title: Physical performance tests for people with long-term spinal pain: aspects of construct validity. Reproducibility of cervical range of motion in patients with neck pain The ability to change of three questionnaires for neck pain. Test performance of the individual NEXUS low-risk clinical screening criteria for cervical spine injury. The value of MR imaging in differentiating between hard and soft cervical disc disease: a comparison with intraoperative findings The Canadian C-spine rule for radiography in alert and stable trauma patients. Head position and impact direction in whiplash injuries: associations with MRI-verified lesions of ligaments and membranes in the upper cervical spine. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Musculoskeletal disorders of the neck and upper limb among sewing machine operators: a clinical investigation. Reliability of Magnetic Resonance Imaging in Predicting Disc Material Posterior to the Posterior Longitudinal Ligament in the Cervical Spine: A Prospective Study Are five-view plain films of the cervical spine unreliable? A prospective evaluation in blunt trauma patients with altered mental status. Gd-DTPA-enhanced 3D MR imaging of cervical degenerative disk disease: initial experience. Provocative cervical discography symptom mapping. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. Chemokines and Their Receptors in Whiplash Injury: Elevated RANTES and CCR-5 Helical computed tomography alone compared with plain radiographs with adjunct computed tomography to evaluate the cervical spine after high-energy trauma. Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. Subjective Health Measure Used on Chinese Patients With Neck Pain in Hong Kong Use of flexion-extension radiographs of the cervical spine in blunt trauma. A new clinical test for cervicocephalic kinesthetic sensibility: "the fly". Psychometric properties of a generic health measure in patients with neck pain MRI of cerebrum and cervical columna within two days after whiplash neck sprain injury. What defines a distracting injury in cervical spine assessment? Mechanical performance and electromyography during repeated maximal isokinetic shoulder forward flexions in female cleaners with and without myalgia of the trapezius muscle and in healthy controls Cervical nonorganic signs: a new clinical tool to assess abnormal illness behavior in neck pain patients: a pilot study. Ambulatory Electromyogram Activity in the Upper Trapezius Region: Patients With Muscle Pain vs. Pain‐free Control Subjects False‐Positive Rates of Cervical Zygapophysial Joint Blocks Efficacy of Cervical Endplay Assessment as an Indicator for Spinal Manipulation Reliability and Diagnostic Accuracy of the Clinical Examination and Patient Self-Report Measures for Cervical Radiculopathy Retrospective application of the NEXUS low-risk criteria for cervical spine radiography in Canadian emergency departments. MRI changes of cervical spine in asymptomatic and symptomatic young adults Cervical Spine Outcomes Questionnaire: Its Development and Psychometric Properties Comparative local anaesthetic blocks in the diagnosis of cervical zygapophysial joint pain Cervical curvature in acute whiplash injuries: prospective comparative study with asymptomatic subjects. Iohexol: summary of North American and European clinical trials in adult lumbar, thoracic, and cervical myelography with a new nonionic contrast medium. Interexaminer reliability in physical examination of the neck. Cervical injury in head trauma. The Prevalence of Chronic Cervical Zygapophysial Joint Pain After Whiplash Does the National Emergency X-ray Utilization Study make a difference? Reliability of the visual analog scale for measurement of acute pain. Validity of a decision rule to reduce cervical spine radiography in elderly patients with blunt trauma. Validity of five common manual neck pain provoking tests. The architecture of diagnostic research The Utility of Comparative Local Anesthetic Blocks Versus Placebo‐Controlled Blocks for the Diagnosis of Cervical Zygapophysial Joint Pain Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Categorising the severity of neck pain: Establishment of cut-points for use in clinical and epidemiological research
abstract: OBJECTIVE The aim of this study was to investigate the construct validity of 6 physical performance tests that had already been shown to have acceptable repeatability . DESIGN Data were collected in a r and omized controlled multi-centre study . SUBJECTS 126 women and 105 men sick-listed for spinal pain carried out the tests and provided personal and background data at inclusion in the study . METHODS One test measured stepping up onto and down from a stool , 2 measured lifting ability and 3 walking speed . Construct validity was examined by analysing the influence of some variables on test performance . RESULTS High-rated pain behaviour and perceived high pain intensity during testing or during the previous 4 weeks were connected with low test performance . Exercise twice a week was connected with high test performance . The test with the highest ability to detect disability in the women with lumbar pain was a lumbar lifting test , while for the men , it was a cervical lifting test . The test with the highest ability to detect disability in the participants with neck pain was the cervical lifting test in addition to a gait test with burden for the women . CONCLUSION Back pain hampered the test performance more than neck pain . Impairments and activity limitations expressed by the patient should guide the choice of test Background Reproducibility measurements of the range of motion are an important prerequisite for the interpretation of study results . The aim of the study is to assess the intra-rater and inter-rater reproducibility of the measurement of active Range of Motion ( ROM ) in patients with neck pain using the Cybex Electronic Digital Inclinometer-320 ( EDI-320 ) . Methods In an outpatient clinic in a primary care setting 32 patients with at least 2 weeks of pain and /or stiffness in the neck were r and omly assessed , in a test- retest design with blinded raters using a st and ardized measurement protocol . Cervical flexion-extension , lateral flexion and rotation were assessed . Results Reliability expressed by the Intraclass Correlation Coefficient ( ICC ) was 0.93 ( lateral flexion ) or higher for intra-rater reliability and 0.89 ( lateral flexion ) or higher for inter-rater reliability . The 95 % limits of agreement for intra-rater agreement , expressing the range of the differences between two ratings were -2.5 ± 11.1 ° for flexion-extension , -0.1 ± 10.4 ° for lateral flexion and -5.9 ± 13.5 ° for rotation . For inter-rater agreement the limits of agreement were 3.3 ± 17.0 ° for flexion-extension , 0.5 ± 17.0 ° for lateral flexion and -1.3 ± 24.6 ° for rotation . Conclusion In general , the intra-rater reproducibility and the inter-rater reproducibility were good . We recommend to compare the reproducibility and clinical applicability of the EDI-320 inclinometer with other cervical ROM measures in symptomatic patients OBJECTIVE To assess the sensitivity to change of three algofunctional scales for neck pain . METHODS Observational , prospect i ve study . Patients with neck disorders were included .  Pain and patients ' perceived h and icap assessed on visual analogue scales ( VAS Pain , VAS H and icap ) , and functional disability measures ( Neck Disability Index , Neck Pain and Disability Scale , Northwick Park Neck Pain Question naire  )  were recorded twice , at baseline and at an 11-month follow-up assessment . Sensitivity to change was assessed using the effect size ( ES ) and the st and ardised response mean ( SRM ) , and the non-parametric Spearman 's rank correlation coefficient ( r ) was used to assess the correlation between quantitative variable changes and patients ' overall opinion . Analysis of variance ( ANOVA ) followed by a Tukey-test was performed to determine if the scales distinguished improved , stable , and deteriorated patients . RESULTS Seventy-one patients ( 43 women , mean age 49 years ) were included and evaluated twice at an interval of 11 + /- 2 months . The three scales showed good sensitivity to change . The ANOVA showed a group effect , and individual changes in the scales scores were statistically different in two-by-two comparisons ( improved , stable or deteriorated patients ) . Changes in NPDS scores had the highest correlation with patient 's overall assessment ( r = 0.592 ) . CONCLUSION The three scales can detect changes in patients with neck disorders . Changes in NPDS score had the best correlation with patients ' overall opinion concerning their neck disorder and this question naire should be given preference in clinical trials BACKGROUND The National Emergency X-Radiography Utilization Study ( NEXUS ) recently vali date d the ability of a decision instrument to define a population with an extremely low risk of cervical spine injury ( CSI ) after blunt trauma . It is unclear whether each of the 5 individual criteria is necessary for the decision instrument to maintain its high sensitivity . METHODS NEXUS was a prospect i ve observational study at 21 emergency departments , which enrolled all patients with blunt trauma for whom cervical spine radiographs were ordered . In this sub study , we examined the NEXUS data base to determine the contribution of each of the 5 individual low-risk clinical criteria to the overall sensitivity of the decision instrument . RESULTS All but 8 of 818 patients with CSI , and all but 2 of 578 patients with significant CSI , were identified by using the decision instrument . A substantial number of patients with CSI ( 236/818 [ 29 % ] ) and patients with significant CSI ( 175/578 [ 30 % ] ) met only 1 of the 5 non -- low-risk criteria , and each of the 5 criteria was the only indicator of non -- low-risk status in at least 8 patients with CSI and at least 5 patients with significant CSI . CONCLUSION Because each of the 5 low-risk criteria was the only marker of non -- low-risk status in at least a few patients with significant CSI , modification of the overall NEXUS decision instrument by eliminating any one of the criteria would markedly reduce sensitivity and make the instrument unacceptable for clinical use Abstract The aim of this study is to assess the accuracy of MRI alone in the differentiation of soft cervical disc protrusion from osteophytic compression in cervical disc disease . In a retrospective study , the  MRI scans of 41 