Application of a diagnosis-based clinical decision guide in patients with neck pain

A model to differentiate WAD patients and people with abnormal pain behaviour based on biomechanical and self-reported tests

The prevalence of malingering among individuals presenting whiplash-related symptoms is significant and leads to a huge economic loss due to fraudulent injury claims. Various strategies have been proposed to detect malingering and symptoms exaggeration. However, most of them have been not consistently validated and tested to determine their accuracy in detecting feigned whiplash. This study merges two different approaches to detect whiplash malingering (the mechanical approach and the qualitative analysis of the symptomatology) to obtain a malingering detection model based on a wider range of indices, both biomechanical and self-reported. A sample of 46 malingerers and 59 genuine clinical patients was tested using a kinematic test and a self-report questionnaire asking about the presence of rare and impossible symptoms. The collected measures were used to train and validate a linear discriminant analysis (LDA) classification model. Results showed that malingerers were discriminated from genuine clinical patients based on a greater proportion of rare symptoms vs. possible self-reported symptoms and slower but more repeatable neck motions in the biomechanical test. The fivefold cross-validation of the LDA model yielded an area under the curve (AUC) of 0.84, with a sensitivity of 77.8% and a specificity of 84.7%.

Rare Neurosurgical Complications of Epidural Injections: An 8-Yr Single-Institution Experience

BACKGROUND

Neurosurgical complications from epidural injections have rarely been reported.

OBJECTIVE

To define the spectrum of complications from these procedures in order to identify risk factors and strategies for prevention.

METHODS

A prospectively maintained database of 14 247 neurosurgical admissions over 8 yr was screened to identify patients who had suffered procedural complications associated with 1182 cervical and 4617 lumbar interlaminar epidural injection procedures performed at a single institution. Patients who developed new neurological symptoms or deficits were included. A retrospective analysis of demographic and procedural features was performed.

RESULTS

Thirteen patients experienced complications requiring neurosurgical treatment, accounting for an overall procedural complication rate of 0.22% (0.51% and 0.15% for cervical and lumbar injections, respectively), and representing 0.09% of all neurosurgical admissions over 8 yr. There were 3 categories: hemorrhage (n = 7), infection (n = 3), and inadvertent dural penetration (n = 3). There was significant association with anticoagulation use among patients with hemorrhagic vs nonhemorrhagic complications ( P < .01, Fisher's exact test). Six patients who developed epidural hematoma had been managed in accordance with current guidelines, either after prolonged cessation of anticoagulation (n = 3) or taking only aspirin (n = 3); all were decompressed promptly with good long-term outcome. All infections were associated with lumbar injection. Dural penetration resulted in diffuse pneumocephalus (n = 1), intramedullary air at the site of injection (n = 1), and acutely symptomatic colloid cyst (n = 1).

CONCLUSION

A majority of neurosurgical complications from epidural injections are hemorrhagic and associated with anticoagulation, although infection and inadvertent dural penetration also occur. Prompt treatment of compressive lesions is associated with good outcome.

Measuring biopsychosocial risk for back pain disability in chiropractic patients using the STarT back screening tool: a cross-sectional survey

Background

The Keele STarT Back Screening Tool (SBT), a 9-item questionnaire, screens for pain, physical functioning, fear-avoidance beliefs, catastrophizing, anxious thoughts, low mood, and bothersomeness in persons with back pain. SBT scores designate low, medium, or high risk for developing persistent disabling back pain. The primary study aim was to report the prevalence of SBT-calculated risk for back pain disability in US patients seeking chiropractic care.

Methods

The SBT questionnaire was administered to patients ≥18 years in 3 Chiropractic College outpatient teaching clinics in Iowa and Illinois (May 2017). Descriptive statistics were used to analyze respondent characteristics and prevalence of SBT-calculated risk subgroups. Binary logistic regression analysis was used to examine the relationship between respondent characteristics and SBT scores (including psychological subscores).

Results

Of 550 respondents, 496 completed the SBT; 392 (79%) scored low-risk, 81 (16%) medium-risk, and 23 (5%) high-risk. Mean (SD) age was 44.8 (15.9), 56.9% were female, 88.2% white, 62.6% employed, mean current pain was 2.9 (2.1) out of 10, and 62% reported symptom duration > 3 months. Eighteen percent of respondents reported anxious thoughts, 32% low mood, 41% ≥ 1 and 21% ≥ 3 SBT psychological risk factors. Respondents reporting higher average pain (OR = 1.8 [1.4, 2.3]) and pain severity (OR = 1.3 [1.0 to 1.6]) were more likely to score with medium or high risk. Respondents reporting mid back versus low back pain (OR = 0.2 [0.1, 0.7]), and those employed less than full-time versus full-time (0.2 [01, 0.5]) were less likely to score with medium or high risk. Respondents reporting higher average pain were more likely to report ≥1 psychological factor (OR = 1.8 [1.5, 2.0]). Respondents employed part-time were less likely to report ≥1 psychological factor than those employed full-time (OR = 0.4 [0.2, 0.7]).

