Neck Solutions

Cervicogenic headache

Cervicogenic headache

From: Pol Merkur Lekarski. 2008 Jun;24(144):549-51 Article in Polish

In 2004 cervicogenic headache (neck related headache) was introduced into ICD-10 classification.The reasons of cervicogenic headache are changes within bones, soft tissue and nervous structures of cervical spine section. The pain may spread to the neck, occipital area of skull, area of jaw and eyeballs, and arms. There are many theories trying to explain spreading of the pain outside the area innervated by C1, C2 and C3 cervical roots. Their common denominator is communication between fibres running in those roots and neurons of trigeminal nerve. Many authors describe a possibility of such connection through the jelly-like nucleus of the trigeminal nerve located in the back funiculi of spinal cord. In this mechanism, the pain conducted via occipital nerves may affect activity of neurons of the trigeminal nerve and influence areas innervated by the trigeminal nerve. In general case history and physical examination are sufficient to make a diagnosis. Additional radiological and imaging examinations support this diagnosis. According to some authors, the necessary condition to make a diagnosis of cervicogenic headache is finding the changes of spondylosis nature of the cervical spine section (neck arthritis or degenerative disc disease) in additional examinations. In doubtful cases, diagnostic blockade of greater occipital nerve, resulting in headache relief, supports finally a diagnosis. Any treatment includes pharmacotherapy, rehabilitation, psychotherapy and surgical methods. The purpose of the study is to view literature on cervicogenic headache which causes many diagnostic problems and hence makes it difficult to choose effective treatment.

Neck injury during whiplash increased with head turned postures

Head-turned postures increase the risk of cervical facet capsule injury during whiplash

From: Spine. 2008 Jul 1;33(15):1643-9

Injury to the cervical facet capsular ligaments is a potential mechanism for chronic neck pain after acute whiplash injury. Distending the facet capsule by injecting contrast media has produced whiplash like pain patterns in normal individuals, and anesthetic blocks have isolated the cervical facet joints as the source of pain in about half of a chronic whiplash population. More recently, in vivo animal models of facet capsule loading have shown that group III and IV afferents (thought to mediate pain) from the facet capsule have a graded electrical response to mechanical loading of the facet joint in the goat and have suggested that a capsular ligament strain threshold exists above which allodynia pain in response to a normally nonnoxious stimulus is produced. These data support a facet capsule based mechanism for whiplash injury, but do not establish whether human capsular ligaments are injured in the low speed rear end collisions to which many whiplash injuries are attributed.

Whiplash patients who had their head turned at impact have more severe and persistent symptoms than patients who were facing forward. These findings have prompted biomechanical studies using human cadaveric necks to investigate why a head turned posture increases injury potential. Dynamic rear impact tests of prerotated ligamentous spines (occiput-T1) produce increased neck flexibility (interpreted as injury) in extension, lateral bending and axial rotation. Though concentrated in the lower cervical spine, these injuries were not isolated to particular spinal ligaments. Detailed measurements of the strain field in the facet capsule have also shown that a head-turned posture generates higher capsular strains than a neutral head posture, but the quasi static loads applied during those tests were limited to pure neck flexion/extension moments and did not include the axial compression or posterior shear present during whiplash loading. Thus the question of how a head turned posture combined with multiaxial whiplash loads affects facet capsular ligament strain has yet to be answered.

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Sitting with ischial and back supports

Sitting with adjustable ischial and back supports: biomechanical changes

From: Spine. 2003 Jun 1;28(11):1113-21

Low back pain is acute or chronic pain involving the lumbosacral, buttock, and/or thigh. Discogenic low back pain is aggravated by the sitting position, which is necessary in many occupations and daily activities. About 100 million workdays are lost annually in the United States due to low back pain. Despite improved knowledge and health care resources for spinal pathology, chronic disability resulting from nonspecific low back pain is rising exponentially. Although the causes of discogenic low back pain are multifactorial and complex, sitting postures could increase stresses within the disc and contribute to disc degeneration and pain. Two major occupational risk factors are static muscle load and flexed curvature of the lumbar spine; both are involved in seated work tasks.

During sitting, the head, arm and trunk weight is carried mainly by the ischial tuberosities and surrounding tissues. High pressure at the tuberosities is closely associated with high load to the spine. A significant mechanical spine loading is associated with low back pain resulting from trunk muscle coactivation. Ischial and lower back interface pressure vary with different sitting postures and body positioning. Repositioning of the lumbar support to redistribute the interface pressure and load is essential in preventing low back pain associated with inappropriate sitting in a working environment. Therefore, a device that decreases the sitting pressure and load carried by the ischial tuberosity may decrease forces within the disc and associated degeneration and pain.

