Assessment of exercise-induced hypoalgesia in chronic low back pain and potential associations with psychological factors and central sensitization symptoms: A case-control study.

INTRODUCTION: Exercise is the most recommended treatment for chronic low back pain (CLBP) and is effective in reducing pain, but the mechanisms underlying its effects remain poorly understood. Exercise-induced hypoalgesia (EIH) may play a role and is thought to be driven by central pain modulation mechanisms. However, EIH appears to be disrupted in many chronic pain conditions and its presence in people with CLBP remains unclear. As people suffering from chronic pain often exhibit psychological factors and central sensitization symptoms influencing pain perception, EIH might be associated with these factors. OBJECTIVE: The aim of this study is to compare the level of EIH between participants with and without CLBP following back and wrist exercises and to assess the associations between EIH, psychological factors, and symptoms of central sensitization (using the central sensitization inventory - CSI) in CLBP. METHOD: Twenty-eight participants with CLBP and 23 without pain were recruited. Pressure pain thresholds (PPT) were measured at 4 sites (2 bony sites = capitate, S1|2 muscle sites = wrist flexors, lumbar erector spinae) before and after each of two exercises (wrist flexion and lumbar extension). Exercise-induced hypoalgesia was defined as percent change in PPT from pre- to post-exercise. Participants with CLBP also completed questionnaires to measure psychological factors (e.g., kinesiophobia, catastrophizing, anxiety, and self-efficacy) and symptoms of central sensitization (CSI), and correlations with EIH were calculated. RESULTS: After wrist exercise, EIH measured at the muscle sites was lower in the CLBP group compared with the pain-free group (p = 0.047) but no differences were found at bony sites (p = 0.49). No significant differences for EIH were observed following back exercise at muscle sites (p = 0.14) or at bony sites (p = 0.65). Exercise-induced hypoalgesia was not correlated with any psychological factors or with the CSI score. CONCLUSION: The lower EIH following wrist exercises may represent an alteration in pain modulation control in CLBP. However, psychological factors and central sensitization symptoms may not explain the differences observed.

Region-specific Exercises vs General Exercises in the Management of Spinal and Peripheral Musculoskeletal Disorders: A Systematic Review With Meta-analyses of Randomized Controlled Trials.

OBJECTIVE: To compare the efficacy of region-specific exercises to general exercises approaches for adults with spinal or peripheral musculoskeletal disorders (MSKDs). DATA SOURCES: Electronic searches were conducted up to April 2020 in Medline, Embase, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health. STUDY SELECTION: Randomized control trials (RCTs) on the efficacy of region-specific exercises compared to general exercises approaches for adults with various MSKDs. DATA EXTRACTION: Mean differences and standardized mean differences were calculated using random-effects inverse variance modeling. Eighteen RCTs (n=1719) were included. Cohorts were composed of participants with chronic neck (n=313) or low back disorders (n=1096) and knee osteoarthritis (OA) (n=310). DATA SYNTHESIS: Based on low-quality evidence in the short-term and very low-quality in the mid- and long-term, there were no statistically significant differences between region-specific and general exercises in terms of pain and disability reductions for adults with spinal disorders or knee OA. Secondary analyses for pain reduction in the short-term for neck or low back disorders did not report any statistically significant differences according to very low- to low-quality of evidence. CONCLUSIONS: The difference in treatment effect remains uncertain between region-specific and general exercises approaches. Based on very low- to low-quality evidence, there appear to have no differences between both types of exercise approaches for pain reduction or disability for adults with spinal disorders. Future trials may change the current conclusions. More evidence is needed for region-specific exercises compared to general exercises for other peripheral MSKDs including knee OA.

Prognostic factors of a favorable outcome following a supervised exercise program for soldiers with sub-acute and chronic low back pain.

BACKGROUND: Low back pain (LBP) encompasses heterogeneous patients unlikely to respond to a unique treatment. Identifying sub-groups of LBP may help to improve treatment outcomes. This is a hypothesis-setting study designed to create a clinical prediction rule (CPR) that will predict favorable outcomes in soldiers with sub-acute and chronic LBP participating in a multi-station exercise program. METHODS: Military members with LBP participated in a supervised program comprising 7 stations each consisting of exercises of increasing difficulty. Demographic, impairment and disability data were collected at baseline. The modified Oswestry Disability Index (ODI) was administered at baseline and following the 6-week program. An improvement of 50% in the initial ODI score was considered the reference standard to determine a favorable outcome. Univariate associations with favorable outcome were tested using chi-square or paired t-tests. Variables that showed between-group (favorable/unfavorable) differences were entered into a logistic regression after determining the sampling adequacy. Finally, continuous variables were dichotomized and the sensitivity, specificity and positive and negative likelihood ratios were determined for the model and for each variable. RESULTS: A sample of 85 participants was included in analyses. Five variables contributed to prediction of a favorable outcome: no pain in lying down (p = 0.017), no use of antidepressants (p = 0.061), FABQ work score < 22.5 (p = 0.061), fewer than 5 physiotherapy sessions before entering the program (p = 0.144) and less than 6 months' work restriction (p = 0.161). This model yielded a sensitivity of 0.78, specificity of 0.80, LR+ of 3.88, and LR- of 0.28. A 77.5% probability of favorable outcome can be predicted by the presence of more than three of the five variables, while an 80% probability of unfavorable outcome can be expected if only three or fewer variables are present. CONCLUSION: The use of prognostic factors may guide clinicians in identifying soldiers with LBP most likely to have a favorable outcome. Further validation studies are needed to determine if the variables identified in our study are treatment effect modifiers that can predict success following participation in the multi-station exercise program. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03464877 registered retrospectively on 14 March 2018.

Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment.

BACKGROUND: Manipulation and mobilisation are commonly used to treat neck pain. This is an update of a Cochrane review first published in 2003, and previously updated in 2010. OBJECTIVES: To assess the effects of manipulation or mobilisation alone compared wiith those of an inactive control or another active treatment on pain, function, disability, patient satisfaction, quality of life and global perceived effect in adults experiencing neck pain with or without radicular symptoms and cervicogenic headache (CGH) at immediate- to long-term follow-up. When appropriate, to assess the influence of treatment characteristics (i.e. technique, dosage), methodological quality, symptom duration and subtypes of neck disorder on treatment outcomes. SEARCH METHODS: Review authors searched the following computerised databases to November 2014 to identify additional studies: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We also searched ClinicalTrials.gov, checked references, searched citations and contacted study authors to find relevant studies. We updated this search in June 2015, but these results have not yet been incorporated. SELECTION CRITERIA: Randomised controlled trials (RCTs) undertaken to assess whether manipulation or mobilisation improves clinical outcomes for adults with acute/subacute/chronic neck pain. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, abstracted data, assessed risk of bias and applied Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methods (very low, low, moderate, high quality). We calculated pooled risk ratios (RRs) and standardised mean differences (SMDs). MAIN RESULTS: We included 51 trials (2920 participants, 18 trials of manipulation/mobilisation versus control; 34 trials of manipulation/mobilisation versus another treatment, 1 trial had two comparisons). Cervical manipulation versus inactive control: For subacute and chronic neck pain, a single manipulation (three trials, no meta-analysis, 154 participants, ranged from very low to low quality) relieved pain at immediate- but not short-term follow-up. Cervical manipulation versus another active treatment: For acute and chronic neck pain, multiple sessions of cervical manipulation (two trials, 446 participants, ranged from moderate to high quality) produced similar changes in pain, function, quality of life (QoL), global perceived effect (GPE) and patient satisfaction when compared with multiple sessions of cervical mobilisation at immediate-, short- and intermediate-term follow-up. For acute and subacute neck pain, multiple sessions of cervical manipulation were more effective than certain medications in improving pain and function at immediate- (one trial, 182 participants, moderate quality) and long-term follow-up (one trial, 181 participants, moderate quality). These findings are consistent for function at intermediate-term follow-up (one trial, 182 participants, moderate quality). For chronic CGH, multiple sessions of cervical manipulation (two trials, 125 participants, low quality) may be more effective than massage in improving pain and function at short/intermediate-term follow-up. Multiple sessions of cervical manipulation (one trial, 65 participants, very low quality) may be favoured over transcutaneous electrical nerve stimulation (TENS) for pain reduction at short-term follow-up. For acute neck pain, multiple sessions of cervical manipulation (one trial, 20 participants, very low quality) may be more effective than thoracic manipulation in improving pain and function at short/intermediate-term follow-up. Thoracic manipulation versus inactive control: Three trials (150 participants) using a single session were assessed at immediate-, short- and intermediate-term follow-up. At short-term follow-up, manipulation improved pain in participants with acute and subacute neck pain (five trials, 346 participants, moderate quality, pooled SMD -1.26, 95% confidence interval (CI) -1.86 to -0.66) and improved function (four trials, 258 participants, moderate quality, pooled SMD -1.40, 95% CI -2.24 to -0.55) in participants with acute and chronic neck pain. A funnel plot of these data suggests publication bias. These findings were consistent at intermediate follow-up for pain/function/quality of life (one trial, 111 participants, low quality). Thoracic manipulation versus another active treatment: No studies provided sufficient data for statistical analyses. A single session of thoracic manipulation (one trial, 100 participants, moderate quality) was comparable with thoracic mobilisation for pain relief at immediate-term follow-up for chronic neck pain. Mobilisation versus inactive control: Mobilisation as a stand-alone intervention (two trials, 57 participants, ranged from very low to low quality) may not reduce pain more than an inactive control. Mobilisation versus another active treatment: For acute and subacute neck pain, anterior-posterior mobilisation (one trial, 95 participants, very low quality) may favour pain reduction over rotatory or transverse mobilisations at immediate-term follow-up. For chronic CGH with temporomandibular joint (TMJ) dysfunction, multiple sessions of TMJ manual therapy (one trial, 38 participants, very low quality) may be more effective than cervical mobilisation in improving pain/function at immediate- and intermediate-term follow-up. For subacute and chronic neck pain, cervical mobilisation alone (four trials, 165 participants, ranged from low to very low quality) may not be different from ultrasound, TENS, acupuncture and massage in improving pain, function, QoL and participant satisfaction at immediate- and intermediate-term follow-up. Additionally, combining laser with manipulation may be superior to using manipulation or laser alone (one trial, 56 participants, very low quality). AUTHORS' CONCLUSIONS: Although support can be found for use of thoracic manipulation versus control for neck pain, function and QoL, results for cervical manipulation and mobilisation versus control are few and diverse. Publication bias cannot be ruled out. Research designed to protect against various biases is needed. Findings suggest that manipulation and mobilisation present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up. Since the risk of rare but serious adverse events for manipulation exists, further high-quality research focusing on mobilisation and comparing mobilisation or manipulation versus other treatment options is needed to guide clinicians in their optimal treatment choices.

