Reliability and validity of the Hindi version of the Neck Pain and Disability Scale in cervical radiculopathy patients

Purpose. To assess the reliability and validity of the Neck Pain and Disability Scale (NPAD) translated into Hindi.

Method. Following a pilot study to ascertain uncertainties with existing terminology in the NPAD scale, a cervical radiculopathy patient cohort (n = 63) was assessed with the translated NPAD. Reliability was assessed by regression analysis for test-retest and by item-factor and factor-total score correlations. Face validity was compared in a cross-sectional design study with an asymptomatic group (n = 38). Convergent and divergent validity were investigated by correlating the NPAD scores with the Numerical Pain Rating Scale (NPRS) for neck and arm pain, and 10 cm long VAS Activity and VAS Depression scales.

Results. ICC values for test-retest NPAD total and factor scores were >0.92 and R² values >0.912. Pearson product moment correlation of item vs. factor scores varied from 0.17 – 0.91 and for factor vs. total scores 0.72 – 0.91. Differences in NPAD scores between the patient and the asymptomatic group were significant (t = 30.90, p < 0.05). Convergent validity was explained when Factor 2 (minus item 20) was correlated (r = 0.67) with NPRS maximum value scores. Divergent validity was illustrated by low correlation with VAS Activity (r = 0.15) and negative correlation with VAS Depression (r = ?0.80) scores.

Conclusion. Based on the results of this study, the Hindi version of the NPAD is a reliable and valid instrument for the assessment of pain and disability in cervical radiculopathy patients.     

Reliability and validity of the Hindi version of the Neck Pain and Disability Scale in cervical radiculopathy patients

PURPOSE: To assess the reliability and validity of the Neck Pain and Disability Scale (NPAD) translated into Hindi. METHOD: Following a pilot study to ascertain uncertainties with existing terminology in the NPAD scale, a cervical radiculopathy patient cohort (n = 63) was assessed with the translated NPAD. Reliability was assessed by regression analysis for test-retest and by item-factor and factor-total score correlations. Face validity was compared in a cross-sectional design study with an asymptomatic group (n = 38). Convergent and divergent validity were investigated by correlating the NPAD scores with the Numerical Pain Rating Scale (NPRS) for neck and arm pain, and 10 cm long VAS Activity and VAS Depression scales. RESULTS: ICC values for test-retest NPAD total and factor scores were >0.92 and R2 values >0.912. Pearson product moment correlation of item vs. factor scores varied from 0.17 - 0.91 and for factor vs. total scores 0.72 - 0.91. Differences in NPAD scores between the patient and the asymptomatic group were significant (t = 30.90, p < 0.05). Convergent validity was explained when Factor 2 (minus item 20) was correlated (r = 0.67) with NPRS maximum value scores. Divergent validity was illustrated by low correlation with VAS Activity (r = 0.15) and negative correlation with VAS Depression (r = -0.80) scores. CONCLUSION: Based on the results of this study, the Hindi version of the NPAD is a reliable and valid instrument for the assessment of pain and disability in cervical radiculopathy patients.     

Investigation of the effectiveness of therapeutic ultrasound with high-resolution ultrasonographic cross-sectional area measurement of cervical nerve roots in patients with chronic cervical radiculopathy: a prospective,controlled, single-blind study

Purpose

The purpose of our study was to evaluate the effects of therapeutic ultrasound (US) on chronic cervical radiculopathy (CR) patients using both the clinical parameters and the cross-sectional area (CSA) values of the cervical nerve roots (NR) measured by high-resolution ultrasonography (HRUS).

Methods

Thirty-two patients with chronic CR were included in this prospective, controlled, and single-blind study. All of the patients received therapeutic US at continuous mode, 1-MHz frequency, and 1.5-W/cm² intensity for 10 sessions. The patients were assessed using VAS for pain, Modified Neck Disability Index, and Short-form 12, and cervical NR were examined with HRUS. The data were obtained before treatment (W0), the second week immediately after treatment (W2), and at the sixth week (W6).

Results

Twenty-nine patients and a total of 42 affected cervical NR and 42 unaffected cervical NR (control group) were evaluated. A significant improvement was observed for all clinical parameters and CSA values of affected cervical NR both at W2 and W6 compared to pre-treatment values (p < 0.05).

Conclusions

We found therapeutic US to be beneficial in improvement of pain, disability, and quality of life of patients with chronic CR. We suggest that CSA measurements may also contribute to both diagnosis and post-treatment evaluation in chronic CR.