Physiologic lumbar lordosis in the standing position ranges from 40° to 60°, with the lordosis occurring mainly at S1-L5 and L4-L5, and with the sacral inclination ranging from 30° to 40°. Compared to standing or lying supine, sitting could cause the pelvis to rotate posteriorly, resulting in decreased sacral inclination and lumbar lordosis and increased forces at the discs. A number of investigators have reported interaction between low back pain and biomechanical changes such as decreased lumbar lordosis, malalignment of lumbar curvature, and narrowing of disc spaces. Williams et al reported that use of a lumbar roll that increased lumbar lordosis reduced low back pain, and the chair backrest also helps increase the lumbar lordosis and decrease intradiscal pressure.

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Incidence of shoulder and neck pain in a working population

Incidence of shoulder and neck pain in a working population: effect modification between mechanical and psychosocial exposures at work? Results from a one year follow up of the Malmö shoulder and neck study cohort

From: J Epidemiol Community Health. 2005 Sep;59(9):721-8

Work related musculoskeletal disorders and complaints constitute an important health problem in many industrialised countries, as they account for a large number of working days lost and considerable workers compensation and disability payments. For a long time, low back pain has been the dominant problem. However, pain from the shoulder and neck region now seems to occur more frequently. The prevalence of shoulder and neck symptoms is highest in the 45–65 year age bracket, as well as among women, manual workers, and certain ethnic groups.

However, its aetiology is still incompletely understood. Mechanical exposure at work and psychosocial conditions within and without the workplace, in addition to lifestyle and individual variables (age, previous symptoms, etc) are frequently discussed as causal factors in the literature.

Shoulder and neck symptoms have been linked to jobs with highly repetitive work, static work, and work above shoulder level. However, mechanical exposure explains only part of these complaints. The role of psychosocial factors in the workplace has therefore received increasing attention. On the job pressure, monotonous work, and a high perceived workload have also been associated with musculoskeletal symptoms just as much as working situations characterised by high psychological demands, low decision latitude, and low social support.

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Musculoskeletal discomfort at work predicts low back, neck and shoulder pain

Does musculoskeletal discomfort at work predict future musculoskeletal pain?

From: Ergonomics. 2008 May;51(5):637-48

The objective of this prospective cohort study was to evaluate if peak or cumulative musculoskeletal discomfort may predict future low back, neck or shoulder pain among symptom free workers. At baseline, discomfort per body region was rated on a 10 point scale six times during a working day. Questionnaires on pain were sent out three times during follow-up. Peak discomfort was defined as a discomfort level of 2 at least once during a day; cumulative discomfort was defined as the sum of discomfort during the day. Reference workers reported a rating of zero at each measurement.

Peak discomfort was a predictor of low back pain (relative risk (RR) 1.79), neck pain (RR 2.56), right or left shoulder pain (RR 1.91 and 1.90). Cumulative discomfort predicted neck pain (RR 2.35), right or left shoulder pain (RR 2.45 and 1.64). These results suggest that both peak and cumulative discomfort could predict future musculoskeletal pain.

Disability in subacute whiplash and the Neck Disability Index

Disability in subacute whiplash patients: Usefulness of the Neck Disability Index

From: Spine J. 2008 August ;33(18)630-635

Whiplash describes a process of hyperextension and hyperflexion of the cervical musculature that may result from motor vehicle collisions. The incidence of whiplash has been estimated to be of 1 case per 1000 habitants per year in Western societies, nevertheless available studies report conflicting rates. Symptoms associated with whiplash problems typically resolve in a relatively brief time (days or weeks), but chronic pain, and long-term disability may occur in 10% to 40% of the cases.

The prevention and treatment of chronic disabling pain in whiplash patients has shown to be elusive. On the one hand, predictive factors of chronic disabling problems in whiplash patients are far from being completely elucidated. Although one can hypothesize that factors from different levels (i.e., physiology, thoughts, feelings, and behavior) and units (i.e., individual, dyad, and context) of analysis play a role, very few and inconsistent findings are available. On the other hand, there is limited evidence about what is the most beneficial treatment for whom and under what circumstances. The use of many different outcome variables and assessment instruments may be responsible, in part at least, of the problems encountered in this area of research to compare results across studies and extract definitive conclusions.

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Intervertebral disc degeneration in a primate model

Intervertebral disc degeneration in a naturally occurring primate model: radiographic and biomechanical evidence

From: J Orthop Res. 2008 Sep;26(9):1283-8

Classic degenerative disc disease is a serious health problem worldwide, whose etiological basis mechanical stimulus, biochemical changes, or natural aging is poorly understood. Animal models are critical to the study of degenerative disc disease initiation and progression and for attempts to regulate, ameliorate, or eliminate it. The macaque represents a primate model with natural disc degeneration that might serve to advance the field; we aimed to provide radiographic (morphologic) and biomechanical evidence of natural disc degeneration in this model. A factorial study design was used to examine the relationship between the radiographic appearance of disc degeneration and its biomechanical consequences. Eighteen macaques of advanced age (22.3 +/- 0.9 years) had radiographs taken to assess the degree of thoracolumbar intervertebral disc degeneration using a standard atlas method. Each spine was harvested and dynamic biomechanical tests were performed. Advancing disc degeneration (degree of disc space narrowing and osteophytosis) was associated with increased stiffness, decreased energy absorption, and increased natural frequency of the intervertebral disc. These associations linking the dynamics of the intervertebral disc and its degree of degeneration are similar to those found in humans. Our results indicate the macaque model with morphologic and biomechanical efficacy could aid in understanding the progression of disc degeneration and in developing therapeutic strategies to prevent or inhibit its course.

