Purpose (1) To evaluate the effectiveness of personalised psychologically-informed physiotherapy in people with neck pain; (2) To explore the mediating role of changes in illness perceptions. Method In this replicated single-case study, 14 patients with non-specific neck pain at risk for chronicity received a personalised intervention addressing unhelpful illness perceptions and dysfunctional movement behaviour, according to principles of cognitive functional therapy. Outcomes included the mediating role of illness perceptions on overall effect, function, pain intensity and self-efficacy. Linear mixed models were used to analyse the data. Results Repeated measurements (14-20 per patient), including a 3-months follow-up, showed a gradual improvement during and/or after psychologically-informed physiotherapy for overall effect, function, pain and to a lesser extent self-efficacy. Changes in each of the illness perception dimensions showed a mediation effect on overall effect, function and pain. When combining the dimensions “consequences,” “personal control,” “identity,” “concern” and “emotional response,” changes in illness perceptions explained approximately 35% of the improvement in overall effect. Conclusion Addressing unhelpful illness perceptions appears valuable in the management of patients with chronic or recurrent non-specific neck pain. Intervention effects extended beyond the treatment period, indicating that patients’ improved understanding of their health condition continued to have a positive impact.

This systematic review aimed to determine the methodological quality of international clinical practice guidelines (CPGs) and the clinical credibility and implementability of recommendations regarding manipulation or mobilization treatment recommendations proposed in CPGs for the management of people with neck pain. A secondary aim of this review was to provide an overview of recommendations for manipulation or mobilization in patients with neck pain. Manipulation or mobilization treatment of patients with neck pain is under debate for its potential risk of serious adverse events. Serious adverse events are rare, but it is the clinicians' responsibility to thoroughly screen patients at risk of vascular complications. A third aim of this review was to describe the extent to which the included guidelines inform clinical practice about screening for the risk of complications due to vascular pathology in the cervical spine. A systematic review of 13 electronic databases and 4 repositories was performed for potentially relevant guidelines published between January 1, 2000 and September 22, 2022. Two reviewers independently appraised eligible guidelines using Appraisal of Guidelines for Research and Evaluation II (AGREE II) and Appraisal of Guidelines for Research and Evaluation: Recommendation EXcellence (AGREE-REX) criteria. A best evidence synthesis was performed, and screening of risk factors was assessed. A total of 19 CPGs were included, of which 5 were of high quality. All high-quality guidelines recommend the use of manipulation or mobilization, with or without exercise. Eight (42%) guidelines described the screening of risk factors for adverse events. Two (11%) guidelines met the a priori defined criteria for screening and scored present and complete. International CPGs consistently recommend the use of manipulations and mobilizations in the treatment of neck pain. There is a notable absence of recommendations regarding the identification of patients at risk for vascular complications. The findings of this study allow guideline developers to improve the quality of future neck pain guidelines and consider including vascular screening tools. Furthermore, it proposes recommendations to physical therapists interested in applying manipulations and mobilizations in the treatment of patients with neck pain. International clinical practice guidelines consistently recommend the use of manipulations and mobilizations in the treatment of neck pain. There is a notable absence of recommendations regarding identifying patients at risk for vascular complications.

OBJECTIVE: To develop and internally validate diagnostic models for cervical nerve root involvement based on patient interview and clinical examination items. DESIGN: Diagnostic predictive modeling study. METHODS: People with a suspicion of cervical nerve root involvement (ie, radicular pain and/or radiculopathy) (N = 134) were included. Three diagnostic models (ie, patient interview items alone, clinical examination alone, and combined patient interview plus clinical examination) were developed using multivariable logistic regression analyses. For internal validation, we performed bootstrapping techniques (250 repetitions). The diagnostic accuracy (area under the curve [AUC]) and explained variance (Nagelkerke’s R2) of the models were assessed. An AUC of 0.7 or higher was considered adequate. RESULTS: The patient interview model consisted of 2 items and showed an explained variance of 0.23 and an AUC of 0.74 (95% CI: 0.66, 0.81) after bootstrapping. The clinical examination model consisted of 2 items and had an explained variance of 0.29, and an AUC of 0.77 (95% CI: 0.69, 0.85) after internal validation. The combined model had an explained variance of 0.38 and an AUC of 0.82 (95% CI: 0.75, 0.89) after bootstrapping and consisted of the Spurling test (odds ratio [OR], 8.0; 95% CI: 3.1, 20.4), “Arm pain worse than neck pain” (OR, 4.8; 95% CI: 1.9, 11.8) and the patient-reported “Presence of paraesthesia and/or numbness” (OR, 2.8; 95% CI: 1.0, 7.8). CONCLUSIONS: The combined model showed the best diagnostic accuracy to determine the likelihood of cervical nerve root involvement. External validation is required before implementing any diagnostic model. JOSPT Open 2025;3(2):1-7. Epub 26 November 2024. doi:10.2519/josptopen.2024.0082