Efficacy of a Psychologically-Informed Physiotherapy Intervention in Patients with Chronic Low Back Pain at High Risk of Poor Prognosis: A Pilot and Feasibility Randomized Controlled Trial.

Purpose: To determine the feasibility of a randomized controlled trial (RCT) testing the efficacy of psychologically-informed physiotherapy (PIPT), which includes usual physiotherapy (UP) interventions, compared with UP, and to explore the preliminary effectiveness of the interventions. Method: People with chronic low back pain at high risk of poor prognosis (using the STarT Back screening tool) were recruited and allocated to PIPT or UP. Effectiveness of recruitment strategies, adherence to intervention, risk of contamination, and specific challenges were assessed. Functional capacity, pain, quality of life, kinesiophobia, catastrophization, central sensitization, and self-efficacy were measured at baseline, 6-, 12- and 24-week follow-ups. Results: Forty participants were recruited mainly by diffusing through Laval University's email list, and 10 physiotherapists treated the participants recruited. The retention rate of participants at 24 weeks was 72.5%. Adherence to treatment by participants and physiotherapists was very good. The risk of contamination was low, and the specific challenges identified were modifiable. Significant improvement over time in all clinical variables of interest, except self-efficacy, was observed with no difference between groups. Conclusions: As most success criteria were met, conducting an RCT evaluating PIPT and PU is feasible with modifications. PIPT and UP appear to be similarly effective.

Objectif: déterminer la faisabilité d'une étude randomisée et contrôlée (ÉRC) évaluant l'efficacité de la physiothérapie fondée sur la psychologie (PTFP), qui inclut les interventions de physiothérapie conventionelle (PC), par rapport à la PC, et explorer l'efficacité préliminaire des interventions. Méthodologie: les chercheurs ont recruté des personnes qui souffrent de douleurs lombaires chroniques, ayant une probabilité élevée de mauvais pronostic (au moyen de l'outil de dépistage STarT Back) et les ont réparties entre la PTFP et la PC. Ils ont évalué l'efficacité des stratégies de recrutement, l'adhésion à l'intervention, le risque de contamination et les difficultés particulières. Ils ont également mesuré la capacité fonctionnelle, la douleur, la qualité de vie, la kinésiophobie, la catastrophisation, la sensibilisation centrale et l'autoefficacité en début d'étude ainsi que lors des suivis à six, 12 et 24 semaines. Résultats: les chercheurs ont recruté 40 participants, principalement en diffusant le projet par courriel à la communauté de l'Université Laval, et dix physiothérapeutes les ont traités. Le taux de rétention des participants était de 72,5 % à 24 semaines. Les participants et les physiothérapeutes ont démontré une très bonne adhésion au traitement. Le risque de contamination était faible, et les difficultés particulières constatées pouvaient être modifiées. Les chercheurs ont observé une amélioration considérable au fil du temps pour toutes les variables cliniques d'intérêt, sauf l'autoefficacité, sans différence entre les groupes. Conclusions: puisque la plupart des critères de succès étaient respectés, il est faisable de réaliser une ÉRC pour évaluer la PTFP et la PU, sous réserve de modifications. La PTFP et la PC semblent avoir une efficacité similaire.

Effectiveness and safety of manual therapy when compared with oral pain medications in patients with neck pain: a systematic review and meta-analysis.

