Astrid Woodhouse

Altered motor control patterns in whiplash and chronic neck pain

BackgroundPersistent whiplash associated disorders (WAD) have been associated with alterations in kinesthetic sense and motor control. The evidence is however inconclusive, particularly for differences between WAD patients and patients with chronic non-traumatic neck pain. The aim of this study was to investigate motor control deficits in WAD compared to chronic non-traumatic neck pain and healthy controls in relation to cervical range of motion (ROM), conjunct motion, joint position error and ROM-variability.MethodsParticipants (n = 173) were recruited to three groups: 59 patients with persistent WAD, 57 patients with chronic non-traumatic neck pain and 57 asymptomatic volunteers. A 3D motion tracking system (Fastrak) was used to record maximal range of motion in the three cardinal planes of the cervical spine (sagittal, frontal and horizontal), and concurrent motion in the two associated cardinal planes relative to each primary plane were used to express conjunct motion. Joint position error was registered as the difference in head positions before and after cervical rotations.ResultsReduced conjunct motion was found for WAD and chronic neck pain patients compared to asymptomatic subjects. This was most evident during cervical rotation. Reduced conjunct motion was not explained by current pain or by range of motion in the primary plane. Total conjunct motion during primary rotation was 13.9° (95% CI; 12.2–15.6) for the WAD group, 17.9° (95% CI; 16.1–19.6) for the chronic neck pain group and 25.9° (95% CI; 23.7–28.1) for the asymptomatic group. As expected, maximal cervical range of motion was significantly reduced among the WAD patients compared to both control groups. No group differences were found in maximal ROM-variability or joint position error.ConclusionAltered movement patterns in the cervical spine were found for both pain groups, indicating changes in motor control strategies. The changes were not related to a history of neck trauma, nor to current pain, but more likely due to long-lasting pain. No group differences were found for kinaesthetic sense.

Natural course of acute neck and low back pain in the general population: The HUNT study

&NA; In subjects who largely refrained from health care treatment, neck and low back pain declined rapidly after a new pain episode, with the exception of some important subgroups. &NA; In this prospective cohort study we aimed to describe the natural course of acute neck and low back pain in a general population of Norway. We screened 9056 subjects aged 20–67 years who participated in a general health survey for a new episode of neck or low back pain the previous month. The screening identified 219 subjects who formed the cohort for this study. Pain intensity was reported on a numeric rating scale (0–10) at 1, 2, 3, 6, and 12 months after start of the new pain episode. The course of pain was described for neck and low back pain, different baseline pain levels, age groups, and number of pain sites at baseline. Use of medication and health care was described and associations between pain intensity and seeking health care were estimated. Pain declined rapidly within 1 month after a new pain episode, with a reduction of 0.91 (95% confidence interval [CI] 0.50–1.32) for neck pain and 1.40 (95% CI 0.82–1.99) for low back pain with little change thereafter. However, pain remained unchanged over the follow‐up year for those with equal pain in the neck and low back areas at baseline and for those reporting 4 or more pain sites at baseline. Only 1 in 5 sought health care for their complaints. Still, the course of pain was comparable to effect sizes reported in interventional studies. This study thus contributes natural course reference data for comparisons of pain outcome in clinical trials and practice.

Reduced head steadiness in whiplash compared with non-traumatic neck pain

OBJECTIVE While sensorimotor alterations have been observed in patients with neck pain, it is uncertain whether such changes distinguish whiplash-associated disorders from chronic neck pain without trauma. The aim of this study was to investigate head steadiness during isometric neck flexion in subjects with chronic whiplash-associated disorders (WAD), those with chronic non-traumatic neck pain and healthy subjects. Associations with fatigue and effects of pain and dizziness were also investigated. METHODS Head steadiness in terms of head motion velocity was compared in subjects with whiplash (n=59), non-traumatic neck pain (n=57) and healthy controls (n=57) during 2 40-s isometric neck flexion tests; a high load test and a low load test. Increased velocity was expected to reflect decreased head steadiness. RESULTS The whiplash group showed significantly decreased head steadiness in the low load task compared with the other 2 groups. The difference was explained largely by severe levels of neck pain and dizziness. No group differences in head steadiness were found in the high load task. CONCLUSION Reduced head steadiness during an isometric holding test was observed in a group of patients with whiplash-associated disorders. Decreased head steadiness was related to severe pain and dizziness.