Conclusion

The sample surveyed was less likely to score with medium or high risk for back pain disability than previous samples studied, perhaps due to differences in study design and sample characteristics. Rates of low mood and anxious thoughts indicate a need for future research to explore psychological factors among persons seeking chiropractic care.

Centralization and directional preference: An updated systematic review with synthesis of previous evidence

BACKGROUND

Centralization and directional preference are common management and prognostic factors in spinal symptoms.

OBJECTIVE

To update the previous systematic review.

DESIGN

Systematic review to synthesis multiple aspects of centralization and directional preference.

METHOD

Contemporary search was made of multiple databases using relevant search terms. Abstracts and titles were filtered by two authors; relevant articles were independently reviewed by two authors for content, data extraction, and quality.

RESULTS

Forty-three additional relevant articles were found. The quality of the studies, using PEDro for randomized controlled trials, was moderate or high in six out of ten RCTs; moderate or high in six out of 12 cohort studies. Prevalence of centralization was 40%, the same as the previous review. Directional preference without Centralization was 26%; thus Centralization and directional preference combined was 66%, which was very similar to the previous review. Neither clinical response was recorded in about a third of patients. Centralization and directional preference were confirmed as key positive prognostic factors, certainly in patients with low back pain, but limited evidence for patients with neck pain. There was no evidence that these might be important treatment effect modifiers. One study evaluated reliability, and found generally poor levels, despite training.

CONCLUSIONS

Centralization and directional preference are worthwhile indicators of prognosis, and should be routinely examined for even in patients with chronic low back pain. But they do not occur in all patients with spinal problems, and there was no evidence that they were treatment effect modifiers.

Understanding Monitoring Technologies for Adults With Pain: Systematic Literature Review

BACKGROUND

Monitoring of patients may decrease treatment costs and improve quality of care. Pain is the most common health problem that people seek help for in hospitals. Therefore, monitoring patients with pain may have significant impact in improving treatment. Several studies have studied factors affecting pain; however, no previous study has reviewed the contextual information that a monitoring system may capture to characterize a patient's situation.

OBJECTIVE

The objective of this study was to conduct a systematic review to (1) determine what types of technologies have been used to monitor adults with pain, and (2) construct a model of the context information that may be used to implement apps and devices aimed at monitoring adults with pain.

METHODS

A literature search (2005-2015) was conducted in electronic databases pertaining to medical and computer science literature (PubMed, Science Direct, ACM Digital Library, and IEEE Xplore) using a defined search string. Article selection was done through a process of removing duplicates, analyzing title and abstract, and then reviewing the full text of the article.

RESULTS

In the final analysis, 87 articles were included and 53 of them (61%) used technologies to collect contextual information. A total of 49 types of context information were found and a five-dimension (activity, identity, wellness, environment, physiological) model of context information to monitor adults with pain was proposed, expanding on a previous model. Most technological interfaces for pain monitoring were wearable, possibly because they can be used in more realistic contexts. Few studies focused on older adults, creating a relevant avenue of research on how to create devices for users that may have impaired cognitive skills or low digital literacy.

CONCLUSIONS

The design of monitoring devices and interfaces for adults with pain must deal with the challenge of selecting relevant contextual information to understand the user's situation, and not overburdening or inconveniencing users with information requests. A model of contextual information may be used by researchers to choose possible contextual information that may be monitored during studies on adults with pain.

Chiropractic Identity in the United States: Wisdom, Courage, and Strength

OBJECTIVE

The objective of this paper was to discuss the chiropractic profession's identity and 3 contentious issues related to identity.

DISCUSSION

The various clinical specialties and independent groups in the chiropractic profession are so different in their beliefs, practice styles, and political agendas that a common identity is unlikely to be created. Areas of disagreement, including advanced practice, vertebral subluxation, and the philosophy of chiropractic, continue to separate those in the profession. Doctors of chiropractic should accept that differences within the profession will remain for the foreseeable future and that the profession should allow each group to live peacefully and supportively alongside each other.

