Implementation of a novel stratified PAthway of CarE for common musculoskeletal (MSK) conditions in primary care: protocol for a multicentre pragmatic randomised controlled trial (the PACE MSK trial)

Introduction

Musculoskeletal (MSK) conditions constitute the highest burden of disease globally, with healthcare services often utilised inappropriately and overburdened. The aim of this trial is to evaluate the effectiveness of a novel clinical PAthway of CarE programme (PACE programme), where care is provided based on people’s risk of poor outcome.

Methods and analysis

Multicentre randomised controlled trial. 716 people with MSK conditions (low back pain, neck pain or knee osteoarthritis) will be recruited in primary care. They will be stratified for risk of a poor outcome (low risk/high risk) using the Short Form Örebro Musculoskeletal Pain Screening Questionnaire (SF-ÖMSPQ) then randomised to usual care (n=358) or the PACE programme (n=358). Participants at low risk in the PACE programme will receive up to 3 sessions of guideline based care from their primary healthcare professional (HCP) supported by a custom designed website (mypainhub.com). Those at high risk will be referred to an allied health MSK specialist who will conduct a comprehensive patient-centred assessment then liaise with the primary HCP to determine further care. Primary outcome (SF 12-item PCS) and secondary outcomes (eg, pain self-efficacy, psychological health) will be collected at baseline, 3, 6 and 12 months. Cost-effectiveness will be measured as cost per quality-adjusted life-year gained. Health economic analysis will include direct and indirect costs. Analyses will be conducted on an intention-to-treat basis. Primary and secondary outcomes will be analysed independently, using generalised linear models. Qualitative and mixed-methods studies embedded within the trial will evaluate patient experience, health professional practice and interprofessional collaboration.

Ethics and dissemination

Ethics approval has been received from the following Human Research Ethics Committees: The University of Sydney (2018/926), The University of Queensland (2019000700/2018/926), University of Melbourne (1954239), Curtin University (HRE2019-0263) and Northern Sydney Local Health District (2019/ETH03632). Dissemination of findings will occur via peer-reviewed publications, conference presentations and social media.

Trial registration number

ACTRN12619000871145.

Outcome measures for assessing the effectiveness of non-pharmacological interventions in frequent episodic or chronic migraine: a Delphi study

OBJECTIVES

The aim of this Delphi survey was to establish an international consensus on the most useful outcome measures for research on the effectiveness of non-pharmacological interventions for migraine. This is important, since guidelines for pharmacological trials recommend measuring the frequency of headaches with 50% reduction considered a clinically meaningful effect. It is unclear whether the same recommendations apply to complementary (or adjunct) non-pharmacological approaches, whether the same cut-off levels need to be considered for effectiveness when used as an adjunct or stand-alone intervention, and what is meaningful to patients.

SETTING

University-initiated international survey.

PARTICIPANTS

The expert panel was chosen based on publications on non-pharmacological interventions in migraine populations and from personal contacts. 35 eligible researchers were contacted, 12 agreed to participate and 10 completed all 3 rounds of the survey. To further explore how migraine patients viewed potential outcome measures, four migraine patients were interviewed and presented with the same measurement tools as the researchers.

PROCEDURES

The initial Delphi round was based on a systematic search of the literature for outcome measures used in non-pharmacological interventions for headache. Suggested outcome measures were rated by each expert, blinded towards the other members of the panel, for its usefulness on a 5-point Likert scale ranging from definitely not useful to extremely useful. Results were combined using median values and IQRs. Tools rated overall as definitely or probably not useful were excluded from subsequent rounds. Experts further suggested additional outcome measures that were presented to the panel in subsequent rounds. Additionally, experts were asked to rank the most useful tools and provide information on feasible cut-off levels for effectiveness for the three highest ranked tools.

RESULTS

Results suggest the use of the Migraine Disability Assessment (MIDAS), Headache Impact Test (HIT-6) and headache frequency as primary outcome measures. Patient experts suggested the inclusion of a measure of quality of life and evaluation of associated symptoms and fear of attacks.

CONCLUSIONS

Recommendations are for the use of the MIDAS, the HIT-6 and headache frequency, in combination with an outcome measure for quality of life. Associated symptoms and fear of attacks should also be considered as secondary outcomes, if relevant for the individual target population. The cut-off level for effectiveness should be lower for non-pharmacological interventions, especially when used as an adjunct to medication.

TRIAL REGISTRATION NUMBER

German Register of Clinical Trials (DRKS00011777).

Enhancing the vocational outcomes of people with chronic disabilities caused by a musculoskeletal condition: development and evaluation of content of self-management training modules

BACKGROUND

No self-management interventions have been developed to empower those chronically disabled by a musculoskeletal condition to find and/or remain at work.