Clinical characteristics, pain, and disability in relation to alar ligament MRI findings.

Study Design. Cross-sectional study. Objective. To evaluate the association between degree of signal changes in the alar ligaments on MRI with respect to pain and disability. Summary of Background Data. Conflicting evidence exists whether areas of high-signal intensity in the alar ligaments on MRI are associated with pain and disability. Methods. A cross-sectional designed study of 173 subjects including a group with persistent whiplash associated disorder (WAD) Grade II after a car accident (n = 59), a group with chronic nontraumatic neck pain (n = 57) and a group without neck pain or previous neck trauma (n = 57). To assess pain and disability, all participants filled in the Brief Pain Inventory (BPI-intensity and BPI-interference), the European Quality of Life (EQ−5D and EQ VAS) and the Hospital Anxiety and Depression Rating Scale (HADS). High-resolution proton-weighted MR images in three planes were evaluated by two experienced neuroradiologists who were blinded to patient history and group allocation. The alar ligaments were evaluated according to a 4-point grading scale; 0 = low-signal intensity throughout the entire cross-section area, 1 = high-signal intensity in one third or less, 2 = high-signal intensity in one third to two thirds, and 3 = high-signal intensity in two thirds or more of the cross-section area. Results. With respect to BPI and HADS, the scores were highest in the WAD group, intermediate in the chronic nontraumatic neck pain group, and lowest among controls. EuroQol scores were lowest in the WAD group, intermediate in the chronic nontraumatic neck pain group, and highest among controls (P < 0.001). There was, however, no significant correlation between the alar ligament changes and measures for pain and disability. Conclusion. The previously reported assumption that changes in the alar ligaments detected on MRI are associated with pain and disability is not supported by this study. The diagnostic value and the clinical relevance of MR-detectable areas of high intensity in the alar ligaments remain questionable.

Chronic widespread pain-the need for a standard definition.

The concept of chronic widespread pain (CWP) came into use with the introduction of the term “fibromyalgia” or “fibromyalgia syndrome” (FMS) to the literature when a dedicated group of rheumatologists began to systematize the ideas around the clinical entity that had previously been called “fibrositis,” “nonarticular rheumatism,” “psychogenic rheumatism” among others. The American College of Rheumatology (ACR) in 1990 published a landmark article presenting criteria for the classification of FMS and firmly placed CWP in the clinical literature. Chronic widespread pain has since been used as a necessary criterion for the diagnosis of FMS but has also taken on a life of its own, considered now as a primary clinical diagnosis. Evidence for this is first that in 2001, a Comprehensive ICF Core Set for CWP was established by the International Classification of Functioning, Disability and Health (ICF), and this organization listed CWP as “a common musculoskeletal disorder.” Second, the newly proposed ICD-11 has a section of diagnoses for chronic pain, CWP being the first diagnosis under the category “chronic primary pain.” If accepted as is expected, the new ICD-11 diagnostic code for CWP will be universally in clinical use. Since there is much ambiguity around the diagnoses of CWP and FMS, guidelines and definitions need clarification. Most research studies concerning FMS continue to use the ACR 1990 definitions for both CWP and FMS as the basis for selecting patients or subjects for study. Chronic widespread pain is now frequently used as a diagnosis on its own and the variability of prevalence data for CWP and FMS can be due to the different definitions which refer to different populations. A commonly accepted definition for CWP would help to clarify the ambiguities because all research would use the same measuring tool to assess the populations of interest. This review focuses on clinical research but this problem has a direct bearing on clinical practice and the use of the same standard definitions in research and clinical practice would ultimately benefit patients as well. Treating population “A” with a method or pharmaceutical proven in population “B” might not be effective.

