Validation of a modified-composite autonomic symptom score (COMPASS-31) as an outcome measure for persistent autonomic symptoms post-concussion: an observational pilot study.

OBJECTIVE: Persistent symptoms post-mild traumatic brain injury (mTBI) includes autonomic dysregulation (AD). The composite autonomic symptoms score, (COMPASS-31), was developed to quantify AD symptom severity in the last year, which limits clinical utility. The primary aim was to determine validity of a modified-COMPASS-31 measuring symptoms in the last month compared to the original, secondarily to compare both original and modified versions to the Neurobehavioral Symptom Inventory (NSI), and tertiarily to detect change post-treatment of the modified-COMPASS-31 compared to NSI and headache intensity (HI). PARTICIPANTS: Thirty-three military personnel with persistent headache post-mTBI. MAIN OUTCOME MEASURES: Total and domain scores for COMPASS-31 (original vs. modified) NSI and HI at baseline. Change in modified-COMPASS-31. NSI, and HI. RESULTS: Baseline COMPASS-31 versions were comparable and highly correlated (r = 0.72, p < 0.001), they were moderately correlated at best to the NSI (r < 0.6), which may suggest differences in measurement metrics. The mean change in modified-COMPASS-31 scores (15.4/100, effect size 0.8) was mild to moderately correlated to the change in HI (r = 0.39) score, but not to NSI (r = 0.28). CONCLUSION: The modified-COMPASS-31 appears to be valid, can measure change of AD symptom severity, and is recommended as an outcome measure.

Pain-free bite force in a healthy population: Within-session test-retest reliability in different sitting positions.

BACKGROUND: Pain-free bite force (PFBF) is a promising measure to evaluate bite function in temporomandibular disorders (TMDs), yet the reliability of the measure is unknown. OBJECTIVES: Establish the (1) within-session test-retest reliability of PFBF in a healthy population for a single and mean of three trials in supported and unsupported sitting; (2) standard error of measurement (SEM) and minimal detectable change (MDC). METHODS: Thirty healthy participants (n = 15 female, mean [SD] age = 34.4 [11.0] years) completed two sessions (30-60 min apart) comprising three PFBF trials on each side, in both supported and unsupported sitting, to provide data for 60 (30 participants × two sides) test-retest assessments. Test-retest reliability for the first trial and mean of three trials in each position were determined using intraclass correlation coefficients (ICCs), before calculating the corresponding SEM and MDC for males (M) and females (F) respectively. RESULTS: Within-session reliability was considered excellent for a single trial in supported sitting (ICC = 0.85; SEM M/F = 99/84 N; MDC M/F = 275/232 N) and unsupported sitting (ICC = 0.91; SEM M/F = 72/59 N, MDC M/F = 200/163 N), and for a mean of three trials in supported sitting (ICC = 0.89; SEM M/F = 66/79 N, MDC M/F = 182/220 N) and unsupported sitting (ICC = 0.92; SEM M/F = 64/59 N, MDC M/F = 177/164 N). CONCLUSION: Single and a mean of three trials in supported and unsupported sitting appear reliable methods to measure PFBF in a healthy population. Testing PFBF using a mean of three trials in unsupported sitting appears superior over other methods though due to higher test-retest reliability, and lower SEM and MDC. Future studies should examine the reliability of PFBF in TMD populations.

An Investigation of Physiological System Impairments in Individuals 4 Weeks to 6 Months Following Mild Traumatic Brain Injury.

OBJECTIVE: The Buffalo Concussion Treadmill Test (BCTT) was developed to identify potential physiological system impairment (PSI) underlying persistent symptoms post-mild traumatic brain injury (mTBI). This study evaluates PSI in individuals 4 weeks to 6 months post-mTBI using the BCTT "failure" criteria, and additional exploratory measures of test duration and heart rate (HR) response. SETTING: Tertiary hospital and university. PARTICIPANTS: Participants included 73 individuals 4 weeks to 6 months post-mTBI and a comparison group of 39 healthy controls (HCs). The mTBI group was further subgrouped at screening into those considering themselves asymptomatic (Asymp mTBI) ( n = 35) or symptomatic (Symp mTBI) ( n = 36). DESIGN: Observational cohort study. MAIN MEASURES: BCTT; failure rate (%), test duration (minutes), HR responses. RESULTS: : Thirty percent of the mTBI group (including 50% of the Symp and 9% of the Asymp subgroups) failed the BCTT. BCTT duration and associated overall HR change was significantly lower in the mTBI group and Symp subgroup compared with HCs. Compared with HCs maximal HR percentage was higher for the first 4 minutes of the test in the mTBI group, and for the first 2 minutes of the test for the Symp subgroup. CONCLUSIONS: Individuals post-mTBI demonstrated PSI impairment subacutely. In some individuals this was despite an initially reported absence of symptoms. The study also showed some preliminary evidence that BCTT duration and HR responses may be additionally informative post-mTBI.