OBJECTIVE

Developand evaluate the content of two self-management training modules to improve vocational outcomes for those with chronic musculoskeletal disorders.

METHODS

Stanford University's Chronic Disease Self-Management Program provided the framework for the new modules. Focus groups with the eightpersons with workdisabilities and concept-mapping sessions with the 12 experienced vocational rehabilitation professionals were conducted to identify factors and themes contributing to workers remaining/returning to work post-injury. Five experienced self-management trainers reviewed the modules for consistency with self-management principles.

RESULTS

Two new self-management modules: 'Navigating the System' and 'Managing a Return to Work' were developed.The persons with work disabilitiesgenerated four themes: accepting and coping with injury; skills to manage pain and life; positive working relationships and, re-inventing self, whereas the rehabilitation professionals identified three themes:communication and support of others; the injured worker's abilities and resources, and knowledge and education.

CONCLUSIONS

Anintervention developed to enhance self-management skills and facilitate positive vocational outcomes of those seeking to return to work post-injury was confirmed as relevant by persons with work disabilities, rehabilitation professionals and self-management trainers.

Cervical Musculoskeletal Impairment in Frequent Intermittent Headache. Part 1: Subjects With Single Headaches

Musculoskeletal disorders are considered the underlying cause of cervicogenic headache, but neck pain is commonly associated with migraine and tension-type headaches. This study tested musculoskeletal function in these headache types. From a group of 196 community-based volunteers with headache, 73 had a single headache classifiable as migraine ( n = 22), tension-type ( n = 33) or cervicogenic headache ( n = 18); 57 subjects acted as controls. Range of movement, manual examination of cervical segments, cervical flexor and extensor strength, the cranio-cervical flexion test (CCFT), cross-sectional area of selected extensor muscles at C2 (ultrasound imaging) and cervical kinaesthetic sense were measured by a blinded examiner. In all but one measure (kinaesthetic sense), the cervicogenic headache group were significantly different from the migraine, tension-type headache and control groups (all P < 0.001). A dicriminant function analysis revealed that collectively, restricted movement, in association with palpable upper cervical joint dysfunction and impairment in the CCFT, had 100% sensitivity and 94% specificity to identify cervicogenic headache. There was no evidence that the cervical musculoskeletal impairments assessed in this study were present in the migraine and tension-type headache groups. Further research is required to validate the predictive capacity of this pattern of impairment to differentially diagnose cervicogenic headache.

Cervical Musculoskeletal Impairment in Frequent Intermittent Headache. Part 2: Subjects With Concurrent Headache Types

A pattern of musculoskeletal impairment inclusive of upper cervical joint dysfunction, combined with restricted cervical motion and impairment in muscle function, has been shown to differentiate cervicogenic headache from migraine and tension-type headache when reported as single headaches. It was questioned whether this pattern of cervical musculoskeletal impairment could discriminate a cervicogenic headache as one type of headache in more complex situations when persons report two or more headaches. Subjects with two or more concurrent frequent intermittent headache types ( n = 108) and 57 non-headache control subjects were assessed using a set of physical measures for the cervical musculoskeletal system. Discriminant and cluster analyses revealed that 36 subjects had the pattern of musculoskeletal impairment consistent with cervicogenic headache. Isolated features of physical impairment, e.g. range of movement (cervical extension), were not helpful in differentiating cervicogenic headache. There were no differences in measures of cervical musculoskeletal impairment undertaken in this study between control subjects and those classified with non-cervicogenic headaches.

Inter-and intra-tester reliability of a battery of cervical movement control dysfunction tests

BACKGROUND

Apart from the cranio-cervical flexion test and the deep neck flexor endurance test, evidence related to reliability of cervical movement control dysfunction tests is lacking.

OBJECTIVES

This study investigated the inter- and intra-tester reliability of a battery of cervical movement control dysfunction tests and the effect of clinician experience on reliability in 15 patients with chronic neck pain and 17 non-neck pain controls. In addition, it explored whether impaired performance on this battery of tests was more frequently observed in the neck pain group.

DESIGN

Inter and intra-tester reliability study.

METHOD

Participants were videotaped while performing a battery of nine active cervical movement control dysfunction tests. Two physiotherapists, with different levels of experience, independently rated all tests on two occasions two weeks apart. They were masked to participants' neck pain or non-neck pain status.

RESULTS

Inter-tester reliability for the complete battery of tests was substantial (κ = 0.69; 95% CI: 0.62, 0.76). Intra-rater reliability values for the expert (κ = 0.86; 95% CI: 0.79, 0.92) and novice (κ = 0.76; 95% confidence intervals (CI): 0.68, 0.84) were overall comparable suggesting that novices can achieve good accuracy with the battery of tests if trained. The frequency of impaired performances in cervical movement control dysfunction tests was low and comparable between groups. Only two tests achieved a greater number of impaired ratings in the patient group.