patients with cervical disc disease , who had previously undergone surgery , were presented to three independent observers , r and omly on two different occasions , to identify the accuracy of the diagnosis of the presence of hard or soft disc or both as a cause of compression . The observers ( two neurosurgeons and one neuroradiologist ) were not involved with the treatment of the cases at any stage and were unaware of the surgical findings . Their observations were compared with those of the surgeon recorded at operation . The intra-observer agreement was poor for diagnosis into three categories as hard or soft disc or both . In distinguishing between the presence or absence of hard disc , there was moderate to good ( Kappa = 0.6 ) intra observer and fair to moderate ( Kappa = 0.4 ) interobserver agreement . The sensitivity of diagnosis of a hard disc was high ( 87 % ) but specificity was low ( 44 % ) , due to the overestimation of the presence of hard disc . There was a significantly higher incidence of hard disc in the elderly age group ( 76 % over the fifth decade , P = 0.0073 ) . It is concluded that MRI alone is not a very efficient diagnostic tool in distinguishing between hard and soft disc in the cervical disc disease CONTEXT High levels of variation and inefficiency exist in current clinical practice regarding use of cervical spine ( C-spine ) radiography in alert and stable trauma patients . OBJECTIVE To derive a clinical decision rule that is highly sensitive for detecting acute C-spine injury and will allow emergency department ( ED ) physicians to be more selective in use of radiography in alert and stable trauma patients . DESIGN Prospect i ve cohort study conducted from October 1996 to April 1999 , in which physicians evaluated patients for 20 st and ardized clinical findings prior to radiography .  In some cases , a second physician performed independent interobserver assessment s. SETTING Ten EDs in large Canadian community and university hospitals . PATIENTS Convenience sample of 8924 adults ( mean age , 37 years ) who presented to the ED with blunt trauma to the head/neck , stable vital signs , and a Glasgow Coma Scale score of 15 . MAIN OUTCOME MEASURE Clinical ly important C-spine injury , evaluated by plain radiography , computed tomography , and a structured follow-up telephone interview .  The clinical decision rule was derived using the kappa coefficient , logistic regression analysis , and chi(2 ) recursive partitioning techniques . RESULTS Among the study sample , 151 ( 1.7 % ) had important C-spine injury . The result ant model and final Canadian C-Spine Rule comprises 3 main questions : ( 1 ) is there any high-risk factor present that m and ates radiography ( ie , age > /=65 years , dangerous mechanism , or paresthesias in extremities ) ? ( 2 ) is there any low-risk factor present that allows safe assessment of range of motion ( ie , simple rear-end motor vehicle collision , sitting position in ED , ambulatory at any time since injury , delayed onset of neck pain , or absence of midline C-spine tenderness ) ? and ( 3 ) is the patient able to actively rotate neck 45 degrees to the left and right ? By cross-validation , this rule had 100 % sensitivity ( 95 % confidence interval [ CI ] , 98%-100 % ) and 42.5 % specificity ( 95 % CI , 40%-44 % ) for identifying 151 clinical ly important C-spine injuries . The potential radiography ordering rate would be 58.2 % . CONCLUSION We have derived the Canadian C-Spine Rule , a highly sensitive decision rule for use of C-spine radiography in alert and stable trauma patients . If prospect ively vali date d in other cohorts , this rule has the potential to significantly reduce practice variation and inefficiency in ED use of C-spine radiography In the present study , we compared magnetic resonance imaging ( MRI ) findings of soft tissue structures in the upper cervical spine between whiplash-associated disorder ( WAD ) patients and population -based control persons , and examined whether MRI-verified abnormalities in WAD patients were related to accident-related factors hypothesized to be of importance for severity of injury . A total of 92 whiplash patients and 30 control persons , r and omly drawn , were included . Information on the accident-related factors ( i.e. , head position and impact direction ) was obtained by a question naire that was answered within 1 week after the accident . The MRI examination was performed 2 - 9 ( mean 6 ) years after the accident . Focus was on MRI abnormalities of the alar and the transverse ligaments , and the tectorial and posterior atlanto-occipital membranes , grade d 0 - 3 . For all neck structures , the whiplash patients had more high- grade lesions ( grade 2 or 3 ) than the control persons ( Chi-square test , p < 0.055 ) . An abnormal alar ligament was most common ( 66.3 % grade d 2 or 3 ) . Whiplash patients who had been sitting with their head/neck turned to one side at the moment of collision more often had high- grade lesions of the alar and transverse ligaments ( p < 0.001 , p = 0.040 , respectively ) . Severe injuries to the transverse ligament and the posterior atlanto-occipital membrane were more common in front than in rear end collisions ( p < 0.001 , p = 0.001 , respectively ) . In conclusion , the difference in MRI-verified lesions between WAD patients and control persons , and in particular the association with head position and impact direction at time of accident , indicate that these lesions are caused by the whiplash trauma STUDY HYPOTHESIS Cervical-spine radiography does not need to be performed on selected blunt trauma patients who are awake , alert , nonintoxicated , do not complain of midline neck pain , and have no tenderness over the bony cervical spine . STUDY POPULATION One thous and consecutive patients seen in the UCLA Emergency Medicine Center with a chief complaint of blunt trauma , for whom cervical-spine films were ordered and for whom prospect i ve data question naires were completed . METHODS Clinicians completed data forms for each patient before radiograph results were known . Data items included mechanism of injury , evidence of intoxication , presence of cervical-spine pain and /or tenderness , level of alertness , presence of focal neurologic deficits , and presence of other severely painful injuries unrelated to the cervical spine . Physicians were also asked to estimate likelihood of significant cervical-spine injury . RESULTS Twenty-seven patients with cervical-spine fracture were among the 974 patients for whom data forms were completed . A number of findings were statistically more common in the group of patients with fracture than without , but no single or paired findings identified all patients with fracture . All 27 patients with fracture had at least one of the following four characteristics : midline neck tenderness , evidence of intoxication , altered level of alertness , or a severely painful injury elsewhere . Three hundred fifty-three of 947 ( 37.3 % ) patients without cervical-spine fracture had none of these findings . CONCLUSION Cervical-spine radiology may not be necessary in patients without spinous tenderness in the neck , intoxication , altered level of alertness , or other severely painful injury . A policy to limit films in such patients would have decreased film ordering by more than one third in this series , while identifying all patients with fracture One hundred and seven women participated in a clinical study of an age-stratified r and om sample of sewing machine operators compared to a group of auxiliary nurses and home helpers . Four groups , according to years of being a sewing machine operator , consisted of : ( controls ) 25 ; ( 0 - 7 years ) 21 ; ( 8 - 15 years ) 25 ; and ( more than 15 years ) 36 . The numbers of the main clinical diagnoses in the four groups were : cervicobrachial fibromyalgia ( myofascial pain syndrome ) 2 , 4 , 11 , 24 ; cervical syndrome 0 , 1 , 3 , 10 ; and rotator cuff syndrome 1 , 1 , 6 , 11 . The observed exposure-response relationship between clinical outcomes and years as a sewing machine operator was maintained when adjusting for current exposure to musculoskeletal strain and other potential confounders . Muscle palpation proved to be a reproducible examination with kappa values around 0.70 Study Design . This was a prospect i ve study to evaluate the accuracy of magnetic resonance imaging in predicting the presence of disc material posterior to the posterior longitudinal ligament ( PLL ) , compared with the accuracy of intraoperative visual and tactile examination of the PLL . Objectives . To determine the accuracy of magnetic resonance imaging in predicting the presence of disc material posterior to the PLL . Summary of Background Data . Whether removal of the disc to the PLL is sufficient when performing an anterior cervical discectomy and fusion or it is necessary to explore the spinal canal by taking down the PLL is controversial . Methods . Fifty‐four cervical levels were examined by magnetic resonance imaging before surgery to determine whether there was disc material posterior to the PLL . During surgery , the PLL was examined and probed for disruption . The ligament was taken down , and free fragments were identified and removed . Results . Of 54 levels , 12 were correctly identified by magnetic resonance imaging as having disc material posterior to the PLL , and 26 were correctly identified as not having disc material posterior to the PLL . Surgery confirmed that at 26 levels there was disc material posterior to the PLL . Of these 26 , 23 ( 88.5 % ) had visual or palpable disruption of the PLL .  Magnetic resonance imaging failed to predict disc material posterior to the PLL in 14 of the cases in which its presence was confirmed during surgery . Magnetic resonance imaging had 46.2 % sensitivity and 92.9 % specificity rates . Conclusions . Because of low sensitivity , magnetic resonance imaging should be used cautiously for predicting free disc material posterior to the PLL . Visual or palpable examination of the PLL during surgery is more accurate for this prediction OBJECTIVES Clearing the cervical spine in a time-sensitive fashion is difficult . We hypothesized that admission computed tomographic scan of the occiput to T1 ( CTS ) with multiplanar reformatted images will replace five-view ( odontoid , anteroposterior , lateral , and oblique ) plain films of the cervical spine ( CSX ) in the initial evaluation of blunt trauma patients with altered mental status . METHODS Between January and July 2001 , all patients aged 16 years or older with altered mental status undergoing both CTS and CSX were prospect ively entered into the study group . Attending physician interpretation defined the presence of cervical spine injury . Unstable fractures were defined as requiring surgical or halo stabilization . RESULTS One thous and six patients met study criteria . One hundred sixteen patients had 172 cervical spine injuries ( CSIs ) ( fracture and subluxation ) .  