Changes in Multiple Aspects of Pain Outcomes After Rehabilitation: Analysis of Pain Data in a Randomized Controlled Trial Evaluating the Effects of Adding Sensorimotor Training to Manual Therapy and Exercise for Chronic Neck Pain.

OBJECTIVES: To examine changes in pain outcomes to fully evaluate the effect of adding sensorimotor training to manual therapy and exercise in patients with chronic neck pain and sensorimotor deficits. Concordance was examined between pain distribution and pain intensity and patient-reported outcomes. METHODS: Participants (n=152) were randomly allocated into 4 intervention groups: One group received local neck treatment (NT) comprising manual therapy and exercise and the other 3 groups received additional sensorimotor training (either joint position sense/oculomotor exercises, balance exercises or both). Treatment was delivered twice a week for 6 weeks. Pain and patient-reported outcomes were measured at baseline, posttreatment, and 3-, 6- and 12-month follow-ups. RESULTS: There were greater changes in pain location, extent, and intensity at 6- and 12-month follow-ups in the sensorimotor training groups compared with the NT group ( P <0.05). A greater number of patients in the sensorimotor training groups gained ≥50% reduction in pain extent and intensity relative to the NT group at 6 and 12 months ( P <0.05). Clinical improvement in pain extent was concordant with pain intensity (adjusted kappa=056 to 0.66, %agreement=78.3 to 82.9, P <0.001) and disability (adjusted kappa=0.47 to 0.58, % agreement=73.7 to 79.0, P <0.01) at 3-, 6- and 12-month follow-ups, but not with function and well-being. The concordance tended to decline with time. DISCUSSION: Multiple aspects of the pain experience improved in the longer term by adding sensorimotor training to NT for patients with neck pain and sensorimotor deficits. The concordance between pain and patient-reported outcomes was not always evident and varied over time, suggesting the need for multidimensional assessments of pain.

Reliability of changes in neck pain and cervical rotation range following manual scapular repositioning.

BACKGROUND: Manual scapular repositioning may result in change in neck pain and cervical rotation range. However, the reliability of such changes performed by examiners remains unknown. OBJECTIVE: To evaluate the reliability of changes in neck pain and cervical rotation range following manual scapular repositioning performed by two examiners and the agreement between these measures and patients' perceptions of change. DESIGN: Cross-sectional study. METHODS: Sixty-nine participants with neck pain and altered scapular position were recruited. Two physiotherapists performed the manual scapular repositioning. Neck pain intensity was measured using a 0-10 numerical scale and cervical rotation range with a cervical range of motion (CROM) device at baseline and in the modified scapular position. Participants' perceptions of any change were rated on a five-item Likert scale. Clinically relevant changes in pain (>2/10) and range (≥7°) were defined as "improved" or "no change" for each measure. RESULTS: ICCs for changes in pain and range between examiners were 0.92 and 0.91. For clinically relevant changes, percent agreement and kappa values between examiners were 82.6%, 0.64 for pain and 84.1%, 0.64 for range. Percent agreement and kappa values between participants' perceptions and measured changes were 76.1%, 0.51 for pain and 77.5%, 0.52 for range. CONCLUSION: Changes in neck pain and rotation range following manual scapular repositioning demonstrated good reliability between examiners. There was moderate agreement between the measured changes and patients' perceptions.

Effectiveness of adding rehabilitation of cervical related sensorimotor control to manual therapy and exercise for neck pain: A randomized controlled trial.

BACKGROUND: Local neck treatments and sensorimotor training can improve cervical proprioception and balance, but it remains unclear what treatments and treatment combination achieve the best outcomes. OBJECTIVES: To investigate the most effective interventions to improve disturbances in joint position sense (JPS) and balance and their effects on neck pain, dizziness and related features in the short- and long-terms. DESIGN: 2x2 factorial, randomized controlled trial. METHODS: Participants with neck pain (n = 152) were randomly allocated to one of four intervention groups: i) local neck treatment (NT), ii) NT + JPS/oculomotor exercises (JPS/OC), iii) NT + balance exercises, and iv) all treatments. Participants received 12 treatments over 6 weeks. Primary outcomes were postural sway and joint position error. Secondary outcomes included gait speed, dizziness, pain intensity and disability, cervical range of motion, functional ability, and quality of life. Outcome measures were taken at baseline, posttreatment and 3-, 6- and 12-month follow-ups. RESULTS: All four interventions resulted in short- and long-term improvements in primary and secondary outcomes with medium to large effect sizes, but JPS and balance in neck torsion improved most with the addition of a combined program of JPS/OC + balance exercises to NT while balance in neck neutral improved most with the addition of balance exercises. Adding sensorimotor training was also more effective in maintaining levels of improvement in neck pain and disability at 6- and 12-months. Effect sizes of additional treatment benefits were medium to large. CONCLUSIONS: Adding specific training of JPS/OC and balance to NT best addresses deficits in cervical proprioception and balance. CLINICAL TRIAL REGISTRATION NUMBER: xxxxx.

