Differences in isometric neck muscle strength between healthy controls and women with chronic neck pain: the use of a reliable measurement

Cagnie B, Cools A, De Loose V, Cambier D, Danneels L. Differences in isometric neck muscle strength between healthy controls and women with chronic neck pain: the use of a reliable measurement.

Objectives

To determine the intra- and interrater reliability of the Biodex isokinetic dynamometer to measure the maximal isometric strength of the cervical flexors and extensors, to develop an age- and sex-based normative database in a healthy population, and to evaluate the differences in neck strength between women with chronic neck pain and healthy controls.

Design

Cross-sectional.

Setting

Physical and rehabilitation medicine department.

Participants

Ninety-six healthy volunteers (4 age groups: 20-29, 30-39, 40-49, 50-59y; each consisting of 12 men and 12 women) and 30 women with chronic neck pain.

Interventions

Not applicable.

Main Outcome Measures

Peak isometric strength of the cervical muscles was tested for flexion and extension by using the Biodex isokinetic dynamometer. The intra- and interrater reliability of the protocol was evaluated in 12 volunteers.

Results

The reliability for strength was high for both flexion and extension (intraclass correlation coefficient, .92-.96). The mean peak torque for flexion and extension was significantly higher in men (24Nm, 36.4Nm, respectively) compared with women (16.6Nm, 26.5Nm, respectively) (P<.001). Peak torque production for extension was significantly lower in the patient group (22.3Nm) compared with the healthy female control group (26.5Nm) (P=.003). No significant differences in flexion strength between patient and female control group were found.

Conclusions

Results show a high degree of intra- and interrater reliability in measuring isometric neck muscle strength when using the Biodex isokinetic dynamometer. The use of normative data for neck strength when evaluating patients with neck disorders needs to take sex into account. The current study has shown that women with chronic neck pain have lower neck muscle strength in extension than the healthy female group.     

Inter-rater reliability of McKenzie assessment in patients with neck pain

Objectives

To determine inter-rater agreement on diagnostic category using the Mechanical Diagnosis and Therapy (MDT) classification system for neck pain. If the diagnostic category was derangement syndrome, inter-rater agreement on the subcategory and the directional preference of treatment was also determined.

Design

Clinicians viewed videotaped MDT examinations of 20 patients with neck pain and rated the MDT diagnosis independently for each patient. If the diagnostic category was derangement syndrome, the subcategory and directional preference of treatment were also rated.

Setting

Private physical therapy outpatient clinics and a university clinical laboratory.

Participants

Fifty-four clinicians trained in MDT for neck pain from the USA and Canada, and 20 adult patients with neck pain.

Main outcome measures

Inter-rater agreement for MDT diagnosis, derangement subcategory and directional preference of treatment was determined using Kappa and percentage agreement.

Results

Overall, agreement was of moderate clinical significance for diagnosis [κ = 0.55, P < 0.001, confidence intervals (CI) 0.52 to 0.58, 67%], derangement subcategory (κ = 0.47, CI 0.44 to 0.50, P < 0.001; 63%) and directional preference of treatment (κ = 0.46, CI 0.43 to 0.49, P < 0.05; 70%).

Conclusions

Clinicians trained in MDT for neck pain demonstrate moderate agreement when classifying the diagnostic category and treatment for neck pain.     

History, physical examination, and differential diagnosis of neck pain

Neck pain is a common and costly problem in Western society. Nearly two-thirds of the US population will experience neck pain at some point in their lives, and at any one time about 5% of the US population has sufficient neck pain to cause disability. Although the likelihood of defining a precise cause of neck pain is low, if the etiology and structural source can be determined, they may be valuable in directing treatment. Patient history serves to identify red flags and yellow flags, whereas the physical examination, guided by the history, serves primarily to confirm those suspicions.     

