Does a combination of physical training, specific exercises and pain education improve health-related quality of life in patients with chronic neck pain? A randomised control trial with a 4-month follow up

High level of post-traumatic stress symptoms in patients with chronic neck pain is associated with poor mental health but does not moderate the outcome of a multimodal physiotherapy programme

INTRODUCTION

Chronic traumatic neck pain has a high prevalence of post-traumatic stress symptoms (PTSS). However, whether PTSS moderates treatment effects is unknown. This study investigated: 1) whether PTSS was associated with patient-reported outcomes and clinical test results at baseline; 2) whether PTSS moderated the effect of a multimodal physiotherapy intervention of exercise therapy and patient education; and 3) whether adherence to the intervention differed across PTSS groups.

METHODS

Secondary data analysis from a randomized controlled trial on chronic neck pain with 12-month follow-up was conducted. Patients were divided into three groups (NT = non-traumatic, LT = traumatic low PTSS, HT = traumatic high PTSS) based on self-reported onset of pain and the Impact of Event Scale. The baseline data were used to analyze the association of PTSS with patient demographics and scores of physical and mental health-related quality of life, depression, neck-related disability, kinesiophobia, and clinical tests. Baseline, 4-month and 12-month follow-up data were analyzed to investigate possible moderating effects on outcomes. Data on adherence were collected at four months.

RESULTS

115 participants were included (NT n = 45; LT n = 46; HT n = 24). The HT group reported lower mental health scores and more depressive symptoms at baseline. PTSS did not significantly moderate the treatment effect on any outcomes. The HT group tended to have lower adherence to the multimodal physiotherapy intervention than the LT group.

CONCLUSION

For patients with traumatic neck pain, high levels of PTSS are associated with poorer psychological outcomes but do not affect the outcomes of multimodal physiotherapy intervention.

The effects of neck exercise in comparison to passive or no intervention on quantitative sensory testing measurements in adults with chronic neck pain: A systematic review

BACKGROUND

Previous systematic reviews have identified the benefits of exercise for chronic neck pain on subjective reports of pain, but not with objective measures such as quantitative sensory testing (QST). A systematic review was conducted to identify the effects of neck specific exercise on QST measures in adults with chronic neck pain to synthesise existing literature and provide clinical recommendations.

METHODS

The study protocol was registered prospectively with PROSPERO (PROSPERO CRD42021297383). For both randomised and non-randomised trials, the following databases and trial registries were searched: AMED, CINAHL, Embase, Google Scholar, Medline, PEDro, PubMed, Scopus, SPORTDiscus, Science Citation Index and Social Science Citation Index from Web of Science Core Collection, clinicaltrials.gov, GreyOpen, and ISRCTN registry. These searches were conducted from inception to February 2022 and were updated until September 2023. Reference lists of eligible studies were screened. Study selection was performed independently by two reviewers, with data extraction and quality appraisal completed by one reviewer and independently ratified by a second reviewer. Due to high heterogeneity, narrative synthesis was performed with results grouped by exercise type.

FINDINGS

Three trials were included. Risk of bias was rated as moderate and the certainty of evidence as low or moderate for all studies. All exercise groups demonstrated statistically significant improvement at an intermediate-term follow-up, with progressive resistance training combined with graded physical training demonstrating the highest certainty of evidence. Fixed resistance training demonstrated statistically significant improvement in QST measures at a short-term assessment.

INTERPRETATION

Fixed resistance training is effective for short-term changes in pain sensitivity based on low-quality evidence, whilst moderate-quality evidence supports progressive resistance training combined with graded physical training for intermediate-term changes in pain sensitivity.

Graded exercise with motion style acupuncture therapy for a patient with failed back surgery syndrome and major depressive disorder: a case report and literature review

Effective treatment of failed back surgery syndrome (FBSS) remains challenging despite urgent medical attention requirements. Depression is a contributing factor to the development and poor prognosis of FBSS, and vice versa. We report the case of a patient with FBSS and major depressive disorder (MDD) treated with graded exercise combined with motion-style acupuncture therapy (MSAT). A 53-year-old male veteran who had undergone lumbar discectomy and laminectomy with instrumented fusion was admitted to the hospital with re-current back pain and radiative pain in the left leg. The effects of failed surgery triggered MDD as a comorbidity. After a six-week routine treatment without remarkable improvement, a three-week program of graded exercise with MSAT was applied. The numeric rating scale (NRS) and short form-36 (SF-36) were used to assess low back pain with radiating leg pain, and daily functioning levels, respectively. The voluntary walking distance of the patients was measured. To analyze the therapeutic effects and other applications of the intervention, we surveyed clinical trials using MSAT or graded exercise therapy (GET). Three weeks of graded exercise with MSAT reduced physical and mental functional disabilities (SF-36, physical component: 15.0 to 37.2, mental component: 21.9 to 30.1) as well as the intensity of low back pain and/or radiative leg pain (NRS: 50 to 30). Furthermore, as the therapeutic intensity gradually increased, there was a significant corresponding increase in daily walking distance (mean daily walking distance, the first week vs. baseline, second, and third week, 3.05 ± 0.56: 2.07 ± 0.79, 4.27 ± 0.96, and 4.72 ± 1.04 km, p = 0.04, p = 0.02, and p = 0.003, respectively). Three randomized controlled trials of GET were included, all showing statistically significant antidepressant effects in the diseased population. Graded exercise with MSAT may be an effective rehabilitative therapy for patients with FBSS and MDD who have impaired daily routines.

Understanding How Patients With Lumbar Radiculopathy Make Sense of and Cope With Their Symptoms

Lumbar radiculopathy, characterized by pain radiating along a nerve root, significantly diminishes the quality of life due to its neuropathic nature. Patients' understanding of their illness and the coping strategies they employ directly influence how they manage their condition. Understanding these illness representations from the patient's perspective is crucial for healthcare providers seeking to optimize treatment outcomes. This study adopted a qualitative interpretive/constructive paradigm to explore this dynamic. A qualitative evidence synthesis approach, utilizing best-fit framework synthesis for data extraction, was applied to analyze primary qualitative studies focused on patient experiences with lumbar radiculopathy. Using SPiDER (Sample, Phenomenon of interest, Design, Evaluation, Research type) to guide the search strategy, extracted data was mapped against the Common-Sense Model of Self-Regulation (CSM) framework. Sixteen studies, with moderate to minor methodological quality concerns, were included in the analysis. Data mapping across CSM domains generated 14 key review findings. Results suggest that patients with high-threat illness representations often exhibit maladaptive coping behaviors (e.g., activity avoidance) driven by emotional responses. In contrast, problem-solving techniques appear to contribute to positive outcomes (e.g., exercise adherence and effective self-management) in patients who perceive their condition as less threatening. These findings highlight the potential benefits of interventions designed to reduce perceived threat levels and enhance self-efficacy in patients with lumbar radiculopathy, leading to improved self-management and ultimately better health outcomes.

The effectiveness of a combined exercise and psychological treatment programme on measures of nervous system sensitisation in adults with chronic musculoskeletal pain - a systematic review and meta-analysis

BACKGROUND

Quantitative sensory testing (QST) offers information regarding underlying mechanisms contributing to chronic pain (CP) in adults with musculoskeletal disorders. This review examined the use of QST measures in adults with CP following participation in a combined exercise and psychological intervention.

METHODS

The review was conducted in accordance with the PRISMA guidelines. Five databases were searched from inception to November 2022. All study designs which evaluated the effects of a combined exercise and psychological treatment on measures of nervous system sensitivity in adults with chronic musculoskeletal pain were included.

RESULTS

A total of 13 studies met the selection criteria, 10 of which were included in a meta-analysis. Local pressure pain thresholds were the most frequently used measure (n = 12 studies). Meta-analysis revealed statistically significantly improvements in favour of the combined exercise and psychological intervention group, compared to a control group, for local pressure pain threshold measures [SMD = 0.44, 95% CI 0.08-0.81, I2 = 84%], pain intensity scores [SMD=-0.89, 95% CI -1.66- -0.13, I2 = 94%] and the Central Sensitisation Inventory [SMD=-0.69, 95% CI -1.37- -0.02, I2 = 87%]. There were no significant differences found between groups for remote pressure pain thresholds, temporal summation or conditioned pain modulation.