     

The development of the DEGRR: A scale to assess pain in young children with cancer

The Gustave Roussy Child Pain Scale (Douleur Enfant Gustave Roussy, DEGR^RScale) is a scale for grading prolonged pain in children aged 2–6 years with cancer. The scale comprised six behaviours specific to pain items, five psychomotor inertia items, and four anxiety items, with a total score ranging from 0 to 60. This work was designed to confirm the scale structure and to study its construct validity and convergent validity. Our work was composed of two parts. In the first part of the study, 152 children with progressive cancer were scored by two nurses using the DEGR^Rscale, in a cross-sectional design. And in the second part, 53 of these 152 children were video-recorded. The tapes were assessed both by a panel of four pain specialists using a 0 to 7 Likert scale and by a nurse using DEGR^Rscale. As for the 152 children, the mean of the total scores derived from the DEGR^Ris 20.2 (SD = 6.2). Both the degree of agreement between the nurses (the weighted κ coefficient) and the internal consistency of the scale (Cronbach α coefficient = 0.90) were high, providing evidence of good reliability. Multivariate factor analyses showed a first factor of intensity of pain (51% of the total variance) and a second factor (14% of the total variance) which distinguishes the psychomotor inertia items from the items concerning voluntary expression of pain. Also, the results showed that psychomotor inertia items contribute to both factors and that it is an important sign of prolonged pain. Construct validity was strengthened by the absence of correlation between DEGR^Rscores and variables not related to pain, including fever, neutropenia and anaemia (indicative of poor medical condition) and the absence of parents’ visits (indicative of psychological distress). Concerning the 53 video-recorded children, the nurses’ DEGR^Rratings were strongly correlated with the specialists panel scores indicating a fairly good case for convergent validity.     

Classifying post‐stroke shoulder pain: Can the DN4 be helpful?

The etiology of post‐stroke shoulder pain (PSSP) is largely unclear and may involve both nociceptive and neuropathic mechanisms. No gold standard is present for PSSP diagnosis. The neuropathic pain diagnostic questionnaire (DN4), was originally developed to identify neuropathic pain in the clinical context. In this study we used the DN4 to categorize PSSP patients and compared symptoms and signs suggestive of either nociceptive or neuropathic pain. Pain complaints and sensory functions were compared between patients with chronic PSSP scoring at least four (DN4+, n=9) or less than four (DN4⁻, n=10) on the DN4. Pain was assessed using a numeric rating scale and the McGill pain questionnaire. Sensory functions were assessed using clinical examination and quantitative sensory testing combined with a cold pressor test. Patients classified as DN4+ reported constant pain, higher pain intensity, a higher impact of pain on daily living, more frequent loss of cold sensation, reduced QST thresholds at the unaffected side and increased QST thresholds at the affected side. Notably, several symptoms and signs suggestive of either neuropathic or nociceptive pain corresponded to the subgroups DN4+ and DN4⁻ respectively. However, since the pathophysiological mechanisms remain unclear and none of the sensory signs could be exclusively related to either DN4+ or DN4⁻, PSSP prognosis and treatment should not be solely based on the DN4. Nonetheless, a thorough assessment of neuropathic and nociceptive pain complaints and somatosensory functions should be included in the diagnostic work‐up of PSSP.     

Quantitative sensory testing somatosensory profiles in patients with cervical radiculopathy are distinct from those in patients with nonspecific neck–arm pain

The aim of this study was to establish the somatosensory profiles of patients with cervical radiculopathy and patients with nonspecific neck–arm pain associated with heightened nerve mechanosensitivity (NSNAP). Sensory profiles were compared to healthy control (HC) subjects and a positive control group comprising patients with fibromyalgia (FM). Quantitative sensory testing (QST) of thermal and mechanical detection and pain thresholds, pain sensitivity and responsiveness to repetitive noxious mechanical stimulation was performed in the maximal pain area, the corresponding dermatome and foot of 23 patients with painful C6 or C7 cervical radiculopathy, 8 patients with NSNAP in a C6/7 dermatomal pain distribution, 31 HC and 22 patients with FM. For both neck–arm pain groups, all QST parameters were within the 95% confidence interval of HC data. Patients with cervical radiculopathy were characterised by localised loss of function (thermal, mechanical, vibration detection P < .009) in the maximal pain area and dermatome (thermal detection, vibration detection, pressure pain sensitivity P < .04), consistent with peripheral neuronal damage. Both neck–arm pain groups demonstrated increased cold sensitivity in their maximal pain area (P < .03) and the foot (P < .009), and this was also the dominant sensory characteristic in patients with NSNAP. Both neck–arm pain groups differed from patients with FM, the latter characterised by a widespread gain of function in most nociceptive parameters (thermal, pressure, mechanical pain sensitivity P < .027). Despite commonalities in pain characteristics between the 2 neck–arm pain groups, distinct sensory profiles were demonstrated for each group.     

Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review

Abstract

Study design: Systematic review of randomized clinical trials.

Objective: Review of current literature regarding the effectiveness of manual therapy in the treatment of cervical radiculopathy.

Background: Cervical radiculopathy (CR) is a clinical condition frequently encountered in the physical therapy clinic. Cervical radiculopathy is a result of space occupying lesions in the cervical spine: either cervical disc herniations, spondylosis, or osteophytosis. These affect the pain generators of bony and ligamentous tissues, producing radicular symptoms (i.e. pain, numbness, weakness, paresthesia) observed in the upper extremity of patients with cervical nerve root pathology. Cervical radiculopathy has a reported annual incidence of 83·2 per 100?000 and an increased prevalence in the fifth decade of life among the general population.

Results: Medline and CINAHL via EBSCO, Cochrane Library, and Google Scholar were used to retrieve the randomized clinical trial studies for this review between the years of 1995 and February of 2011. Four studies met inclusion criteria and were considered to be high quality (PEDro scores of ?5). Manual therapy techniques included muscle energy techniques, non-thrust/thrust manipulation/mobilization of the cervical and/or thoracic spine, soft-tissue mobilization, and neural mobilization. In each study, manual therapy was either a stand-alone intervention or part of a multimodal approach which included therapeutic exercise and often some form of cervical traction. Although no clear cause and effect relationship can be established between improvement in radicular symptoms and manual therapy, results are generally promising.

Conclusion: Although a definitive treatment progression for treating CR has not been developed a general consensus exists within the literature that using manual therapy techniques in conjunction with therapeutic exercise is effective in regard to increasing function, as well as AROM, while decreasing levels of pain and disability. High quality RCTs featuring control groups are necessary to establish clear and effective protocols in the treatment of CR.     

Manual unloading of the lumbar spine: can it identify immediate responders to mechanical traction in a low back pain population? A study of reliability and criterion referenced predictive validity

Background:: To date, no research has examined the reliability or predictive validity of manual unloading tests of the lumbar spine to identify potential responders to lumbar mechanical traction.

Purpose:: To determine: (1) the intra and inter-rater reliability of a manual unloading test of the lumbar spine and (2) the criterion referenced predictive validity for the manual unloading test.

Methods:: Ten volunteers with low back pain (LBP) underwent a manual unloading test to establish reliability. In a separate procedure, 30 consecutive patients with LBP (age 50·86±11·51) were assessed for pain in their most provocative standing position (visual analog scale (VAS) 49·53±25·52 mm). Patients were assessed with a manual unloading test in their most provocative position followed by a single application of intermittent mechanical traction. Post traction, pain in the provocative position was reassessed and utilized as the outcome criterion.

Results:: The test of unloading demonstrated substantial intra and inter-rater reliability K?=?1·00, P?=?0·002, K?=?0·737, P?=?0·001, respectively. There were statistically significant within group differences for pain response following traction for patients with a positive manual unloading test (P<0·001), while patients with a negative manual unloading test did not demonstrate a statistically significant change (P>0·05). There were significant between group differences for proportion of responders to traction based on manual unloading response (P?=?0·031), and manual unloading response demonstrated a moderate to strong relationship with traction response Phi?=?0·443, P?=?0·015.

Discussion and conclusion:: The manual unloading test appears to be a reliable test and has a moderate to strong correlation with pain relief that exceeds minimal clinically important difference (MCID) following traction supporting the validity of this test.     

