Clinical assessment of prognostic factors for long term pain and handicap after whiplash injury: a 1-year prospective study
From: Eur J Neurol. 2008 Sep 18; [Epub ahead of print]
Physical mechanisms are the possible factors involved in the development and maintenance of long term handicaps after acute whiplash injury. This study prospectively examined the role of active neck mobility, cervical and extra-cervical pains, as well as non painful complaints after a whiplash injury as predictors for subsequent handicap. Consecutive acute whiplash patients (n = 688) were interviewed and examined by a study nurse after the median of 5 days after injury, and divided into a high or a low risk group by an algorithm based on pain intensity, number of non painful complaints and active neck mobility. All 458 high risk patients and 230 low risk patients received mailed questionnaires after 3, 6 and 12 months. Two examiners examined all high risk patients (n = 458) and 41 consecutive low risk patients at median 11, 109, 380 days after whiplash injury. The main outcome measures were: handicaps, severe headaches, neck pain and neck disability.
The relative risk for a 1 year disability increased by 3.5 with initial intense neck pain and headaches, by 4.6 times with reduced active neck mobility and by four times with multiple non painful complaints. Reduced active neck mobility, immediate intense neck pain and headaches and the presence of multiple non painful complaints are the important prognostic factors for a 1 year handicap after acute whiplash.
Poor outcome in patients with spine related leg or arm pain who are involved in compensation claims: a prospective study of patients in the secondary care sector
From: Scand J Rheumatol. 2008 Sep 25;:1-7 [Epub ahead of print]
To investigate whether poor outcome after spinal pain episodes is linked with the claim process and, if so, whether this link is independent of other potential risk factors of chronic pain and disability in patients with spine related leg or arm pain. A 1-year prospective outcome study with internal control groups in two Danish secondary care, public, multidisciplinary, non surgical spine clinics. Patients with low back pain radiating to the leg (n = 1243) or with neck and arm pain thought to emanate from the neck (n = 202) were referred to the clinics by their general practitioners. Rheumatologists, physiotherapists, and nurses examined, treated, and informed the patients based on cognitive principles. Follow-up data were collected with a postal questionnaire. Claim, defined as seeking some sort of financial compensation or filing any sort of financial claim, such as workers’ compensation, was the main independent variable. Potential confounders examined were: age, sex, social class, smoking, duration and severity of pain and disability. The main outcome measures were: global assessment (main outcome variable), pain, disability, and intake of analgesics.
Financial claims were registered by 31% of patients. After adjustment for covariates, the odds ratio for claim and no improvement was calculated to be 4.2 for the low back pain and leg patients and 17.4 for the neck and arm pain patients. A claim for financial compensation is strongly and independently linked with a poor prognosis for Danish patients with pain radiating from the low back or neck.
Melatonin to prevent migraine or tension type headache in children
From: Neurol Sci. 2008 Sep;29(4):285-7. Epub 2008 Sep 20
A 3 month open label trial of melatonin prophylaxis in children with primary headache. After a one month baseline period without receiving preventive drugs, all children received a 3-month course of melatonin, 3 mg, administered orally, at bedtime. A total of 22 children were enrolled (10 boys, mean age 12.2+/-2.6 years, age range 6-16 years), 13 had recurrent migraine without aura, 1 with aura and 8 had chronic tension type headache. When the trial ended, 14 of the 21 subjects reported that the headache attacks had decreased by more than 50% in respect to baseline and 4 of them reported having no headache attacks. After receiving melatonin for one month one subject dropped out because of excessive daytime sleepiness. Our promising results warrant randomized placebo controlled trials in children to assess the real effectiveness of melatonin in preventing primary headache.
Psychosocial factors and low back pain among college students
From: J Am Coll Health. 2008 Sep-Oct;57(2):191-6.
