Exercise prescription for chronic back or neck pain: Who prescribes it? who gets it? What is prescribed?
From: Arthritis Rheum. 2009 Jan 29;61(2):192-200. [Epub ahead of print]
The purpose of this study is to describe exercise prescription in routine clinical practice for individuals with chronic back or neck pain because, although current practice guidelines promote exercise for chronic back and neck pain, little is known about exercise prescription in routine care.
The authors conducted a computer assisted telephone survey of a representative sample of 684 individuals with chronic back or neck pain who saw a physician, chiropractor, and/or physical therapist (PT) in the past 12 months. Individuals were asked about whether they were prescribed exercise, the amount of supervision received, and the type, duration, and frequency of the prescribed exercise. Descriptive and multivariable regression analyses were conducted.
Of the 684 subjects, 48% were prescribed exercise. Of those prescribed exercise, 46% received the prescription from a physical therapist, 29% from a physician, 21% from a chiropractor, and 4% from other. In multivariable analyses, seeing a physical therapist or a chiropractor were the strongest predictors of exercise prescription. The likelihood of exercise prescription was increased in women, those with higher education, and those receiving worker’s compensation. Physical therapists were more likely to provide supervision and prescribe strengthening exercises compared with physicians and chiropractors, and were more likely to prescribe stretching exercises compared with physicians.
Their findings suggest that exercise is being underutilized as a treatment for chronic back and neck pain and, to some extent, that the amount of supervision and types of exercises prescribed do not follow current practice guidelines. Exercise prescription provided by physical therapists appears to be most in line with current guidelines.
Impaired jaw function and eating difficulties in whiplash associated disorders
From: Swed Dent J. 2008;32(4):171-7
Eating requires mouth opening, biting, chewing and swallowing and should be performed without dysfunction or pain. Previous studies have shown that jaw opening and closing movements are the result of coordinated activation of both jaw and neck muscles, with simultaneous movements in the temporomandibular, atlanto-occipital and cervical spine joints. Consequently, it can be assumed that pain or dysfunction in any of the three joint systems involved could impair jaw activities. In fact, recent findings support this hypothesis by showing an association between neck injury and reduced amplitudes, speed and coordination of integrated jaw and neck movements.
This study investigated the possible association between neck injury and disturbed eating behaviour. Fifty Whiplash associated disorders patients with pain and dysfunction in the jaw and face region and 50 healthy age and sex matched controls without any history of neck injury participated in the study. All participants were assessed by a questionnaire, which contained 26 items about eating behaviour, jaw pain and dysfunction. For the whiplash associated disorders group there were significant differences in jaw pain and dysfunction and eating behaviour before and after the accident, but no significant differences between whiplash associated disorders before and healthy. The healthy and the whiplash associated disorders group before the accident reported no or few symptoms. The whiplash associated disorders patients after the accident reported pain and dysfunction during mouth opening, biting, chewing, swallowing and yawning and felt fatigue, stiffness and numbness in the jaw and face region. In addition, a majority also reported avoiding tough food and big pieces of food, and taking breaks during meals.
Altogether, these observations suggest an association between neck injury and disturbed jaw function and therefore impaired eating behaviour. A clinical implication is that examination of jaw function should be recommended as part of the assessment and rehabilitation of whiplash associated disorders patients.
Performance in the cranio-cervical flexion test is altered in elderly subjects
From: Man Ther. 2009 Jan 24. [Epub ahead of print]
The cranio-cervical flexion test tests the coordination of the deep and superficial cervical flexor muscles during a cranio-cervical flexion task. The test has revealed impairments in muscle function in younger/middle aged patients with various neck pain disorders. Neck pain and headache are common in elders but it is unknown if age alone affects performance in the cranio-cervical flexion test. This study compared performance in the cranio-cervical flexion test between healthy asymptomatic elderly and younger subjects. Electromyographic (EMG) amplitude in the sternocleidomastoid, angle of cranio-cervical flexion and ability to target the pressure levels of each test stage were examined in 44 elderly and 39 young participants.
