Geoff M. Schneider

Are Joint Injury, Sport Activity, Physical Activity, Obesity, or Occupational Activities Predictors for Osteoarthritis? A Systematic Review

STUDY DESIGN Systematic review with meta-analysis. OBJECTIVES To identify risk factors for osteoarthritis (OA) of the knee, hip, and ankle, including joint injury, sport, physical activity, overweight/obesity, and occupational activity, in all age groups. BACKGROUND OA is a significant health problem worldwide, affecting up to 10% of men and 18% of women over 60 years of age. There has not been a comprehensive review examining modifiable physical risk factors associated with the onset of OA. This evidence is important to inform the physiotherapy management of individuals following onset of OA. METHODS Twelve electronic databases were systematically reviewed. The studies selected met the following criteria: (1) original data; (2) joint injury, sport activity, physical activity, overweight/obesity, and/or occupational activity investigated as risk factors; (3) outcomes included OA (hip, knee, and/or ankle); and (4) analytic component of study design. The data extracted included study design, years of follow-up, study population, OA definition, risk factors, and results (effect estimates reported or calculated where available). The quality of evidence was assessed based on a modified version of the Downs and Black checklist. RESULTS Joint injury, obesity, and occupational activity were associated with an increased risk of OA of the knee and hip. Sport and physical activity produced inconsistent findings. Joint injury was identified as a significant risk factor for knee OA (combined odds ratio = 3.8; 95% confidence interval: 2.0, 7.2) and hip OA (combined odds ratio = 5.0; 95% confidence interval: 1.4, 18.2), as was previous meniscectomy with or without anterior cruciate ligament injury for knee OA (combined odds ratio = 7.4; 95% confidence interval: 4.0, 13.7). There is a paucity of research examining risk factors associated with ankle OA; this review identified only 2 studies with this outcome. CONCLUSION Joint injury, obesity, and occupational activity are associated with an increased risk of knee and hip OA. Some findings remain inconclusive, including levels of physical activity and sport specificity in individuals who do not suffer an injury. Early identification of individuals at risk for OA provides an opportunity for physiotherapy management or other interventions to modify risk-related behavior. There is a need in the literature for additional high-quality studies, such as prospective cohort studies, that minimize potential bias in examining the relationship between physical risk factors and OA. LEVEL OF EVIDENCE Prognosis, level 2a-.

Examining Sport Concussion Assessment Tool ratings for male and female youth hockey players with and without a history of concussion

Background Concussion is one of the most commonly occurring injuries in sport today. The Sport Concussion Assessment Tool (SCAT) is a commonly used paper neurocognitive tool. To date, little is known about SCAT baseline normative values in youth athletes. Objective The purpose of this study was to determine normative values on the SCAT for male and female youth hockey players. Methods This is a secondary data analysis of pooled data from three prospective cohort studies examining the risk of injury in paediatric ice hockey players aged 9–17 years. A preseason baseline demographic and injury history questionnaire was completed by each player. Results A total of 4193 players completed SCATs at baseline and were included in the analysis. 781 players (18.6%) reported a previous history of concussion. Fatigue and low energy followed by headache were the most commonly reported symptoms in all players. The majority of youth players could recite all five words immediately but only three words when delayed. A smaller proportion of the males were able to report the months of the year in reverse order compared with females of a similar age. The median number of digits recited in reverse order was 4. Conclusions Youth ratings varied between age groups, gender and from previously reported ratings of varsity athletes, possibly reflecting developmental and gender differences. An understanding of these differences in youth athletes is important to ensure appropriate performance expectations on the SCAT and when making clinical decisions following a concussion.

Minimizing the source of nociception and its concurrent effect on sensory hypersensitivity: an exploratory study in chronic whiplash patients.