The authors evaluated psychosocial factors of stress and their effects on the prevalence of low back pain among a population of college students in a major university in Colorado. This was a nested cross-sectional study of 973 respondents who completed the National College Health Assessment survey. The authors evaluated a subset of questions pertaining to psychosocial stressors against the presence of low back pain. Results: The annual prevalence of low back pain among the population studied was 42.8%. The stressful psychosocial variables of feeling very sad, exhausted, and overwhelmed were associated with the prevalence of low back pain. The prevalence of low back pain among this younger population is significant and understudied.
Usefulness of posture training for patients with temporomandibular disorders
From: J Am Dent Assoc. 2000 Feb;131(2):202-10
Poor posture is widespread in the general population and appears to be an adaptive, self-perpetuating trait that most people lack the cognitive ability or desire to correct by themselves. Many practitioners have speculated that poor posture may have a negative effect on temporomandibular, or TMJ, symptoms and treatment outcome.
Forward head posture is the most common form of poor posture and is assumed by many authors to be related to a multitude of myofascial pain disorders. It requires the person to flex the lower portion of the neck forward and bend the upper portion of the neck backward.
With this posture, the head’s center of gravity is forward of the spine’s weght-bearing axis, which increases the strain within the posterior neck muscles, ligaments and apophyseal joints. Two studies have independently demonstrated that when the head is positioned forward, the upper trapezius muscle’s electromyocardiographic, or EMG, activity is significantly higher than it is when the head is in normal alignment (the greater the EMG activity, the more likely the patient is to have pain from overusing the muscles).
It has been demonstrated that neck muscle activity influences masticatory muscle activity. Practitioners have theorized that the additional demand that is placed on the posterior cervical region by the forward head posture alters the masticatory system so that people are more susceptible to masticatory muscle strain, spasm and pain.
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The Neck Disability Index: state-of-the-art, 1991-2008
From: J Manipulative Physiol Ther. 2008 Sep;31(7):491-502
The Neck Disability Index was the first instrument designed to assess self-rated disability in patients with neck pain. This article reviews the history of the Neck Disability Index and the current state of the research into its psychometric properties, reliability, validity, and responsiveness as well as its translations. Focused reviews are presented into its use in studies of the prognosis of whiplash injured patients as well as its use in clinical trials of conservative therapies for neck pain.
The Neck Disability Index is a relatively short, paper and pencil instrument that is easy to apply in both clinical and research settings. It has strong psychometric characteristics and has proven to be highly responsive in clinical trials. As of late 2007, it has been used in approximately 300 publications; it has been translated into 22 languages, and it is endorsed for use by a number of clinical guidelines.
The Neck Disability Index is the most widely used and most strongly validated instrument for assessing self-rated disability in patients with neck pain. It has been used effectively in both clinical and research settings in the treatment of this very common problem.
Influence of forward head posture on condylar position
From: J Oral Rehabil. 2008 Sep 19; [Epub ahead of print]
There are several reports suggesting that forward head posture is associated with temporomandibular disorders and restraint of mandibular growth, possibly due to mandibular displacement posteriorly. However, there have been few reports in which the condylar position was examined in forward head posture. The purpose of this study was to test the hypothesis that the condyle moves posteriorly in the forward head posture. The condylar position and electromyography from the masseter, temporal and digastric muscles were recorded on 15 healthy male adults at mandibular rest position in the natural head posture and deliberate forward head posture. The condylar position in the deliberate forward head posture was significantly more posterior than that in the natural head posture. The activity of the masseter and digastric muscles in the deliberate forward head posture was slightly increased. These results suggest that the condyle moves posteriorly in subjects with forward head posture.
STIR sequence for depiction of degenerative changes in posterior stabilizing elements in patients with lower back pain
From: AJR Am J Roentgenol. 2008 Oct;191(4):973-9
The aims of this study were to investigate whether degenerative posterior paraspinal changes are a cause of lower back pain and to determine the age and sex related distribution of these changes on MR images acquired with a STIR (Short T1 Inversion Recovery) sequence. The lumbar MRI findings of 372 patients (141 men, 231 women; mean age, 51.2 years) with nonradicular lower back pain and of 249 healthy persons acting as controls (126 men, 123 women; mean age, 49.3 years) were analyzed. The sagittal STIR sequence was used for all MRI examinations. Presence of interspinous ligament edema, facet joint effusion, neocysts, paraspinal muscle edema, subcutaneous edema, disc herniation, and disc degeneration was evaluated, and the incidence of each finding was determined. All findings were grouped according to age and sex.
