Consensus for a primary care clinical decision-making tool for assessing, diagnosing, and managing low back pain in Alberta, Canada.

BACKGROUND: Low back pain (LBP) is a common condition causing disability and high healthcare costs. Alberta faces challenges with unnecessary referrals to specialists and long wait times. A province-wide standardized clinical care pathway based on evidence-based best practices can improve efficiency, reduce wait times, and enhance patient outcomes. Implementing such pathways has shown success in other areas of healthcare in Alberta. This study developed a clinical decision-making pathway to standardize care and minimize uncertainty in assessment, diagnosis, and management. METHODS: A systematic rapid review identified existing tools and evidence that could support a comprehensive LBP clinical decision-making tool. Forty-seven healthcare professionals participated in four rounds of a modified Delphi approach to reach consensus on the assessment, diagnosis, and management of patients presenting to primary care with LBP in Alberta, Canada. This project was a collaborative effort between Alberta Health Services' Bone and Joint Health Strategic Clinical Network (BJHSCN) and the Alberta Bone and Joint Health Institute (ABJHI). RESULTS: A province-wide expert panel consisting of professionals from different health disciplines and regions collaborated to develop an LBP clinical decision-making tool. This tool presents clinical care pathways for acute, subacute, and chronic LBP. It also provides guidance for history-taking, physical examination, patient education, and management. CONCLUSIONS: This clinical decision-making tool will help to standardize care, provide guidance on the diagnosis and management of LBP, and assist in clinical decision-making for primary care providers in both public and private sectors.

Preseason Measures of Cervical Spine Function, Vestibulo-Ocular Reflex, Dynamic Balance, and Divided Attention in Youth Ice Hockey Players.

OBJECTIVES: Report typical scores and examine preseason cervical spine, vestibulo-ocular reflex, dynamic balance, and divided attention measures in competitive youth ice hockey players aged 10 to 18 years with and without a previous concussion history. DESIGN: Cross-sectional secondary analysis. METHODS: The exposure of interest was self-reported history of concussion. The main outcomes were cervical spine measures (Cervical Flexor Endurance [CFE; seconds], Cervical Flexion-Rotation Test [normal/abnormal], Anterolateral Cervical Spine Strength [kilograms], Head Perturbation Test (/8), and Joint Position Error [JPE; centimeters]), vestibulo-ocular reflex (Dynamic Visual Acuity [logMAR], Head Thrust Test [Positive/Negative]), dynamic balance (Functional Gait Assessment [/30]) and divided attention (Walking While Talking Test [seconds]). Multivariable linear or logistic regression, adjusted for age-group, sex, level of play, and clustered by team, were used to assess potential differences by concussion history. RESULTS: We included data from 2311 participants in this study (87.2% male, 12.8% female, 39.0% reported a previous concussion). No differences by concussion history were found across any of the measures (P values range: 0.17-0.99). Measures of cervical spine function and divided attention differed by age group (eg, Median Left Anterolateral Cervical Spine Strength [kilograms] for males: U13 = 7.46, U15 = 9.10, U18 = 9.67). CONCLUSION: Clinical outcomes scores in youth ice hockey players did not differ by concussion history. Performance on cervical spine strength, CFE, and JPE test outcomes may improve with age, highlighting the importance of developmental considerations when interpreting test scores. J Orthop Sports Phys Ther 2024;54(3):1-11. Epub 30 November 2023. doi:10.2519/jospt.2023.11958.

Examining later-in-life health risks associated with sport-related concussion and repetitive head impacts: a systematic review of case-control and cohort studies.

OBJECTIVE: Concern exists about possible problems with later-in-life brain health, such as cognitive impairment, mental health problems and neurological diseases, in former athletes. We examined the future risk for adverse health effects associated with sport-related concussion, or exposure to repetitive head impacts, in former athletes. DESIGN: Systematic review. DATA SOURCES: Search of MEDLINE, Embase, Cochrane, CINAHL Plus and SPORTDiscus in October 2019 and updated in March 2022. ELIGIBILITY CRITERIA: Studies measuring future risk (cohort studies) or approximating that risk (case-control studies). RESULTS: Ten studies of former amateur athletes and 18 studies of former professional athletes were included. No postmortem neuropathology studies or neuroimaging studies met criteria for inclusion. Depression was examined in five studies in former amateur athletes, none identifying an increased risk. Nine studies examined suicidality or suicide as a manner of death, and none found an association with increased risk. Some studies comparing professional athletes with the general population reported associations between sports participation and dementia or amyotrophic lateral sclerosis (ALS) as a cause of death. Most did not control for potential confounding factors (eg, genetic, demographic, health-related or environmental), were ecological in design and had high risk of bias. CONCLUSION: Evidence does not support an increased risk of mental health or neurological diseases in former amateur athletes with exposure to repetitive head impacts. Some studies in former professional athletes suggest an increased risk of neurological disorders such as ALS and dementia; these findings need to be confirmed in higher quality studies with better control of confounding factors. PROSPERO REGISTRATION NUMBER: CRD42022159486.