Investigation of Sensorimotor Impairments in Individuals 4 Weeks to 6 Months After Mild Traumatic Brain Injury.

OBJECTIVE: To identify whether adults 4 weeks to 6 months post mild traumatic brain injury (mTBI) have sensorimotor impairments compared with controls without mTBI. A secondary aim was to determine if impairments were evident irrespective of participant perceived absence of symptoms. DESIGN: Observational cohort study. SETTING: Tertiary university and hospital. PARTICIPANTS: Participants included 113 individuals (N=113) aged 18-60 years, consisting of 39 controls with no prior concussion history and 74 individuals 4 weeks to 6 months post mTBI, of which 35 considered themselves asymptomatic (ASYMP) and 37 symptomatic (SYMP). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Assessments of oculomotor, vestibulo-ocular reflex (VOR) control, balance, single- and dual-task tandem walk, and vestibular positional testing. RESULTS: Poorer balance and tandem walk performance as well as a higher frequency of positive oculomotor, VOR, and vestibular positional tests were evident in the mTBI group compared with controls. In particular ≥2 positive oculomotor findings were evident in 53.7% of the participants with mTBI compared with 10.8 % of controls. The mTBI group who considered themselves recovered (ASYMP) demonstrated significantly increased dual-task tandem walk time, and a higher proportion 53% had ≥2 positive oculomotor tests compared with controls. CONCLUSIONS: Persistent sensorimotor impairments, particularly evidenced by disturbed oculomotor function and deficits in dual-task tandem walking were identified among adults 4 weeks to 6 months post mTBI. These disturbances were evident regardless of whether ongoing symptoms were reported. The findings support recommendations for routine clinical assessment of sensorimotor function post mTBI with implications for injury prevention.

Cervical musculoskeletal, physical and psychological factors associated with ongoing dizziness in patients with whiplash associated disorder, 12 months after undertaking a neck specific or general exercise intervention.

BACKGROUND: Exercise in the management of persistent whiplash often doesn't specifically address dizziness. This study aimed to determine cervical musculoskeletal and sensorimotor measures, quality of life and psychological factors associated with the presence of dizziness in individuals with persistent whiplash 12 months post exercise intervention commencement. METHODS: A retrospective cross sectional review of questionnaires on dizziness, physical and psychological disability, quality of life and physical measures prospectively collected from 172 individuals during a randomised controlled trial. Associations between dizziness at 12 months post intervention and possible predictors was analysed with simple and multiple logistic regression models. RESULTS: Sixty-three % reported dizziness with a mean University of California Los Angeles dizziness score of 9 (SD 5) and dizziness intensity during activity of 26 mm (SD 24). They had poorer performance on sharpened Rhomberg, Neck muscle endurance (NME), and range of motion, elevated scores on pain, Neck disability index (NDI) and psychological and quality of life measures compared to those without dizziness. Less improvement in NDI and NME flexion from baseline to 12 months post exercise commencement, along with some baseline covariates were related to persistent dizziness and explained 50% of the variance. CONCLUSION: Dizziness following exercise at 12 months post follow-up was associated with lack of improvement in NDI and NME flexion suggesting a cervicogenic role. Alternatively, the presence of dizziness may inhibit exercise response. Additional causes or contributing factors of dizziness should be investigated in those with persistent whiplash to improve quality of life.

The management experiences, needs and preferences of individuals seeking care for persistent intra-articular temporomandibular disorders: A qualitative study.

