59 trials met our inclusion criteria (n = 4108 participants). Due to clinical and statistical heterogeneity, the findings were synthesized narratively. There is very-low certainty evidence supporting the use of acupuncture, prednisolone, cervical manipulation, and low-level laser therapy for pain and disability in the immediate to short-term, and thoracic manipulation and low-level laser therapy for improvements in cervical range of motion in the immediate term. There is low to very-low certainty evidence for multimodal interventions, providing inconclusive evidence for pain, disability, and range of motion. There is inconclusive evidence for pain reduction after conservative management compared with surgery, rated as very-low certainty.

DISCUSSION

There is a lack of high-quality evidence, limiting our ability to make any meaningful conclusions. As the number of people with CR is expected to increase, there is an urgent need for future research to help address these gaps.

Relationship of Healthy Building Determinants With Back and Neck Pain: A Systematic Review

OBJECTIVE

Back pain and neck pain are very common, costly, and disabling. Healthy building determinants within the built environment have not been adequately assessed as contributors to these conditions. The objective of this study was to systematically review the literature on the relationship of healthy building determinants with back and neck pain.

DATA SOURCE

PubMed, CINAHL, EMBASE, Google Scholar, and PEDRo. Study Inclusion and Exclusion Criteria: Studies were included if they met the following criteria: Adults, comparison of healthy building determinants (air quality, ventilation, dust and pests, lighting and views, moisture, noise, safety/security, thermal health, water quality) with back and neck pain, original research, English. Studies were excluded if full text articles were unavailable and if the focus was patient and materials handling or ergonomics.

DATA EXTRACTION

Data extraction and other review procedures were elaborated according to PRISMA guidelines. Data Synthesis: Data were synthesized with an approach adapted from Oxford Centre for Evidence-Based Medicine and American Physical Therapy Association.

RESULTS

37 articles enrolling 46,223 participants were eligible. Most articles were cross-sectional (31/37) and fair quality (28/37). None were interventional. Evidence was found to generally support a relationship indicating that as healthy building determinants worsen, the risk of back and neck pain increases.

CONCLUSION

Although the available evidence precludes interpretations about causality, the study's findings are starting points to guide future research, knowledge creation, and health promotion initiatives about the relationships of the built environment with back and neck pain.

Efficacy and Safety of Electro-Thumbtack Needle Therapy for Patients With Chronic Neck Pain: Protocol for a Randomized, Sham-Controlled Trial

Background

Chronic neck pain is a prevalent condition adversely impacting patients' wellbeing in both life and work experience. Electro-thumbtack needle (ETN) therapy, combining acupuncture with transcutaneous stimulation, might be one of the effective complementary and alternative medicine (CAM) therapies in treating chronic neck pain, although the evidence is scarce. This study aims to estimate the efficacy and safety of ETN therapy for chronic neck pain.

Methods and Analysis

This is a sham-controlled, randomized clinical trial. A total of 180 subjects will be randomly allocated to either the ETN group or the sham ETN group. Treatment will be administrated three times a week for four consecutive weeks, with a 6-month follow-up. The primary outcome measure will be the Numerical Rating Scale for neck pain (NRS-NP) over a period of the 4 weeks. Secondary outcome measures include the Northwick Park Neck Pain Questionnaire (NPQ), Neck Disability Index (NDI), Patient Global Impression of Change (PGIC), patient expectation, and preference assessment. The chi-square test or Fisher's exact test will be used for proportions of participants having clinically meaningful improvement. Analysis of covariance or repeated-measures analysis of variance will be applied to examine changes in the outcome measures from baseline.

Discussions

This prospective trial will contribute to evaluating the efficacy and safety of ETN in the treatment of chronic neck pain, with an intermediate-term follow-up. This study will provide further evidence for clinical neck pain management.

Ethics and Dissemination

This trial has been approved by the Research Ethical Committee of Guang'anmen Hospital (ethical approval number: 2021-039-KY-01). Recruitment began in March 2022 and will continue until December 2023. Dissemination plans include posters, WeChat, websites, and bulletin boards in hospital and communities.

Clinical Trial Registration

This trial is registered at ClinicalTrials.gov (identifier: NCT04981171).

The effect of spinal manipulative therapy and home stretching exercises on heart rate variability in patients with persistent or recurrent neck pain: a randomized controlled trial

BACKGROUND

Persistent or recurrent neck pain is, together with other chronic conditions, suggested to be associated with disturbances of the Autonomic Nervous System. Acute effects on the Autonomic Nervous System, commonly measured using Heart Rate Variability, have been observed with manual therapy. This study aimed to investigate the effect on Heart Rate Variability in (1) a combination of home stretching exercises and spinal manipulative therapy versus (2) home stretching exercises alone over 2 weeks in participants with persistent or recurrent neck pain.

METHODS

A randomized controlled clinical trial was carried out in five multidisciplinary primary care clinics in Stockholm from January 2019 to April 2020. The study sample consisted of 131 participants with a history of persistent or recurrent neck. All participants performed home stretching exercises daily for 2 weeks and were scheduled for four treatments during this period, with the intervention group receiving spinal manipulative therapy in addition to the home exercises. Heart Rate Variability at rest was measured at baseline, after 1 week, and after 2 weeks, with RMSSD (Root mean square of successive RR interval differences) as the primary outcome. Both groups were blinded to the other group intervention. Thus, they were aware of the purpose of the trial but not the details of the "other" intervention. The researchers collecting data were blinded to treatment allocation, as was the statistician performing data analyses. The clinicians provided treatment for participants in both groups and could not be blinded. A linear mixed-effects model with continuous variables and person-specific random intercept was used to investigate the group-time interaction using an intention to treat analysis.

RESULTS

Sixty-six participants were randomized to the intervention group and sixty-five to the control group. For RMSSD, a B coefficient of 0.4 (p value: 0.9) was found, indicating a non-significant difference in the regression slope for each time point with the control group as reference. No statistically significant differences were found between groups for any of the Heart Rate Variability indices.

CONCLUSION

Adding four treatments of spinal manipulation therapy to a 2-week program of daily stretching exercises gave no significant change in Heart Rate Variability.

TRIAL REGISTRATION

The trial was registered 03/07/2018 at ClinicalTrials.gov, registration number: NCT03576846. ( https://pubmed.ncbi.nlm.nih.gov/31606042/ ).

The effect of two weeks of spinal manipulative therapy and home stretching exercises on pain and disability in patients with persistent or recurrent neck pain; a randomized controlled trial

Background

Recurrent or persistent neck pain affects a vast number of people globally, leading to reduced quality of life and high societal costs. Clinically, it is a difficult condition to manage, and treatment effect sizes are often moderate at best. Activity and manual therapy are first-line treatment options in current guidelines. We aimed to investigate the combination of home stretching exercises and spinal manipulative therapy in a multicentre randomized controlled clinical trial, carried out in multidiscipline ary primary care clinics.

Methods

The treatment modalities utilized were spinal manipulative therapy and home stretching exercises compared to home stretching exercises alone. Both groups received 4 treatments for 2 weeks. The primary outcome was pain, where the subjective pain experience was investigated by assessing pain intensity (NRS − 11) and the quality of pain (McGill Pain Questionnaire). Neck disability and health status were secondary outcomes, measured using the Neck Disability Indexthe EQ-5D, respectively. One hundred thirty-one adult subjects were randomized to one of the two treatment groups. All subjects had experienced persistent or recurrent neck pain the previous 6 months and were blinded to the other group intervention. The clinicians provided treatment for subjects in both group and could not be blinded. The researchers collecting data were blinded to treatment allocation, as was the statistician performing data analyses. An intention-to-treat analysis was used.