CONCLUSIONS

The results suggest that a combined exercise and psychological intervention may lead to greater improvements in local pressure pain threshold, pain intensity and Central Sensitisation Inventory scores when compared to a control intervention in adults with CP, however these findings must be interpreted with caution as a large degree of heterogeneity was present in these results (I2: 84-94%). Further large, longitudinal studies are required using standardised QST measurement procedures and patient reported outcome measures to explore changes in nervous system sensitisation.

TRIAL REGISTRATION

This systematic review is registered with PROSPERO, ID Number CRD42022380464.

Pain neuroscience education for reducing pain and kinesiophobia in patients with chronic neck pain: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Chronic neck pain (CNP) is a common musculoskeletal disorder. Pain neuroscience education (PNE) is a promising nonpharmacological intervention for CNP, however, its effectiveness remains unclear. This systematic review and meta-analysis aimed to evaluate the effectiveness of PNE in treating CNP.

METHODS

Electronic databases from inception to February 2023 were searched for randomized controlled trials (RCTs) on the effects of PNE on CNP. The primary outcome was the change in pain intensity, and the secondary outcome was improvement in kinesiophobia, standardized using Hedges' g. Two authors independently scrutinized eligible articles, extracted data and assessed quality; a random-effects model was employed for data pooling.

RESULTS

In total, seven RCTs comprising 479 participants were included and demonstrated that PNE significantly reduced pain intensity (Hedges' g = -0.730, 95% CI = -1.340 to -0.119, p = 0.019, I2  = 89.288%). Subgroup analysis revealed that the adult group experienced significant pain reduction after PNE, whereas the adolescent group did not. PNE also reduced kinesiophobia which was evaluated in four of seven RCTs (Hedges' g = -0.444, 95% CI = -0.735 to -0.154, p = 0.003, I2  = 36.822%). The meta-regression analysis indicated that an increased intervention duration contributed to greater pain reduction. No adverse events were reported following PNE or the control treatment.

CONCLUSIONS

PNE effectively reduced pain intensity and kinesiophobia in patients with CNP. A longer PNE time leads to greater pain reduction and is more effective in adults than in adolescents. Further studies are required to examine the long-term effects on CNP management.

SIGNIFICANCE

This is the first meta-analysis evaluating the effectiveness of treating chronic neck pain with pain neuroscience education. Pain neuroscience education is successful in reducing pain and decreasing kinesiophobia in the chronic neck pain population. Longer treatment time leads to greater pain reduction.

Physical therapist-led interventions based on the biopsychosocial model provide improvement in disability and pain for spinal disorders: A systematic review and meta-analysis

OBJECTIVE

To summarize the effects of physical therapist-led interventions based on the biopsychosocial (BPS) model in spinal disorders compared to interventions with no BPS model through a systematic review and meta-analysis of randomized-controlled trials. TYPE: Systematic review and meta-analysis.

LITERATURE SURVEY

We searched the Web of Science, CENTRAL, MEDLINE, PsycINFO, CINAHL, and PEDro up to October 27, 2022.

METHODOLOGY

Pain intensity and disability were primary outcomes and psychological factors were secondary outcomes in spinal disorders. The included intervention was physical therapist-led interventions based on the BPS model. The control group received no physiotherapy intervention for BPS. Pooled effects were analyzed as standardized mean differences (SMDs) and 95% confidence intervals (CIs), and the random-effects model was used for the meta-analysis. The subgroup analysis was divided into low back pain group and neck pain group. Another subgroup analysis was conducted only of the groups that had received training of the BPS model.

SYNTHESIS

Fifty-seven studies with 5471 participants met the inclusion criteria. For pain intensity, there was a statistically significant effect for the BPS model led by physical therapists in the short, medium, and long terms. The SMDs with 95% CIs were -0.44 (-0.62, -0.27), -0.24 (-0.37, -0.12), and -0.17 (-0.28, -0.06), respectively. Outcomes were clinically significant, except in the long term. For disability, there was a statistically significant effect in the short, medium, and long terms. The SMDs with 95% CIs were -0.48 (-0.69, -0.27), -0.44 (-0.64, -0.25), and -0.37 (-0.58, -0.15), respectively. All periods were clinically significant. The quality of the evidence was low for all of the main outcomes for all of the terms.

CONCLUSION

Physical therapist-led interventions based on the BPS model effectively improve pain intensity and disability in patients with spinal disorders based on low-quality evidence.

Exercise therapy including the cervical extensor muscles in individuals with neck pain: A systematic review

OBJECTIVE

To review the use (dosage parameters and combination with other therapeutic interventions) of cervical extensor muscle exercises and their effect on pain, disability (primary outcomes), range of motion, endurance and strength (secondary outcomes) in people with neck pain.

DATA SOURCES

An extensive literature search was conducted through MEDLINE (Ovid), Scopus (Elsevier) and Physiotherapy Evidence Database (PEDro) up to May 2023. The reference lists of all included studies and relevant reviews were screened for additional studies.

REVIEW METHODS

Randomised controlled trials reporting the use of cervical extensor muscle exercises (alone or combined) applied to adults with idiopathic or traumatic neck pain were included. Study selection, data extraction and critical appraisal (PEDro assessment scale) were performed by two blinded reviewers. Data extraction included dosage parameters, other modalities combined with these exercises and outcomes.

RESULTS

Thirty-five randomised controlled trails (eight of which were complementary analyses) with 2409 participants fulfilled the inclusion criteria. Twenty-six were of moderate to high quality. In most studies, cervical extensor muscle exercises were combined with various other therapeutic modalities and applied at different dosages. Only two studies (one high and one low quality) specifically assessed their effectiveness. The high-quality study showed significant improvements in neck pain and disability, pressure point threshold and neck mobility after both low load and high load training for 6 weeks.

CONCLUSION

The results suggest cervical extensor muscle exercises may reduce neck pain and disability; however firm conclusions cannot be drawn because of the few studies that addressed this question and the heterogeneity of the dosage parameters.

Training-induced hypoalgesia and its potential underlying mechanisms

It is well-established that a single bout of exercise can reduce pain sensitivity (i.e., exercise-induced hypoalgesia) in healthy individuals. However, exercise-induced hypoalgesia is often impaired in individuals with chronic pain. This might suggest that repeated bouts of exercise (i.e., exercise training) are needed in order to induce a reduction in pain sensitivity (i.e., training-induced hypoalgesia) among individuals with chronic pain, given that a single bout of exercise seems to be insufficient to alter pain. However, the effect of repeated bouts of exercise on pain sensitivity and its underlying mechanisms remain poorly understood. Therefore, the purpose of this review was to provide an overview of the existing literature on training-induced hypoalgesia, as well as discuss potential mechanisms of training-induced hypoalgesia and offer considerations for future research. Existing literature suggests that training interventions may induce hypoalgesic adaptations potentially driven by central nervous system and immune system factors. However, the limited number of randomized controlled trials available, along with the lack of understanding of underlying mechanisms, provides a rationale for future research.

Combining Cognitive Behavioral Therapy for Insomnia and Chronic Spinal Pain Within Physical Therapy: A Practical Guide for the Implementation of an Integrated Approach

Most people who have nonspecific chronic spinal pain (nCSP) report comorbid insomnia. However, in current treatment strategies for nCSP, insomnia is usually not addressed. Considering the bidirectional interaction between pain and sleep and its underlying psychophysiological mechanisms, insomnia may increase the risk of developing adverse physical and psychological health outcomes and should thus no longer be left untreated. As suggested by previous pilot studies, adding cognitive behavioral therapy for insomnia to the contemporary evidence-based biopsychosocial physical therapy approach may also improve pain outcomes in nCSP. This manuscript aims to provide practical guidelines on hybrid physical therapy, including the combination of the following components: (1) pain neuroscience education (eg, to reconceptualize pain) and cognition-targeted exercise therapy (eg, graded exposure to functional daily life movements), and (2) cognitive behavioral therapy for insomnia (sleep psychoeducation, behavioral and cognitive therapy, correction of sleep hygiene, and relaxation therapy) can be deployed for the management of patients who have chronic spinal pain. Impact. Due to the major impact sleep disturbances have on pain and disability, insomnia as a comorbidity should no longer be ignored when treating patients with chronic spinal pain.

