Background:
Headache and neck pain are closely related. Office-workers are regarded especially vulnerable for both conditions. The objectives of the study are, to examine the effects of a 12 month intervention, consisting of neck exercise and health promotion, on headache outcome variables in office workers in two public departments in Switzerland.
Methods: The study is a stepped-wedge cluster randomized controlled trial. One-hundred twenty participants were randomly allocated within their cluster (n=8 per cluster) to the time point for entering the intervention phase. Five of 15 clusters were randomized to either the intervention or control phase at each time point (t0, t2, t3). At t1, the trial had to be suspended for 3 months, but outcomes had been sampled. Secondary outcomes were headache occurrence (Yes/No), headache frequency (days/4 weeks) and the "headache impact test-6 (HIT-6) questionnaire. For each outcome variable several regression models had been calculated, to test for the effect of treatment (intervention /no intervention), period (four time periods) and calendar time (time being in the intervention phase), and their interactions.

Results: For the occurrence of headache (Yes/No) the simplest model fitted best the data, showing a 54% reduction in headache occurrence (95% Confidence interval: 26 to 84% reduction). For headache days within the last 4 weeks, the model including the interaction effects (intervention *period) best fitted the data. At t1, the intervention effect was largest with a reduction in headache days per four weeks of 43% (95% CI: 26 to 54%), while at later time points effects could not be maintained. For the HIT-6, also the model accounting for the period of the intervention best fitted the data. There was no effect found for any contrast, when accounting for the intervention period (-0.84 points on the HIT-6, 95% CI: -2.4 to +0.7 points).

Discussion: The NEXpro intervention had some effect on headache outcomes in office workers. The strongest effect had been found for the occurrence of headache, with an average reduction of 54% in reporting headaches in the last 4 weeks. As the other outcome variables showed, the strongest effect had been found during the first intervention period, while later on effects were smaller. Positive effects attenuated over time, even though participants were encouraged to continue their exercise programme. No effects were found for the HIT-6 questionnaire. Exercise and health promotion programmes have positive effects on headache, but they may need periodic refreshment to maintain the effects.

Introduction: Concussion has been associated with a range of subsystem impairments persisting beyond expected recovery time. Regardless of the nature of subsystem impairments, patients post-concussion often present with similar symptom profiles which can challenge management decisions. Cluster analyses may be used to identify patient subgroups with similar physical impairments post-concussion, as previously used to identify neck impairment subgroups in headache phenotypes. Subgrouping may aid in the development of more streamlined post-concussion assessment and management processes.
Aims: To identify how healthy individuals and those who present both asymptomatically and with persistent symptoms 4 to 26 weeks post-concussion group, based on their performances across cervical musculoskeletal and sensorimotor (cervical, vestibular, oculomotor, balance) assessments.
Methods: This secondary exploratory study utilised data from a previous cohort study, conducted in a Tertiary Teaching Hospital and University setting. Participants included 72 adults aged 18-60 years who were 4 to 26 weeks post a diagnosed concussion (35 asymptomatic and 37 symptomatic) and 39 healthy controls with no concussion history. Those with history of cervical spine or vestibular disorders were excluded. Results from measures of cervical musculoskeletal (flexor endurance, segmental joint dysfunction, kinematics) and sensorimotor function (joint position sense, smooth pursuit gain, ≥2 oculomotor indicators of dysfunction using video nystagmography, near point convergence, single-dual tandem walk test time difference, postural sway) were included in a Ward’s hierarchical agglomerative clustering analysis. Dissimilarities were calculated using Gower’s Distance and Agglomerative Coefficients (AC) examined strength of clustering structures.
Results: Four clusters (AC=0.96) including minimal or nil impairments (Cluster 1), vestibulo-ocular (Cluster 2), cervical spine musculoskeletal/ sensorimotor (Cluster 3), and multi-subsystem impairments (Cluster 4) were identified. Each cluster was characterised by either an absence or presence of clinically relevant assessment findings. Most healthy controls (71.8%), and a minority of symptomatic individuals (7.7%) grouped in Cluster 1, whereas the opposite occurred in Cluster 4 (43.2% symptomatic, 5.1% healthy controls). Asymptomatic individuals post-concussion were distributed across all four clusters.
Conclusion: Individuals post-concussion, including those not reporting ongoing symptoms, may present within physical impairment subgroups potentially underpinning persistent cervical and or sensorimotor dysfunction. Future research should aim to identify and manage these individuals to better inform decisions related to recovery and return to pre-injury activities post-concussion.

