Ashley Smith

Background: Medial branch blocks (MBB) and radiofrequency ablations (RFA) are common diagnostic, prognostic, and interventional procedures performed for the management of cervical and lumbar spine facetogenic pain. Although these procedures have established utility as pain management strategies, it is unclear if the disruption in function of the medial branch nerve leads to patient balance impairment. Objective: (1) To determine if there was a difference in postural balance, measured using a head mountable physiological vibration acceleration (Phybrata) sensor, between those pursuing cervical or lumbar MBBs/RFAs compared to an asymptomatic healthy cohort (HC). (2) To determine differences in balance and sensory reweighting prior to and following MBBs/RFAs, and the association with clinical measures of pain and balance using the 4‐Stage Balance Test. Design: Quasiexperimental study with matched controls. Setting: Community multidisciplinary chronic musculoskeletal pain practice. Participants: Sixty individuals with chronic axial back pain and 60 age‐/gender‐matched healthy individuals. Interventions/main outcome measures: Standing balance measures recorded with the Phybrata sensor, subjective report of pain (numerical rating scale), and clinical measures of balance (4‐Stage Balance Test) were analyzed before and after participants underwent MBBs/RFAs and compared to an asymptomatic HC. Results: Participants with axial spinal pain of facet joint origin (≥ 50% relief post MBB/RFA) demonstrated balance degradation when standing with eyes closed, when compared to participants with nonspecific axial spinal pain (< 50% pain relief) or HCs – both prior to and following MBBs/RFAs. Following MBBs/RFAs, participants undergoing C2/3 procedures demonstrated increased postural sway. The remainder of participants with axial spinal pain did not show any further balance deficits, with corresponding sensory reweighting adaptation. Phybrata measures were not associated with pain location or pain intensity prior to or after MBBs/RFAs. Conclusions: These results suggest the risk of developing significant balance impairments following MBB/RFA procedure of either the cervical (excluding C2/3) or lumbar spine is low, although residual balance deficits remain.

Background/Objectives: Platelet-rich plasma (PRP) is emerging as a safe and effective treatment for facet-mediated pain. Studies have demonstrated reductions in pain and improvements in function, both in the short (3 months) and longer term (6 and 12 months). The mechanisms underlying clinical improvements are largely unknown. It is also unclear whether reported outcomes are due to the PRP administered or concurrently applied rehabilitation. Methods: A prospective case series was conducted in a single, multidisciplinary chronic pain centre. Forty-two participants with chronic WAD and cervical facet-mediated pain who received PRP (64% female; mean age (SD) 42.8 (11.6) years; median WAD duration [IQR] 23 [18,29] mths), attended rehabilitation, and reported successful outcomes 3 months post-PRP fulfilled the inclusion criteria. Measures of pain, cervical isometric strength, and range of motion were collected at baseline and 3 months post-PRP. Mediation analyses were performed to determine how these factors influenced disability. Results: Participants demonstrated clinically significant and relevant improvements in pain, disability, and isometric strength measures (all p < 0.01). Causative mediation analyses demonstrated independent direct, but not indirect, effects of both pain and strength on disability (both p < 0.001), with no direct or indirect effects of cervical ROM on disability.

Objective: The objectives of this study were to evaluate functional outcomes of cervical motor control, strength and endurance following active transcranial direct current stimulation (tDCS) with exercise therapy (ET) compared to sham tDCS/+ET in patient with cervicogenic headache (CGH), Design: This was a pilot sham-controlled, participant and assessor blinded, randomized controlled trial. Methods: Thirty-two participants with CGH were randomized to active tDCS/+ET or sham tDCS/+ET. Participants completed 6-weeks of daily ET concurrently combined with 3 sessions per week of tDCS. Assessments included: craniocervical flexion test (mmHg), cervical isometric strength (N), cervical flexor and extensor endurance (seconds), and range of motion (degrees) pre-treatment, post-treatment, 6-weeks and 12-weeks post treatment. Linear mixed effect models evaluated group-time interactions at each follow-up while accounting for exercise program adherence and sex. Results: There were significant group-time interactions for activation scores on the craniocervical flexion test from pre-treatment to post-treatment (β = 1.571; 95%CI[0.155, 2.988]; p = 0.030), 6-weeks (β = 1.571; 95%CI[0.155, 2.988]; p = 0.030), and 12-weeks (β = 1.954; 95%CI[0.465, 3.443]; p = 0.011) favoring the active tDCS/+ET group. Conclusions: Active tDCS/+ET demonstrated significant benefits in deep cervical flexor motor control compared to sham tDCS/+ET that remained improved up to 12 weeks post-treatment. This suggests tDCS/+ET may improve of functional outcomes for patients with CGH.

The purpose of this study was to investigate the relationship between symptoms across body systems and health outcomes in individuals with chronic whiplash-associated disorders (WADs). A cross-sectional study was conducted at a multidisciplinary chronic pain center in Calgary, Canada, between October 2019 and December 2021. Participants with a history of WAD completed questionnaires assessing pre-existing symptoms across bodily systems and related health outcomes. Mediation analyses evaluated the associations between symptom profiles and health outcomes, as well the role of pain cognitions. Of 305 participants in the registry database, 238 were eligible. The majority reported symptoms from 2 or more body systems, especially neurological, gastrointestinal, and psychological symptoms. Participants demonstrated moderate-to-severe pain and disability, with low physical health-related quality of life. While multiple symptoms correlated with worse health outcomes, mediation analyses revealed pain cognitions primarily influenced these associations, except for eye-related symptoms, which directly correlated with pain and disability. The study highlights that chronic WAD is characterized by a complex symptom profile across various bodily systems. Although a broader symptom profile is linked to poorer health outcomes, the effects are often mediated by pain cognitions. Notably, prior health conditions did not adversely impact outcomes, suggesting a need for targeted interventions focusing on cognitive aspects in patients with chronic WAD.