Conservative treatment for neck pain: medications, physical therapy, and exercise

This article offers conservative treatment strategies for patients suffering from musculoskeletal causes of neck pain. Basic pharmacology is reviewed, including that of opioids, nonsteroidal anti-inflammatory drugs, adjuvants, and topical analgesics. Moreover, indications for therapeutic exercise, manual therapy, and modalities are reviewed, along with any supporting literature. Treatment considerations with each category of medication and physical therapy are discussed. This article is meant to serve as a resource for physicians to tailor conservative treatment options to their individual patients.     

Cognitive Functional Therapy (CFT) for chronic non-specific neck pain

This case report presents the effect of Cognitive Functional Therapy (CFT) in a patient with chronic non-specific neck pain. The patient believed that pain signified tissue damage, and demonstrated pain catastrophizing, hypervigilance, stress sensitivity, and movement impairment of the neck, during extension and rotation. The CFT intervention integrated a cognitive approach with manual therapy and active exercises to encourage the patient to trust her neck again. One month after the first appointment, the patient had recovered confidence, and the pain and disability had disappeared almost entirely.     

The interrater reliability of a pain mechanisms-based classification for patients with nonspecific neck pain

ObjectiveTo examine the interrater reliability and agreement of a pain mechanisms-based classification for patients with nonspecific neck pain (NSNP).MethodsDesign – Observational, cross-sectional reliability study with a simultaneous examiner design. Setting: University hospital-based outpatient physical therapy clinic. Participants: A random sample of 48 patients, aged between 18 and 75 years old, with a primary complaint of neck pain was included. Interventions: Subjects underwent a standardized subjective and clinical examination, performed by 1 experienced physical therapist. Two assessors independently classified the participants’ NSNP on 3 main outcome measures. Main outcome measures: The Cohen kappa, percent agreement, and 95% confidence intervals (CIs) were calculated to determine the interrater reliability for (1) the predominant pain mechanism; (2) the predominant pain pattern; and (3) the predominant dysfunction pattern (DP).ResultsThere was almost perfect agreement between the 2 physical therapists’ judgements on the predominant pain mechanism, kappa = .84 (95% CI, .65–1.00), p < .001. There was substantial agreement between the raters’ judgements on the predominant pain pattern and predominant DP with respectively kappa = .61 (95% CI, .42–.80); and kappa = .62 (95% CI, .44–.79), p < .001.Conclusion(s)The proposed classification exhibits substantial to almost perfect interrater reliability. Further validity testing in larger neck pain populations is required before the information is used in clinical settings.Clinical trial registration numberNCT03147508 (https://clinicaltrials.gov/ct2/show/NCT03147508).     

The clinical significance of immediate symptom responses to manual therapy treatment for neck pain: Observational secondary data analysis of a randomized trial

The objective was to explore aspects of symptom responses to manual therapy treatment for neck pain. An observational secondary data analysis of a randomized trial was conducted. 181 participants seeking care from a physiotherapist or chiropractor for a new episode of neck pain were included. Outcome variables included recovery-time and participant-perceived effect of treatment (GPE) at 3-months. There was a significant reduction of ≥1.4 points (95%CI 1.2–1.5) in pre- and post-treatment pain scores at each occasion of treatment. There was also small but significant increases in pain of ≤0.7 points (95%CI 0.4–1.0) between each treatment session, without regression to the preceding pre-treatment level. The relationships between immediate post-treatment effects and longer-term outcomes were explored using multivariate regression analyses. There was significant univariate association between recovery time and cumulative post-treatment changes in pain from the second, third and fourth (Exp(B) = 1.2) treatment sessions, as well as the presence of post-treatment headache (Exp(B) = 0.7) and other minor adverse symptoms (Exp(B) = 0.6). There was significant univariate association between GPE at 3-months and cumulative pain responses from first (B = 0.2), second (B = 0.3), third (B = 0.3) and fourth (B = 0.4) treatment sessions. The change in pain after session 1 was independently associated with GPE (B = 0.2). There was a consistently significant difference of ≥0.7 points (95%CI 0.43–0.89) in the different methods of reporting pain. Our results showed that manual therapy for neck pain involves a “two-steps forward, one-step back” recovery pattern. Whilst minor adverse events are undesirable, they do not seem to be significantly associated with long-term recovery.     

