Neck Solutions

Clinimetric evaluation of methods to measure muscle functioning in patients with non-specific neck pain: a systematic review

From: BMC Musculoskelet Disord. 2008 Oct 19;9(1):142 [Epub ahead of print]

Neck pain is a common but significant health problem in modern society, with reported 1-year prevalence values in the world population varying from 16.7% to 75.1% for adults, with a mean of 37.2%. Annual incidence rates of neck pain in general practice in the Netherlands have been estimated at 23 of every 1000 persons registered with a GP. The incidence rates increase with age up to 40 to 60 years, and then decrease slightly. Neck pain is generally more common in women than in men. It often has a continuous or intermittent course. Approximately 30% of people with neck pain face restrictions in their activities of daily living. In the Netherlands, 51% of patients with acute non-specific neck pain who consult their general practitioners are referred to musculoskeletal practitioners for treatment.

It is estimated that the neck musculature contributes about 80% to the mechanical stability of the cervical spine, while the osseoligamentous system contributes the remaining 20%. There is evidence to suggest that patients with neck pain have reduced maximal isometric neck strength and endurance capacity. Furthermore, jerky and irregular neck movements and poor position sense acuity have been found in patients with chronic neck pain. Musculoskeletal practitioners apply various treatment modalities to treat patients with non specific neck pain. Exercises are commonly used to improve neck muscle function and thereby decrease pain or other symptoms. Evaluating the progress of neck muscle function during treatment requires tests which can be carried out easily and meet certain standards for clinimetric properties.

A 2001 review of the reliability and validity of neck muscle strength, endurance and proprioception concluded that there was a lack of reliable and valid instruments to measure strength, endurance and proprioception. This review did not formulate any criteria for quality assessment, and although it included all the instruments suitable for measuring neck muscle function, it did not address cost, practicality and use of the tests. In the present review we have included only those instruments that can be easily used in daily practice (maximum of 5 minutes required for testing) and that are affordable (maximum 1000 euros). The purpose of this literature review is thus to summarise the clinimetric properties of the tests or instruments for neck muscle function in patients with neck pain which can be easily applied in daily practice.

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Hypoesthesia occurs in acute whiplash irrespective of pain and disability levels and the presence of sensory hypersensitivity

From: Clin J Pain. 2008 November/December;24(9):759-766

In contrast to the increasing knowledge of the sensory dysfunction involved in chronic whiplash associated disorders, the use of comprehensive quantitative sensory testing in the acute stage of the condition is sparse. In this study, we sought to investigate the presence of sensory hypoesthesia in participants with acute whiplash injury. Fifty-two volunteers within 4 weeks after a motor vehicle accident and 31 healthy asymptomatic volunteers were recruited for this study. We classified our cohort into either a high risk (signs associated with poor recovery including Neck Disability Index scores greater than 30, cold and mechanical hyperalgesia, heightened brachial plexus provocation test responses) or low risk group (without these signs). Detection thresholds to electrical, thermal, and vibration stimuli measured in lower cervical nerve root innervation zones and psychologic distress and posttraumatic stress symptoms were compared between the groups using multivariate analysis of covariance.

Both the high risk and low risk groups exhibited significant elevation in sensory detection when compared with controls. There was no difference in detection thresholds between the 2 whiplash groups, except for electrical detection which was greater in the high risk group. Both groups were psychologically distressed. Our findings demonstrate generalized hypoesthesia in acute whiplash associated disorders suggesting adaptive central nervous system processing mechanisms are involved, regardless of pain and disability. The elevated levels of psychologic distress seen in both groups may also play a role.

Catastrophizing and Causal Beliefs in Whiplash

From: Spine. 2008 Oct 15;33(22):2427-33;

In recent decades, whiplash has become the most common diagnosis following motor vehicle accidents. In its acute phase whiplash is defined as myogenic neck complaints after a sprain of the neck.