Background: Work ability is of utmost importance to investigate after treatment for individuals with chronic Whiplash-Associated Disorders (WAD). There is current lack of information about work related factors for individuals with WAD. More efficient, flexible ways of delivering neck-specific exercises with fewer visits are needed, especially for working individuals with WAD. In a randomized controlled trial, a neck-specific exercise programme in combination with four physiotherapy visits (NSEIT) was non-inferior to the same exercises performed at a physiotherapy clinic (NSE) twice a week for three months (24 visits). The results revealed sustained clinically important changes in disability and pain for approximately 50% of participants. However, work-related factors were not presented.
Purpose: To compare the effects of NSEIT to the same exercises performed at a physiotherapy clinic (NSE) regarding secondary outcomes of work-related factors.
Methods: This is a prospective, multicentre, randomized controlled trial regarding secondary outcomes of work-related factors in 140 individuals with chronic WAD grade 2 and 3, with 3- and 15-month follow-up. Protocol registered before data collection started: clinicaltrials.gov NCT03022812.
Results: There were no group differences between NSE and NSEIT in the Work Ability Scale or work subscales of the Neck Disability Index, Whiplash Disability Questionnaire or Fear Avoidance Beliefs Questionnaire (FABQ-work). Both groups improved in all work-related outcome measures, except for FABQ-work after the 3-month intervention and results were maintained at the 15-month follow-up.
Conclusions: Despite fewer physiotherapy visits for the NSEIT group, there were no group differences between NSEIT and NSE at 3- and 15 months follow-up. The improvements in most work-related measures at 3-month follow-up were maintained at the 15-month follow-up.
Implications: A neck-specific exercise program with an internet support improves work ability to the same extent as several visits to a physiotherapy clinic. In addition, the internet-support may provide individuals a more flexible way to adhere to the program. The results of the present study are promising, showing that NSEIT and NSE can improve work ability after a whiplash injury.

Background
Persistent pain and disability after whiplash injury constitutes a substantial personal and societal burden. A whiplash injury can alter neck muscle function, which remains years after the injury and may explain why symptoms such as persistent pain and disability occur. There is limited knowledge of dynamic neck muscle function in chronic whiplash-associated disorders (WAD), and to what extent altered muscle function can improve after rehabilitation. Methods to improve the diagnostic of neck muscle function in WAD is therefore of high priority.

Purpose:
The aims of the present study were to; compare dorsal mechanical neck muscle function in chronic WAD versus age- and sex matched healthy controls during dynamic neck rotation and evaluate neck muscle function in WAD after three months of neck-specific exercises.

Methods:
This study included 34 individuals with chronic WAD grade II and III, and 34 pain-free controls, matched for age and sex. The neck muscles were recorded by real-time ultrasound and were analyzed with speckle tracking analyses. Thirty individuals in the WAD group completed a 12-week neck-specific exercise program. Mixed design analyses of variance (ANOVA) were used to evaluate between group (WAD and controls) and within group (WAD, baseline to 3-moths follow-up) change in five neck muscles: Trapezius, Splenius, Semispinalis capitis, Semispinalis cervicis, and Multifidus. Effect sizes was displayed as partial Eta squared (ηp2); 0.01 small effect, 0.06 intermediate effect, and 0.14 large effect.