BackgroundThe cervical zygapophyseal joints may be a primary source of pain in up to 60% of individuals with chronic whiplash associated disorders (WAD) and may be a contributing factor for peripheral and centrally mediated pain (sensory hypersensitivity). Sensory hypersensitivity has been associated with a poor prognosis. The purpose of the study was to determine if there is a change in measures indicative of sensory hypersensitivity in patients with chronic WAD grade II following a medial branch block (MBB) procedure in the cervical spine.MethodsMeasures of sensory hypersensitivity were taken via quantitative sensory testing (QST) consisting of pressure pain thresholds (PPTs) and cold pain thresholds (CPTs). In patients with chronic WAD (n = 18), the measures were taken at three sites bilaterally, pre- and post- MBB. Reduced pain thresholds at remote sites have been considered an indicator of central hypersensitivity. A healthy age and gender matched comparison group (n = 18) was measured at baseline. An independent t-test was applied to determine if there were any significant differences between the WAD and normative comparison groups at baseline with respect to cold pain and pressure pain thresholds. A dependent t-test was used to determine whether there were any significant differences between the pre and post intervention cold pain and pressure pain thresholds in the patients with chronic WAD.ResultsAt baseline, PPTs were decreased at all three sites in the WAD group (p < 0.001). Cold pain thresholds were increased in the cervical spine in the WAD group (p < 0.001). Post-MBB, the WAD group showed significant increases in PPTs at all sites (p < 0.05), and significant decreases in CPTs at the cervical spine (p < 0.001).ConclusionsThe patients with chronic WAD showed evidence of widespread sensory hypersensitivity to mechanical and thermal stimuli. The WAD group revealed decreased sensory hypersensitivity following a decrease in their primary source of pain stemming from the cervical zygapophyseal joints.

Preseason reports of neck pain, dizziness, and headache as risk factors for concussion in male youth ice hockey players.

Objective:The objective of this study was to determine the risk of concussion in youth male hockey players with preseason reports of neck pain, headaches, and/or dizziness. Design:Secondary data analysis of pooled data from 2 prospective cohort studies. Setting:Ice hockey rinks in Alberta and Quebec, Canada. Participants:A total of 3832 male ice hockey players aged 11 to 14 years (280 teams) participated. Assessment of Risk Factors:Participants recorded baseline preseason symptoms of dizziness, neck pain, and headaches on the Sport Concussion Assessment Tool. Incidence rate ratios (IRR) were estimated using Poisson regression, adjusted for cluster by team, hours of exposure, and other covariates. Main Outcome Measures:Concussions that occurred during the season were recorded using a validated prospective injury surveillance system. Results:Preseason reports of neck pain and headache were risk factors for concussion (IRR = 1.67; 95% confidence interval [CI], 1.15–2.41 and IRR = 1.47; 95% CI, 1.01–2.13). Dizziness was a risk factor for concussion in the Pee Wee nonbody checking cohort (IRR = 3.11; 95% CI, 1.33–7.26). A combination of any 2 symptoms was a risk factor in the Pee Wee nonbody checking cohort (IRR = 3.65; 95% CI, 1.20–11.05) and the Bantam cohort (IRR = 2.40; 95% CI, 1.15–4.97). Conclusions:Male youth athletes reporting headache and neck pain at baseline were at an increased risk of concussion during the season. The risk associated with dizziness and any 2 of dizziness, neck pain, or headaches depended on age group and body checking. Clinical Relevance:Baseline testing may be of benefit to identify individuals with symptoms of dizziness, neck pain, and headaches who may be at a higher risk of concussion during the season.

Cervical Radiofrequency Neurotomy Reduces Central Hyperexcitability and Improves Neck Movement in Individuals with Chronic Whiplash

OBJECTIVE This study aims to determine if cervical medial branch radiofrequency neurotomy reduces psychophysical indicators of augmented central pain processing and improves motor function in individuals with chronic whiplash symptoms. DESIGN Prospective observational study of consecutive patients with healthy control comparison. SETTING Tertiary spinal intervention centre in Calgary, Alberta, Canada. SUBJECTS Fifty-three individuals with chronic whiplash associated disorder symptoms (Grade 2); 30 healthy controls. METHODS Measures were made at four time points: two prior to radiofrequency neurotomy, and 1- and 3-months post-radiofrequency neurotomy. Measures included: comprehensive quantitative sensory testing (including brachial plexus provocation test), nociceptive flexion reflex, and motor function (cervical range of movement, superficial neck flexor activity during the craniocervical flexion test). Self-report pain and disability measures were also collected. One-way repeated measures analysis of variance and Friedmans tests were performed to investigate the effect of time on the earlier measures. Differences between the whiplash and healthy control groups were investigated with two-tailed independent samples t-test or Mann-Whitney tests. RESULTS Following cervical radiofrequency neurotomy, there were significant early (within 1 month) and sustained (3 months) improvements in pain, disability, local and widespread hyperalgesia to pressure and thermal stimuli, nociceptive flexor reflex threshold, and brachial plexus provocation test responses as well as increased neck range of motion (all P < 0.0001). A nonsignificant trend for reduced muscle activity with the craniocervical flexion test (P > 0.13) was measured. CONCLUSIONS Attenuation of psychophysical measures of augmented central pain processing and improved cervical movement imply that these processes are maintained by peripheral nociceptive input.