Although the majority of patients show spontaneous recovery within the first few months after a traffic accident, in as many as 40% of cases these acute complaints lead to a chronic syndrome with neck pain and often cognitive complaints. This chronic syndrome is often referred to as late or postwhiplash syndrome, characterized by unexplained physical and cognitive symptoms. Although still subject to debate, a general consensus is building that postwhiplash syndrome should be regarded as a functional somatic syndrome in which cultural as well as psychological factors play a major role.

Postwhiplash syndrome can lead to invalidating effects and long term work disability. It is therefore of paramount importance to gain insight into the factors responsible for this chronic course.

Earlier work in the context of other chronic disorders characterized by unexplained physical complaints, such as chronic low back pain, provided evidence to suggest that pain catastrophizing and attributional bias are of crucial importance in the development of chronic complaints. In the Fear Avoidance model for chronic musculoskeletal pain, the pathway from pain experience to fear, anxiety, and avoidance, leading ultimately to disuse and disability, is modulated by catastrophizing and threatening illness beliefs. Similar mechanisms may also apply to chronic neck complaints. Preliminary support for this comes from recent studies showing that fear of pain and the presence of relatively intense anxiety symptoms are related to poor prognosis of neck complaints following motor vehicle accidents.

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Patient education for neck pain with or without radiculopathy

From: Cochrane Database Syst Rev. 2008 Oct 8;(4):CD005106

Neck disorders are common, disabling, and costly. The effectiveness of patient education strategies is unclear. To assess whether patient education strategies, either alone or in combination with other treatments, are of benefit for pain, function, global perceived effect, quality of life, or patient satisfaction, in adults with neck pain with and without radiculopathy.

Computerized bibliographic databases were searched from their start up to May 31, 2008. Eligible studies were quasi or randomized trials (RCT) investigating the effectiveness of patient education strategies for neck disorder. Paired independent review authors carried out study selection, data abstraction, and methodological quality assessment. Relative risk and standardized mean differences (SMD) were calculated. The appropriateness of combining studies was assessed on clinical and statistical grounds. Because of differences in intervention type or disorder, no studies were considered appropriate to pool.

Of the 10 selected trials, two (20%) were rated high quality. Advice was assessed as follows: Eight trials of advice focusing on activation compared to no treatment or to various active treatments, including therapeutic exercise, manual therapy and cognitive behavioural therapy, showed either inferiority or no difference for pain, spanning a full range of follow-up periods and disorder types. When compared to rest, two trials that assessed acute whiplash associated disorders showed moderate evidence of no difference for various forms of advice focusing on activation. Two trials studying advice focusing on pain & stress coping skills found moderate evidence of no benefit for pain in chronic mechanical neck disorder at intermediate/long-term follow-up. One trial compared the effects of ‘traditional neck school’ to no treatment, yielding limited evidence of no benefit for pain at intermediate-term follow-up in mixed acute/subacute/chronic neck pain.

This review has not shown effectiveness for educational interventions in various disorder types and follow-up periods, including advice to activate, advice on stress coping skills, and ‘neck school’. In future research, further attention to methodological quality is necessary. Studies of multimodal interventions should consider study designs, such as factorial designs, that permit discrimination of the specific educational components.

Temporomandibular joint dysfunction : A consequence of whiplash injury

From: HNO. 2008 Oct 3; [Epub ahead of print] [Article in German]

In 10-20% of patients with a simple whiplash injury without severe structural lesions, a chronification of the complaints occurs. The question is whether some unidentified pathogenic factors exist. Investigations have demonstrated that mandibular and head and neck movements are coordinated and centrally controlled and that a craniocervical neck dysfunction can lead to a temporomandibular joint dysfunction by reflex action and vice versa. This study investigated whether a whiplash injury can lead to a temporomandibular joint dysfunction. A total of 187 patients with whiplash associated disorders were examined for temporomandibular joint dysfunction. Simple tests with and without loading of the mandible were used to initially diagnose temporomandibular joint dysfunction and the diagnosis was confirmed electrophysiologically. Temporomandibular joint dysfunction could be verified in all patients with whiplash associated disorders. According to these investigations a craniocervical neck dysfunction was regularly found in patients with whiplash associated disorders and relief from suffering can often not be achieved without treatment of the craniocervical neck dysfunction.

