July « 2009 « necksolutions.com Blog

July 30, 2009

Modic changes and lumbar intervertebral disc degeneration

Filed under: Back Pain, Disc Problems — Administrator @ 9:26 am

Modic changes, possible causes and promotion to lumbar intervertebral disc degeneration

From: Med Hypotheses. 2009 Jul 23. [Epub ahead of print]

Modic changes are bone marrow and endplate lesions visible in magnetic resonance imaging (MRI). They are regarded as a part of degenerative disc disease and associated with low back pain. And severe disc degeneration was occurred more in the patients with Modic changes. But there is still no study to analyze the relationship between Modic changes and intervertebral disc degeneration. The authors hypothesize that Modic changes are the possible causes and promotion of lumbar intervertebral disc degeneration. And there are three possible mechanisms for this hypothesis:

A structural cause: Modic changes make cartilaginous material easier in extruded disc herniations, to destroy the structure of intervertebral disc and inhibit the absorption of the disc.

A biomechanical cause: Modic changes alter the mechanical loading distribution on disc, to initiate a series of disc disruption and inhibit the self-recovery of the disc.

A nutritional cause: Modic changes destroy the vascular architecture in vertebral endplate and block the most important metabolism pathway between vertebrae and disc.

Perspectives:

(1) Find out procedures to cure Modic changes may be an important breakthrough for disc degenerative disease.

(2) Treatment of Modic changes may be a critical step of biotherapy for disc degeneration disease.

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July 29, 2009

Managing injuries of neck trial in whiplash injuries

Filed under: Neck Pain, Whiplash — Administrator @ 7:36 pm

Development and delivery of a physiotherapy intervention for the early management of whiplash injuries: the Managing Injuries of Neck Trial (MINT) Intervention

From: Physiotherapy. 2009 Mar;95(1):15-23. Epub 2009 Jan 23

Managing Injuries of Neck Trial is a multi-centre randomised controlled trial to estimate the clinical effectiveness of a stepped care approach to whiplash injuries on clinical outcomes over 12 months, the effectiveness in pre-specified sub-groups of patients (those with severe physical symptoms, prior neck problems, psychological or physical risk factors for poor outcome, and those seeking compensation), and the costs and cost-effectiveness of each strategy.

This paper describes the development and implementation of a physiotherapy intervention for a large multicentred randomised controlled trial of the early management of whiplash injuries in a National Health Service setting. Participants were eligible if they were classified as having whiplash associated disorder grades I to III and self-referred for treatment within 6 weeks of injury. The intervention development was informed through a variety of methods including the current evidence base, published guidelines, clinician opinion, a pilot study and expert opinion. The intervention was targeted at known, potentially modifiable risk factors for poor recovery, and utilised manual therapy, exercises and psychological strategies. The treatment was individually tailored, with a maximum of six treatments allowed within the trial protocol over an 8-week period. The intervention was delivered to 300 participants. The amount and types of treatments delivered are described.

A substantial proportion of patients with whiplash injuries develop chronic symptoms. However, the best treatment of acute injuries to prevent long-term problems is uncertain. A stepped care treatment pathway has been proposed, in which patients are given advice and education at their initial visit to the emergency department (ED), followed by review at three weeks and physiotherapy for those with persisting symptoms. Managing Injuries of Neck Trial is a two-stage randomised controlled trial to evaluate two components of such a pathway: 1. use of The Whiplash Book versus usual advice when patients first attend the emergency department; 2. referral to physiotherapy versus reinforcement of advice for patients with continuing symptoms at three weeks.

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July 28, 2009

Whiplash associated disorder and low back pain

Filed under: Back Pain, Neck Pain, Whiplash — Administrator @ 8:59 am

Can patients with low energy whiplash associated disorder develop low back pain

From: Injury. 2009 Jul 20. [Epub ahead of print]

800 consecutive claimant generated medicolegal reports were analysed for symptomatology of whiplash associated disorder including the presence of mid and low back pain. The authors aimed to establish whether the two were linked and if so if there were correlations between accident vector and severity. The authors also aimed to establish if a low back injury could result from a vehicular accident in the absence of a neck injury. In addition we examined if occupant bracing and occupant neutral position at the time of the accident affected symptom patterns.

