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

J Orthop Sports Phys Ther, Epub 30 April 2013. doi:10.2519/jospt.2013.4490

KEY WORDS: cervical radicular pain, clinical prediction rule, medical nomogram, neurodynamic treatment, penalized regression

Clinical trial registration involves placing the protocol for a clinical trial on a free, publicly available, and electronically searchable register. Registration is considered to be prospective if the protocol is registered before the trial commences (ie, before the first participant is enrolled). Prospective registration has several potential advantages. It could help avoid trials being duplicated unnecessarily and it could allow people with health problems to identify trials in which they might participate. Perhaps more importantly, however, it tackles 2 big problems in clinical research: selective reporting and publication bias. Prospective clinical trial registration is of great potential value to the clinicians, consumers, and researchers who rely on clinical trial data, and that is why the International Society of Physiotherapy Journal Editors (ISPJE) is recommending that members enact a policy for prospective trial registration.

J Orthop Sports Phys Ther 2012;42(12):978-981. doi:10.2519/jospt.2012.0111

KEY WORDS: ISPJE, prospective registration, publication bias, selective reporting

STUDY DESIGN: Prospective longitudinal. OBJECTIVE: To quantify the temporal development of magnetic resonance imaging changes in oropharyngeal morphometry in subjects with varying levels of disability following a whiplash injury. BACKGROUND: A recent cross-sectional investigation has identified reductions in the size and shape of the oropharynx in subjects with chronic whiplash-related disability when compared to healthy controls. The temporal development of such changes and their relationship to persistent disability have yet to be investigated. METHODS: Forty-one subjects (30 women) with acute whiplash injury were included. Repeated measures T1-weighted magnetic resonance imaging was used to measure and compare cross-sectional area (CSA) in square millimeters and shape ratio (SR) of the oropharynx at 4 weeks, 3 months, and 6 months postinjury. Subjects were classified at 6 months by their Neck Disability Index scores into the following categories: recovered (less than 8%), mild disability (10%-28%), and moderate/severe disability (greater than 30%). The effects of time and group and the interaction effect of group by time on oropharynx morphometry (CSA, SR) were investigated using repeated-measures, linear, mixed-model analysis. Based on previous research findings, age, gender, and body mass index were entered into the analyses as covariates. Where significant main or interaction effects were detected, pairwise comparisons were performed to investigate specific differences in the dependent variable between groups and within groups over time. RESULTS: There was a significant interaction effect for group by time for both the CSA and SR values. Age significantly influenced SR (P = .024) and body mass index significantly influenced CSA (P = .001). There was no difference in CSA or SR across all groups at 4 weeks postinjury. However, at 6 months, CSA was significantly different between the recovered group and the moderate/severe group (P = .001). The recovered group demonstrated a significant increase in CSA (P = .04) over time, whereas the moderate/severe group significantly decreased (P = .01). At 6 months, the moderate/severe group had a reduced SR compared to the mild group (P = .03). No differences in CSA or SR of the oropharynx were found between the mild and recovered groups throughout the study. CONCLUSION: Temporal reductions in CSA of the oropharynx occur following whiplash and persist to a greater extent in those with moderate/severe symptoms at 6 months postinjury. Studies are planned (1) to better investigate the underlying mechanisms of CSA reductions, (2) to determine their relevance to functional recovery and production of voice following whiplash, and (3) to evaluate multidisciplinary assessment and management of these patients.

J Orthop Sports Phys Ther 2012;42(11):912-918. Epub 17 August 2012. doi:10.2519/jospt.2012.4280

KEY WORDS: chronic neck pain, dysphagia, oropharyngeal morphometry, pain-related disability, voice recovery

SYNOPSIS: The validity of upper-limb neurodynamic tests (ULNTs) for detecting peripheral neuropathic pain (PNP) was assessed by reviewing the evidence on plausibility, the definition of a positive test, reliability, and concurrent validity. Evidence was identified by a structured search for peer-reviewed articles published in English before May 2011. The quality of concurrent validity studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool, where appropriate. Biomechanical and experimental pain data support the plausibility of ULNTs. Evidence suggests that a positive ULNT should at least partially reproduce the patient's symptoms and that structural differentiation should change these symptoms. Data indicate that this definition of a positive ULNT is reliable when used clinically. Limited evidence suggests that the median nerve test, but not the radial nerve test, helps determine whether a patient has cervical radiculopathy. The median nerve test does not help diagnose carpal tunnel syndrome. These findings should be interpreted cautiously, because diagnostic accuracy might have been distorted by the investigators' definitions of a positive ULNT. Furthermore, patients with PNP who presented with increased nerve mechanosensitivity rather than conduction loss might have been incorrectly classified by electrophysiological reference standards as not having PNP. The only evidence for concurrent validity of the ulnar nerve test was a case study on cubital tunnel syndrome. We recommend that researchers develop more comprehensive reference standards for PNP to accurately assess the concurrent validity of ULNTs and continue investigating the predictive validity of ULNTs for prognosis or treatment response.

J Orthop Sports Phys Ther 2012;42(5):413-424, Epub 8 March 2012. doi:10.2519/jospt.2012.3988

KEY WORDS: carpal tunnel syndrome, cervical radiculopathy, cubital tunnel syndrome, reliability

NOTE: Video for this article is not currently available but will be posted as soon as possible.