Immediate effects of the central posteroanterior mobilization technique on pain and range of motion in patients with mechanical neck pain

Purpose.?To determine the immediate effects of the central posteroanterior (PA) mobilization technique on both pain and active cervical range of motion in patients with mechanical neck pain presenting with central or bilateral symptoms.

Methods.?A randomized controlled trial was conducted in 60 patients who were randomly allocated into either ‘central PA’ or ‘random’ mobilization group. Two physical therapists and one assessor participated. Outcome measures included neck pain at rest, pain on the most painful movement, and active cervical range of motion taken before and immediately 5?min after the mobilization treatment.

Results.?Significant reductions in pain at rest and on the most painful movement were noted within-group comparisons (p?<?0.001). However, the ‘central PA’ mobilization group obtained a significantly greater reduction in pain on the most painful movement than the ‘random’ mobilization group (p?<?0.05). Both mobilization techniques had no effects on the active cervical range of motion. However, the differences in the means of pain reduction between both mobilization techniques were modest (<10?mm).

Conclusion.?The clinical recommendation regarding the selection of the central PA mobilization technique for treating patients with central or bilateral mechanical neck pain is therefore arguably.     

A mechanical diagnosis and treatment (MDT) approach for a patient with discogenic low back pain and a relevant lateral component: a case report

Patients with a lateral lumbar shift are often managed with a frontal plane, manual correction first described by McKenzie. However, there is a subset of patients that require a frontal plane correction who do not demonstrate a lateral shift. Both of these patient groups have what is termed a relevant lateral component (RLC). The subset of patients who have an RLC, without a shift, has received very little attention in the literature to date. This case report describes a patient with no shift who had a remarkable disc extrusion identified by magnetic resonance imaging (MRI). The patient responded nicely to a combination of frontal and transverse plane loading strategies in six treatments using the mechanical diagnosis and treatment (MDT) evaluation and treatment system. The case report is unique in the literature in that it describes a patient with no apparent frontal plane, lumbar deformity that had documented evidence of a large disc extrusion and who responded to a variation of McKenzie’s flexion–rotation mobilization. The centralization phenomenon was demonstrated immediately when a non-weight bearing, multiplanar, loading strategy was administered.     

Program of therapeutic exercises associated with electrotherapy in patients with chronic neck pain: Protocol for a randomized controlled trial

Conservative treatment is the most common clinical management for the proper rehabilitation of patients with chronic neck pain, and there is a trend towards the use of therapeutic exercise. However, some uncertainty about the efficacy of therapeutic exercises remains, and it is necessary to conduct more studies with high methodological rigor, especially in regard to multimodal treatment, as in the combination of therapeutic exercises with electrotherapy. Thus, the objective of this study will be to evaluate the clinical effects of adding high- and low-frequency transcutaneous electrical nerve stimulation (TENS) in a program of specific therapeutic exercises for the treatment of patients with chronic neck pain. Sixty participants will be randomized into three groups: therapeutic exercise + placebo TENS group (n = 20), therapeutic exercise + high-frequency TENS group (n = 20), and therapeutic exercise + low-frequency TENS group (n = 20). Eight treatment sessions will be performed, and participants will be evaluated before and after the eight sessions and four weeks after the end of treatment. The Numerical Rating Pain Scale, Neck Disability Index, Pain-Related Catastrophizing Thoughts Scale, and Tampa Scale for Kinesiophobia will be used for participant evaluations. In the statistical analysis, a linear mixed model will be applied considering interaction between time and group factors. The addition of this electrotherapeutic modality to a therapeutic exercise program is expected to generate clinical improvements for patients with chronic neck pain, and if the results demonstrate benefits in the treatment group, this form of care could be used.     