BACKGROUND: Little is known about the management experiences, needs and preferences of individuals seeking care for persistent intra-articular temporomandibular disorders (TMD). Investigating these experiences may improve understanding of the impact management has on individuals, and factors that shape these experiences. This information may advance current practice and guide future management of individuals with intra-articular TMD. OBJECTIVES: To investigate the management experiences, needs and preferences of individuals with persistent intra-articular TMD. METHODS: A qualitative study was performed. Thirteen eligible participants (mean age 32.7 years, 12 female) were recruited via purposive sampling, and interviewed using a semi-structured framework. Data were analysed using a thematic analysis approach. RESULTS: Four themes were established from interview data: (i) searching for help; (ii) wanting answers; (iii) wanting to regain control; and (iv) meeting needs, preferences and expectations, and the implications on care. Numerous factors influenced the experiences of those seeking care, including the ability to navigate care and management expectations. Specific to intra-articular TMD, the absence of pain made seeking care harder, and often, patients perceived neglect of mechanical symptoms by healthcare practitioners, which negatively impacted care. Often, those wanting management expressed the need for answers and to regain control over their jaw symptoms. CONCLUSIONS: Strategies to improve healthcare navigation are needed for those wanting help for intra-articular TMD. Within management, a person-centred approach is encouraged. Practitioners should respect individuals' specific needs and preferences, and address underlying management expectations, to facilitate positive care experiences. Consideration of symptoms other than pain in intra-articular TMD populations is paramount.

What conservative interventions improve bite function in those with temporomandibular disorders? A systematic review using self-reported and physical measures.

BACKGROUND: Bite is an important function of the human stomatognathic system. Despite this, it is commonly impaired in temporomandibular disorder (TMD) populations. The aim of this review is to evaluate the effectiveness of conservative interventions on self-reported and physical measures of bite function in individuals with TMD. METHODS: This review was performed in compliance with PRISMA guidelines. An electronic search was performed on databases including PubMed, CINAHL, Embase, and Cochrane Central. Inclusion criteria were journal articles evaluating the effect of any non-pharmacological conservative interventions on bite function in participants diagnosed with TMD. Risk of bias for individual studies was assessed using the Cochrane risk-of-bias v2 tool, and the NIH NHLBI pre-post tool. Data was synthesised based on outcome measures of bite function, and the quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: Eleven studies were eligible for this review. Interventions included splinting, photobiomodulation, needling, exercise, manual therapy, and patient education, which were evaluated using mastication-related pain, self-reported chewing difficulty, and bite force/endurance outcome measures. Findings suggested manual therapy, needling, oral splinting, exercise, and PBM interventions may improve bite function in TMD, although confidence in cumulative evidence ranged from moderate to very low. There was no evidence that patient education improved bite function. CONCLUSION: Conservative interventions may be helpful to address bite-related impairments associated with TMD, although further research is needed to improve the quality of evidence and direct clinical guidelines.

Neck pain associated with migraine does not necessarily reflect cervical musculoskeletal dysfunction.

OBJECTIVE: To identify how frequently the neck pain associated with migraine presents with a pattern of cervical musculoskeletal dysfunction akin to cervical musculoskeletal disorders, and to determine if pain hypersensitivity impacts on cervical musculoskeletal function in persons with migraine. BACKGROUND: Many persons with migraine experience neck pain and often seek local treatment. Yet neck pain may be part of migraine symptomology and not from a local cervical source. If neck pain is of cervical origin, a pattern of musculoskeletal impairments with characteristics similar to idiopathic neck pain should be present. Some individuals with migraine may have neck pain of cervical origin, whereas others may not. However, previous studies have neglected the disparity in potential origins of neck pain and treated persons with migraine as a homogenous group, which does not assist in identifying the origin of neck pain in individuals with migraine. METHODS: This cross-sectional, single-blinded study was conducted in a research laboratory at the University of Queensland, Australia. Persons with migraine (total n = 124: episodic migraine n = 106, chronic migraine = 18), healthy controls (n = 32), and persons with idiopathic neck pain (n = 21) were assessed using a set of measures typically used in the assessment of a cervical musculoskeletal disorder, including cervical movement range and accuracy, segmental joint dysfunction, neuromuscular and sensorimotor measures. Pain hypersensitivity was assessed using pressure pain thresholds and the Allodynia Symptom Checklist. People with migraine with diagnoses of comorbid neck disorders were excluded. Cluster analysis was performed to identify how participants grouped on the basis of their performance across cervical musculoskeletal assessments. Post hoc analyses examined the effects of pain hypersensitivity on musculoskeletal function, and if any symptoms experienced during testing were related to musculoskeletal function. RESULTS: Two distinct clusters of cervical musculoskeletal function were found: (i) neck function similar to healthy controls (n = 108) and (ii) neck dysfunction similar to persons with neck pain disorders (n = 69). Seventy-six of the individuals with migraine (62 with neck pain and 14 without neck pain) were clustered as having normal cervical musculoskeletal function, whereas the remaining 48 with neck pain had cervical dysfunction comparable with a neck disorder. Musculoskeletal dysfunction was not related to pain hypersensitivity or symptoms experienced during testing. CONCLUSIONS: Neck pain when present with migraine does not necessarily indicate the existence of cervical musculoskeletal dysfunction. Skilled assessment without reliance only on the person reporting symptoms is needed to identify actual cervical dysfunction. Treatments suitable for neck musculoskeletal disorders would seem inappropriate for the individuals without cervical dysfunction. Future studies evaluating any potential effects of such treatments should only select participants with neck pain of cervical origin.

