Neck Solutions

Shoulder pain in whiplash neck injury

Subacromial Impingement in patients with whiplash injury to the cervical spine

From: Journal of Orthopedic Surgery. 2008 Jun 27;3(1):25 [Epub ahead of print]

Impingement syndrome and shoulder pain have been reported to occur in a proportion of patients following whiplash injuries to the neck. In this study they aim to examine these findings to establish the association between subacromial impingement and whiplash injuries to the cervical spine. They examined 220 patients who had presented to the senior author for a medico-legal report following a whiplash injury to the neck. All patients were assessed for clinical evidence of subacromial impingement. 56/220 patients (26%) had developed shoulder pain following the injury; of these, 11/220 (5%) had clinical evidence of impingement syndrome. Only 3/11 patients (27%) had the diagnosis made prior to evaluation for their medico-legal report. In the majority, other clinicians had overlooked the diagnosis. The seatbelt shoulder was involved in 83% of cases.

After a neck injury a significant proportion of patients present with shoulder pain, some of whom have treatable shoulder pathology such as impingement syndrome. The diagnosis is, however, frequently overlooked and shoulder pain is attributed to pain radiating from the neck resulting in long delays before treatment. It is important that this is appreciated and patients are specifically examined for signs of subacromial impingement after whiplash injuries to the neck. Direct seatbelt trauma to the shoulder is one possible explanation for its aetiology.

Pain associated with backpacks in children

Asymmetric Loads and Pain Associated With Backpack Carrying by Children

From: J Pediatr Orthop. 2008 July/August;28(5):512-517

Shoulder and back pain in school children is associated with wearing heavy backpacks. Such pain may be attributed to the magnitude of the backpack load and the manner by which children distribute the load over their shoulders and back. The purpose of this study is to quantify the pressures under backpack straps of children while they carried a typical range of loads during varying conditions.

Ten healthy children (aged, 12-14 years) wore a backpack loaded at 10%, 20%, and 30% body weight. Backpacks were carried under 2 conditions, low on back or high on back. Pressure sensors (0.1 mm thick) measured pressures beneath the shoulder straps.

When walking with the backpack straps over both shoulders, contact pressures were significantly greater in the low-back condition than in the high-back condition (P = 0.004). In addition, when children carried the backpack in the low-back condition, mean pressures (+/-SE) over the right shoulder were as follows: 98 +/- 31, 153 +/- 48, and 170 +/- 54 mm Hg at 10%, 20%, and 30% body weight, respectively, which were significantly higher than those over the left shoulder (46 +/- 14, 92 +/- 29, and 90 +/- 29 mm Hg, respectively). Perceived pain with the backpack over 1 shoulder was significantly greater than that for donning with both shoulders in the low back condition.

Pressures at 10%, 20%, and 30% body weight loads on the right or left shoulder, during low back or high back conditions, are higher than the pressure thresholds (approximately 30 mm Hg) to occlude skin blood flow. Furthermore, asymmetric and high pressures exerted for extended periods of time may help explain the shoulder and back pain attributed to backpacks. Ergonomic Backpacks are clinically proven to reduce backpack stress and are important for the prevention of back, neck and shoulder pain in children.

General practitioner prediction of whiplash neck impairment

Can long term impairment in general practitioner whiplash patients be predicted using screening and patient-reported outcomes?

From: International Journal of Rehabilitation Research. 2008 Mar;31(1):79-80

The objective of this prospective pilot study was to investigate the predictors of outcome at 6 months for whiplash associated disorder in a general practitioner primary care population. Psychosocial screening questionnaires, patient-reported outcomes of neck functional impairment, demographic and accident-specific data have been indicated as predictive of future recovery status and treatment requirements. Participants (n=30, age=37+/-14 years, 77% females) from eight general practitioners were initially screened with a modified Orebro Musculoskeletal Pain Questionnaire, and had recovery status monitored and classified for 6 months using both patient-reported outcomes, quantitatively (Neck Disability Index) and qualitatively (patient status self-classification). Analysis at two separate cutoff levels showed 30% of whiplash participants nonrecovered and 17% with moderate/severe impairment. Nonrecovery whiplash status and increased treatment was predicted by a 109-point screening score cutoff while moderate/severe impairment was predicted by including the presence of neck rotation at impact. Initial cervical functional impairment status measured with the Neck Disability Index was sensitive but not specific for prediction. A larger whiplash population study investigating these protocols is warranted.