Results:
The results showed significant altered neck muscle function in the three deepest neck muscles (Semispinalis capitis, Semispinalis cervicis, Multifidus) in cervical rotation to the most painful side in WAD compared to controls (F=12.4, p < 0.001, ηp2=0.17). After three months of neck-specific exercises, the differences between the WAD and control groups were no longer significant (F= 2.7, p=0.10, ηp2=0.05), and the WAD group showed significant improvements over time (F=5.1, p=0.03, ηp2=0.16).

Conclusion(s):
Real-time ultrasound with speckle-tracking analyses could detect differences in the deepest neck muscles in WAD compared to controls. In addition, after three months of neck-specific exercises were deformation in these muscles improved to a similar deformation pattern as controls, and the significant baseline group differences ceased. Moreover, these promising results included those with longstanding neurological signs after whiplash injury, WAD grade III.

Implications: The non-invasive ultrasound method with speckle-tracking analyses can be used in the assessment and diagnosis of patients following whiplash trauma.

Background: Evidence suggests that manual therapy combined with therapeutic exercise is superior to routine physical therapy for neck pain. However, its underlying mechanisms remain unknown. Changes in structural brain following interventions may provide valuable insights into underlying mechanisms of chronic neck pain and treatment effectiveness.

Purposes: The primary aim was to investigate the effects of manual therapy combined with therapeutic exercise (MT+Exs) compared to routine physical therapy (RPT) on cortical thickness and volume in patients with chronic nonspecific neck pain (NSNP). The secondary objectives were to assess changes in clinical features, cervical range of motion (CROM) and cranio-cervical flexor (CCF) strength after the interventions.

Methods: This study was a single-blinded, randomized controlled trial. A total of 52 participants with chronic NSNP (> 3 months) were recruited. Participants were randomly allocated to either the MT+Exs group (n = 26) or RPT (n = 26) group as control in a 1:1 ratio. The MT+Exs group received cervical mobilization and specific cervical and scapular training for 10 weeks (2 visits/week). The RPT group received routine physical therapy (e.g., modalities and stretching exercise). The primary outcome was cortical thickness and volume of regions of interest (ROIs) including primary somatosensory cortex (S1), precuneus, insula, prefrontal cortex (PFC) and anterior cingulate cortex (ACC). The secondary outcomes were clinical features (neck pain intensity, disability and psychological symptoms), CROM in all directions and maximal CCF strength. All outcome measures were taken at baseline and post-intervention. The cortical thickness and volume were computed using FreeSurfer analysis and a general linear model.

Results: There was no loss to follow-up. Compared to baseline, the MT+Exs group showed decreased cortical thickness in the left and right S1, left and right precuneus and left PFC as well as increased cortical thickness in the left and right ACC at post-intervention (p < 0.05). The RPT group showed decreased cortical thickness in the left S1 and right precuneus at post-intervention (p < 0.05). After the 10-week interventions, the MT+Exs group showed increased cortical thickness in the left and right ACC compared to the RPT group (p < 0.05). There were no within- and between-group differences in cortical volume (p > 0.05). The secondary outcomes were improved in both groups at post-intervention (p < 0.05). The MT+Exs group had greater improvements in pain intensity, disability and CROM compared to the RPT group (p < 0.05). No adverse events were reported.

Conclusion: A 10-week intervention of manual therapy combined with exercise and routine physical therapy induced structural changes (thickness) in various pain-related regions of the brain in patients with chronic NSNP. A change in the ACC thickness was greater with manual therapy in combination with exercise than routine physical therapy. The results suggest that both interventions can influence neural plasticity in the brain regions related to pain modulation, with the effects varying according to the specific intervention.

Implications: Understanding changes in structural brain following interventions can further advance knowledge of pain mechanisms, potentially leading to the development of more effective treatment strategies to alleviate chronic NSNP.