CONCLUSIONS

If the profession embraces the ideals of truth, respect, and tolerance, it can continue to grow and provide diverse health care services well into the future.

Application of the Harms Technique to Treat Undiagnosed Intractable C1-C2 Unilateral Neck Pain: A Case Report

A 79-year-old female presented with incapacitating chronic neck pain. The patient's pain which was greatest on the left side persisted for 18 months and was described as stabbing in nature (10/10 intensity). In addition to her neck pain, the patient described having frequent headaches. After six weeks of physical therapy and undergoing a rhizotomy procedure, she showed no prolonged improvement. An epidural steroid injection provided only temporary pain relief and was followed by a successful posterior fusion using the Harms technique with iliac crest autogenous bone grafting and placement of polyaxial screws in the C1 lateral masses and C2 pedicles. At the one-year follow-up the patient reported no pain or complaints. In general, C1-C2 arthrodesis is a surgical challenge due to the proximity of neurovascular structures (vertebral arteries and spinal cord) and wide range of the joint motion. The Harms technique is one of many techniques developed to reduce anatomical risk and improve results related to biomechanical stability and fusion rates.

Cervicobrachial pain - How Often is it Neurogenic?

INTRODUCTION

Neck pain associated with pain in the arm (cervicobrachial pain) is a common complaint in patients seeking physiotherapy management. The source of symptoms for this complaint is commonly presumed to be neural. However, this pain pattern could also result from various other innervated tissue structures of the upper quarter. Knowledge about frequency of neural structures being a predominant source of symptoms would help in implementing appropriate therapeutic strategies such as neural tissue mobilization along with other complimentary therapies for optimal outcomes.

AIM

To determine the frequency of cervicobrachial pain being neurogenic.

MATERIALS AND METHODS

Participants (n=361) aged between 20-65 years, reporting cervicobrachial pain were screened for neurogenic nature of symptoms. These physical signs included: active and passive movement dysfunction, adverse responses to neural tissue provocation tests, tenderness on palpating nerve trunks and related cutaneous tissues and evidence of a related local area of pathology (Clinical/radiological). The consistency of all these signs was checked to identify a significant neural involvement.

RESULTS

Descriptive statistics were used to analyse data. Of 361 participants, 206 were males (44.6 ±10.8 years) and 155 were females (41.8 ± 11.2 years). The frequency of neurogenic cervicobrachial pain was determined to be 19.9% (n=72) and the non-neurogenic sources for symptoms were attributed to 80.1% (n=289) of screened participants.

CONCLUSION

Lower frequency of cervicobrachial pain being neurogenic indicates thorough screening for appropriate therapeutic interventions to be successful.

Chronic neck pain: making the connection between capsular ligament laxity and cervical instability

The use of conventional modalities for chronic neck pain remains debatable, primarily because most treatments have had limited success. We conducted a review of the literature published up to December 2013 on the diagnostic and treatment modalities of disorders related to chronic neck pain and concluded that, despite providing temporary relief of symptoms, these treatments do not address the specific problems of healing and are not likely to offer long-term cures. The objectives of this narrative review are to provide an overview of chronic neck pain as it relates to cervical instability, to describe the anatomical features of the cervical spine and the impact of capsular ligament laxity, to discuss the disorders causing chronic neck pain and their current treatments, and lastly, to present prolotherapy as a viable treatment option that heals injured ligaments, restores stability to the spine, and resolves chronic neck pain. The capsular ligaments are the main stabilizing structures of the facet joints in the cervical spine and have been implicated as a major source of chronic neck pain. Chronic neck pain often reflects a state of instability in the cervical spine and is a symptom common to a number of conditions described herein, including disc herniation, cervical spondylosis, whiplash injury and whiplash associated disorder, postconcussion syndrome, vertebrobasilar insufficiency, and Barré-Liéou syndrome. When the capsular ligaments are injured, they become elongated and exhibit laxity, which causes excessive movement of the cervical vertebrae. In the upper cervical spine (C0-C2), this can cause a number of other symptoms including, but not limited to, nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches. In the lower cervical spine (C3-C7), this can cause muscle spasms, crepitation, and/or paresthesia in addition to chronic neck pain. In either case, the presence of excessive motion between two adjacent cervical vertebrae and these associated symptoms is described as cervical instability. Therefore, we propose that in many cases of chronic neck pain, the cause may be underlying joint instability due to capsular ligament laxity. Currently, curative treatment options for this type of cervical instability are inconclusive and inadequate. Based on clinical studies and experience with patients who have visited our chronic pain clinic with complaints of chronic neck pain, we contend that prolotherapy offers a potentially curative treatment option for chronic neck pain related to capsular ligament laxity and underlying cervical instability.