The patient was a 22-year-old male physical therapy student whose tutor suspected the absence of the lower portion of the left trapezius muscle. During left lower trapezius manual muscle testing, it was noted that he was unable to achieve satisfactory control of the left scapula and the left lower trapezius was visibly and palpably absent compared to the right side. Because absence of the lower trapezius muscle was suspected, magnetic resonance imaging was completed to confirm its absence.

J Orthop Sports Phys Ther 2011;41(8):614. doi:10.2519/jospt.2011.0416

KEY WORDS: magnetic resonance imaging, neck pain, scapula

SYNOPSIS: There is irrefutable evidence of an association between mechanical neck pain (MNP) and dysfunction of the muscles of the cervical spine. A myriad of impairments have been demonstrated that include changes in the physical structure (cross-sectional area, fatty infiltration, fiber type), as well as changes in behavior (timing and activation level), of the cervical muscles. Such changes suggest an impaired capacity of the cervical muscles to generate, sustain, and maintain precision of the required levels of torque needed for optimal function. In the context of physical support, these changes potentially have deleterious consequences for the cervical region, which relies heavily on its muscles for mechanical stability. While interventions focused on the retraining of cervical muscle function have shown favorable responses in alleviating MNP, the development of best practice strategies for the assessment and management of cervical muscle dysfunction is still a work in progress. One obstacle in researching the efficacy of cervical muscle training is that, as yet, we do not possess the capacity to optimally measure and classify those patients most likely to respond to different methods of training that would enrich clinical practice. While gains in this area are emerging, the ability of a clinician to best identify the need and implement the most appropriate method of training cervical muscle function is still largely dependent on a comprehensive examination of the patient that considers all aspects of the patient's disorder and functional requirements. LEVEL OF EVIDENCE: Level 5.

J Orthop Sports Phys Ther 2009;39(5):324-333, Epub 15 December 2008. doi:10.2519/jospt.2009.2872

KEY WORDS: mechanical neck pain, rehabilitation, therapeutic exercise

STUDY DESIGN: A multivariate repeated measures independent-group study design.OBJECTIVES: To compare the effect of a craniocervical flexion exercise (CCFEx) program to that of a conventional cervical flexion exercise (CFEx) program in training isometric craniocervical flexor muscle performance. BACKGROUND: The craniocervical flexor muscles are important muscles of the cervical spine, as they have been shown to be impaired in persons with chronic neck pain. While both CCFEx and CFEx protocols have been advocated to train craniocervical flexor muscle performance, at present there is no consensus as to the most effective method. METHODS AND MEASURES: Fifty females with chronic mild neck pain and disability status were randomly allocated into a 6-week program of either CCFEx (n = 27) or CFEx (n = 23). Isometric dynamometry measurements of craniocervical flexor muscle performance (maximal voluntary contraction, endurance at 50% of maximal voluntary contraction) were recorded before and following the exercise program. Changes in craniocervical flexor muscle performance (pretraining-posttraining) within and between exercise groups were analyzed with analysis of variance models. RESULTS: Both exercise interventions significantly improved isometric craniocervical flexor muscle performance (P<.02). No significant differences in improvement of muscle performance were observed between the 2 exercise interventions.CONCLUSION: It appears that isometric craniocervical flexor muscle performance can be trained with either a CCFEx protocol or a conventional CFEx protocol in patients with mild neck pain and disability.  

J Orthop Sports Phys Ther. 2007;37(1):3-9. doi:10.2519/jospt.2007.2237 

KEY WORDS: cervical spine, craniocervical flexion, neck pain, rehabilitation

Study Design: Single-group, posttest only, using a sample of convenience. Objective: To measure the repositioning error of subjects with low back pain for lumbar sagittal movement using a simple kinesthetic test previously described. Background: Patients with low back pain are commonly observed to have difficulty in adopting a mid or neutral position of the lumbar spine. Methods and Measurements: Twenty subjects with low back pain were required to reproduce an upright neutral posture of the lumbar spine following movement into flexion in a sitting position. Trunk positioning accuracy was measured with an electromagnetic tracking device. Results: The mean absolute value of the repositioning error in the sagittal plane was 2.25° ± 0.88° on day 1 and 2.32° ± 1.62° on day 2. The performance of patients with low back pain was similar to that of asymptomatic patients in a previous study, although subjects with low back pain overshot the neutral position more frequently (79%) than did nonimpaired subjects (50%). Conclusions: Subjects with low back pain may have attempted to use extra mechanoreceptive cues to compensate for some kinesthetic deficit. Nevertheless, the kinesthetic test used was not sensitive enough to detect any repositioning deficits, and reasons for this are explored.

J Orthop Sports Phys Ther. 1999;29(5):294-299.

Key Words: kinesthesia, back pain, measurement

Poor lumbar spine kinesthetic awareness is often observed in low back pain patients and is usually evaluated qualitatively in the clinical situation. The purpose of this study was to investigate a simple, kinesthetic test for the lumbar spine. The experimental protocol utilized a 3Space Fastrak™ to determine the error, within and between days, of 10 healthy subjects in reproducing a neutral lumbopelvic (T10-S2) position following movement into flexion. The mean value of the repositioning error for the sagittal plane movement (flexion/extension) over the 3 repetitions within day 1 was 2.6 ± 1.2° and for day 2 was 2.6 ± 1.7°. No statistically significant difference existed between days. These repositioning errors were well within the ranges described by other authors for various asymptomatic joint complexes. These results provide a basis for further evaluation of this test on patients with low back pain to investigate its ability to detect any kinesthetic deficit.

J Orthop Sports Phys Ther. 1996;24(6):354-358.

Key Words: lumbar spine, kinesthesia, measurement