Neck Solutions

Are Children’s Backpack Weight Limits Enough?: A Critical Review of the Relevant Literature

From: Spine:Volume 29(19)1 October 2004pp 2184-2190

Back pain is a widespread musculoskeletal condition in the adult population. This problem has stretched into the younger age groups and has become a condition often experienced by adolescents. The overall lifetime prevalence of low back pain in children has been reported as high as 65%.1 Other lifetime prevalence reports in children (less than 18 years) are more modest and are reported between 30% and 50%. Although the debate continues, some researchers hypothesize that use of heavy backpacks may contribute to the high reports of back pain in children. This hypothesis has led to recommended load limits of 10% to 15% of a child’s body weight by many health professional associations. Although these weight limits have been recommended in several states or countries, controversy continues to exist in the literature about the effects of backpack weight on back pain in children. The purpose of this review is to evaluate the literature that has contributed to the recommended weight limits for children’s backpacks. The current use of backpacks by children, injuries related to backpack use, the physiologic and biomechanical findings that were used to develop the recommended weight limits, and the need for research into children’s backpack design will be discussed.

Studies indicate that the incidence of backpack use by school children in the developed world is at least 90%. The weight carried by students varies by region and day of the week. Although the average loads vary greatly between studies, the majority of reports indicate that the loads carried by students are greater than the recommended limits. A study found that the average daily load of Italian students over a week ranged from 22.0% body weight to 27.5% body weight with one student who carried 46.2% body weight. In this group, 34.8% carried more than 30% of their body weight. Other studies report more modest loads ranging from 10.3% body weight to 20% body weight. Although these values are less extreme, the majority of students surveyed are still above the recommended limits. Only two studies were found where the mean load was less than 10% body weight.

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Fatty infiltrate in the cervical extensor muscles is not a feature of chronic, insidious onset neck pain

From: Clin Radiol. 2008 Jun;63(6):681-7. Epub 2008 Jan 31

To investigate the presence of fatty infiltrate in the cervical extensor musculature in patients with insidious-onset neck pain to better understand the possible pathophysiology underlying such changes in chronic whiplash associated disorders. A sample of convenience of 23 women with persistent insidious onset neck pain (mean age 29.2+/-6.9 years) was recruited for the study. Magnetic resonance imaging (MRI) was used to quantify fatty infiltration in the cervical extensor musculature. Quantitative Sensory Testing (QST; pressure and thermal pain thresholds) was performed as sensory features are present in chronic whiplash. Self-reported pain and disability, as well as psychological distress, were measured using the Neck Disability Index and the General Health Questionnaire-28 (GHQ-28), respectively. Measures were compared with those of a previous dataset of chronic whiplash patients (n=79, mean age 29.7+/-7.8 years). Using a classification tree, insidious onset neck pain was clearly identified from whiplash, based on the presence of MRI fatty infiltrate in the cervical extensor musculature (0/102 individuals) and altered temperature thresholds (cold; 3/102 individuals).

Fatty infiltrates in the cervical extensor musculature and widespread hyperalgesia were not features of the insidious onset neck pain group in this study; whereas these features have been identified in patients with chronic whiplash associated disorders. This novel finding may enable a better understanding of the underlying pathophysiological processes in patients with chronic whiplash.

Is it time for a population health approach to neck pain?

From: J Manipulative Physiol Ther. 2008 Jul-Aug;31(6):442-6

Neck pain and its associated disorders cause significant health burden in the general population and after road traffic and occupational injury. Individual level health care treatments have been well studied, but population health approaches to this problem have not. In this study they used a best evidence synthesis to examine population level approaches to the prevention and control of neck pain and its associated disorders.

The systematic review examined studies published between 1980 and 2006 that addressed the incidence, prevalence, risk factors, prevention, cost, assessment and classification, interventions, and course and prognostic factors for neck pain and its associated disorders. Citations were screened for relevance, scientifically reviewed, and synthesized. Valid studies addressing public policies or population level approaches to the prevention and control of neck pain and its associated disorders were identified and used in the evidence synthesis.

Only 8 of the 552 scientifically admissible studies were considered relevant to a public or population health approach to preventing and controlling the burden of neck pain and its associated disorders. For whiplash associated disorders, active head restraints and seat backs were protective in rear end collisions; insurance policies affected the incidence and recovery; government funding of multidisciplinary rehabilitation programs did not benefit recovery; and early intensive health care delayed recovery. In the workplace, 2 randomized trials failed to show any preventive effect for ergonomic interventions or physical training and stress management. One study documented the societal cost of neck pain.

The authors concluded there is little evidence on which to make public or population level recommendations, despite the important public health burden and costs of neck pain and its associated disorders. Population level approaches to preventing and controlling neck pain and its associated disorders should be investigated.