Impact of accommodation, convergence and stereoacuity on perceived symptoms and surgical performance among surgeons.

BACKGROUND: Minimally invasive surgery (MIS) is not without impact on surgeons' neck/shoulder/head and eyes. However, the mechanisms for concurrent symptoms are not clear. This study aims to examine the effect of visual impairments on physical symptoms and surgical performance among surgeons performing simulated surgical tasks using two-dimensional (2D) and three-dimensional (3D) viewing modes. METHODS: Gynaecologists with experience in laparoscopy performed four simulated surgical tasks in the 2D and 3D viewing modes. Visual parameters (accommodation, convergence and stereoacuity) were measured prior to commencement. Objective performance measures were derived from the laparoscopic tasks, and surgeons also self-reported their mental and physical workload using the NASA-TLX. In addition, perceived symptoms were measured using Visual Analogue Scales, the Simulator Sickness Questionnaire and the Computer Vision Syndrome Questionnaire. RESULTS: Seventeen healthy gynaecologists participated in this study. There were significant relationships between visual impairments and both the perceived symptoms and surgical performance scores of MIS surgeons. Surgeons with a higher number of accommodation/convergence dysfunctions and/or poorer stereoacuity tended to have poorer objective performance scores on simulated surgical tasks in both viewing modes. NASA-TLX scores indicated that surgeons with poorer stereoacuity also perceived themselves to have been less successful at accomplishing tasks. However, these surgeons also reported less intense physical symptoms and simulator sickness. CONCLUSIONS: Surgeons' performance for the simulated surgical tasks correlated with visual functions, and it also impacted on the symptoms experienced. Regular screening of surgeons' vision and vision therapy may be required to decrease physical symptoms and improve surgical performance.

Is jaw muscle activity impaired in adults with persistent temporomandibular disorders? A systematic review and meta-analysis.

Understanding jaw muscle activity changes in temporomandibular disorders (TMD) is crucial to guide clinical management. The nature of these changes is currently unclear. Explore changes in jaw muscle activity in TMD. Electronic databases (PubMed, EMBASE, CINAHL, Scopus, Web of Science, Cochrane) and bibliographies were searched from inception to 9 July 2020 for eligible studies, including grey literature. Case-control and interventional studies reporting time-domain and frequency-domain electromyographic measures of jaw muscle activity in TMD and control groups were included. SIGN checklist for case-control studies was used to evaluate risk of bias. Results were pooled for meta-analysis using random-effects model. Confidence in cumulative evidence was established using American Academy of Neurology guidelines. Forty-five studies were included. Most were rated moderate risk of bias. Activity of four muscles (masseter, temporalis, lateral pterygoid, suprahyoids) was assessed across six domains (resting, clenching, chewing, swallowing, concentrating, resisted mandibular movements), with partial meta-analysis scope. Masseter and temporalis activity were significantly higher at rest (P = .05, P < .0001), but lower during brief maximal clenching (P = .005, P = .04) in TMD vs controls. Insufficient data precluded meta-analysis of remaining outcomes and subgroup analysis. Confidence in cumulative evidence ranged from moderate to very low. Changes in jaw muscle activity exist in TMD, which are both task-specific and muscle-specific. It remains unclear whether jaw muscle activity changes vary between TMD subgroups. Muscle function should be considered in clinical management of TMD. Insufficient subgroup data highlight future direction for research.