The results indicated that the elderly group had higher measures of normalized EMG signal amplitude in the sternocleidomastoid during the test, greater shortfalls from the target pressures of all stages of the test, except for the 22mmHg stage, and larger variability of the cranio-cervical flexion range of motion for the five successive stages of the test (particularly at 26, 28 and 30mmHg stages) compared to young subjects. Clinicians must be aware of this occurrence when assessing performance in the cranio-cervical flexion test in elders with neck pain.
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Rehabilitation of chronic whiplash: treatment of cervical dysfunctions or chronic pain syndrome?
From: Clin Rheumatol. 2009 Jan 22. [Epub ahead of print]
Chronic whiplash associated disorders remains a challenging condition for clinicians. There is substantial evidence for the presence of various cervical dysfunctions (e.g., increased cervical muscle tone and impaired cervical movement control), but their contribution to the complex clinical picture of subjects with chronic whiplash associated disorders seems rather limited. There is consistent evidence for increased responsiveness of the central nervous system in those with chronic whiplash associated disorders , and central pain processing is likely to play a crucial role in the transition from an acute whiplash trauma towards chronic whiplash associated disorders . The manuscript explains how our current understanding of chronic whiplash associated disorders can be used to steer the content of conservative interventions and how treatment of cervical dysfunctions in patients with chronic whiplash associated disorders should account for the processes involved in chronicity. It is recommended to prevent sensorimotor incongruence, target cognitive-emotional sensitization, and apply a cognitive behavioral therapy-guided exercise program.
Grade II whiplash injuries to the neck: what is the benefit for patients treated by different physical therapy modalities?
From: Patient Saf Surg. 2009 Jan 16;3(1):2. [Epub ahead of print]
In a majority of cases, whiplash injuries are a domain of conservative therapy. Nevertheless it remains unclear whether physiotherapy is of medical or economic benefit in patients with whiplash injuries. The term “whiplash” in connection with motor vehicle collisions was first used by Gay and abbott in 1953 to describe the whip-like hyperextension with subsequent hyperflexion as a result of a rear-end collision. Meanwhile several studies
simulating whiplash, describe three reproducible phases of head-neck kinematics. In the first phase, the cervical spine shows a S-shaped curvature in which the more cranial motion segments undergo flexion, coupled with extension in the more caudal segments. It is supposed that injuries mainly located in the lower cervical spine are caused in this vulnerable phase. In the second phase, all segments of the cervical spine become extended, followed by a third phase in which the cervical spine passes once again through the initial position to finally reach maximum flexion.
Whiplash injuries represent one of the most common types of trauma in this age of increasing individual traffic mobility and their incidence continues to rise. After a complaint-free interval of a few hours to one day (five hours, on average), 47 – 88% of patients report pain in the neck. To describe the most determinant clinical symptoms, the Quebec Task Force (QTF) developed 1995 a classification system which allows a good assessment of the severity of the injury. In cases of QTF I° and II° whiplash injuries, the posttraumatic treatment is a domain of conservative therapy. Therapeutic measures have been exhaustively studied and compared. Physical therapy has been assessed predominantly with respect to its effects on pain intensity and improving patients’ range of motion. It seems that its efficacy is limited to a certain degree of improvement of these parameters in the acute stage of convalescence.
The quality of past studies, however, has been criticized and the therapeutic recommendation to “act as usual” has been considered adequate for comparable therapeutic success. There is, therefore, the overall impression that, compared with a spontaneous clinic course, physical therapy results in no statistically measurable advantage and the costs associated with physical therapy are not justified. It is important to note, however, that the effect of physical therapy in whiplash associated disorders has only been investigated in mixed QTF I and II populations. Considering the better prognosis of QTF I compared to QTF II injuries, it is probable that the therapeutic outcome of previously conducted therapy studies constitute a false-positive evaluation of the QTF II sub-populations.