Predicting persistent neck pain: a 1-year follow-up of a population cohort

From: Spine. 2004 Aug 1;29(15):1648-54

Neck pain is a common experience. Within the U.K. general population, around one fifth of adults report the onset of a new episode of neck pain during the previous year; and among European and North American populations, two thirds experience neck pain at some point during their lives. However, although the prevalence is high, it may just reflect recurrent or persistent symptoms, similar to the intermittent pain pattern described for chronic low back pain. Although a number of cross-sectional surveys have been published, there has been little research into persistent neck pain within the general population using longitudinal methods.

Identifying factors that predispose individuals to persistent neck problems may contribute to primary or secondary prevention. Primary prevention is directed toward reducing the risk of initial onset of neck pain, for example, by preventing neck injury. For clinicians treating neck pain, secondary prevention of persistence or of the recurrence of symptoms is a more pragmatic approach and involves addressing those factors that increase the risk for neck pain persisting. It is with this latter issue that the current paper and analysis is concerned.

A number of studies have examined the clinical predictors for chronicity among those who consult health services for neck pain. These include factors such as duration of current episode, disability, expectations of treatment, number of pain sites, and general well-being. In addition, prospective occupational cohort studies have identified workplace risk factors for neck pain, which include physical and psychosocial elements along with job demands and coworker support. New clinical strategies are using this information to develop interventions that aim to prevent acute neck pain from persisting. These interventions recognize that many chronic regional pain syndromes have similar risk factors, including psychosocial factors, general health, and previous pain experience; consequently, such approaches frequently use cognitive behavioral approaches.

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Assessment of temporomandibular and cervical spine disorders in tinnitus patients

From: Prog Brain Res. 2007;166:215-9

In treating patients with temporomandibular joint (TMJ) dysfunction it was noticed that tinnitus and vertigo were common in such patients and there was also muscular tension in jaw and neck. During treatment of these patients it was also noted that injection of lidocaine in a jaw muscle reduced not only their muscular problems but also that the tinnitus was reduced while the local anesthetic was active. Evaluation of 39 patients with disabling tinnitus, and all suffered from tinnitus, revealed that 10 of them had bilateral tinnitus and TMJ disorders revealed that pain in the face, temples or jaw occurred often among these patients. Many of such patients had also symptoms of cervical spine disorders, head, neck and shoulder pain, and limitations in side bending and rotation were also frequent complaints. One-third of these patients could influence tinnitus by jaw movements and 75% could trigger vertigo by head or neck movements. Treatment of jaw and neck disorders in 24 patients with Ménière’s disease had a beneficial effect on not only their episodic vertigo but also on their tinnitus and aural fullness. At the 3-year follow-up, intensity of all symptoms were significantly reduced.

Delayed temporomandibular joint pain and dysfunction induced by whiplash trauma

From: J Am Dent Assoc, Vol 138, No 8, 1084-1091. 2007

The Quebec Task Force on Whiplash Associated Disorders published a systematic review of the literature on whiplash injuries in 1995 followed by an updated review in 2001. They considered 24 studies of prognosis to be scientifically admissible, one of which focused on the temporomandibular joint (TMJ) but did not include control subjects. Since the updated review, two TMJ related studies have been published. The first study was a controlled follow-up that investigated TMJ pain and dysfunction. It only included patients between the ages of 20 and 35 with signs and symptoms corresponding to whiplash associated disorders grade 11 (that is, a neck complaint of pain, stiffness or tenderness but no physical signs). The patients, therefore, were not representative of the general population that is exposed to whiplash trauma. The second study was population-based and included patients who had been exposed to either an indirect whiplash trauma or a direct trauma to the head. It evaluated the incidence and recovery of reduced or painful jaw movements that began with the car collision but did not account for whether there was TMJ affliction. Impaired and painful jaw movements can be symptoms of TMJ injury, but they also can be associated directly with the neck injury in patients who have whiplash associated disorders. It remains unclear whether a delayed onset of symptoms can occur in TMJs that appear unaffected directly after whiplash trauma.

A study was conducted to enhance knowledge about short-term and long-term TMJ pain, dysfunction or both induced by whiplash trauma. We hypothesized that delayed symptoms frequently develop in the TMJ after whiplash trauma and that the sex of the patient affects the development of posttraumatic symptoms in the TMJ.

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Trunk muscle onset and cessation in golfers with and without low back pain

From: J Biomech. 2008 Aug 19; [Epub ahead of print]

The knowledge of the onset and cessation timing of the paraspinal muscles that surround the lumbar spine is an important area of research for the understanding of low back pain. This study examined the timing of the erector spinae and external oblique muscle activity in a group of golfers with and without low back pain. The study compared the results of surface electromyography measurements for two groups of golfers. Twelve male golfers who had reported a mild or greater level of pain in the lower back that was experienced while playing golf were examined. A further fifteen male golfers who had reported no history of lower back pain in the previous 12 months were recruited as controls. The results showed that the low back pain golfers switched on their erector spinae muscle significantly in advance of the start of the backswing. This finding was not evident in the group who did not have low back pain symptoms. Low back pain golfers, therefore, may use the erector spinae muscle as a primary spinal stabiliser instead of the stronger deeper muscles such as transversus abdominis and multifidus. These results may have important implications for conditioning programmes for golfers with low back pain.