CSX missed 90 of 172 ( 52.3 % ) CSIs in 65 of 172 ( 56.0 % ) patients . Anatomically , CSX failed to identify 14 of 15 occipital fractures ( 93.3 % ) , 17 of 36 ( 47.2 % ) C1 - 3 fractures , and 59 of 121 ( 48.8 % ) C4-T1 CSIs . CSX failed to identify 5 of 29 ( 17.2 % ) patients with unstable CSIs . CTS failed to diagnose 3 of 172 ( 1.7 % ) CSIs that were stable ( spinous process fractures at C6 - 7 ) . Two patients exhibited spinal cord injury without radiologic abnormality missed by both modalities . CTS had a sensitivity of 97.4 % , a specificity of 100 % , a prevalence of 11.5 % , a positive predictive value of 100 % , and a negative predictive value of 99.7 % . CSX had a sensitivity of 44.0 % , a specificity of 100 % , a prevalence of 11.5 % , a positive predictive value of 100 % , and a negative predictive value of 93.2 % . CONCLUSION CTS outperformed five-view CSX in a group of patients with altered mental status or distracting injuries . Five-view CSX failed to diagnose 52.3 % of cervical spine fractures identified by CTS . Five-view CSX failed to diagnose five patients with unstable cervical fractures and failed to identify 93.3 % of patients with occipital condyle fractures PURPOSE To assess whether a single enhanced T1-weighted gradient echo volume sequence , with the appropriate reformatted images , could be equivalent to a more conventional 2D set of MR sequences for the evaluation of cervical extradural degenerative disk disease ( bony canal and foraminal stenosis ; disk herniation ) . MATERIAL S AND METHODS Sixty-one patients evaluated for extradural degenerative disease by MR were imaged with a " st and ard " MR examination ( Sagittal T1-weighted spin echo , axial low flip angle gradient echo ) , were then given 0.1 mmol/kg Gd-DTPA intravenously , and reimaged with either a 3D FLASH ( fast low angle shot ) , TR 40/TE 7/1 excitation ) , 40 degree flip angle , acquired as 64 , 2-mm sagittal partitions , or a 3D turbo FLASH ( MP RAGE-magnetization prepared rapid acquisition gradient echo ) ( 10/4/1 ) , 10 degree flip angle acquired as 128 , 2-mm coronal partitions . The volume sequences were reconstructed in the axial plane , and right and left 45 degree oblique coronal planes . The two sets of examinations ( st and ard vs volume ) were prospect ively interpreted by two neuroradiologists for quality of examination , and location , type , and severity of extradural degenerative disease in a r and om , blinded , independent fashion . RESULTS There was no significant difference between the st and ard examination and the 3D MP RAGE for central extradural disease . The 3D FLASH examination was significantly worse than the st and ard examination in identification of central extradural disease , with an average of 21 herniations not identified , or underestimated in size . Neither the 3D FLASH , nor the 3D MP RAGE examinations showed any significant improvement compared to the routine 2D examination for the location and severity of foraminal disease . CONCLUSION If extradural degenerative disk disease is being evaluated , then a single enhanced 3D T1-weighted imaging sequence taking 6 minutes can be equivalent to a routine set of mixed 2D spin echo and low flip angle gradient echo sequences BACKGROUND CONTEXT In a small prospect i ve study assessing 10 symptomatic and 10 asymptomatic subjects , Schellhas et al. compared cervical discography to magnetic resonance imaging . Within that study he reported on the distribution of pain for the C3-C4 to C6-C7 levels . Four years later , Grubb and Ellis reported retrospective data from his 12-year experience using cervical discography from C2-C3 to C7-T1 in 173 patients . To date , no large prospect i ve study defining pain referral patterns for each cervical disc has been performed . PURPOSE To conduct a prospect i ve visual and statistical descriptive study of pain provocation of a cohort of subjects undergoing cervical discography .  STUDY DESIGN / SETTING Prospect i ve multicenter descriptive study . METHODS Pain referral maps were generated for each disc level from patients undergoing cervical discography with at least two levels assessed . If concordant pain was reproduced in a morphologically abnormal disc , the subject immediately completed a pain diagram . An independent observer interviewed the subject and recorded the location of provoked symptoms . Visual data were compiled using a body sector bit map , which consisted of 48 clinical ly relevant body regions . Visual maps with graduated color codes and frequencies of symptom location at each cervical disc level were generated . RESULTS A total of 101  symptom provocation maps  were recorded during cervical discography on 41 subjects . There were 10 at C2-C3 , 19 at C3-C4 , 27 at C4-C5 , 27 at C5-C6 , 16 at C6-C7 and 2 at C7-T1 . Predominantly unilateral symptoms were provoked just as often as bilateral symptoms . The C2-C3 disc referred pain to the neck , subocciput and face . The C3-C4 disc referred pain to the neck , subocciput , trapezius , anterior neck , face , shoulder , interscapular and limb . The C4-C5 disc referred pain to the neck , shoulder , interscapular , trapezius , extremity , face , chest and subocciput . The C5-C6 disc referred pain to the neck , trapezius , interscapular , suboccipital , anterior neck , chest and face . The C6-C7 disc referred pain to the neck , interscapular , trapezius , shoulder , extremity and subocciput . At C7-T1 we produced neck and interscapular pain . Visual maps with graduated color codes and frequencies of symptom location at each cervical disc level were generated . CONCLUSIONS In conclusion , these results confirm the observations of prior investigators that cervical internal disc disruption can elicit axial and peripheral symptoms . The particular patterns of pain generation allow the discographer to preprocedurally anticipate disc levels to assess . With these data , the number of disc punctures that are required can be limited rather than routinely assessing all cervical discs BACKGROUND Because clinicians fear missing occult cervical-spine injuries , they obtain cervical radiographs for nearly all patients who present with blunt trauma . Previous research suggests that a set of clinical criteria ( decision instrument ) can identify patients who have an extremely low probability of injury and who consequently have no need for imaging studies . METHODS We conducted a prospect i ve , observational study of such a decision instrument at 21 centers across the United States . The decision instrument required patients to meet five criteria in order to be classified as having a low probability of injury : no midline cervical tenderness , no focal neurologic deficit , normal alertness , no intoxication , and no painful , distracting injury . We examined the performance of the decision rule in 34,069 patients who underwent radiography of the cervical spine after blunt trauma . RESULTS The decision instrument identified all but 8 of the 818 patients who had cervical-spine injury ( sensitivity , 99.0 percent [ 95 percent confidence interval , 98.0 to 99.6 percent ] ) . The negative predictive value was 99.8 percent ( 95 percent confidence interval , 99.6 to 100 percent ) , the specificity was 12.9 percent , and the positive predictive value was 2.7 percent . Only two of the patients classified as unlikely to have an injury according to the decision instrument met the preset definition of a clinical ly significant injury ( sensitivity , 99.6 percent [ 95 percent confidence interval , 98.6 to 100 percent ] ; negative predictive value , 99.9 percent [ 95 percent confidence interval , 99.8 to 100 percent ] ; specificity , 12.9 percent ; positive predictive value , 1.9 percent ) , and only one of these two patients received surgical treatment . According to the results of assessment with the decision instrument , radiographic imaging could have been avoided in the cases of 4309 ( 12.6 percent ) of the 34,069 evaluated patients . CONCLUSIONS A simple decision instrument based on clinical criteria can help physicians to identify reliably the patients who need radiography of the cervical spine after blunt trauma . Application of this instrument could reduce the use of imaging in such patients The human sufferings and socioeconomic burden due to whiplash-associated disorders ( WAD ) are obvious but the pathogenesis of WAD is obscure . The possible involvement of the immune system during the disease process in WAD is not known . Effector molecules including chemokines and their receptors could play a role in WAD . In a prospect i ve study using flow cytometry , we examined percentages of blood mononuclear cells ( MNC ) expressing the chemokines RANTES , MCP-1 , MIP-1α , MIP-1β , and IL-8 , the chemokine receptor CCR-5 , the T cell activation marker CD25 , and the T cell chemoattractant IL-16 in patients with WAD and , for reference , in healthy controls . Higher percentages of RANTES-expressing blood MNC and T cells were observed in patients with WAD examined within 3 days compared to 14 days after the whiplash injury and , likewise , compared with healthy controls . The patients with WAD examined within 3 days after the accident also had higher percentages of CCR-5-expressing blood MNC , T cells , and CD45RO+ T cells compared to healthy controls . In contrast , there were no differences for any of these variables between patients with WAD examined 14 days after injury and healthy controls . In conclusion , WAD is associated with a systemic but transient dysregulation in percentages of RANTES and CCR-5 expressing MNC and T cells BACKGROUND Current literature supports the use of the three-view plain-radiograph series supplemented , when necessary , with helical computed tomography to evaluate the cervical spine in patients who have sustained trauma injury . The purpose of this study was to determine if helical computed tomography alone can be used to evaluate the cervical spine for acute osseous injury following high-energy trauma , thus eliminating the need to make radiographs . METHODS Patients were prospect ively evaluated with helical computed tomography scanning of the cervical spine and st and ard three-view plain radiography . At a later date , the plain radiographs and computed tomography scans were independently review ed by two radiologists who were blinded to both the initial interpretation and the interpretation of the corresponding study . The radiologists documented whether the plain radiographs were adequate and whether they showed an acute process . The findings in the study were compared with the initial findings and , when necessary , with the discharge summaries to determine if an injury had been identified . The accuracy of the plain radiographs , of the plain radiographs that had been deemed adequate , and of helical computed tomography used alone was ascertained . RESULTS Plain radiographs and helical computed tomography scans were made for 407 patients , and traumatic injuries were identified in fifty-eight of them .  