Reliability, Validity, and Responsiveness of the Craniocervical Flexion Test in People Who Are Asymptomatic and Patients With Nonspecific Neck Pain: A Systematic Review and Meta-Analysis

OBJECTIVE

Among the tests designed to evaluate neck neuromuscular function, the craniocervical flexion test (CCFT) assesses the function of the deep cervical flexor muscles (DCFs). The purpose of this study was to conduct a review and meta-analysis of published articles about all measurement properties of the different CCFT versions (CCFT Activation Score [CCFT-AS], CCFT Performance Index [CCFT-PI], CCFT Cumulative Performance Index [CCFT-CPI], and CCFT alternative procedures for measuring activation level (CCFT1) or endurance (CCFT2) in people who were asymptomatic and people with nonspecific neck pain.

METHODS

PubMed Central, MEDLINE, CINAHL, Scopus, Web of Science, and Google Scholar were searched from inception to June 30, 2020. Studies were selected if they reported data on reliability, validity, and/or responsiveness of the CCFT in adults who were asymptomatic or who had nonspecific neck pain. Two reviewers independently selected the studies, conducted quality assessment, and extracted the results. All meta-analyses used a random-effects model.

RESULTS

Twenty-one studies met the inclusion criteria. The rating of interrater reliability (assessed for CCFT-AS and CCFT-CPI) was positive only for using the test at a group level. The same rating was ascribed to the intrarater reliability of CCFT-AS, CCFT1, and CCFT2, whereas CCFT-PI and CCFT-CPI showed positive intrarater reliability for assessment of individuals as well. CCFT validity was rated as positive for expressly assessing DCF action when measuring DCF activation through electromyography-not through ultrasonography-or craniocervical flexion motion as well as for differentiating patients who were asymptomatic and patients who had nonspecific neck pain (only the AS version). CCFT validity was rated as negative for investigating the CCFT performance correlation with the severity of nonspecific neck pain. CCFT responsiveness was rated as negative.

CONCLUSIONS

The CCFT is a potentially useful tool for detecting impairment in DCF control and identifying patients who have nonspecific neck pain and who would benefit from a targeted intervention. However, the limited reliability affects its suitability for that purpose. Further research on the reliability of different CCFT versions in which the raters are thoroughly trained is strongly recommended.

IMPACT

The CCFT might help to detect impairment in DCF control and identify patients who have nonspecific neck pain and who would benefit from a targeted intervention. However, the poor reliability of most versions of the test greatly limits its application in clinical practice. Only CCFT-PI and CCFT-CPI seem reliable enough to help in clinical decision-making at the individual level.

The effectiveness of telerehabilitation-based structured exercise therapy for chronic nonspecific neck pain: A randomized controlled trial

INTRODUCTION

The aim of this research was to investigate the effects of telerehabilitation-based remote supervised or unsupervised structured exercise therapy on pain, disability, and quality of life related to chronic nonspecific neck pain.

METHOD

The study was designed as a single-blinded randomized controlled trial. Sixty-six eligible chronic nonspecific neck pain patients were randomized across three groups: remote supervised group (RSG, n = 22), unsupervised group (UG, n = 22), and waitlist control group (CG, n = 22). Progressive structured exercise therapy program was delivered weekly to patients in remote supervised group and unsupervised group to perform four days a week for four weeks. Remote supervised group was supervised by videoconference and text message. Pain, disability, and quality of life of participants were assessed at baseline, week 2, and post-therapy.

RESULTS

Post-therapy pain and disability total change scores were -3.64 (95% CI -4.85 to -2.42) and -7.27 (95% CI -11.05 to -3.50) for remote supervised group compared with a change of -2.44 (95% CI -3.46 to -1.43) and -5.77 (95% CI -8.54 to -3.01) for unsupervised group, respectively. Post-therapy, quality of life improvements were greater for remote supervised group than unsupervised group overall (general health; remote supervised group: 19.01 (95% CI 6.86 to 31.16), unsupervised group: 12.50 (95% CI 4.79 to 20.21), and physical health; remote supervised group: 18.35 (95% CI 10.35 to 26.35), unsupervised group: 7.31 (95% CI 0.01 to 14.60)). Significant improvements in psychological health and environment-telerehabilitation for remote supervised group were not seen for unsupervised group and outcomes differences did not reach significance for control group (p > 0.05) post-therapy, except environment-telerehabilitation.

DISCUSSION

Structured exercise therapy can improve chronic nonspecific neck pain outcomes when remotely supervised or unsupervised. Structured exercise therapy content and frequent communication are important for remote chronic nonspecific neck pain management.

Effects of workplace upper extremity resistance exercises on function and symptoms of workers at a tertiary hospital: a randomized controlled trial protocol

Background

Work-related musculoskeletal disorders (WRMDs) are often caused by inadequate use of the musculoskeletal system during work. Evidence suggests that multimodal intervention through exercises, massage, education, and ergonomic guidelines reduces pain and symptoms in the neck and upper extremities and help to prevent musculoskeletal disorders. The purpose of this study will be to assess the additive effectiveness of a specific and individualized workplace strengthening exercise program to an ergonomic guidance in reducing fatigue, pain and discomfort in the upper extremities and neck perceived by workers.

Methods

This trial was designed according to the Consolidated Standards of Reporting Trials - CONSORT guidelines. Participants will be employees of a tertiary hospital, with any complaints of pain or discomfort in the upper extremities during the past 12 months, without clinical musculoskeletal diagnosis. 166 participants will be randomized into parallels groups as control and workplace exercises. The primary outcomes will be Numerical Pain Scale, isokinetic muscle strength of abduction and isometric handgrip strength. Secondary outcomes on discomfort, fatigue, work capacity and dysfunction will be assessed by QuickDASH, Patient Specific Functional Scale, Neck Disability Index, Need for recovery, Work Ability Index self-report questionnaires and FIT-HANSA performance test. The Ergonomic Work Analysis will be done by Quick Expose Check, RULA, REBA, RARME, ROSA and HARM risk assessment ergonomic tools. We will analyze the difference between baseline and 12 weeks of intervention by T test of independent samples (95% confidence interval, p < 0.05). Clinical significance will be analyzed by the minimum clinically important difference and effect size by Cohen index. The association between the variables will be analyzed by construct validity with the hypothesis of correlations between pain and muscle strength, strength and functionality and strength and fatigue.

Discussion

Although studies have shown promise outcomes for workplace exercises as an available therapeutic resource used to minimize complaints of pain and discomfort related to work, the results of this study aim to bring evidence about the benefit of a specific resistance exercise as an effective modality to facilitate mechanisms of neuromuscular adaptations, with gradual and posterior hypertrophy in the later phases.

Trial registration

(NCT04047056, https://clinicaltrials.gov/ct2/show/NCT04047056?term=NCT04047056&draw=2&rank=1) on Dec 03, 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05059-5.

Does group-based cognitive therapy improve functional ability, pain, catastrophic thoughts and quality of life in patients with persistent low back pain and psychological risk factors? A randomised controlled trial in a secondary care setting

OBJECTIVE

To investigate the effects of a group-based cognitive behavioural intervention for patients with persistent low back pain (LBP) and psychological risk factors referred to secondary care.

DESIGN

A randomised controlled trial.

SETTING

Silkeborg Regional Hospital, Denmark.

SUBJECTS

A total of 136 participants with chronic LBP and psychological risk factors.

INTERVENTIONS

Participants were randomised to the standard care group, including examination by a rheumatologist and/or a physiotherapist, or the intervention group, including standard care plus a multidisciplinary group-based pain management programme.

