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Table 2 Decision model for selecting tailored treatment

From: Effects of tailored neck-shoulder pain treatment based on a decision model guided by clinical assessments and standardized functional tests. A study protocol of a randomized controlled trial

Main factor Test Cut-off criteria Rationale for cut-off
1. Cervical flexibility 1.1 Range of motion, upper cervical   
Three sub-factors a) Flexion-extension a) < 68° a) 20% below reference values of normative control data[44] resulting in 97% specificity.
b) Passive rotation in maximal flexed position b) < 32° b) 18-29% below reference values of normative control data[4547]. Also discriminating cut off for cervicogenic headache[47, 48].
  Qualifier: Either a) or b)  
1.2. Range of motion, lower cervical   
Flexion-extension < 17° 35% below reference values of normative control data[44] resulting in 94% specificity.
1.3. Range of motion, upper and lower cervical   
  Axial rotation < 109° 20% below reference values of normative control data[44] resulting in 97 % specificity.
2. Cervical strength 2.1.Cranio-cervical flexion test   
Three sub-factors a) Maximal voluntary contraction (MVC) a) < 2,5 Nm a) Empirical experience, value indicating clear impairment (Shaun O’Leary, personal communication)
b) Endurance (50 % MVC) b) < 20 sec b) 88,5% specificity based on normative control data (Pilot study, unpublished data, n = 26).
  Qualifier: Either a) or b)  
2.2. Cervico-thoracic test   
a) Flexion MVC a) < 40 N a) 95% specificity according to data simulation based on[49, 50].
b) Extension MVC b) < 140 N b) 95 % specificity according to data simulation based on[49, 50].
  Qualifier: Either a) or b)  
2.3. Arm strength in lifting task   
a) Cervical Progressive Isoinertial lifting evaluation test (C-PILE)[51] a) Max weight / adjusted body weight[52]: <0,12 kg/kg[28, 53] a) Cut off to discriminate between neck pain and healthy: Specificity 81%[53]
b) Subjective rating of the ability to carry and to lift b) At least answer “rather bad, rather difficult” on the questions “Because of your neck problems, how do you manage to carry/lift?” (≥4 on the scale 1 = Very good, no problem; 6 = Very bad, very difficult/impossibly) b) Specificity data N/A. Chosen cut-off renders 47% of women with neck pain positive. (non-published data, ISRCTN92199001)
   Qualifier: a) and b) Comment: From a clinical perspective, we thought it important to combine estimates of physical capability and subjective rating in the treatment decision process.
3. Trapezius myalgia a) Diagnosed trapezius myalgia right or left a) Criteria according to Ohlsson and coworkers[27], with amendments[26]. a) Specificity N/A. In an attempt to sharpen and objectify the trapezius myalgia criteria we have added pain pressure measurements.
b) Pain pressure threshold of the upper trapezius muscles b) < 175 N right trapezius, < 168 N left trapezius b) 20 % below reference values of nonspecific neck pain subjects without trapezius myalgia.
   Qualifier: a) and b) The combination of criteria predicts 40% positive tests (non-published data, ISRCTN92199001).
4. Cervicogenic headache Diagnosed cervicogenic headache Criteria of the Cervicogenic Headache International Study Group[54] with amendment of reduced range of motion specific for the upper cervical levels and palpable upper cervical joint dysfunction[55]. The reason for the amendment is to increase the sensitivity and specificity[55]. Note that the tests of reduced upper cervical range of motion are the same as for cervical flexibility 1a and b.[44, 47, 48]
5. Sensorimotor control 5.1. Symptoms and activity limitations a) Rather strong/often dizziness or balance disturbances: (≥4 on both questions. Scale 1–6.)[28] a) Prediction 11%.
Two sub-factors    
Combinations of: - Dizziness or balance disturbances b) Light dizziness or balance disturbances (3 on both questions, or >3 on one. Scale 1–6.)[28] and headache associated to neck problems (but not cervicogenic headache) b) or c) Prediction 30%.
- Headache associated to neck problems - Difficulties to rotate the head due to neck problems c) Light dizziness or balance disturbances and, due to neck problems, difficulties to rotate the head Disturbances of sensorimotor control and its associations to symptoms like dizziness/balance disturbances and headache is supported in the literature (for references see[56, 57].
  (≥4 on scale 1–6.) To predict the number of positive cases for the combinations in a), b) and c) we used 117 women with nonspecific neck pain (Own non-published data, ISRCTN92199001):
  Qualifier: Either a) or b)or c)  
5.2. Cervical motor function < 170°/sec 50% below reference control data giving 97% specificity[32]
  Peak speed of cervical axial rotation.   Reduced ability to perform fast cervical rotations may reflect altered sensorimotor function in neck pain patients[32].
  1. MVC: Maximal voluntary contraction; C_PILE: Cervical Progressive Isoinertial lifting evaluation test.