Neck Solutions

Cervicogenic headache

Cervicogenic headache

From: Pol Merkur Lekarski. 2008 Jun;24(144):549-51 Article in Polish

In 2004 cervicogenic headache (neck related headache) was introduced into ICD-10 classification.The reasons of cervicogenic headache are changes within bones, soft tissue and nervous structures of cervical spine section. The pain may spread to the neck, occipital area of skull, area of jaw and eyeballs, and arms. There are many theories trying to explain spreading of the pain outside the area innervated by C1, C2 and C3 cervical roots. Their common denominator is communication between fibres running in those roots and neurons of trigeminal nerve. Many authors describe a possibility of such connection through the jelly-like nucleus of the trigeminal nerve located in the back funiculi of spinal cord. In this mechanism, the pain conducted via occipital nerves may affect activity of neurons of the trigeminal nerve and influence areas innervated by the trigeminal nerve. In general case history and physical examination are sufficient to make a diagnosis. Additional radiological and imaging examinations support this diagnosis. According to some authors, the necessary condition to make a diagnosis of cervicogenic headache is finding the changes of spondylosis nature of the cervical spine section (neck arthritis or degenerative disc disease) in additional examinations. In doubtful cases, diagnostic blockade of greater occipital nerve, resulting in headache relief, supports finally a diagnosis. Any treatment includes pharmacotherapy, rehabilitation, psychotherapy and surgical methods. The purpose of the study is to view literature on cervicogenic headache which causes many diagnostic problems and hence makes it difficult to choose effective treatment.

Neck injury during whiplash increased with head turned postures

Head-turned postures increase the risk of cervical facet capsule injury during whiplash

From: Spine. 2008 Jul 1;33(15):1643-9

Injury to the cervical facet capsular ligaments is a potential mechanism for chronic neck pain after acute whiplash injury. Distending the facet capsule by injecting contrast media has produced whiplash like pain patterns in normal individuals, and anesthetic blocks have isolated the cervical facet joints as the source of pain in about half of a chronic whiplash population. More recently, in vivo animal models of facet capsule loading have shown that group III and IV afferents (thought to mediate pain) from the facet capsule have a graded electrical response to mechanical loading of the facet joint in the goat and have suggested that a capsular ligament strain threshold exists above which allodynia pain in response to a normally nonnoxious stimulus is produced. These data support a facet capsule based mechanism for whiplash injury, but do not establish whether human capsular ligaments are injured in the low speed rear end collisions to which many whiplash injuries are attributed.

Whiplash patients who had their head turned at impact have more severe and persistent symptoms than patients who were facing forward. These findings have prompted biomechanical studies using human cadaveric necks to investigate why a head turned posture increases injury potential. Dynamic rear impact tests of prerotated ligamentous spines (occiput-T1) produce increased neck flexibility (interpreted as injury) in extension, lateral bending and axial rotation. Though concentrated in the lower cervical spine, these injuries were not isolated to particular spinal ligaments. Detailed measurements of the strain field in the facet capsule have also shown that a head-turned posture generates higher capsular strains than a neutral head posture, but the quasi static loads applied during those tests were limited to pure neck flexion/extension moments and did not include the axial compression or posterior shear present during whiplash loading. Thus the question of how a head turned posture combined with multiaxial whiplash loads affects facet capsular ligament strain has yet to be answered.

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Incidence of shoulder and neck pain in a working population

Incidence of shoulder and neck pain in a working population: effect modification between mechanical and psychosocial exposures at work? Results from a one year follow up of the Malmö shoulder and neck study cohort

From: J Epidemiol Community Health. 2005 Sep;59(9):721-8

Work related musculoskeletal disorders and complaints constitute an important health problem in many industrialised countries, as they account for a large number of working days lost and considerable workers compensation and disability payments. For a long time, low back pain has been the dominant problem. However, pain from the shoulder and neck region now seems to occur more frequently. The prevalence of shoulder and neck symptoms is highest in the 45–65 year age bracket, as well as among women, manual workers, and certain ethnic groups.

However, its aetiology is still incompletely understood. Mechanical exposure at work and psychosocial conditions within and without the workplace, in addition to lifestyle and individual variables (age, previous symptoms, etc) are frequently discussed as causal factors in the literature.

Shoulder and neck symptoms have been linked to jobs with highly repetitive work, static work, and work above shoulder level. However, mechanical exposure explains only part of these complaints. The role of psychosocial factors in the workplace has therefore received increasing attention. On the job pressure, monotonous work, and a high perceived workload have also been associated with musculoskeletal symptoms just as much as working situations characterised by high psychological demands, low decision latitude, and low social support.

