From: Arch Phys Med Rehabil. 2010 Sep;91(9):1313-1318

To determine whether neck manipulation is more effective for neck pain than mobilization, a randomized controlled trial with blind assessment of outcome was undertaken by the authors. The setting was Primary care physiotherapy, chiropractic, and osteopathy clinics in Sydney, Australia.

Patients (N=182) with nonspecific neck pain less than 3 months in duration and deemed suitable for treatment with manipulation by the treating practitioner were randomly assigned to receive treatment with neck manipulation (n=91) or mobilization (n=91). Patients in both groups received 4 treatments over 2 weeks, from which the number of days taken to recover from the episode of neck pain.

The median number of days to recovery of pain was 47 in the manipulation group and 43 in the mobilization group. Participants treated with neck manipulation did not experience more rapid recovery than those treated with neck mobilization. The authors concluded that neck manipulation is not appreciably more effective than mobilization. The authors further noted that the use of neck manipulation therefore cannot be justified on the basis of superior effectiveness.

It would be interesting to note a similar number of patients without any neck manipulation or mobilization and the number of median days to recover from nonspecific neck pain of less than 3 months duration. Additionally, the conclusion that “the use of neck manipulation therefore cannot be justified on the basis of superior effectiveness” should include – for nonspecific neck pain less than 3 months in duration with 4 treatments over a 2 week period. Without the entire article, one can only speculate why 4 treatments over 2 weeks would be deemed reasonable treatment for a nonspecific entity with either modality.

I presume the full article would delineate the criteria for being deemed suitable for treatment with manipulation or mobilization by the treating practitioner and if the evaluation methods were uniform between practitioners. Furthermore, the article should indicate specific analysis to reach a broad conclusion that manipulation cannot be justified on the basis of superior effectiveness – in fact, the abstract should have indicated that mobilization was more effective than manipulation for nonspecific neck pain of less than 3 months duration in a heterogeneous group of treating practitioners performing 4 treatments over a 2 week period.

Clin Biomech (Bristol, Avon). 2010 Aug 23. [Epub ahead of print]

Much is known about intervertebral disc degeneration, but little effort has been made to relate this information to the clinical problem of discogenic back pain, and how it might be treated. The authors re-interpret the scientific literature in order to provide a rationale for physical therapy treatments for discogenic back pain.

Intervertebral discs deteriorate over many years, from the nucleus outwards, to an extent that is influenced by genetic inheritance and metabolite transport. Age-related deterioration can be accelerated by physical disruption, which leads to disc “degeneration” or prolapse. Degeneration most often affects the lower lumbar discs, which are loaded most severely, and it is often painful because nerves in the peripheral anulus or vertebral endplate can be sensitised by inflammatory-like changes arising from contact with blood or displaced nucleus pulposus. Surgically-removed human discs show an active inflammatory process proceeding from the outside-in, and animal studies confirm that effective healing occurs only in the outer anulus and endplate, where cell density and metabolite transport are greatest. Healing of the disc periphery has the potential to relieve discogenic pain, by re-establishing a physical barrier between nucleus pulposus and nerves, and reducing inflammation.

Physical therapies should aim to promote healing in the disc periphery, by stimulating cells, boosting metabolite transport, and preventing adhesions and re-injury. Such an approach has the potential to accelerate pain relief in the disc periphery, even if it fails to reverse age-related degenerative changes in the nucleus.

Eur J Pain. 2010 Aug 19. [Epub ahead of print]

Back pain is common and some sufferers consult GPs, yet many sufferers develop persistent problems. Combining information on risk of persistence and prognostic indicator prevalence provides more information on potential intervention targets than risk estimates alone.

The aims of this study were to determine the proportion of primary care back pain patients with persistent problems whose outcome is related to measurable prognostic factors.

A Prospective cohort study of back pain patients (30-59years) at five general practices in Staffordshire, UK (n=389). Baseline factors (demographic; episode duration; symptom severity; pain widespreadness; anxiety; depression; catastrophising; fear-avoidance; self-rated health) were assessed for their association with disabling and limiting pain after 12-months. The proportion of those with persistent problems whose outcome was related to each factor was calculated.

Prevalence of prognostic factors ranged from 23% to 87%. Strongest predictors were unemployment and high pain intensity. The largest proportions of persistent problems were related to high pain intensity and unemployment. Combining these indicated that 85% of poor back pain outcome is related to these two factors. Poor self-rated health, functional disability, upper body pain and pain bothersomeness were related with outcome for over 40% of those with persistent problems.