MAIN MEASURES

Patient-reported outcomes were collected at baseline and after 6 and 12 months. The primary outcome was disability (Roland Morris Disability Questionnaire). Secondary outcomes included low back pain intensity, pain catastrophising, health-related quality of life, and sick leave.

RESULTS

Among 136 participants, 68 (mean age: 41.7 years (SD 11.8)) were randomised to standard care and 68 (mean age: 46.0 years (SD 10.8)) were randomised to the intervention group. Except for age, baseline characteristics were comparable between groups. 12-month follow-up was completed by 92.6% in the intervention group and 80.9% in the standard care group. Both groups achieved significant improvements on disability, with a reduction of -4.8 points (SD 6.1) in the intervention group compared to -3.7 points (SD 5.2), resulting in an insignificant difference between groups. No significant differences were found in the secondary outcomes.

CONCLUSION

A group-based pain management programme was no more effective than standard care for patients with persistent LBP and psychological risk factors.

The Unknown Prevalence of Postrandomization Bias in 15 Physical Therapy Journals: A Methods Review

OBJECTIVES

To determine the prevalence of prospective clinical trial registration and postrandomization bias in published musculoskeletal physical therapy randomized clinical trials (RCTs).

DESIGN

A methods review.

LITERATURE SEARCH

Articles indexed in MEDLINE and published between January 2016 and July 2020 were included.

STUDY SELECTION CRITERIA

Two independent blinded reviewers identified the RCTs using Covidence. We included RCTs related to musculoskeletal interventions that were published in International Society of Physiotherapy Journal Editors member journals.

DATA SYNTHESIS

Data were extracted independently for the variables of interest from the identified RCTs by 2 blinded reviewers. The data were presented descriptively or in frequency tables.

RESULTS

One hundred thirty-eight RCTs were identified. One third of RCTs were consistent with their prospectively registered intent (49/138); consistency with prospectively registered intent could not be determined for two thirds (89/138) of the RCTs. Four RCTs (8%)reported inconsistent results with the primary aims and 7 (14%) with the outcomes from the prospective clinical trial registry, despite high methodological quality (Physiotherapy Evidence Database [PEDro] scale score). Differences between prospectively registered and non-prospectively registered RCTs for PEDro scale scores had a medium effect size (r = 0.30). Two of 15 journals followed their clinical trial registration policy 100% of the time; in 1 journal, the published RCTs were consistent with the clinical trial registration.

CONCLUSION

Postrandomization bias in musculoskeletal physical therapy RCTs could not be ruled out, due to the lack of prospective clinical trial registration and detailed data analysis plans. J Orthop Sports Phys Ther 2021;51(11):542-550. Epub 21 Sep 2021. doi:10.2519/jospt.2021.10491.

Can Acupuncture Improve Chronic Spinal Pain? A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To investigate the effect and safety of acupuncture for the treatment of chronic spinal pain.

METHODS

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, the WHO Clinical Trial Registry, and the US National Library of Medicine clinical trial registry were searched from January 1, 2000, to November 1, 2019. Randomized controlled trials (RCTs) involving patients with chronic spinal pain treated by acupuncture versus sham acupuncture, no treatment, or another treatment were included.

RESULTS

Data was extracted from 22 RCTs including 2588 patients. Pooled analysis revealed that acupuncture can reduce chronic spinal pain compared to sham acupuncture (weighted mean difference [WMD] -12.05, 95% confidence interval [CI] -15.86 to -8.24), mediation control (WMD -18.27, 95% CI -28.18 to -8.37), usual care control (WMD -9.57, 95% CI -13.48 to -9.44), and no treatment control (WMD -17.10, 95% CI -24.83 to -9.37). In terms of functional disability, acupuncture can improve physical function at immediate-term follow-up (standardized mean difference [SMD] -1.74, 95% CI -2.04 to -1.44), short-term follow-up (SMD -0.89, 95% CI -1.15 to -0.62), and long-term follow-up (SMD -1.25, 95% CI -1.48 to -1.03).

CONCLUSION

In summary, compared to no treatment, sham acupuncture, or conventional therapy such as medication, massage, and physical exercise, acupuncture has a significantly superior effect on the reduction in chronic spinal pain and function improvement. Acupuncture might be an effective treatment for patients with chronic spinal pain and it is a safe therapy.

Aerobic Physical Exercise for Pain Intensity, Aerobic Capacity, and Quality of Life in Patients With Chronic Pain: A Systematic Review and Meta-Analysis

BACKGROUND

Currently, chronic pain is a disabling condition that is difficult to manage, which generates a high burden on health systems. The objective is to determine the effects of aerobic physical exercise in adults with chronic pain.

METHODS

A systematic review of searches in databases including MEDLINE, LILACS, ScienceDirect, PEDro, OTseeker, The Cochrane Library, EBSCO, and Google Scholar was conducted. The search process was carried out until July 31, 2020, and the study selection process was independently carried out through a criteria analysis for each phase. Outcome measures were chosen: aerobic capacity, physical function, quality of life, and pain.

RESULTS

Twenty-seven studies were included in which aerobic exercise was considered as an option to treat chronic pain. These studies showed significant results compared with other treatment options in terms of pain measurements (-0.22 [-0.42 to -0.03]) and aerobic capacity. For quality of life, there were significant improvements in the physical function component over the mental health component evaluated with the short form health survey-36/12.

CONCLUSION

Aerobic exercise is a nonpharmacological therapeutic option for treatment. Also, aerobic capacity and endurance improved when this type of exercise was prescribed, thus resulting in a substantial improvement in the quality of life of people suffering from chronic pain.

Characteristics affecting cervical sagittal alignment in patients with chronic low back pain

BACKGROUND

Sagittal spino-pelvic malalignment in patients with chronic low back pain (CLBP) have been reported in the past, which may also affect cervical spine lesions. The purpose of this study is to investigate the cervical alignment in patients with CLBP.

METHOD

Of the patients who visited an orthopedic specialist due to low back pain lasting more than three months, 121 cases (average 71.5-years-old, 46 male and 75 female) with whole standing spinal screening radiographs were reviewed (CLBP group). Cervical parameters included cervical lordosis (CL), C2-C7 sagittal vertical axis (C2-7 SVA), and the T1 slope minus CL (T1S-CL). Cervical spine deformity was defined as C2-7 SVA >4 cm, CL <0°, or T1S-CL ≧20°. We compared the cervical alignment of these patients with 121 age and gender matched volunteers (control group).

RESULTS

The prevalence of cervical spine deformity was significantly higher in the CLBP group than in the control group (20.7% vs. 10.7%, P = 0.034). The mean CL was smaller in the CLBP group than in the control group (16.1° vs. 21.4°, P = 0.002). The mean C2-7 SVA was 17.6 mm vs. 18.7 mm in the CLBP group and in the control group, respectively (P = 0.817). The mean T1S-CL was larger in the CLBP group than in the control group (9.1° vs. 3.5°, P < 0.001). Multivariate analysis showed that people with CLBP were more likely to have cervical deformities than people without CLBP (odds ratio 2.16, 95% confidence interval 1.006 to 4.637).

CONCLUSIONS

This study results suggest that people with CLBP present with worse cervical sagittal alignment and higher prevalence of cervical spine deformities than age and gender matched volunteers with no CLBP. This means CLBP impacts cervical spine lesions negatively.

LEVEL OF EVIDENCE

Ⅳ.