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Musculoskeletal discomfort at work predicts low back, neck and shoulder pain

Does musculoskeletal discomfort at work predict future musculoskeletal pain?

From: Ergonomics. 2008 May;51(5):637-48

The objective of this prospective cohort study was to evaluate if peak or cumulative musculoskeletal discomfort may predict future low back, neck or shoulder pain among symptom free workers. At baseline, discomfort per body region was rated on a 10 point scale six times during a working day. Questionnaires on pain were sent out three times during follow-up. Peak discomfort was defined as a discomfort level of 2 at least once during a day; cumulative discomfort was defined as the sum of discomfort during the day. Reference workers reported a rating of zero at each measurement.

Peak discomfort was a predictor of low back pain (relative risk (RR) 1.79), neck pain (RR 2.56), right or left shoulder pain (RR 1.91 and 1.90). Cumulative discomfort predicted neck pain (RR 2.35), right or left shoulder pain (RR 2.45 and 1.64). These results suggest that both peak and cumulative discomfort could predict future musculoskeletal pain.

Disability in subacute whiplash and the Neck Disability Index

Disability in subacute whiplash patients: Usefulness of the Neck Disability Index

From: Spine J. 2008 August ;33(18)630-635

Whiplash describes a process of hyperextension and hyperflexion of the cervical musculature that may result from motor vehicle collisions. The incidence of whiplash has been estimated to be of 1 case per 1000 habitants per year in Western societies, nevertheless available studies report conflicting rates. Symptoms associated with whiplash problems typically resolve in a relatively brief time (days or weeks), but chronic pain, and long-term disability may occur in 10% to 40% of the cases.

The prevention and treatment of chronic disabling pain in whiplash patients has shown to be elusive. On the one hand, predictive factors of chronic disabling problems in whiplash patients are far from being completely elucidated. Although one can hypothesize that factors from different levels (i.e., physiology, thoughts, feelings, and behavior) and units (i.e., individual, dyad, and context) of analysis play a role, very few and inconsistent findings are available. On the other hand, there is limited evidence about what is the most beneficial treatment for whom and under what circumstances. The use of many different outcome variables and assessment instruments may be responsible, in part at least, of the problems encountered in this area of research to compare results across studies and extract definitive conclusions.

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Thoracic spine manipulation, electrotherapy and thermal program for acute mechanical neck pain

Inclusion of thoracic spine thrust manipulation into an electro-therapy/thermal program for the management of patients with acute mechanical neck pain

From: Man Ther. 2008 Aug 7; [Epub ahead of print]

Approximately 25% of all outpatient physical therapy visits consist of patients with symptoms involving the neck region. It has been found that nearly half of the individuals with neck pain will experience debilitating symptoms. Over a third of patients with neck pain will develop chronic symptoms lasting more than 6 months, and nearly a third who experience a first time onset of neck pain will continue to report continued healthcare utilization for their symptoms at a 10-year follow-up.

Physical therapists utilize a number of interventions in the management of neck pain including joint manipulation (non-thrust and thrust), exercises, massage, thermo-therapy or electrotherapy (American Physical Therapy Association, 2001). However, robust evidence to support the use of many of these therapeutic strategies for neck pain is lacking. The Philadelphia Panel Clinical Practice Guidelines concluded that many commonly used interventions for patients with neck pain lack sufficient evidence to justify their clinical use. Recently, evidence has begun to emerge for the use of manual procedures directed at the thoracic spine for patients with mechanical neck pain. Cleland et al. found that thoracic thrust manipulation results in immediate improvements in neck pain at rest as measured by the visual analogue scale, compared to patients receiving a placebo manipulation. Further, it has also been found that at short-term follow-up patients receiving thoracic manipulation exhibit superior outcomes to patients receiving non-thrust techniques.

The importance of investigating the effectiveness of thoracic spinal manipulation is necessary considering the fact that the thoracic spine is the region of the spine most often manipulated, despite the fact that more patients complain of neck pain. Further, decreased mobility in the thoracic spine has been shown to be related to the presence of neck pain symptoms, so it is possible that manipulation of the thoracic spine may alter the biomechanics of the cervical region and decrease mechanical stress. Finally, it has previously been identified that either cervical mobilization or manipulation induces an activation of descending inhibitory mechanisms; hence, thoracic spine thrust manipulations may also result in a reduction of neck symptoms.