Results

Sixty-six subjects were randomized to the intervention group, and sixty-five to the control group. For NRS − 11, a B-coefficient of − 0,01 was seen, indication a 0,01 improvement for the intervention group in relation to the control group at each time point with a p-value of 0,305. There were no statistically significant differences between groups for any of the outcome measures.

Conclusion

Based on the current findings, there is no additional treatment effect from adding spinal manipulative therapy to neck stretching exercises over 2 weeks for patients with persistent or recurrent neck pain.

Trial registration

The trial was registered 03/07/2018 at ClinicalTrials.gov, registration number: NCT03576846.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04772-x.

Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain

Spine pain is a highly prevalent condition affecting over 11% of the world's population. It is the single leading cause of activity limitation and ranks fourth in years lost to disability globally, representing a significant personal, social, and economic burden. For the vast majority of patients with back and neck pain, a specific pathology cannot be identified as the cause for their pain, which is then labeled as non-specific. In a growing proportion of these cases, pain persists beyond 3 months and is referred to as chronic primary back or neck pain. To decrease the global burden of spine pain, current data suggest that a conservative approach may be preferable. One of the conservative management options available is spinal manipulative therapy (SMT), the main intervention used by chiropractors and other manual therapists. The aim of this narrative review is to highlight the most relevant and up-to-date evidence on the effectiveness (as it compares to other interventions in more pragmatic settings) and efficacy (as it compares to inactive controls under highly controlled conditions) of SMT for the management of neck pain and low back pain. Additionally, a perspective on the current recommendations on SMT for spine pain and the needs for future research will be provided. In summary, SMT may be as effective as other recommended therapies for the management of non-specific and chronic primary spine pain, including standard medical care or physical therapy. Currently, SMT is recommended in combination with exercise for neck pain as part of a multimodal approach. It may also be recommended as a frontline intervention for low back pain. Despite some remaining discrepancies, current clinical practice guidelines almost universally recommend the use of SMT for spine pain. Due to the low quality of evidence, the efficacy of SMT compared with a placebo or no treatment remains uncertain. Therefore, future research is needed to clarify the specific effects of SMT to further validate this intervention. In addition, factors that predict these effects remain to be determined to target patients who are more likely to obtain positive outcomes from SMT.

Effectiveness of self-applied acupressure for cervical pain of benign origin (EDIDO-CUH): a randomized controlled clinical trial

BACKGROUND

Cervical pain is a problem with a high prevalence of ~13% of the population, and is more common in women (16.5%). The most affected age group is 65-74 years. Our aim was to assess the effectiveness of self-applied acupressure for decreasing benign-origin cervical pain, under the supervision of a health professional and in combination with usual treatment, as well as to examine its impact on the patient's self-perceived health condition and their opinion of the technique.

METHODS

Pragmatic, multicenter, controlled clinical trial randomized by healthcare center. A total of 160 patients with benign-origin cervical pain between 18 and 65 years of age who attended primary care were included from 12 healthcare centers in the autonomous community of Madrid by consecutive sampling, and randomly assigned to a control or intervention group. The main outcome variable was pain intensity measured on a visual analogue scale (VAS) and secondary variables were self-perceived quality of life (EuroQol-5D utility index) and functional ability (neck disability index). An explanative model of generalized estimating equations was built taking into account the lack of independence among observations. The analysis was performed over 6 months.

RESULTS

In total, 150 patients completed the study. Mean age was 45 years (SD: 10.7), 86.7% were women, 86.2% were currently employed, and 57.9% did not perform any physical exercise. Average days experiencing pain was 32.9 (SD: 2.8) and 80% were undergoing previous pharmacological treatment. The quality of life utility index after 3 months was 1.6 points (95% CI: 0.54-2.71) higher in the intervention group. The pain score on the VAS was 0.16 points (95% CI: 0.80-0.48) lower in the intervention group. The health professional explained 10.4% of the reduction in pain observed on the VAS throughout the medical visits.

CONCLUSION

Acupressure applied in addition to usual practice appeared to improve cervical pain in the long term. The effectiveness of this technique was partially explained by the health professional that trained the participants on technique application.

TRIAL REGISTRATION NUMBER:

NCT01855893.

Efficacy of Manual Therapy and Transcutaneous Electrical Nerve Stimulation in Cervical Mobility and Endurance in Subacute and Chronic Neck Pain: A Randomized Clinical Trial

Neck pain is a frequent health problem. Manual therapy (MT) and transcutaneous electrical nerve stimulation (TENS) are recommended techniques for treatment of mechanical neck disorders (MND) in Spanish Public Primary Care Physiotherapy Services. The aim of this study was to compare the efficacy of MT versus TENS in active mobility and endurance in cervical subacute or chronic neck pain. Ninety patients with MND were randomly allocated to receive ten 30-min sessions of either MT or TENS, in a multi-centered study through 12 Primary Care Physiotherapy Units in the Madrid community. Active cervical range of motion (CD-ROM) and endurance (Palmer and Epler test) were evaluated pre- and post-intervention and at 6-month follow-up. A generalized linear model of repeated measures was constructed for the analysis of differences. Post-intervention MT yielded a significant improvement in active mobility and endurance in patients with subacute or chronic MND, and at 6-month follow-up the differences were only significant in endurance and in sagittal plane active mobility. In the TENS group, no significant improvement was detected. With regard to other variables, MT improved mobility and endurance more effectively than TENS at post-intervention and at 6-month follow-up in the sagittal plane. Only MT generated significant improvements in cervical mobility and endurance in the three movement planes.

The effects of pillow designs on neck pain, waking symptoms, neck disability, sleep quality and spinal alignment in adults: A systematic review and meta-analysis

BACKGROUND

Neck pain is a prevalent condition that can adversely affect quality of life, productivity at work, and sleep quality. The aim of this systematic review and meta-analysis was to identify clinical trials assessing the effect of different types of pillows on neck pain, waking symptoms, neck disability, sleep quality, and spinal alignment.

METHODS

We systematically searched CINAHL Complete, Cochrane Library, EMBASE, Medline, Pubmed and Psychinfo databases from inception to September 2020. Two reviewers independently assessed the articles and evaluated the methodological quality using PEDro.

FINDINGS

Thirty-five articles fulfilled the inclusion criteria of the study. There were nine high-quality studies involving 555 participants. The meta-analysis revealed significant differences favouring the use of rubber pillows to reduce neck pain [standardized mean difference (SMD): -0.263; P < 0.001). Moreover, waking pain (SMD: -0.228; P < 0.001) and neck disability (SMD: -0.506; P = 0.020) were reduced while the satisfaction rate was enhanced (SMD: 1.144; P < 0.001) with pillow use. Pillow designs did not influence sleep quality (SMD = 0.047; P = 0.703) in patients with chronic neck pain.

INTERPRETATION

The use of spring and rubber pillows are effective in reducing neck pain, waking symptoms, and disability and enhancing pillow satisfaction in patients with chronic neck pain. Moreover, there may be no change in the alignment of the cervical spine in the side-lying position, regardless of the use of rubber or feather pillows. Rather, the cervical alignment may be significantly impacted by the shape and height of the pillow.

Extrapolating Beyond the Data in a Systematic Review of Spinal Manipulation for Nonmusculoskeletal Disorders: A Fall From the Summit

OBJECTIVE

The purpose of this article is to discuss a literature review-a recent systematic review of nonmusculoskeletal disorders-that demonstrates the potential for faulty conclusions and misguided policy implications, and to offer an alternate interpretation of the data using present models and criteria.

