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.

Discord Between Approaches to Spinal and Extremity Disorders: Is It Logical?

Rapid advances in the basic, clinical, and behavioral sciences are molding developments in conservative management of musculoskeletal disorders. Curiously, there seems to be discord developing between approaches to the assessment and management of patients, depending on whether they present with an extremity or spinal disorder. This viewpoint will comment on examples of differences emerging in some current practices. The aim is not to present a scientific treatise about underpinning sciences and evidence-based practice or to comment on what is correct or incorrect. Rather, the aim is to stimulate thought on the seeming discord in clinical practice, with respect to both the clinical evaluation of, as well as management approaches to, extremity and spinal disorders. J Orthop Sports Phys Ther 2016;46(11):938-941. doi:10.2519/jospt.2016.0610.

Cervical muscle activity during loaded arm lifts in patients 10 years postsurgery for cervical disc disease.

OBJECTIVE: The purpose of this study was to compare the mechanical activity of the neck muscles during loaded arm lifting tasks in individuals with long-standing disability after anterior cervical decompression and fusion (ACDF) with that of healthy controls. METHODS: Ten individuals (mean age, 60 years; SD, 7.1) who underwent ACDF (10-13 years previously) for cervical disc disease and 10 healthy age- and sex-matched controls participated in the study. Ultrasonography was used to investigate the degree of deformation and deformation rate of ventral and dorsal neck muscles at the C4 segmental level during a single (1× arm flexion to 120°) and repeated (10× arm flexion to 90°) loaded arm elevation condition. RESULTS: The ACDF group showed greater deformation and deformation rate of the longus capitis (P=.02) and deformation rate of the sternocleidomastoid (P=.04) during the 120° arm lift. For repeated 90° arm lift, there was a significant group effect with higher deformation rate values observed in the longus capitis (P=.005-.01) and multifidus (P=.03) muscles in the ACDF group. Muscle behavior did not change the repeated arm lifts (no group×time interactions) for either the ventral or the dorsal muscles. CONCLUSIONS: For study participants, greater muscle mechanical activity levels were observed in the ventral and multifidus muscles of patients with persistent symptoms after ACDF. These differences may indicate altered motor strategy in this patient group when performing the upper limb task and may need to be considered when prescribing exercise for postsurgical rehabilitation.

Baseline characteristics of patients with nerve-related neck and arm pain predict the likely response to neural tissue management.

STUDY DESIGN: Planned secondary analysis of a randomized controlled trial comparing neural tissue management (NTM) to advice to remain active. OBJECTIVE: To develop a model that predicts the likelihood of patient-reported improvement following NTM. BACKGROUND: Matching patients to an intervention they are likely to benefit from potentially improves outcomes. However, baseline characteristics that predict patients' responses to NTM are unknown. METHODS: Data came from 60 consecutive adults who had nontraumatic, nerve-related neck and unilateral arm pain for at least 4 weeks. Participants were assigned to a group that received NTM (n = 40), which involved brief education, manual therapy, and nerve gliding exercises for 4 treatments over 2 weeks, or to a group that was given advice to remain active (n = 20), which involved instruction to continue their usual activities. The participants' global rating of change at a 3- to 4-week follow-up defined improvement. Penalized regression of NTM data identified the best prediction model. A medical nomogram was created for prediction model scoring. Post hoc analysis determined whether the model predicted a specific response to NTM. RESULTS: Absence of neuropathic pain qualities, older age, and smaller deficits in median nerve neurodynamic test range of motion predicted improvement. Prediction model cutoffs increased the likelihood of improvement from 53% to 90% (95% confidence interval: 56%, 98%) or decreased the likelihood of improvement to 9% (95% confidence interval: 1%, 42%). The model did not predict the outcomes of the advice to remain active group. CONCLUSION: Baseline characteristics of patients with nerve-related neck and arm pain predicted the likelihood of improvement with NTM. Model performance needs to be validated in a new sample using different comparison interventions and longer follow-up. Australian New Zealand Clinical Trials Registry (ACTRN 12610000446066). LEVEL OF EVIDENCE: Prognosis, level 2b-.