BACKGROUND: This systematic review and meta-analysis seeks to investigate the effectiveness and safety of manual therapy (MT) interventions compared to oral pain medication in the management of neck pain. METHODS: We searched from inception to March 2023, in Cochrane Central Register of Controller Trials (CENTRAL), MEDLINE, EMBASE, Allied and Complementary Medicine (AMED) and Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO) for randomized controlled trials that examined the effect of manual therapy interventions for neck pain when compared to medication in adults with self-reported neck pain, irrespective of radicular findings, specific cause, and associated cervicogenic headaches. We used the Cochrane Risk of Bias 2 tool to assess the potential risk of bias in the included studies, and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach to grade the quality of the evidence. RESULTS: Nine trials (779 participants) were included in the meta-analysis. We found low certainty of evidence that MT interventions may be more effective than oral pain medication in pain reduction in the short-term (Standardized Mean Difference: -0.39; 95% CI -0.66 to -0.11; 8 trials, 676 participants), and moderate certainty of evidence that MT interventions may be more effective than oral pain medication in pain reduction in the long-term (Standardized Mean Difference: - 0.36; 95% CI - 0.55 to - 0.17; 6 trials, 567 participants). We found low certainty evidence that the risk of adverse events may be lower for patients that received MT compared to the ones that received oral pain medication (Risk Ratio: 0.59; 95% CI 0.43 to 0.79; 5 trials, 426 participants). CONCLUSIONS: MT may be more effective for people with neck pain in both short and long-term with a better safety profile regarding adverse events when compared to patients receiving oral pain medications. However, we advise caution when interpreting our safety results due to the different level of reporting strategies in place for MT and medication-induced adverse events. Future MT trials should create and adhere to strict reporting strategies with regards to adverse events to help gain a better understanding on the nature of potential MT-induced adverse events and to ensure patient safety. TRIAL REGISTRATION: PROSPERO registration number: CRD42023421147.

Moving from the clinic to telehealth during the COVID-19 pandemic - a pilot clinical trial comparing in-clinic rehabilitation versus telerehabilitation for persisting symptoms following a mild Traumatic brain injury.

PURPOSE: The objective of this study was to compare the effects of an in-clinic cervicovestibular rehabilitation program (education, home exercises, manual techniques, sub-symptom threshold aerobic exercise [STAE] program) to a similar program (education, home-exercises, STAE program), but without manual techniques, provided in a telerehabilitation format in adults with persisting post-concussion symptoms (PCS). MATERIALS AND METHODS DESIGN: In this parallel-group non-randomized clinical trial, 41 adults with persisting PCS were allocated to the in-clinic (n = 30) or telerehabilitation (n = 11) program. The outcome measures, which included the Post-Concussion Symptom Scale (PCSS; primary outcome), Numerical Pain Rating Scale (NPRS) for neck pain and headache and three disability questionnaires, were collected at baseline, weeks 6, 12, and 26. Non-parametric analysis for longitudinal data (NparLD) was used. RESULTS: For the PCSS, there was a group-by-time interaction (p = 0.05) with significant between-group differences at week 6, 12, and 26 (p < 0.05) for the in-clinic group. There were also group-by-time interactions for NPRS neck pain and headache (p < 0.05) for the in-clinic group. CONCLUSION: The study suggests that a telehealth format failed to reach the efficiency of an in-clinic rehabilitation program in terms of symptoms reduction and functional improvement. These results must be interpreted with caution given the limited number of participants. ClinicalTrials.gov Identifier: NCT03677661.IMPLICATION FOR REHABILITATIONThe telerehabilitation format for adults with persisting post-concussion symptoms was widely implemented in the COVID-19 pandemic without any evidence of efficacy over the more traditional in-clinic rehabilitation format.The study suggests that a telerehabilitation format failed to reach the efficiency of an in-clinic rehabilitation program in terms of symptoms reduction and functional improvement.Clinicians should try to incorporate some in-clinic appointments when a telerehabilitation format is required such as for patients in underserved area.

Is assessing trunk muscle endurance in military with sub-acute and chronic low back pain clinically meaningful?

Introduction: Trunk muscle endurance (TME) tests are commonly used by clinicians to assess muscle performance changes in response to rehabilitation in patients with low back pain (LBP). The aim of this study was to assess the responsiveness of three TME-tests in patients with LBP and to evaluate the relationships between changes in TME and improvement in self-reported function. Materials and Methods: Eighty-four LBP patients were evaluated at baseline and after completion of a 6-week training program. Function was assessed with the modified Oswestry Disability Index (ODI) while TME was estimated using three tests: (1) the Biering-Sørensen, (2) the side bridge endurance tests (both sides), and (3) the trunk flexor endurance test. The standardized response mean (SRM) and the minimal clinical important difference (MCID) for each TME-test, and the relationships between changes in TME and improvement in ODI were calculated. Results: SRMs were small to large for TME-tests (range: 0.43-0.82), and large for the ODI (2.85) and no clinically useful MCID was identified for the TME-tests (area under the curve below 0.70). No significant correlations were found between changes in the TME and change in ODI scores (r < 0.15; all P > 0.05). Conclusion: Our results show a weak responsiveness of TME-tests in patients with LBP. There was no association between endurance performance change and self-reported functional change. TME-tests may not be a key component of rehabilitation monitoring in patients with LBP.

Cervical radiculopathy: study protocol of a randomised clinical trial evaluating the effect of mobilisations and exercises targeting the opening of intervertebral foramen [NCT01500044].