Effects of dry needling of the obliquus capitis inferior on sensorimotor control and cervical mobility in people with neck pain: A double-blind, randomized sham-controlled trial.

BACKGROUND: Impairments of sensorimotor control relating to head and eye movement control and postural stability are often present in people with neck pain. The upper cervical spine and particularly the obliquus capitis inferior (OCI) play an important proprioceptive role; and its impairment may alter cervical sensorimotor control. Dry needling (DN) is a valid technique to target the OCI. OBJECTIVES: To investigate if a single DN session of the OCI muscle improves head and eye movement control-related outcomes, postural stability, and cervical mobility in people with neck pain. METHODS: Forty people with neck pain were randomly assigned to receive a single session of DN or sham needling of the OCI. Cervical joint position error (JPE), cervical movement sense, standing balance and oculomotor control were examined at baseline, immediately post-intervention, and at one-week follow-up. Active cervical rotation range of motion and the flexion rotation test were used to examine the global and upper cervical rotation mobility, respectively. RESULTS: Linear mixed-models revealed that the DN group showed a decrease of JPE immediately post-intervention compared to the sham group (mean difference [MD]= -0.93°; 95% confidence interval [CI]: -1.85, -0.02) which was maintained at one-week follow-up (MD= -1.64°; 95%CI: -2.85, -0.43). No effects on standing balance or cervical movement sense were observed in both groups. Upper cervical mobility showed an increase immediately after DN compared to the sham group (MD= 5.14°; 95%CI: 0.77, 9.75) which remained stable at one-week follow-up (MD= 6.98°; 95%CI: 1.31, 12.40). Both group showed an immediate increase in global cervical mobility (MD= -0.14°; 95%CI: -5.29, 4.89). CONCLUSION: The results from the current study suggest that a single session of DN of the OCI reduces JPE deficits and increases upper cervical mobility in patients with neck pain. Future trials should examine if the addition of this technique to sensorimotor control training add further benefits in the management of neck pain.

Predictors for Positive Response to Home Kinematic Training in Chronic Neck Pain.

OBJECTIVES: There is strong evidence for exercise therapy in neck pain, but a wide variety of protocols. Predictors for outcome are unknown and current practice is based on trial and error. The objective of this study was to identify predictors for response to home kinematic training (KT) considering improvement in both self-reported and kinematic measures. METHODS: A continuing analysis of data from the second phase of a randomized controlled trial, which included 4 weeks of KT using laser or virtual reality, with baseline, postintervention, and 3-month follow-up measures. Positive self-reported response was defined as a ≥50% pain reduction, ≥7% reduction in neck disability index (NDI), or a global perceived effect of 3 to 5 of 5. A second model defined improvement by ≥40% increase in cervical velocity. RESULTS: Data were retrieved from 79 participants with chronic neck pain who completed the postintervention evaluation and 52 who completed the 3-month follow-up. Self-reported response was 71% to 73% and kinematic response was 41% to 46%. Prediction models indicated an immediate increase in self-reported measures in men with NDI ≥ 20% slower (≤65°/s), and less accurate (≥16° error) cervical motion at baseline. In the longer term, older patients with higher NDI seemed to benefit more. In the second model, no factors significantly predicted improvement in kinematic measures at either time point. CONCLUSION: A high positive response rate to home KT was found by self-reported criteria. Males with poorer clinical and kinematic presentation at baseline, that is greater disability and slower neck motion, were more likely to respond.

Retrospective Review: Effectiveness of Cervical Proprioception Retraining for Dizziness After Mild Traumatic Brain Injury in a Military Population With Abnormal Cervical Proprioception.

OBJECTIVE: This study aimed to assess the outcomes of 2 treatments for patients with dizziness after mild traumatic brain injury (mTBI) who demonstrate abnormal cervical spine proprioception (CSP). METHODS: A retrospective records review was conducted on the medical charts of patients treated for dizziness after mTBI who received either standard care (vestibular rehabilitation therapy [VRT]) or cervical spine proprioceptive retraining (CSPR) from 2009 to 2013. All patients included in the analysis were active-duty military with recurring dizziness after mTBI who had at least 1 abnormal CSP test. Patients were excluded for dizziness with a clear peripheral vestibular or central symptom origin, incomplete data, or no CSP assessment, or if both treatments were administered. Forty-eight total patients were included in the final dataset (22 VRT; 26 CSPR). Traditional VRT was compared with CSPR when abnormal CSP tests were present, regardless of the presence or absence of neck pain. A clinician review of records was used to determine improvement of dizziness based on patient reports of symptoms at discharge evaluation (ie, no symptoms for at least 2 weeks). RESULTS: Patients who received CSPR were 30 times more likely to report improvement in dizziness symptoms compared with those who received VRT (adjusted odds ratio: 30.12; 95% confidence interval 4.44-204.26, P < .001) when abnormal CSP tests were present. Patients with dizziness over 1 year were significantly less likely to improve. CONCLUSION: These results suggest that patients with dizziness after mTBI and who had abnormal CSP assessments responded better to CSPR compared with those who received VRT.