BackgroundThe CROM-VAS Test is a novel method to quantify immediate hypoalgesic treatment effects for neck pain by measuring the reduction in pain intensity (using a VAS) at the same (sub)maximal neck position (using a CROM device) before and after treatment. It is a novel test designed to quantify immediate pain relief following treatment, without the potentially confounding effects of simultaneous improvements in function. Objectives(1) To describe the CROM-VAS Test, (2) To assess reliability and absolute agreement of the CROM-VAS Test, and (3) To evaluate its distinctiveness by comparing it to changes in pressure pain threshold (PPT) and baseline pain scores. DesignCross-sectional study. MethodsThe CROM-VAS Test was assessed in 58 people with non-specific neck pain treated with cervical mobilisation and cervicothoracic manipulation. Inter-rater reliability (intraclass correlation coefficient (ICC1.1)) and absolute agreement (standard error of measurement (SEM), minimal detectable change (MDC) and Bland-Altman limits of agreement (LoA)) were determined. ResultsReliability was high (ICC1.1: 0.91 (95%CI: 0.85–0.95) for the CROM-VAS Test in the painful direction and 0.73 (95%CI: 0.54–0.85) in the non/least painful direction). Agreement was good (CROM-VAS Test (painful direction): SEM: 2.3 mm; MDC: 6.4 mm; LoA: 13.5 to 16.6 mm; CROM-VAS Test (non/least painful direction): SEM: 4.0 mm; MDC: 11.1 mm; LoA: 14.7 to 22.0 mm). Low or negative correlations were observed between CROM-VAS Test scores and changes in PPT and baseline neck pain scores. ConclusionThe CROM-VAS Test has good clinimetric properties. It measures a distinct dimension of pain relief compared to PPTs and baseline pain scores.

Background/Objectives: To investigate if intra-articular biomarkers relate to peripheral and central sensitization in patients with late-stage knee osteoarthritis (KOA). Methods: A total of 17 (6M, 11F) patients (aged 69 ± 10 years) were assessed for peripheral (pressure pain thresholds (PPT)) and central (temporal summation (TS) and conditioned pain modulation (CPM)) sensitization the day before total knee arthroplasty. Synovial fluid was collected during surgery and assayed for IL-6, IL-8, IL-10, TNF-α, CXCL-10, BDNF, NGF, CCL2, CCL5, VEGF, IL-1RI, MMP-1, MMP-7, IL-1β, and CXCL-9. Associations of biomarkers and their combinations reflecting chronic (CXCL-9) and acute ((CCL2×CXCL-10)/IL-10)) inflammation, cartilage degeneration (MMP-1×MMP-7), and neurotrophy (NGF×BDNF) with PPT, TS, and CPM were analyzed by bivariate correlations and by multiple linear regression analyses corrected for BMI, sex, and age. Results: The medial joint line and the superior medial joint region showed the lowest PPT. Higher acute inflammation related significantly to worse pressure tenderness at the superior medial joint region (R2 = 0.642; p = 0.010). Cartilage degeneration and chronic inflammation were associated with both absolute (R2 = 0.827; p = 0.001) and relative CPM (R2 = 0.882; p < 0.001). Acute inflammation and neurotrophy were related to relative TS at the m. tibialis anterior (R2 = 0.728; p = 0.02). Conclusions: This study demonstrates that increased levels of intra-articular biomarkers of acute inflammation are related to peripheral sensitization and that biomarkers of cartilage degeneration and chronic inflammation are associated with central sensitization. These results may be a stepping-stone toward a better understanding of the working mechanism of peripheral and central sensitization in KOA pain and the development of more targeted therapeutic interventions.

