Only Cervical Segments C0-C2, Not C3 Are Relevant for Subgrouping Migraine Patients According to Manual Palpation and Pain Provocation

Background and Aims: Subgrouping of migraine patients according to the pain response to manual palpation of the upper cervical spine has been recently described. Based on the neuroanatomy and the convergence of spinal and trigeminal nerves in the trigeminocervical complex, the cervical segments C1 to C3 are potentially relevant. To date it has not been investigated whether palpation results of all upper cervical segments are based on one underlying construct which allows combining the results of several tests.Methods: Seventy-one migraine patients with chronic or frequent episodic migraine diagnosed according to the IHS classification version 3 were examined by one physiotherapist. Manual palpation was performed on the upper three cervical segments unilaterally left and right. The results of the palpation according to the patients’ responses were combined using factor analysis to determine whether results from all three segments form one underlying construct. In addition, item response theory (IRT) was used to investigate the structure of the response pattern as well as item difficulty and discriminationFindings: Factor analysis (principal component) showed that the palpation of C3 loads less onto the underlying construct than the palpation of C1 and C2. Considering a cut-off value >1.0, the eigenvalues of all three segments do not represent one underlying construct. When excluding the results from C3, remaining items form one construct. The internal consistency of the pain response to palpation of C1 and C2 is acceptable with a Cronbach’s alpha of 0.69. IRT analysis showed that the rating scale model fits best to the pain response pattern. The discrimination value (1.24) was equal for all 4 items. Item difficulty showed a clear hierarchical structure between the palpation of C1 and C2, indicating that people with a higher impairment are more likely to respond with referred pain during palpation of the segment C2. Conclusion: Statistical analysis confirms that results from the palpation of the cervical segments C1 and C2 in migraine patients can be combined. IRT analysis confirmed the ordinal pattern of the pain response and showed the higher probability of a pain response during palpation of C2. Registration of main Study: German registry of clinical trials (DRKS00015995), Registered 20. December 2018, https://www.drks.de/drks_web/setLocale_EN.do

“Taking action” to reduce pain—Has interpretation of the motor adaptation to pain been too simplistic?

Movement adapts during acute pain. This is assumed to reduce nociceptive input, but the interpretation may not be straightforward. We investigated whether movement adaptation during pain reflects a purposeful search for a less painful solution. Three groups of participants performed two blocks (Baseline, Experimental) of wrist movements in the radial-ulnar direction. For the Control group (n = 10) both blocks were painfree. In two groups, painful electrical stimulation was applied at the elbow in Experimental conditions when the wrist crossed radial-ulnar neutral. Different stimulus intensities were given for specific wrist angles in a secondary direction (flexion-extension) as the wrist passed radial-ulnar neutral (Pain 5–1 group:painful stimulation at ~5 or ~1/10—n = 21; Pain 5–0 group:~5 or 0(no stimulation)/10—n = 6)). Participants were not informed about the less painful alternative and could use any strategy. We recorded the percentage of movements using the wrist flexion/extension alignment that evoked the lower intensity noxious stimulus, movement variability, and change in wrist/forearm alignment during pain. Participants adapted their strategy of wrist movement during pain provocation and reported less pain over time. Three adaptations of wrist movement were observed; (i) greater use of the wrist alignment with no/less noxious input (Pain 5–1, n = 8/21; Pain 5–0, n = 2/6); (ii) small (n = 9/21; n = 3/6) or (iii) large (n = 4/21; n = 1/6) change of wrist/forearm alignment to a region that was not allocated to provide an actual reduction in noxious stimulus. Pain reduction was achieved with “taking action” to relieve pain and did not depend on reduced noxious stimulus.

Inter-examinerreliability study of physical examination procedures to assess the cervical spine

Objective The objective of this study was to establish the level of inter-examiner reliability for six common cervical manual and physical examination procedures used to assess the cervical spine. Materials: Reliability study that used a convenience sample of 51 patients between the ages of 16–70 years presenting with a chief complaint of neck pain. Two physical therapists independently performed the same series of cervical physical examination procedures on each of the participant. The clinicians were blinded to each other’s findings and the clinical status of the patient. Kappa coefficients (κ) were calculated for levels of agreement between the clinicians for each procedure. Results When assessing for asymmetrical motion, excellent levels of reliability (κ range: 0.88–0.96) were observed for the Bilateral Modified Lateral Shear (asymmetry criterion), Bilateral C2 Spinous Kick (asymmetry criterion) and Flexion-Rotation Tests. When pain provocation was used as the indicator of a positive test during palpation of the cervical facet joints, moderate to substantial levels of reliability (κ range: 0.53–0.76) were observed. When patients were instructed not to provide feedback to the clinicians about pain provocation during facet joint palpation and clinicians relied solely on their qualitative assessment of segmental mobility, the level of reliability was lower (κ range: 0.45–0.53). Due to 100 % prevalence of negative findings, Kappa values could not be calculated for the Sharp-Purser test or the Unilateral C2 Spinous Kick Test. Conclusions Most physical examination procedures examined in this study demonstrated moderate to excellent levels of inter-examiner reliability. Palpation for segmental mobility without pain provocation demonstrated a lower level of reliability compared to palpation for pain provocation. Correlation with clinical findings is necessary to establish validity and the applicability of these procedures in clinical practice.

