Quebec Task Force Research Articles

Latent class analysis derived subgroups of low back pain patients \u2013 do they have prognostic capacity?

BackgroundHeterogeneity in patients with low back pain is well recognised and different approaches to subgrouping have been proposed. One statistical technique that is increasingly being used is Latent Class Analysis as it performs subgrouping based on pattern recognition with high accuracy. Previously, we developed two novel suggestions for subgrouping patients with low back pain based on Latent Class Analysis of patient baseline characteristics (patient history and physical examination), which resulted in 7 subgroups when using a single-stage analysis, and 9 subgroups when using a two-stage approach. However, their prognostic capacity was unexplored. This study (i) determined whether the subgrouping approaches were associated with the future outcomes of pain intensity, pain frequency and disability, (ii) assessed whether one of these two approaches was more strongly or more consistently associated with these outcomes, and (iii) assessed the performance of the novel subgroupings as compared to the following variables: two existing subgrouping tools (STarT Back Tool and Quebec Task Force classification), four baseline characteristics and a group of previously identified domain-specific patient categorisations (collectively, the ‘comparator variables’).MethodsThis was a longitudinal cohort study of 928 patients consulting for low back pain in primary care. The associations between each subgroup approach and outcomes at 2 weeks, 3 and 12 months, and with weekly SMS responses were tested in linear regression models, and their prognostic capacity (variance explained) was compared to that of the comparator variables listed above.ResultsThe two previously identified subgroupings were similarly associated with all outcomes. The prognostic capacity of both subgroupings was better than that of the comparator variables, except for participants’ recovery beliefs and the domain-specific categorisations, but was still limited. The explained variance ranged from 4.3%–6.9% for pain intensity and from 6.8%–20.3% for disability, and highest at the 2 weeks follow-up.ConclusionsLatent Class-derived subgroups provided additional prognostic information when compared to a range of variables, but the improvements were not substantial enough to warrant further development into a new prognostic tool. Further research could investigate if these novel subgrouping approaches may help to improve existing tools that subgroup low back pain patients.

Isometric muscle fatigue of the paravertebral and upper extremity muscles after whiplash injury.

BACKGROUNDWhiplash-associated disorders (WAD) result from injury of neck structures that most often occur during traffic accidents as a result of rapid acceleration-deceleration. The dominant symptoms manifest in the musculoskeletal system and include increased fatigue. Because of the frequency of whiplash injuries, a simple, cheap and useful diagnostic tool is needed to differentiate whiplash injury from healthy patients or those faking symptoms.OBJECTIVESTo determine muscle fatigue in patients with whiplash injury in six body positions.DESIGNAnalytical cross-sectional study.SETTINGEmergency center, university hospital.PATIENTS AND METHODSWe studied patients with whiplash injury from vehicular traffic accidents who presented to the emergency center within 6 hours of sustaining the injury. We determined whiplash injury grade according to the Quebec Task Force (QTF) classification and measured isometric muscle endurance in six different body positions. Control subjects for each patient were matched by age, gender and anthropomorphic characteristics. Cut-off values were determined to distinguish patients with whiplash injury from controls and for determination of injury grade.MAIN OUTCOME MEASURE(S)QTF grade, time to muscle fatigue in seconds.RESULTSFrom September 2013 to September 2016, we enrolled 75 patients with whiplash injury and 75 matching control subjects. In all six positions, the patients with whiplash injury felt muscle fatigue faster than equivalent controls (P<.05) and the time to onset of muscle fatigue decreased with increasing injury grades in all six positions. Assignment to the patient or control group and to injury grade could be predicted with more than 90% accuracy on the basis of time to muscle fatigue. The most efficient position was the highest injury grade, by which 99.9% of the patients were accurately categorized. Isometric muscle endurance correlated with whiplash injury grade in all six positions (P<.01).CONCLUSIONUnder clinical conditions, muscle endurance and the appearance of isometric muscle fatigue during testing can be a useful indicator of whiplash injury and grade.LIMITATIONSThe size of the sample was small. An objective parameter such as electromyography is needed to confirm isometric muscle fatigue.