Plain radiographs alone were adequate for 194 ( 48 % ) of the 407 patients .  Plain radiographs had a sensitivity of 45 % , a specificity of 97 % , a positive predictive value of 74 % , and a negative predictive value of 91 % . Adequate plain radiographs had a sensitivity of 52 % , a specificity of 98 % , a positive predictive value of 81 % , and a negative predictive value of 93 % . Helical computed tomography had a sensitivity and specificity of 98 % , a positive predictive value of 89 % , and a negative predictive value of > 99 % . The sensitivity , positive predictive value , and negative predictive value of adequate plain radiographs differed significantly from those of helical computed tomography alone ( p < 0.001 ) . Twelve ( 48 % ) of twenty-five adequate plain radiographs of patients in whom an injury had been identified on computed tomography missed that injury . Helical computed tomography alone missed one ( 2 % ) of the fifty-eight injuries . CONCLUSIONS Although helical computed tomography has a limited ability to detect pure ligamentous injury , it can be safely used without plain radiographs to evaluate the cervical spine for osseous abnormalities such as fractures and dislocations after high-energy trauma Previous investigations with plain radiography , myelography , and computed tomography have shown that degenerative disease of the cervical spine frequently occurs in the absence of clinical symptoms . We studied the magnetic resonance-imaging scans of sixty-three volunteers who had no history of symptoms indicative of cervical disease . The scans were mixed r and omly with thirty-seven scans of patients who had a symptomatic lesion of the cervical spine , and all of the scans were interpreted independently by three neuroradiologists . The scans were interpreted as demonstrating an abnormality in 19 per cent of the asymptomatic subjects : 14 per cent of those who were less than forty years old and 28 per cent of those who were older than forty . Of the subjects who were less than forty , 10 per cent had a herniated nucleus pulposus and 4 per cent had foraminal stenosis . Of the subjects who were older than forty , 5 per cent had a herniated nucleus pulposus ; 3 per cent , bulging of the disc ; and 20 per cent , foraminal stenosis . Narrowing of a disc space , degeneration of a disc , spurs , or compression of the cord were also recorded . The disc was degenerated or narrowed at one level or more in 25 per cent of the subjects who were less than forty years old and in almost 60 per cent of those who were older than forty . The prevalence of abnormal magnetic-resonance images of the cervical spine as related to age in asymptomatic individuals emphasizes the dangers of predicating operative decisions on diagnostic tests without precisely matching those findings with clinical signs and symptoms Study Design . A prospect i ve observational study was conducted on the use of the Chinese version of the Northwick Park Neck Pain Question naire . Objective . To examine the reliability , validity , and responsiveness of the Chinese version of the Northwick Park Neck Pain Question naire in Chinese patients with neck pain in Hong Kong . Summary of Background Data . There is increasing recognition that patient perspectives are essential both in making medical decisions and in judging the treatment outcomes . A valid Chinese version of a neck disability index question naire is urgently needed for effective and reliable evaluation of the treatment outcomes for patients with neck pain . Methods . Two sample s with 532 consecutive adult patients with neck pain from seven physiotherapy outpatient departments in Hong Kong who completed the Northwick Park Neck Pain Question naire  were observed and measured at different intervals : at the beginning of physiotherapy , at 7 days , at 3 weeks , and 6 weeks after physiotherapy . Results . The question naire had good content validity , very good test – retest reliability , and internal consistency ( intraclass correlation coefficient , 0.95 ; Cronbach ’s alpha , 0.87 ) . It also had good validity ( Spearman correlation coefficient of 0.59 when the score was correlated with that of a generic 42-item Chinese health question naire ) and good responsiveness ( effect size of 1.11 at week 6 after treatment began ) . Conclusions . The Chinese version of the Northwick Park Neck Pain Question naire has been shown to demonstrate very good content validity , a high degree of test – retest reliability , and internal consistency . It also exhibited good construct validity and high sensitivity to changes in severity over time STUDY OBJECTIVE Flexion-extension ( F/E ) radiographs of the cervical spine are often used in patients with blunt trauma when the evaluating physician remains concerned about bony or ligamentous injuries despite negative or nondiagnostic st and ard radiographs . The use of this approach has never been addressed in a large prospect i ve study . We sought to determine the clinical factors associated with ordering F/E views and the incidence of diagnostic F/E films in patients with a normal 3-view cervical spine series . METHODS Patients with blunt trauma selected for radiographic cervical spine imaging at 21 participating institutions in the National Emergency X-Radiography Utilization Study project underwent st and ard 3-view ( cross-table lateral , anteroposterior , and odontoid views ) series , as well as any other imaging deemed necessary by their physicians . Injuries detected by means of screening radiography were then compared with final injury status for each patient , as determined by review of all radiographic studies . Patients who underwent F/E views were analyzed separately . RESULTS Of 818 patients ultimately found to have cervical spine injury , 86 ( 10.5 % ) underwent F/E testing . Two patients sustained stable bony injuries detected only on F/E views . Four other patients had a subluxation detected only on F/E views , but all had other injuries apparent on routine cervical spine imaging . CONCLUSION F/E imaging adds little to the acute evaluation of patients with blunt trauma . Other approaches , including magnetic resonance imaging , computed tomography , or delayed F/E , in the presence of specific clinical concerns would seem to provide a more reasonable approach to adjunctive imaging OBJECTIVE To investigate the reliability and discriminative ability of a new test design ed to detect accuracy of neck movements . DESIGN Repeated- measures . Case-control . SETTING University musculoskeletal research clinic in Icel and . PARTICIPANTS Twenty women ( mean age + /- st and ard deviation [ SD ] , 30.8+/-9.1 y ; range , 18 - 49 y ) with chronic whiplash-associated disorders ( WAD ) grade s I and II ( duration , 6 mo-6 y ) , with current pain score on a visual analog scale of 46.8+/-21.8 , and a disability score on the Northwick Park Neck Pain Disability Index of 45%+/-14 % . Twenty asymptomatic women ( mean age + /- SD , 29.3+/-8.6 y ; range , 18 - 48 y ) with no history of whiplash or insidious onset neck pain served as controls . INTERVENTION A slowly moving object appeared on a computer screen and traced an unpredictable movement path that the subjects were required to follow by moving their heads . Three r and omly ordered movement patterns were tested . MAIN OUTCOME MEASURE A new software program connected to a 3Space Fastrak system  was used to measure the mean absolute error ( in millimeters ) of 3 trials in each movement pattern . RESULTS The mean differences ( + /-2 SD ) between days 1 and 2 were.01+/-.64 mm for the asymptomatic group and .33+/-1.80 mm for the WAD group . The between-day intraclass correlation coefficients were between.60 and .77 for the asymptomatic group and .79 and .86 for the WAD group . Repeated- measures analysis of variance revealed a significant difference between groups ( P=.02 ) . The Tukey post hoc test showed significant between-group differences for each movement pattern ( P</=.05 ) . In each successive trial , a slight improvement for the asymptomatic group and a slight worsening for the WAD group were detected . CONCLUSIONS Better reliability was detected for the asymptomatic group than for the WAD group . The test could discriminate between the asymptomatic group versus the chronic WAD group Objective : To examine the reliability , validity and responsiveness of the generic Current Perceived Health 42 ( CPH42 ) Profile in Chinese patients with neck pain in Hong Kong . Design : A prospect i ve observational study . Setting : Physiotherapy outpatient departments . Subjects : Two sample s with 472 consecutive adult patients with neck pain from seven physiotherapy outpatient departments in Hong Kong . Methods : Subjects were requested to complete the CPH42 Profile , and their pain intensity was measured using the 11-point numerical rating scale ( NRS ) . They were observed and measured at the beginning of physiotherapy , at seven days , at week 3 and at week 6 after treatment began . Results : The CPH42 Profile had very good test – retest reliability and internal consistency ( intraclass correlation coefficient 0.91 , Cronbach 's alpha 0.90 ) . Validity was confirmed by a moderate correlation with the NRS at the beginning of treatment and week 6 ( rank correlation 0.41–0.53 ) . Moreover , a significant difference in scores was found between those who had sought medical consultation and /or had taken medication because of neck pain than those who did not . The responsiveness measured from the beginning of treatment to week 3 and week 6 ( st and ard response means of 0.33 and 0.36 ) was comparable