BACKGROUND: Cervical radiculopathy is a common form of neck pain and has been shown to lead to severe disability. Clinical rehabilitation approaches for cervical radiculopathies commonly include exercise and manual therapy interventions targeting the opening of intervertebral foramen, but evidence regarding their effectiveness is scarce. The primary objective of this randomised clinical trial is to compare, in terms of pain and disability, a rehabilitation program targeting the opening of intervertebral foramen to a conventional rehabilitation program, for patients presenting acute or subacute cervical radiculopathies. The hypothesis is that the rehabilitation program targeting the opening of intervertebral foramen will be significantly more effective in reducing pain and disability than the conventional rehabilitation program. METHODS/DESIGN: This study is a double-blind (participants and evaluators blinded) randomised clinical trial that will allow the comparison of patients with a cervical radiculopathy randomly assigned to one of two groups: one group will receive a 4-week rehabilitation program targeting the opening of intervertebral foramen, and the second group will receive a 4-week conventional rehabilitation program. Thirty-six subjects with cervical radiculopathy will be recruited from participating medical and physiotherapy clinics and will be evaluated at baseline, at the end of the 4-week program and four weeks following the end of the program. The primary outcome measure will be the validated Neck Disability Index questionnaire. Secondary outcome measures will include the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire, a numerical pain rating scale, cervicothoracic mobility and patients' perceived global rating of change. During the 4-week rehabilitation program, each participant will take part in eight physiotherapy treatment sessions (2 session/week) and will perform a home exercise program. A mixed-model, 2-way ANOVA will be used to analyze the effects of the rehabilitation programs. DISCUSSION: Control trials are needed to define ideal intervention approaches in rehabilitation for this population. This randomised clinical trial will be the first study that directly compares a rehabilitation program targeting the opening of intervertebral foramen to a conventional rehabilitation program for patients with cervical radiculopathy. The results of this study may help to establish best clinical practice guidelines for this patient population. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01500044.

Responsiveness of the Post-Concussion Symptom Scale to Monitor Clinical Recovery After Concussion or Mild Traumatic Brain Injury.

Background: The Post-Concussion Symptom Scale (PCSS) is used to assess the number and intensity of symptoms after a concussion/mild traumatic brain injury. However, its responsiveness to monitor clinical recovery has yet to be determined. Purpose: To evaluate the responsiveness of the PCSS to change and longitudinal validity in patients with persistent postconcussive symptoms as well as to explore the responsiveness of other clinical outcome measures to monitor recovery of physical symptoms in patients with persistent postconcussive symptoms. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Patients with persistent symptoms after a concussion (N = 109) were evaluated using self-reported questionnaires at baseline and after a 6-week rehabilitation program. The program consisted of an individualized symptom-limited aerobic exercise program combined with education. Questionnaires included the PCSS, Neck Disability Index (NDI), Headache Disability Inventory (HDI), Dizziness Handicap Inventory (DHI), and Numeric Pain Rating Scale (NPRS) related to 1) neck pain and 2) headache. Internal responsiveness was evaluated using the effect size (ES) and standardized response mean (SRM), and external responsiveness was determined with the minimal clinically important difference (MCID) calculated using a receiver operating characteristic curve. The global rating of change was used as the external criterion. Pearson correlations were used to determine the longitudinal validity. Results: The PCSS was highly responsive (ES and SRM, >1.3) and had an MCID of 26.5 points (of 132) for the total score and 5.5 (of 22) for the number of symptoms. For longitudinal validity, low to moderate correlations were found between changes in PCSS and changes in NDI, HDI, and DHI. The NDI, HDI, DHI, and NPRS were also highly responsive (ES and SRM, >0.8). Conclusion: All questionnaires including the PCSS were highly responsive and can be used with confidence by clinicians and researchers to evaluate change over time in a concussion population with persistent symptoms.

Cervicovestibular Rehabilitation in Adults with Mild Traumatic Brain Injury: A Randomized Clinical Trial.

The objective of this study was to compare the effects of a cervicovestibular rehabilitation program combined with symptom-limited aerobic exercise (SLAE) program to a SLAE program alone in adults with persistent symptoms after mild traumatic brain injury (mTBI) on severity of symptoms and other indicators of clinical recovery. In this single-blind, parallel-group randomized controlled trial, 60 adults with persistent symptoms after mTBI were randomly assigned to: (1) a 6-week SLAE program or (2) a 6-week cervicovestibular rehabilitation program combined with a SLAE program. All participants took part in four evaluation sessions (baseline, week 6, 12, and 26) performed by a blinded evaluator. The primary outcome was the Post-Concussion Symptoms Scale (PCSS). The secondary outcomes were Numerical Pain Rating Scale (NPRS), Neck Disability Index (NDI), Headache Disability Inventory (HDI), Dizziness Handicap Inventory (DHI), time to return to function, and physical cervical and vestibular measures. Non-parametric analysis for longitudinal data was used to evaluate the effect of interventions on outcomes. For PCSS, NPRS, NDI, HDI, DHI, and return to function, there were no group-by-time interactions at any time points follow-up (p > 0.05); clinically significant time effects were, however, observed (p < 0.05). There were group-by-time interactions at weeks 6 and 12 for vestibulo-ocular reflex (p < 0.003) and the craniovertebral mobility (p < 0.001) measures in favor of the cervicovestibular rehabilitation group. The study indicates that a cervicovestibular rehabilitation program combined with SLAE was not superior to a SLAE program alone in term of symptoms and functional level improvement but resulted in improved physical cervical and vestibular function.