Individual, work, and flight related issues in F-16 pilots reporting neck pain

From: Aviat Space Environ Med. 2008 Aug;79(8):779-83

Neck pain is a common problem in F-16 pilots. A cross-sectional survey was used to determine the self-reported 1-yr prevalence of neck pain and to compare individual, work related, and flight related characteristics in F-16 pilots with and without neck pain. There were 90 male F-16 pilots of the Belgian Air Force and The Royal Netherlands Air Force who voluntarily completed an anonymous survey. The 1-yr prevalence of neck pain was 18.9%. Pilots were divided into two groups: healthy and neck pain group. This study could not identify individual or specific flight related differences between these two groups. High force demands, often sitting for a long time, frequently holding the neck in a forward bent posture, and being physically tired were all physical work related factors that were reported significantly more often in the neck pain group. The neck pain group also reported significantly more psychosocial factors, such as being mentally tired at the end of the day and being annoyed by others at the workplace.

Since the specific flight related factors were not significantly different between the healthy and the neck pain group, physical and psychosocial factors could have been important factors in the development or maintenance of neck pain in F-16 pilots. The results of this study highlight for the first time that, in addition to flight related issues, other aspects must be considered in analyzing neck pain. These other aspects stress the importance of a broader approach when considering neck pain, even in this population that is exposed to very high loads during flight.

Whiplash (grade II) and cervical radiculopathy share a similar sensory presentation: an investigation using quantitative sensory testing

From: Clin J Pain. 2008 Sep;24(7):595-603

Recent research has identified the coexistence of generalized sensory hypersensitivity and hypoesthetic changes suggestive of a neuropathic component to chronic whiplash associated disorders. This study aimed to compare chronic whiplash with a cervical neuropathic condition cervical radiculopathy, using Quantitative Sensory Testing. Fifty participants with chronic grade II whiplash associated disorders (greater than 3 mo), 38 participants with radiculopathy, and 31 controls who were age and sex matched to participants with whiplash associated disorders participated in the study. Quantitative Sensory Testing including detection thresholds (electrical, thermal, and vibration) and pain thresholds (pressure, cold) were measured from bilateral hand sites corresponding to innervation areas of the lower cervical nerve roots and a remote site in the lower limb.

The whiplash and cervical radiculopathy groups demonstrated lower pain thresholds to both pressure and cold stimuli at all sites compared with the controls. The symptomatic limbs of the radiculopathy group showed the greatest elevation in detection thresholds for all stimuli compared with the asymptomatic limbs of this group, the whiplash and control groups. There was no difference in detection thresholds between the asymptomatic limbs of the radiculopathy group and the whiplash group but both these groups showed higher detection thresholds than the controls. Generalized sensory hypersensitivity and hypoesthesia occur in both chronic whiplash and cervical radiculopathy. This may represent disordered central pain processing but could indicate peripheral nerve dysfunction.

Abdominal exercise intensities on firm and compliant surfaces

From: Percept Mot Skills. 2008 Jun;106(3):917-26

When doing sit ups it is important to refrain from pulling on your neck as you move forward. Compensation or “overdoing it” can cause undue pressure on the posterior neck. Along with straining, this can have a negative influence on the muscles, ligaments and discs of the cervical spine. Partial sit ups may seem like a reasonable alternative to full sit ups, however, patients with neck pain should use other forms of core exercise to strengthen the abdominals. An interesting article sheds some light on sit up exercises and neck muscle activity.

Muscle activities at 15 sites were compared within a group of healthy young adults to evaluate their relative intensities during six abdominal exercises: partial and full sit ups on a firm surface (floor) and on an exercise ball that was either stabilized or unstabilized. The most strenuous abdominal exercise overall (i.e., whole body workout) was the full sit up on a firm surface which included significant muscle activities in the lower extremities. Exercise intensity was also high in the full and partial sit ups when performed on a ball. The partial sit up on the floor was the least strenuous of the six exercises. The greatest effect on the abdominal muscles was observed in the partial sit up on a ball (stabilized and unstabilized). Results suggest that, although abdominal exercises on a ball may be gentler on the hip and lower back, overall exercise intensity is not necessarily lower than that on the floor. Moreover, partial sit ups, both on the floor and on a ball, also required greater neck muscle activities than full sit ups. In deciding what type of sit up to do, exercise surface and different muscular activities between the partial and full sit ups should be considered.