Developing biologically-based assessment tools for physical therapy management of neck pain

Development and validation of the ND10 to measure neck-related functional disability

BACKGROUND

Previous neck-specific patient-reported outcome measures (PROMs) have tended to measure both symptoms and disability. This multi-staged study developed and evaluated a neck-specific PROM focusing on functional disability.

METHODS

This study integrated findings from systematic reviews on neck-specific outcome measures, patient interviews, qualitative studies on neck disability, and iterative item testing to develop a 10-item measure of neck-related disability (ND10). Content validity was assessed by classifying items using the International Classification of Functioning, Disability and Health (ICF) and perspective linking. Patients (n = 78) with neck pain completed cognitive interviews, exploring items of the Neck Disability Index (NDI) and ND10, and completed structured questions related to literacy and relevance. Test-retest reliability and internal consistency were evaluated using intraclass correlation coefficients, Bland Altman graphs, and Cronbach's alpha. Concurrent convergent validity was evaluated by comparing the ND10 to the NDI, Single Assessment Numeric Evaluation (SANE), and Disabilities of the Arm, Shoulder and Hand (DASH). Known group validity was determined by comparing ND10 scores from patients, who rated their neck as more or less than 1/2 of "normal" on the SANE, using t-tests.

RESULTS

The ND10 requires respondents to make rational judgements about their neck-related body function and disability. It has high internal consistency (0.94) and re-test reliability (0.87; SEM = 3.2/100; MDC = 7.5); and no re-test bias (mean re-test difference of 0.6). It followed expected correlation patterns, being highly correlated with related multi-item PROMs (r = 0.85-0.91), and moderately correlated to the single-item SANE. More patients agreed that the ND10 was easily readable than did so for the NDI (84% vs 68%; p < 0.05). All the PROMs distinguished the patients who perceived themselves as being abnormal/normal defined by a dichotomized SANE (p < 0.01).

CONCLUSION

The ND10 is reliable and valid for measuring neck-related functional disability. Longitudinal and cross-cultural translation studies are needed to support future use.

A Novel Biopsychosocial Approach to Neck Pain in Military Helicopter Aircrew

INTRODUCTION: Flight-related neck pain (FRNP) is a frequently reported musculoskeletal complaint among military helicopter aircrew. However, despite its prevalence and suspected causes, little is known of the underpinning pain mechanisms or the impact of neck pain on aircrews in-flight task performance. The biopsychosocial (BPS) approach to health, combined with the contemporary conceptualization of musculoskeletal pain, in which injury and pain are not necessarily synonymous, provides a relatively new holistic framework within which to consider the problem of FRNP in military helicopter aircrew. Combining these concepts, a new conceptual model is proposed to illustrate how biopsychosocial factors may influence pain perception, potentially affecting aircrews capacity to process information and, therefore, threatening in-flight task performance. Recommendations are made for considering the underlying pain mechanisms of FRNP to aid prognoses and guide the development of holistic evidence-based countermeasures for FRNP in military helicopter aircrew. Development of instruments able to measure psychosocial factors, such as self-efficacy and functional ability, validated in the military helicopter aircrew population, would assist this task.Vail RE, Harridge SDR, Hodkinson PD, Green NDC, Pavlou M. A novel biopsychosocial approach to neck pain in military helicopter aircrew. Aerosp Med Hum Perform. 2021; 92(5):333341.

Quantitative ultrasound of trapezius muscle involvement in myofascial pain: comparison of clinical and healthy population using texture analysis

PURPOSE

Ultrasound is a non-invasive quantitative method to characterize sonographic textures of skeletal muscles. To date, there is no information available on the trapezius muscle. This study assessed the trapezius muscles of patients with myofascial pain compared with normal healthy participants.

METHODS

The trapezius muscles of 15 healthy and 17 myofascial pain participants were assessed using B-mode ultrasound to obtain 120 images for healthy and 162 images from myofascial pain participants. Texture features such as blob area, count and local binary patterns (LBP) were calculated. Multi-feature classification and analysis were performed using principal component analysis (PCA) and MANOVA to determine whether there were statistical differences.

