Neck Solutions

Internal disc disruption and axial back pain in the athlete

From: Phys Med Rehabil Clin N Am. 2000 Nov;11(4):837-65

Axial back pain is commonly encountered by the sports medicine physician and has a variety of potential pain generators. Internal disc disruption is an important diagnosis to consider, particularly if there is a history of spinal trauma. The pathogenesis of internal disc disruption is not definitively known, although related theories exist. The process may begin with a vertebral endplate fracture followed by an inflammatory degradation of the disc matrix. Annular tears extend from the nucleus pulposus to the periphery and nociceptive nerve endings grow into the inner annulus and become sensitized by the biochemical degradative products. This lowers the pain threshold for mechanical stimulation during normal loading of the lumbar disc. Athletes are at high risk for internal disc disruption because of the repetitive axial compressive and torsional forces required in many sports. Diagnostic evaluation includes a thorough history and physical examination, whereas MR imaging is the modality of greatest use. Acute internal disc disruption is a symptomatic annular tear that commonly responds to aggressive conservative care delineated in the five-stage rehabilitation program. Chronic internal disc disruption may be episodic or constant. Pressure-controlled, provocative discography should be considered for athletes with chronic constant lumbar discogenic pain. Minimally invasive treatment options, such as IDET, may prove useful for a subset of patients with discographically proven internal disc disruption. Further clinical and basic science research is needed. Spinal fusion rarely is indicated for the athlete with internal disc disruption and no evidence of instability. Technological advances should continue to contribute to the arsenal of future treatments for internal disc disruption.

Pharmacological enhancement of disc diffusion and differentiation of healthy, ageing and degenerated discs : Results from in-vivo serial post-contrast MRI studies in 365 human lumbar discs

From: Eur Spine J. 2008 May;17(5):626-43

Degenerative disc disease is still a poorly understood phenomenon because of the lack of availability of precise definition of healthy, ageing and degenerated discs. Decreased nutrition is the final common pathway for degenerative disc disease and the status of the endplate plays a crucial role in controlling the extent of diffusion, which is the only source of nutrition. The vascular channels in the subchondral plate have muscarinic recptors but the possibility of enhancing diffusion pharmacologically by dilation of these vessels has not been probed. Although it is well accepted that endplate damage will affect diffusion and thereby nutrition, there is no described method to quantify the extent of endplate damage. Precise definitions with an objective method of differentiating healthy, ageing and degenerated discs on the basis of anatomical integrity of the disc and physiological basis of altered nutrition will be useful. This information is an urgent necessity for better understanding of degenerative disc disease and also strategizing prevention and treatment.

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Moderate alcohol consumption may decrease risk of intervertebral disc degeneration

From: Med Hypotheses. 2008 Jul 14; [Epub ahead of print]

Intervertebral disc degeneration is a serious health problem worldwide. Unfortunately, efforts to control intervertebral disc degeneration are largely unsuccessful. It is therefore important to get better understanding of risks. Various evidences indicate that moderate alcohol consumption has protective effect on intervertebral disc degeneration. Here, we review the clinical evidence on alcohol consumption and intervertebral disc degeneration, and propose a possible mechanism. There is increasing evidence indicating that moderate alcohol consumption keeps the feeding arteries smooth. Furthermore, strong evidence indicates that some inflammatory factors are very important in the pathophysiology of intervertebral disc degeneration, while moderate alcohol consumption can decrease the expression of these inflammatory factors. Moreover, experimental studies show that alcohol exposure could increase the type II collagen and aggrecan, the major constituents of nucleus pulposus matrix. Given the above background, we hypothesize that moderate alcohol consumption may reduce the risk of intervertebral disc degeneration.

Myofascial pain syndromes in the maxillofacial area: a common but underdiagnosed cause of head and neck pain

From: Int J Oral Maxillofac Surg. 2008 Jul 14; [Epub ahead of print]