Beyond acute concussion assessment to office management: a systematic review informing the development of a Sport Concussion Office Assessment Tool (SCOAT6) for adults and children.

OBJECTIVES: To systematically review the scientific literature regarding the assessment of sport-related concussion (SRC) in the subacute phase (3-30 days) and provide recommendations for developing a Sport Concussion Office Assessment Tool (SCOAT6). DATA SOURCES: MEDLINE, Embase, PsycINFO, Cochrane CENTRAL, CINAHL, SPORTDiscus and Web of Science searched from 2001 to 2022. Data extracted included study design, population, definition of SRC diagnosis, outcome measure(s) and results. ELIGIBILITY CRITERIA: (1) Original research, cohort studies, case-control studies, diagnostic accuracy and case series with samples >10; (2) SRC; (3) screening/technology that assessed SRC in the subacute period and (4) low risk of bias (ROB). ROB was performed using adapted Scottish Intercollegiate Guidelines Network criteria. Quality of evidence was evaluated using the Strength of Recommendation Taxonomy classification. RESULTS: Of 9913 studies screened, 127 met inclusion, assessing 12 overlapping domains. Results were summarised narratively. Studies of acceptable (81) or high (2) quality were used to inform the SCOAT6, finding sufficient evidence for including the assessment of autonomic function, dual gait, vestibular ocular motor screening (VOMS) and mental health screening. CONCLUSION: Current SRC tools have limited utility beyond 72 hours. Incorporation of a multimodal clinical assessment in the subacute phase of SRC may include symptom evaluation, orthostatic hypotension screen, verbal neurocognitive tests, cervical spine evaluation, neurological screen, Modified Balance Error Scoring System, single/dual task tandem gait, modified VOMS and provocative exercise tests. Screens for sleep disturbance, anxiety and depression are recommended. Studies to evaluate the psychometric properties, clinical feasibility in different environments and time frames are needed. PROSPERO REGISTRATION NUMBER: CRD42020154787.

Amsterdam 2022 process: A summary of the methodology for the Amsterdam International Consensus on Concussion in Sport.

The purpose of this paper is to summarise the consensus methodology that was used to inform the International Consensus Statement on Concussion in Sport (Amsterdam 2022). Building on a Delphi process to inform the questions and outcomes from the 5th International Conference on Concussion in Sport, the Scientific Committee identified key questions, the answers to which would help encapsulate the current science in sport-related concussion and help guide clinical practice. Over 3½ years, delayed by 2 years due to the pandemic, author groups conducted systematic reviews on each selected topic. The 6th International Conference on Concussion in Sport was held in Amsterdam (27-30 October 2022) and consisted of 2 days of systematic review presentations, panel discussions, question and answer engagement with the 600 attendees, and abstract presentations. This was followed by a closed third day of consensus deliberations by an expert panel of 29 with observers in attendance. The fourth day, also closed, was dedicated to a workshop to discuss and refine the sports concussion tools (Concussion Recognition Tool 6 (CRT6), Sport Concussion Assessment Tool 6 (SCAT6), Child SCAT6, Sport Concussion Office Assessment Tool 6 (SCOAT6) and Child SCOAT6). We include a summary of recommendations for methodological improvements for future research that grew out of the systematic reviews.

Evolving the SCAT5 for Ruling Out Higher-Severity Traumatic Brain Injuries-Can Decision Rules Developed for Emergency Settings Help?