Cervical outcome measures: testing for postural stability and balance

From: J Manipulative Physiol Ther. 2008 Sep;31(7):540-6

Clinical tests assessing a correlation between structural pathology and cervical pain have been unsuccessful, leading the way for the development of functionally based tests. The purpose of this narrative is to review 4 promising functional tests for the assessment of sensorimotor dysfunction in patients with neck pain. The Joint Position Error/Head Repositioning Accuracy tests, and the Rod and Frame Test were reviewed. The SPNTT was developed to test proprioceptive mechanisms in the neck by applying torsion to mainly mechanoreceptors in the cervical spine. The Joint Position Error and Head Repositioning Accuracy test cervicocephalic kinesthesia or the ability to perceive both movement and position of the head in space related to the trunk. The Rod and Frame Test assesses patients’ perception of the vertical orientation of their head in 3-dimensional space. All of these tests evaluate important mechanisms responsible for maintaining postural stability and balance and are thought to be applicable for use in mechanical neck pain patients.

All of the reviewed tests show clinical promise because they are able to distinguish patients with neck pain, particularly those with whiplash trauma and dizziness from asymptomatic controls. All of the tests assess cervical sensorimotor dysfunction, although considerably more research is needed to more clearly establish the psychometric properties for each test including minimal clinical important difference. Although these tests can be used in routine clinical practice, they should be used in combination with other related tests.

Validity of the Neck Disability Index and Neck Pain and Disability Scale for measuring disability associated with chronic, non traumatic neck pain

From: Man Ther. 2008 Sep 26; [Epub ahead of print]

Neck pain has a lifetime prevalence of about 70% in the general population. Although acute neck pain often resolves, about 19% of the population may suffer from chronic neck pain at any given time. Measurement of the impact of neck pain on the sufferer presents a challenge due to the variability between patients in pain intensity, and the effect of the disorder on physical and psychological functions. Measures of pain intensity and tissue sensitivity have been used to quantify the sensory dimension of neck pain disorders, while range of motion and muscle function has been used to measure impairments of physical function. However, recent recommendations place greater emphasis on functional status and quality of life more broadly, in the evaluation of neck pain disorders.

Measurement of function has been a developing theme in neck pain research as this shifts the focus away from signs and symptoms towards the specific effects of the symptoms on patient function. In relation to neck pain, this includes neck function, physical function more generally, and psychological function. A range of neck pain specific questionnaires have been developed for this purpose, and have been incorporated into recent clinical studies. The value of questionnaires is dependent on a range of factors but of primary importance is the validity, particularly in relation to construct and content. A recent review of neck pain specific questionnaires concluded that most have not been extensively validated, and recommended a comparative study to better define the psychometric properties of the commonly used instruments.

The Neck Disability Index is the most commonly used questionnaire for the measurement of neck pain disability. It was originally developed to evaluate the activities of daily living in patients with disabling neck pain, particularly that resulting from whiplash trauma. The Neck Disability Index includes 10 questions of which 7 examine functional activities, 2 ask about symptoms and the final question considers concentration. The Neck Pain and Disability Scale was developed to provide clinicians with a tool to assess the multi dimensional effects of the neck pain disorder. The scale consists of 20 questions relating to 4 domains (neck function, pain intensity, emotion/cognition and activities of daily living) which look at the effects of the neck pain disorder on patients’ physical and emotional functions. The potential limitation of these questionnaires, and others with fixed questions, is that they constrain the scope of the evaluation to the specific issues included. Therefore, the questionnaire may include questions not relevant to some patients, and may not include issues of importance.