A comparison of physical and psychological features of responders and non-responders to cervical facet blocks in chronic whiplash

BackgroundCervical facet block (FB) procedures are often used as a diagnostic precursor to radiofrequency neurotomies (RFN) in the management of chronic whiplash associated disorders (WAD). Some individuals will respond to the FB procedures and others will not respond. Such responders and non-responders provided a sample of convenience to question whether there were differences in their physical and psychological features. This information may inform future predictive studies and ultimately the clinical selection of patients for FB procedures.MethodsThis cross-sectional study involved 58 individuals with chronic WAD who responded to cervical FB procedures (WAD_R); 32 who did not respond (WAD_NR) and 30 Healthy Controls (HC)s. Measures included: quantitative sensory tests (pressure; thermal pain thresholds; brachial plexus provocation test); nociceptive flexion reflex (NFR); motor function (cervical range of movement (ROM); activity of the superficial neck flexors during the cranio-cervical flexion test (CCFT). Self-reported measures were gained from the following questionnaires: neuropathic pain (s-LANSS); psychological distress (General Health Questionnaire-28), post-traumatic stress (PDS) and pain catastrophization (PCS). Individuals with chronic whiplash attended the laboratory once the effects of the blocks had abated and symptoms had returned.ResultsFollowing FB procedures, both WAD groups demonstrated generalized hypersensitivity to all sensory tests, decreased neck ROM and increased superficial muscle activity with the CCFT compared to controls (p < 0.05). There were no significant differences between WAD groups (all p > 0.05). Both WAD groups demonstrated psychological distress (GHQ-28; p < 0.05), moderate post-traumatic stress symptoms and pain catastrophization. The WAD_NR group also demonstrated increased medication intake and elevated PCS scores compared to the WAD_R group (p < 0.05).ConclusionsChronic WAD responders and non-responders to FB procedures demonstrate a similar presentation of sensory disturbance, motor dysfunction and psychological distress. Higher levels of pain catastrophization and greater medication intake were the only factors found to differentiate these groups.

Intrarater and interrater reliability of select clinical tests in patients referred for diagnostic facet joint blocks in the cervical spine

OBJECTIVE To measure the intra- and interrater reliability of select standardized clinical tests used for the assessment of patients with axial neck pain referred for diagnostic facet joint blocks. DESIGN Single-group, repeated-measures study. SETTING Tertiary interventional pain management center. PARTICIPANTS Consecutive patients with persistent neck pain, referred to a tertiary interventional pain management center, were approached to participate. Fifty-six patients consented to participate in the study. INTERVENTIONS Subjects underwent a standardized clinical testing protocol, performed by 2 physiotherapists, before receiving diagnostic facet joint blocks. Subjects were examined twice by 1 assessor for the determination of the intrarater reliability of the testing protocol, and again by a second assessor for determination of interrater reliability. MAIN OUTCOME MEASURES Intraclass correlation coefficients (ICCs), kappa coefficients, and 95% confidence intervals were calculated to determine the intra- and interrater reliability for cervical range of motion (ROM; 6 directions), extension-rotation (ER) test, manual spinal examination (MSE), and palpation for paraspinal tenderness (PST) from C2 through C7. RESULTS For intrarater reliability, kappa coefficients ranged from .51 to .88 for the ER test, MSE, and PST, and ICCs ranged from .91 to .97 for ROM. For interrater reliability, kappa coefficients ranged from .74 to .96 for the ER test, MSE, and PST, and ICCs ranged from .90 to .95 for ROM. CONCLUSIONS The standardized clinical tests exhibited moderate to substantial reliability in patients with axial neck pain referred for diagnostic facet joint blocks. The data justify the incorporation of these tests into a clinical prediction model to screen patients before referral for diagnostic facet blocks.