An Integrated Model of Chronic Whiplash-Associated Disorder.

Synopsis The development of persistent symptoms following whiplash injury from a motor vehicle collision is common and contributes substantially to societal and personal costs. The popular Quebec Task Force classification system of whiplash-associated disorders (WADs) was meant to function as a prognostic and intervention decision aid, but its usefulness has been questioned. Emerging evidence highlights the heterogeneity of WAD by demonstrating physical and psychological impairments that are unique to those who develop persistent symptoms. These impairments are not recognized in the Quebec Task Force classification system. The purpose of this clinical commentary is to describe an integrated model that focuses on how psychological and neurobiological factors interact with, and are influenced by, existing personal and environmental factors to contribute to the development of chronic WAD. The model has been developed through more than 20 years of work in the field, consultation with experts, in-depth synthesis of existing evidence, and new evidence from the authors' own research programs. A subtheme is that a point of convergence currently exists between the psychological, physiological, and social determinants of health literature that can further explain the complex presentation of WAD. The new model is proposed to orient future research toward more interdisciplinary efforts across nontraditional fields, including data scientists and consumers, to clarify the WAD condition. J Orthop Sports Phys Ther 2017;47(7):462-471. Epub 16 Jun 2017. doi:10.2519/jospt.2017.7455.

Leg pain location and neurological signs relate to outcomes in primary care patients with low back pain

BackgroundLow back pain (LBP) patients with related leg pain and signs of nerve root involvement are considered to have a worse prognosis than patients with LBP alone. However, it is unclear whether leg pain location above or below the knee and the presence of neurological signs are important in primary care patients. The objectives of this study were to explore whether the four Quebec Task Force categories (QTFC) based on the location of pain and on neurological signs have different characteristics at the time of care seeking, whether these QTFC are associated with outcome, and if so whether there is an obvious ranking of the four QTFC on the severity of outcomes.MethodAdult patients seeking care for LBP in chiropractic or general practice were classified into the four QTFC based on self-reported information and clinical findings. Analyses were performed to test the associations between the QTFC and baseline characteristics as well as the outcomes global perceived effect and activity limitation after 2 weeks, 3 months, and 1 year and also 1-year trajectories of LBP intensity.ResultsThe study comprised 1271 patients; 947 from chiropractic practice and 324 from general practice. The QTFC at presentation were statistically significantly associated with most of the baseline characteristics, with activity limitation at all follow-up time points, with global perceived effect at 2 weeks but not 3 months and 1 year, and with trajectories of LBP. Severity of outcomes in the QTFC increased from LBP alone, across LBP with leg pain above the knee and below the knee to LBP with nerve root involvement. However, the variation within the categories was considerable.ConclusionThe QTFC identify different LBP subgroups at baseline and there is a consistent ranking of the four categories with respect to outcomes. The differences between outcomes appear to be large enough for the QTFC to be useful for clinicians in the communication with patients. However, due to variation of outcomes within each category individuals’ outcome cannot be precisely predicted from the QTFC alone. It warrants further investigation to find out if the QTFC can improve existing prediction tools and guide treatment decisions.

Significance of sub grouping patients with chronic low back pain in management decisions: A prospective study

Background: The Quebec Task Force classification (QTF) was originally designed to help in making a clinical decision and to aid in determining the prognosis. However, the predictive validity and prognostic significance of the classification was debated. We conducted the study to determine the discriminative and prognostic significance of the modified Quebec Task Force classification in chronic low back pain patientsMaterials & Methods: 183 consecutive chronic low back pain(>7 weeks of continuous pain) patients in the age groups of 18-65 years who presented to a tertiary care centre in South India and followed up for a minimum of 6 months were included in the study. Patients were assigned to one of the four QTF categories after a detailed history and examination. Pain severity and functional disability were assessed using LBPRS and RMDQ respectively. The patients were then put on the common specific rehabilitation protocol and analgesics, and followed up every six weeks to look for compliance with the treatment. The scores (LBPRS, RMDQ) were noted again at 3 and 6 months. The comparison of scores was done among the 4 QTF categories at the time of presentation, at 3 months and at 6 months Result: There were no significant differences in the distribution of age, sex, occupation or educational status among different QTF categories. Non-parametric tests using Wilcoxon Signed Rank test showed significant improvement in LBPRS and RMDQ scores with time in each category(p value