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Work Disability After Whiplash: A Prospective Cohort Study
From: Spine. 2009 Jan 14. [Epub ahead of print]
To investigate the consequences of neck pain after motor vehicle accidents in terms of disability for work and the relationship this has with symptom and work-related factors. Previous studies on work disability related to whiplash are very heterogeneous, are often limited in sample size and show a wide variability in terms of results. A relationship has been suggested between poor recovery from or persistent work disability after whiplash and female gender, older age, marital status, heavy manual work, self-employment, prior psychological problems, subjective complaints of poor concentration, pain catastrophizing, and kinesiophobia.
Individuals with neck complaints after involvement in traffic accidents, who initiated compensation claim procedures with a Dutch insurance company (n = 879), were sent questionnaires (Q1) concerning the accident, the injuries that they had sustained, their complaints at that time, and questions regarding work and disability. The course of complaints and work disability was monitored at 6 (Q2) and 12 months (Q3) after the accident. A total of 58.8% of the population with neck complaints studied was work-disabled after the accident. Age and impaired concentration complaints after 1 month were found to be related to work disability at 1 year, independent of physical complaints and work characteristics.
The results show that work disability due to postwhiplash syndrome after a motor vehicle accident is a common problem. A total of 58.8% of the studied population with neck complaints was work-disabled after the accident. However, the vast majority of this group recovered from work disability in the first year: 31.3% in the first month, 66.7% in the first 6 months, and 78.3% in the first year, leaving 21.7% participants with persistent work disability after 1 year (12.6% of the individuals with initial neck complaints), which is in line with the reported 12% return from work disability in the first year reported in a previous research. However, it is much lower than the 44% reported, most probably because of population differences
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Evidence of a pelvis-driven flexion pattern: Are the joints of the lower lumbar spine fully flexed in seated postures?
From: Clin Biomech (Bristol, Avon). 2009 Jan 10. [Epub ahead of print]
Seated postures are achieved with a moderate amount of lumbo-sacral flexion and sustained lumbo-sacral spine flexion has been associated with detrimental effects to the tissues surrounding a spinal joint. The purpose of this study was to determine if the lower intervertebral joints of the lumbo-sacral spine approach their end ranges of motion in seated postures.
Static sagittal digital X-ray images of the lumbo-sacral region from L3 to the top of the sacrum were obtained in five standing and seated postures from 27 participants. Vertebral body bony landmarks were manually digitized and intervertebral joint angles were calculated for the three lower lumbo-sacral joints.
In upright sitting, the L5/S1 intervertebral joint was flexed to more than 60% of its total range of motion. Each of the lower three intervertebral joints approached their total flexion angles in the slouched sitting posture. These observations were the same regardless of gender. The results support the idea that lumbo-sacral flexion is driven by rotation of the pelvis and lower intervertebral joints in seated postures.
This is the first study to quantitatively show that the lower lumbo-sacral joints approach their total range of motion in seated postures. While not directly measured, the findings suggest that there could be increased loading of the passive tissues surrounding the lower lumbo-sacral intervertebral joints, contributing to low back pain and/or injury from prolonged sitting.