Dyspnea could be accurately assessed by a caregiver in hospitalized patients with respiratory diseases: Interrater reliability and agreement study

BackgroundThe perception of dyspnea is a subjective feeling typically self-assessed by the patient. However, the assessment by a caregiver is sometimes required.ObjectivesThe primary aim was to compare patient self-assessment and caregiver assessment of dyspnea (interrater reliability) using the modified Borg and visual analog scale (VAS) in hospitalized patients. The secondary aim was to compare dyspnea assessment between the two scales for patients and caregiver (inter-instrument reliability).MethodsSelf-assessment of dyspnea intensity of hospitalized patients with respiratory diseases was compared with caregiver's assessment. Dyspnea intensity was measured using two scales, the modified Borg scale (0–10 scale) and the 10 cm VAS. Mean difference and 95% confidence interval (CI) between assessors (i.e. patient versus caregiver) were calculated for each scale. Inter- and intra-rater reliability was calculated using intraclass correlation coefficients (ICCs).ResultsA total of 254 patients were recruited. The mean differences between patient and caregiver ratings were 0.31 (95% CI: 0.09, 0.53) for the modified Borg scale and 0.36 (95% CI: 0.06, 0.65) for the VAS scale. Interrater reliability was good for both scales with ICC of 0.79 (95% CI: 0.73, 0.84) for VAS and 0.82 (95% CI: 0.77, 0.86) for the modified Borg scale. The mean differences in scores between scales were 0.93 (95% CI 0.69, 1.17) for patients' ratings and 0.88 (95% CI 0.72, 1.04) for caregiver's rating. The inter-instrument reliability was moderate to good and similar for both assessors.ConclusionDyspnea can be accurately estimated by caregivers when patients with lung diseases cannot self-report. Scores on the VAS to rate dyspnea were higher than the scores on the Borg scale.     

Is there a need for cervical collar usage post anterior cervical decompression and fusion using interbody cages? A randomized controlled pilot trial

Anterior cervical discectomy and fusion (ACDF) is a common surgical intervention for radiculopathy resulting from degenerative cervical spine conditions. Post-surgical cervical collar use is believed to reduce post-operative pain, provide the patient with a sense of security during activities of daily living and even reduce rates of non-fusion. This prospective randomized controlled pilot trial investigates trial design feasibility in relation to prospective physical, functional, and quality of life-related outcomes of patients undergoing ACDF with interbody cage, with (n?=?17) and without (n?=?16) post-operative cervical collar usage. Results show that the sample provides sufficient statistical power to show that the use of a rigid cervical collar during 6 post-operative weeks is associated with significantly lower levels of neck disability index after 6 weeks and significantly lower levels of prospective neck pain. To investigate causal quality of life or fusion rate outcomes, sample size needs to be increased at least fourfold and optimally sixfold when accounting for data loss in prospective follow-up. The study suggests that post-surgical cervical collar usage may help certain patients cope with initial post-operative pain and disability.     

Attentional modulation fails to attenuate the subjective pain experience in chronic,unexplained pain

Background: Chronic, unexplained pain is a common, ill‐understood clinical problem. Increased sensitivity for pain and other stimuli is often implied as an underlying mechanism. Attentional processes influence central pain processing and might mediate hypersensitivity at a cerebral level. Aims: To study patients with chronic, unexplained pain with respect to (a) subjective pain experience; (b) effects of attentional manipulation; (c) level at which alterations in pain processing occur: locally (symptomatic body region), or generalised. Methods: We compared 16 patients with chronic, unexplained limb pain with 16 matched healthy controls. Pain thresholds to electrical stimuli were recorded. Subjects then received individually thresholded painful and non‐painful stimuli, with manipulation of attention towards or away from pain. The intensity of pain perception was recorded by means of visual analogue scales (VAS). Pain thresholds and effects of Attention and Laterality on VAS scores were compared between groups by means of general linear modelling (restricted to 12 patients with unilateral pain and 12 controls). Results: Distraction increased thresholds for pain in healthy volunteers, but this effect was significantly attenuated in patients. Significant interactions between attention‐effects, stimulus laterality and stimulus intensity indicated that VAS scores for painful stimuli were attenuated during distraction in healthy controls, but not in pain patients. Conclusions: Results support the notion that pain processing is enhanced in chronic, unexplained pain, and that the influence of attentional modulation on pain processing is attenuated. Potential cerebral mechanisms are changes in either attentional allocation or attention‐mediated descending pain modulation. The changes seem to occur at a generalised level.     