Evidence for a general stiffening motor control pattern in neck pain: a cross sectional study

BackgroundNeck pain is associated with several alterations in neck motion and motor control. Previous studies have investigated single constructs of neck motor control, while few have applied a comprehensive set of tests to investigate cervical motor control. This comparative cross- sectional study aimed to investigate different motor control constructs in neck pain patients and healthy controls.MethodsA total of 166 subjects participated in the study, 91 healthy controls (HC) and 75 neck pain patients (NP) with long-lasting moderate to severe neck pain. Neck flexibility, proprioception, head steadiness, trajectory movement control, and postural sway were assessed using a 3D motion tracking system (Liberty). The different constructs of neck motion and motor control were based on tests used in previous studies.ResultsNeck flexibility was lower in NP compared to HC, indicated by reduced cervical ROM and conjunct motion. Movement velocity was slower in NP compared to HC. Tests of head steadiness showed a stiffer movement pattern in NP compared to HC, indicated by lower head angular velocity. NP patients departed less from a predictable trajectory movement pattern (figure of eight) compared to healthy controls, but there was no difference for unpredictable movement patterns (the Fly test). No differences were found for postural sway in standing with eyes open and eyes closed. However, NP patients had significantly larger postural sway when standing on a balance pad. Proprioception did not differ between the groups. Largest effect sizes (ES) were found for neck flexibility (ES range: 0.2- 0.8) and head steadiness (ES range: 1.3- 2.0). Neck flexibility was the only construct that showed a significant association with current neck pain, while peak velocity was the only variable that showed a significant association with kinesiophobia.ConclusionsNP patients showed an overall stiffer and more rigid neck motor control pattern compared to HC, indicated by lower neck flexibility, slower movement velocity, increased head steadiness and more rigid trajectory head motion patterns. Only neck flexibility showed a significant association with clinical features in NP patients.

The role of stress in absenteeism: Cortisol responsiveness among patients on long-term sick leave.

Objective This study aimed to (1) See whether increased or decreased variation relate to subjective reports of common somatic and psychological symptoms for a population on long-term sick leave; and (2) See if this pattern in variation is correlated with autonomic activation and psychological appraisal. Methods Our participants (n = 87) were referred to a 3.5-week return-to-work rehabilitation program, and had been on paid sick leave >8 weeks due to musculoskeletal pain, fatigue and/or common mental disorders. An extensive survey was completed, addressing socio-demographics, somatic and psychological complaints. In addition, a physician and a psychologist examined the participants, determining baseline heart rate, medication use and SCID-I diagnoses. During the 3.5-week program, the participants completed the Trier Social Stress Test for Groups. Participants wore heart rate monitors and filled out Visual Analogue Scales during the TSST-G. Results Our participants presented a low cortisol variation, with mixed model analyses showing a maximal increase in free saliva cortisol of 26% (95% CI, 0.21–0.32). Simultaneously, the increase in heart rate and Visual Analogue Scales was substantial, indicating autonomic and psychological activation consistent with intense stress from the Trier Social Stress Test for Groups. Conclusions The current findings are the first description of a blunted cortisol response in a heterogeneous group of patients on long-term sick leave. The results suggest lack of cortisol reactivity as a possible biological link involved in the pathway between stress, sustained activation and long-term sick leave.

Transdiagnostic group-based occupational rehabilitation for participants with chronic pain, chronic fatigue and common mental disorders. A feasibility study