Association of low back pain with neck pain

Associations of low back pain with neck pain A study of industrial employees with 5, 10, and 28 year follow-ups

From: Eur J Pain. 2008 Jun 19; [Epub ahead of print]

Low back pain and neck pain are common among the adult population but relatively few reports exist on the associations between these. We examined cross-sectional and prospective relationships of low back pain with neck pain in an employee cohort studied repeatedly over 28 years. Locally perceived pain was studied separately from pain with a radiating component. At baseline, adjusted for age, gender, and occupational class, the prevalence ratio of local neck pain for those with local low back pain was 1.93, and for those with radiating low back pain 2.16, while the prevalence ratio of radiating neck pain for those with local low back pain was 1.51 and for those with radiating low back pain 3.24. These associations remained stable at the 5, 10, and 28 year follow-ups. Both local and radiating low back pain at baseline predicted new cases of radiating neck pain at the 5 and 10 year follow-ups, but not at the 28 year follow-up. In analyses stratified by gender, both the cross-sectional and prospective associations were more pronounced in men. The study showed a clear association of low back pain with neck pain that persisted on a similar level irrespective of the aging of the cohort. Particularly, radiating low back pain was associated with radiating neck pain. The prospective associations of low back pain at baseline with new reports of radiating neck pain decreased as the length of follow-up increased.

Motor control patterns in whiplash and chronic neck pain

Altered motor control patterns in whiplash and chronic neck pain

From: BMC Musculoskelet Disord. 2008 Jun 20;9(1):90 [Epub ahead of print]

Whiplash associated disorders have been studied mainly in comparison to asymptomatic subjects and it remains controversial whether whiplash represent a diagnostic entity different from chronic neck pain. whiplash patients are separated from chronic neck pain merely on the history of trauma. The trauma designation is however not reflected in structural injuries of the cervical spine or the cerebrum. Consequently, somatosensory and motor deficits have gained research attention. There are consistent findings of hypersensitivity and widespread pain in whiplash compared to healthy subjects, and when comparing whiplash patients to chronic neck pain patients. While this points to centrally mediated somatosensory alterations in whiplash, it is not clear whether motor areas are also affected. If such changes exist, altered motor control as well as kinaesthetic change should be present in whiplash, which would also provide important information for clinicians.

There is conflicting evidence for presence of kinaesthetic change in whiplash patients, as measured by head repositioning or joint position error in comparison to healthy controls, and the reported repositioning errors are generally small. The smooth pursuit eye movement test, believed to reflect cervical afferent dysfunction, has also shown inconsistent results.

There is consistent documentation for reduced standing balance and increased sway in whiplash patients compared to healthy subjects. Small differences, and only for difficult balance tasks, have been found between whiplash and non-traumatic neck pain patients. Less attention has been given to local motor control in the neck. Proprioceptive information from the neck greatly influence head and trunk position sense and motor control and mechanisms controlling head motion may be different from those that control the trunk. whiplash patients present with reduced cervical range of motion (neck range of motion) relative to asymptomatic individuals, but they also show increased variability in neck range of motion. These tests may however be affected by motivational factors. For trajectory head movement patterns whiplash patients showed greater variation between days than asymptomatic controls. More jerky movement patterns were found in whiplash and chronic neck pain patients compared to healthy subjects, but there were no differences between the two pain groups. Although the latter two studies address relevant motor control issues, they were both small and neither could provide evidence for a difference between whiplash and chronic non-traumatic neck pain. In fact, of the above studies on postural control only two included non-traumatic chronic neck pain patients in addition to whiplash and healthy subjects. In other words, the other studies were not designed to reveal whether postural control deficits are related to the trauma or just long-standing pain. If whiplash patients are distinguished by altered motor control strategies, their movement patterns should be different from that seen in both nontraumatic neck pain patients and in healthy controls.