Background
More than half of migraine patients experience motion sensitivity and report symptoms of kinetosis and postural instability. Given the high prevalence of neck pain in this population, sensorimotor integration impairments of cervical afferents could be related to these symptoms. However, this topic is relatively unexplored among patients with migraine.
 
Purpose
The aim of this cross-sectional study was to investigate the influence of head movements on motion sensitivity and its association with balance alterations.
 
Method
Patients with migraine (n= 15) and healthy controls (n=15) reported presence and severity of kinetosis symptoms during the modified Cervical Torsion Test (CTT) and the Head Neck Differentiation Test (HNDT) using a Visual Analog Scale (0-100) and the Simulator Sickness Questionnaire (SSQ). Furthermore, their quiet standing balance was assessed over a foam with eyes closed for 30 seconds and the the postural sway (area and total sway) was calculated.
 
Results
Patients with migraine (66.7%) experienced greater motion sensitivity especially during the neck components of the HNDT and CTT tests, and also more often than healthy controls (20%), (Chi2= 6.65, p=0.01). SSQ scores reflecting severity of symptoms were higher in migraine than in controls (U=56.0, p=0.004). SSQ scores correlated moderately and positively with balance total sway (r=0.54, p=0.020) and sway area (r=0.50, p=0.029).
 
Conclusion
The higher frequency of triggered symptoms in migraineurs during the neck components of the tests and its association with balance impairment provides a first indication of involvement of cervical afferences and dysfunctional sensorimotor processing among migraineurs.
 
Implications
The understanding of the susceptibility of migraineurs to cervical provoked symptoms could improve clinical decision making for physiotherapists considering the impact of neck dysfunction on vestibular symptoms and kinetosis in migraine patients. Future research is required to evaluate the potential of the CTT and HNDT as valuable diagnostic tools for evaluating the neck as a source of dizziness and motion sensitivity in this population.

Background
People with whiplash associated disorders (whiplash) have poor outcomes and those with poor outcomes contribute to the highest rehabilitation costs in many countries. In Australia, despite two decades of guideline development and implementation, gaps remain in the assessment of people at risk of poor outcome and providing care matched to risk profile. Many stakeholder groups assess risk based on personal opinion, their experience or simply guess. Clinical guidelines developed using robust methods will allow clinicians to make informed and accurate choices about assessment of prognosis for people with whiplash.

Purpose
This project aimed to develop new multi-disciplinary guidelines for both acute and chronic whiplash associated disorders by i) following a robust process recommended by the National Health and Medical Research Council (NHMRC) in Australia and ii) following the GRADE process to develop recommendations for prognosis. The multi-disciplinary process aimed to ensure key stakeholders likely to implement recommendations were involved from the commencement of the project.

Methods
Following the NHMRC guidelines, an 18 member multidisciplinary committee was convened comprising key stakeholders from clinical professions (e.g. Physiotherapy, General Practice, Physicians, Psychology, Chiropractic, Exercise Physiology), research experts, insurer, legal, government regulator and consumer representatives. A systematic review was performed to identify prospective longitudinal cohort studies or secondary analysis of randomised controlled trials that have assessed both prognostic tools and prognostic factors predicting outcome for people with acute and chronic whiplash. Inclusion criteria were based on the PICOTS (Population, Index Prognostic factor, Comparator prognostic factors, Outcome, Timing, Setting) criteria. Studies meeting these criteria were meta-analysed where possible. The GRADE “certainty of evidence” and “evidence to decision frameworks” were followed by the guideline committee to determine prognosis recommendations. Guidelines then underwent both public consultation and external review before submission to the NHMRC for endorsement.