The feasibility of gym-based exercise therapy for patients with persistent neck pain

Background and aims Persistent neck pain is common and can be detrimental to the health of those who are affected. This is particularly common after neck trauma, where it poses a challenge to health care providers. In this paper, we present the design and results of a study aimed primarily at assessing the feasibility of a supervised exercise intervention for patients with persistent neck pain after trauma. As a secondary aim, we analyzed the results of the intervention. Methods We designed and conducted a feasibility study using a mixed methods design. Ten patients with persistent neck pain (nine with a history of neck trauma and one with sudden onset of neck pain) were recruited from a specialized pain rehabilitation center and underwent a gym-based individual exercise therapy intervention, supervised by a physical therapist. We assessed the feasibility of the exercise therapy intervention based on the experiences of the patients and physical therapists. We analyzed both quantitative and qualitative results using descriptive statistics, content analysis, and questionnaires. Results The study found the exercise therapy to be a feasible alternative for patients with persistent neck pain. Most of the practical aspects of the intervention and study were executed as planned, and the study was well received by the patients, who found it a valuable part of their rehabilitation. In the quantitative analysis, improvements were observed on the Neck Disability Index, numerical rating scale for pain, EuroQol 5D, and physical activity, with scores on the Neck Disability Index showing a statistically significant improvement. Scores on the Disability Rating Index showed a non-significant deterioration. The qualitative analysis uncovered one overarching theme and four themes for the patients and three themes for the physical therapist. Conclusions The exercise therapy intervention seems to be feasible with favorable outcomes for the patients. The quantitative and qualitative analyses demonstrated exercise therapy to be beneficial from several different perspectives. However, although structured, the training needs customization and individual adaption from a clinical reasoning perspective in order to meet each patient's individual needs. Implications This study shows that supervised gym-based exercise therapy is feasible for patients with severe, persistent neck pain. It facilitates and motivates the execution of a larger, controlled trial, which might then lead to a new and potentially effective addition to the toolbox of all health care providers treating patients with persistent neck pain.

Association between muscle strength, upper extremity fatigue resistance, work ability and upper extremity dysfunction in a sample of workers at a tertiary hospital

Background

Upper extremity musculoskeletal disorders negatively affect ability to perform activities of daily living, self-care and work. Therefore, outcome measurements that address muscle strength, fatigue resistance, functionality and work physical capacity must be defined to assess and plan specific actions to minimize them.

Objective

To investigate the association of upper extremity muscle strength with upper extremity fatigue resistance, work ability and upper extremity dysfunction in a sample of workers from a tertiary hospital.

Methods

Shoulder and elbow isokinetic strength were assessed by Biodex System 4™, isometric hand grip by JAMAR™, upper extremity fatigue resistance by Functional Impairment Test Hand and Neck/Shoulder/Arm (FIT-HaNSA), ability to work by the Work Ability Index and upper extremity dysfunction by the Quick-Disabilities of the Arm, Shoulder and Hand QuickDASH-Br questionnaire. The Nordic questionnaire and Numeric Pain Rating Scale (NPRS) were used for pain description. The associations were analysed by Spearman’s correlation coefficient (rho) (p < 0.05).

Results

Twenty-seven participants: 59.2% women; mean age 46 years old; 70.3% obese/overweight; 62.9% active with predominantly dynamic muscle contraction work. Besides predominance of good to moderate work ability (81.4%) and comorbidities (37%), all participants had symptoms of the upper extremities for at least 12 months, with a predominance of low-intensity in the shoulder (55.5%). In addition, 88.8% reported pain in other segments. Muscle strength of abduction (rho = 0.49), adduction (rho = 0.40), internal rotation (rho = 0.44) and hand grip (rho = 0.68) presented moderate correlation with FIT-HaNSA. Hand grip (rho = − 0.52) showed moderate correlation with upper extremity dysfunction.

Conclusions

The results of this preliminary study suggested the association of shoulder strength with fatigue resistance. Also, hand grip strength was associated with upper extremity dysfunction and fatigue resistance. No association was found with the Work Ability Index in this sample. So, it is suggested that hand grip and shoulder strength could be outcome measurements used for future interventions focused on upper extremity preventive exercises to improve strength and fatigue resistance of workers at risk for the development of musculoskeletal disorders. Other individual, psychosocial and organizational risk factors must also be considered as influences on upper extremity function.

Influence of Baseline Kinesiophobia Levels on Treatment Outcome in People With Chronic Spinal Pain

BACKGROUND

Pain neuroscience education (PNE) combined with cognition-targeted exercises is an effective treatment for people with chronic spinal pain (CSP). However, it is unclear why some patients benefit more from this treatment. We expect that patients with more pronounced maladaptive pain cognitions, such as kinesiophobia, might show poorer treatment responses.

OBJECTIVE

The objective of this study was to assess the influence of baseline kinesiophobia levels on the treatment outcomes of PNE combined with cognition-targeted exercises in people with CSP. This study was a secondary analysis of a multicenter, double-blind, randomized controlled trial.

METHODS

Outcome measures included a numeric rating scale for pain (NRS), the Pain Disability Index (PDI), quality of life (Medical Outcomes Study 36-Item Health Survey [SF-36]), Pain Catastrophizing Scale (PCS), and Pain Vigilance and Awareness Questionnaire (PVAQ). Regression models were built using treatment (PNE plus cognition-targeted exercises or neck/back school plus general exercises), baseline scores on the Tampa Scale for Kinesiophobia (TSK), and time (in months) as independent variables.

RESULTS

A significant 3-way interaction effect was found for the models of PDI, PCS, PVAQ, and the SF-36 mental domain, with estimates of -0.01, -0.01, -0.01, and 0.07, respectively. A significant effect of baseline TSK scores was found for the physical domain of the SF-36 (estimate = -3.16). For the NRS, no significant effect of baseline TSK scores was found.

CONCLUSION

Our findings indicate that PNE plus cognition-targeted exercises can successfully decrease the unfavorable influence of pretreatment kinesiophobia on disability, mental health, pain catastrophizing, and hypervigilance over time in people with CSP. Nevertheless, higher scores in pretreatment kinesiophobia might still be a key factor for the lack of improvement in pain catastrophizing and hypervigilance following treatment. Regardless of the followed treatment program, pretreatment kinesiophobia was also shown to significantly influence physical health in people with CSP.

IMPACT

This study provides novel insight into the unfavorable influence of kinesiophobia on treatment outcomes in people with CSP, and how PNE plus cognition-targeted exercises can limit this impact. Because this is one of the first studies to research possible predictors of this experimental treatment, its findings motivate further exploration of other possible influencing factors for treatment success of PNE plus cognition-targeted exercises.

LAY SUMMARY

People with chronic spinal pain and high levels of fear of movement were found to have worse treatment outcomes compared to people with low levels of fear of movement. However, our experimental treatment, which includes pain neuroscience education combined with exercise therapy that reintroduces specific movements patients might fear, can decrease this negative influence of fear of movement in these patients.

Immediate clinical benefits of combining therapeutic exercise and interferential therapy in adults with chronic neck pain: a randomized controlled trial

BACKGROUND

Therapeutic exercise is highly recommended for the management of non-specific neck pain and has shown promising results combined with interferential current therapy. Yet, the clinical relevance of the pooled effect of these approaches remains uncertain.

AIM

To investigate the immediate clinical effect size of combining therapeutic exercise and interferential therapy, compared with the isolated use of therapeutic exercise, in adults with chronic non-specific neck pain.

DESIGN

Randomized, single-blinded, controlled, superiority trial.

SETTING

Outpatients, primary care center.

POPULATION

Forty-nine adults with chronic non-specific neck pain.

METHODS

Participants with neck pain (grades I or II) lasting for more than 12 weeks were allocated to a therapeutic exercise plus interferential currents group (n = 25) or to a therapeutic exercise only group (n = 24). All individuals underwent treatment 5 times a week for 2 weeks. The primary outcome was current neck pain intensity (11-point numeric pain rating scale). Secondary outcomes included neck disability (Neck Disability Index) and active cervical range-of-movement (CROM device). Measurements were taken at baseline and immediately after treatment. An intention-to-treat analysis was carried out. To quantify the effect size of the interventions, the relative risk, the absolute and relative risk reduction, and the number needed to treat were calculated.

RESULTS

A significant time*group effect was found for pain intensity, disability, and neck flexion and right rotation (all, p < 0.05). In the analysis for treatment benefit, the number needed to treat was 2 (95% CI: 2 to 4, p < 0.001) for neck pain and disability, and 3 (95% CI: 2 to 11, p = 0.029) for neck flexion.

CONCLUSIONS

Adding interferential therapy to therapeutic exercise is clinically more effective than therapeutic exercise alone to immediately improve neck pain and disability, but not active cervical range-of-movement, in adults with persistent neck pain.