Are jaw range of motion, muscle function and proprioception impaired in adults with persistent temporomandibular disorders? A systematic review and meta-analysis.

BACKGROUND: The nature of certain musculoskeletal impairments associated with temporomandibular disorders (TMD) is unclear. Understanding impairments within TMD subgroups is important to guide management. OBJECTIVES: Characterise local musculoskeletal impairments in adults with persistent TMD. METHODS: PubMed, EMBASE, CINAHL, Scopus, Web of Science and Cochrane databases were searched from inception to 12 January 2020. Bibliographies were searched for additional articles, including grey literature. Case-control and interventional studies reporting temporomandibular range of motion (ROM), muscle function (MF) or proprioception in TMD and control groups were included. Risk of bias was assessed using SIGN checklist for case-control studies. Results were pooled using random-effects model. Confidence in cumulative evidence was determined using American Academy of Neurology guidelines. RESULTS: Sixty-six studies were included, most rated moderate risk of bias. Twelve primary outcomes were assessed, with partial scope for meta-analysis. Significant reductions were found for active maximal mouth opening (P < .00001, MD=-4.65 mm), protrusion (P < .0001, MD=-0.76 mm) and maximum bite force (P < .00001) in TMD versus controls. Subgroup analysis scope was limited. Reduced AMMO was found in myogenic TMD subgroups versus controls (P = .001, MD= -3.28 mm). Few studies measured proprioception, with high methodological variability. Confidence in cumulative evidence ranged from high to very low. CONCLUSION: ROM and bite force impairments accompany TMD. Insufficient data were available to investigate impairments within TMD subgroups. IMPLICATIONS: Several musculoskeletal impairments have been identified, which may guide clinical management of TMD. Lack of subgroup data, and data for proprioception and MF, highlights future direction for research. PROSPERO: CRD42020150734.

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.

Remote kinematic training for patients with chronic neck pain: a randomised controlled trial.

PURPOSE: To evaluate short- and intermediate-term effects of kinematic training (KT) using virtual reality (VR) or laser in patients with chronic neck pain. METHODS: A randomised controlled trial with three arms (laser, VR, control) to post-intervention (N = 90), and two arms (laser or VR) continuing to 3 months follow-up. Home training intervention was provided during 4 weeks to VR and laser groups while control group waited. OUTCOME MEASURES: Primary outcome measures included neck disability index (NDI), global perceived effect (GPE), and cervical motion velocity (mean and peak). Secondary outcome measures included pain intensity (VAS), health status (EQ5D), kinesiophobia (TSK), range, smoothness, and accuracy of neck motion as measured by the neck VR system. Measures were taken at baseline, immediately post-training, and 3 months later. RESULTS: Ninety patients with neck pain were randomised to the trial, of which 76 completed 1 month follow-up, and 56 the 3 months follow-up. Significant improvements were demonstrated in NDI and velocity with good effect sizes in intervention groups compared to control. No within-group changes were presented in the control group, compared to global improvements in intervention groups. Velocity significantly improved at both time points in both groups. NDI, VAS, EQ5D, TSK and accuracy significantly improved at both time points in VR and in laser at 3 months evaluation in all but TSK. GPE scores showed 74-84% of participants perceived improvement and/or were satisfied. Significant advantages to the VR group compared to laser were found in velocity, pain intensity, health status and accuracy at both time points. CONCLUSION: The results support home kinematic training using VR or laser for improving disability, neck pain and kinematics in the short and intermediate term with an advantage to the VR group. The results provide directions for future research, use and development. TRIAL REGISTRATION: ACTRN12615000231549.

Intra and interrater reliability and clinical feasibility of a simple measure of cervical movement sense in patients with neck pain.