Comparing 2 Whiplash Grading Systems to Predict Clinical Outcomes

ObjectiveTwo whiplash severity grading systems have been developed: Quebec Task Force on Whiplash-Associated Disorders (QTF-WAD) and the Croft grading system. The majority of clinical studies to date have used the modified grading system published by the QTF-WAD in 1995 and have demonstrated some ability to predict outcome. But most studies include only injuries of lower severity (grades 1 and 2), preventing a broader interpretation. The purpose of this study was assess the ability of these grading systems to predict clinical outcome within the context of a broader injury spectrum. MethodsThis study evaluated both grading systems for their ability to predict the bivalent outcome, recovery, within a sample of 118 whiplash patients who were part of a previous case-control designed study. Of these, 36% (controls) had recovered, and 64% (cases) had not recovered. The discrete bivariate distribution between recovery status and whiplash grade was analyzed using the 2-tailed cross-tabulation statistics. ResultsApplying the criteria of the original 1993 Croft grading system, the subset comprised 1 grade 1 injury, 32 grade 2 injuries, 53 grade 3 injuries, and 32 grade 4 injuries. Applying the criteria of the modified (QTF-WAD) grading system, there were 1 grade 1 injury, 89 grade 2 injuries, and 28 grade 3 injuries. Both whiplash grading systems correlated negatively with recovery; that is, higher severity grades predicted a lower probability of recovery, and statistically significant correlations were observed in both, but the Croft grading system substantially outperformed the QTF-WAD system on this measure. ConclusionsThe Croft grading system for whiplash injury severity showed a better predictive measure for recovery status from whiplash injuries as compared with the QTF-WAD grading system.

Reliability and measurement error of frontal and horizontal 3D spinal motion parameters in 219 patients with chronic low back pain

BackgroundIn order for measurements to be clinically useful, data on psychometric conditions such as reliability should be available in the population for which the measurements are intended to be used. This study comprises a test-retest design separated by 7 to 14 days, and evaluates the intra and interrater reliability of regional frontal and horizontal spinal motion in 219 chronic LBP patients using the CA6000 Spine Motion Analyzer. In addition, it compares these results on the frontal and horizontal plane with previously published results on the sagittal plane. 219 individuals with chronic mechanical LBP, classified as either Quebec Task Force group 1, 2, 3 or 4 were included, and kinematics of the lumbar spine were sampled during standardized spinal lateral flexion and rotation motion using a 6-df instrumented spatial linkage system. Test-retest reliability and measurement error were evaluated using intraclass correlation coefficients ICC(1,1) and Bland-Altman limits of agreement (LOAs).ResultsThe reliability analysis based on the whole study sample showed ICC(1,1) coefficients varying between 0.68 and 0.73 for the frontal plane and 0.33 and 0.49 for the horizontal plane. Relatively wide LOAs were observed for all parameters. Reliability measures in patient subgroups ICC(1,1) ranged between 0.55 and 0.81 for the frontal plane and 0.28 and 0.69 for the horizontal plane. Greater ICC(1,1) coefficients and smaller LOA were observed when patients were examined by the same examiner, had a stable pain level between tests, and were male. ROM measurements were more reliable in patients with a BMI higher than 30, and measurements on patients with LBP and leg pain showed higher reliability and smaller measurement error in all parameters except for the jerk index.ConclusionFrontal plane measurements obtained using the CA6000 Spine Motion Analyzer are sufficiently reliable to be used for group comparisons but not individual comparisons. Measurements in the horizontal plane can be used for neither group nor individual comparisons.