Proprioception in musculoskeletal rehabilitation. Part 2: Clinical assessment and intervention.

INTRODUCTION: Proprioception can be impaired in gradual-onset musculoskeletal pain disorders and following trauma. Understanding of the role of proprioception in sensorimotor dysfunction and methods for assessment and interventions is of vital importance in musculoskeletal rehabilitation. In Part 1 of this two-part Masterclass we presented a theory-based overview of the role of proprioception in sensorimotor control, causes and findings of altered proprioception in musculoskeletal conditions, and general principles of assessment and interventions. PURPOSE: The aim of this second part is to present specific methods for clinical assessment and interventions to improve proprioception in the spine and extremities. IMPLICATIONS: Clinical assessment of proprioception can be performed using goniometers, inclinometers, laser-pointers, and pressure sensors. Manual therapy, taping, and bracing can immediately enhance proprioception and should be used to prepare for exercise interventions. Various types of exercise (active joint repositioning, force sense, co-ordination, muscle performance, balance/unstable surface, plyometric, and vibration training) should be employed for long-term enhancement of proprioception.

Proprioception in musculoskeletal rehabilitation. Part 1: Basic science and principles of assessment and clinical interventions.

INTRODUCTION: Impaired proprioception has been reported as a feature in a number of musculoskeletal disorders of various body parts, from the cervical spine to the ankle. Proprioception deficits can occur as a result of traumatic damage, e.g., to ligaments and muscles, but can also occur in association with painful disorders of a gradual-onset nature. Muscle fatigue can also adversely affect proprioception and this has implications for both symptomatic and asymptomatic individuals. Due to the importance of proprioception for sensorimotor control, specific methods for assessment and training of proprioception have been developed for both the spine and the extremities. PURPOSE: The aim of this first part of a two part series on proprioception in musculoskeletal rehabilitation is to present a theory based overview of the role of proprioception in sensorimotor control, assessment, causes and findings of altered proprioception in musculoskeletal disorders and general principles of interventions targeting proprioception. IMPLICATIONS: An understanding of the basic science of proprioception, consequences of disturbances and theories behind assessment and interventions is vital for the clinical management of musculoskeletal disorders. Part one of this series supplies a theoretical base for part two which is more practically and clinically orientated, covering specific examples of methods for clinical assessment and interventions to improve proprioception in the spine and the extremities.

Sensorimotor function and dizziness in neck pain: implications for assessment and management.

SYNOPSIS: The term sensorimotor describes all the afferent, efferent, and central integration and processing components involved in maintaining stability in the postural control system through intrinsic motor-control properties. The scope of this paper is to highlight the sensorimotor deficits that can arise from altered cervical afferent input. From a clinical orthopaedic perspective, the peripheral mechanoreceptors are the most important in functional joint stability; but in the cervical region they are also important for postural stability, as well as head and eye movement control. Consequently, conventional musculoskeletal intervention approaches may be sufficient only for patients with neck pain and minimal sensorimotor proprioceptive disturbances. Clinical experience and research indicates that significant sensorimotor cervical proprioceptive disturbances might be an important factor in the maintenance, recurrence, or progression of various symptoms in some patients with neck pain. In these cases, more specific and novel treatment methods are needed which progressively address neck position and movement sense, as well as cervicogenic oculomotor disturbances, postural stability, and cervicogenic dizziness. In this commentary we review the most relevant theoretical and practical knowledge on this matter and implications for clinical assessment and management, and we propose future directions for research. LEVEL OF EVIDENCE: Level 5.

Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control.

The receptors in the cervical spine have important connections to the vestibular and visual apparatus as well as several areas of the central nervous system. Dysfunction of the cervical receptors in neck disorders can alter afferent input subsequently changing the integration, timing and tuning of sensorimotor control. Measurable changes in cervical joint position sense, eye movement control and postural stability and reports of dizziness and unsteadiness by patients with neck disorders can be related to such alterations to sensorimotor control. It is advocated that assessment and management of abnormal cervical somatosensory input and sensorimotor control in neck pain patients is as important as considering lower limb proprioceptive retraining following an ankle or knee injury. Afferent information from the cervical receptors can be altered via a number of mechanisms such as trauma, functional impairment of the receptors, changes in muscle spindle sensitivity and the vast effects of pain at many levels of the nervous system. Recommendations for clinical assessment and management of such sensorimotor control disturbances in neck disorders are presented based on the evidence available to date.