METHODS

We participated in a chiropractic meeting (Global Summit) that aimed to perform a systematic review of the literature on the efficacy and effectiveness of mobilization or spinal manipulative therapy (SMT) for the primary, secondary, and tertiary prevention and treatment of nonmusculoskeletal disorders. After considering an early draft of the resulting manuscript, we identified points of concern and therefore declined authorship. The present article was developed to describe those concerns about the review and its conclusions.

RESULTS

Three main concerns were identified: the inherent limitations of a systematic review of 6 articles on the topic of SMT for nonmusculoskeletal disorders, the lack of biological plausibility of collapsing 5 different disorders into a single category, and considerations for best practices when using evidence in policy-making. We propose that the following conclusion is more consistent with a review of the 6 articles. The small cadre of high- or moderate-quality randomized controlled trials reviewed in this study found either no or equivocal effects from SMT as a stand-alone treatment for infantile colic, childhood asthma, hypertension, primary dysmenorrhea, or migraine, and found no or low-quality evidence available to support other nonmusculoskeletal conditions. Therefore, further research is needed to determine if SMT may have an effect in these and other nonmusculoskeletal conditions. Until the results of such research are available, the benefits of SMT for specific or general nonmusculoskeletal disorders should not be promoted as having strong supportive evidence. Further, a lack of evidence cannot be interpreted as counterevidence, nor used as evidence of falsification or verification.

CONCLUSION

Based on the available evidence, some statements generated from the Summit were extrapolated beyond the data, have the potential to misrepresent the literature, and should be used with caution. Given that none of the trials included in the literature review were definitively negative, the current evidence suggests that more research on nonmusculoskeletal conditions is warranted before any definitive conclusions can be made. Governments, insurers, payers, regulators, educators, and clinicians should avoid using systematic reviews in decisions where the research is insufficient to determine the clinical appropriateness of specific care.

Changes in Opioid Therapy Use by an Interprofessional Primary Care Team: A Descriptive Study of Opioid Prescription Data

OBJECTIVE

The purpose of this study was to describe changes in opioid-therapy prescription rates after a family medicine practice included on-site chiropractic services.

METHODS

The study design was a retrospective analysis of opioid prescription data. The database included opioid prescriptions written for patients seeking care at the family medicine practice from April 2015 to September 2018. In June 2016, the practice reviewed and changed its opioid medication practices. In April 2017, the practice included on-site chiropractic services. Opiod-therapy use was defined as the average rate of opioid prescriptions over all medical providers at the practice.

RESULTS

There was a significant decrease of 22% in the average monthly rate of opioid prescriptions after the inclusion of chiropractic services (F_1,40 = 10.69; P < .05). There was a significant decrease of 32% in the prescribing rate of schedule II opioids after the inclusion of chiropractic services (F_2,80 = 6.07 for the Group × Schedule interaction; P < .05). The likelihood of writing schedule II opioid prescriptions decreased by 27% after the inclusion of chiropractic services (odds ratio, 0.73; 95% confidence interval, 0.59-0.90). Changes in opioid medication practices by the medical providers included prescribing a schedule III or IV opioid rather than a schedule II opioid (F_6,76 = 29.81; P < .05) and a 30% decrease in the daily doses of opioid prescriptions (odds ratio, 0.70; 95% confidence interval, 0.50-0.98).

CONCLUSION

This study demonstrates that there were decreases in opioid-therapy prescribing rates after a family medicine practice included on-site chiropractic services. This suggests that inclusion of chiropractic services may have had a positive effect on prescribing behaviors of medical physicians, as they may have been able to offer their patients additional nonpharmaceutical options for pain management.

Effect of selected group of asana when used as an adjunct in management of cervical spondylosis of mild to moderate severity: An observational study

BACKGROUND

"Cervical spondylosis" (CS) is a collective term used for non-specific neck pain post 30 age group. Management of CS is mainly non-surgical, particularly in mild to moderate severity that includes the oral anti-inflammatory drugs, exercises, manipulation, mobilization, or combination of these.

OBJECTIVE

The objective of the study is to assess the possible benefit of a selected group of asana in a group of patients over a short time frame and assess their functional outcome.

MATERIALS AND METHODS

An observational study of cohort of patients having mild to moderate CS, who visited the AYUSH department between May 2016 and November 2016 were included. "Selected group of Asana (SGOA)" was practiced for 30 min supervised and then home-based for a period of 8 weeks with usual standard treatment. Patients followed up fortnightly, and their degree of severity & disability assessed.

RESULTS

Thirty patients with 19 males and 11 females having ages mean ± SD 45.61 ± 8.3 and 44.18 ± 9.78 having NDI score of mean ± SD 17.83 ± 4.749 at baseline (0 weeks) were included. Patients showed an improvement in NDI score to finally 7.40 ± 3.180, p-value = 0.0001. This improvement was also noted at various time intervals (p-value = 0.0001 each time), as seen in the post hoc analysis.

CONCLUSION

Yogic practices "Specific Group of Asana" done for eight weeks on a home-based program could be useful in reducing pain and disability in people suffering from CS of mild to a moderate degree. However, more extensive, comparative, and multi-centric trials are required for establishing this as a treatment modality.

Effects of sling-based manual therapy on cervicothoracic junction in patients with neck pain and forward head posture: A randomized clinical trial

OBJECTIVE

The purpose of this study was to investigate the effect of 4 weeks of sling-based manual therapy on the cervicothoracic junction (CTJ) area in patients with neck pain and forward head posture.

DESIGN

Single-blind randomized controlled trial.

SETTING

Outpatient, Chonbuk National University hospital, Republic of Korea.

SUBJECTS

A total of 22 participants with neck pain (Numeric Pain Rating Scale >3) and forward head posture (craniovertebral angle <51) were randomly assigned to a CTJ group or a control group (n = 11 each).

INTERVENTION

In the control group, joint mobilization and motor control training was applied for the upper cervical spine (C0-C1). The CTJ group applied the same intervention to the upper cervical spine and cervicothoracic junction (C7-T3).

MAIN MEASURES

Numeric pain rating scale and neck disability index, craniovertebral angle, active range of motion, and muscle activity were evaluated before and after 4 weeks of intervention.

RESULT

The CTJ group participants showed significant improvement in the craniovertebral angle and cervical extension range after the intervention than the control group (P = 0.025, P = 0.001). While both groups presented significant differences after the intervention regarding Numeric pain rating scale, neck disability index, and muscle activity (sternocleidomastoid and anterior scalene muscle), there were no statistically significant differences between the groups (P > 0.05).

CONCLUSION

Our results suggest that the CTJ and the upper cervical region in patients with neck pain and forward head posture represent an area which if approached by manual therapy, improves cervical mobility and posture.

Effect of Therapeutic Ultrasound for Neck Pain: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the effects and safety of therapeutic ultrasound in patients with neck pain.

DATA SOURCES

The PubMed, EMBASE, CENTRAL, and Physiotherapy Evidence databases were searched for articles published before December 1, 2020.

STUDY SELECTION

Randomized controlled trials that compared the effects of therapeutic ultrasound on neck pain were included in this review. The included studies compared therapeutic ultrasound plus other treatments with the other treatments alone or compared therapeutic ultrasound with sham or no treatment. Outcome measures involved the effects on pain, disability, and quality of life. Other treatments included all nonultrasonic therapies (eg, various exercises, massage, electrotherapy).

DATA EXTRACTION

Data on the study population, therapeutic ultrasound intervention, combined intervention, outcome measures, and follow-up were extracted.