The authors found that a claimed back injury following whiplash associated disorder was independent of both accident severity and accident vectors, approximately 40% claiming injury in low, medium and high violence groups and with rear, frontal and side impact. The authors established that it was unusual to have a back injury in the absence of a neck injury (18 out of 325, 5.5%) without a past medical history of back pain (72.2% of this group having previous back pain). Occupant bracing was not protective. The authors also showed that occupant neutral position was not protective against a back injury. The authors were surprised that patients with next to no car damage had the same incidence of back pain as those involved in more violent crashes when biomechanically unlikely. The complex biopsychosocial response and the relationship to constitutional factors are discussed. The literature concerning forces across the lumbar spine and possibilities of injury is reviewed.

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July 25, 2009

Association between cervical curvature and sympathetic symptoms

Filed under: Arthritis, Neck Pain, Tinnitus — Administrator @ 11:22 am

Association between cervical curvature and cervical sympathetic symptoms

From: Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2009 Jun;31(3):381-2

To investigate the association between cervical curvature and cervical sympathetic symptoms, the clinical data of 318 patients with cervical spondylosis who underwent surgical treatment in our department between July 2003 and December 2007 were retrospectively analyzed. All patients were divided into group without sympathetic symptoms (n = 284) and group with sympathetic symptoms (n = 34). The curvatures of both groups on cervical lateral radiographs were measured using Borden method and statistical analysis was performed.

The incidence of abnormal cervical curvature in group with cervical sympathetic symptoms were 67.6% (23/34), which was significantly higher than that in group without cervical sympathetic symptoms (50.7%, 144/284). Cervical curvature abnormality may be an independent factor that affects the cervical sympathetic symptoms.

In Zhonghua Wai Ke Za Zhi. 2008 Sep 15;46(18):1424-7, Treatment and mechanism of cervical spondylosis with sympathetic symptoms concluded: The sympathetic nerve fibers distributed in the cervical posterior longitudinal ligament maybe another one significant factor causing sympathetic symptom of cervical spondylosis.

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July 23, 2009

Motion analysis of neck pain in chronic whiplash

Filed under: Neck Pain, Whiplash — Administrator @ 10:00 am

Pre and post operative motion analysis for evaluation of neck pain in chronic whiplash

From: J Brachial Plex Peripher Nerve Inj. 2009 Jul 17;4(1):10. [Epub ahead of print]

Chronic neck pain after whiplash is notoriously refractory to conservative treatment, and positive radiological findings to explain the symptoms are scarce. The apparent dis-proportionality between subjective complaints and objective findings is significant for the planning of treatment, impairment ratings, and judicial questions on causation. However, failure to identify a symptom’s focal origin with routine imaging studies does not invalidate the symptom per se. It is therefore not only of general interest to develop effective therapeutic strategies in chronic whiplash, but also to establish techniques for objective evaluation of treatment outcomes.

Twelve patients with chronic neck pain after whiplash underwent pre and post operative computerized 3-D gait analysis. Significant improvement was found in all gait parameters, cervical range of motion (ROM), and self-reported pain using the visual analog scale (VAS). Chronic neck pain is associated with abnormal gait patterns. 3-D gait analysis is a useful instrument to assess the outcome of treatment for neck pain.

Serious persistent problems after whiplash trauma to the neck, sometimes referred to as Whiplash Associated Disorders is a common and costly condition; estimates indicate an incidence of over 250,000 in the United States, at an annual cost in 2002 of $2.7 billion or close to $10,000 per incident. Although initial symptoms from acceleration-deceleration trauma to the neck may improve spontaneously or with physical therapy over the course of weeks-to-months, chronic and potentially disabling symptoms persist in a significant percentage of all cases. A complicating factor, which is also a reason for controversy, is the frequent failure of routine clinical laboratory investigative methods including MRI and electrodiagnostic studies, to objectively identify the cause of pain and other symptoms.

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July 19, 2009

Cervical Traction, Compression and Spurling Test

Filed under: Neck Pain — Administrator @ 10:20 pm

The Influence of Cervical Traction, Compression, and Spurling Test on Cervical Intervertebral Foramen Size

From: Spine. 2009 34(16):1658–1662

The purpose of this study was to evaluate functional changes in the cervical intervertebral foramen during the axial compression test, axial distraction test, and Spurling test.

Although alterations of the cross-sectional area of the cervical intervertebral foramen during flexion/extension and rotation have been reported, there are no studies that have measured functional changes in foramen cross-sectional area or shape during the simulation of clinical tests for cervical radiculopathy.