People seeking treatment for a new episode of neck pain typically have rapid improvement in symptoms: an observational study.

QUESTION: What is the clinical course of a new episode of non-specific neck pain in people who are treated with multimodal physical therapies in a primary care setting? DESIGN: Observational study with 3-month follow-up, run in conjunction with a randomised trial. PARTICIPANTS: 181 adults who consulted a physiotherapist or chiropractor for a new episode of nonspecific neck pain. OUTCOME MEASURES: Time to recover from the episode of neck pain, time to recover normal activity, and pain and neck-related disability at three months. Clinical and demographic characteristics were investigated as potential predictors of recovery. RESULTS: Within 3 months, 53% of participants reported complete recovery from the episode of neck pain. On a scale from 0 (none) to 10 (worst), pain improved from 6.1 (SD 2.0) at baseline to 2.5 (SD 2.1) at 2 weeks and to 1.5 (SD 1.8) at 3 months. On a scale from 0 (none) to 50 (worst), disability improved from 15.5 (SD 7.4) at baseline to 5.4 (SD 6.4) at 3 months. Faster recovery was independently associated with better self-rated general health, shorter duration of symptoms, being a smoker, and absence of concomitant upper back pain or headache. Higher disability at 3 months was independently associated with higher disability at baseline, concomitant upper or lower back pain, older age, and previous sick leave for neck pain. CONCLUSION: People who seek physical treatments for a new episode of neck pain in this primary care setting typically have high pain scores that improve rapidly after commencing treatment. Although almost half of those who seek treatment do not recover completely within three months, residual pain and disability in this group is relatively low. Physiotherapists should reassure people with a new episode of neck pain that rapid improvement in symptoms is common, modifying this advice where applicable based on risk factors.

Immediate and short-term effects of Mulligan's mobilization with movement on knee pain and disability associated with knee osteoarthritis--a prospective case series.

Manual therapy has proven to be a benefit in the management of knee osteoarthritis (OA), but the effects of the method of Mulligan's mobilization with movement (MWM) have yet to be explored in knee OA. As a first step, this case series investigated MWM's immediate and short-term benefits over three occasions of treatment in 19 patients with knee OA. Patients (71.1 ± SD 13.9 years, 14 females and 5 males) received individually prescribed MWM and performed self-MWM. Outcome measures included: 1) pain intensity (visual analog scales) during walking, ascending and descending stairs, and sit-to-stand; 2) passive flexion and extension range of motion (ROM); and 3) Activities of Daily Living Scale of the Knee Outcome Survey (KOS-ADLS). Pain and ROM were assessed at baseline, after the initial treatment, before the second treatment and at exit following the fourth consultation. The KOS-ADLS was assessed at baseline and at exit. Significant improvements from baseline were detected in flexion ROM and pain scores in all tasks following the initial treatment (P < 0.05/3). The KOS-ADLS score improved significantly from baseline (67.1% ± SD 16.6%) to exit (86.3% ± SD 12.6%) (P < 0.001). MWM was associated with immediate pain relief and improved knee function, suggesting its potential as a component of early management of knee OA.

A physiotherapist-delivered integrated exercise and pain coping skills training intervention for individuals with knee osteoarthritis: a randomised controlled trial protocol.