to the respective changes in pain intensity . Conclusion : The CPH42 Profile has been shown to demonstrate good reliability and validity , and it is sensitive to changes in severity over time . It is suitable for use as an outcome measure for evaluation of patients with neck pain The present study was undertaken to evaluate if MRI within 2 days of a motor vehicle accident could reveal pathology of importance for underst and ing long-term disability after whiplash neck-sprain injuries . As part of a prospect i ve study cervical and cerebral MRI was performed on 40 neck sprain patients with whiplash injury after car accidents . The imaging was done within 2 days of the injury to make sure that any neck muscle bleeding , oedema or other soft tissue injuries could be detected . The MRI findings from the patients were both correlated to reported symptoms 6 months after the accident and compared to a control group of 20 volunteers . The  MRI  of both brain and neck revealed no significant differences between the patients and the control group . When the patients were grouped according to the main MRI findings at intake and compared according to the development of subjective symptoms reported by the patients , the only significant difference was more headaches at 6 months in the groups with disk pathology or spondylosis when compared to the group with no pathology . In conclusion , MRI within 2 days of the whiplash neck-sprain injury could not detect pathology connected to the injury nor predict symptom development and outcome BACKGROUND The National Emergency X-Radiography Utilization Study defined five criteria for obtaining cervical spine radiographic investigations in blunt trauma patients . Distracting injury was given as the indication for more than 30 % of all x-ray studies ordered . The hypothesis of this study was that upper and lower torso injuries would have different effects on clinical cervical spine assessment . METHODS This is a single-center , prospect i ve , observational study of admitted , alert , adult blunt-trauma patients . All patients underwent cervical spine plain-film radiography .  Data were collected on all injuries , physical examination findings , narcotic administration , and radiograph results . Patients with upper and lower torso injuries were compared in their ability complain of pain or midline tenderness relative to a cervical spine fracture . RESULTS In all , 406 patients participated . All patients received narcotic analgesics before examination . Forty patients ( 9.9 % ) had cervical spine fractures , of whom seven had a nontender neck examination . All seven patients with a nontender cervical spine and a neck fracture had at least one upper torso injury . None of the 99 patients with injuries isolated to the lower torso and a nontender neck had a cervical spine fracture ( p < 0.05 ) . The frequency of cervical spine fracture among patients with cervical spine tenderness was 19.8 % ( n = 33 ) . CONCLUSIONS The National Emergency X-Radiography Utilization Study definition of a distracting injury may be narrowed . Upper torso injuries may be sufficiently painful to distract from a reliable cervical spine examination . Patients may detect spine tenderness in the presence of isolated painful lower torso injuries . Patients with spine tenderness warrant imaging Abstract This cross-sectional study aim ed at investigating the influence of occupational exposure to static and highly repetitive work involving the neck and shoulder muscles , myalgia of and tender point in the trapezius muscle on biomechanical output , and electromyogram ( EMG ) variables ( mean frequency MNF , signal amplitude and ability to relax ) during maximal forward flexions of the shoulder muscles . Groups of 25 cleaners suffering from chronic myalgia of the trapezius muscle , 25 cleaners free from myalgia of the trapezius muscle and 21 teachers performed 150 forward flexions using an isokinetic dynamometer .  Perception of fatigue was reported and surface EMG was recorded from four muscles during the endurance test . The cleaners were stronger than the teachers . Myalgia was associated with lower levels of endurance and a high degree of perceived fatigue . The ability to relax the trapezius muscle decreased with age and was even lower in cleaners with and without myalgia . Higher MNF of the deltoid muscle but not of the trapezius muscle was found in the group suffering from myalgia compared to the groups free from myalgia . This cross-sectional study indicated that myalgia of the trapezius muscle did not influence the strength but did influence the endurance of the forward flexor muscles of cleaners . The observed decrease in the ability to relax the trapezius muscle in cleaners compared to healthy teachers might be indicative of a future insufficiency in the muscle . Prospect i ve studies are needed to define the significance of the results presented here OBJECTIVE To develop and assess the reliability of a group of cervical nonorganic physical signs to be used as a simple screening tool for identifying patients with low neck pain who exhibit abnormal illness behavior . DESIGN Survey , consecutive sample . DATA SET Double masked . SETTING Functional restoration program . PATIENTS Twenty-six consecutive patients with complaints of chronic neck pain ( greater than 4 months duration ) . Each patient was evaluated by a physician and then again by either a physical or occupational therapist , for the presence of specific cervical nonorganic signs . Both of the evaluations occurred on the same day . MAIN OUTCOME MEASURES Five categories consisting of eight tests were appraised : ( 1 ) tenderness , ( 2 ) simulation , ( 3 ) range of motion , ( 4 ) regional disturbance , and ( 5 ) overreaction . RESULTS The percent agreement between raters ranged from a high of 100 % for regional sensory disturbance , to a low of 68 % for one of the simulation tests . The average agreement between raters across all of the nonorganic test signs was 84.6 % . Likewise , kappa coefficients ranged from 1.00 to .16 , reflecting differences in strength of agreement . CONCLUSION For many years , the lumbar nonorganic signs ( developed by Waddell and colleagues ) have been a useful screening tool in the assessment of abnormal illness behavior in the low back pain population . For the first time , a group of cervical nonorganic signs have been developed , st and ardized , and proven reliable Study Design This study compared the  ambulatory electromyogram activity of persons reporting pain in the shoulder and cervical regions with an equal group of persons not reporting such pain .  Ambulatory electromyogram data were obtained over 3‐day periods . In addition , all participants completed several st and ard psychological question naires . Objectives The results were analyzed with inferential statistics to determine whether subjects reporting significant pain in the shoulder and cervical regions had greater ambulatory electromyogram activity than an equal number of subjects not reporting pain . Summary of Background Data Considerable controversy exists regarding the role of muscle activity in the etiology and maintenance of muscle pain disorders . Given the availability of ambulatory recording devices that can provide a detailed record of muscle activity over an extended period of time , the present research was conducted to determine whether persons reporting shoulder and cervical pain could be differentiated from a group of normal subjects . Methods All subjects ( N = 20 ) completed a battery of tests with st and ardized psychometric instruments and then were fitted with ambulatory electromyogram monitors to record  electromyographic activity of the upper trapezius region of the dominant side ; the time , duration , and amplitude of electromyogram activity greater than 2 μV was recorded . The monitors were worn during normal working hours ( mean , 6.2 hours per day ) over 3 consecutive days . In addition to wearing the monitors , all subjects completed hourly self‐ratings of perceived muscle tension during the recording periods . Results As expected , subjects with muscle pain reported significantly more pain ( mean , 4.9 ) than did the normal control subjects ( mean , 0.9 ) , t(15 ) = 3.29 , P < 0.01 . However , patients with muscle pain did not have greater average electromyogram activity ( mean , 6.4 μV ) over the 3‐day period as compared to the normal controls ( mean , 7.1 μV ) , t(18 ) = ‐0.25 , P < 0.80 . Self‐monitoring of perceived muscle tension also did not reveal differences between pain subjects and the normal control subjects ( P < 0.75 ) . Conclusions Ambulatory measurements of electromyogram activity did not differentiate persons reporting upper trapezius or cervical pain from those that did not report such pain . Persons reporting pain are also not distinguishable from normal control subjects on a variety of self‐report measures . These results raise questions regarding the role of ambulatory electromyogram recordings in the evaluation and treatment of muscle pain disorders Objective : To determine the false-positive rate of anesthetic blocks of the medial branches of the cervical dorsal rami in the diagnosis of cervical zygapophysial joint pain . Design : Comparison between single diagnostic blocks , and a criterion st and ard of double-blind , controlled , differential anesthetic blocks . Setting : Tertiary referral center . Patients : The first 55 consecutive patients with neck pain for > 3 months after and attributable to a motor vehicle accident , and who had completed a second diagnostic block after an initial positive response . A total of 60 joints was studied , with five patients providing two joints each . The mean age was 41 years : 61 % were female . Methods : Each patient had been investigated with radiologically controlled blocks of the medial branches of the cervical dorsal rami to anesthetize the target cervical zygapophysial joint . The initial block was performed using either 0.5 % bupivacaine or 2 % lignocaine , r and omly selected . The duration of pain relief was assessed in a double-blind fashion . The procedure was repeated with the complementary anesthetic . Only patients experiencing a longer period of pain relief from bupivacaine were considered to have true-positive responses . Results : The second block failed to relieve pain in two of the tested joints . In a further 14 joints , the control blocks relieved pain , but the patient failed to correctly discriminate the longer acting anesthetic . The remaining 44 joints met the criteria for true-positive responses . The false-positive rate of single blocks was 16 of 60 or 27 % ( 95 % confidence interval 15 % , 38 % ) . Conclusion : Uncontrolled diagnostic blocks are compromised by a significant false-positive rate that seriously detracts from the specificity of the test Study Design . Double-blind , r and omized , placebo-controlled trial . Objectives . To evaluate the effect of manual endplay assessment on neck pain and stiffness outcomes in neck pain patients receiving spinal manipulation .  