CONCLUSIONS

Although reliable, further research in larger neck pain populations is required to explore this battery of tests, in order to establish their diagnostic accuracy for identifying clinically relevant cervical movement control dysfunction.

Preliminary evaluation of dorsal muscle activity during resisted cervical extension in patients with longstanding pain and disability following anterior cervical decompression and fusion surgery

OBJECTIVES

To compare mechanical activity (deformation and deformation rate) of the dorsal neck muscles between individuals with longstanding symptoms after anterior cervical decompression and fusion (ACDF) surgery and healthy controls.

DESIGN

Preliminary cross-sectional study.

SETTING

Neurosurgery clinic.

PARTICIPANTS

Ten individuals {mean age 60 [standard deviation (SD) 7.1]} who had undergone ACDF surgery 10 to 13 years previously and 10 healthy age- and sex-matched controls.

MAIN OUTCOMES

Mechanical activity of the different layers of dorsal neck muscles, measured at the C4 segment using ultrasonography (speckle tracking analysis) during a standardised, resisted cervical extension task.

RESULTS

A significant group×muscle interaction was found for muscle deformation (P<0.03) but not for deformation rate (P>0.79). The ACDF group showed significantly less deformation of the semispinalis capitis muscle during the extension task compared with the control group [mean 3.12 (SD 2.06) and 6.64 (SD 4.17), respectively; mean difference 3.34 (95% confidence interval -0.54 to 7.21)].

CONCLUSIONS

As the semispinalis capitis muscle is a powerful neck extensor, the finding of altered activation following ACDF surgery lends support to the inclusion of exercise to train neck muscle performance in the management of these patients.

Interactive effects from self-reported physical and psychosocial factors in the workplace on neck pain and disability in female office workers

This study explored the interaction between physical and psychosocial factors in the workplace on neck pain and disability in female computer users. A self-report survey was used to collect data on physical risk factors (monitor location, duration of time spent using the keyboard and mouse) and psychosocial domains (as assessed by the Job Content Questionnaire). The neck disability index was the outcome measure. Interactions among the physical and psychosocial factors were examined in analysis of covariance. High supervisor support, decision authority and skill discretion protect against the negative impact of (1) time spent on computer-based tasks, (2) non-optimal placement of the computer monitor and (3) long duration of mouse use. Office workers with greater neck pain experience a combination of high physical and low psychosocial stressors at work. Prevention and intervention strategies that target both sets of risk factors are likely to be more successful than single intervention programmes. STATEMENT OF RELEVANCE: The results of this study demonstrate that the interaction of physical and psychosocial factors in the workplace has a stronger association with neck pain and disability than the presence of either factor alone. This finding has important implications for strategies aimed at the prevention of musculoskeletal problems in office workers.

Neuromuscular efficiency of the sternocleidomastoid and anterior scalene muscles in patients with chronic neck pain

PURPOSE

This study compared the neuromuscular efficiency (NME) of the sternocleidomastoid (SCM) and anterior scalene (AS) muscles between 20 chronic neck pain patients and 20 asymptomatic controls.

METHOD

Myoelectric signals were recorded from the sternal head of SCM and the AS muscles as subjects performed sub-maximal isometric cervical flexion contractions at 25 and 50% of the maximum voluntary contraction (MVC). The NME was calculated as the ratio between MVC and the corresponding average rectified value of the EMG signal. Ultrasonography was used to measure subcutaneous tissue thickness over the SCM and AS to ensure that differences did not exist between groups.

RESULTS

For both the SCM and AS muscles, NME was shown to be significantly reduced in patients with neck pain at 25% MVC (p<0.05). Subcutaneous tissue thickness over the SCM and AS muscles was not different between groups.

CONCLUSIONS

Reduced NME in the superficial cervical flexor muscles in patients with neck pain may be a measurable altered muscle strategy for dysfunction in other muscles. This aberrant pattern of muscle activation appears to be most evident under conditions of low load. NME, when measured at 25% MVC, may be a useful objective measure for future investigation of muscle dysfunction in patients with neck pain.

Conservative treatments for tennis elbow do subgroups of patients respond differently?

OBJECTIVES

To determine if subgroups of patients with tennis elbow respond differently in treatment.

METHODS

This study used individual patient data (n = 383) from two randomized controlled trials that investigated a wait-and-see policy, corticosteroid injections and physiotherapy. Common outcome measures were: pain severity, global improvement, severity assessed by a blinded assessor, elbow disability and pain free grip strength. Subgroup analyses for previous history of elbow pain, baseline pain severity, duration of the current episode and employment status were performed at 6 and 52 weeks.