Results
From 2417 titles screened, recommendations were made from 5 prognostic tool studies, 57 acute whiplash prognostic factor studies and 6 chronic whiplash prognostic factor studies. Two prognostic tools were recommended (WhipPredict and SF-Orebro) to identify those at risk of poor prognosis. Individual prognostic factors with strong recommendations to determine poor outcome in people with acute whiplash were symptom factors (initial pain intensity, initial neck related disability, number of painful body areas number of painful symptoms) and psychological factors (post-traumatic stress symptoms and expectations of recovery). For people with chronic whiplash similar symptom factors were conditionally recommended (initial neck pain intensity and neck disability) to identify those likely to have ongoing poor outcome. Factors that are not recommended to assess to determine prognosis include crash related, imaging and socio-demographic factors.

Conclusion(s):
Clinicians are primarily recommended to administer a prognostic tool early after injury to identify both those with a good (likely to recover well) and poor prognosis. Stratified care, where care is matched to the risk profile is then recommended to be chosen from the guideline treatment recommendations.

Background: The clinical criteria and grading system for nociplastic pain involves the presence of (1) chronic symptoms; (2) regional pain distribution, (3) predominantly non-nociceptive or neuropathic pain origin, and (4) clinical signs of pain hypersensitivity (i.e., mechanical hyperalgesia) in the pain region. People with chronic whiplash-associated disorders (WAD) may demonstrate features of nociplastic pain. One of the possible co-morbidities of nociplastic pain is increased light sensitivity, which shifts the nociplastic pain classification from possible to probable. Light sensitivity can be measured via the Pupillary Light Reflex (PLR). Light sensitivity has not previously been evaluated in chronic WAD. It is unknown if light sensitivity is a feature of chronic WAD and if it is associated with clinical measures of nociplastic pain.

Purpose: To determine: (1) there is a significant difference in PLR measures between a healthy cohort (HC) and people with chronic WAD, and (2) if clinical measures of nociplastic pain are correlated to PLR measures in both HC and WAD cohorts.

Methods: Asymptomatic people (HC) from the community and an age/sex-matched cohort with chronic WAD and nociplastic pain (Cervical and tibialis anterior PPTs were reduced by more than 2 standard errors of measurement from the HC = mechanical hyperalgesia) attending a multidisciplinary chronic pain centre were recruited for the study. Clinical measures of nociplastic pain were collected, inclusive of pain intensity, Central Sensitisation Inventory – CSI, Pressure Pain Thresholds – PPTs, Temporal Summation – TS and Conditioned Pain Modulation – CPM. Measures of PLR were collected using a validated iPhone app in a standardized room environment. Independent t-tests evaluated group differences and Pearson’s correlation analyses measured the relationship between clinical measures of nociplastic pain and PLR.

Results: Twenty-six HC (15 female; mean age = 41.2 ± 12.7 yrs) and 26 people with chronic WAD (15 female; 43.2 ± 12.8 yrs) of median [interquartile range] 21 [12, 31] months duration of symptoms and mean pain (SD) of 6.5 (± 1.4)/10 were enrolled in the study. Participants demonstrated elevated CSI, reduced local and distal PPTs (as per inclusion criteria), and facilitated TS when compared to the HC. There were no differences in CPM. Chronic WAD demonstrated significantly reduced maximum constriction amplitude and quicker time to return to 75% of resting pupil diameter. PLR measures were not correlated to measures of nociplastic pain in either the HC or chronic WAD cohorts.

Conclusion(s): The between-group differences in PLR support other research in chronic WAD demonstrating autonomic nervous system dysfunction; with altered pupil constriction amplitude suggestive of changes in parasympathetic, and increased responsiveness of pupil re-dilatation suggestive of altered sympathetic nervous system function. There was no relationship between PLR and clinical measures of nociplastic pain, suggesting that altered nociceptive input is not driving this aberrant response in chronic WAD. Other comorbidities are required to establish that chronic WAD is a probable nociplastic pain condition.

Implications: Clinical utility of PLR is not currently warranted until research establishes parameters associated with clinical manifestations. Further research is also warranted to evaluate autonomic nervous system in chronic WAD.