BACKGROUND: Pattern tracing tasks can be used to assess cervical spine movement sense (CMS). A simple clinical measure of CMS (tracing fixed figure-of-eight (F8) and zigzag (ZZ) patterns with a head mounted laser) has been proposed and assessed in asymptomatic subjects. It is important to determine if examiner ratings of the traces are reliable and feasible for clinical use in those with neck pain. We therefore examined the intra- and inter-rater reliability of rating video recordings of the CMS tasks, and the feasibility of undertaking the tests in clinic by comparing slow motion versus real-time video ratings. METHODS: Cross-sectional study examining neck pain subjects from a physiotherapy clinic. F8 and ZZ patterns traced with a head-mounted laser pointer at two velocities (accurate; accurate & fast) were videoed and later examined. Time (total time taken to complete the pattern), error frequency (number of deviations) and error magnitude (sum of deviations multiplied by distance from the central line) were measured. Two assessors independently evaluated the laser tracing videos in slow motion; a third rated the videos in real time. Intraclass correlation coefficients (ICC) and standard error of measurements (SEM) were calculated for intra- and inter-tester reliability, and feasibility. RESULTS: Twenty neck pain patient (13 women) videos were assessed. Intra-and inter-rater reliability was substantial to almost-perfect (ICC 0.76-1.00; SEM < 0.01-2.50). Feasibility was moderate to almost-perfect (ICC 0.54-1; SEM <  0.01-2.98). CONCLUSIONS: Video (slow motion) ratings of time and errors for F8 and ZZ movement patterns in neck pain subjects showed high intra and inter-rater reliability. Achieving reliable ratings in clinic (real-time) appears feasible. Synthesising our results, the most reliable and feasible CMS ratings appear to be when the subject uses accurate rather than accurate and fast execution. The ZZ movement pattern may be superior to F8 in terms of rating. Time and error frequency for tracing F8 and ZZ as accurately as possible in determining CMS appears promising for use in clinic. Future research directions were identified.

Effects of local treatment with and without sensorimotor and balance exercise in individuals with neck pain: protocol for a randomized controlled trial.

BACKGROUND: Impaired cervical joint position sense and balance are associated with neck pain. Specific therapeutic exercise and manual therapy are effective for improving neck pain and functional ability but their effects on joint position sense and balance impairments remain uncertain. Changes in the joint position sense and balance may need to be addressed specifically. The primary objective is to investigate the most effective interventions to improve impaired cervical joint position sense and balance in individuals with neck pain. The secondary objective is to assess the effectiveness of the interventions on pain intensity and disability, pain location, dizziness symptoms, cervical range of motion, gait speed, functional ability, treatment satisfaction and quality of life. METHODS: A 2 × 2 factorial, single blind RCT with immediate, short- and long-term follow-ups. One hundred and sixty eight participants with neck pain with impaired joint position sense and balance will be recruited into the trial. Participants will be randomly allocated to one of four intervention groups: i) local neck treatment, ii) local treatment plus tailored sensorimotor exercises, iii) local treatment plus balance exercises, and iv) local treatment plus sensorimotor and balance exercises. Participants receive two treatments for 6 weeks. Primary outcomes are postural sway and cervical joint position error. Secondary outcomes include gait speed, dizziness intensity, neck pain intensity, neck disability, pain extent and location, cervical range of motion, functional ability, perceived benefit, and quality of life. Assessment will be measured at baseline, immediately after treatment and at 3, 6, 12 month-follow ups. DISCUSSION: Neck pain is one of the major causes of disability. Effective treatment must address not only the symptoms but the dysfunctions associated with neck pain. This trial will evaluate the effectiveness of interventions for individuals with neck pain with impaired cervical joint position sense and balance. This trial will impact on clinical practice by providing evidence towards optimal and efficient management. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT03149302 ). May 10, 2017.

Combined transcranial and trans-spinal direct current stimulation in chronic headache: A feasibility and safety trial for a novel intervention.