Background: Acute low back pain has a high prevalence, and when persisting into chronicity, it results in enormous socio-economic consequences. Sensory preferences may be key factors in predicting central sensitization as the main mechanism of nociplastic pain and chronicity. Objectives: Build a model to predict central sensitization symptoms using sensory profiles based on the PROGRESS framework. Methods: A Prognostic Model Research study was carried out to predict central sensitization symptoms at 12 weeks, using baseline sensory profiles, based on 114 patients with acute low back pain. Independent variables were sensory profiles, state and trait anxiety, age, duration, pain severity, depressive symptoms, and pain catastrophizing. Results: This model, based on continuous data, significantly predicts central sensitization symptoms at 12 weeks. It contains two significantly contributing variables: sensory profile Sensory Sensitive (unstandardized B-value = 0.42; p = 0.01) and trait anxiety (unstandardized B-value = 0.53; p ≤ 0.001). The model has a predictive value of R2 = 0.38. Conclusions: This model significantly predicts central sensitization symptoms based on sensory profile Sensory Sensitive and trait anxiety. This model may be a useful tool to intervene in a bottom-up and top-down approaches to prevent chronicity in clinical practice, including individual sensory preferences and behavioral responses to sensory stimulation in rehabilitation strategies.

Differences in organization of the primary motor cortex and altered trunk motor control (sensing, processing and motor output) have been reported in people with low back pain (LBP). Little is known to what extent these differences are related. We investigated differences in 1) organization of the primary motor cortex and 2) motor and sensory tests between people with and without LBP, and 3) investigated associations between the organization of the primary motor cortex and motor and sensory tests. We conducted a case-control study in people with (N=25) and without (N=25) LBP. The organization of the primary motor cortex (Center of Gravity (CoG) and Area of the cortical representation of trunk muscles) was assessed using neuronavigated transcranial magnetic stimulation, based on individual MRIs. Sensory tests (quantitative sensory testing, graphaesthesia, two-point discrimination threshold) and a motor test (spiral-tracking test) were assessed. Participants with LBP had a more lateral and lower location of the CoG and a higher temporal summation of pain. For all participants combined, better vibration test scores were associated with a more anterior, lateral, and lower CoG and a better two-point discrimination threshold was associated with a lower CoG. A small subset of variables showed significance. Although this aligns with the concept of altered organization of the primary motor cortex in LBP, there is no strong evidence of the association between altered organization of the primary motor cortex and motor and sensory test performance in LBP. Focusing on subgroup analyses regarding pain duration can be a topic for future research.