Transverse oscillatory pressure in management of cervical radiculopathy: A randomised controlled study

BackgroundCervical radiculopathy is an important subgroup of neck disorders causing severe pain and disability.ObjectivesThe study assessed the effect of transverse oscillatory pressure (TOP) on pain intensity and functional disability of patients with cervical radiculopathy.MethodsTwenty-six individuals with unilateral radiating neck pain were randomly allocated into Group A (8 males and 5 females) and Group B (6 males and 7 females). Participants in the two groups received kneading massage, cryotherapy, and active isometric exercises to the posterior paraspinal muscles, trapezuis, and sternomastoid muscles. TOP was administered to Group A, whereas Group B served as control. Treatment was applied three times per week for 4 weeks, making 12 treatment sessions for each participant. Visual analogue scale and Neck Disability Index were used to assess pain intensity and neck disability, respectively, at baseline, 2 weeks, and 4 weeks. Data were analysed using repeated-measures analysis of variance.ResultsThere was a significant improvement in pain intensity and neck functional disability of patients between baseline, 2^nd week, and 4^th week of treatment sessions in Groups A and B (p < 0.05). There was a significant reduction in pain intensity in Group A (f = 7.08, p < 0.05) at the 2^nd week and 4^th week compared with Group B.ConclusionIt can be concluded that TOP reduces pain faster in patients with cervical radiculopathy.     

A psychophysical analysis of acupuncture analgesia

A psychophysical analysis of acupuncture analgesia was carried out in which low back pain patients made visual analogue scale (VAS) responses both to their chronic pain and to different levels of experimental heat pain (5 sec exposures to 43–51 °C) before and after electroacupuncture. VAS (sensory) responses to chronic pain, direct temperature matches to chronic pain, and VAS (sensory) responses to experimental pain were reduced in an internally consistent manner 1–2 h after treatment. The magnitude of this analgesic response was similar for dermatomes within the region of chronic pain and acupuncture needle placement (lower back) as well as for dermatomes remote from needle placement and chronic pain (forearm). Individual patients manifested either (1) a central-inhibitory pattern of analgesia wherein experimental and chronic pain in back regions and experimental pain in forearm regions were reduced, or (2) an origin-specific pattern wherein only the chronic low back pain was reduced. Patients tested several days after treatment all manifested the latter pattern of analgesia. VAS sensory and VAS affective analgesic responses to electroacupuncture treatment showed a delayed onset (1–24 h) to maximum effect and a duration of 10–14 days. Cumulative sensory and affective analgesic effects were observed at the end of 4 months of biweekly acupuncture treatments. The results of this analysis reveal the unique spatial and temporal properties of electroacupuncture analgesia and the extent to which it is mediated by at least two different mechanisms.     

Validation of the NHANES ADL scale in a sample of patients with report of cervical pain: Factor analysis,item response theory analysis,and line item validity

Background.?Few functional outcomes scales have used Item Response Theory (IRT) for validation. IRT allows individual line item validations and offers substantial advantages over classic methods of scale validation or the simplest from of IRT known as Rasch. Rasch analysis reduces data to dichotomous variables thus decreasing the sensitivity of Likert-type data responses.

Purpose.?The purpose of this study was to create an outcome scale associated with the latent trait of functioning and disability, validated using IRT, in a population with report of cervical pain.

Methods.?Using the NHANES database, a recently created scale (NHANES ADL scale) was analysed using factor analysis, internal analyses of consistency, IRT, and comparison with internal measures of functioning and disability.

Results.?The newly created NHANES ADL scale demonstrated uni-dimensionality, was internally reliable, and was correlated to internal measures of functioning and disability. Additionally, the majority of the scale items demonstrate strong discrimination and suitable thresholds.

Discussion.?The NHANES ADL scale effectively measures physical, social, and emotional disability in patients with a cervical impairment, and may be an efficient measure of perceived limitations from working and generalized daily physical activity.

Conclusion.?The newly created NHANES ADL scale demonstrates internal consistency, unidimensionality, and line item validity. The NHANES ADL scale appears to be a useful instrument in measurement of functioning and disability in patients with report of cervical pain.     