RESULTS

Patients' age, previous elbow symptoms and baseline pain severity were similar between trials, but other characteristics differed between trial populations. Based on individual patient data from both trials, we found that corticosteroid injections were statistically and clinically superior at 6 weeks, but significantly worse at 52 weeks compared with both wait-and-see and physiotherapy. Subgroup effects were scarce and small. Patients with higher baseline pain score showed less benefit on pain outcomes between physiotherapy and a wait-and-see policy at 6 weeks. It also appeared that non-manual workers who had an injection were the only work subgroup to follow the general trend that injections were significantly worse than a wait-and-see policy on global improvement at 52 weeks.

CONCLUSION

The treatment outcomes were largely similar between trials and not different between most subgroups studied. In tennis elbow, it would appear that patient characteristics play only a small role in predicting treatment outcomes, which supports the generalizability of individual trial results.

Alterations in cervical muscle activity in functional and stressful tasks in female office workers with neck pain

This study determined differences between computer workers with varying levels of neck pain in terms of work stressors, employee strain, electromyography (EMG) amplitude and heart rate response to various tasks. Participants included 85 workers (33, no pain; 38, mild pain; 14, moderate pain) and 22 non-working controls. Work stressors evaluated were job demands, decision authority, and social support. Heart rate was recorded during three tasks: copy-typing, typing with superimposed stress and a colour word task. Measures included electromyography signals from the sternocleidomastoid (SCM), anterior scalene (AS), cervical extensor (CE) and upper trapezius (UT) muscles bilaterally. Results showed no difference between groups in work stressors or employee strain measures. Workers with and without pain had higher measured levels of EMG amplitude in SCM, AS and CE muscles during the tasks than controls (all P < 0.02). In workers with neck pain, the UT had difficulty in switching off on completion of tasks compared with controls and workers without pain. There was an increase in heart rate, perceived tension and pain and decrease in accuracy for all groups during the stressful tasks with symptomatic workers producing more typing errors than controls and workers without pain. These findings suggest an altered muscle recruitment pattern in the neck flexor and extensor muscles. Whether this is a consequence or source of the musculoskeletal disorder cannot be determined from this study. It is possible that workers currently without symptoms may be at risk of developing a musculoskeletal disorder.

Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash? – A preliminary RCT

Patients with chronic whiplash associated disorders present with varied sensory, motor and psychological features. In this first instance it was questioned whether a multimodal program of physical therapies was an appropriate management to be broadly prescribed for these patients when it was known that some would have sensory features suggestive of a notable pain syndrome. A randomised controlled trial was conducted with 71 participants with persistent neck pain following a motor vehicle crash to explore this question. Participants were randomly allocated to receive either a multimodal physiotherapy program (MPT) or a self-management program (SMP) (advice and exercise). In the randomisation process, participants were stratified according to the presence or not of widespread mechanical or cold hyperalgesia. The intervention period was 10 weeks and outcomes were assessed immediately following treatment. Even with the presence of sensory hypersensitivity in 72.5% of subjects, both groups reported some relief of neck pain and disability (Neck Disability Index) and it was superior in the group receiving multimodal physiotherapy (p=0.04). Post-hoc observations however suggested that relief was marginal in the subgroup with both widespread mechanical and cold hyperalgesia. Further research is required to test the validity of this sub-group observation and to test the effect of the intervention in the long term.

Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache

Persistent intermittent headache is a common disorder and is often accompanied by neck aching or stiffness, which could infer a cervical contribution to headache. However, the incidence of cervicogenic headache is estimated to be 14-18% of all chronic headaches, highlighting the need for clear criterion of cervical musculoskeletal impairment to identify cervicogenic headache sufferers who may benefit from treatments such as manual therapy. This study examined the presence of cervical musculoskeletal impairment in 77 subjects, 27 with cervicogenic headache, 25 with migraine with aura and 25 control subjects. Assessments included a photographic measure of posture, range of movement, cervical manual examination, pressure pain thresholds, muscle length, performance in the cranio-cervical flexion test and cervical kinaesthetic sense. The results indicated that when compared to the migraine with aura and control groups who scored similarly in the tests, the cervicogenic headache group had less range of cervical flexion/extension (P=0.048) and significantly higher incidences of painful upper cervical joint dysfunction assessed by manual examination (all P<0.05) and muscle tightness (P<0.05). Sternocleidomastoid normalized EMG values were higher in the latter three stages of the cranio-cervical flexion test although they failed to reach significance. There were no between group differences for other measures. A discriminant analysis revealed that manual examination could discriminate the cervicogenic headache group from the other subjects (migraine with aura and control subjects combined) with an 80% sensitivity.