Cervical radiculopathy is, by definition, a disease of the cervical nerve root and is most commonly caused by a cervical disc herniation or other space-occupying lesion, resulting in nerve root inflammation, impingement, or both. A number of tests have been reported as useful for the diagnosis of cervical radiculopathy and include the: foraminal compression test, Spurling test, distraction test, shoulder abduction test, and upper limb tension test. The purpose of these tests is to either induce or alleviate mechanical deformation on the cervical nerve roots by one the following mechanisms: enlargement or narrowing of the intervertebral foramen, and elongation of the neural elements creating increases in intrathecal pressure.

The foraminal compression test is designed to provoke symptoms and is used if the patient complains of pain potentially arising from compromise of a nerve root. It is advocated performing the foraminal compression test in 3 stages, each of which is increasingly provocative. If at any stage symptoms are increased then the test is positive. The first stage involves axial compression applied through the head, with the neck in neutral. The second stage involves axial compression with the neck in extension, and the final stage is axial compression with the neck in extension and rotation, first to the unaffected side, then to the symptomatic side. The third part of the test more closely follows Spurling test. In contrast, the distraction test is used to alleviate symptoms and is performed in the presence of radicular symptoms. With the patient in supine, the examiner places one hand under the patient’s chin and the other hand around the occiput, then slowly distracts the patient’s neck. An axial traction force of approximately 10 to 15 kg is applied. The test is classified as positive if the pain is relieved or decreased when the head is distracted, indicating pressure on nerve roots that has been relieved. To date no studies have investigated the validity of the foraminal compression test or the distraction test.

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July 16, 2009

Fear avoidance model in whiplash injuries

Filed under: Neck Pain, Whiplash — Administrator @ 7:34 pm

The fear avoidance model in whiplash injuries

From: Eur J Pain. 2009 May;13(5):518-23. Epub 2008 Jul 21

The aim of this work was to study whether fear of movement, and pain catastrophizing predict pain related disability and depression in subacute whiplash patients. Moreover, the authors wanted to test if fear of movement is a mediator in the relation between catastrophizing and pain related disability and/or depression as has been suggested by the fear avoidance model. Fear of movement and/or reinjury in chronic low back pain and its relation to behavioral performance.

The convenience sample used was of 147 subacute whiplash patients (pain duration less than 3 months). Two stepwise regression analyses were performed using fear of movement and catastrophizing as the independent variables, and disability and depression as the dependent variables. After controlling for descriptive variables and pain characteristics, catastrophizing and fear of movement were found to be predictors of disability and depression. Pain intensity was a predictor of disability but not of depression. The mediation effect of fear of movement in the relationships between catastrophizing and disability, and between catastrophizing and depression was also supported. The results of this study are in accordance with the fear avoidance model, and support a biopsychosocial perspective for whiplash disorders.

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July 15, 2009

Intervertebral disc and articular cartilage matrix

Filed under: Back Pain, Disc Problems — Administrator @ 10:19 pm

The internal mechanical functioning of intervertebral discs and articular cartilage, and its relevance to matrix biology

From: Matrix Biol. 2009 Jul 5. [Epub ahead of print]

Degeneration of intervertebral discs and articular cartilage can cause pain and disability. Risk factors include genetic inheritance and age, but mechanical loading also is important. Its influence has been investigated using miniature pressure transducers to measure the distribution of compressive stress (force per unit area) within loaded tissue. The technique quantifies stress concentrations, and detects regions that behave in a fluid-like manner.

Intervertebral discs demonstrate a central fluid-like region which normally extends beyond the anatomical nucleus pulposus so that the whole disc functions like a “water bed”. With increasing age, the fluid region shrinks and pressure within it falls. Stress concentrations appear in the surrounding anulus fibrosus, with location depending on posture. Stress concentrations become large in degenerated discs, and are intensified by sustained loading or injury. Articular cartilage never exhibits an internal fluid pressure: stress gradients and concentrations normally occur within it, and are intensified by sustained loading.

Excessive matrix stresses can cause pain and progressive damage. They also inhibit matrix synthesis and stimulate production of matrix degrading enzymes. In this way, injury to chondroid tissues can initiate a ‘vicious circle’ of abnormal matrix stresses, abnormal metabolism, weakened matrix, and further injury, which explains many features of their degeneration.