CLINICAL REHABILITATION IMPACT

Our results suggest that this multimodal intervention can be a useful strategy for rehabilitation of patients with non-specific neck pain. This is the first study on this topic reporting findings in terms of clinical relevance, which is key to transfer research evidence into practice.

Effect of Multi-Modal Therapies for Kinesiophobia Caused by Musculoskeletal Disorders: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to identify the effect of multi-modal therapies that combined physical and psychological therapies for kinesiophobia caused by musculoskeletal disorders compared with uni-modal therapy of only phycological therapy or psychological therapy. The search terms and their logical connector were as following: (1) “kinesiophobia” at the title or abstract; and (2) “randomized” OR “randomized” at title or abstract; not (3) ”design” OR “protocol” at the title. They were typed into the databases of Medline (EBSCO), PubMed, and Ovid, following the different input rules of these databases. The eligibility criteria were: (1) Adults with musculoskeletal disorders or illness as patients; (2) Multi-modal therapies combined physical and psychological therapy as interventions; (3) Uni-modal therapy of only physical or psychological therapy as a comparison; (4) The scores of the 17-items version of the Tampa Scale of Kinesiophobia as the outcome; (5) Randomized controlled trials as study design. As a result, 12 studies were included with a statistically significant polled effect of 6.99 (95% CI 4.59 to 9.38). Despite a large heterogeneity within studies, multi-modal therapies might be more effective in reducing kinesiophobia than the unimodal of only physical or psychological therapy both in the total and subdivision analysis. The effect might decrease with age. What’s more, this review’s mathematical methods were feasible by taking test-retest reliability of the Tampa Scale of Kinesiophobia into consideration.

The Effects of Exercise Dosage on Neck-Related Pain and Disability: A Systematic Review With Meta-analysis

OBJECTIVE

To (1) evaluate whether exercise therapy is effective for managing neck pain, and (2) investigate the relationship between exercise therapy dosage and treatment effect.

DESIGN

Intervention systematic review with meta-analysis and meta-regression.

LITERATURE SEARCH

An electronic search of 6 databases was completed for trials assessing the effects of exercise therapy on neck pain.

STUDY SELECTION CRITERIA

We included randomized controlled trials that compared exercise therapy to a no-exercise therapy control for treating neck pain. Two reviewers screened and selected studies, extracted outcomes, assessed article risk of bias, and rated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

DATA SYNTHESIS

Data were pooled using random-effects meta-analysis. We used meta-regression to analyze the effect of exercise dosage on neck pain and disability.

RESULTS

Fourteen trials were included in the review. Seven trials were at high risk of bias, 4 were at unclear risk of bias, and 3 were at low risk of bias. Exercise therapy was superior to control for reducing pain (visual analog scale mean difference, -15.32 mm) and improving disability (Neck Disability Index mean difference, -3.64 points). Exercise dosage parameters did not predict pain or disability outcomes.

CONCLUSION

Exercise was beneficial for reducing pain and disability, regardless of exercise therapy dosage. Therefore, optimal exercise dosage recommendations remain unknown. We encourage clinicians to use exercise when managing mechanical neck pain. J Orthop Sports Phys Ther 2020;50(11):607-621. doi:10.2519/jospt.2020.9155.

Electromyographic Evaluation of Specific Elastic Band Exercises Targeting Neck and Shoulder Muscle Activation

Background: Specific strength training at a high intensity is effective in reducing work related neck/shoulder pain. However, it remains to be documented as to which exercises most specifically target neck and shoulder muscles at high activation level while using simple equipment as e.g., elastic bands. We hypothezised that selected exercises would specifically target the respective muscles, as follows: (1) shrugs and reverse flyes: the upper trapezius muscle, (2) cervical extension and lateral flexion: the upper neck extensor muscle, and (3) cervical flexion and rotation: the sternocleidomastoideus muscle. Methods: Eleven healthy males (25.9 ± 1.4 years, BMI 24.3 ± 1.4) with no neck/shoulder pain (VAS = 0) performed the six exercises with elastic bands at 12RM (repetition maximum) and 20RM in a randomized order. Electromyography was bilaterally recorded from the three muscles and it was normalized to maximal voluntary activation (%MVE). Exercises that evoke more than 60%MVE were considered as high intensity activation. Results: High muscle activation level was attained during 12RM in the upper trapezius muscle during shrugs (100.3 ± 29.8%MVE) and reverse flyes (91.6 ± 32.8%MVE) and in the upper neck extensor muscle during cervical extension (67.6 ± 29.8%MVE) and shrugs (61.9 ± 16.8%MVE). In the sternocleidomastoideus muscle, the highest activity was recorded during cervical flexion (51.7 ± 16.4%MVE) but it did not exceed 60%MVE. The overall activity was ~10% higher during 12RM when compared to 20RM. Conclusion: The simple exercises shrugs and reverse flyes resulted in high intensity activation of both the upper trapezius and neck extensors, while no exercises activated sternocleidomastoideus at high intensity.

Visceral Origin: An Underestimated Source of Neck Pain. A Systematic Scoping Review

The diagnosis of neck pain is challenging. Many visceral disorders are known to cause it, and clinical practice guidelines recommend to rule them out during neck pain diagnosis. However, the absence of suspicion of any cause impedes one from establishing that specific aetiology as the final diagnosis. To investigate the degree of consideration given to visceral aetiology, a systematic search of trials about neck pain was carried out to evaluate their selection criteria. The search yielded 309 eligible articles, which were screened by two independent reviewers. The PEDro scale score was used to assess the methodological quality of the studies. The following information was retrieved: number of authors affiliated to a clinical or non-clinical institution, number of citations in the Web of Science, study aims, characteristics of participants, and eligibility criteria. The top 15 most cited trials, and the 15 most recent studies about treatment efficacy in neck pain, published in first quartile journals of the Journal Citation Reports, were selected. Females represented 67.5% of participants. A single study was of poor methodological quality (4/10). Based on the eligibility criteria of the articles that were systematically reviewed, it would appear that visceral aetiology was not considered in eighty percent of the trials on neck pain, showing a low level of suspicion both in research and clinical settings.

Best Evidence Rehabilitation for Chronic Pain Part 4: Neck Pain

Neck pain, whether from a traumatic event such as a motor vehicle crash or of a non-traumatic nature, is a leading cause of worldwide disability. This narrative review evaluated the evidence from systematic reviews, recent randomised controlled trials, clinical practice guidelines, and other relevant studies for the effects of rehabilitation approaches for chronic neck pain. Rehabilitation was defined as the aim to restore a person to health or normal life through training and therapy and as such, passive interventions applied in isolation were not considered. The results of this review found that the strongest treatment effects to date are those associated with exercise. Strengthening exercises of the neck and upper quadrant have a moderate effect on neck pain in the short-term. The evidence was of moderate quality at best, indicating that future research will likely change these conclusions. Lower quality evidence and smaller effects were found for other exercise approaches. Other treatments, including education/advice and psychological treatment, showed only very small to small effects, based on low to moderate quality evidence. The review also provided suggestions for promising future directions for clinical practice and research.

Effect of specific deep cervical muscle exercises on functional disability, pain intensity, craniovertebral angle, and neck-muscle strength in chronic mechanical neck pain: a randomized controlled trial

Background

Exercise is known to be an important component of treatment programs for individuals with neck pain. The study aimed to compare the effects of semispinalis cervicis (extensor) training, deep cervical flexor (flexor) training, and usual care (control) on functional disability, pain intensity, craniovertebral (CV) angle, and neck-muscle strength in chronic mechanical neck pain.

Methods

A total of 54 individuals with chronic mechanical neck pain were randomly allocated to three groups: extensor training, flexor training, or control. A Thai version of the Neck Disability Index, numeric pain scale (NPS), CV angle, and neck-muscle strength were measured at baseline, immediately after 6 weeks of training, and at 1- and 3 -month follow-up.