Abstract Purpose: The aim was to investigate the feasibility of introducing a novel transdiagnostic occupational rehabilitation program delivered in groups mixing participants with chronic pain, chronic fatigue and common mental disorders. Materials and methods: Observational data on group climate and individual participation were triangulated with qualitative data from focus group interviews on the participants’ experiences with transdiagnostic groups. Results: The study included 222 participants receiving a temporary work disability benefit. Self-reported chronic pain (75%), chronic fatigue (79%), and mental distress (62%) were prevalent and the majority reported overlapping conditions (78%). Program completion among participants was high (96%). Those completing participated actively (95%) in the program. Overall group climate was stable with moderately high engagement. Participants with clinically confirmed mental disorders (22%) showed similar outcomes. Self-reported problems with “working in a group” prior to rehabilitation were not associated with how participants experienced group climate. Qualitative data supported the findings of positive participant experiences with transdiagnostic group settings. Conclusions: Transdiagnostic groups showed high participation rates, moderately high group engagement across symptom profiles and positive participant experiences. Implementing transdiagnostic occupational rehabilitation in groups mixing participants with chronic pain, chronic fatigue and common mental disorders was feasible and acceptable to participants. Implications for rehabilitation Most research has been done on disorder-specific occupational rehabilitation programs, but emerging evidence supports a more generic approach. Transdiagnostic therapies, such as Acceptance and Commitment Therapy (ACT), have shown promising results for both somatic and mental disorders. The feasibility of implementing transdiagnostic rehabilitation groups, their acceptability to participants and the demand for such groups has not been established. This study indicates that it is feasible to introduce a novel transdiagnostic group-based occupational rehabilitation program for mixed groups of sick-listed participants with chronic pain, chronic fatigue and/or common mental disorders.

Exercises for Women with Persistent Pelvic and Low Back Pain after Pregnancy

Background: Specific stabilizing exercises activating deep local muscles in coordination with global muscles are recommended in the treatment of pregnancy-related lumbopelvic pain. Some studies have suggested that recruitment of the deepest abdominal muscle, transversus abdominis, is crucial in the development and improvement of lumbopelvic pain. Objective: This exploratory study aimed to describe the development of pain, disability and transversus abdominis recruitment before, during and after an individually designed intervention including an exercise program for women with persisting lumbopelvic pain after delivery. Design: A multiple-baseline, single-subject experimental design was applied. Methods: Sixteen women with lumbopelvic pain after delivery were included and received tailored exercise therapy, including ultrasound-guided activation of deep muscles, strengthening and stretching exercises and advice. Pain, disability and ultrasound-recorded activation of transversus abdominis was registered weekly. Treatment and testing was performed in a primary care setting in Trondheim, Norway. Results: All sixteen included women reported reduced pain and decreased disability over the intervention period. The magnitude of transversus abdominis activation varied substantially between individuals and tests. While there was a statistically significant correlation between change in pain and change in disability, no correlation was observed between change in transversus abdominis activation and change in symptoms. Limitations: This is an exploratory study and results cannot be generalized without replication in controlled studies. Conclusions: Pain and disability due to persistent low back and pelvic pain after delivery were reduced after specific, individual adapted exercise including deep and superficial lumbopelvic muscles. Changes in pain and disability were not associated with changes in transversus abdominis activation.

Describing patients with a duration of sick leave over and under one year in Norway

Abstract Objective: This study aimed to describe the somatic, social, psychological, and work-related factors that characterize participants with a duration of sick leave over and under one year. Methods: During 2012, 181 patients on long-term sick leave were consecutively recruited and asked to answer an extensive survey. Several outcomes were reported, addressing work-related factors and somatic, psychological, and social symptoms. In cross-sectional analyses, sick leave duration was dichotomized as > or < one year, based on Norwegian legislation. Linear and logistic regressions were used to estimate population probabilities and means. Results: The estimated prevalence of pain, fatigue, anxiety, and depression was overall high. There was a tendency towards a higher prevalence of fatigue, anxiety, and depression in those with sick leave duration less than one year, with the exception of sleep problems, which was more frequent in the population with longer duration. Relationship with friends, family, co-workers, and the last workplace were worse in the population with longer duration. Conclusions: Cross-sectional analyses indicated that social and work-related problems are more adverse in patients with longer duration of sick leave, while psychological and somatic symptoms appear less adverse. This is one of the first studies quantitatively demonstrating these differences through comprehensive, simultaneously measured self-report questionnaires.