Predicting the analgesic effect to oxycodone by ‘static’ and ‘dynamic’ quantitative sensory testing in healthy subjects

The large inter-individual variability in the magnitude of analgesia in response to opioids and the high prevalence of adverse events associated with their use underline the clinical importance of being able to predict who will or will not respond to opioid treatment. The present study used both static and dynamic quantitative sensory testing (QST) on 40 healthy volunteers in order to test whether this methodology can predict the analgesic effects of oral oxycodone, as compared to a placebo, on latency to onset, pain intensity, and tolerance to the cold pressor test (CPT). Static QST consisted of measuring heat and cold pain thresholds. Dynamic QST included measurements of the magnitude of the diffuse noxious inhibitory control (DNIC)-like effect and of temporal summation (TS). Results showed that oxycodone, but not the placebo, significantly elevated the latency and tolerance to cold pain and significantly reduced pain intensity. The static QST results showed that heat pain thresholds predicted the magnitude of reduction in pain intensity in response to oxycodone treatment (F_(1,22) = 5.63, p = 0.027, R² = 0.17). The dynamic QST results showed that TS predicted the effect of oxycodone on the tolerance to CPT (F_(1,38) = 9.11, p = 0.005, R² = 0.17). These results suggest that both static and dynamic QST have the potential to be useful in the prediction of the response to opioid treatment.     

Elevated detection thresholds for mechanical stimuli in chronic pain patients: support for a central mechanism

OBJECTIVE: To investigate the relation between pain provoking cervical segments identified by diagnostic dorsal root blockades and elevation of detection thresholds in patients suffering from chronic cervicobrachialgia (CCB). DESIGN: Quantitative sensory testing (light touch) of the cervical dermatomes using Semmes-Weinstein monofilaments. SETTING: A university pain clinic. SUBJECTS: Thirty-nine patients with CCB, with no clinical or diagnostic evidence of radiculopathy or surgically treatable bony lesion and with one main pain-provoking cervical segment identified by diagnostic dorsal root blockades. OUTCOME MEASURES: Detection thresholds with 95% confidence intervals (95% CI) of pain-provoking segments, compared with surrounding and contralateral segments and with normal values for cervical dermatomes. RESULTS: Patients' detection thresholds were significantly (p < .001) higher than those for normal subjects: 3.51 (95% CI, 2.71-4.31) and 3.10 (95% CI, 2.34-3.86), respectively. No significant differences existed between the segments. The elevations were systematic. However, thresholds on the painful side were consistently, slightly higher than those on the contralateral side. CONCLUSION: Supporting earlier studies, results from CCB patients in the present study showed systematic elevation of detection thresholds (low threshold mechanoreceptors), an adaptation in contrast with, but not contradictory to, central sensitization of high threshold neurons in chronic pain.     

Hyperkyphosis and back pain are not associated with prevalent vertebral fractures in women with osteoporosis

Abstract

Vertebral fractures (VFs) are the clinical consequence of spinal osteoporosis and may be associated with back pain and aggravated kyphosis. However, the relative importance of VFs as an underlying cause of kyphosis and chronic back pain is not known. The aim of this study was to investigate the relationship between prevalent VFs and the size of kyphosis, and back pain in osteoporotic women. Thirty-six women, aged 74.6?±?8.3 years, were consecutively recruited from the osteoporosis unit at Uppsala University Hospital. The patients had 1–9 radiographic verified VFs. Tragus wall distance (TWD) and numeric rating scale were used to measure kyphosis and pain. All patients had a hyperkyphosis (TWD?≥?10?cm). Notably, there were no associations between numbers or location of VFs versus size of kyphosis (ρ?=?0.15, p?=?0.4; ρ?=??0.27, p?=?0.12) or severity of back pain (ρ?=??0.08, p?=?0.66; ρ?=?0.16, p?=?0.35). Furthermore, no association was evident between kyphosis and back pain (ρ?=??0.02, p?=?0.89). There was, however, an association between size of kyphosis and age (R?=?0.44, p?=?0.008). In conclusion, these data suggest that prevalent VFs are not significantly associated with kyphosis or chronic back pain, in patients with manifest spinal osteoporosis.     

Development and validation of an Arabic rheumatoid hand disability scale

Purpose: To develop a rheumatoid hand disability scale in the Arabic language adapted for local sociocultural specificities and to test its psychometric properties.

Methods: The choice of hand activities was based on several published indices. The selected items were translated by the forward and backward translation procedures, several modifications were made, and after some questions were added, a provisional scale was obtained. In- and outpatients with rheumatoid arthritis (RA) according to the ACR criteria were chosen to answer the provisional scale and to assess the final scale. Impairment outcome measures (pain as measured on a visual analogue scale, morning stiffness, hand swelling, tenderness), and assessment of disability (on Lee's and Revel's functional indices) were also recorded. The intraclass correlation coefficient and the Bland and Altman methods were used to assess reliability. Construct (convergent and divergent) validity was investigated with use of Spearman's rank correlation, and a factor analysis was performed.

