Knowledge to action: a challenge for neck pain treatment.

SYNOPSIS: For clinicians, systematic reviews can enhance incorporation into practice of the large volumes of information emerging from research on effectiveness and risks. But we believe that these reviews are most useful with simplified tools to facilitate translation of this knowledge into practice. We provide a "Neck Care Tool Kit" that gives a diagrammatic approach to prioritizing intervention. The evidence from a series of 11 systematic reviews by the Cervical Overview Group is depicted in decision flow-charts and tables to enhance clinical interpretation of the overview findings. On simple visual inspection of symbols in a table, the reader can establish where there is evidence of benefit or no benefit, the strength of the recommendation, and if these data represent short- or long-term findings. Where possible, we guide clinicians to dosage of specific treatment methods. There is no consensus as to which outcome measures to prioritize among the large number in use. This clinical commentary guides clinicians to view the evidence in enough detail to integrate it into their clinical practice environment. We conclude by delineating research gaps and proposing future research directions. LEVEL OF EVIDENCE: Therapy, level 5.

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

SYNOPSIS: Neck pain is a common and episodic condition that is treated using a spectrum of interventions known to be moderately effective but is associated with a significant incidence of chronic pain. Recently, there has been increased focus on defining biological aspects of neck pain. Studies have indicated that neurophysiological, biomechanical, and motor control abnormalities are present and may be useful either in prognosis or classification. We review some of these findings in the context of our own work defining biological markers that may form the basis for clinical tests that can be used for prognosis, classification, or outcome evaluation in patients with neck pain. We have identified abnormalities in neurophysiology using quantitative sensory testing (vibration, touch, and current perception) and response to cold provocation that are related to neck disability. We have identified altered muscle biochemistry by measuring circulating muscle proteins in a lumbar surgery model and are now applying those methods to whiplash injury. We have incorporated capnography into treatment to address central physiological changes present in some patients by monitoring and training CO2 levels. We have developed an innovative new test, the Neck Walk Index, that captures abnormal control of head movement during slow gait as a means of differentiating patients with neck pain from either unaffected controls or individuals with other pathologies. We have used time-varying 3-dimensional joint orientation kinematics to assess deficits in motor control during an upper extremity reach task, the results showing that poor coordination and control of the shoulder girdle leads to shoulder guarding and inconsistencies in elbow joint movement. Despite some promising early results, future research is needed to determine how these measures help clinicians to diagnose, evaluate, and forecast future outcome for patients who present with neck pain. LEVEL OF EVIDENCE: Diagnosis, level 5.

Vitamin D for the treatment of multiple sclerosis: a meta-analysis.

OBJECTIVE: There is an association between latitude, relative vitamin D deficiency and risk of multiple sclerosis (MS), and an association between vitamin D and disease progression. We have performed a meta-analysis with the aim of investigating the role of therapeutic vitamin D in MS. METHODS: A systematic search of databases was performed to identify clinical trials assessing vitamin D in patients with relapsing-remitting MS. Studies were selected based on inclusion and exclusion criteria. Analysis was performed using RevMan 5.3 software. RESULTS: Twelve studies involving 950 patients were included in the final analysis. Studies were divided into four groups because of heterogeneity in study design. Studies were judged to be at low or unclear risk of bias, except in three studies, and this was confirmed by funnel plots. No statistically significant difference was seen for any of the outcome measures. There were non-significant trends in favour of vitamin D for all outcome measures, particularly when only placebo-controlled studies were included. Dose comparison studies showed a significant increase in annualised relapse rate (mean difference 0.15 [95%CI 0.01-0.30]) and non-significant trends of increased Expanded Disability Status Scale and gadolinium-enhancing lesions for the higher-dose arms. CONCLUSION: These findings suggest that vitamin D supplementation may have a therapeutic role in the treatment of MS. However, there is uncertainty with regard to the most appropriate dose, with high doses potentially being associated with worse outcomes. There remains the need for further well-performed randomised, dose-ranging, placebo-controlled trials of vitamin D in MS.

Reliability of the long-range power-law correlations obtained from the bilateral stride intervals in asymptomatic volunteers whilst treadmill walking.