Botulinum toxin for subacute/chronic neck pain.

BACKGROUND: Neck disorders are common, disabling and costly. Botulinum toxin (BoNT) intramuscular injections are often used with the intention of treating neck pain. OBJECTIVES: To systematically evaluate the literature on the treatment effectiveness of BoNT for neck pain, disability, global perceived effect and quality of life in adults with neck pain with or without associated cervicogenic headache, but excluding cervical radiculopathy and whiplash associated disorder. SEARCH STRATEGY: We searched CENTRAL, MEDLINE, AMED, Index to Chiropractic Literature, CINAHL, LILACS, and EMBASE from their origin to 20 September 2010. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials in which BoNT injections were used to treat subacute or chronic neck pain. DATA COLLECTION AND ANALYSIS: A minimum of two review authors independently selected articles, abstracted data, and assessed risk of bias, using the Cochrane Back Review Group criteria. In the absence of clinical heterogeneity, we calculated standardized mean differences (SMD) and relative risks, and performed meta-analyses using a random-effects model. The quality of the evidence and the strength of recommendations were assigned an overall grade for each outcome. MAIN RESULTS: We included nine trials (503 participants). Only BoNT type A (BoNT-A) was used in these studies.High quality evidence suggests there was little or no difference in pain between BoNT-A and saline injections at four weeks (five trials; 252 participants; SMD pooled -0.07 (95% confidence intervals (CI) -0.36 to 0.21)) and six months for chronic neck pain. Very low quality evidence indicated little or no difference in pain between BoNT-A combined with physiotherapeutic exercise and analgesics and saline injection with physiotherapeutic exercise and analgesics for patients with chronic neck pain at four weeks (two trials; 95 participants; SMD pooled 0.09 (95% CI -0.55 to 0.73)) and six months (one trial; 24 participants; SMD -0.56 (95% CI -1.39 to 0.27)). Very low quality evidence from one trial (32 participants) showed little or no difference between BoNT-A and placebo at four weeks (SMD 0.16 (95% CI -0.53 to 0.86)) and six months (SMD 0.00 (95% CI -0.69 to 0.69)) for chronic cervicogenic headache. Very low quality evidence from one trial (31 participants), showed a difference in global perceived effect favouring BoNT-A in chronic neck pain at four weeks (SMD -1.12 (95% CI: -1.89 to -0.36)). AUTHORS' CONCLUSIONS: Current evidence fails to confirm either a clinically important or a statistically significant benefit of BoNT-A injection for chronic neck pain associated with or without associated cervicogenic headache. Likewise, there was no benefit seen for disability and quality of life at four week and six months.

Measurement properties of the Pain Self-Efficacy Questionnaire in populations with musculoskeletal disorders: a systematic review.

A higher level of pain self-efficacy has been suggested as a predictor of a better outcome in patients with musculoskeletal disorders. The Pain Self-Efficacy Questionnaire (PSEQ) is one of the most frequently used patient-reported outcome measures for pain self-efficacy. The purpose of this study was to conduct a systematic review that would identify, appraise, and synthetize the psychometric properties of the PSEQ. Embase, MEDLINE, and CINAHL databases were searched for publications reporting on psychometric properties of the PSEQ in populations with musculoskeletal disorders. After applying selection criteria on identified citations, 28 studies (9853 participants) were included. The methodological quality as measured with the COSMIN risk of bias tool varied from adequate to very good for most measurement properties. The results showed a weighted mean intraclass correlation coefficient of 0.86 (range: 0.75-0.93) for test-retest reliability for the original 10-item PSEQ and the minimal detectable change at 95% confidence interval was 11.52 out of 60 points. Effect size and standardized response mean values were 0.53 and 0.63, respectively, whereas the minimal clinically important difference ranged from 5.5 to 8.5 in patients with chronic low back pain. Internal consistency (Cronbach alpha) ranged from 0.79 to 0.95. The results also showed that the PSEQ has low to moderate correlations with measures of quality of life, disability, pain, pain interference, anxiety, depression, and catastrophizing. Finally, the PSEQ has been adapted and validated in 14 languages. Overall, the results demonstrate that the PSEQ has excellent validity, reliability, and responsiveness. Further high-quality studies are needed to determine responsiveness in populations other than chronic low back pain.

Motor Control Exercises Compared to Strengthening Exercises for Upper- and Lower-Extremity Musculoskeletal Disorders: A Systematic Review With Meta-Analyses of Randomized Controlled Trials.