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July 9, 2009

Postural changes in women with chronic pelvic pain

Filed under: Chronic Pain, Posture — Administrator @ 10:22 pm

Postural changes in women with chronic pelvic pain

From: BMC Musculoskelet Disord. 2009 Jul 7;10(1):82. [Epub ahead of print]

Among women, chronic pelvic pain is a highly prevalent (2% to 25%) clinical problem, with substantial costs as well as social and marital repercussions. Chronic pelvic pain is defined as continuous or recurrent pain in the lower abdomen or pelvis lasting at least six months, not related to pregnancy, and sufficiently severe to interfere with the habitual activities of the patient. Chronic pelvic pain excludes pain occurring exclusively in association with menstruation (dysmenorrhea) or during sexual intercourse (dyspareunia).

Although the etiology is often unknown, it may result from complex interactions among the gastrointestinal, urinary, gynecologic, musculoskeletal, neurologic and endocrine systems, as well as being influenced by psychological and sociocultural factors. To date, few therapeutic modalities have been effective in relieving the symptoms of chronic pelvic pain, particularly over the long term. An interdisciplinary approach has therefore been recommended, both to diagnose the presumed primary etiology, and to diagnose and control all the secondary factors associated with chronic pelvic pain.

In clinical practice, postural changes are frequently observed among women with chronic pelvic pain. Although this disease has been associated with musculoskeletal changes and particular postures, to date there have been no studies of the detailed postural evaluation of women with chronic pelvic pain, which can be performed by attending physicians, especially primary care physicians and gynecologists. Postural assessment can lead to early detection of uneven positions, shortenings, antalgic postures and tensions. Although these changes may not be the primary cause of the clinical condition, they can contribute significantly to the worsening of pain and tension. The authors therefore determined the frequency of postural changes in women with chronic pelvic pain, as assessed only by clinical examinations.

The authors observed statistically significant differences in the cervical spine and scapulae between women with chronic pelvic pain and control women. The authors believe that the changes observed in women with chronic pelvic pain resulted from a vicious cycle of pain and antalgic postures acquired over time. The mean duration of symptoms among women with chronic pelvic pain was about five years, and postural impairments over time can contribute significantly to the maintenance or worsening of pain. Nevertheless, the authors cannot conclude that women with chronic pelvic pain always show the same postural pattern. First, although the authors observed an association between chronic pelvic pain and postural changes, the control group, consisting of women who did not report any type of pain, also presented with several postural changes.

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July 6, 2009

Cervical kinesio taping for whiplash injury

Filed under: Neck Pain, Whiplash — Administrator @ 9:05 am

Short-Term Effects of Cervical Kinesio Taping on Pain and Cervical Range of Motion in Patients With Acute Whiplash Injury

From: J Orthop Sports Phys Ther. 2009;39(7):515-521

To determine the shortterm effects of Kinesio Taping, applied to the cervical spine, on neck pain and cervical range of motion in individuals with acute whiplash associated disorders. Researchers have begun to investigate the effects of Kinesio Taping on different musculoskeletal conditions (eg, shoulder and trunk pain). Considering the demonstrated short term effectiveness of Kinesio Tape for the management of shoulder pain, it is suggested that Kinesio Tape may also be beneficial in reducing pain associated with whiplash associated disorders.

Forty-one patients (21 females) were randomly assigned to 1 of 2 groups: the experimental group received Kinesio Taping to the cervical spine (applied with tension) and the placebo group received a sham Kinesio Taping application (applied without tension). Both neck pain (11-point numerical pain rating scale) and cervical range of motion data were collected at baseline, immediately after the Kinesio Tape application, and at a 24-hour follow-up by an assessor blinded to the treatment allocation of the patients.

The group-by-time interaction for the 2-by-3 mixed-model ANOVA was statistically significant for pain as the dependent variable, indicating that patients receiving Kinesio Taping experienced a greater decrease in pain immediately postapplication and at the 24-hour follow-up. The group-by-time interaction was also significant for all directions of cervical range of motion: flexion, extension, right and left lateral flexion, and right and left rotation. Patients in the experimental group obtained a greater improvement in range of motion than those in the control group.

Patients with acute whiplash associated disorders receiving an application of Kinesio Taping, applied with proper tension, exhibited statistically significant improvements immediately following application of the Kinesio Tape and at a 24-hour follow-up. However, the improvements in pain and cervical range of motion were small and may not be clinically meaningful. Future studies should investigate if Kinesio Taping provides enhanced outcomes when added to physical therapy interventions with proven efficacy or when applied over a longer period.

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