Effectiveness of mechanical diagnosis and therapy in patients with back pain who meet a clinical prediction rule for spinal manipulation

Recently a clinical prediction rule (CPR) for lumbar regional spinal thrust manipulation (STM) has shown predictive success in patients with back pain who met specific selection criteria. The purpose of this study was to compare the effectiveness of STM and mechanical diagnosis and therapy (MDT) in patients who are positive for the STM CPR. Following initial examination, 31 participants were randomized to the STM group (n = 16) and to the MDT group (n = 15). Two weeks following initial examination, four participants chose to cross over from the STM group to the MDT group. The Oswestry Disability Index (ODI), Fear-Avoidance Beliefs Questionnaire work subscale (FABQw), and the Numerical Pain Rating Scale (NPRS) were administered initially, and at 2-weeks and 4 week follow-up (discharge). Data were analyzed to determine changes in ODI and NPRS scores from initial examination through one month. Of the 31 participants, one patient who met only three of five selection criteria and four others who chose to switch groups were removed from the analysis. Both groups exhibited statistically significant improvements in ODI and NPRS scores from baseline to final visit but there was no significant difference in scores between groups at 4 weeks. In this sample of patients, the selection criteria for this CPR were not exclusive for lumbopelvic STM. Mechanical diagnosis and therapy was an equally viable choice for these patients.     

Comparative effectiveness of proprioceptive neuromuscular facilitation and passive vertebral mobilization for neck disability in patients with mechanical neck pain: A randomized controlled trial

ObjectiveTo compare the effectiveness of Proprioceptive Neuromuscular Facilitation (PNF) and Passive Vertebral Mobilization (PVM), both when given in adjunct to routine physical therapy (RPT), on neck disability in patients with mechanical neck pain (MNP).MethodsA single-blinded randomized controlled trial was conducted on 90 patients with MNP at the National Institute of Rehabilitation Medicine, Islamabad, Pakistan, from September 2015 to March 2018. The participants aged between 18 and 65 years were recruited through a simple random sampling technique and randomly divided into three groups i.e. PNF + RPT, PVM + RPT, and RPT. Each participant was evaluated pre and post-intervention (after four weeks) through neck disability index (NDI). The data were analyzed by using SPSS version 21.ResultsThe MANOVA was run on the pre-post mean differences of the variables to determine the changes within the groups which showed that the participants improved significantly in all the groups in terms of the NDI components and overall NDI score (p < 0.05). Univariate analysis with the post-hoc comparison and Tuckey HSD correction was used to determine the differences between the groups which showed that there was a significant difference between the interventional groups in the overall pain intensity, as well as pain experienced while performing personal care activities, reading, doing work, driving, sleeping, recreation and in the total NDI score (p < 0.05).ConclusionPVM (in adjunct to RPT) was more effective than PNF (in adjunct to RPT) for the patients with MNP to manage themselves in daily activities.Clinical trial registrationNCT03813680 (at clinicaltrials.gov) (https://clinicaltrials.gov/ct2/show/NCT03813680)     

When should a cervical collar be used to treat neck pain?

Neck pain is one of the most prevalent and costly health problems in the United States. It remains a complex, subjective experience with a variety of musculoskeletal causes. Although, cervical collars are a seemingly benign intervention, they can have adverse effects, especially when used for longer periods of time. It is feared that a long period of immobilization, can result in atrophy-related secondary damage. Many physicians cite anecdotal evidence of their clinical utility and soft cervical collars are often prescribed by convention for patients complaining of neck pain. The use of cervical collars to treat neck pain is an area of controversy. This review article examines the current evidence and studies related to recommending cervical collars for neck pain of a variety of etiologies.     