Straight chiropractic philosophy as a barrier to Medicare compliance: a discussion of 5 incongruent issues

OBJECTIVE

The purpose of this commentary is to discuss potential 5 factors within straight chiropractic philosophy and practice that may prevent Medicare compliance.

DISCUSSION

The national Medicare Benefit Policy Manual and the Florida Local Coverage Determination were reviewed to identify documentation and conceptual issues regarding chiropractic practice. Five Medicare positions were contrasted with tenets of straight chiropractic philosophy. Based on Medicare's documentation requirements, Medicare defines subluxation and chiropractic practice from the perspective of treating spinal pain and related functional disability. In contrast, traditional straight chiropractic philosophy is not based on the treatment of spinal pain and disability or other symptomatic presentations. In this context, 5 potential areas of conflict are discussed.

CONCLUSION

The Medicare version of chiropractic practice is not consistent with traditional straight chiropractic philosophy, which may play a role in preventing Medicare compliance. The chiropractic profession may need to consider the fashion in which "philosophy" as it relates to technique and practice is presented to students and doctors to facilitate compliance with the documentation requirements of Medicare.

A systematic comparison between subjects with no pain and pain associated with active myofascial trigger points

OBJECTIVE

To determine whether standard evaluations of pain distinguish subjects with no pain from those with myofascial pain syndromes (MPS) and active myofascial trigger points (MTrPs) and to assess whether self-reports of mood, function, and health-related quality of life differ between these groups.

DESIGN

A prospective, descriptive study.

SETTING

University.

PATIENTS

Adults with and without neck pain.

METHODS

We evaluated adults with MPS and active (painful) MTrPs and those without pain. Subjects in the "active" (A) group had at least one active MTrP with spontaneous pain that was persistent, lasted longer than 3 months, and had characteristic pain on palpation. Subjects in the "no pain" (NP) group had no spontaneous pain. However, some of these subjects had discomfort upon MTrP palpation (latent MTrP), whereas others in the NP group had no discomfort upon palpation of nodules or had no nodules.

OUTCOME MEASURES

Each participant underwent range of motion measurement, a 10-point manual muscle test, and manual and algometric palpation. The latter determined the pain/pressure threshold using an algometer of 4 predetermined anatomic sites along the upper trapezius. Participants rated pain using a verbal analog scale (0-10) and completed the Brief Pain Inventory and Oswestry Disability Scale (which included a sleep subscale), the Short -Form 36 Health Survey, and the Profile of Mood States.

RESULTS

The A group included 24 subjects (mean age 36 years; 16 women), and the NP group included 26 subjects (mean age 26 years; 12 women). Group A subjects differed from NP subjects in the number of latent MTrPs (P = .0062), asymmetrical cervical range of motion (P = .01 for side bending and P = .002 for rotation), and in all pain reports (P < .0001), algometry (P < .03), Profile of Mood States (P < .038), Short Form 36 Health Survey (P < .01), and Oswestry Disability Scale (P < .0001).

CONCLUSION

A systematic musculoskeletal evaluation of people with MPS reliably distinguishes them from subjects with no pain. The 2 groups are significantly different in their physical findings and self-reports of pain, sleep disturbance, disability, health status, and mood. These findings support the view that a "local" pain syndrome has significant associations with mood, health-related quality of life, and function.

Clinical decision rules, spinal pain classification and prediction of treatment outcome: A discussion of recent reports in the rehabilitation literature

Clinical decision rules are an increasingly common presence in the biomedical literature and represent one strategy of enhancing clinical-decision making with the goal of improving the efficiency and effectiveness of healthcare delivery. In the context of rehabilitation research, clinical decision rules have been predominantly aimed at classifying patients by predicting their treatment response to specific therapies. Traditionally, recommendations for developing clinical decision rules propose a multistep process (derivation, validation, impact analysis) using defined methodology. Research efforts aimed at developing a "diagnosis-based clinical decision rule" have departed from this convention. Recent publications in this line of research have used the modified terminology "diagnosis-based clinical decision guide." Modifications to terminology and methodology surrounding clinical decision rules can make it more difficult for clinicians to recognize the level of evidence associated with a decision rule and understand how this evidence should be implemented to inform patient care. We provide a brief overview of clinical decision rule development in the context of the rehabilitation literature and two specific papers recently published in Chiropractic and Manual Therapies.