RESULTS

We demonstrate the two principal components composed of a combination of LBP and blob parameters which explain 92.55% of the cumulative variance of our data set. In addition, blob characteristics were significantly different between healthy and myofascial pain participants.

CONCLUSION

Our study provides evidence that texture analysis techniques can differentiate between healthy and myofascial pain affected trapezius muscles. Further research is necessary to evaluate the nature of these differences.

Sex-specific effects of intranasal oxytocin on thermal pain perception: A randomised, double-blind, placebo-controlled cross-over study

Chronic neck and shoulder pain (CNSP) is a common musculoskeletal disorder in adults, which is linked to hypersensitivity to noxious stimuli. The hormone oxytocin has been implicated as a potential therapeutic for the management of chronic pain disorders, and has been suggested to have sex-specific effects on the salience of threatening stimuli. This study investigated the influence of intranasal oxytocin on the perception of noxious thermal stimuli. Participants were 24 individuals with CNSP lasting >12months (eight women), and 24 age- and sex-matched healthy, pain-free controls. In a randomised double-blind, placebo-controlled, cross-over study, participants attended two sessions, self-administering intranasal oxytocin (24 IU) in one session, and placebo in another. Participants rated intensity and unpleasantness of thermal heat stimuli at three body sites: the cervical spine, deltoid, and tibialis anterior, on 11-point numerical rating scales. Compared with placebo, intranasal oxytocin increased the perceived intensity of noxious heat stimuli in women with CNSP (Cohen's d=0.71), but not in men with CNSP, or healthy, pain-free controls. Men and women displayed divergent sensitivity across target sites for ratings of pain intensity (partial eta squared=0.12) and pain unpleasantness (partial eta squared=0.24), irrespective of drug condition. Men were more sensitive at the cervical spine and deltoid, whereas women were more sensitive at the tibialis. These findings suggest that oxytocin and endogenous sex hormones may interact to influence the salience of noxious stimuli. The hyperalgesic effects of oxytocin in women suggest that caution should be taken when considering oxytocin in the management of chronic pain.

TRIAL REGISTRATION

CT-2016-CTN-01313-1; ACTRN12616000532404.

Experimental integrative muscular movement technique enhances cervical range of motion in patients with chronic neck pain: a pilot study

INTRODUCTION

Neck pain presents a tremendous physical and financial burden. This study compared the efficacy of the complementary and alternative medical treatments of integrative muscular movement technique (IMMT) and Swedish massage on neck pain in women of occupation age, the largest demographic group with neck pain.

METHODS

A total of 38 women were assigned to IMMT (n=28) or Swedish massage (n=10) in a blinded manner. Both groups received eight 30-minute treatments over 4 weeks. Cervical range of motion (ROM) in flexion, extension, sidebending, and rotation was measured before and after treatment. Each patient's pain was assessed by using an analogue pain scale of 0-10.

RESULTS

Compared with the Swedish massage group, patients receiving IMMT experienced a significant increase in ROM in cervical flexion (p<0.001), extension (p<0.001), sidebending (p<0.05), and rotation (p<0.001). Absolute change in pain for IMMT was -1.75 units compared with -0.3 units for Swedish massage (p<0.05).

CONCLUSION

Patients receiving the IMMT demonstrated significantly improved cervical ROM in every movement measured compared with Swedish massage. Inclusion of the IMMT in a treatment regimen for chronic neck pain may lead to decreased pain and increased cervical ROM. These positive effects of the IMMT intervention may have a role in enhancing functional outcomes in patients with neck pain.

The current perception threshold test differentiates categories of mechanical neck disorder

STUDY DESIGN

Cross-sectional discriminative analysis.

OBJECTIVE

To determine whether current perception threshold (CPT) can differentiate between categories of patients with mechanical neck disorders (MNDs).