OBJECTIVE: The purpose of this review was to compare the efficacy of motor control exercises (MCEs) to strengthening exercises for adults with upper- or lower-extremity musculoskeletal disorders (MSKDs). METHODS: Electronic searches were conducted up to April 2020 in Medline, Embase, Cochrane CENTRAL, and CINAHL. Randomized controlled trials were identified on the efficacy of MCEs compared to strengthening exercises for adults with upper- or lower-extremity MSKDs. Data were extracted with a standardized form that documented the study characteristics and results. For pain and disability outcomes, pooled mean differences (MDs) and standardized mean differences (SMDs) were calculated using random-effects inverse variance models. RESULTS: Twenty-one randomized controlled trials (n = 1244 participants) were included. Based on moderate-quality evidence, MCEs lead to greater pain (MD = -0.41 out of 10 points; 95% CI = -0.72 to -0.10; n = 626) and disability reductions (SMD = -0.28; 95% CI = -0.43 to -0.13; n = 713) when compared to strengthening exercises in the short term; these differences are not clinically important. When excluding trials on osteoarthritis (OA) participants and evaluating only the trials involving participants with rotator cuff-related shoulder pain, shoulder instability, hip-related groin pain, or patellofemoral pain syndrome, there is moderate quality evidence that MCEs lead to greater pain (MD = -0.74 out of 10 points; 95% CI = -1.22 to -0.26; n = 293) and disability reductions (SMD = -0.40; 95% CI = -0.61 to -0.19; n = 354) than strengthening exercises in the short term; these differences might be clinically important. CONCLUSIONS: MCEs lead to statistically greater pain and disability reductions when compared to strengthening exercises among adults with MSKDs in the short term, but these effects might be clinically important only in conditions that do not involve OA. Inclusion of new trials might modify these conclusions. IMPACT: These results suggest that MCEs could be prioritized over strengthening exercises for adults with the included non-OA MSKDs; however, results are unclear for OA disorders.

Tremor-ataxia with central hypomyelination (TACH) leukodystrophy maps to chromosome 10q22.3-10q23.31.

Leukodystrophies are a heterogeneous group of disorders associated with abnormal central nervous system white matter. The clinical features invariably include upper motor neuron signs and developmental regression with or without other neurological manifestations. The objective of this study was to characterize clinically and genetically a new form of childhood-onset leukodystrophy with ataxia and tremor. We recruited seven French-Canadian cases belonging to five families affected by an unknown form of childhood-onset leukodystrophy. Genome-wide scans (GWS) were performed using the Illumina Hap310 or Hap610 Bead Chip to identify regions of shared homozygosity that were further studied for linkage with STS markers. All cases presented between the ages of 1 and 5 years with spasticity along with other upper motor neuron signs, prominent postural tremor, and cerebellar signs. Though motor regression is a constant feature, cognitive functions are relatively preserved, even late in the course of the disease. The higher frequency of founder diseases in the French-Canadian population and the segregation in pedigrees are suggestive of a recessive mode of inheritance. By homozygosity mapping, we established linkage to a 12.6-Mb SNP-haplotyped region on chromosome 10q22.3-10q23.31 (maximum LOD score: 5.47). We describe an autosomal recessive childhood-onset leukodystrophy with ataxia and tremor mapping to a 12.6 Mb interval on chromosome 10q22.3-10q23.31. Identification of the mutated gene will allow precise diagnosis and genetic counseling and shed light on how its perturbed function leads to white matter abnormalities.

Aerobic Exercise for Sport-related Concussion: A Systematic Review and Meta-analysis.

INTRODUCTION: Approximately 25% of people with sport-related concussion (SRC) experiences persistent symptoms. The 2016 Berlin consensus on SRC recommends symptom-limited aerobic exercise as a rehabilitation option for persistent symptoms after concussion. However, this recommendation is based on a limited body of knowledge because there is uncertainty about the effectiveness of such interventions. The objective of this systematic review is to assess the effects of symptom-limited aerobic exercise programs compared with control interventions on symptom intensity in individuals with SRC. METHODS: A structured search was conducted in MEDLINE, EMBASE, CINHAL, and EBM reviews. Randomized clinical trials (RCT) including aerobic exercise programs as an intervention for SRC were included. After selection, the risk of bias and Grading of Recommendations, Assessment, Development and Evaluation recommendations were applied to pooled studies for quantitative analysis. Standard mean differences (SMD) and 95% confidence interval (CI) were calculated. A descriptive analysis was also performed. RESULTS: Seven RCT (326 participants) in adolescent populations were included. Three of seven RCT had a high risk of bias. Symptom-limited aerobic exercise programs have a significant beneficial effect on the perception of symptoms (6 studies, 277 participants, low-quality evidence; pooled SMD, -0.44; 95% CI, -0.68 to -0.19). When introduced in the acute phase, symptom-limited aerobic exercise programs have a significant beneficial effect on symptomatic recovery compared with control interventions (3 studies, 206 participants, moderate quality evidence, pooled SMD, -0.43; 95% CI, -0.71 to -0.15). CONCLUSIONS: Symptom-limited aerobic exercise programs are beneficial in improving symptoms of adolescents after an SRC. Good-quality studies are needed to determine effects on adults and on other outcomes.