DATA SYNTHESIS

Twelve randomized controlled trials (705 patients) fulfilled the inclusion criteria. Seven studies compared therapeutic ultrasound plus other treatments vs the other treatments alone (449 patients). Therapeutic ultrasound yielded additional benefits for pain, but there was high heterogeneity and we could not draw a clear conclusion. Ultrasound did not have a better effect on disability or quality of life when it was combined with other treatments. Five studies compared therapeutic ultrasound with sham or no treatment (256 patients), and the pooled data showed that therapeutic ultrasound significantly reduced pain intensity. No adverse events of therapeutic ultrasound were reported in the included studies.

CONCLUSIONS

Therapeutic ultrasound may reduce the intensity of pain more than sham or no treatment, and it is a safe treatment. Whether therapeutic ultrasound in combination with other conventional treatments produced additional benefits on pain intensity, disability, or quality of life is not clear. The randomized trials included in this review had different levels of quality and high heterogeneity. A large trial using a valid methodology is warranted.

Differences in force-time parameters and electromyographic characteristics of two high-velocity, low-amplitude spinal manipulations following one another in quick succession

BACKGROUND

Spinal manipulative therapy is an effective treatment for neck pain. However, the mechanisms underlying its clinical efficacy are not fully understood. Previous studies have not systematically compared force-time parameters and electromyographic responses associated with spinal manipulation. In this study, force-time parameters and electromyographic characteristics associated with multiple manual high-velocity, low-amplitude cervical and upper thoracic spinal manipulations were investigated. The purpose of this analysis was to compare the force-time parameters and electromyographic characteristics between two spinal manipulations delivered following one another in quick succession if the first thrust was not associated with an audible cavitation.

METHODS

Nine asymptomatic and eighteen symptomatic participants received six Diversified-style spinal manipulations to the cervical and upper thoracic spines during data collected February 2018 to September 2019. Peak force, rate of force application and thrust duration were measured using a pressure pad. Bipolar surface electrodes were used to measure the electromyographic responses and reflex delay times in sixteen neck, back and limb outlet muscles bilaterally. Differences in force-time parameters and electromyographic data were analyzed between the first and second thrust.

RESULTS

Fifty-two spinal manipulations were included in this analysis. Peak force was greater (p < 0.001) and rate of force application faster (p < 0.001) in the second thrust. Furthermore, peak electromyographic responses were higher following the second thrust in asymptomatic (p < 0.001) and symptomatic (p < 0.001) subjects. Also, electromyographic delays were shorter in the symptomatic compared to the asymptomatic participants for the second thrust (p = 0.039). There were no adverse patient events.

CONCLUSION

When a second manipulation was delivered because there was not audible cavitation during the first thrust, the second thrust was associated with greater treatment forces and faster thrust rates. Peak electromyographic responses were greater following the second thrust.

A strategic initiative to facilitate knowledge translation research in rehabilitation

BACKGROUND

While there is a growing body of literature supporting clinical decision-making for rehabilitation professionals, suboptimal use of evidence-based practices in that field persists. A strategic initiative that ensures the relevance of the research and its implementation in the context of rehabilitation could 1) help improve the coordination of knowledge translation (KT) research and 2) enhance the delivery of evidence-based rehabilitation services offered to patients with physical disabilities. This paper describes the process and methods used to develop a KT strategic initiative aimed at building capacity and coordinating KT research in physical rehabilitation and its strategic plan; it also reports the initial applications of the strategic plan implementation.

METHODS

We used a 3-phase process consisting of an online environmental scan to identify the extent of KT research activities in physical rehabilitation in Quebec, Canada. Data from the environmental scan was used to develop a strategic plan that structures KT research in physical rehabilitation. Seven external KT experts in health science reviewed the strategic plan for consistency and applicability.

RESULTS

Sixty-four KT researchers were identified and classified according to the extent of their level of involvement in KT. Ninety-six research projects meeting eligibility criteria were funded by eight of the fourteen agencies and organizations searched. To address the identified gaps, a 5-year strategic plan was developed, containing a mission, a vision, four main goals, nine strategies and forty-two actions.

CONCLUSION

Such initiatives can help guide researchers and relevant key stakeholders, to structure, organize and advance KT research in the field of rehabilitation. The strategies are being implemented progressively to meet the strategic initiative's mission and ultimately enhance users' rehabilitation services.

Self-Kinematic Training for Flight-Associated Neck Pain: a Randomized Controlled Trial

BACKGROUND: Flight-associated neck pain (FANP) is a serious problem in fighter pilots. Despite the high impact of FANP there is little evidence for effective management. However, self-kinematic training showed a positive effect in the general population. The purpose of this study was to investigate the effectiveness of a self-kinematic training program using virtual reality in improving neck pain in fighter pilots.METHODS: There were 45 pilots with FANP who were randomized to a control group (N 23) or a training group (N 22). Training participants were instructed to exercise using a personalized self-training program, for 20 min/wk, for 4 wk. Primary outcome measures were neck disability (NDI%) and mean velocity ( s¹), and secondary were pain, health status, accuracy, and isometric strength. Assessments were conducted by a blinded assessor and intention-to-treat analysis by a blinded statistician.RESULTS: There were 40 pilots who completed the postintervention assessments, and 35 completed the 6-mo follow-up. Baseline measurements showed mild pain and disability (mean VAS 43 22.73, NDI 17.76 9.59%) and high kinematic performance. Compliance with self-training was poor. No differences were observed in self-reported measures and strength. Exercise duration was correlated with NDI% improvement.DISCUSSION: This self-kinematic training promoted kinematic performance, but was ineffective in engaging the pilots to exercise, and consequently did not improve pain and disability. Poor compliance was previously reported in self-training for FANP, suggesting further studies should prioritize supervised training. Considering the high baseline kinematic performance, kinematics does not seem to be a key factor in FANP, and future exercise research should aim for intense strengthening to increase endurance to the high G_z pilots experience.Sarig Bahat H, German D, Palomo G, Gold H, Frankel Nir Y. Self-kinematic training for flight-associated neck pain: a randomized controlled trial. Aerosp Med Hum Perform. 2020; 91(10):790797.

Predictors for Positive Response to Home Kinematic Training in Chronic Neck Pain

OBJECTIVES

There is strong evidence for exercise therapy in neck pain, but a wide variety of protocols. Predictors for outcome are unknown and current practice is based on trial and error. The objective of this study was to identify predictors for response to home kinematic training (KT) considering improvement in both self-reported and kinematic measures.

METHODS

A continuing analysis of data from the second phase of a randomized controlled trial, which included 4 weeks of KT using laser or virtual reality, with baseline, postintervention, and 3-month follow-up measures. Positive self-reported response was defined as a ≥50% pain reduction, ≥7% reduction in neck disability index (NDI), or a global perceived effect of 3 to 5 of 5. A second model defined improvement by ≥40% increase in cervical velocity.

RESULTS

Data were retrieved from 79 participants with chronic neck pain who completed the postintervention evaluation and 52 who completed the 3-month follow-up. Self-reported response was 71% to 73% and kinematic response was 41% to 46%. Prediction models indicated an immediate increase in self-reported measures in men with NDI ≥ 20% slower (≤65°/s), and less accurate (≥16° error) cervical motion at baseline. In the longer term, older patients with higher NDI seemed to benefit more. In the second model, no factors significantly predicted improvement in kinematic measures at either time point.

CONCLUSION

A high positive response rate to home KT was found by self-reported criteria. Males with poorer clinical and kinematic presentation at baseline, that is greater disability and slower neck motion, were more likely to respond.