A Study of the Modified Quebec Task Force Classification of Chronic Low Back Pain with Regards to Activity Limitation, Global Percieved Effect, Sick Leave, and its Prognostic Implications

Introduction The Quebec Task Force(QTF) on activity related spinal disorders was a group of experts in various fields brought together by the Quebec Worker's Health and Safety Commission. It formally recognized that clinicians couldnot reliably differentiate between different patho anatomic causes of low back pain(LBP). Classifying patients as described by the QTF has shown associated differences on several characteristics which showed increasing severity from category 1(local LBP) across the categories of LBP+radiation above knee (category 2), LBP+radiation below knee (category 3) to LBP+neurological signs (category 4). The objective of the study is to determine the prognostic significance of the QTF classification in patients with chronic LBP and to compare the efficacy of the chronic LBP rehabilitation protocol among various categories of QTF. Material and Methods Routine data was collected at the time of presentation to an outpatient department of a tertiary care center in India. After taking a detailed history and clinical examination, the pain severity is assessed by Low Back Pain Rating scale (LBPRS) and the activity limitation is assessed by Roland Morris Disability Questionnaire (RMDQ). The patients were advised treatment according to the common standard rehabilitation protocol. The patients were followed up every 6 weeks to check for the progression of symptoms clinically and for the compliance with the rehabilitation protocol. The patients were evaluated at 3 months and again at 6 months for Global Perceived Effect (GPE), activity limitation (RMDQ questionnaire) and sick leave status along with LBPRS. Results A total of 188 patients were included with 75% 3 month and 70% 6 month follow up.category 1 had the least and category 4 had the most severe activity limitation at all time points.Patients in category 4 improved the most at the end of 6 months with the common rahabilitation protocol.Patients in category 4 landed up more frequently in surgery compared with others. There were no significant differences in comparisions between category 2 and category 3 Conclusion Categorizing patients based on QTF classification has shown significant association with activity limitation. Prognosis of the patient's condition based on the symptoms at presentation can be roughly estimated using the QTF classification. However, differentiating patients based on radiating pain above or below the knee has no significant prognostic implications. It was found difficult to establish a diagnosis based on symptoms alone. Hence, targeted treatment based on the QTF classification may have a potential role in better management of patients with chronic LBP.

The relationship between Quebec Task Force Classification and outcome in patients with low back pain treated through mechanical diagnosis and therapy

Objective: To determine the correlation between the Quebec Task Force Classification (QTFC) system and outcome in patients with non-specific low back pain (LBP).Methods: Forty-nine patients who were treated in outpatient physical therapy clinics of Catholic Health System (CHS) of Western New York (WNY) were classified according to the QTFC at the initial examination by physical therapists (PTs) with training in Mechanical Diagnosis and Therapy (MDT). The patient’s perceived level of function was assessed with the Focus On Therapeutic Outcomes (FOTO) tool at the initial examination, 2 weeks following the initiation of physical therapy and again at discharge.Results: A linear regression model between acuity and change in FOTO score was performed and demonstrated statistical significance (P<0·05) as the more favorable outcome was found with the more acute patients. Spearman correlations between change in FOTO score and QTFC, duration of treatment and acuity of condition, and number of visits and change in FOTO score were not found to be statistically significant.Conclusions: The patients treated in this study demonstrated functional improvement in an average of eight visits, indicating efficacious care. Future research is needed to determine prioritized intervention strategies for designated LBP classifications.