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Behaviour graded activity program versus conventional exercise for chronic neck pain

Effectiveness of a behaviour graded activity program versus conventional exercise for chronic neck pain patients

From: Eur J Pain. 2008 Aug 7; [Epub ahead of print]

Chronic neck pain is a common complaint in the Netherlands with a point prevalence of 14.3%. Patients with chronic neck pain are often referred to physiotherapy and, nowadays, are mostly treated with exercise therapy. It is, however, unclear which type of exercise therapy is to be preferred. Therefore, this study evaluates the effectiveness of behaviour graded activity compared with conventional neck exercises for patients with chronic neck pain. Eligible patients with non-specific chronic neck were randomly allocated to either behaviour graded activity or conventional neck exercises. Primary treatment outcome is the patient’s global perceived effect concerning recovery from complaint and daily functioning. Outcome assessment was performed at baseline, and at 4, 9, 26, and 52 weeks after randomization. Effectiveness was examined with general estimating equations analyses. Baseline demographics and patient characteristics were well balanced between the two groups. Mean age was 45.7 years and the median duration of complaints was 60 months. The mean number of treatments was 6.6 in behaviour graded activity and 11.2 in conventional neck exercises.

No significant differences between treatments were found in their effectiveness of managing patients with chronic neck pain. In both behaviour graded activity and conventional neck exercises some patients reported recovery from complaints and daily function but the proportion of recovered patients did not exceed 50% during the 12-month follow-up period. Both groups showed clinically relevant improvements in physical secondary outcomes.

Association between cervical pillar hyperplasia and degenerative joint disease

Segment-specific association between cervical pillar hyperplasia and degenerative joint disease

From: Chiropractic & Osteopathy 2006, 14:21

Cervical pillar hyperplasia is a radiological finding which first made its appearance in the literature less than 30 years ago. Its etiology and clinical significance are presently unknown; nevertheless, studies have shown that cervical pillar hyperplasia is a frequently overlooked etiology for the loss of the cervical lordosis. While these findings were disputed by several authors, other consequences of cervical pillar hyperplasia are not known at the present time. It has been theorized that the architectural difference that the presence of hyperplasia introduces into the cervical pillar may cause segmental biomechanical changes and may lead to a higher prevalence of degenerative joint disease at the hyperplastic or adjacent cervical levels. The clinical significance of this phenomenon, if found to be related to degenerative joint disease, should prompt an astute clinician into evaluating the articular pillars on all cervical spine radiographs – particularly because there could be a chance that the patient may develop degeneration at the specific cervical levels and may experience associated neck pain. The architecture of the cervical pillars cannot be modified by conservative therapy; therefore, clinicians should be aware that some of the symptoms may be attributed to degeneration and may influence the expected prognosis of the management of neck pain in those particular patients.

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Whiplash injuries can be visible by functional magnetic resonance imaging

Whiplash injuries can be visible by functional magnetic resonance imaging

From: Pain Res Manag. 2006 Autumn;11(3):197-9

Whiplash trauma can result in injuries that are difficult to diagnose. Diagnosis is particularly difficult in injuries to the upper segments of the cervical spine (craniocervical joint complex). Studies indicate that neck injuries in that region may be responsible for the cervicoencephalic syndrome, as evidenced by headache, balance problems, vertigo, dizziness, eye problems, tinnitus, poor concentration, sensitivity to light and pronounced fatigue. Consequently, diagnosis of lesions in the craniocervical joint region is important.

Functional magnetic resonance imaging is a radiological technique that can visualize injuries of the ligaments and the joint capsules, and accompanying pathological movement patterns. Three severely injured patients that had been extensively examined without any findings of structural lesions were diagnosed by functional magnetic resonance imaging to have injuries in the craniocervical joint region. These injuries were confirmed at surgery, and after surgical stabilization the medical condition was highly improved. It is important to draw attention to the urgent need to diagnose lesions and dysfunction in the craniocervical joint complex and also improve diagnostic methods in whiplash injuires.

Subendplate microcirculation disturbance in intervertebral disc degeneration

Subendplate microcirculation disturbance directly contributes to intervertebral disc degeneration

From: Zhonghua Wai Ke Za Zhi. 2008 Feb 1;46(3):213-6 Article in Chinese

To build subendplate microcirculation disturbance animal model and to investigate the potential pathogenesis of intervertebral disc degeneration. Twenty four New Zealand white rabbits were divided into treatment group (Group A) and control group (Group B). In Group A, animals received endotoxin and corticosteroid application to build subendplate microcirculation disturbance animal model, validated by microthrombus staining. In Group B, animals were given no drug, but standard feeding. After 3 month, the extent of intervertebral disc degeneration was evaluated by the water content, biochemistry analysis, and morphology. Subendplate microthrombus staining confirmed the exist of microcirculation disturbance.

The water content and biochemistry components content of disc in Group A were lower than those of disc in Group B, and intervertebral disc degeneration was observed in morphology. Subendplate microcirculation disturbance can directly contribute to intervertebral disc degeneration, the nutrients diffusion barrier is the potential pathogenesis of intervertebral disc degeneration.