MRI Detection of Active Sacroiliitis in First Degree Relatives of Ankylosing Spondylitis Patients with Clinical and Laboratory Correlations

Background. Detection of ankylosing spondylitis (AS) in the preclinical stage could help prevent long term morbidity in this patients’ population. The aim of this study was to examine the prevalence of active sacroiliitis in first-degree relatives of AS patients using MRI with clinical and laboratory correlations as these patients may benefit from MRI screening and early treatment.Methods. Seventeen first-degree relatives of AS patients were recruited prospectively. AS screening questionnaires (Ankylosing Spondylitis Disease Activity Score, Bath Ankylosing Spondylitis Disease Activity Index & Visual Analogue Scale), blood tests (C-Reactive Protein, HLA-B27), and an MRI of the SIJs were taken. Two musculoskeletal radiologists interpreted the MRI scans, and two physiotherapists applied four symptom provocation tests (Gaenslen's test, posterior pelvic pain provocation test, Patrick's Faber (PF) test and palpation of the long dorsal SIJ ligament test), and two functional movement tests (active straight leg raise and Stork test). Results. Seven (41%) of the 17 participants demonstrated MRI evidence of active sacroiliitis. Of the 7 participants with active sacroiliitis, two (29%) had no history of recent low back pain (LBP), two (29%) had negative HLA-B27, and one (14%) participant had neither back pain nor positive HLA-B27. The Cohen's Kappa score for the interobserver agreement between the radiologists was 1.00 (p-value <0.0001). Despite fair to strong between therapist agreement for the physical test outcomes (Kappa 0.26 to 1.00), the physical test results per se did not have any predictive association with a positive MRI.Conclusions. MRI detected active sacroiliitis in 41% of first-degree relatives of AS patients. The lack of a history of prior LBP or positive HLA-B27 in active sacroiliitis participants might suggest that MRI screening for this high-risk population is warranted; however, further larger studies are needed to help elucidate its cost-effectiveness and long-term benefits.

Validation of self-administered tests for screening for chronic pregnancy-related pelvic girdle pain

Background Many women develop pelvic girdle pain (PGP) during pregnancy and about 10% have chronic pain several years after delivery. Self-administered pain provocation tests are one way to diagnose and evaluate this pain. Their validity in post-partum women is not yet studied. The purpose of this study was to evaluate the validity of self-administered test for assessment of chronic pregnancy-related PGP several years after delivery. Methods Women who previously have had PGP during pregnancy and who participated in one of three RCT studies were invited to a postal follow up of symptoms including performance of self-administered tests after two, 6 or 11 years later, respectively. In total, 289 women returned the questionnaire and the test-results. Of these, a sub-group of 44 women with current PGP underwent an in-person clinical examination. Comparisons were made between test results in women with versus without PGP but also, in the sub-group, between the self-administered tests and those performed during the clinical examination. Results Fifty-one women reported PGP affecting daily life during the last 4 weeks, and 181 reported pain when performing at least one of the tests at home. Those with chronic PGP reported more positive tests (p < 0.001). There was no significant difference between diagnosis from the self-administered tests compared to tests performed during the in-person clinical examination (p = 0.305), either for anterior or posterior PGP. There were no significant differences of the results between the tests performed self-administered vs. during the clinical examination. Conclusion A battery of self-administered tests combined with for example additional specific questions or a pain-drawing can be used as a screening tool to diagnose chronic PGP years after delivery. However, the modified SLR test has limitations which makes its use questionable.

Evaluation of Cervical Dysfunctions in Temporomandibular Disorders

Objective: The purpose of this study is to investigate upper cervical segmental dysfunctions in female patients with chronic TMD with and without neck pain and to compare them with healthy subjects. Method: Patients admitted to our hospital with jaw pain were evaluated in this study, and a total of 152 patients and healthy subjects who met the inclusion criteria for the study were divided into 3 groups: TMD with neck pain (n = 94), TMD without neck pain (n = 28) and control (n = 30). Patients with myofascial pain (category I) or disc displacements (category II) were diagnosed based on the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) guidelines. Upper cervical segmental dysfunctions were identified using functional and pain provocation tests in patients with TMD and healthy subjects. Results: When patients with TMD were classified, there was a significant difference between TMD with neck pain (category I, 62.8%; category II, 37.2%) and TMD without neck pain (category I, 28.6%; category II, 71.4%) groups (p = 0.002). There was a statistically significant dysfunction [difference] in all upper cervical segments in favor of the TMD with neck pain group compared TMD without neck pain group and healthy control group (p < 0.05). 51.1% Occiput-C1, 81.9% C1-C2 and 53.2% C2-C3 segment dysfunction rates were detected in TMD with neck pain group. Conclusion: Upper cervical segmental dysfunction rate was higher in TMD group with neck pain than TMD without neck pain and healthy control group.

Clinical examination of the sacroiliac joint

Introduction: Sacroiliac joint (SIJ) can be a nociceptive source of the pain in lower back. Clinical diagnosis of SIJ pain remains yet problematic. The cause of SIJ pain is multifactorial. The pain may be a result of an inflammatory disease, arthrosis, traumatic injury, infectious process or overload. The potential role in SIJ examination have pain provocation tests. Objective: To review and further discuss the validity of some of the mostly used clinical provocation tests such as Distraction test, Thigh Thrust test, Compression test, Sacral Thrust test, Patrick’s (FABER), Gaenslen’s test, Standing Flexion Test, Gillet Test and Shimpi Prone test. Method: A literature search was conducted using PubMed. Reviewed were studies between 2005 and 2020 in English, Slovak and Czech with keywords: sacroiliac joint, sacroiliac assessment, provocation tests. The methodology of studies was not considered. Discussion: It is challenging to determine whether SIJ is the actual source of the pain by using only one of the provocation tests. Therefore, it is beneficial to combine more compression tests, what will also increase the validity of testing. Other widely used SIJ tests are palpation test, however their validity is poor.