BACKGROUND: Chronic primary headache disorders are associated with frequent, severe pain and significant functional impairment, with treatment remaining challenging. OBJECTIVE: We examined the feasibility and safety of a novel brain [transcranial direct current stimulation (tDCS)] and spinal cord stimulation [trans-spinal cord direct current stimulation (tsDCS)] treatment in chronic headache. METHODS: Nine participants (3 males; aged, 40 ± 15 years) suffering from chronic daily headache, chronic tension-type headache, or chronic migraine received the combined brain and spinal cord intervention for 5 consecutive days. Stimulation was applied for a total of 40 minutes (20 minutes of tDCS followed by 20 minutes of tsDCS) at 1 mA. Pain sensitivity and headache symptoms (frequency, severity, duration, and medications recorded via a headache diary, 4 weeks before and after treatment) were assessed. RESULTS: The treatment was safe, feasible, and well tolerated. Headache frequency was reduced following the treatment (p = 0.026) in chronic tension-type headache and chronic migraine, but not in chronic daily headache. Headache severity was reduced immediately post-treatment in 67% of sessions. A trend towards a reduction in medication use was observed (p = 0.075). No changes in headache severity (p = 0.16) or duration (p = 0.34) were present. CONCLUSION: These data suggest that combined tDCS and tsDCS intervention is safe and feasible, and may improve headache frequency in patients with chronic primary headache disorders.

Neck motion kinematics: an inter-tester reliability study using an interactive neck VR assessment in asymptomatic individuals.

BACKGROUND AND PURPOSE: The use of virtual reality (VR) for assessment and intervention of neck pain has previously been used and shown reliable for cervical range of motion measures. Neck VR enables analysis of task-oriented neck movement by stimulating responsive movements to external stimuli. Therefore, the purpose of this study was to establish inter-tester reliability of neck kinematic measures so that it can be used as a reliable assessment and treatment tool between clinicians. METHODS: This reliability study included 46 asymptomatic participants, who were assessed using the neck VR system which displayed an interactive VR scenario via a head-mounted device, controlled by neck movements. The objective of the interactive assessment was to hit 16 targets, randomly appearing in four directions, as fast as possible. Each participant was tested twice by two different testers. RESULTS: Good reliability was found of neck motion kinematic measures in flexion, extension, and rotation (0.64-0.93 inter-class correlation). High reliability was shown for peak velocity globally (0.93), in left rotation (0.9), right rotation and extension (0.88), and flexion (0.86). Mean velocity had a good global reliability (0.84), except for left rotation directed movement with moderate reliability (0.68). Minimal detectable change for peak velocity ranged from 41 to 53 °/s, while mean velocity ranged from 20 to 25 °/s. CONCLUSIONS: The results suggest high reliability for peak and mean velocity as measured by the interactive Neck VR assessment of neck motion kinematics. VR appears to provide a reliable and more ecologically valid method of cervical motion evaluation than previous conventional methodologies.

Validity and intra-rater reliability of an android phone application to measure cervical range-of-motion.

BACKGROUND: Concurrent validity and intra-rater reliability using a customized Android phone application to measure cervical-spine range-of-motion (ROM) has not been previously validated against a gold-standard three-dimensional motion analysis (3DMA) system. FINDINGS: Twenty-one healthy individuals (age:31 ± 9.1 years, male:11) participated, with 16 re-examined for intra-rater reliability 1-7 days later. An Android phone was fixed on a helmet, which was then securely fastened on the participant's head. Cervical-spine ROM in flexion, extension, lateral flexion and rotation were performed in sitting with concurrent measurements obtained from both a 3DMA system and the phone.The phone demonstrated moderate to excellent (ICC = 0.53-0.98, Spearman ρ = 0.52-0.98) concurrent validity for ROM measurements in cervical flexion, extension, lateral-flexion and rotation. However, cervical rotation demonstrated both proportional and fixed bias. Excellent intra-rater reliability was demonstrated for cervical flexion, extension and lateral flexion (ICC = 0.82-0.90), but poor for right- and left-rotation (ICC = 0.05-0.33) using the phone. Possible reasons for the outcome are that flexion, extension and lateral-flexion measurements are detected by gravity-dependent accelerometers while rotation measurements are detected by the magnetometer which can be adversely affected by surrounding magnetic fields. CONCLUSION: The results of this study demonstrate that the tested Android phone application is valid and reliable to measure ROM of the cervical-spine in flexion, extension and lateral-flexion but not in rotation likely due to magnetic interference. The clinical implication of this study is that therapists should be mindful of the plane of measurement when using the Android phone to measure ROM of the cervical-spine.