Summary of the Background Data . There have been no studies on the efficacy of palpation used as an indicator for manipulation in the management of back and neck pain . Methods . Neck pain patients ( n = 104 ) were r and omly assigned to two groups . The study group received manipulation targeted to individual cervical vertebrae according to endplay restriction noted by the examining clinician . The control group received manipulation determined by sham , computer-generated examination findings ; endplay examination was ignored and served as a placebo assessment . Treatment was rendered on a single occasion by a chiropractor . Outcomes were neck pain and stiffness assessed before and after manipulation and at least 5 hours following treatment . Results . The study and control groups showed clinical ly important improvement in neck pain and stiffness . However , there were no clinical ly important or statistically significant differences between the study and control groups in terms of pain or stiffness outcomes . Findings were robust across patient , complaint , and treatment characteristics . Conclusions . Endplay assessment in and of itself did not contribute to the same-day pain and stiffness relief observed in neck pain patients receiving spinal manipulation .  The impact on a longer course of treatment remains to be investigated . The data suggest that pain modulation may not be limited to mechanisms associated with manipulation of putative motion restrictions Study Design . A blinded , prospect i ve diagnostic test study was conducted . Objectives . To assess the reliability and accuracy of individual clinical examination items  and  self-report instruments  for the diagnosis of cervical radiculopathy , and to identify and assess the accuracy of an optimum test-item cluster for the diagnosis of cervical radiculopathy . Summary of Background Data . Although cervical radiculopathy remains largely a clinical diagnosis , the reliability and diagnostic accuracy of clinical examination items , individually or in combination , for cervical radiculopathy is largely unknown . Methods . Patients with suspected cervical radiculopathy or carpal tunnel syndrome received st and ardized electrophysiologic examination of the symptomatic upper quarter followed by a st and ardized clinical examination by physical therapist examiners blinded to diagnosis . Diagnostic properties were assessed using a neural impairment reference criterion st and ard . Results . The study involved 82 patients . More than two thirds of 34 clinical examination items had reliability coefficients rated at least fair or better , and 13 items had likelihood ratio point estimates above 2 or below 0.50 . A single diagnostic test item cluster of four variables was identified and produced a positive likelihood ratio point estimate of 30.3 . The 95 % confidence intervals for all likelihood ratio point estimates in this study were wide . Conclusions . Many items of the clinical examination were found to be reliable and to have acceptable diagnostic properties , but the test item cluster identified was more useful for indicating cervical radiculopathy than any single test item . Upper limb tension Test A was the most useful test for ruling out cervical radiculopathy . Further investigation is required both to vali date the test item cluster and to improve point estimate precision STUDY OBJECTIVE We evaluate the accuracy , reliability , and potential impact of the National Emergency X-Radiography Utilization Study ( NEXUS ) low-risk criteria for cervical spine radiography , when applied in Canadian emergency departments ( EDs ) . METHODS The Canadian C-Spine Rule derivation study was a prospect i ve cohort study conducted in 10 Canadian EDs that recruited alert and stable adult trauma patients . Physicians completed a 20-item data form for each patient and performed interobserver assessment s when feasible . The prospect i ve assessment s included the 5 individual NEXUS criteria but not an explicit interpretation of the overall need for radiography according to the criteria . Patients underwent plain radiography , flexion-extension views , and computed tomography at the discretion of the treating physician .  Patients who did not have radiography  were followed up with a structured outcome assessment by telephone to determine clinical ly important cervical spine injury , a previously vali date d outcome measurement . Analyses included sensitivity and specificity with 95 % confidence interval ( CI ) , kappa coefficient , and potential radiography rates . RESULTS Among 8,924 patients , 151 ( 1.7 % ) patients had an important cervical spine injury . The combined NEXUS criteria identified important cervical spine injury with a sensitivity of 92.7 % ( 95 % CI 87 % to 96 % ) and a specificity of 37.8 % ( 95 % CI 37 % to 39 % ) . Application of the NEXUS criteria would have potentially reduced cervical spine radiography rates by 6.1 % from the actual rate of 68.9 % to 62.8 % . Of 11 patients with important injuries not identified , 2 were treated with internal fixation and 3 with a halo . CONCLUSION This retrospective validation found the NEXUS low-risk criteria to be less sensitive than previously reported . The NEXUS low-risk criteria should be further explicitly and prospect ively evaluated for accuracy and reliability before widespread clinical use outside of the United States Abstract . Several work-related , psychosocial and individual factors have been verified as being related to neck and shoulder pain , but the role of pathology visualized by magnetic resonance imaging ( MRI ) remains unclear . In this study , the relationship between neck and shoulder pain and cervical high-field MRI findings was investigated in a sample of persons in a longitudinal survey . The study aim ed to determine whether subjects with persistent or recurrent neck and shoulder pain were more likely to have abnormal MRI findings of cervical spine than those without neck and shoulder pain . A r and om sample of 826 high-school students was investigated initially when the students were 17–19 years , and again when they had reached 24–26 years of age . Eighty-seven percent participated in the first survey in 1989 , of whom 76 % took part in the second survey , in 1996 . The vali date d Nordic Musculoskeletal Question naire was used to collect data about neck and shoulder symptoms . Two groups were chosen for the MRI study : the first group ( n=15 ) consisted of the participants who had reported no neck and shoulder symptoms in either of the inquiries , while the second group ( n=16 ) comprised those who were suffering from neck and shoulder symptoms once a week or more often at the time of both surveys . The degrees of disc degeneration , anular tear , disc herniation and protrusion were assessed by two radiologists . The differences between the two study groups were evaluated . The study found that abnormal MRI findings were common in both study groups . Disc herniation was the only MRI finding that was significantly associated with neck pain . These findings indicate that pathophysiological changes of cervical spine verified on MRI seem to explain only part of the occurrence of neck and shoulder pain in young adults Study Design . A cross-sectional study was conducted to analyze a convenience sample of patients seeking treatment for cervical spine conditions . Objective . To develop and evaluate the psychometric properties of a comprehensive , disease-specific question naire for characterizing complaints of neck pain and evaluating the outcomes of treatments for these complaints . Summary of Background Data . There currently are a number of generic and disease-specific instruments for assessing complaints of neck pain . None comprehensively cover the wide range of factors considered essential in evaluating treatment outcomes . Methods . The authors developed a comprehensive , disease-specific question naire for characterizing complaints of neck pain and evaluating the outcomes of treatments for these complaints . In this study , 216 patients who underwent surgery for cervical spine disorders completed the Cervical Spine Outcomes Question naire before treatment , then at 3 and 6 months after treatment . The data were used to evaluate the reliability , validity , and responsiveness of the question naire . Results . The authors have shown that the Cervical Spine Outcomes Question naire has high test – retest reliability , good construct validity , and responsiveness to change after treatment . Conclusions . The Cervical Spine Outcomes Question naire is a comprehensive , disease-specific instrument for assessing complaints of neck pain and evaluating the outcomes of treatments for these complaints . It provides information on demographics , pain severity , functional disability , psychological distress , physical symptoms , health care utilization , and satisfaction . It appears to be acceptable to patients , easy to administer , highly reliable , valid , and responsive . It should be considered for use in monitoring patients with cervical spine conditions and in studies of cervical spine disorders and their treatments & NA ; The utility of r and omised , double‐blind , controlled , comparative local anaesthetic blocks for the diagnosis of cervical , zygapophysial joint pain was studied in 47 patients with chronic neck pain following whiplash injury . Each patient was investigated with radiologically controlled blocks of the medial branches of the cervical , dorsal rami to anaesthetise the target cervical , zygapophysial joint . The blocks were performed using either lignocaine or bupivacaine , r and omly allocated , and the patients ' responses were assessed in a double‐blind fashion . Any positive response was subsequently assessed by repeating the block with the complementary anaesthetic . Only those patients experiencing a longer period of pain relief from the bupivacaine were considered to have true‐positive responses . Forty‐four patients had pain relief from two blocks at a single level , of whom 34 had longer pain relief from bupivacaine . This result is unlikely to have occurred by chance ( P = 0.0002 ) . The duration s of pain relief obtained from the anaesthetics were consistent with the known characteristics of these drugs with bupivacaine lasting significantly longer than lignocaine ( P = 0.0003 ) . A subgroup of 13 patients were identified with unexpected , prolonged responses to one or both of the anaesthetics . Comparative , diagnostic blocks are a valid technique in the identification of painful zygapophysial joints , and constitute an implementable alternative to normal saline controls The cervical curvature of 488 patients with acute whiplash injury was prospect ively studied by comparison with 495 asymptomatic healthy volunteers .  