Continue reading Motor control patterns in whiplash and chronic neck pain…

Clinical course and prognostic factors in acute neck pain

Clinical Course and Prognostic Factors in Acute Neck Pain: An Inception Cohort Study in General Practice

From: Pain Med. 2008 Jun 18; [Epub ahead of print]

To describe the natural course of patients with acute neck pain presenting in general practice and to identify prognostic factors for recovery and sick leave. Questionnaires were collected at baseline and after 6, 12, 26, and 52 weeks. Days of sick leave were dichotomized into two groups: below and above 7 days of sick leave. Logistic regression was used to identify prognostic factors for recovery and sick leave. Patients. Consecutive patients with nonspecific neck pain lasting no longer than 6 weeks were invited to participate.

One hundred eighty-seven patients were included and 138 (74%) provided follow-up data. After 1 year, 76% of the patients stated to be fully recovered or much improved, although 47% reported to have ongoing neck pain. Almost half of the patients on sick leave at baseline returned to work within 7 days. Multivariate analysis showed that the highest association with recovery was the advice of the general practitioner “to wait and see”. For sick leave, referral by the general practitioner, for physical therapy or to a medical specialist, showed the highest association.

Acute neck pain had a good prognosis for the majority of patients, but still a relatively high proportion of patients reported neck pain after 1-year follow-up. The advice given by the general practitioner “to wait and see” was associated with recovery, and “referral” was associated with prolonged sick leave.

Chiropractic and pain clinic management for chronic low back pain

A comparison between chiropractic management and pain clinic management for chronic low back pain in a national health service outpatient clinic

From: J Altern Complement Med. 2008 Jun;14(5):465-73

To compare outcomes in perception of pain and disability for a group of patients suffering with chronic low back pain when managed in a hospital by either a regional pain clinic or a chiropractor. Design: The study was a pragmatic, randomized, controlled trial. The trial was performed at a National Health Service hospital outpatient clinic (pain clinic) in the United Kingdom. Subjects and interventions: Patients with chronic low back pain (i.e., symptom duration of >12 weeks) referred to a regional pain clinic (outpatient hospital clinic) were assessed and randomized to either chiropractic or pain-clinic management for a period of 8 weeks. The study was pragmatic, allowing for normal treatment protocols to be used. Treatment was administered in an National Health Service hospital setting. Outcome measures: The Roland-Morris Disability Questionnaire (RMDQ) and Numerical Rating Scale were used to assess changes in perceived disability and pain. Mean values at weeks 0, 2, 4, 6, and 8 were calculated. The mean differences between week 0 and week 8 were compared across the two treatment groups using Student’s t-tests. Ninety-five percent (95%) confidence intervals (CIs) for the differences between groups were calculated.

Randomization placed 12 patients in the pain clinic and 18 in the chiropractic group, of which 11 and 16, respectively, completed the trial. At 8 weeks, the mean improvement in RMDQ was 5.5 points greater for the chiropractic group (decrease in disability by 5.9) than for the pain-clinic group (0.36) (95% CI 2.0 points to 9.0 points; p = 0.004). Reduction in mean pain intensity at week 8 was 1.8 points greater for the chiropractic group than for the pain-clinic group (p = 0.023).

This study suggests that chiropractic management administered in an National Health Service setting may be effective for reducing levels of disability and perceived pain during the period of treatment for a subpopulation of patients with chronic low back pain.