Myofascial pain syndromes are a large group of muscular disorders, characterized by the presence of hypersensitive spots called trigger points. The maxillofacial region is a high-frequency area for developing trigger points. The aim of this paper was to review and summarize the most important methods of management of myofascial pain syndromes in head and neck pain. A literature review was carried out from Medline and database sources. A range of study types were selected for analysis. Trigger point formation and activity result in a reverberating circuit of sustained neural activity. Central mechanisms, primarily associated with psychosocial factors, lead to chronicity. Other synergistic factors are metabolic disorders, nutritional imbalances and regional anatomic disorders. A detailed history and physical examination are important for proper diagnosis. The aim of Myofascial pain syndrome management is pain relief and restoration of full muscle function. Treatment may require enhancing central inhibition, using pharmacological and/or behavioural techniques, and reducing peripheral inputs, using physical therapy. There are various effective methods of inactivation of trigger points. Recognition and reduction of synergistic factors may be important. Myofascial pain syndromes have a very high prevalence in the general population, despite low awareness among physicians, affecting patients’ quality of life. There is a need for interdisciplinary teams of health professionals to achieve proper diagnosis, management and sustainable outcomes.

Consciously postural sway and cervical vertigo after whiplash injury

From: Spine. 2008 Jul 15;33(16):E539-42.

Cross-sectional study of whiplash injury patients with vertigo and healthy volunteers consciously pretending to have postural sway as in malingering. The aim of this study was to evaluate the postural sway in malingerers by posturography. Malingering is not a problem in the majority of cases with whiplash injury and diagnosis should be made carefully. However, some patients with whiplash injury might exaggerate their symptoms or be malingerers because of the potential gain associated with insurance claims. We designed a diagnostic study to screen putative malingerers.

Subjects were 20 healthy volunteers who were tested under standing condition (normal group), consciously swaying the body under standing condition like malingerers (pseudomalingering group) and 32 patients who complained of neck pain with vertigo or dizziness after whiplash injury with whiplash associated disorders grade I and II . The movement of the center of pressure (COP) was measured using a force platform to quantify postural sway. Static posturography was performed under open and closed eyes. We analyzed (1) total envelop area per unit of time, (2) shifting length per second, (3) sway pattern, and (4) Romberg rate representing total shifting length under eyes-closed/eyes-open.

In open eyes condition, the values of envelop area and length per second were significant higher under pseudomalingering than both of the control and whiplash associated disorders groups. The Romberg rate was 1.30 +/- 0.17, 1.13 +/- 0.19, and 1.83 +/- 0.94 in control, pseudomalingering, and whiplash associated disorders group, respectively, and was less than 1.0 in 45% of pseudomalingering. There were significant differences in the envelop area, length per second, and Romberg rate between pseudomalingering and the other 2 groups.

Results suggest that compared with normal subjects and whiplash associated disorder patients, malingerers are more likely to exhibit a wide envelop area, a long sway length per second, and a low Romberg rate. Malingering must be diagnosed carefully and posturography could be a helpful supplementary tool for differentiating whiplash associated vertigo from malingering.

Biomechanical Implications of Degenerative Joint Disease in the Apophyseal Joints of Human Thoracic and Lumbar Vertebrae

From: Am J of Physical Anthrop. 136:318–326 (2008) The extent to which degenerative joint disease in bone may be seen as an indicator of mechanical or occupational stress has long been a focus of debate within osteoarchaeology. While some studies of paleopathology continue to use degenerative joint disease as a predictor of specific activity patterns, most urge caution. Clinical studies have failed to demonstrate a simple relationship between degenerative joint disease and specific patterns of movement or activity. Certain aspects of degenerative joint disease appear to be related to age, whereas others appear to be related to sex, genetic inheritance, or body weight. degenerative joint disease is probably best thought of as resulting from a combination of ‘‘systemic’’ risk factors (which can lead to degenerative changes to many joints within an individual) and localized factors which may be more closely related to the mechanical loading experienced at a particular joint. An additional complication is that skeletal tissues are able to strengthen in response to mechanical loading which does not damage them, so that moderate loading appears to be better for the joints than either low or high loading. Not surprisingly, this complexity has tended to discourage consideration of the biomechanical implications of degenerative joint disease, even where the presence and pattern of such pathology is well documented.

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Randomised Clinical Trial for Primary Care Patients With Neck Pain: Manual Therapy Versus Electrical Stimulation

From: Atencion Primaria. 2008 Jul 1;40(7):337-343. [Article in Spanish]

To compare the effectiveness of manual therapy versus transcutaneous electrical nervous stimulation (TENS) in reducing the intensity of pain in patients with subacute or chronic neck pain attended at primary care physiotherapy units. Randomised clinical trial. Thirteen primary care physiotherapy units in 4 health districts of the Community of Madrid, Spain. Ninety patients with subacute or chronic neck pain attended. At random, 47 patients were allocated to manual therapy treatment and 43 to TENS. Social and demographic characteristics and prognosis variables in the intervention groups were measured. Intensity of neck pain before and after intervention was calculated by mean values on the analogue visual scale (present moment, average and worst pain of the last 2 weeks). Side-effects were also measured.