Effects of Corrective Exercises on Posture, Pain, and Muscle Activation of Patients With Chronic Neck Pain Exposed to Anterior-Posterior Perturbation

OBJECTIVES

This study aimed to evaluate the effects of corrective exercises on posture, pain, and muscle activation of patients with chronic neck pain exposed to anterior-posterior perturbation.

METHODS

A total of 32 women (37.76 ± 3.83 years) with chronic, nonspecific neck pain were randomized into corrective exercise and control groups. The experimental group underwent a corrective exercise program for 8 weeks, 30 min/d, 3 days per week. The control group received active self-exercise instructions. Neck pain, forward head and protracted shoulder posture, and timing of superficial neck muscle activation were evaluated using the visual analog scale, photogrammetry, and electromyogram, respectively, before and then 48 hours after the 8-week program for both the experimental and control groups. All measurements at pretest and posttest were taken by a blinded assessor.

RESULTS

Significant alterations were observed in cervical angle (P = .003, effect size = 0.329), shoulder angle (P = .008, effect size = 0.457), neck pain and disability (P = .009, effect size = 0.645), movement control (P = .038, effect size = 0.353), activation onset of the upper trapezius (P = .015, effect size = 0.746), the sternocleidomastoid (P = .018, effect size = 0.879) and cervical erector spinae (P = .031, effect size = 0.765), and the root mean square of the upper trapezius (P = .033, effect size = 0.742), the sternocleidomastoid (P = .041, effect size = 0.587), and the cervical erector spinae (P = .024, effect size = 0.832) in the intervention group from pre- to posttest (P < .05).

CONCLUSION

Positive and significant alterations have been observed in the forward head and protracted shoulder posture, the timing of superficial neck muscle activation, neck pain, and disability in female patients with chronic neck pain exposed to anterior-posterior perturbation after performing an 8-week corrective exercise program.

Crew-Friendly Countermeasures Against Musculoskeletal Injuries in Aviation and Spaceflight

Aviation and space medicine face many common musculoskeletal challenges that manifest in crew of rotary-wing aircraft (RWA), high-performance jet aircraft (HPJA), and spacecraft. Furthermore, many astronauts are former pilots of RWA or HPJA. Flight crew are exposed to recurrent musculoskeletal risk relating to the extreme environments in which they operate, including high-gravitational force equivalents (g-forces), altered gravitational vectors, vibratory loading, and interaction with equipment. Several countermeasures have been implemented or are currently under development to reduce the magnitude and frequency of these injuries. Cervical and lumbar spine, as well as extremity injuries, are common to aviators and astronauts, and occur in training and operational environments. Stress on the spinal column secondary to gravitational loading and unloading, ± vibration are implicated in the development of pain syndromes and intervertebral disk pathology. While necessary for operation in extreme environments, crew-support equipment can contribute to musculoskeletal strain or trauma. Crew-focused injury prevention measures such as stretching, exercise, and conditioning programs have demonstrated the potential to prevent pre-flight, in-flight, and post-flight injuries. Equipment countermeasures, especially those addressing helmet mass and center of gravity and spacesuit ergonomics, are also key in injury prevention. Furthermore, behavioral and training interventions are required to ensure that crew are prepared to safely operate when faced with these exposures. The common operational exposures and risk factors between RWA and HPJA pilots and astronauts lend themselves to collaborative studies to develop and improve countermeasures. Countermeasures require time and resources, and careful consideration is warranted to ensure that crew have access to equipment and expertise necessary to implement them. Further investigation is required to demonstrate long-term success of these interventions and inform flight surgeon decision-making about individualized treatment. Lessons learned from each population must be applied to the others to mitigate adverse effects on crew health and well-being and mission readiness.

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.

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.

Predicting the evolution of neck pain episodes in routine clinical practice

BACKGROUND

The objective of this study was to develop models for predicting the evolution of a neck pain (NP) episode.

METHODS

Three thousand two hundred twenty-five acute and chronic patients seeking care for NP, were recruited consecutively in 47 health care centers. Data on 37 variables were gathered, including gender, age, employment status, duration of pain, intensity of NP and pain referred down to the arm (AP), disability, history of neck surgery, diagnostic procedures undertaken, imaging findings, clinical diagnosis, and treatments used. Three separate multivariable logistic regression models were developed for predicting a clinically relevant improvement in NP, AP and disability at 3 months.

RESULTS

Three thousand one (93.5%%) patients attended follow-up. For all the models calibration was good. The area under the ROC curve was ≥0.717 for pain and 0.664 for disability. Factors associated with a better prognosis were: a) For all the outcomes: pain being acute (vs. chronic) and having received neuro-reflexotherapy. b) For NP: nonspecific pain (vs. pain caused by disc herniation or spinal stenosis), no signs of disc degeneration on imaging, staying at work, and being female. c) For AP: nonspecific NP and no signs of disc degeneration on imaging. d) For disability: staying at work and no signs of facet joint degeneration on imaging.

CONCLUSIONS

A prospective registry can be used for developing valid predictive models to quantify the odds that a given patient with NP will experience a clinically relevant improvement.

Broad External Validation and Update of a Prediction Model for Persistent Neck Pain After 12 Weeks

STUDY DESIGN

A prospective observational study.

OBJECTIVE

To externally validate the prediction model developed by Schellingerhout and colleagues predicting global perceived effect at 12 weeks in patients with neck pain and to update and internally validate the updated model.

SUMMARY OF BACKGROUND DATA

Only one prediction model for neck pain has undergone some external validation with good promise. However, the model needs testing in other populations before implementation in clinical practice.

METHODS

Patients with neck pain (n = 773) consulting Norwegian chiropractors were followed for 12 weeks. Parameters from the original prediction model were applied to this sample for external validation. Subsequently, two random samples were drawn from the full study sample. One sample (n = 436) was used to update the model; by recalibration, removing noninformative covariates, and adding new possible predictors. The updated model was tested in the other sample (n = 303) using stepwise logistic regression analysis. Main outcomes for performance of models were discrimination and calibration plots.

RESULTS

Three hundred seventy patients (47%) in the full study sample reported persistent pain at 12 weeks. The performance of the original model was poor, area under the receiver operating characteristics curve was 0.55 with a Confidence Interval of 0.51-0.59. The updated model included Radiating pain to shoulder and/or elbow, education level, physical activity, consultation-type (first- time, follow-up or maintenance consultation), expected course of neck pain, previous course of neck pain, number of pain sites, and the interaction term Physical activity##Number of pain sites. The area under the receiver operating characteristics curve was 0.65 with a 95% Confidence Interval of 0.58-0.71 for the updated model.

CONCLUSION

The predictive accuracy of the original model performed insufficiently in the sample of patients from Norwegian chiropractors and the model is therefore not recommended for that setting. Only one predictor from the original model was retained in the updated model, which demonstrated reasonable good performance predicting outcome at 12 weeks. Before considering clinical use, a new external validation is required.

LEVEL OF EVIDENCE

3.

Changes in chronic neck pain following the introduction of a visco-elastic polyurethane foam pillow and/or chiropractic treatment

BACKGROUND

Sleep ergonomics are increasingly prescribed as an adjunct treatment to chronic neck pain. Postulated benefits to maintaining the ideal sleeping posture are improved tissue repair in and around the facet joints, decrease in tension of associated musculature and better quality sleep.

AIM

The purpose of this study was to determine if the inclusion of a visco-elastic polyurethane (VEP) pillow could benefit the chiropractic treatment of chronic neck pain.

SETTING

The study took place at a chiropractic training clinic in Johannesburg.