BackgroundChronic low-grade inflammatory profile (CLIP) is one of the pathways involved in type 2 diabetes (T2D). Currently, there is limited evidence for ameliorating effects of combined lifestyle interventions on CLIP in type 2 diabetes. We investigated whether a 13-week combined lifestyle intervention, using hypocaloric diet and resistance exercise plus high-intensity interval training with or without consumption of a protein drink, affected CLIP in older adults with T2D. MethodsIn this post-hoc analysis of the PROBE study 114 adults (≥55 years) with obesity and type 2 (pre-)diabetes had measurements of C-reactive protein (CRP), pro-inflammatory cytokines interleukin (IL)-6, tumor-necrosis-factor (TNF)-α, and monocyte chemoattractant protein (MCP)-1, anti-inflammatory cytokines IL-10, IL-1 receptor antagonist (RA), and soluble tumor-necrosis-factor receptor (sTNFR)1, adipokines leptin and adiponectin, and glycation biomarkers carboxymethyl-lysine (CML) and soluble receptor for advanced glycation end products (sRAGE) from fasting blood samples. A linear mixed model was used to evaluate change in inflammatory biomarkers after lifestyle intervention and effect of the protein drink. Linear regression analysis was performed with parameters of body composition (by dual-energy X-ray absorptiometry) and parameters of insulin resistance (by oral glucose tolerance test). ResultsThere were no significant differences in CLIP responses between the protein and the control groups. For all participants combined, IL-1RA, leptin and adiponectin decreased after 13 weeks (p = 0.002, p < 0.001 and p < 0.001), while ratios TNF-α/IL-10 and TNF-α/IL-1RA increased (p = 0.003 and p = 0.035). CRP increased by 12 % in participants with low to average CLIP (pre 1.91 ± 0.39 mg/L, post 2.13 ± 1.16 mg/L, p = 0.006) and decreased by 36 % in those with high CLIP (pre 5.14 mg/L ± 1.20, post 3.30 ± 2.29 mg/L, p < 0.001). Change in leptin and IL-1RA was positively associated with change in fat mass (β = 0.133, p < 0.001; β = 0.017, p < 0.001) and insulin resistance (β = 0.095, p = 0.024; β = 0.020, p = 0.001). Change in lean mass was not associated with any of the biomarkers. Conclusion13 weeks of combined lifestyle intervention, either with or without protein drink, reduced circulating adipokines and anti-inflammatory cytokine IL-1RA, and increased inflammatory ratios TNF-α/IL-10 and TNF-α/IL-1RA in older adults with obesity and T2D. Effect on CLIP was inversely related to baseline inflammatory status.

BackgroundWhen instructing exercises to improve Range of Motion (ROM), clinicians often create an internal focus of attention, while motor performance may improve more when using an external focus. Objectives: Using Virtual Reality (VR), we investigated the effect of tasks with an internal and external focus on maximal ROM in people with neck pain and explored whether this effect was associated with fear of movement. MethodIn this cross-over experimental design study, the cervical ROM of 54 participants was measured while performing a target-seeking exercise in a VR-environment (external focus task) and during three maximal rotation and flexion-extension movements with the VR-headset on, without signal (internal focus task). The main statistical analysis included two dependent T-tests. Pearson correlation coefficients were calculated to investigate whether the differences in ROM in both conditions were correlated to fear of movement. ResultsMaximal neck rotation was larger in the external focus condition than in the internal focus condition (mean difference: 26.4°, 95% CI [20.6, 32.3]; p < 0.001, d = 1.24). However, there was a difference favouring the internal focus condition for flexion-extension (mean difference: 8.2°, 95% CI [-14.9, −1.5]; p = 0.018, d = 0.33). The variability in ROM was not explained by variability in fear of movement (for all correlations p ≥ 0.197). ConclusionAn external focus resulted in a larger range of rotation, but our flexion-extension findings suggest that the task has to be specific to elicit such an effect. Further research, using a task that sufficiently elicits movement in all directions, is needed to determine the value of an external focus during exercise.

ABSTRACT Introduction Acute lower back pain can lead to neuroplastic changes in the central nervous system, and symptoms of central sensitization after 12 weeks. While sensory sensitivity has been shown to predict symptoms of central sensitization, trait sensory profiles may be prognostic in the persistence of central sensitization symptoms in low back pain over time. Objective To examine sensory profiles as prognostic symptoms of central sensitization in people with acute low back pain. Methods A longitudinal type 2 prognostic factor research study was performed according to the PROGRESS framework. Baseline and 12-week follow-up measures were taken using the Adolescent/Adult Sensory Profile and the Central Sensitization Inventory measures. Study participants were consecutively included from primary care physiotherapy practices. Univariable, and multivariable regression analyses were performed to adjust sensory profiles based on previous history of low back pain, baseline Central Sensitization Inventory scores, level of pain, disability, age, and duration of low back pain. Results After adjustment, the sensory profiles of Low Registration B = 0.44, 95%CI (0.18, 0.70), Sensation Seeking B = 0.38, 95%CI (0.19, 0.57), Sensory Sensitive B = 0.49, 95%CI (0.25, 0.74), Sensation Avoiding B = 0.40, 95% CI (0.15, 0.65) was significantly associated with the persistence of central sensitization symptoms (N = 103). Conclusion Sensory profiles may predict symptoms of central sensitization after 12 weeks in people with acute low back pain.