Coxib Safety in Patients with Inflammatory Bowel Diseases: A Meta-analysis

Background: Patients with inflammatory bowel diseases (IBD) frequently have extraintestinal manifestations including arthritis, sacroiliitis, and ankylosing spondylitis. While the treatment of these rheumatological conditions with traditional non-steroidal anti-inflammatory drugs (NSAIDs) has been reported to lead to frequent IBD exacerbation, the safety of cyclooxygenase-2 (COX-2) inhibitors (Coxibs) remains unclear. Objectives: Our aim is to carry out a meta-analysis to verify if Coxibs, employed to treat rheumatological manifestations, are associated with an increased risk of exacerbation of IBD compared to placebo. Study Design and Setting: A MEDLINE, SCOPUS, ISI-Web of Knowledge, and EMBASE search of all studies published in English from 1965 to April 15, 2015, was conducted. Articles on the safety of Coxibs in patients with IBD were identified using the terms “Coxibs or cyclooxygenase-2 inhibitors or COX-2 inhibitors AND inflammatory bowel disease.” Methods: The criteria of exclusion of the studies were NSAIDs administration within 2 weeks before starting Coxibs. For the “proportion” meta-analysis, the studies had to report the proportion of patients that had to discontinue the Coxibs therapy due to an exacerbation of IBD; for the “relative risk” meta-analysis, the studies had to be prospective with a comparison between patients taking Coxibs and patients taking placebo. Two authors independently reviewed titles and abstracts of references retrieved from the literature search and selected potentially relevant studies. Differences in opinion were resolved by discussion until consensus was reached. If an agreement failed to be reached, a third author was consulted. The quality of each study was assessed on a 5-point scale adapted from studies by the Quebec Task Force on Whiplash-Associated disorders and Jadad. Results: The search identified 72 publications of which 7 studies reported the proportion of patients with IBD that had to stop the Coxibs therapy because of a worsening of the activity of IBD. The pooled proportion of flare up of IBD in patients that received Coxibs was 14.4% (95% CI: 6.7 – 24.4%). There was no statistically significant difference between patients that assumed Coxibs and those that assumed placebo (total fixed effect relative risk = 0.86, 95% CI: 0.39 – 1.88, P = 0.7). Limitations: A proportion of patients received maintenance therapy with azathioprine or 6-mercaptopurine and these co-interventions could have protected against a Coxib-induced flare; furthermore, the duration of Coxib assumption in the prospective studies is shorter compared to that of the medical practice. Three of the studies included in our meta-analysis had an insufficient quality but due to the higher number of recruited patients, the studies with a better quality had a higher weight in the final result. Moreover, to assess the relative risk of flare up of IBD only randomized controlled trials have been used in the second meta-analysis. Conclusions: This meta-analysis showed that Coxibs are safe in most patients with IBD. Controlled trials of Coxibs compared with NSAIDs would be useful, at least in patients suffering from rheumatic pain refractory to standard treatment. Key words: Acute pain, ankylosing spondylitis, arthritis, coxibs, chronic pain, inflammatory bowel disease, rheumatic manifestations, sacroiliitis

Effects of spinal manipulation on sensorimotor function in low back pain patients – A randomised controlled trial

BackgroundLow back pain (LBP) is a major health problem in industrialized societies. Spinal manipulation (SM) is often used for treating LBP, though the therapeutic mechanisms remain elusive. Research suggests that sensorimotor changes may be involved in LBP. It is hypothesized that SM may generate its beneficial effects by affecting sensorimotor functions. ObjectivesTo compare changes in sensorimotor function, as measured by postural sway and response to sudden load, in LBP patients following the delivery of high-velocity low amplitude (HVLA)-SM or low-velocity variable amplitude (LVVA)-SM versus a sham control intervention. DesignA three-arm (1:1:1 ratio) randomized controlled trial. MethodsA total of 221 participants who were between 21 and 65 years, having LBP intensity (numerical rating scale) ≥4 at either phone screen or the first baseline visit and ≥2 at phone screen and both baseline visits, and Quebec Task Force diagnostic classifications of 1, 2, 3 or 7 were enrolled to receive four SM treatments over two weeks. Study outcomes were measured at the first and fifth visits with the examiners blinded from participant group assignment. ResultsThe LVVA-SM group demonstrated a significant increase in medial-to-lateral postural excursion on the soft surface at the first visit when compared to the control group. No other significant between-group differences were found for the two sensorimotor tests, whether during the first visit or over two weeks. ConclusionsIt appears that short-term SM does not affect the sensorimotor functions as measured by postural sway and response to sudden load in this study.