METHOD

Participants were randomly assigned to either a chiropractic treatment only group (CHI) (n = 15) or a chiropractic treatment with a VEP pillow group (CHI+P) (n = 15). Both groups underwent six chiropractic treatments spaced at 3-4-day intervals and the CHI+P were provided with a VEP pillow. Baseline and post-test measurements consisted of the initial Numerical Pain Rating Scale (NRS) and the Vernon-Mior Neck Pain and Disability Index (NDI).

RESULTS

Both the CHI and CHI+P groups significantly (p ≤ 0.05) improved their NRS (p = 0.001 for both groups) and NDI (p = 0.001 and p = 0.000, respectively) scores. Furthermore, post hoc analysis indicated a significant difference at post-test between the two groups for NRS (p = 0.015), but not for NDI (p = 0.195). The CHI+P demonstrated an improved minimum clinically important difference (MCID) (43% vs. 73% for NRS and 59% vs. 71% for the NDI).

CONCLUSION

Findings of this study suggest that a VEP pillow could be included as an adjunct management tool to chiropractic treatment of chronic neck pain.

Concussion part II: Rehabilitation - The need for a multifaceted approach

INTRODUCTION

While most individuals recover in the initial days to weeks following a concussion, in up to 30% of cases symptoms and functional limitations may persist beyond the initial four weeks. There is emerging evidence that multifaceted physiotherapy techniques for individuals who have ongoing symptoms following concussion may be of benefit.

PURPOSE

The purpose of this masterclass article is to summarize the evidence for rehabilitation, describe treatment techniques and multifaceted interventions following concussion.

IMPLICATIONS

Concussion is a heterogenous injury and multiple types of rehabilitation may be required to address ongoing alterations in function. A greater understanding of evidence based rehabilitative techniques will enable the clinician to direct treatment and facilitate recovery for individuals who have ongoing symptoms following concussion.

A randomised controlled trial of multimodal physiotherapy versus advice for recent onset, painful cervical radiculopathy - the PACeR trial protocol

BACKGROUND

A research gap exists for optimal management of cervical radiculopathy in the first 12 weeks and short term natural history of the condition is somewhat unclear, although thought to be favourable. The primary aim of this assessor blinded, superiority, 2 parallel group randomised controlled trial is to investigate the effects of a 4 week physiotherapy programme (6-8 sessions) of manual therapy, exercise and upper limb neural unloading tape, compared to a control of weekly phone advice; on disability, pain and selected biopsychosocial measures, in acute and sub-acute cervical radiculopathy patients. A secondary aim is to identify whether any baseline variables, symptom duration or group allocation can predict outcome.

METHODS

Participants are recruited from GP referrals in an urban setting, from a neurosurgery non-urgent waiting list and from self-referral through Facebook advertising. Eligible participants (n = 64) are diagnosed with radiculopathy based on a clinical prediction rule and must have symptoms of unilateral, single level, radiculopathy for between 2 and 12 weeks, without having yet received physiotherapy. Random 1:1 group allocation (using variable block sizes), allocation concealment, blinded assessment and intention to treat analysis are being employed. Treatment is provided by clinical specialist physiotherapists in primary and secondary care settings. Outcomes are measured at baseline, 4 (primary endpoint) and 12 weeks. Participants' report of pain, disability and their rating of recovery is also recorded by telephone interview at 6 months. Statistical analysis of between group differences will be performed with ANOVAs and MANOVAs, and multivariable regression analysis will be undertaken to explore predictor variables. Ethical approval for this study has been received from the Beaumont Hospital and Irish College of General Practitioners Research Ethics Committees. The trial is registered at ClinicalTrials.gov (NCT02449200).

DISCUSSION

An internal pilot study to test retention and recruitment strategies led to trial expansion and this is now a multi centre trial involving 5 clinical sites.

TRIAL REGISTRATION

NCT02449200 . Registered 20/05/15.

Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration

OBJECTIVES

To develop an evidence-based guideline for the non-pharmacological management of persistent headaches associated with neck pain (i.e., tension-type or cervicogenic).

METHODS

This guideline is based on systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of clinical benefits, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience includes clinicians; target population is adults with persistent headaches associated with neck pain.

RESULTS

When managing patients with headaches associated with neck pain, clinicians should (a) rule out major structural or other pathologies, or migraine as the cause of headaches; (b) classify headaches associated with neck pain as tension-type headache or cervicogenic headache once other sources of headache pathology has been ruled out; (c) provide care in partnership with the patient and involve the patient in care planning and decision making; (d) provide care in addition to structured patient education; (e) consider low-load endurance craniocervical and cervicoscapular exercises for tension-type headaches (episodic or chronic) or cervicogenic headaches >3 months duration; (f) consider general exercise, multimodal care (spinal mobilization, craniocervical exercise and postural correction) or clinical massage for chronic tension-type headaches; (g) do not offer manipulation of the cervical spine as the sole form of treatment for episodic or chronic tension-type headaches; (h) consider manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine for cervicogenic headaches >3 months duration. However, there is no added benefit in combining spinal manipulation, spinal mobilization and exercises; and (i) reassess the patient at every visit to assess outcomes and determine whether a referral is indicated.

CONCLUSIONS

Our evidence-based guideline provides recommendations for the conservative management of persistent headaches associated with neck pain. The impact of the guideline in clinical practice requires validation.

SIGNIFICANCE

Neck pain and headaches are very common comorbidities in the population. Tension-type and cervicogenic headaches can be treated effectively with specific exercises. Manual therapy can be considered as an adjunct therapy to exercise to treat patients with cervicogenic headaches. The management of tension-type and cervicogenic headaches should be patient-centred.

Is a government-regulated rehabilitation guideline more effective than general practitioner education or preferred-provider rehabilitation in promoting recovery from acute whiplash-associated disorders? A pragmatic randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a government-regulated rehabilitation guideline compared with education and activation by general practitioners, and to a preferred-provider insurance-based rehabilitation programme on self-reported global recovery from acute whiplash-associated disorders (WAD) grade I-II.

DESIGN

Pragmatic randomised clinical trial with blinded outcome assessment.

SETTING

Multidisciplinary rehabilitation clinics and general practitioners in Ontario, Canada.

PARTICIPANTS

340 participants with acute WAD grade I and II. Potential participants were sampled from a large automobile insurer when reporting a traffic injury.

INTERVENTIONS

Participants were randomised to receive one of three protocols: government-regulated rehabilitation guideline, education and activation by general practitioners or a preferred-provider insurance-based rehabilitation.

PRIMARY AND SECONDARY OUTCOME MEASURES

Our primary outcome was time to self-reported global recovery. Secondary outcomes included time on insurance benefits, neck pain intensity, whiplash-related disability, health-related quality of life and depressive symptomatology at 6 weeks and 3, 6, 9 and 12 months postinjury.

RESULTS

The median time to self-reported global recovery was 59 days (95% CI 55 to 68) for the government-regulated guideline group, 105 days (95% CI 61 to 126) for the preferred-provider group and 108 days (95% CI 93 to 206) for the general practitioner group; the difference was not statistically significant (Χ²=3.96; 2 df: p=0.138). We found no clinically important differences between groups in secondary outcomes. Post hoc analysis suggests that the general practitioner (hazard rate ratio (HRR)=0.51, 95% CI 0.34 to 0.77) and preferred-provider groups (HRR=0.67, 95% CI 0.46 to 0.96) had slower recovery than the government-regulated guideline group during the first 80 days postinjury. No major adverse events were reported.

CONCLUSIONS

Time-to-recovery did not significantly differ across intervention groups. We found no differences between groups with regard to neck-specific outcomes, depression and health-related quality of life.