Results

Neck Disability Index scores improved significantly more in the exercise groups than in the control group after 6 weeks training and at 1- and 3-month follow-up in both the exten-sor (P=0.001) and flexor groups (P=0.003, P=0.001, P=0.004, respectively). NPS scores also improved significantly more in the exercise groups than in the control group after 6 weeks’ training in both the extensor (P<0.0001) and flexor groups (P=0.029. In both exercise groups, the CV angle improved significantly compared with the control group at 6 weeks and 3 months (extensor group, P=0.008 and P=0.01, respectively; flexor group, P=0.002 and 0.009, respectively). At 1 month, the CV angle had improved significantly in the flexor group (P=0.006). Muscle strength in both exercise groups had improved significantly more than in the control group at 6 weeks and 1- and 3-month follow-up (extensor group, P=0.04, P=0.02, P=0.002, respectively; flexor group, P=0.002, P=0.001, and 0.001, respectively). The semispinalis group gained extensor strength and the deep cervical flexor group gained flexor strength.

Conclusion

The results suggest that 6 weeks of training in both exercise groups can improve neck disability, pain intensity, CV angle, and neck-muscle strength in chronic mechanical neck pain.

Trial registration

NCT02656030

Health related quality of life improvement in chronic non-specific neck pain: secondary analysis from a single blinded, randomized clinical trial

BACKGROUND

Chronic non-specific neck pain is related to limited cervical mobility, impaired function, neck muscles myofascial pain syndrome, and stress at work. The aforementioned factors are strongly related and may lead to a negative impact on health-related quality of life. There are some effective conservative Physical therapy interventions for treating chronic non-specific neck pain. Currently, Deep Dry Needling is emerging as an alternative for improving symptoms and consequently, the quality of life in patients with chronic non-specific neck pain. The purpose of the study was to examine the effectiveness of Deep Dry Needling of myofascial trigger points on health-related quality of life improvement, as a secondary analysis, in people with chronic non-specific neck pain.

METHODS

A randomized parallel-group blinded controlled clinical trial was conducted at a public Primary Health Care Centre in Madrid, Spain, from January 2011 to September 2014. One hundred thirty subjects with chronic non-specific neck pain and active myofascial trigger points in neck muscles were randomly allocated into two groups. Subjects in the intervention group (n = 65) were treated with Deep Dry Needling in active myofascial trigger points plus stretching in neck muscles; Control group (n = 65) received only stretching. Both interventions lasted 2 weeks, 2 sessions per week. Health-related quality of life was measured with Short Form-36 (SF-36), in 5 assessments: at baseline, after intervention period; and at 1, 3 and 6 months after intervention.

RESULTS

For both groups, SF-36 mean values increased in all dimensions in every assessment. Significant differences (p < 0.05) were found in favor of the intervention group for all dimensions at the last assessment. For some dimensions (physical function, physical role, social function and vitality), the evidence was more consistent from the beginning.

CONCLUSIONS

Deep Dry Needling plus stretching is more effective than stretching alone for Health-related quality of life improvement, especially for physical function, physical role, social function and vitality dimensions, in people with non-specific neck pain.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN22726482 . Registered 9 October 2011.

Effects of preoperative mental distress versus surgical modality, arthroplasty, or fusion on long-term outcome in patients with cervical radiculopathy

OBJECTIVE

Several efforts have been made to investigate the long-term efficacy of artificial disc replacement surgery compared with that of fusion after decompression for the treatment of cervical degenerative disc disease and radiculopathy. However, research on the impact of mental distress on surgical treatment outcome has been sparse. The aim of the authors was to investigate the potential predictive value of preoperative risk factors in determining long-term outcome.

METHODS

A total of 153 patients (mean age 47 years) with single- or double-level cervical degenerative disc disease and radiculopathy were randomly assigned to undergo either anterior cervical discectomy and fusion (n = 70) or artificial disc replacement (n = 83). The primary outcome was the Neck Disability Index (NDI) score, a patient-reported function score that ranges from 0% to 100%; higher scores indicate greater disability. Preoperative variables such as sex, age, smoking status, employment status, having a strenuous job, neck pain duration, arm pain duration, amount of regular exercise, Hospital Anxiety and Depression Scale (HADS) score, NDI score, whether surgery was performed on 1 or 2 levels, and allocated treatment were analyzed in multiple linear regression models with the 5-year NDI score as the outcome.

RESULTS

A total of 47 (31%) patients had either a HADS anxiety or HADS depression score of 10 points or higher. High values on the preoperative HADS were a negative predictor of outcome (p = 0.009). Treatment allocation had no effect on 5-year NDI scores (p = 0.32).

CONCLUSIONS

Preoperative mental distress measured with the HADS affects long-term outcome in surgically treated patients with cervical radiculopathy.

Pain extent is more strongly associated with disability, psychological factors, and neck muscle function in people with non-traumatic versus traumatic chronic neck pain: a cross sectional study

BACKGROUND

Neck pain is presented with a variety of symptoms. Pain drawings are used in the clinical assessment of people with neck pain. Pain extent based upon pain drawings can be associated with different factors. However, the relation between pain extent and function limitations in people with neck pain is unknown.

AIM

The aim of this study was to explore the associations between pain extent extracted from pain drawings, and self-reported neck pain related disability, quality of life, depression, self-reported neck function, cervical muscle function, and range of motion in a chronic neck pain population and possible differences depending on the onset of pain being traumatic or not.

DESIGN

Observational cross-sectional study.

SETTING

Primary and secondary healthcare.

POPULATION

People with chronic neck pain (N.=200) of traumatic (N.=120) or non-traumatic (N.=80) origin.

METHODS

Outcome measures: Pain extent, Short Form 36 Health Survey Physical and Mental Component Summary (SF36-PCS/MCS), TAMPA Scale of Kinesiophobia (TSK), Beck Depression Inventory-II (BDI-II), Neck Disability Index (NDI), Craniocervical Flexion Test (CCFT), Cervical Extension Test (CE), and Cervical Range of Motion (ROM). Correlations were calculated using Spearman or Pearson correlation coefficients. Correlation between pain extent and outcomes were calculated for all participants collectively and then separately for those with a traumatic versus non-traumatic neck pain.

RESULTS

Overall, significant positive correlations were observed between pain extent and NDI (r=0.33; P<0.001), BDI-II (r=0.29; P<0.001), CCFT (r=-0.24; P=0.001) and CE (r=-0.19; P=0.006). No difference was observed in pain extent between patients with traumatic (mean: 7.6±6.7%) and non-traumatic onset (7.4±6.8%). Pain extent correlated moderately with NDI, BDI-II, TSK, CCFT and CE in those with non-traumatic onset, but weakly with NDI, BDI-II, CCFT and CE in those with trauma-induced chronic neck pain.

CONCLUSIONS

Pain extent is correlated with patient-reported neck function, depression and muscle test performance in people with chronic neck pain. These correlations were strongest in those with non-traumatic neck pain.

CLINICAL REHABILITATION IMPACT

Patients presenting with larger pain areas show poorer psychological and physical function. Pain drawings can therefore indicate a need for addressing these functions in management of a person with chronic neck pain.

Blended-Learning Pain Neuroscience Education for People With Chronic Spinal Pain: Randomized Controlled Multicenter Trial

BACKGROUND

Available evidence favors the use of pain neuroscience education (PNE) in patients with chronic pain. However, PNE trials are often limited to small sample sizes and, despite the current digital era, the effects of blended-learning PNE (ie, the combination of online digital media with traditional educational methods) have not yet been investigated.

OBJECTIVE

The study objective was to examine whether blended-learning PNE is able to improve disability, catastrophizing, kinesiophobia, and illness perceptions.

DESIGN

This study was a 2-center, triple-blind randomized controlled trial (participants, statistician, and outcome assessor were masked).

SETTING

The study took place at university hospitals in Ghent and Brussels, Belgium.

PARTICIPANTS

Participants were 120 people with nonspecific chronic spinal pain (ie, chronic neck pain and low back pain).

INTERVENTION

The intervention was 3 sessions of PNE or biomedically focused back/neck school education (addressing spinal anatomy and physiology).

MEASUREMENTS

Measurements were self-report questionnaires (Pain Disability Index, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, Illness Perception Questionnaire, and Pain Vigilance and Awareness Questionnaire).