Mid-term follow-up of whiplash with Bournemouth Questionnaire: The significance of the initial depression to pain ratio

The Bournemouth Questionnaire (BQ) was used to report the short to mid-term outcome of a prospective cohort of patients who had sustained Whiplash Associated Disorder (WAD), and establish whether outcome could be predicted on initial assessment. One hundred patients with WAD grades I-III on the Quebec Task Force Classification were referred for physiotherapy (neck posture advice, initially practised under the direct supervision of a therapist). BQ scores were recorded on the first visit, at six weeks, then at final follow-up. Seventy-six percent of patients were available at final follow-up, 58% women. The mean age was 43.2 years old and follow-up time 38 months (28-48). Symptoms plateaued after six weeks in the majority and improved gradually thereafter. When the individual BQ components on initial presentation were reassessed, patients who score disproportionately highly in BQ Question 5 (Depression) had a worse outcome. To quantify this, the ratio of BQ Questions 5 (Depression)/1 (Pain) was calculated. BQ5/1 ratio greater than 1 on initial presentation had an odds ratio of 2 for poor outcome (p= 0.02). The BQ can therefore be used to identify patients with a disproportionately high depression score (BQ5) who are highly likely to clinically deteriorate in the medium term.

In a secondary care setting, differences between neck pain subgroups classified using the Quebec task force classification system were typically small - a longitudinal study.

BackgroundThe component of the Quebec Task Force Classification System that subgroups patients based on the extent of their radiating pain and neurological signs has been demonstrated to have prognostic implications for patients with low back pain but has not been tested on patients with neck pain (NP).The main aim of this study was to examine the association between these subgroups, their baseline characteristics and outcome in chronic NP patients referred to an outpatient hospital department.MethodsThis was an observational study of longitudinal data extracted from systematically collected, routine clinical data. Patients were classified into Local NP only, NP + arm pain above the elbow, NP + arm pain below the elbow, and NP with signs of nerve root involvement (NP + NRI). Outcome was pain intensity and activity limitation. Associations were tested in longitudinal linear mixed models.ResultsA total of 1,852 people were classified into subgroups (64 % females, mean age 49 years). Follow ups after 3, 6 and 12 months were available for 45 %, 32 % and 40 % of those invited to participate at each time point.A small improvement in pain was observed over time in all subgroups. There was a significant interaction between subgroups and time, but effect sizes were small. The local NP subgroup improved slightly less after 3 months as compared with all other groups, but continued to have the lowest level of pain. After 6 and 12 months, those with NP + pain above the elbow had improved the least and patients with NP + NRI had experienced the largest improvements in pain intensity. Similar results were obtained for activity limitation.ConclusionsThis study found baseline and outcome differences between neck pain subgroups classified using the Quebec Task Force Classification System. However, differences in outcome were typically small in size and mostly differentiated the local NP subgroup from the other subgroups. A caveat to these results is that they were obtained in a cohort of chronic neck pain patients who only displayed small improvements over time and the results may not apply to other cohorts, such as people at earlier stages of their clinical course and in other clinical settings.

The Chiropractic Hospital-Based Interventions Research Outcomes Study: Consistency of Outcomes Between Doctors of Chiropractic Treating Patients With Acute Lower Back Pain

ObjectiveThe aim of this study was to determine if effectiveness differs between community-based doctors of chiropractic administering standardized evidence-based care that includes high-velocity low-amplitude spinal manipulative therapy (SMT) for acute low back pain (LBP). MethodsA secondary analysis of randomized controlled trial and observational pilot study data was performed with nonrandom allocation to 4 DCs. Patients included those with Quebec Task Force categories less than or equal to 2 and acute LBP of 2 to 4 weeks' duration. The intervention provided was clinical practice guidelines–based care including high-velocity low-amplitude SMT. Primary outcomes included changes from baseline in modified Roland Disability Questionnaire (RDQ) at 24 weeks. Comparisons of simple main effects at 24 weeks and of marginal main effects in repeated-measures analyses were performed. ResultsBetween groups, adjusted point-specific differences in RDQ change were minimally clinically important but not statistically significant at 24 weeks (largest pairwise difference, −3.1; 95% confidence interval, −6.3 to 0.1; overall P = .10). However, in optimal analyses that considered the repeated nature of the measurements for each outcome, significant differences in marginal mean RDQ changes were found between groups (largest pairwise difference, −3.8; 95% confidence interval, −4.9 to 2.6; overall P = .03). ConclusionsOverall, DCs differed modestly in their effectiveness in improving LBP-specific disability. The point estimates mirrored typically reported effect sizes from recent systematic reviews of SMT; however, confidence limits did not exclude clinically negligible effects.