Physical and psychological aspects of whiplash

Physical and psychological aspects of whiplash: Important considerations for primary care assessment

From: Manual Therapy. Volume 13, Issue 2, Pages 93-102 (April 2008)

Whiplash is a heterogenous and in many, a complex condition involving both physical and psychological factors. Primary care practitioners are often the first healthcare contact for individuals with a whiplash injury and as such play an important role in gauging prognosis as well as providing appropriate management for whiplash injured patients. It is imperative that factors associated with poor outcome are recognized and managed in the primary care environment at the crucial early acute stage post injury. This paper outlines the heterogeneity of the whiplash condition in terms of both physical (particularly the sensory presentation) and psychological characteristics and the relationships between these features. The clinical assessment of these factors will be explored as well as direction for appropriate early interventions. An early co-ordinated inter-professional management approach, particularly in patients with a complex clinical presentation involving central hyperexcitability and symptoms of posttraumatic stress will be required.

The development of persistent pain and other symptoms following whiplash injury during a motor vehicle crash is common. Whilst it has generally been stated that only a minority of injured individuals will make the transition to chronic pain and disability, recent Australian data indicate that the prognosis may not be so favourable. In these studies approximately 60% of people continued to report pain and associated disability 6 months and 2 years after the original motor vehicle crash. Whiplash is a significant public health problem with most of the social and financial burden arising from those who develop chronic pain and disability.

Whiplash is a heterogenous condition. The presence of certain physical and psychological characteristics (hyperalgesia, movement loss, posttraumatic stress symptoms, moderate/severe levels of pain and disability) demonstrates a complex clinical picture in some. This clinical presentation reflects multifaceted mechanisms underlying whiplash pain, including augmented central pain processing mechanisms in association with posttraumatic stress. The early presence of these factors is predictive of poor functional recovery from the injury. This suggests that early intervention comprising management options to address these factors may be necessary in order to prevent the transition to chronic pain and disability in ‘at risk’ patients.

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Gender differences in lumbopelvic movement with low back pain

Gender-related differences in prevalence of lumbopelvic region movement impairments in people with low back pain

From: J Orthop Sports Phys Ther. 2007 Dec;37(12):744-53. Epub 2007 Aug 29

Cross-sectional, secondary analysisto to examine potential gender differences in prevalence of lumbopelvic region movement impairments during clinical tests in a sample of people with low back pain. A number of studies have identified factors contributing to differences between men and women in prevalence of lower extremity injuries. Few studies have examined potential gender differences in impairments of people with low back pain. Eighty-four males and 86 females (mean +/- SD age, 41.5 +/- 13.3 years) with low back pain participated in a standardized examination. Responses from 7 movement tests that examine early lumbopelvic movement were analyzed using chi-square statistics. A greater proportion of men than women displayed early lumbopelvic movement during the majority of limb movements (3/4) and movements potentially affected by limb tissue stiffness (2/2) (P<.05). There were no differences in the proportions of men and women displaying early lumbopelvic movement during a movement presumed to not be affected by limb tissue stiffness (P>.05). Similar results were obtained when analyzing only the subsets of subjects who reported an increase in symptoms with a specific test. Results provide data to suggest men and women with low back pain may move differently in the lumbopelvic region during clinical tests of limb movements and movements potentially affected by limb tissue stiffness. Recognition of gender differences in prevalence of movement impairments is important for improving examination and intervention of people with low back pain.

Isometric muscle endurance tests in postural neck pain

Reliability of isometric muscle endurance tests in subjects with postural neck pain

From: J Manipulative Physiol Ther. 2008 Jun;31(5):348-54

The purpose of this study was to determine the reliability of 3 isometric muscle endurance tests in subjects with postural neck pain. Twenty-one subjects with chronic postural neck pain performed 3 submaximal muscle tests twice on the first occasion and once at the second session 3 days later. The tests examined isometric neck flexion, neck extension, and scapular muscle endurance. Reliability was excellent for the neck flexor test (intraclass correlation coefficient [ICC] = 0 93), moderate for the scapular test (ICC = 0.67), and good for the neck extensor test (ICC = 0 88). The standard error of measure for the tests was 6.4, 10.9, and 25.9 seconds, respectively. The minimum change required to represent real change in muscle endurance was 17.8 seconds for the neck flexor test, 30.1 seconds for the scapular test, and 71.3 seconds for the neck extensor test. This study showed the reliability of 3 cervical spine and shoulder girdle submaximal muscle endurance tests in patients with postural neck pain.