Cervicovestibular rehabilitation in adult with mild traumatic brain injury: a randomised controlled trial protocol.

BACKGROUND: Mild traumatic brain injury (mTBI) is an acknowledged public health problem. Up to 25% of adult with mTBI present persistent symptoms. Headache, dizziness, nausea and neck pain are the most commonly reported symptoms and are frequently associated with cervical spine and vestibular impairments. The most recent international consensus statement (2017 Berlin consensus) recommends the addition of an individualized rehabilitation approach for mTBI with persistent symptoms. The addition of an individualized rehabilitation approach including the evaluation and treatment of cervical and vestibular impairments leading to symptoms such as neck pain, headache and dizziness is, however, recommended based only on limited scientific evidence. The benefit of such intervention should therefore be further investigated. OBJECTIVE: To compare the addition of a 6-week individualized cervicovestibular rehabilitation program to a conventional approach of gradual sub-threshold physical activation (SPA) alone in adults with persistent headache, neck pain and/or dizziness-related following a mTBI on the severity of symptoms and on other indicators of clinical recovery. We hypothesize that such a program will improve all outcomes faster than a conventional approach (between-group differences at 6-week and 12-week). METHODS: In this single-blind, parallel-group randomized controlled trial, 46 adults with subacute (3 to12 weeks post-injury) persistent mTBI symptoms will be randomly assigned to: 1) a 6-week SPA program or 2) SPA combined with a cervicovestibular rehabilitation program. The cervicovestibular rehabilitation program will include education, cervical spine manual therapy and exercises, vestibular rehabilitation and home exercises. All participants will take part in 4 evaluation sessions (baseline, week 6, 12 and 26) performed by a blinded evaluator. The primary outcome will be the Post-Concussion Symptoms Scale. The secondary outcomes will be time to clearance to return to function, number of recurrent episodes, Global Rating of Change, Numerical Pain Rating Scale, Neck Disability Index, Headache Disability Inventory and Dizziness Handicap Inventory. A 2-way ANOVA and an intention-to-treat analysis will be used. DISCUSSION: Controlled trials are needed to determine the best rehabilitation approach for mTBI with persistent symptoms such as neck pain, headache and dizziness. This RCT will be crucial to guide future clinical management recommendations. TRIAL REGISTRATION: ClinicalTrials.gov Identifier - NCT03677661, Registered on September, 15th 2018.

Beyond the Joint: The Role of Central Nervous System Reorganizations in Chronic Musculoskeletal Disorders.

To a large extent, management of musculoskeletal disorders has traditionally focused on structural dysfunctions found within the musculoskeletal system, mainly around the affected joint. While a structural-dysfunction approach may be effective for musculoskeletal conditions in some populations, especially in acute presentations, its effectiveness remains limited in patients with recurrent or chronic musculoskeletal pain. Numerous studies have shown that the human central nervous system can undergo plastic reorganizations following musculoskeletal disorders; however, they can be maladaptive and contribute to altered joint control and chronic pain. In this Viewpoint, the authors argue that to improve rehabilitation outcomes in patients with chronic musculoskeletal pain, a global view of the disorder that incorporates both central (neural) and peripheral (joint-level) changes is needed. The authors also discuss the challenge of evaluating and rehabilitating central changes and the need for large, high-level studies to evaluate approaches incorporating central and peripheral changes and emerging therapies. J Orthop Sports Phys Ther 2017;47(11):817-821. doi:10.2519/jospt.2017.0608.

Cervical Spine Involvement in Mild Traumatic Brain Injury: A Review.

Background. There is a lack of scientific evidence in the literature on the involvement of the cervical spine in mTBI; however, its involvement is clinically accepted. Objective. This paper reviews evidence for the involvement of the cervical spine in mTBI symptoms, the mechanisms of injury, and the efficacy of therapy for cervical spine with concussion-related symptoms. Methods. A keyword search was conducted on PubMed, ICL, SportDiscus, PEDro, CINAHL, and Cochrane Library databases for articles published since 1990. The reference lists of articles meeting the criteria (original data articles, literature reviews, and clinical guidelines) were also searched in the same databases. Results. 4,854 records were screened and 43 articles were retained. Those articles were used to describe different subjects such as mTBI's signs and symptoms, mechanisms of injury, and treatments of the cervical spine. Conclusions. The hypothesis of cervical spine involvement in post-mTBI symptoms and in PCS (postconcussion syndrome) is supported by increasing evidence and is widely accepted clinically. For the management and treatment of mTBIs, few articles were available in the literature, and relevant studies showed interesting results about manual therapy and exercises as efficient tools for health care practitioners.