Objective The study’s primary objective was to compare the effectiveness of intra-articular platelet-rich plasma injections versus corticosteroid injections for the treatment of cervical facetogenic pain. Secondary aims were to compare self-rated disability, pain self-efficacy, and the safety of the procedure between groups. Methods A single-site randomized double-blind controlled trial with 40 participants assigned to receive either leucocyte-poor, low-concentrate platelet-rich plasma injections or corticosteroid injection without local anesthetic into the cervical facet joint under fluoroscopy. Outcomes were collected via telephone at 1, 3, and 6 months to determine treatment effectiveness. Results Low-concentrate platelet-rich plasma and corticosteroid injections had similar effects on cervical facetogenic pain intensity over a 6-month period post injection as demonstrated by a non-significant group-by-time interaction for Numeric Rating Scale scores (p>0.05). However, both groups showed a statistically significant decrease in cervical facetogenic pain intensity 1 month post treatment compared with baseline (p=0.02), while the platelet-rich plasma group also demonstrated a clinically significant decrease in pain intensity at the same time point. There was a significant interaction at 1 month post intervention for pain self-efficacy (p=0.04), with the platelet-rich plasma injection group showing a larger increase in pain self-efficacy compared with the corticosteroid injection group. No significant interaction was observed for self-rated disability; however, significant reductions were shown at 3 and 6 months post treatment compared with baseline in both groups (pConclusion Both platelet-rich plasma and corticosteroid injections induced similar improvements in cervical facetogenic pain intensity (1 month post) and self-rated disability (3 and 6 months post). Pain self-efficacy demonstrated a significant interaction with platelet-rich plasma injection showing greater improvement 1 month post. Additionally, both treatments exhibited a similar low prevalence of adverse events; however, those receiving platelet-rich plasma injection reported less procedural pain.

Background: Motivation can be investigated with the BIS (Behavioural Inhibition System)/BAS (Behavioural Activation System) scale. BAS regulates the motivation to approach goal‐oriented outcomes, particularly rewarding stimuli and situations, while BIS regulates escape and avoidance of unpleasant outcomes. Chronic whiplash‐associated disorders (WAD) is a heterogenous pain condition with known alterations in motivated behaviour. The study aimed (1) to investigate the relationship between BIS/BAS, and pain and disability with quality of life and psychological measures in chronic WAD; (2) to determine if BIS and/or BAS mediate the relationships between pain, disability, and psychological symptoms and quality of life.Methods: 254 chronic WAD patients participated in the study. Outcome measures were assessed using self‐report questionnaires. BIS/BAS scores were compared to published normative data. Differences in health outcomes for participants within/outside normative 95% confidence intervals were compared and correlations with health measures tested. Mediation models explored bi‐directional associations between stress, anxiety, depression, post‐traumatic stress severity, pain catastrophizing, and quality of life with pain and disability.Results: Participants who exceeded normative 95% confidence intervals for BIS demonstrated higher scores for pain interference, disability and all mental health measures. No mediating role of BIS/BAS on the relation between pain and disability with quality of life and health outcomes could be confirmed.Conclusions: A comparatively large proportion of the sample exceeded the 95% confidence interval for BIS and BAS scores with associations of these scores with health outcomes, but altered motivation to approach goal‐oriented outcomes appears to play only a subordinate role in chronic WAD.Significance statement: In line with current theories, we found a large proportion (30%–50%) of patients with whiplash‐associated disorders (WAD) showing signs of altered function in the Behavioural Inhibition System (BIS) and Behavioural Activation System (BAS) suggesting altered reward processing and motivation in these patients. While such altered functions showed associations with pain interference, disability and all mental health measures, reward processing could no be demonstrated as a pathogenetically relevant factor in chronic WAD patients.

Purpose Chronic whiplash-associated disorders (WAD) is a heterogeneous condition with limited effective treatment options available. This study evaluated the effectiveness of multimodal physiotherapy versus usual care in chronic WAD with facet-mediated pain receiving platelet-rich plasma (PRP) injections to determine if pain interference and confidence completing activities in the presence of neck pain could be improved. Materials and Methods A multiple-baseline, single-case experimental design was used to evaluate the 6-week effect of physiotherapy or usual care in two groups of three participants each. Results All six participants demonstrated a significant reduction in pain interference, and three participants showed improved confidence to perform daily activities when in pain. Weighted Tau-U demonstrated a significant reduction of pain interference with large to very large effect sizes (> 0.75) for both interventions in all participants irrespective of treatment allocation with no significant group difference demonstrated. Similar effects were demonstrated for the confidence to perform daily activities with neck pain (ES > 0.46), although this was only evident in three participants (two PT and one UC). Generalization measures also showed improvements in pain and disability, psychological and quality of life outcomes. No adverse events were reported. Conclusions Both physiotherapy and usual care demonstrated improvements in pain interference and confidence to perform activities of daily living with neck pain in people with chronic WAD following cervical facet joint PRP. Trial Registration The trial was registered with ClinicalTrials.gov (Protocol Number: NCT03949959)