Whiplash associated disorder

Following traumatic injury, the clinician is sometimes exposed to an apparent discrepancy between the magnitude or duration of pain described by patients and the magnitude of the objective physical injury. In the medico-legal sphere this discrepancy takes on greater importance, with the legal system requiring comment on the biological plausibility, treatment and prognosis for such conditions. Whiplash-associated disorder (WAD) is a frequently encountered example of a medical condition where often there is an apparent disconnect between magnitude of injury and magnitude of disability. In this article we will review some of the current concepts that have been used to explain the pain and disability associated with WAD. We will also consider the biological mechanisms which may underlie these symptoms in order to propose rational treatment approaches to address this complex and multidimensional malady. The Quebec Task Force on Whiplash-Associated Disorders defined whiplash as “an acceleration-deceleration mechanism of energy transferred to the neck that results in soft tissue injury that may lead to a variety of clinical manifestations including neck pain and its associated symptoms.” That task force also coined the term “whiplash-associated disorders” (WAD) to describe the clinical entities related to the injury, and to distinguish them from the injury mechanism. The term ‘whiplash’ on its own should be used to refer to the acute, localised neck pain resulting from an acceleration/deceleration mechanism. Estimates vary widely, but authors report that about 30% to 50% of patients who sustain a symptomatic whiplash injury go on to report chronic, and potentially more widespread symptoms, which may be termed WAD. Acute pain will typically be initiated peripherally through the activation of nerve fibres sensitive to noxious stimuli (nociceptors). From that point, to pain perception, interpretation and disability, there exists a complex neurochemical cascade involving both the peripheral and central nervous systems. Extensive reviews …

Patterns of acute whiplash-associated disorder in the Lithuanian population after road traffic accidents.

To investigate acute whiplash-associated disorder in the Lithuanian population who are unaware of the phenomenon. Controlled cohort study. Seventy-one patients were enrolled from the emergency departments of the Kaunas region of Lithuania following road traffic accidents, examined within 3-14 days after the accident, and compared with 53 matched controls. Clinical neurological examination, including range of motion and motion-evoked pain or stiffness in the neck; spontaneous pain and pain pressure threshold. Questionnaires: Quebec Task Force questionnaire (QTFQ); Disability Rating Index (DRI); Cognitive Failures Questionnaire (CFQ); Hospital Anxiety and Depression Scale (HADS) and health perception. Sixty-six of 71 (93%) patients developed acute symptoms. The most frequent symptoms found after road traffic accidents were neck or shoulder pain; reduced or painful neck movements, including decreased range of motion; multiple subjective symptoms according to QTFQ and significantly reduced pain threshold. Perceived health status was decreased and DRI was increased, while HADS showed a significantly higher risk of developing anxiety. Higher grade whiplash-associated disorder was linked with a greater reduction in range of motion and more prominent neck pain. Road traffic accidents induce whiplash-associated disorder in patients who seek help, but who are unaware of the condition whiplash-associated disorder. Whiplash-associated disorder should be considered and treated as an entity per se.

Study protocol for patient response to spinal manipulation - a prospective observational clinical trial on physiological and patient-centered outcomes in patients with chronic low back pain.