BACKGROUND: Decision rules (eg, Canadian computed tomography head rule [CCHR] for adults and Pediatric Emergency Care Applied Research Network [PECARN] rule for children/adolescents) are used in emergency settings (emergency room [ER] rules) to assess traumatic brain injuries (TBIs). The rules have a high-sensitivity and near-perfect negative predictive value that help to rule out more severe TBI. CLINICAL QUESTION: Which criteria should be added to the Sport Concussion Assessment Tool 5 (SCAT5) to reach the sensitivity of the ER rules and improve the utility of the SCAT5 for screening for higher-severity head and brain injuries? KEY RESULTS: We performed a comparative analysis of the SCAT5 with the CCHR and PECARN rules. We compared the presence (yes or no) and comparative "face value" sensitivity (lower, identical, or higher) of the SCAT5 criteria to the ER rules criteria. Loss of consciousness, vomiting, severe/increasing headache, and seizure are SCAT "red flags" with similar or higher sensitivity compared to ER rules criteria. Five criteria had lower sensitivity or were absent from the SCAT. Emergency room rules include any abnormality on the Glasgow Coma Scale (GCS<15), but only a "deterioration of the state of consciousness" is considered a "red flag" in the SCAT5. Persistent retrograde amnesia for more than 30 minutes, age>65, severity of the mechanism of injury, and signs of skull fractures are not mentioned in the SCAT5. CLINICAL APPLICATION: We identified 5 criteria that could inform the evolution the SCAT5 to improve its ability to rule out more severe TBI in a sideline assessment context. J Orthop Sports Phys Ther 2023;53(3):113-119. Epub: 9 December 2022. doi:10.2519/jospt.2022.11301.

A clinical test to assess isometric cervical strength in chronic whiplash associated disorder (WAD): a reliability study.

BACKGROUND: Cervical spine muscle weakness is well demonstrated in individuals with chronic neck pain. There is a lack of literature evaluating clinically applicable means of assessing isometric cervical strength in chronic whiplash associated disorder (WAD). This study assessed the reliability of self-resisted isometric cervical strength testing using a handheld dynamometer. The relationship between strength and neck pain-related disability and kinesiophobia was also investigated. METHODS: Twenty subjects with chronic WAD performed maximum-effort isometric cervical flexion, extension, side flexion, and rotation against a hand held dynamometer. The dynamometer was held by the subject, who provided self-resistance. Subjects completed two sessions of testing on one day with two different examiners, and one session on a subsequent day with one of the original examiners. Subjects completed the Neck Disability Index (NDI) and Tampa Scale for Kinesiophobia (TSK) prior to the first testing session. RESULTS: Intraclass correlation coefficients (ICC) for directional strength measures were fair to high (0.71-0.88 for intra-rater and 0.79-0.91 for inter-rater). Total strength (sum of all directional strengths) ICCs were high for both intra-rater (ICC = 0.91) and inter-rater (ICC = 0.94) measures. All statistical tests for ICCs demonstrated significance (α < 0.05). Agreement was assessed using Bland Altman (BA) analysis with 95% limits of agreement. BA analysis demonstrated difference scores between the two testing sessions that ranged from 3.0-17.3% and 4.5-28.5% of the mean score for intra and inter-rater measures, respectively. Most measures did not meet the a priori standard for agreement. A moderate to good inverse relationship was demonstrated between kinesiophobia (TSK score) and six out of seven strength measures (α < .05). No significant correlation was found between neck disability (NDI) and cervical strength in any direction. CONCLUSION: This study demonstrated fair to high reliability of self resisted isometric cervical strength testing in the chronic WAD population. All directional strength measures except flexion demonstrated a significant inverse relationship with kinesiophobia. No cervical strength measures were correlated with neck disability. These results support testing cervical strength in this manner to reliably assess change over time within individual patients. The value of such measurement requires further consideration given the lack of correlation between cervical strength and disability. Further research is required to establish normative values and enhance clinical utility.

Psychological Manifestations and Chronic Pain in Whiplash-Associated Disorder Mechanisms: The Whole Pie, Please.

In the last decade, as the biopsychosocial model of patient health care has expanded, there has been an increased focus on the influence of psychological manifestations on patient symptoms and health-related outcomes. This Viewpoint explores the scientific underpinnings of psychological manifestations in chronic whiplash-associated disorders (WADs)-where opinions vary widely concerning the reason for persistent symptoms and nonrecovery. It also provides an epidemiological and scientific foundation for the management of chronic WAD, incorporating the spectrum of the biopsychosocial model. J Orthop Sports Phys Ther 2019;49(3):118-121. doi:10.2519/jospt.2019.0603.