RESULTS

None of the treatment groups showed a significant change in the perceived disability (Pain Disability Index) due to pain (mean group difference posteducation: 1.84; 95% CI = -2.80 to 6.47). Significant interaction effects were seen for kinesiophobia and several subscales of the Illness Perception Questionnaire, including negative consequences, cyclical time line, and acute/chronic time line. In-depth analysis revealed that only in the PNE group were these outcomes significantly improved (9% to 17% improvement; 0.37 ≤ Cohen d ≥ 0.86).

LIMITATIONS

Effect sizes are small to moderate, which might raise the concern of limited clinical utility; however, changes in kinesiophobia exceed the minimal detectable difference. PNE should not be used as the sole treatment modality but should be combined with other treatment strategies.

CONCLUSIONS

Blended-learning PNE was able to improve kinesiophobia and illness perceptions in participants with chronic spinal pain. As effect sizes remained small to medium, PNE should not be used as a sole treatment but rather should be used as a key element within a comprehensive active rehabilitation program. Future studies should compare the effects of blended-learning PNE with offline PNE and should consider cost-effectiveness.

Is the word "osteoporosis" a reason for kinesiophobia?

BACKGROUND

Osteoporosis is a systemic skeletal disease that causes weakening of the bones which increases the risk of fractures. Especially hip fractures lead to substantial physical, psychological, social and economic burden both for the patients and the governments. Exercises and physically active life style are essential preventive and therapeutic approaches for osteoporosis. Kinesiophobia is an irrational fear of movement due to the belief of susceptibility to injury. It is associated with lower levels of physical activity. Having a diagnosis of osteoporosis without an adequate education about the disease may lead to kinesiophobia in patients due to an illogical belief about increasing possibility of falls and related fractures during physical activity.

AIM

To evaluate relationship between the diagnosis of osteoporosis and kinesiophobia.

DESIGN

Case-control study.

SETTING

Division of Rheumatology, Department of Rehabilitation, University Hospital.

POPULATION

Fifty-four subjects with osteoporosis and fifty-four healthy subjects who were age- and gender-matched.

METHODS

Demographic data of subjects (age, gender, weight, height, body mass index, disease duration) were recorded. The Tampa Kinesiophobia Scale (TKS) was applied to determine the level of fear of movement. Hospital Anxiety and Depression Scale (HADS) was used to evaluate mood status. The Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO-41) was performed to assess health related quality of life. Scores were compared between groups by Mann Whitney U test. Correlation between kinesiophobia and QUALEFFO-41 scores was performed by Spearman rank correlation.

RESULTS

Subjects with osteoporosis had higher level of kinesiophobia than healthy control subjects. There was no significant difference in HADS scores between the groups. QUALEFFO-41 total score was worse in subjects with osteoporosis than those in healthy subjects. There was a significant correlation between QUALEFFO-41 total score and kinesiophobia score in subjects with osteoporosis.

CONCLUSIONS

Subjects with osteoporosis have higher levels of kinesiophobia compared to age and gender-matched healthy subjects. Kinesiophobia may affect the quality of life in subjects with osteoporosis.

CLINICAL REHABILITATION IMPACT

As physical activity is essential for bone and general health, individuals should be educated and counseled about osteoporosis and the importance of physical activity to overcome kinesiophobia.

Responsiveness of clinical tests for people with neck pain

BACKGROUND

Responsiveness of a clinical test is highly relevant in order to evaluate the effect of a given intervention. However, the responsiveness of clinical tests for people with neck pain has not been adequately evaluated. The objective of the present study was to examine the responsiveness of four clinical tests which are low cost and easy to perform in a clinical setting, including the craniocervical flexion test, cervical active range of movement, test for the cervical extensors and pressure pain threshold testing.

METHODS

This study is a secondary analysis of data collected in a previously published randomised controlled trial. Participants were randomized to either physical training, exercises and pain education combined or pain education only. Participants were tested on the clinical tests at baseline and at 4-month follow-up. An anchor-based approach using Receiver Operator Characteristics (ROC) curves was used to evaluate responsiveness of the clinical tests. The Neck Disability Index was used to discriminate between those who had improved and those who were unchanged at the 4-month follow-up. Minimum Clinically Important Difference (MCID), together with sensitivity, specificity, positive and negative predictive values, in addition to positive and negative likelihood ratios were calculated.

RESULTS

In total, 164 participants completed the 4 month follow up. One-hundred forty four participants were classified as unchanged whereas 20 patients were considered to be improved. Twenty-six participants didn't complete all of the clinical tests, leaving a total of 138 to be included for analyses. Area Under Curve (AUC) ranged from 0.50-0.62 for the clinical tests, and were all below an acceptable level. MCID was generally large, and the corresponding sensitivity and specificity was low with sensitivity ranging from 20 to 60%, and specificity from 54 to 86%. LR+ (0.8-2.07) and LR- (0.7-1.1) showed low diagnostic value for all variables, with PPV ranging from 12.1 to 26.1 and NPV ranging from 84.7 to 89.2.

CONCLUSION

Responsiveness of the included clinical tests was generally low when using change in NDI score as the anchor from baseline to the 4-month follow up. Further investigations of responsiveness are warranted, possibly using other anchors, which to a higher degree resemble similar dimensions as the clinical tests.

Chronic neck pain patients with traumatic or non-traumatic onset: Differences in characteristics. A cross-sectional study

BACKGROUND AND AIMS

Patients with chronic neck pain can present with disability, low quality of life, psychological factors and clinical symptoms. It is unclear whether patients with a traumatic onset differ from those with a non-traumatic onset, by having more complex and severe symptoms. The purpose of this study was to investigate the clinical presentation of chronic neck pain patients with and without traumatic onset by examining cervical mobility, sensorimotor function, cervical muscle performance and pressure pain threshold in addition to the following self-reported characteristics: quality of life, neck pain and function, kinesiophobia, depression, and pain bothersomeness.

METHODS

This cross-sectional study included 200 participants with chronic neck pain: 120 with traumatic onset and 80 with non-traumatic onset. Participants were recruited from physiotherapy clinics in primary and secondary health care. For participants to be included, they were required to be at least 18 years of age, have had neck pain for at least 6 months, and experienced neck-related activity limitation as determined by a score of at least 10 on the Neck Disability Index. We conducted the following clinical tests of cervical range of motion, gaze stability, eye movement, cranio-cervical flexion, cervical extensors, and pressure pain threshold. The participants completed the following questionnaires: physical and mental component summary of the Short Form Health Survey, EuroQol-5D, Neck Disability Index, Patient-Specific Functional Scale, Pain Bothersomeness, Beck Depression Inventory-II, and TAMPA scale of kinesiophobia. The level of significance for all analyses was defined as p<0.01. Differences between groups for the continuous data were determined using either a Student's t-test or Mann Whitney U test.

RESULTS

In both groups, the majority of the participants were female (approximately 75%). Age, educational level, working situation and sleeping patterns were similar in both groups. The traumatic group had symptoms for a shorter duration (88 vs. 138 months p=0.001). Participants in the traumatic group showed worse results on all measures compared with those in the non-traumatic group, significantly on neck muscle function (cervical extension mobility p=0.005, cranio-cervical flexion test p=0.007, cervical extensor test p=0.006) and cervical pressure pain threshold bilateral (p=0.002/0.004), as well on self-reported function (Neck Disability Index p=0.001 and Patient-Specific Functional Scale p=0.007), mental quality of life (mental component summary of the Short Form Health Survey p=0.004 and EuroQol-5D p=0.001) and depression (Beck Depression Inventory-II p=0.001).

CONCLUSIONS

This study showed significant differences between chronic neck pain patients when differentiated into groups based on their onset of pain. However, no specific clinical test or self-reported characteristic could differentiate between the groups at an individual patient level.

IMPLICATIONS

Pressure pain threshold tests, cervical muscle performance tests and patient-reported characteristics about self-perceived function and psychological factors may assist in profiling chronic neck pain patients. The need for more intensive management of those with a traumatic onset compared with those with a non-traumatic onset should be examined further.