BackgroundLow back pain (LBP) is a major health issue due to its high prevalence rate and socioeconomic cost. While spinal manipulation (SM) is recommended for LBP treatment by recently published clinical guidelines, the underlying therapeutic mechanisms remain unclear. Spinal stiffness is routinely examined and used in clinical decisions for SM delivery. It has also been explored as a predictor for clinical improvement. Flexion-relaxation phenomenon has been demonstrated to distinguish between LBP and healthy populations. The primary objective of the current study is to collect preliminary estimates of variability and effect size for the associations of these two physiological measures with patient-centered outcomes in chronic LBP patients. Additionally biomechanical characteristics of SM delivery are collected with the intention to explore the potential dose–response relationship between SM and LBP improvement.Methods/DesignThis is a prospective, observational study applying side-lying, high velocity, low amplitude SM as treatment for patients with LBP over a course of 6 weeks. Approximately 80 participants will be enrolled if they present with chronic LBP of 1, 2 or 3 in Quebec Task Force Classification for spinal disorders, a Roland-Morris Disability Questionnaire (RMDQ) score ≥ 6, and persistent LBP ≥ 2 with a maximum ≥ 4 using numerical rating scale. Patient-centered outcomes include LBP using visual analog scale, RMDQ, and PROMIS-29. Lumbar spine stiffness is assessed using palpation, a hand-held instrumented device, and an automated device. Flexion-relaxation is assessed using surface electromyography at the third level of the lumbar spine. Biomechanical characteristics of SM are assessed using a self-reported, itemized description system, as well as advanced kinetic measures that will be applied to estimate forces and moments at the lumbar segment level targeted by SM.DiscussionBeside alterations in material properties of the passive components of the spine, increased neuromuscular activity may also contribute to a stiffened spine. Examining changes in both spinal stiffness and flexion-relaxation along the course of the treatment provides an opportunity to understand if the therapeutic effect of SM is associated with its action on active and/or passive components of the spine.Trial registrationNCT01670292 on clinicaltrials.gov.

SP0029 Phenotyping Neck Pain in Order to Personnalize the Treatment

The first step of the diagnosis is to eliminate a specific disease: Infections, neoplastic conditions (bone and spinal cord) rheumatoid arthritis, spondylarthropathy, polymyalgia rheumatica, crystal depositions, ... All these diseases...

Reliability and measurement error of sagittal spinal motion parameters in 220 patients with chronic low back pain using a three-dimensional measurement device

Background contextA basic premise for any instrument measuring spinal motion is that reliable outcomes can be obtained on a relevant sample under standardized conditions. PurposeThe purpose of this study was to assess the overall reliability and measurement error of regional spinal sagittal plane motion in patients with chronic low back pain (LBP), and then to evaluate the influence of body mass index, examiner, gender, stability of pain, and pain distribution on reliability and measurement error. Study design/settingThis study comprises a test-retest design separated by 7 to 14 days. Patient sampleThe patient cohort consisted of 220 individuals with chronic LBP. Outcome measuresKinematics of the lumbar spine were sampled during standardized spinal extension-flexion testing using a 6-df instrumented spatial linkage system. MethodsTest-retest reliability and measurement error were evaluated using interclass correlation coefficients (ICC1,1) and Bland-Altman limits of agreement (LOAs). ResultsThe overall test-retest reliability (ICC1,1) for various motion parameters ranged from 0.51 to 0.70, and relatively wide LOAs were observed for all parameters. Reliability measures in patient subgroups (ICC1,1) ranged between 0.34 and 0.77. In general, greater (ICC1,1) coefficients and smaller LOAs were found in subgroups with patients examined by the same examiner, patients with a stable pain level, patients with a body mass index less than below 30 kg/m2, patients who were men, and patients in the Quebec Task Force classifications Group 1. ConclusionsThis study shows that sagittal plane kinematic data from patients with chronic LBP may be sufficiently reliable in measurements of groups of patients. However, because of the large LOAs, this test procedure appears unusable at the individual patient level. Furthermore, reliability and measurement error varies substantially among subgroups of patients.

Erratum to: prognostic implications of the Quebec Task Force classification of back-related leg pain: an analysis of longitudinal routine clinical data

Erratum to: prognostic implications of the Quebec Task Force classification of back-related leg pain: an analysis of longitudinal routine clinical data