Physical Examination and Self-Reported Pain Outcomes From a Randomized Trial on Chronic Cervicogenic Headache.
From: J Manipulative Physiol Ther. 2010 Jun;33(5):338-348.
Objective clinical measures for use as surrogate markers of cervicogenic headache pain have not been established. In this analysis, the authors investigate relationships between objective physical examination measures with self-reported cervicogenic headache outcomes.
This was an exploratory analysis of data generated by attention control physical examination from an open-label randomized clinical trial. Of 80 subjects, 40 were randomized to 8 treatments (spinal manipulative therapy or light massage control) and 8 physical examination over 8 weeks. The remaining subjects received no physical examination. Physical examination included motion palpation of the cervical and upper thoracic regions, active cervical range of motion and associated pain, and algometric pain threshold evaluated over articular pillars.
Self-reported outcomes included cervicogenic headache and neck pain and disability, number of cervicogenic headaches, and related disability days. Associations between physical examination and self-reported outcomes were evaluated using generalized linear models, adjusting for sociodemographic differences and study group.
At baseline, number of cervicogenic headache and disability days were strongly associated with cervical active range of motion. Neck pain and disability were strongly associated with range of motion-elicited pain but not later in the study. After the final treatment, pain thresholds were strongly associated with week 12 neck pain and disability and cervicogenic headache disability and disability days.
Cervical range of motion was most associated with the baseline headache experience. However, 4 weeks after treatment, algometric pain thresholds were most associated. No one physical examination measure remained associated with the self-reported headache outcomes over time.
Muscle Atrophy and Changes in Spinal Morphology: Is the Lumbar Spine Vulnerable After Prolonged Bed-Rest?
Spine (Phila Pa 1976). 2010 Jun 30. [Epub ahead of print]
Prospective longitudinal study to evaluate the effect of bed rest on the lumbar musculature and soft-tissues. Earlier work has suggested that the risk of low back injury is higher after overnight bed rest or spaceflight. Changes in spinal morphology and atrophy in musculature important in stabilizing the spine could be responsible for this, but there are limited data on how the lumbar musculature and vertebral structures are affected during bed rest.
Nine male subjects underwent 60 days head down tilt bed rest as part of the second Berlin Bed Rest Study. Disc volume, intervertebral spinal length, intervertebral lordosis angle, and disc height were measured on sagittal plane magnetic resonance images. Axial magnetic resonance images were used to measure cross-sectional areas of the multifidus, erector spinae, quadratus lumborum, and psoas from L1 to L5. Subjects completed low back pain questionnaires for the first 7-days after bed-rest.
Increases in disc volume, spinal length (greatest at lower lumbar spine), loss of the lower lumbar lordosis, and move to a more lordotic position at the upper lumbar spine were seen. The cross-sectional areas of all muscles changed, with the rate of atrophy greatest at L4 and L5 in multifidus and at L1 and L2 in the erector spinae. Atrophy of the quadratus lumborum was consistent throughout the muscle, but cross-sectional areas of psoas muscle increased. Subjects who reported low back pain after bed rest showed, before reambulation, greater increases in posterior disc height, and greater losses of multifidus cross-sectional areas at L4 and L5 than subjects who did not report pain. These results provide evidence that changes in the lumbar discs during bed rest and selective atrophy of the multifidus muscle may be important factors in the occurrence of low back pain after prolonged bed rest.
Differential development of sensory hypersensitivity and a measure of spinal cord hyperexcitability following whiplash injury
From: Pain. 2010 Jun 29. [Epub ahead of print]
Widespread sensory hypersensitivity is present in acute whiplash and is associated with poor recovery. Decreased nociceptive flexion reflex thresholds (spinal cord hyperexcitability) are a feature of chronic whiplash but have not been investigated in the acute to chronic injury stage. This study compared the temporal development of sensory hypersensitivity and nociceptive flexion reflex responses from soon after injury to either recovery or to transition to chronicity. It also aimed to identify predictors of persistent spinal cord hyperexcitability. Pressure and cold pain thresholds, nociceptive flexion reflex responses (threshold and pain VAS) were prospectively measured in 62 participants at <3 weeks, 3 and 6 months post whiplash injury and in 22 healthy controls on two occasions a month apart. Pain levels and psychological distress (GHQ-28; IES) were measured at baseline. Whiplash participants were classified at 6 months post-injury using the Neck Disability Index: recovered (8%), mild pain and disability (10-28%) or moderate/severe pain and disability (30%).
All whiplash groups demonstrated spinal cord hyperexcitability (lowered nociceptive flexion reflex thresholds) at 3 weeks post-injury. This hyperexcitability persisted in those with moderate/severe symptoms at 6 months but resolved in those who recovered or reported lesser symptoms at 6 months. In contrast generalized sensory hypersensitivity (pressure and cold) was only ever present in those with persistent moderate/severe symptoms and remained unchanged throughout the study period. This suggests different mechanisms underlie sensory hypersensitivity and nociceptive flexion reflex responses. In multivariate analyses only initial Neck Disability Index scores were a unique predictor of persistent spinal cord hyperexcitability indicating possible ongoing peripheral nociception following whiplash injury.
Manual therapy and exercise for neck pain: a systematic review.
From: Man Ther. 2010 Aug;15(4):334-54
Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematic review update assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. Computerized searches were performed to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk and standardized mean differences were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias. Low quality evidence suggests clinically important long-term improvements in pain, function/disability, and global perceived effect when manual therapy and exercise are compared to no treatment. High quality evidence suggests greater short-term pain relief than exercise alone, but no long-term differences across multiple outcomes for (sub)acute/chronic neck pain with or without cervicogenic headache. Moderate quality evidence supports this treatment combination for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash. Evidence regarding radiculopathy was sparse. Specific research recommendations are made.