This helps to explain some of the relief of low back pain associated with prolonged sitting by using a backtivator which helps keep the lumbo-sacral spine in motion and avoids increased and sustained loading of the passive tissues surrounding the lower lumbo-sacral intervertebral joints
Influence of single-level lumbar degenerative disc disease on the behavior of the adjacent segments
From: J Biomech. 2009 Jan 9. [Epub ahead of print]
The current study investigated mechanical predictors for the development of adjacent disc degeneration. A 3-D finite element model of a lumbar spine was modified to simulate two grades of degeneration at the L4-L5 disc. Degeneration was modeled by changes in geometry and material properties. All models were subjected to follower preloads of 800N and moment loads in the three principal directions of motion using a hybrid protocol. Degeneration caused changes in the loading and motion patterns of the segments above and below the degenerated disc. At the level (L3-L4) above the degenerated disc, the motion increased due to moderate degeneration by 21% under lateral bending, 26% under axial rotation and 28% under flexion/extension. At the level (L5-S1) below the degenerated disc, motion increased only during lateral bending by 20% due to moderate degeneration. Both the L3-L4 and L5-S1 segment showed a monotonic increase in both the maximum von Mises stress and shear stress in the annulus as degeneration progressed for all loading directions, expect extension at L3-L4. The most significant increase in stress was observed at the L5-S1 level during axial rotation with nearly a ten fold increase in the maximum shear stress and 103% increase in the maximum von Mises stress. The L5-S1 segment also showed a progressive increase in facet contact force for all loading directions with degeneration. Nucleus pressure did not increase significantly for any loading direction at either the caudal or cephalic adjacent segment. Results suggest that single-level degeneration can increase the risk for injury at the adjacent levels.
Effectiveness of Specific Neck Stabilization Exercises or a General Neck Exercise Program for Chronic Neck Disorders
From: J Rheumatol. 2008 Dec 15. [Epub ahead of print]
In a cohort of primary care patients with chronic neck pain, to determine whether specific neck stabilization exercises, in addition to general neck advice and exercise, provide better clinical outcome at 6 weeks than general neck advice and exercise alone. This was a multicenter randomized controlled trial in 4 physical therapy departments. Seventy-four participants (mean age 51.3 yrs) were randomized to specific neck stabilization exercises with a general neck advice and exercise program (n = 37) or a general neck advice and exercise program alone (n = 37). They attended a 1-hour clinical examination, followed by a maximum of 4 treatment sessions. Assessments were undertaken at baseline, 6 weeks, and 6 months. The primary outcome was the Neck Pain and Disability Scale. Analysis was by intention to treat.
Seventy-one (96%) participants received their allocated intervention. There was 91% followup at 6 weeks and 92% followup at 6 months. The mean (SD) 6-week improvement (reduction) in Neck Pain and Disability Scale score was 10.6 (20.2) for the specific exercise program and 9.3 (15.7) for the general exercise program. There were no significant between-group differences in the Neck Pain and Disability Scale at either 6 weeks or 6 months. For secondary outcomes, participants in the specific exercise group were less likely to be taking pain medication at 6-week followup. There were no other significant between group differences. Adding specific neck stabilization exercises to a general neck advice and exercise program did not provide better clinical outcome overall in the physical therapy treatment of chronic neck pain.
Clinical Significance of Cervical Vertebral Flexion and Extension Spatial Alignment Changes
From: Spine. 2009 Jan 1;34(1):21-26
Physiologic cervical lordosis maintains basic biomechanical balance of the cervical spine, through intricate interrelation between physiologic lordosis, anteroposterior intervertebral disc edge space height, and sagittal spatial alignment. Cervical vertebral spatial alignment changes induce changes in the sagittal cervical curvature. During dynamic flexion and extension, each cervical vertebral body and intervertebral disc allows for relative spatial displacement, adjusting according to postural changes. At present, there are few measurement reports analyzing the effect of dynamic changes on cervical vertebrae, direct vertebral body alignment, physiologic curvature changes, and its relationships to adjacent vertebrae. The primary goal of orthopedic cervical kyphosis correction is restoration of the physiologic cervical curvature, optimizing normal segmental vertebral spatial structure and alignment. Orthopedic cervical kyphosis correction, especially with severe cervical kyphosis presents high surgical risks and lacks standardized theoretical surgical design guidelines, therefore surgeons are unable to plan correction methods or predict results. This may result from insufficient knowledge and understanding of changes in alignment and curvature of the cervical vertebral column in the sagittal plane. To understand cervical vertebrae and curvature dynamic variation patterns in the sagittal plane and provide a theoretical reference for orthopedic correction of cervical kyphosis, they measured spatial position and alignment of the cervical vertebrae on sagittal plane films of various postures.
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