BACKGROUND

Neck pain is the third most common musculoskeletal disorder and affects a third of all adults each year. It can present as neck pain without musculoskeletal signs, neck pain with musculoskeletal signs but no neurological signs, or neck pain with neurological signs. CPT testing can assess altered sensory perception that may reflect neurological changes.

METHODS

Patients with MNDs (n = 106) were classified into 3 groups, based on a standardized musculoskeletal examination process performed by an experienced physiotherapist who was blinded to CPT scores. The 3 groups were defined as neck pain without musculoskeletal signs (MND I) (n = 60), neck pain with musculoskeletal signs (MND II) (n = 29), and neck pain with neurological signs (MND III) (n = 17). A rapid protocol of CPT testing was performed at 3 frequencies (5, 250, and 2000 Hz), using 3 dermatomal locations on the hand. A 1-way analysis of variance with post hoc comparison and effect sizes was calculated to compare the mean CPT scores between the groups. A binary logistic-regression model was used to predict probability of higher CPT in MND III and to create a receiver-operating-characteristic curve.

RESULTS

Mean CPT differed significantly across the 3 MND groups (MND I, 9.7; MND II, 10.6; and MND III, 11.8; P<.001; η(2) = 0.6). Post hoc comparisons indicated differences between MND I and MND II (P = .05) and between MND II and MND III (P = .01) that had large effect sizes (MND I versus II, d = 1 and MND II versus III, d = 2.2). CPT testing was able to distinguish between MND II and III when a threshold value of greater than 11 was used to indicate MND III. The predicted probability of abnormal CPT in MND III had an estimated 73% sensitivity and 81% specificity; the odds ratio was 11.5 (P = .001) for the differentiation capacity of CPT between MND II and III, with a cutoff of 11. The area under the receiver-operating-characteristic curve was 0.84 (95% confidence interval: 0.72, 0.96; P<.001).

CONCLUSION

CPT testing has moderate discriminatory accuracy, specificity, and sensitivity for classification of MND categories into neck pain with or without neurological signs. J Orthop Sports Phys Ther 2014;44(7):532-540. Epub 10 May 2014. doi:10.2519/jospt.2014.4691.

The Current Perception Threshold Test Differentiates Categories of Mechanical Neck Disorder

Study Design Cross-sectional discriminative analysis. Objective To determine whether current perception threshold (CPT) can differentiate between categories of patients with mechanical neck disorders (MNDs). Background Neck pain is the third most common musculoskeletal disorder, affecting a third of all adults each year. It can present as neck pain without musculoskeletal signs; neck pain with musculoskeletal signs but no neurological signs; neck pain with neurological signs. CPT testing can assess altered sensory perception that may reflect neurological changes. Methods Patients with MNDs (n=106) were classified into 3 groups based on a standardized musculoskeletal examination process performed by an experienced physiotherapist blinded to CPT scores. The 3 groups were defined as: MND-I, neck pain without musculoskeletal signs (n=60); MND-II, neck pain with musculoskeletal signs (n=29); MND-III, neck pain with neurological signs (n=17). A rapid protocol of CPT testing was performed at 3 frequencies (5, 250, 2000 Hz), using 3 dermatomal locations on the hand. A 1-way ANOVA with post hoc comparison and effect sizes were calculated to compare the mean CPT score between the groups. A binary logistic regression model was used to predict probability of higher CPT in MND-III and used to create a receiver operating characteristic (ROC) curve. Results Mean CPT differed significantly across the 3 MND groups (MND-I, 9.7; MND-II, 10.6; and MND-III, 11.8; P < .001, η2 = .6). Post hoc comparisons indicated differences between MND-I and MND-II (P = .05) and between MND-II and MND-III (P = .01), that were large effect sizes (MND I versus II, d = 1 and MND II versus III, d = 2.2). CPT testing was able to distinguish between MND II and III when a threshold value of greater than 11 was used to indicate MND-III. The predicted probability of abnormal CPT in MND-III had an estimated 73% sensitivity and 81% specificity; the odds ratio was 11.5 (P =.001) for the differentiation capacity of CPT between MND-II and III with a cut-off of 11. The area under the ROC curve (AUC) was .84 (95% CI =.72 to .96, P < .001). Conclusions CPT testing has moderate discriminatory accuracy, specificity, and sensitivity for classification of MND categories into neck pain with or without neurological signs. J Orthop Sports Phys Ther, Epub 10 May 2014. doi:10.2519/jospt.2014.5691.