Modulation of Cervical Facet Joint Nociception and Pain Attenuates Physical and Psychological Features of Chronic Whiplash: A Prospective Study.

OBJECTIVE: To investigate changes in clinical (physical and psychological) features of individuals with chronic whiplash-associated disorder who had previously undergone cervical radiofrequency neurotomy at the time point when the effects of radiofrequency neurotomy had dissipated and pain returned. DESIGN: Prospective cohort observational trial of consecutive patients. SETTING: Tertiary spinal intervention centre in Calgary, Alberta, Canada. PATIENTS: A total of 53 consecutive individuals with chronic whiplash-associated disorder. METHODS: Individuals underwent radiofrequency neurotomy and were assessed before radiofrequency neurotomy, at 1 and 3 months postprocedure, and then after the return of pain (approximately 10 months postprocedure). MAIN OUTCOME MEASUREMENTS: Quantitative sensory tests (pressure; thermal pain thresholds; brachial plexus provocation test), nociceptive flexion reflex, and motor function (cervical range of movement; craniocervical flexion test) were measured. Self-reported disability, psychological distress, pain catastrophization, and posttraumatic stress disorder symptoms also were measured. RESULTS: Upon the return of pain after radiofrequency neurotomy, levels of disability increased (P < .0001), and were no different to those before radiofrequency neurotomy (P = .99). There also was a significant deterioration in quantitative sensory testing measures and reduced cervical range of motion after the return of pain (all P < .05); all approaching values were recorded before radiofrequency neurotomy (P > .22). There were no significant changes in pressure hyperalgesia (P > .054) or craniocervical flexion test performance (P > .07) after the return of pain. Psychological distress and pain catastrophizing increased significantly after the return of pain (P < .01), and again were no different than measures taken prior to radiofrequency neurotomy (P > .13). However, there was no difference in number or severity of posttraumatic stress symptoms after the return of pain (P > .30). CONCLUSIONS: Physical and psychological features of chronic whiplash-associated disorder are modulated dynamically with cervical radiofrequency neurotomy. These findings indicate that peripheral nociception is involved in the manifestations of chronic whiplash-associated disorder in this cohort of individuals.

Cervical radiofrequency neurotomy reduces psychological features in individuals with chronic whiplash symptoms.

BACKGROUND: Individuals with chronic whiplash associated disorder (WAD) demonstrate various psychological features. It has previously been demonstrated that cervical radiofrequency neurotomy (cRFN) resolves psychological distress and anxiety. It is unknown if cRFN also improves or reduces a broader spectrum of psychological substrates now commonly identified in chronic whiplash, such as post-traumatic stress disorder (PTSD) and pain catastrophizing. OBJECTIVES: To determine if reducing pain in the cervical spine (following cRFN) significantly reduces psychological features (distress, pain catastrophizing and post-traumatic stress symptoms) in individuals with chronic WAD. SETTING:   Tertiary spinal intervention centre in Calgary, Alberta, Canada. STUDY DESIGN: Prospective observational study of consecutive patients. PATIENTS: Fifty-three individuals with chronic whiplash associated disorder symptoms (Grade 2). INTERVENTION: Cervical RFN following successful response to cervical facet joint blockade. Measures were made at 4 time points: 2 prior to RFN, and 1-month and 3-months post-RFN. Psychological measures included the General Health Questionnaire (GHQ-28); Pain Catastrophizing Scale (PCS) and the Post Traumatic Stress Diagnostic Scale (PDS). Self-reported pain (VAS) and disability (NDI) measures were also collected. RESULTS: Pain, disability, psychological distress and pain catastrophization significantly decreased at both 1-month and 3 months following cervical RFN. There was no significant change in post-traumatic stress symptom severity (P = 0.39). Reducing pain via cRFN was associated with significant improvement in psychological distress and pain catastrophizing, but not posttraumatic stress symptoms. LIMITATIONS: Individual administering questionnaires was not blinded to aim(s) of the study. Other psychological features possibly present in WAD were not measured. CONCLUSION: Effective pain relief would seem a crucial element in the management of psychological features associated with chronic WAD. IRB Approval: University of Calgary Conjoint Health Research Ethics Board ID#: E-22082.

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.

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 Friedman's 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.

BACKGROUND: Cervical 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. METHODS: This 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. RESULTS: Following 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). CONCLUSIONS: Chronic 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.

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-.

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.

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.