TRIAL REGISTRATION NUMBER

NCT00546806.

Intervertebral kinematics of the cervical spine before, during, and after high-velocity low-amplitude manipulation

BACKGROUND CONTEXT

Neck pain is one of the most commonly reported symptoms in primary care settings, and a major contributor to health-care costs. Cervical manipulation is a common and clinically effective intervention for neck pain. However, the in vivo biomechanics of manipulation are unknown due to previous challenges with accurately measuring intervertebral kinematics in vivo during the manipulation.

PURPOSE

The objectives were to characterize manual forces and facet joint gapping during cervical spine manipulation and to assess changes in clinical and functional outcomes after manipulation. It was hypothesized that patient-reported pain would decrease and intervertebral range of motion (ROM) would increase after manipulation.

STUDY DESIGN/SETTING

Laboratory-based prospective observational study.

PATIENT SAMPLE

12 patients with acute mechanical neck pain (4 men and 8 women; average age 40 ± 15 years).

OUTCOME MEASURES

Amount and rate of cervical facet joint gapping during manipulation, amount and rate of force applied during manipulation, change in active intervertebral ROM from before to after manipulation, and numeric pain rating scale (NPRS) to measure change in pain after manipulation.

METHODS

Initially, all participants completed a NPRS (0-10). Participants then performed full ROM flexion-extension, rotation, and lateral bending while seated within a custom biplane radiography system. Synchronized biplane radiographs were collected at 30 images/s for 3 seconds during each movement trial. Next, synchronized, 2.0-milliseconds duration pulsed biplane radiographs were collected at 160 images/s for 0.8 seconds during the manipulation. The manipulation was performed by a licensed chiropractor using an articular pillar push technique. For the final five participants, two pressure sensors placed on the thumb of the chiropractor (Novel pliance system) recorded pressure at 160 Hz. After manipulation, all participants repeated the full ROM movement testing and once again completed the NPRS. A validated volumetric model-based tracking process that matched subject-specific bone models (from computed tomography) to the biplane radiographs was used to track bone motion with submillimeter accuracy. Facet joint gapping was calculated as the average distance between adjacent articular facet surfaces. Pre- to postmanipulation changes were assessed using the Wilcoxon signed-rank test.

RESULTS

The facet gap increased 0.9 ± 0.40 mm during manipulation. The average rate of facet gapping was 6.2 ± 3.9 mm/s. The peak force and rate of force application during manipulation were 65 ± 4 N and 440 ± 58 N/s. Pain score improved from 3.7 ± 1.2 before manipulation to 2.0 ± 1.4 after manipulation (p <. 001). Intervertebral ROM increased after manipulation by 1.2° (p = .006), 2.1° (p = .01), and 3.9° (p = .003) at the C4/C5, C5/C6, and C6/C7 motion segments, respectively, during flexion-extension; by 1.5° (p = .028), 1.9° (p = .005), and 1.3° (p = .050) at the C3/C4, C4/C5, and C5/C6 motion segments, respectively, during rotation; and by 1.3° (p = .034) and 1.1° (p = .050) at the C4/C5 and C5/C6 motion segments, respectively, during lateral bending. Global head ROM relative to the torso increased after manipulation by 8º (p = .023), 10º (p = .002), and 13º (p = .019) during lateral bending, axial rotation and flexion-extension, respectively, after manipulation.

CONCLUSIONS

This study is the first to measure facet gapping during cervical manipulation on live humans. The results demonstrate that target and adjacent motion segments undergo facet joint gapping during manipulation and that intervertebral ROM is increased in all three planes of motion after manipulation. The results suggest that clinical and functional improvement after manipulation may occur as a result of small increases in intervertebral ROM across multiple motion segments. This study demonstrates the feasibility of characterizing in real time the manual inputs and biological responses that comprise cervical manipulation, including clinician-applied force, facet gapping, and increased intervertebral ROM. This provides a basis for future clinical trials to identify the mechanisms behind manipulation and to optimize the mechanical factors that reliably and sufficiently impact the key mechanisms behind manipulation.

The identity, role, setting, and future of chiropractic practice: a survey of Australian and New Zealand chiropractic students

OBJECTIVE:

To evaluate Australian and New Zealand chiropractic students' opinions regarding the identity, role setting, and future of chiropractic practice.

METHODS:

An online, cross-sectional survey was administered to chiropractic students in all chiropractic programs in Australia and New Zealand. The survey explored student viewpoints about the identity, role/scope, setting, and future of chiropractic practice as it relates to chiropractic education and health promotion. Associations between the number of years in the program, highest degree preceding chiropractic education, institution, and opinion summary scores were evaluated by multivariate analysis of variance tests.

RESULTS:

A total of 347 chiropractic students participated in the study. For identity, most students (51.3%) hold strongly to the traditional chiropractic theory but also agree (94.5%) it is important that chiropractors are educated in evidence-based practice. The main predictor of student viewpoints was a student's chiropractic institution (Pillai's trace =.638, F[16, 1368] = 16.237, p < .001). Chiropractic institution explained over 50% of the variance around student opinions about role/scope of practice and approximately 25% for identity and future practice.

CONCLUSIONS:

Chiropractic students in Australia and New Zealand seem to hold both traditional and mainstream viewpoints toward chiropractic practice. However, students from different chiropractic institutions have divergent opinions about the identity, role, setting, and future of chiropractic practice, which is most strongly predicted by the institution. Chiropractic education may be a potential determinant of chiropractic professional identity, raising concerns about heterogeneity between chiropractic schools.

Both positive and negative beliefs are important in patients with spine pain: findings from the Occupational and Industrial Orthopaedic Center registry

BACKGROUND CONTEXT

Negative beliefs are known to influence treatment outcome in patients with spine pain (SP). The impact of positive beliefs is less clear.

PURPOSE

We aimed to assess the influence of positive and negative beliefs on baseline and treatment responses in patients with SP.

STUDY DESIGN/SETTING

A retrospective cross-sectional and longitudinal analysis of prospectively collected data of outpatient physical therapy patients with SP was carried out. Questionnaires administered before and during treatment included the STarT Back distress scale (negative beliefs), and expectation and self-efficacy questions (positive beliefs).

PATIENT SAMPLE

Patients with SP with a baseline assessment and follow-up assessment comprised the study sample.

OUTCOME MEASURE

Perceived disability was measured using the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI). A clinical meaningful change (minimum clinically important difference [MCID]) was defined as decrease in ODI or NDI of ≥30%.

METHODS

We used the Akaike Information Criterion from the first imputed dataset of the prediction model to select predictor variables. Prediction models were fitted to the outcome variables.

RESULTS

In the cross-sectional analysis, 1,695 low back pain (LBP) episodes and 487 neck pain (NP) episodes were analyzed. STarT Back Screening Tool (SBST)-distress was positively associated with perceived disability in both LBP (beta 2.31, 95% confidence interval [CI] 1.75-2.88) and NP (beta 2.57, 95% CI 1.47-3.67). Lower self-efficacy was negatively associated with more perceived disability for LBP (beta 0.50, 95% CI 0.29-0.72) but not for NP, whereas less positive expectations was associated with more perceived disability in NP (beta 0.57, 95% CI 0.02-1.12) but not in LBP. In the longitudinal analysis, 607 LBP episodes (36%) and 176 (36%) NP episodes were included. SBST-distress did not predict treatment outcome in spine patients. In LBP, patients with a lower positive expectation were less likely to experience an MCID in perceived disability (odds ratio [OR] per point increase 0.89, 95% CI 0.83-0.96), and there was a similar trend in NP (OR per point increase 0.90, 95% CI 0.79-1.03). In patients with LBP, lower self-efficacy at baseline was associated with a higher likelihood that an MCID was achieved (OR per point increase 1.09, 95% CI 1.01-1.19). In NP, self-efficacy was not included in the final model.