An endurance-strength training regime is effective in reducing myoelectric manifestations of cervical flexor muscle fatigue in females with chronic neck pain

OBJECTIVE

The purpose of this study was to investigate whether an endurance-strength training program is effective in reducing myoelectric manifestations of sternocleidomastoid (SCM) and anterior scalene (AS) muscle fatigue which have been found to be greater in people with chronic neck pain.

METHODS

Fifty-eight female patients with chronic non-severe neck pain were randomized into one of two 6-week exercise intervention groups: an endurance-strength training regime for the cervical flexor muscles or a referent exercise intervention involving low load retraining of the cranio-cervical flexor muscles. The primary outcomes were a change in maximum voluntary contraction (MVC) force and change of the initial value and rate of change of the mean frequency, average rectified value and conduction velocity detected from the SCM and AS muscles during sub-maximal isometric cervical flexion contractions at 50, 25 and 10% MVC.

RESULTS

At the 7th week follow-up assessment, the endurance-strength training group revealed a significant increase in MVC force and a reduction in the estimates of the initial value and rate of change of the mean frequency for both the SCM and AS muscles (P<0.05). Both exercise groups reported a reduced average intensity of neck pain and reduced neck disability index score (P<0.05).

CONCLUSIONS

An endurance-strength exercise regime for the cervical flexor muscles is effective in reducing myoelectric manifestations of superficial cervical flexor muscle fatigue as well as increasing cervical flexion strength in a group of patients with chronic non-severe neck pain.

SIGNIFICANCE

Provision of load to challenge the neck flexor muscles is required to reduce the fatigability of the SCM and AS muscles in people with neck pain. Improvements in cervical muscle strength and reduced fatigability may be responsible for the reported efficacy with this type of exercise program.

Further evaluation of an EMG technique for assessment of the deep cervical flexor muscles

A novel surface electromyographic (EMG) technique was recently described for the detection of deep cervical flexor muscle activity. Further investigation of this technique is warranted to ensure EMG activity from neighbouring muscles is not markedly influencing the signals recorded. This study compared deep cervical flexor (DCF) muscle activity with the activity of surrounding neck and jaw muscles during various anatomical movements of the neck and jaw in 10 volunteer subjects. DCF EMG activity was recorded with custom electrodes inserted via the nose and fixed by suction to the posterior mucosa of the oropharynx. Surface electrodes were placed over the sternocleidomastoid, anterior scalene, masseter and suprahyoid muscles. Positioned in supine, subjects performed isometric cranio-cervical flexion, cervical flexion, right and left cervical rotation, jaw clench and resisted jaw opening. Across all movements examined, EMG amplitude of the DCF muscles was greatest during neck movements that would require activity of the DCF muscles, particularly during cranio-cervical flexion, their primary anatomical action. The actions of jaw clench and resisted jaw opening demonstrated significantly less DCF EMG activity than the cranio-cervical flexion action (p<0.05). Across all other movements, the neighbouring neck and jaw muscles demonstrated greatest EMG amplitude during their respective primary anatomical actions, which occurred in the absence of increased EMG amplitude recorded from the DCF muscles. The finding of substantial EMG activity of the DCF muscles only during neck actions that would require their activity, particularly cranio-cervical flexion, and not during actions involving the jaw, provide further assurance that the majority of myoelectric signals detected from the nasopharyngeal electrode are from the DCF muscles.

Spatio-temporal evaluation of neck muscle activation during postural perturbations in healthy subjects

The purpose of this study was to examine the spatio-temporal activation of the sternocleidomastoid (SCM) and cervical extensor (CE) muscles with respect to the deltoid muscle onset during rapid voluntary upper limb movement in healthy volunteers. The repeatability and reliability of the spatio-temporal aspects of the myoelectric signals were also examined. Ten subjects performed bilateral and unilateral rapid upper limb flexion, abduction and extension in response to a visual stimulus. EMG onsets and normalised root mean square (nRMS) values were calculated for the SCM and CE muscles. Subjects attended three testing sessions over non-consecutive days allowing the repeatability and reliability of these measures to be assessed. The SCM and CE muscles demonstrated feed-forward activation (activation within 50 ms of deltoid onset) during rapid arm movements in all directions. The sequence and magnitude of neck muscle activation displayed directional specificity, however, the neck flexor and extensor muscles displayed co-activation during all perturbations. EMG onsets demonstrated high repeatability in terms of repeated measure precision (nSEM in the range 1.9-5.7%). This was less evident for the repeatability of nRMS values. The results of this study provide a greater understanding of cervical neuromotor control strategies. During bilateral and unilateral upper limb perturbations, the SCM and CE muscles demonstrate feed-forward co-activation. It seems apparent that feed-forward activation of neck muscles is a mechanism necessary to achieve stability for the visual and vestibular systems, whilst ensuring stabilisation and protection of the cervical spine.

Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients

There has been little investigation into whether or not differences exist in the nature of physical impairment associated with neck pain of whiplash and insidious origin. This study examined the neck flexor synergy during performance of the cranio-cervical flexion test, a test targeting the action of the deep neck flexors. Seventy-five volunteer subjects participated in this study and were equally divided between Group 1, asymptomatic control subjects, Group 2, subjects with insidious onset neck pain and Group 3, subjects with neck pain following a whiplash injury. The cranio-cervical flexion test was performed in five progressive stages of increasing cranio-cervical flexion range. Subjects' performance was guided by feedback from a pressure sensor inserted behind the neck which monitored the slight flattening of the cervical lordosis which occurs with the contraction of longus colli. Myoelectric signals (EMG) were detected from the muscles during performance of the test. The results indicated that both the insidious onset neck pain and whiplash groups had higher measures of EMG signal amplitude (normalized root mean square) in the sternocleidomastoid during each stage of the test compared to the control subjects (all P<0.05) and had significantly greater shortfalls from the pressure targets in the test stages (P<0.05). No significant differences were evident between the neck pain groups in either parameter indicating that this physical impairment in the neck flexor synergy is common to neck pain of both whiplash and insidious origin.

Recent advances in therapeutic exercise for the neck: implications for patients with head and neck pain

There have been recent advances in the rehabilitation of the muscles that control the head and neck. These advances are based on evidence of specific neck muscle dysfunction in individuals with persistent head and neck pain. Traditional rehabilitation strategies have focused predominantly on muscle strength and endurance under high loads. New evidence suggests that in people with neck pain there are underlying neuromuscular problems that may require more immediate attention and may not be adequately addressed by simple strength and high-load endurance retraining. Evidence of altered coordination between the deep and superficial neck muscles, greater neck muscle fatigue under sustained low loads, and deficits in kinaesthetic sense have been identified in symptomatic individuals. There is evidence to indicate that addressing these muscle control problems, with specific gentle exercise strategies, results in a reduction in neck pain and associated symptoms.

Feedforward activity of the cervical flexor muscles during voluntary arm movements is delayed in chronic neck pain

The objective of this study was to compare onset of deep and superficial cervical flexor muscle activity during rapid, unilateral arm movements between ten patients with chronic neck pain and 12 control subjects. Deep cervical flexor (DCF) electromyographic activity (EMG) was recorded with custom electrodes inserted via the nose and fixed by suction to the posterior mucosa of the oropharynx. Surface electrodes were placed over the sternocleidomastoid (SCM) and anterior scalene (AS) muscles. While standing, subjects flexed and extended the right arm in response to a visual stimulus. For the control group, activation of DCF, SCM and AS muscles occurred less than 50 ms after the onset of deltoid activity, which is consistent with feedforward control of the neck during arm flexion and extension. When subjects with a history of neck pain flexed the arm, the onsets of DCF and contralateral SCM and AS muscles were significantly delayed ( p<0.05). It is concluded that the delay in neck muscle activity associated with movement of the arm in patients with neck pain indicates a significant deficit in the automatic feedforward control of the cervical spine. As the deep cervical muscles are fundamentally important for support of the cervical lordosis and the cervical joints, change in the feedforward response may leave the cervical spine vulnerable to reactive forces from arm movement.

Measuring range of active cervical rotation in a position of full head flexion using the 3D Fastrak measurement system: an intra-tester reliability study

Most external assessments of cervical range of motion assess the upper and lower cervical regions simultaneously. This study investigated the within and between days reliability of the clinical method used to bias this movement to the upper cervical region, namely measuring rotation of the head and neck in a position of full cervical flexion. Measurements were made using the Fastrak measurement system and were conducted by one operator. Results indicated high levels of within and between days repeatability (range of ICC2,1 values: 0.85-0.95). The ranges of axial rotation to right and left, measured with the neck positioned in full flexion, were approximately 56% and 50%, respectively of total cervical rotation, which relates well to the proportional division of rotation in the upper and lower cervical regions. These results suggest that this method of measuring rotation would be appropriate for use in subject studies where movement dysfunction is present in the upper cervical region, such as those with cervicogenic headache.

Myoelectric manifestations of sternocleidomastoid and anterior scalene muscle fatigue in chronic neck pain patients

OBJECTIVE

This study compares myoelectric manifestations of fatigue of the sternocleidomastoid (SCM) and anterior scalene (AS) muscles between 10 chronic neck pain subjects and 10 normal matched controls.

METHODS

Surface electromyography (sEMG) signals were recorded from the sternal head of SCM and AS muscles bilaterally during sub-maximal isometric cervical flexion contractions at 25 and 50% of the maximum voluntary contraction (MVC). The mean frequency, average rectified value and conduction velocity of the sEMG signal were calculated to quantify myoelectric manifestations of muscle fatigue.