The incidences of facet joint effusion, interspinous ligament edema, neocyst formation, and paraspinal muscle edema were found to be statistically significantly higher in patients with lower back pain than in controls. The incidences of intervertebral disc degeneration, disc herniation, and subcutaneous edema in persons with and those without lower back pain were similar. Intervertebral disc degeneration, disc herniation, subcutaneous edema, and muscle edema were found to increase with age in both persons with and those without symptoms.
- Degenerative changes in the posterior paraspinal structures were found in a higher percentage of subjects with lower back pain than in controls.
Use of a STIR sequence with homogeneous fat suppression facilitates visualization of these changes.
Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test
From: J Manipulative Physiol Ther. 2008 Sep;31(7):525-33
The craniocervical flexion test is a clinical test of the anatomical action of the deep cervical flexor muscles, the longus capitis, and colli. It has evolved over 15 years as both a clinical and research tool and was devised in response to research indicating the importance of the deep cervical flexors in support of the cervical lordosis and motion segments and clinical observations of their impairment with neck pain.
The craniocervical flexion test could be described as a test of neuromotor control. The features assessed are the activation and isometric endurance of the deep cervical flexors as well as their interaction with the superficial cervical flexors during the performance of five progressive stages of increasing craniocervical flexion range of motion. It is a low-load test performed in the supine position with the patient guided to each stage by feedback from a pressure sensor placed behind the neck. While the test in the clinical setting provides only an indirect measure of performance, the construct validity of the craniocervical flexion test has been verified in a laboratory setting by direct measurement of deep and superficial flexor muscle activity.
Research has established that patients with neck pain disorders, compared to controls, have an altered neuromotor control strategy during craniocervical flexion characterized by reduced activity in the deep cervical flexors and increased activity in the superficial flexors usually accompanied by altered movement strategies. Furthermore, they display reduced isometric endurance of the deep cervical flexor muscles. The muscle impairment identified with the craniocervical flexion test appears to be generic to neck pain disorders of various etiologies. These observations prompted the use of the craniocervical flexion action for retraining the deep cervical flexor muscles within a motor relearning program for neck pain patients, which has shown positive therapeutic benefits when tested in clinical trials.
Impact of motor vehicle accidents on neck pain and disability in general practice
From: Br J Gen Pract. 2008 Sep;58(554):624-9
High levels of continuous neck pain after a motor vehicle accident are reported in cross-sectional studies. Knowledge of this association in general practice is limited. This study compares the differences in perceived pain and disability in patients with acute neck pain due to an motor vehicle accident versus other self-reported causes. The secondary aim was to identify prognostic factors for continuous neck pain.
From general practices in Rotterdam and its suburban region, patients with non-specific acute neck pain were invited to participate. Questionnaires were collected at baseline and after 6, 12, 26, and 52 weeks. The numerical pain-rating scale and the neck disability index were measured. Regression analysis was used to identify prognostic factors for continuous neck pain.
A total of 187 patients were included. The motor vehicle accident subgroup (n = 42) was significantly younger, reported more sick leave, higher levels of headache and higher neck disability index scores at baseline but lower scores for previous neck pain compared to the remaining cohort. At follow-up themotor vehicle accident subgroup had higher scores for continuous neck pain (63% versus 40%) and at the neck disability index (11.0 versus 7.1). After multivariate analysis pain in the upper part of the neck, duration of complaints at baseline longer than 2 weeks, and a motor vehicle accident were significantly correlated with outcome.
Individuals exposed to motor vehicle accidents constitute a relevant subgroup of patients with neck pain. A motor vehicle accident and a longer duration of complaints are prognostic factors for continuous neck pain.