CONCLUSIONS

Our study demonstrates that both negative and positive beliefs are associated with perceptions of disability. However, in this study, only positive beliefs were associated with treatment outcome.

A narrative review on cervical interventions in adults with chronic whiplash-associated disorder

Introduction

Whiplash injuries are common in society, but clinical interventions are inconclusive on the most effective treatment. Research and reviews have been completed with the goal of determining clinical interventions that are effective for whiplash injuries and disorders, but literature has not recently been summarised on best practices for cervical spine interventions for adults with chronic whiplash.

Purpose

The objective of this narrative review is to update and expand on previous works, to provide recommendations for clinical interventions and future research in the area of cervical spine rehabilitation for adults with chronic whiplash-associated disorder.

Method

The Arskey and O'Malley methodology was used for this narrative review. CINHAL, EMBASE, Medline, PsychInfo, Scopus, Web of Science, as well as grey literature, were searched from 2003 to April 2017. Two reviewers screened titles and abstracts for relevance to the review, and content analysis summarised the study findings. A total of 14 citations were included in the final review.

Findings

Exercise-based interventions targeted at the cervical spine appear most beneficial for adults with chronic whiplash-associated disorder (WAD). Invasive interventions still require more rigorous studies to deem their effectiveness for this population.

Conclusion

Further research is required to investigate and determine clinically relevant results for cervical spine intervention in patients with chronic WAD.

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: applying evidence-based guidelines on the non-invasive management of back and neck pain to low- and middle-income communities

PURPOSE

The purpose of this review was to develop recommendations for the management of spinal disorders in low-income communities, with a focus on non-invasive pharmacological and non-pharmacological therapies for non-specific low back and neck pain.

METHODS

We synthesized two evidence-based clinical practice guidelines for the management of low back and neck pain. Our recommendations considered benefits, harms, quality of evidence, and costs, with attention to feasibility in medically underserved areas and low- and middle-income countries.

RESULTS

Clinicians should provide education and reassurance, advise patients to remain active, and provide information about self-care options. For acute low back and neck pain without serious pathology, primary conservative treatment options are exercise, manual therapy, superficial heat, and nonsteroidal anti-inflammatory drugs (NSAIDs). For patients with chronic low back and neck pain without serious pathology, primary treatment options are exercise, yoga, cognitive behavioral therapies, acupuncture, biofeedback, progressive relaxation, massage, manual therapy, interdisciplinary rehabilitation, NSAIDs, acetaminophen, and antidepressants. For patients with spinal pain with radiculopathy, clinicians may consider exercise, spinal manipulation, or NSAIDs; use of other interventions requires extrapolation from evidence regarding effectiveness for non-radicular spinal pain. Clinicians should not offer treatments that are not effective, including benzodiazepines, botulinum toxin injection, systemic corticosteroids, cervical collar, electrical muscle stimulation, short-wave diathermy, transcutaneous electrical nerve stimulation, and traction.

CONCLUSION

Guidelines developed for high-income settings were adapted to inform a care pathway and model of care for medically underserved areas and low- and middle-income countries by considering factors such as costs and feasibility, in addition to benefits, harms, and the quality of underlying evidence. The selection of recommended conservative treatments must be finalized through discussion with the involved community and based on a biopsychosocial approach. Decision determinants for selecting recommended treatments include costs, availability of interventions, and cultural and patient preferences. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: applying evidence-based guidelines on the non-invasive management of back and neck pain to low- and middle-income communities

PURPOSE

The purpose of this review was to develop recommendations for the management of spinal disorders in low-income communities, with a focus on non-invasive pharmacological and non-pharmacological therapies for non-specific low back and neck pain.

METHODS

We synthesized two evidence-based clinical practice guidelines for the management of low back and neck pain. Our recommendations considered benefits, harms, quality of evidence, and costs, with attention to feasibility in medically underserved areas and low- and middle-income countries.

RESULTS

Clinicians should provide education and reassurance, advise patients to remain active, and provide information about self-care options. For acute low back and neck pain without serious pathology, primary conservative treatment options are exercise, manual therapy, superficial heat, and nonsteroidal anti-inflammatory drugs (NSAIDs). For patients with chronic low back and neck pain without serious pathology, primary treatment options are exercise, yoga, cognitive behavioral therapies, acupuncture, biofeedback, progressive relaxation, massage, manual therapy, interdisciplinary rehabilitation, NSAIDs, acetaminophen, and antidepressants. For patients with spinal pain with radiculopathy, clinicians may consider exercise, spinal manipulation, or NSAIDs; use of other interventions requires extrapolation from evidence regarding effectiveness for non-radicular spinal pain. Clinicians should not offer treatments that are not effective, including benzodiazepines, botulinum toxin injection, systemic corticosteroids, cervical collar, electrical muscle stimulation, short-wave diathermy, transcutaneous electrical nerve stimulation, and traction.

CONCLUSION

Guidelines developed for high-income settings were adapted to inform a care pathway and model of care for medically underserved areas and low- and middle-income countries by considering factors such as costs and feasibility, in addition to benefits, harms, and the quality of underlying evidence. The selection of recommended conservative treatments must be finalized through discussion with the involved community and based on a biopsychosocial approach. Decision determinants for selecting recommended treatments include costs, availability of interventions, and cultural and patient preferences. These slides can be retrieved under Electronic Supplementary Material.

Has the quality of physiotherapy care in patients with Whiplash-associated disorders (WAD) improved over time? A retrospective study using routinely collected data and quality indicators

PURPOSE

To develop valid quality indicators (QIs) for physiotherapy care based on best available evidence, and to use these QIs to explore trends in the quality of physiotherapy care of patients with Whiplash-associated disorders (WAD) using guideline-based routinely collected data (RCD) gathered between 1996 and 2011.

MATERIALS AND METHODS

The study consisted of two phases: 1) development of QIs and 2) analysis of patient records. A set of QIs was developed based on recommendations in the scientific literature and the Dutch Clinical Practice Guideline (CPG) "Physiotherapy Management and WAD". QIs were expressed as percentages, allowing target performance levels to be defined (≥80% or ≤30% depending on whether desired performance required a high or low score on a QI). We then analyzed WAD patient data (N = 810) collected over a period of 16 years in two physiotherapy practices, separating patients into two groups defined as before (Group A 1996-2002; n = 353) and after (Group B 2003-2011; n = 457) implementation and transition to the Dutch CPG "Physiotherapy Management and WAD".

RESULTS

Using an iterative process and input from both experts and users, 28 QIs were developed and subsequently classified per step of the clinical reasoning process for physiotherapy care. Based on 16 years of RCD, we found that the clinical reasoning process differed significantly (P ≤ 0.05) between the groups, in favor of Group B. Twelve of the 25 indicators (48.0%) in Group A and 19 of 26 indicators (73.1%) in Group B met predetermined performance targets. The number of target indicators also differed significantly between groups, favoring Group B (P ≤ 0.05).

CONCLUSION

A preliminary set of novel QIs was developed. Using RCD and these QIs, we conclude that physiotherapy care in our study setting improved over the period 1996-2011. Furthermore, the QIs met the performance targets set for the clinical reasoning process after the transition to the Dutch CPG "Physiotherapy Management and WAD".

Responsiveness of clinical tests for people with neck pain

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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