RESULTS

For both the SCM and AS muscles, the Mann-Whitney U test indicated that the initial value and slope of the mean frequency in neck pain patients were greater than in healthy subjects (P < 0.05). This was significant both at 25 and 50% of MVC.

CONCLUSIONS

These results suggest: (a) a predominance of type-II fibres in the neck pain patients and/or (b) greater fatigability of the superficial cervical flexors in neck pain patients. These results are in agreement with previous muscle biopsy studies in subjects with neck pain, which identified transformation of slow-twitch type-1 fibres to fast-twitch type-IIB fibres, as well as the clinical observation of reduced endurance in the cervical flexors in neck pain patients.

Cervicocephalic kinaesthesia: reliability of a new test approach

BACKGROUND AND PURPOSE

Relocating either the natural head posture (NHP) or predetermined points in range are clinical tests of impaired neck proprioception but memory might influence these tests. Three new tests, reasoned to be more challenging for the proprioceptive system, were developed. The objectives were to assess the reliability of all tests and whether the three new tests were more challenging for the proprioceptive system.

METHOD

A test-retest design was used to assess the reproducibility and errors of all five tests. Twenty asymptomatic volunteers were assessed a week apart, using an electromagnetic movement sensor system, the 3-Space Fastrak. A measure of error magnitude was used to detect kinaesthetic sensibility. Comparison of the means and their corresponding dispersion were analysed descriptively. The between-day intraclass correlation coefficients (ICCs) were calculated and plots of mean differences between days 1 and 2 were conducted to estimate test reliability. Multivariate analysis of variance (MANOVA) and least significant difference (LSD) pairwise comparisons were performed to compare the test accuracy between different target positions.

RESULTS

ICCs were between 0.35 and 0.9, but plotting the data modified the interpretation in some tests. Relocating a NHP was easier when the trunk was in a neutral position than when pre-rotated (error 2.46 degrees (+/- 0.2 degree) versus 5.95 degrees (+/- 0.7 degree). Relocating a 30 degrees rotation position (error 5.8 degrees (+/- 0.6 degree) and repeatedly moving through a target (error 4.82 degrees (+/- 0.7 degree) was also difficult.

CONCLUSIONS

The new tests were more challenging than relocating the NHP but the reliability of tests relocating uncommon positions was questionable.

Responses to a clinical test of mechanical provocation of nerve tissue in whiplash associated disorder

Involvement of nerve tissue may contribute to the persistence of pain following a whiplash injury. This study aimed to investigate responses to the brachial plexus provocation test (BPPT) in 156 subjects with chronic whiplash associated disorder (WAD) with and without associated arm pain and 95 asymptomatic control subjects. The range of elbow extension (ROM) and visual analogue scale (VAS) pain scores were measured. Subjects with chronic WAD demonstrated significantly less ROM and higher VAS scores with the BPPT than the asymptomatic subjects (P<0.001). These effects occurred bilaterally. Within the whiplash population, subjects whose arm pain was reproduced by the BPPT demonstrated significantly less ROM on both the symptomatic and asymptomatic sides when compared to the whiplash subjects whose arm pain was not reproduced by the BPPT (P=0.003) and significantly less ROM and higher VAS scores than those whiplash subjects with no arm pain (P=0.003, 0.01). Only the whiplash subjects whose arm pain was reproduced by the BPPT demonstrated differences between the symptomatic and asymptomatic sides. These generalized hyperalgesic responses to the BPPT support the hypothesis of central nervous system hypersensitivity as contributing to persistent pain experienced by WAD patients.

Location of innervation zones of sternocleidomastoid and scalene muscles--a basis for clinical and research electromyography applications

OBJECTIVES

Advances in surface electromyography (sEMG) techniques provide a clear indication that refinement of electrode location relative to innervation zones (IZ) is required in order to optimise the accuracy, relevance and repeatability of the sEMG signals. The aim of this study was to identify the IZ for the sternocleidomastoid and anterior scalene muscles to provide guidelines for electrode positioning for future clinical and research applications.

METHODS

Eleven volunteer subjects participated in this study. Myoelectric signals were detected from the sternal and clavicular heads of the sternocleidomastoid and the anterior scalene muscles bilaterally using a linear array of 8 electrodes during isometric cervical flexion contractions. The signals were reviewed and the IZ(s) were identified, marked on the subjects' skin and measurements were obtained relative to selected anatomical landmarks.

RESULTS

The position of the IZ lay consistently around the mid-point or in the superior portion of the muscles studied.

CONCLUSIONS

Results suggest that electrodes should be positioned over the lower portion of the muscle and not the mid-point, which has been commonly used in previous studies. Recommendations for sensor placement on these muscles should assist investigators and clinicians to ensure improved validity in future sEMG applications.