Difference between before-and-after pain was 21.83 mm for the group treated with Transcutaneous electrical nervous stimulation and 22.87 mm for manual therapy. The difference in averages on comparing the 2 procedures for improvement was 1.04. TENS and manual therapy significantly reduce patients’ perceived intensity of neck pain, although there were no differences between the 2 groups.There are no conclusive results for the alternative physiotherapy treatments that determine a clear strategy of intervention for neck pain.

The influence of neck pain on balance and gait parameters in community-dwelling elders

From: Man Ther. Volume 13, Issue 4, Pages 317-324 (August 2008)

Neck pain has been shown to be associated with balance disturbances. Balance and gait speed are also known to decline with ageing. The aim of this study was to determine whether the presence of neck pain was associated with a decline in postural stability and gait speed over and above what is expected with normal ageing. Twenty female subjects with idiopathic neck pain and 20 healthy female controls aged between 65 and 82 years were studied. Subjects performed balance tests on a computerised force plate under conditions of eyes open, eyes closed on firm and soft surfaces in comfortable and narrow stance. Sway energy and root mean square (RMS) amplitude of sway were measured. Subjects also undertook a Timed Ten Metre Walk Test, with and without head turning.

Age-related functional decline in the motor and sensory systems may affect balance function. Balance and postural control have been shown to decline with age and the role of factors such as vestibular function, motor control of back and pelvic musculature and muscle strength has been investigated in elderly people.

Musculoskeletal conditions, and specifically neck pain in this instance, might also contribute to balance deficits in the elderly. Neck pain is not uncommon in this age group. March et al. documented a neck pain prevalence of 40.5% in elderly women and 36.1% in elderly men living independently in the community. Cervical afferent input is an important contributor to balance and balance disturbances have been documented in young and middle aged individuals with neck pain of both insidious and traumatic onset. Subsequent improvements in balance have been demonstrated following localised treatment to the cervical spine.

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MRI analysis of the size and shape of the oropharynx in chronic whiplash

From: Otolaryngol Head Neck Surg. 2008 Jun;138(6):747-51

To quantify differences in the size/shape of the oropharynx between female subjects with whiplash and controls. A total of 113 subjects (79 whiplash, 34 controls) were included. T1-weighted MRI was used to measure 1) cross-sectional area and 2) shape ratios for the oropharynx. Reliability data were established. Whiplash subjects had significantly smaller oropharynx and shape ratios compared with healthy controls. Self-reported levels of pain and disability and duration of symptoms were not associated with size and shape of the oropharynx in whiplash subjects. Age and BMI did influence the size and shape of the oropharynx in the whiplash subjects, but only 20 to 30 percent of the variance could be explained by these factors. Significant difference in the size and shape of the oropharynx was noted in subjects with chronic whiplash compared with controls. Future studies are required to investigate the relationships between oropharynx morphometry and symptoms in patients with chronic whiplash.

Balneotherapy in elderly patients: effect on pain from degenerative knee and spine conditions and on quality of life

From: Isr Med Assoc J. 2008 May;10(5):365-9

Balneotherapy is an established treatment modality for musculoskeletal disease, but few studies have examined the efficacy of spa therapy in elderly patients with degenerative spine and joint diseases. To assess the effects of balneotherapy on chronic musculoskeletal pain, functional capacity, and quality of life in elderly patients with osteoarthritis of the knee or with chronic low back pain. The 81 patients in the study group underwent a 1 day course of 30 minute daily baths in mineral water. Changes were evaluated in the following parameters: pain intensity, functional capacity, quality of life, use of non-steroidal anti-inflammatory or analgesic drugs, subjective disease severity perceived by the patients, investigator-rated disease severity, and severity of pain perceived by the patients. We analyzed the results of 76 subjects as 5 did not complete the study.

Compared to baseline, all monitored parameters were significantly improved by balneotherapy in both investigated groups. Moreover, the favorable effect was prolonged for 3 months after treatment. This study showed that balneotherapy is an effective treatment modality in elderly patients with osteoarthritis of the knee or with chronic low back pain, and its benefits last for at least 3 months after treatment.