Derivation of a clinical decision guide in the diagnosis of cervical facet joint pain

OBJECTIVE To derive a clinical decision guide (CDG) to identify patients best suited for cervical diagnostic facet joint blocks. DESIGN Prospective cohort study. SETTING Pain management center. PARTICIPANTS Consecutive patients with neck pain (N=125) referred to an interventional pain management center were approached to participate. INTERVENTIONS Subjects underwent a standardized testing protocol, performed by a physiotherapist, prior to receiving diagnostic facet joint blocks. All subjects received the reference standard diagnostic facet joint block protocol, namely controlled medial branch blocks (MBBs). The physicians performing the MBBs were blinded to the local anesthetic used and findings of the clinical tests. MAIN OUTCOME MEASURES Multivariate regression analyses were performed in the derivation of the CDGs. Sensitivity, specificity, positive and negative likelihood ratios, and 95% confidence intervals (CIs) were calculated for the index tests and CDGs. RESULTS A CDG involving the findings of the manual spinal examination (MSE), palpation for segmental tenderness (PST), and extension-rotation (ER) test demonstrated a specificity of 84% (95% CI, 77-90) and a positive likelihood ratio of 4.94 (95% CI, 2.8-8.2). Sensitivity of the PST and MSE were 94% (95% CI, 90-98) and 92% (95% CI, 88-97), respectively. Negative findings on the PST were associated with a negative likelihood ratio of .08 (95% CI, .03-.24). CONCLUSIONS MSE, PST, and ER may be useful tests in identifying patients suitable for diagnostic facet joint blocks. Further research is needed to validate the CDGs prior to their routine use in clinical practice.

Screening of patients suitable for diagnostic cervical facet joint blocks - A role for physiotherapists

The cervical facet joint is a prevalent source of pain in patients with chronic cervical spine pain. Patients with persistent, disabling neck pain, are increasingly being referred for diagnostic facet joint blocks, with the aim of assessing their suitability for interventional procedures such as radiofrequency neurotomy (RFN). A positive response to the block is an indicator of more substantive benefits from RFN. Physiotherapists and medical practitioners are challenged to make appropriate referrals for diagnostic facet joint blocks. This lack of selection contributes to lengthy wait-lists, unnecessary invasive procedures for those who have a negative response and significant costs to the health care system. Physiotherapists use manual examination to identify the facet joint as the primary source of a patients pain but its diagnostic accuracy and reliability is variable. It is reasoned that a combination of findings of a physical, manual and psychological assessment may better indicate that a patient will respond positively or negatively to a diagnostic facet joint block. Clinical prediction guides (CPG) allow practitioners to use the results of the patient history, self-report measures and physical examination toward optimal diagnostic and therapeutic decisions. It is proposed that the development and validation of a CPG may aid in the appropriate selection of patients for this diagnostic procedure.

Are pre-season reports of neck pain, dizziness and/or headaches risk factors for concussion in male youth ice hockey players?

Background Concussion is a commonly encountered injury associated with potential long-term sequelae. No previous studies have evaluated dizziness, neck pain and headache as potential risk factors for concussion. Objective The objective of this study is to determine the risk of concussion in male youth hockey players with preseason reports of neck pain, headaches and dizziness. Design This study is a secondary data analysis of a prospective cohort study examining the risk of injury associated with body checking among paediatric ice hockey players. Setting Youth ice hockey in Alberta and Quebec, Canada. Participants A total of 3902 11–14 year old males from 282 teams participated. Assessment of risk factors Each participant completed a pre-season baseline demographic and injury history questionnaire. Preseason reports of neck pain, headache or dizziness were documented on the Sport Concussion Assessment Tool. Main outcome measurements Diagnosed concussions were recorded during the season of play via a previously validated, prospective injury surveillance system. Results A total of 178 concussions occurred during the studies, with 11 players sustaining two concussions. Incidence rate ratios were calculated using Poisson regression, adjusted for exposure hours, cluster by team and potential covariates. Dizziness was not a significant predictor of concussion. Individuals reporting a headache or neck pain at the start of the season were 1.48 (95% CI 1.02 to 2.14) and 1.69 (95% CI 1.16 to 2.44) times more likely to suffer a concussion during the season than those not reporting these symptoms. Individuals reporting any two of dizziness, headache and neck pain were 1.99 (95% CI 1.20 to 3.32) times more likely to sustain a concussion. Conclusion Male youth athletes reporting headache or neck pain at baseline were at an increased risk of concussion during the season. From an injury prevention perspective, baseline testing may aid in identifying individuals at a higher risk for concussion.