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Intrarater Reliability of CROM Measurement of Cervical Spine Active Range of Motion in Persons With and Without Neck Pain

From: J Orthop Sports Phys Ther. 2008 Oct;38(10):640-5

Clinical measurement, intrarater reliability study to determine the intrarater reliability of cervical active range of motion (AROM) measurement of subjects with and without neck pain using the cervical range of motion device (CROM). Cervical spine cervical active range of motion data are used by physical therapists to assist in identifying movement impairment, monitor patient progress, and evaluate the effectiveness of intervention. Presently, insufficient literature exists regarding the intrarater reliability of cervical active range of motion measurements using the cervical range of motion device. Twenty-five adult subjects without neck pain and 22 adult subjects with neck pain volunteered for the study. Two trials of cervical active range of motion measurement (6 movements) were performed for each subject. Practice sessions, methods of measurement, and rest time between trials were standardized; order of measurement was randomized.

The intraclass correlation coefficients for the subjects without neck pain ranged from 0.87 for flexion to 0.94 for left rotation. The standard error of the measurement ranged from 2.3 degrees to 4.0 degrees. The intraclass correlation coefficients for the subjects with neck pain ranged from 0.88 for flexion to 0.96 for left rotation. The standard error of the measurement ranged from 2.5 degrees to 4.1 degrees. Minimal detectable change ranged from 5.4 degrees for left rotation in the subjects without neck pain to 9.6 degrees for flexion in the subjects with neck pain.

Intrarater reliability for cervical active range of motion measurement of persons with and without neck pain is sufficient to consider use of the cervical range of motion device in clinical practice, although changes between 5 degrees to 10 degrees are needed to feel confident that a real change in spine mobility has occurred.

Education of Patients After Whiplash Injury: Is Oral Advice Any Better Than a Pamphlet?

From: Spine. 2008 Sep 29; [Epub ahead of print]

Whiplash associated disorders are a condition with neck pain and a variety of other symptoms that may follow an acceleration deceleration trauma to the neck. Most frequently whiplash associated disorders is a result of a car collision. Large resources are allocated to the treatment of whiplash associated disorders and to financial compensation because of lost working ability due to whiplash.

A number of recent trials have pointed toward the lack of positive results of active treatments after whiplash injuries when compared to just informing patients about the injury and giving them advice to stay active. Neither immobilization in a semirigid collar nor active mobilization following the principles of Mechanical Diagnosis and Therapy were more effective than information given during an approximately 1 hour session with a nurse, in which focus was on reassurance of the patient and recommendation of activity despite the pain. Additionally, information given by the general practitioner has been shown to be as effective as education, advice, and active exercise therapy at physiotherapists.

The evidence to support that patient education actually affects the prognosis is somewhat conflicting. An educational pamphlet focusing on reassurance and continuation of normal activities did not reduce the risk of long-lasting symptoms compared to usual emergency department care, and a 20-minute video sent to patients only showed a tendency to improve the outcome. Oppositely, in one trial a 12-minute educational video shown at the bedside improved the prognosis dramatically compared with the standard care at the emergency unit.

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Degenerative and traumatic changes in the lower cervical spine facet joints

From: Scand J Rheumatol. 2008 Sep-Oct;37(5):375-84

The aim of this study was to examine anatomical variables of the lower cervical spine facet joints with regard to age, gender, and exposure to trauma. The lower four cervical spine segments (C4-C7 included) were obtained from 40 subjects during autopsy: 12 females and 28 males (median age 35 years, range 20-49). Through an available 636 unique facets (318 joints), 1830 randomly obtained observation lines were defined. Each of these lines resembled a 3-mm-thick parasaggital slice through a facet from which 10-microm-thick histological sections were produced and evaluated microscopically. Inter and intraobserver agreement was tested on four randomly selected facets from each subject.

Significant age, gender, and trauma related changes in the bone, cartilage, and soft tissues were observed, including subchondral sclerosis, fibrillation and splitting of cartilage, and cartilage length differences. Females were less affected by changes in the cartilage than males. Two synovial folds were present in all but one joint. Moderate interobserver and good intraobserver agreement were achieved. This study provides knowledge of the anatomy of the cervical spine facet joints. The findings support existing knowledge that males are more commonly affected by degenerative changes than females and that these changes are common from a young age. Histomorphometry confirms the presence of synovial folds in all of the facet joints. Following spinal trauma, pathological lesions may be produced in the facet joints and/or accentuate already existing pathology. The information provided in this study may have relevance for patients with neck pain.