The effect of musculoskeletal pain on motor activity and control

Aberrant movement patterns and postures are obvious to clinicians managing patients with musculoskeletal pain. However, some changes in motor function that occur in the presence of pain are less apparent. Clinical and basic science investigations have provided evidence of the effects of nociception on aspects of motor function. Both increases and decreases in muscle activity have been shown, along with alterations in neuronal control mechanisms, proprioception, and local muscle morphology. Various models have been proposed in an attempt to provide an explanation for some of these changes. These include the vicious cycle and pain adaptation models. Recent research has seen the emergence of a new model in which patterns of muscle activation and recruitment are altered in the presence of pain (neuromuscular activation model). These changes seem to particularly affect the ability of muscles to perform synergistic functions related to maintaining joint stability and control. These changes are believed to persist into the period of chronicity. This review shows current knowledge of the effect of musculoskeletal pain on the motor system and presents the various proposed models, in addition to other shown effects not covered by these models. The relevance of these models to both acute and chronic pain is considered. It is apparent that people experiencing musculoskeletal pain exhibit complex motor responses that may show some variation with the time course of the disorder.

Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity

Recent findings that spinal manual therapy (SMT) produces concurrent hypoalgesic and sympathoexcitatory effects have led to the proposal that SMT may exert its initial effects by activating descending inhibitory pathways from the dorsal periaqueductal gray area of the midbrain (dPAG). In addition to hypoalgesic and sympathoexcitatory effects, stimulation of the dPAG in animals has been shown to have a facilitatory effect on motor activity. This study sought to further investigate the proposal regarding SMT and the PAG by including a test of motor function in addition to the variables previously investigated. Using a condition randomised, placebo-controlled, double blind, repeated measures design, 30 subjects with mid to lower cervical spine pain of insidious onset participated in the study. The results indicated that the cervical mobilisation technique produced a hypoalgesic effect as revealed by increased pressure pain thresholds on the side of treatment (P=0.0001) and decreased resting visual analogue scale scores (P=0.049). The treatment technique also produced a sympathoexcitatory effect with an increase in skin conductance (P<0.002) and a decrease in skin temperature (P=<0.02). There was a decrease in superficial neck flexor muscle activity (P<0.0002) at the lower levels of a staged cranio-cervical flexion test. This could imply facilitation of the deep neck flexor muscles with a decreased need for co-activation of the superficial neck flexors. The combination of all findings would support the proposal that SMT may, at least initially, exert part of its influence via activation of the PAG.

Pressure pain thresholds of upper limb peripheral nerve trunks in asymptomatic subjects

BACKGROUND AND PURPOSE

Palpation of peripheral nerve trunks has been advocated as a method of assessing the presence of hyperalgesic nerve tissue as a contributing factor to pain syndromes in musculoskeletal disorders of the upper quadrant. This study investigated, in the first instance, the pressure pain thresholds of the median, radial and ulnar nerve trunks of the upper limb in healthy, asymptomatic subjects.

METHOD

Forty-five male and 50 female healthy volunteer subjects participated in this study which involved measurement of pressure pain thresholds by use of pressure algometry bilaterally over the three peripheral nerve trunks in the upper limbs.

RESULTS

Pressure pain thresholds were shown to be lowest in the median nerve (p = 0.001) and lower in female subjects (p = 0.001). Laterality (p = 0.077) or the age of the subject (p = 0.254) did not significantly influence results.

CONCLUSIONS

The study demonstrated differences in pressure pain thresholds in the three nerve trunks of the upper limb. These findings should be taken into account when interpreting the findings of nerve palpation in musculoskeletal upper quadrant disorders.

Mid-thoracic tenderness: a comparison of pressure pain threshold between spinal regions, in asymptomatic subjects

Palpation for tenderness forms an important part of the manual therapy assessment for musculoskeletal dysfunction. In conjunction with other testing procedures it assists in establishing the clinical diagnosis. Tenderness in the thoracic spine has been reported in the literature as a clinical feature in musculoskeletal conditions where pain and dysfunction are located primarily in the upper quadrant. This study aimed to establish whether pressure pain thresholds (PPTs) of the mid-thoracic region of asymptomatic subjects were naturally lower than those of the cervical and lumbar areas. A within-subject study design was used to examine PPT at four spinal levels C6, T4, T6, and L4 in 50 asymptomatic volunteers. Results showed significant (P<0.001) regional differences. PPT values increased in a caudal direction. The cervical region had the lowest PPT scores, that is was the most tender. Values increased in the thoracic region and were highest in the lumbar region. This study contributes to the normative data on spinal PPT values and demonstrates that mid-thoracic tenderness relative to the cervical spine is not a normal finding in asymptomatic subjects.