Table 2 Decision model for selecting tailored treatment
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[45–47]. 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 20 sec | b) 88,5% specificity based on normative control data (Pilot study, unpublished data, n = 26).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]. |