Results: The provisional scale had 21 questions. The adaptation process left 10 questions about hand activity, with four levels of answers. Eighty patients with RA were recruited for the validation of the final scale. The intra- and interrater reliabilities of the scale were 0.96 and 0.94, respectively. Analysis by the Bland and Altman method showed no systematic trend. The scale had good construct validity, with expected convergence with Lee's functional index (r_s?=?0.79) and Revel's functional index (r_s?=?0.81) and divergence with age (r_s?=?0.05), morning stiffness (r_s?=?0.40), pain (r_s?=?0.32), and tenderness (r_s?=???0.48). The factorial structure of the scale was satisfying, with two factors explaining 73% of the variance.

Conclusion: We developed an Arabic index that assesses hand disability due to RA and suits Tunisian people. Further studies are needed to confirm the validity of the scale in other Arabic countries.     

Treatment of a Patient with Cervical Radiculopathy Using Thoracic Spine Thrust Manipulation, Soft Tissue Mobilization, and Exercise

While there is currently little evidence to suggest which non-operative treatment approach is best for the management of patients with cervical radiculopathy, emerging evidence suggests that these patients benefit from a multimodal treatment approach. The purpose of this case report is to describe the physical therapy management of a patient with cervical radiculopathy. Diagnosis was based on the patient''s meeting three of the four criteria in the diagnostic test cluster currently used to identify patients with cervical radiculopathy. Treatment included thrust manipulation of the thoracic spine, soft tissue mobilization, and therapeutic exercise. After three visits, patient-perceived disability, as measured by the Patient-Specific Functional Scale, improved from 5/10 to 10/10. The Numeric Pain Rating Score decreased from 4.66/10 to 0/10. The patient rated his improvement as a very great deal better on the Global Rating of Change Scale. These clinically meaningful improvements were maintained at the 14-week follow-up. While a cause-and-effect relationship may not be established from a case report, a multimodal approach including thoracic spine manipulation, soft tissue mobilization, and therapeutic exercise was associated with decreased pain and perceived disability in a patient with cervical radiculopathy. Further research is needed to investigate benefits of the components of this approach.Key Words: Cervical Radiculopathy, Physical Therapy, Soft Tissue Mobilization, Spinal ManipulationCervical radiculopathy is a disorder of a cervical nerve root¹ and is common in the general population, with an annual incidence of approximately 83 per 100,000². Patients with cervical radiculopathy often report neck pain; however, they most frequently seek treatment to address their arm pain^1,3,4. People with neck pain combined with upper extremity symptoms experience greater levels of disability than do people with neck pain alone⁴. Authors have suggested that patients with neck and arm pain should be treated more expeditiously in order to avoid the further negative impact on mental health status associated with chronic symptoms⁴.Treatment strategies for patients with cervical radiculopathy range from conservative management to surgery. Evidence suggests that patients who are treated conservatively may experience superior outcomes compared to those who undergo surgery⁵; however, there is little evidence to suggest which non-operative interventions are the most effective^6,7. Recently, two case series^3,8 used a combination of thrust and non-thrust mobilization/manipulation techniques directed at the cervical and thoracic spine, mechanical cervical traction, and exercise to treat patients with a clinical diagnosis of cervical radiculopathy. Cleland et al³ reported that 10 of 11 patients demonstrated clinically meaningful improvement in pain and function at discharge and 6-month follow-up. Waldrop⁸ reported improvement of 13% to 88% in the Northwick Park Neck questionnaire scores in 6 patients, with scores ranging from 13% to 88%. A recent prospective cohort study⁷ also described the use of an individualized approach including thrust and non-thrust cervical mobilization/manipulation techniques, repeated endrange exercises to promote centralization of symptoms, neural mobilization, traction, and cervical stabilization exercises. Of the participants, 77% surpassed the minimally clinically important difference on the Bournemouth Disability Questionnaire at discharge (mean=11 visits). This value increased to 93% at long-term follow-up (mean=8.2 months).While these preliminary reports suggest that a multimodal treatment approach may be beneficial for patients with cervical radiculopathy, exactly which interventions should be included in this approach, and in what combination, requires further research. The purpose of this case report is to describe the evaluation, clinical decision-making process, and treatment of a patient with cervical radiculopathy. The rationale for thrust manipulation of the thoracic spine and soft tissue mobilization are discussed. Approval for this case report was provided by the Institutional Review Board at Cayuga Medical Center, Ithaca, New York.