BACKGROUND: Knee osteoarthritis (OA) is a prevalent chronic musculoskeletal condition with no cure. Pain is the primary symptom and results from a complex interaction between structural changes, physical impairments and psychological factors. Much evidence supports the use of strengthening exercises to improve pain and physical function in this patient population. There is also a growing body of research examining the effects of psychologist-delivered pain coping skills training (PCST) particularly in other chronic pain conditions. Though typically provided separately, there are symptom, resource and personnel advantages of exercise and PCST being delivered together by a single healthcare professional. Physiotherapists are a logical choice to be trained to deliver a PCST intervention as they already have expertise in administering exercise for knee OA and are cognisant of the need for a biopsychosocial approach to management. No studies to date have examined the effects of an integrated exercise and PCST program delivered solely by physiotherapists in this population. The primary aim of this multisite randomised controlled trial is to investigate whether an integrated 12-week PCST and exercise treatment program delivered by physiotherapists is more efficacious than either program alone in treating pain and physical function in individuals with knee OA. METHODS/DESIGN: This will be an assessor-blinded, 3-arm randomised controlled trial of a 12-week intervention involving 10 physiotherapy visits together with home practice. Participants with symptomatic and radiographic knee OA will be recruited from the community in two cities in Australia and randomized into one of three groups: exercise alone, PCST alone, or integrated PCST and exercise. Randomisation will be stratified by city (Melbourne or Brisbane) and gender. Primary outcomes are overall average pain in the past week measured by a Visual Analogue Scale and physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index subscale. Secondary outcomes include global rating of change, muscle strength, functional performance, physical activity levels, health related quality of life and psychological factors. Measurements will be taken at baseline and immediately following the intervention (12 weeks) as well as at 32 weeks and 52 weeks to examine maintenance of any intervention effects. Specific assessment of adherence to the treatment program will also be made at weeks 22 and 42. Relative cost-effectiveness will be determined from health service usage and outcome data. DISCUSSION: The findings from this randomised controlled trial will provide evidence for the efficacy of an integrated PCST and exercise program delivered by physiotherapists in the management of painful and functionally limiting knee OA compared to either program alone. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry reference number: ACTRN12610000533099.

Altered trapezius muscle behavior in individuals with neck pain and clinical signs of scapular dysfunction.

OBJECTIVE: The purpose of this study was to compare the behavior of the trapezius muscle in patients with chronic mechanical neck pain (MNP) and clinical signs of scapula dysfunction to healthy controls. METHODS: This is a cross-sectional, between-participant study of trapezius muscle behavior. Eighteen volunteers with chronic MNP and 20 healthy controls participated in the study. Participants performed isometric shoulder abduction, external rotation, and flexion at 3 intensities of effort (maximum voluntary contraction [MVC], 50% MVC, and 20% MVC). Electromyographic signals were recorded unilaterally from the upper, middle, and lower portions of the trapezius muscle during isometric shoulder contractions. RESULTS: Significantly greater levels of lower trapezius electromyographic signals were observed in patients with MNP compared with controls for the abduction (P < .027) and external rotation (P < .036) conditions but not for the flexion condition (P > .392). No differences in activity were observed in the upper (P > .248) or middle (P > .052) portions of trapezius between groups during any of the isometric shoulder girdle conditions. CONCLUSIONS: These findings represent a change in the behavior of the lower trapezius muscle in individuals with MNP who exhibit clinical signs of scapular dysfunction. Clinicians should consider the potential involvement of the axioscapular muscles when assessing patients with chronic neck pain, as retraining scapular function may be required for the successful management of these patients.

A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain.

UNLABELLED: A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. OBJECTIVE: To determine whether neck manipulation is more effective for neck pain than mobilization. DESIGN: Randomized controlled trial with blind assessment of outcome. SETTING: Primary care physiotherapy, chiropractic, and osteopathy clinics in Sydney, Australia. PARTICIPANTS: Patients (N=182) with nonspecific neck pain less than 3 months in duration and deemed suitable for treatment with manipulation by the treating practitioner. INTERVENTIONS: Participants were randomly assigned to receive treatment with neck manipulation (n=91) or mobilization (n=91). Patients in both groups received 4 treatments over 2 weeks. MAIN OUTCOME MEASURE: The number of days taken to recover from the episode of neck pain. RESULTS: The median number of days to recovery of pain was 47 in the manipulation group and 43 in the mobilization group. Participants treated with neck manipulation did not experience more rapid recovery than those treated with neck mobilization (hazard ratio=.98; 95% confidence interval, .66-1.46). CONCLUSIONS: Neck manipulation is not appreciably more effective than mobilization. The use of neck manipulation therefore cannot be justified on the basis of superior effectiveness.