What does the evidence tell us about design of future treatment trials for whiplash-associated disorders?

STUDY DESIGN

Reflective critique and recommendation development.

OBJECTIVE

To reflect on limitations in past trials and propose recommendations on innovative trial designs and methodologies for whiplash-associated disorders (WAD).

SUMMARY OF BACKGROUND DATA

The cost of doing clinical research and risk of retaining an evidence void is an overarching threat to lessening the transition of WAD to chronicity.

METHODS

Review trial limitations on neck pain and propose recommendations to amend these.

RESULTS

Three innovative trial designs, 20 methodological recommendations, and two knowledge translation (KT) research strategies are proposed. Many of the gaps in our current understanding of neck disorders can be linked to an inadequate research design and implementation. Increased utilization of three design options for evaluating therapies could lead to a more accurate and efficient understanding of the merits of various therapies singly and multimodal. Increased utilization of mixed methods or biological subcomponents may advance our understanding of neck disorders and the resulting disability. There is a need for harmonization and standardization across participant disorder classification; identification and tracking of prognostic factors and adverse events; adequate intervention description and dosing; and outcome selection comparable across studies and across International Classification Framework domains. Reasons for discordant conclusions including subjective elements need to be explored in future trials using qualitative methods. KT research that defines the barriers to implementation of existing knowledge and strategies to reduce the evidence to practice gap is urgently needed.

CONCLUSION

Our recommendations suggest an overarching need for adherence to CONSORT guidelines, a consensus taxonomy illuminating neck pain characterization, prognostic indicators, and diagnostic criteria as well as a core set of trial outcomes. Innovative trial design could lead to a more accurate and efficient understanding of the merits of various therapies. As the evidence emerges, studies of KT can inform us how it will impact clinical actions.

Concurrent validation of the DASH and the QuickDASH in comparison to neck-specific scales in patients with neck pain

STUDY DESIGN

Concurrent validity study.

OBJECTIVE

To examine the validity of the Disabilities of Arm, Shoulder, and Hand (DASH) and the QuickDASH in patients with neck pain in comparison with the Neck Disability Index (NDI), the Cervical Spine Outcome Questionnaire (CSOQ), and the Visual Analogue Scale (VAS) for pain. To examine the agreement between the DASH and the QuickDASH and assess whether the QuickDASH can be used instead of full DASH in patients with neck pain.

SUMMARY OF BACKGROUND DATA

NDI is commonly used for measuring neck-related disability in patients with neck pain; but it does not offer to assess the potential for upper extremity disability.

METHODS

Patients with neck pain (N = 66) were assessed on one occasion. They completed the NDI and the DASH, and 42 of them completed the CSOQ. The QuickDASH scores were extracted from the full DASH. Correlations were tested between both versions of the DASH, the NDI, the subscales of the CSOQ, and the VAS-pain. Correlations were considered high with r >0.75. Ranked item difficulty analysis was performed for both versions of the DASH and the NDI. The Bland and Altman technique was used to assess the nature and size of score differences between 2 versions of the DASH.

RESULTS

Item ranks identified the DASH and the QuickDASH items to be as problematic to patients as NDI items. Both the versions of DASH showed high correlation (0.82-0.83) with the NDI and moderate correlation with the CSOQ and VAS-pain. The mean QuickDASH scores were higher (2.77 points) compared to the full DASH.

CONCLUSION

Though the QuickDASH reported higher disability compared to the full DASH in this patient group, high correlation between the QuickDASH and the NDI and agreement between both versions of the DASH provide preliminary evidence that the QuickDASH can be used to measure upper extremity disability in patients with neck pain.