Stride intervals measured during steady-state walking are irregular. These stride interval fluctuations are not random but exhibit long-range power-law correlation (alpha) such that a given stride interval is 'influenced' by earlier variations in the stride intervals. To estimate alpha, one requires a minute long sequence of right or left side stride interval data. However, to obtain a reliable alpha point estimate, the minimal stride sequence length is unknown. Additionally, it is unknown if the right and left side alpha are equivalent. In this study, the within-day and the right and left side reliabilities of alpha point estimates were examined in 23 volunteers performing three 8-min treadmill walks. In addition, eight volunteers were retested on three additional days to estimate between-day reliability. The standard error of measurement (S.E.M.) and the within- and between-day intraclass correlation (ICC) values, and their 95% confidence intervals, each calculated using the combined right and left leg 8-min alpha estimates were acceptable [0.047 (0.044-0.051); 0.914 (0.882-0.932) and 0.769 (0.689-0.815), respectively]. The left alpha (0.688 +/- 0.93) was greater than the right alpha (0.664 +/- 0.094), albeit this finding was underpowered (0.55). The alpha point estimates obtained from the full 8-min walks provided minimal S.E.M. and maximal within- and between-day ICCs. However, the minimal S.E.M. was statistically indistinguishable from the 6- and 7-min walk durations and all of the within-day and between-day ICCs were similar except for the 3- and 8-min between-day ICCs. This study suggests that data from four 3 min, three 6 min or two 8 min walk duration trials provide reliable alpha point estimates from a short series of short treadmill walks.

The impact of neurodynamic testing on the perception of experimentally induced muscle pain.

Neurodynamic tests such as the straight leg raising (SLR) and slump test are frequently used for assessment of mechanosensitivity of neural tissues. However, there is ongoing debate in the literature regarding the contributions of neural and non-neural tissues to the elicited symptoms because many structures are affected by these tests. Sensitizing manoeuvres are limb or spinal movements added to neurodynamic tests, which aim to identify the origin of the symptoms by preferentially loading or unloading neural structures. A prerequisite for the use of sensitizing manoeuvres to identify neural involvement is that the addition of sensitizing manoeuvres has no impact on pain perception when the origin of the pain is non-neural. In this study, experimental muscle pain was induced by injection of hypertonic saline in tibialis anterior or soleus in 25 asymptomatic, naive volunteers. A first experiment investigated the impact of hip adduction, abduction, medial and lateral rotation in the SLR position. In a second experiment, the different stages of the slump test were examined. The intensity and area of experimentally induced muscle pain did not increase when sensitizing manoeuvres were added to the SLR or throughout the successive stages of the slump test. The findings of this study lend support to the validity of the use of sensitizing manoeuvres during neurodynamic testing.

Breathing evaluation and retraining as an adjunct to manual therapy.

Back and neck pain are extremely common reasons for patients seeking manual therapy treatment. Epidemiological evidence supports a link between breathing difficulties and back pain. Since trunk muscles perform both postural and breathing functions, it is theorized that disruption in one function can negatively impact the other. Altered breathing mechanics can change respiratory chemistry and therefore pH causing smooth muscle constriction, altered electrolyte balance and decreased tissue oxygenation. These changes can profoundly impact any body system. Increased excitability in the muscular and nervous systems may be most relevant to a manual therapist. Respiratory function can be tested via capnography which measures CO2 at the end of exhale known as End Tidal CO2 (ETCO2). ETCO2 closely reflects arterial CO2 in people with normal cardiopulmonary function. A case series of twenty nine outpatients with neck or back pain who had plateaued with manual therapy and exercise were identified all of whom were found to have low ETCO2. Breathing retraining improved ETCO2, pain and function in all patients with 93% achieving at least a clinically important change in either pain or function. Screening for breathing dysfunction using capnography may improve patient outcomes in those patients where manual therapy, exercise and education do not provide full resolution of symptoms.

Breathing evaluation and retraining in manual therapy.

Patients with back and neck pain commonly seek body work yet there are some who do not experience full recovery with the typical tool kit of manual therapy, education and exercise, suggesting the need for additional clinical approaches. Epidemiological literature linking back pain with breathing difficulties suggests one possibility. Altered motor control associated with back and neck pain appears to negatively impact breathing mechanics, which may have negative consequences on respiratory chemistry. Changes in respiratory chemistry can have profound effects on body system function. Altered breathing has been recognized for many years as a potential source of a wide variety of unexplained symptoms. There has been controversy around accurate diagnosis with symptoms and questionnaires often being the only methods used. Capnography, which is routinely used in critical care settings, offers an objective measure of respiratory chemistry providing physiological data on which to base a diagnosis of poor breathing. Capnography can also be used as biofeedback to guide breathing retraining.