Acute neck pain: cervical spine range of motion and position sense prior to and after joint mobilization

Despite the relatively high prevalence of cervical spine pain, the efficacy of treatment procedures is limited. In the current study, range of motion and proprioception was assessed prior to and after specific cervical spine mobilisation techniques. A 44-year-old male office worker presented with a history of cervical pain of 1 day duration. He had woken with pain, stiffness and a loss of range of motion. Examination findings indicated pain to be at C5–6 on the left side. Measurement of maximal three-dimensional cervical motion was undertaken using a Zebris system. A position matching task tested the individual's ability to actively reposition their head and neck. The treatment undertaken involved grade III down-slope mobilisations on the left side at C5–6 and C6–7 in supine lying. This technique was then progressed by placing the subject in an upright sitting position, and sustained natural apophyseal glides were performed at C6.Immediately following the treatment, the patient reported a considerable decrease in pain, less difficulty in movement and reduced stiffness. Motion analyses showed the most marked percentage improvements in range of motion after treatment were in flexion (55%), extension (35%), left rotation (56%), and left lateral flexion (22%). Ipsilateral lateral flexion with axial rotation was also notably improved following treatment. No change in proprioceptive ability was found following the treatment. The findings showed that the application of standardised specific mobilisation techniques led to substantial improvements in the range of motion and the restitution of normal coupled motion.     

Work and neck pain: A prospective study of psychological, social, and mechanical risk factors

To determine the impact of occupational psychological/social and mechanical factors on neck pain, a prospective cohort study with a follow-up period of 2 years was conducted with a sample of Norwegian employees. The following designs were tested: (i) cross-sectional analyses at baseline (n = 4569) and follow-up (n = 4122), (ii) prospective analyses with baseline predictors, (iii) prospective analyses with average exposure over time [(T1 + T2)/2] as predictor, and (iv) prospective analyses with measures of change in exposure from T1 to T2 as predictors. A total of 2419 employees responded to both the baseline and follow-up questionnaire. Data were analyzed using ordinal logistic regression. After adjustment for age, sex, neck pain at T1, and other exposure factors that had been estimated to be confounders, the most consistent risk factors were role conflict (highest OR 2.97, 99% CI: 1.29-6.74) and working with arms raised to or above shoulder level (highest OR 1.37, 99% CI: 1.05-1.78). The most consistent protective factors were empowering leadership (lowest OR 0.53, 99% CI: 0.35-0.81) and decision control (lowest OR 0.60, 99% CI: 0.36-1.00). Hence, psychological and social factors are important precursors of neck pain, along with mechanical factors. Although traditional factors such as quantitative demands and decision control play a part in the etiology of neck pain at work, in this study several new factors emerged as more important.     

The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial

Objective

To determine the effect of mobilization and routine physiotherapy on pain, disability, neck range of motion (ROM) and neck muscle endurance (NME) in patients having chronic mechanical neck pain (NP).

Vacuum myofascial therapy device for non-specific neck pain. A single blind randomized clinical trial

ObjectivesThis study aimed to investigate the efficacy of a vacuum myofascial therapy device (VT) for improving pressure pain thresholds (PPTs), range of motion (ROM), neck pain-related disability, pain, and quality of life in patients with non-specific neck pain.MethodsA randomized controlled trial in which thirty-eight participants with non-specific neck pain (NP) were randomly assigned to either an experimental (VT) or a comparison physical therapy program (PTP) group. The VT group (n = 19) received five sessions of treatment with a vacuum myofascial therapy device while the PTP group (n = 19) received five sessions of massage, ultrasound therapy (US), and transcutaneous electric nerve stimulation (TENS) over two weeks. The outcome measures were the numerical pain rating scale (NPRS), range of motion, quality of life (SF-12), neck disability Index (NDI), and PPTs at the end of treatment and at one-month follow-up.ResultsAlthough both groups experienced improvements in pain, neck disability, range of motion, and pressure pain, these only were statistically significant in the VT group. At one-month follow-up, the VT group still showed improvements in pain, neck disability, and range of motion.DiscussionVacuum myofascial therapy applied with a device offers similar results to other vacuum-based techniques such as cupping therapy. Moreover, in this device the parameters are digitally controlled, which allows for the precise reproduction of treatment.