Plain radiography of the cervical spine in the neutral position was evaluated qualitatively . No significant difference was noted in frequencies of non-lordotic cervical curvature and local angular kyphosis between acute whiplash injury patients and asymptomatic subjects .  No significant association was apparent between clinical symptoms and cervical curvature . These results suggest that non-lordotic cervical curvature and angular kyphosis in acute whiplash injury patients constitute normal variants rather than pathological findings Iohexol , a new water-soluble nonionic contrast medium , was evaluated in clinical trials in Europe and North America for lumbar , thoracic , and cervical myelography using direct C1 - 2 or lumbar puncture . Iohexol was administered at 180 , 240 , or 300 mg I/ml to 677 adult patients for visualization of the lumbar subarachnoid space , and to 368 adult patients for evaluation of the cervical area . Compared with metrizamide , use of iohexol result ed in equivalent opacification but significantly reduced patient morbidity ( headache , nausea , vomiting , dizziness ) . No epileptogenic activity was recorded in over 370 patients receiving iohexol . No mental or psycho-organic syndrome manifestations were observed in any of the 1,045 patients receiving iohexol .  Adverse reactions occurring after iohexol injection were not related to the concentration or site used or to total dose administered . Iohexol has , thus far , proven superior to metrizamide for myelography BACKGROUND There are numerous clinical tests used in the evaluation of patients with symptoms arising from the cervical spine . It is necessary to use clinical tests with high validity and reliability . Previous studies of reliability of clinical tests used in the evaluation of the cervical spine have come to various conclusions , most of which suggest low reliability . This might be explained by differences between examiners in performance and where the limit of normality is placed . OBJECTIVE To evaluate the interexaminer reliability of clinical tests used in everyday clinical work , where the examiners base their evaluations on a comparison between left and right sides . STUDY DESIGN A total of 50 volunteers were examined by two physiotherapists . The interexaminer reliability of clinical tests included in the physical examination of patients with symptoms from the cervical spine was evaluated . METHODS Two physiotherapists independently examined volunteers . RESULTS An acceptable reliability was found for two of 10 clinical tests . CONCLUSION When it is possible to compare left and right sides , it is possible to show acceptable reliability for some clinical tests . Reliability studies most often find low reliability , perhaps because of bias ; clinical tests are not st and ardized . In future studies , greater efforts should be taken to reduce bias Criteria for excluding cervical spine injury in patients who have sustained blunt head or neck trauma were prospect ively studied at four hospitals in the Chicago area . The authors attempted to define a subset of these adult patients who , based on clinical criteria , could reliably be excluded from cervical spine radiography , thus avoiding unnecessary radiation and saving considerable time and money in their evaluation . Patients fell into four groups : ( 1 ) patients who were awake , alert , and had no complaint of neck pain or tenderness on physical examination ; ( 2 ) patients who were awake , alert , but had complaint of neck pain or tenderness on physical examination laterally over the trapezius muscle only ; ( 3 ) patients who were awake , alert , but had complaint of central neck pain or tenderness on physical examination over the cervical spine or center of the neck ; and ( 4 ) patients who were not fully awake or alert , were clinical ly intoxicated , had other painful or distracting injuries , or had focal neurologic findings . Patients in group 4 had significantly more fractures ( 21/387 ) when compared with all other patients ( 7/478 ) . Patients with central neck pain or tenderness ( group 3 ) had significantly more fractures ( 7/237 ) than patients without pain or tenderness or with these findings limited to the trapezius area ( 0/236 ) . It is clear that patients who have altered mental status , abnormal examination findings , distracting injury , or pain or tenderness over the cervical spine must have cervical spine radiographs . ( ABSTRACT TRUNCATED AT 250 WORDS Study Design . A survey of the prevalence of cervical zygapophysial jooint pain was conducted . Objectives . To determine the prevalence of cervical zygapophysial joint pain in patients with chronic neck pain after whiplash . Summary of Backgound Data . In a significant porportion of patients with whiplash , chronic , refractory neck pain develops . Provisional data suggests many of these patients have zygapophysial joint pain , but the diagnosis has been established by single , uncontrolled diagnostic blocks . Methods . Fifty consecutive , referred patients with chronic neck pain after whiplash injury were studid using double-blind , controlled , diagnotic blocks of the cervical zygapophysial joints . On separate occasions , the joint was blocked with either lignocaine or bupivacaine in r and om order . Results . A positive diagnosis was made only if both blocks relieved the patient 's pain and bupivacaine provided longer relief , Painful joints were identified in 54 % of the patients ( 95 % confidence interval , 40 % to 68 % ) . Conclusion . In this population , cervical zygapophysial joint pain was the most common source of chronic neck pain after whiplash Objective To assess whether the introduction of the National Emergency X-ray Utilization Study guidelines in a UK emergency department reduced the number of patients having cervical spine radiographs  and altered the accuracy of diagnosis of  cervical spine injury . Methods This was a prospect i ve , observational study . The number of patients with recent neck injury who had cervical spine radiographs taken was assessed for 3 months before and three months after the introduction of the National Emergency X-ray Utilization Study guidelines to an urban emergency department in the UK . The number of injuries missed by emergency department doctors during the two 3-month periods was also recorded . Results Prior to using the guidelines , 252 of 715 patients ( 35 % ) were X-rayed and when using the guidelines , 268 of 706 patients ( 38 % ) were X-rayed . No significant difference was observed between the rates of X-ray in the two groups ( P=0.288 ) . No injuries were missed by emergency department doctors either before or after the introduction of the guidelines . Conclusion Introduction of the National Emergency X-ray Utilization Study guidelines to a UK emergency department did not reduce the number of patients having cervical spine radiographs after neck trauma and had no effect on the pick-up rate for cervical spine injuries OBJECTIVE Reliable and valid measures of pain are needed to advance research initiatives on appropriate and effective use of analgesia in the emergency department ( ED ) . The reliability of  visual analog scale ( VAS ) scores  has not been demonstrated in the acute setting where pain fluctuation might be greater than for chronic pain . The objective of the study was to assess the reliability of the  VAS  for measurement of acute pain . METHODS This was a prospect i ve convenience sample of adults with acute pain presenting to two EDs . Intraclass correlation coefficients ( ICCs ) with 95 % confidence intervals ( 95 % CIs ) and a Bl and -Altman analysis were used to assess reliability of  paired VAS measurements  obtained 1 minute apart every 30 minutes over two hours . RESULTS The summary ICC for all paired VAS scores was 0.97 [ 95 % CI = 0.96 to 0.98 ] . The Bl and -Altman analysis showed that 50 % of the paired measurements were within 2 mm of one another , 90 % were within 9 mm , and 95 % were within 16 mm . The paired measurements were more reproducible at the extremes of pain intensity than at moderate levels of pain . CONCLUSIONS Reliability of the  VAS  for acute pain measurement as assessed by the ICC appears to be high . Ninety percent of the pain ratings were reproducible within 9 mm . These data suggest that the VAS is sufficiently reliable to be used to assess acute pain STUDY OBJECTIVES A decision instrument based on 5 clinical criteria has been shown to be highly sensitive in selecting patients who require cervical spine imaging after blunt trauma , while simultaneously reducing overall imaging . We examine the performance of this instrument in the elderly and explore some of the common features of geriatric cervical spine injury ( CSI ) .  METHODS The National Emergency X-radiography Utilization Study ( NEXUS ) was a prospect i ve , observational , multicenter study conducted at 21 geographically diverse centers . We analyzed the performance of the NEXUS decision instrument among patients at least 65 years of age . RESULTS The study group consisted of 2,943 ( 8.6 % ) geriatric patients , representing 8.6 % of the entire NEXUS sample . The rate of CSI was twice as great in these patients as it was in nongeriatric patients ( 4.59 % versus 2.19 % ) . Odontoid fractures were particularly common in geriatric patients , accounting for 20 % of geriatric fractures compared with 5 % of nongeriatric fractures . The frequency of patients meeting NEXUS criteria was similar in the 2 groups , with 14 % of geriatric patients and 12.5 % of nongeriatric patient classified as low risk . CSI occurred in only 2 low-risk geriatric patients , and these patients ' injuries met our preset definition of a clinical ly insignificant injury . The sensitivity of the NEXUS decision instrument for clinical ly significant injury in the geriatric group was therefore 100 % ( 95 % confidence interval 97.1 % to 100 % ) . CONCLUSION The prevalence of CSI , and especially odontoid fracture , is relatively increased among geriatric patients with blunt trauma . The NEXUS decision instrument can be applied safely to these patients , with an expected reduction in cervical imaging comparable with that achieved in nongeriatric patients The purpose of the present study was to assess five manual tests for pain provocation of the neck to determine their suitability for epidemiological investigations . To 75 r and omly selected men , five manual pain-provoking tests were applied in a single-blind design . Prevalence of reported neck dysfunction , sensitivity , specificity , and positive and negative predicted value for each test were calculated . 