Electromyography for assessment of pain in low back muscles

Electromyography for Assessment of Pain in Low Back Muscles

From: Phys Ther. 2008 Aug 8; [Epub ahead of print]

Pain is currently evaluated with “subjective” methods (eg, patient self-report). This study aimed to test whether fatigue indexes are able to accurately discriminate between subjects with and subjects without low back pain. Sixty subjects separated into 2 groups-a group with low back pain (n=30) and a group without low back pain (n=0)-participated in this study. Electromyographic (EMG) and force data were obtained during a muscle fatigue test. The same test was repeated to monitor recovery. Linear regression analysis was used to obtain fatigue indexes. Subjects with pain produced significantly lower force values than those without pain. The use of fatigue indexes and force values permitted accurate classification in 89.5% of cases. The results confirm that subjects with pain show early myoelectrical manifestations of muscle fatigue and that EMG can be a useful tool in the evaluation of low back pain.

Thoracic spine manipulation, electrotherapy and thermal program for acute mechanical neck pain

Inclusion of thoracic spine thrust manipulation into an electro-therapy/thermal program for the management of patients with acute mechanical neck pain

From: Man Ther. 2008 Aug 7; [Epub ahead of print]

Approximately 25% of all outpatient physical therapy visits consist of patients with symptoms involving the neck region. It has been found that nearly half of the individuals with neck pain will experience debilitating symptoms. Over a third of patients with neck pain will develop chronic symptoms lasting more than 6 months, and nearly a third who experience a first time onset of neck pain will continue to report continued healthcare utilization for their symptoms at a 10-year follow-up.

Physical therapists utilize a number of interventions in the management of neck pain including joint manipulation (non-thrust and thrust), exercises, massage, thermo-therapy or electrotherapy (American Physical Therapy Association, 2001). However, robust evidence to support the use of many of these therapeutic strategies for neck pain is lacking. The Philadelphia Panel Clinical Practice Guidelines concluded that many commonly used interventions for patients with neck pain lack sufficient evidence to justify their clinical use. Recently, evidence has begun to emerge for the use of manual procedures directed at the thoracic spine for patients with mechanical neck pain. Cleland et al. found that thoracic thrust manipulation results in immediate improvements in neck pain at rest as measured by the visual analogue scale, compared to patients receiving a placebo manipulation. Further, it has also been found that at short-term follow-up patients receiving thoracic manipulation exhibit superior outcomes to patients receiving non-thrust techniques.

The importance of investigating the effectiveness of thoracic spinal manipulation is necessary considering the fact that the thoracic spine is the region of the spine most often manipulated, despite the fact that more patients complain of neck pain. Further, decreased mobility in the thoracic spine has been shown to be related to the presence of neck pain symptoms, so it is possible that manipulation of the thoracic spine may alter the biomechanics of the cervical region and decrease mechanical stress. Finally, it has previously been identified that either cervical mobilization or manipulation induces an activation of descending inhibitory mechanisms; hence, thoracic spine thrust manipulations may also result in a reduction of neck symptoms.

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Behaviour graded activity program versus conventional exercise for chronic neck pain

Effectiveness of a behaviour graded activity program versus conventional exercise for chronic neck pain patients

From: Eur J Pain. 2008 Aug 7; [Epub ahead of print]

Chronic neck pain is a common complaint in the Netherlands with a point prevalence of 14.3%. Patients with chronic neck pain are often referred to physiotherapy and, nowadays, are mostly treated with exercise therapy. It is, however, unclear which type of exercise therapy is to be preferred. Therefore, this study evaluates the effectiveness of behaviour graded activity compared with conventional neck exercises for patients with chronic neck pain. Eligible patients with non-specific chronic neck were randomly allocated to either behaviour graded activity or conventional neck exercises. Primary treatment outcome is the patient’s global perceived effect concerning recovery from complaint and daily functioning. Outcome assessment was performed at baseline, and at 4, 9, 26, and 52 weeks after randomization. Effectiveness was examined with general estimating equations analyses. Baseline demographics and patient characteristics were well balanced between the two groups. Mean age was 45.7 years and the median duration of complaints was 60 months. The mean number of treatments was 6.6 in behaviour graded activity and 11.2 in conventional neck exercises.

No significant differences between treatments were found in their effectiveness of managing patients with chronic neck pain. In both behaviour graded activity and conventional neck exercises some patients reported recovery from complaints and daily function but the proportion of recovered patients did not exceed 50% during the 12-month follow-up period. Both groups showed clinically relevant improvements in physical secondary outcomes.