22 of the 75 reported present neck pain , while the remainder reported freedom from neck pain for at least one year . Palpation over the facet joints in the cervical spine was found to be the most appropriate screening test to corroborate the replies in self-reported question naires on dysfunctions of the neck . The outcome of this test was quite consistent with the reported neck pain . The test of the formina intervertebralia and the upper limb tension test caused pain in almost all subjects with reported neck dysfunctions , though not causing referred pain in the arm as an indication of neurogenous tissue origin , as it was aim ed to . Neither the neck rotation test nor the active flexion/extension test was sufficiently provocative to confirm the reported neck pain in these subjects , as both were insufficiently sensitive This is the second in a series of five articles Considerable effort has been expended at the interface between clinical medicine and scientific methods to achieve the maximum validity and usefulness of diagnostic tests . This article focuses on the specific kinds of questions that arise in diagnostic research and the study architectures ( the conversions of these clinical questions into appropriate research design s ) used to answer them . As an example we shall take shall take assessment of the value of the plasma concentration of B-type natriuretic peptide ( BNP )  in the diagnosis of left ventricular dysfunction.1  R and omised controlled trials are dealt with elsewhere . As in other forms of clinical research , there are several different ways study ing the potential or real diagnostic value of a physical sign or laboratory test , and each is appropriate to one kind of question and inappropriate for others . Among the possible questions about the relation between a putative diagnostic test and a target disorder ( for example , the concentration of BNP and left ventricular dysfunction ) , four are most relevant . # # # # Summary points Diagnostic studies should match methods to diagnostic questions The keys to validity in diagnostic test studies are Both specificity and sensitivity may change as the same diagnostic test is applied in primary , Background : The development of target-specific local anesthetic blocks has enabled pain physicians to explore the anatomical source of chronic spinal pain . However , such blocks rely on subjective responses and may be subject to the placebo effect . Comparative local anesthetic blocks have been advocated as a means of identifying true-positive cases and excluding placebo responders . This paradigm employs two local anesthetics with different duration s of action ; only patients who obtain reproducible relief and correctly identify the longer-acting agent are considered positive . Objective : Our objective was to evaluate the reliability of comparative blocks of the medial branches of the cervical dorsal rami in the diagnosis of cervical zygapophysial joint pain .  Design : We compared comparative blocks and the criterion-st and ard of r and omized , double-blind , placebo-controlled blocks . Setting : The study was conducted at a tertiary referral center . Patients : We studied the first 50 consecutive patients referred for assessment of chronic neck pain ( > 3 months ' duration ) after a motor vehicle accident , who completed a series of placebo-controlled blocks after an initial positive response . Patients were 41 ± 11 years ( mean ± SD ) old with a male/female ratio of 1:2 . Methods : Patients underwent three blocks using three different agents— lignocaine , bupivacaine , and normal saline — administered on separate occasions , in r and om order and under double-blind conditions . The diagnostic decision based on comparative blocks alone was compared with that based on placebo-controlled blocks . Results : Comparative blocks were found to have a specificity of 88 % , but only marginal sensitivity ( 54 % ) . Although comparative blocks result in few false-positive diagnoses , their liability is that they result in a high proportion of false-negative diagnoses . Exp and ing the comparative blocks diagnostic criteria to include all patients with reproducible relief , irrespective of duration , increases sensitivity to 100 % but lowers specificity to 65 % . Conclusions : Whether physicians use comparative or placebo-controlled blocks depends upon the implication s of their results . If innocuous therapy will be prescribed , comparative blocks might suffice . However , when diagnostic certainty is critical , such as in a medicolegal context or when surgical intervention is contemplated , placebo-controlled blocks are recommended STUDY OBJECTIVE We determine whether the use of an emergency medical services ( EMS ) protocol for selective spine immobilization would result in appropriate immobilization without spinal cord injury associated with nonimmobilization . METHODS A 4-year prospect i ve study examined EMS and hospital records for patients after the implementation of an EMS protocol for selective spine immobilization .  EMS personnel were trained to perform and document a spine injury assessment for out-of-hospital trauma patients with a mechanism of injury judged sufficient to cause a spine injury . The assessment included these clinical criteria : altered mental status , evidence of intoxication , neurologic deficit , suspected extremity fracture , and spine pain or tenderness . The protocol required immobilization for patients with a positive assessment on any of those criteria . Outcome characteristics included the presence or absence of spine injury and spine injury management . RESULTS The study collected data on 13,483 patients ; 126 of the patients were subsequently excluded from the study because of incomplete data , leaving a study sample of 13,357 patients with complete data .  Spine injuries were confirmed in the hospital records for 3 % ( n=415 ) of patients , including 50 patients with cord injuries and 128 patients with cervical injuries . Sensitivity of the EMS protocol was 92 % ( 95 % confidence interval [ CI ] 89.4 to 94.6 % ) result ing in nonimmobilization of 8 % of the patients with spine injuries ( 33 of 415 ) . None of the nonimmobilized patients sustained cord injuries . The specificity was 40 % ( 95 % CI 38.9 to 40.5 % ) . CONCLUSION The use of our selective immobilization protocol result ed in spine immobilization for most patients with spine injury without causing harm in cases in which spine immobilization was withheld Abstract Grading pain intensity scales into simple categories provides useful information for both clinicians and epidemiologists and methods to classify pain severity for numerical rating scales have been recommended . However , the establishment of cut‐points is still in its infancy and little is known as to whether cut‐points are affected by age or gender . The objectives of this paper were to establish optimal cut‐points in pain severity in individuals with neck pain ( NP ) and to investigate if the cut‐points were influenced by gender , age , and NP duration . Data from the population ‐based ‘ Funen Neck and Chest Pain Study ’ was used . Univariate and multivariate analyses of variance were performed to calculate optimal single and double cut‐points for three different pain intensity scores within the past 2 weeks relative to two neck disability scales ( ‘ global assessment of NP ’ and the ‘ Copenhagen Neck Functional Disability Scale ’ ) . The two disability scales showed small differences in optimal cut‐points . Furthermore , cut‐points changed for each of the three pain intensity scales . Only small gender differences in cut‐points were seen and no specific trend was noted in either single or double cut‐points in different age groups . The cut‐points were almost identical for acute , subacute , and chronic NP . This paper has implication s for underst and ing the impact of using different pain intensity scales and provides reference cut‐points in NP for use in future clinical and epidemiological research
target: Screening protocol s have high predictive values to detect cervical spine fracture in alert , low-risk patients seeking emergency care after blunt neck trauma .
  Computerized tomography ( CT ) scans had better validity ( in adults and elderly ) than radiographs in assessing high-risk and /or multi-injured blunt trauma neck patients .
  In the absence of serious pathology , clinical physical examinations are more predictive at excluding than confirming structural lesions causing neurologic compression .
  One exception is the manual provocation test for cervical radiculopathy , which has high positive predictive value .
  There was no evidence that specific MRI findings are associated with neck pain , cervicogenic headache , or whiplash exposure .
  No evidence supports using cervical provocative discography , anesthetic facet , or medial branch blocks in evaluating neck pain .
  Reliable and valid self-report question naires are useful in assessing pain , function , disability , and psychosocial status in individuals with neck pain .
  CONCLUSION The scientific evidence supports screening protocol s in emergency care for low-risk patients ; and CT-scans for high-risk patients with blunt trauma to the neck .
  In nonemergency neck pain without radiculopathy , the validity of most commonly used objective tests is lacking .
background: OBJECTIVE To critically appraise and synthesize the literature on assessment of  neck pain .
  SUMMARY OF BACKGROUND DATA The published literature on assessment of neck pain is large and of variable quality .
  There have been no prior systematic review s of this literature .