Several factors increased risk of poor outcome in back pain patients, notably high pain and unemployment. These risks in combination with high prevalence of risk factors in this population distinguish factors that can help identify targets or sub-groups for intervention.

From: Eur Neurol. 2010 Aug 18;64(4):214-218. [Epub ahead of print]

The objective of this study was to estimate the incidence of posttraumatic dissections of cervical arteries in patients with whiplash injury acquired in a car accident. The authors performed a retrospective analysis of medical records of 500 patients with whiplash injury acquired in car accidents between 1996 and 2005 and searched for dissections of cervical arteries occurring within 12 months after injury. Eight cases of cervical arterial dissection occurred within 12 months following whiplash injury. In 7 cases (87.5%), the dissection was complicated by brain infarction. The incidence of posttraumatic dissections after whiplash injuries was much higher than the overall incidence of cervical arterial dissections in the general population. The risk of cerebrovascular events was still increased 4-12 months after whiplash injury vs. the general population.

There is an increased risk of posttraumatic dissection and cerebrovascular events within 12 months after whiplash injury. Car accident is an important risk factor for arterial dissections. The victims of car accidents should be screened for arterial dissections. The results of this study should be more thoroughly investigated in a prospective trial of car accident victims as a risk factor for arterial dissections.

From: Man Ther. 2010 Aug 11. [Epub ahead of print]

In the management of neck pain disorders, McKenzie recommends performing neck extension exercises from a fully neck retracted position in order to achieve a maximum range of lower cervical extension. However, no study has investigated the impact of pre-positioning the neck prior to the extension exercise. This study compared end-range sagittal cervical segmental rotation and translation from three starting positions: the neck in neutral, retraction and protraction.

Twenty asymptomatic healthy volunteers were recruited. Lateral radiographs were taken in neutral and at each of the three end-range extension positions and differences in sagittal rotation angles and translation from the neck neutral posture were calculated at each segment.

The results indicated that there was a significant difference in the pattern of the sagittal segmental rotation but no difference in summed rotations (total extension) between the three conditions. Protraction generated significantly greater extension range at C1-2 and retraction produced significantly greater extension range at C6-7 than alternate conditions. In contrast, there was no significant difference in segmental translation values between the three conditions. These results indicate initial neck positions can influence cervical segmental extension range at C1-2 and C6-7.

Pain Med. 2010 Aug;11(8):1169-78

The objective of the study was to investigate clinical effects of low-level laser therapy in patients with acute neck pain with radiculopathy. This was a double-blind, randomized, placebo-controlled study. The study was carried out between January 2005 and September 2007 at the Clinic for Rehabilitation at the Medical School, University of Belgrade, Serbia.

Sixty subjects received a course of 15 treatments over 3 weeks with active or an inactivated laser as a placebo procedure. Low-level laser therapy was applied to the skin projection at the anatomical site of the spinal segment involved with the following parameters: wavelength 905 nm, frequency 5,000 Hz, power density of 12 mW/cm(2), and dose of 2 J/cm(2), treatment time 120 seconds, at whole doses 12 J/cm(2).

The primary outcome measure was pain intensity as measured by a visual analog scale. Secondary outcome measures were neck movement, neck disability index, and quality of life. Measurements were taken before treatment and at the end of the 3-week treatment period.

Statistically significant differences between groups were found for intensity of arm pain and for neck extension. Low-level laser therapy gave more effective short-term relief of arm pain and increased range of neck extension in patients with acute neck pain with radiculopathy in comparison to the placebo procedure.

From: Pain. 2010 May;149(2):222-8. Epub 2010 Mar 16.

Myofascial pain of the temporomandibular region is a common, but poorly understood chronic disorder. It is unknown whether the condition is a peripheral problem, or a disorder of the central nervous system. To investigate possible central nervous system substrates of myofascial temporomandibular pain, the authors compared the brain morphology of 15 women with myofascial temporomandibular pain to that of 15 age- and gender-matched healthy controls. High-resolution structural brain and brainstem scans were carried out using magnetic resonance imaging (MRI), and data were analyzed using a voxel-based morphometry approach.

The myofascial temporomandibular pain group evidenced decreased or increased gray matter volume compared to controls in several areas of the trigeminothalamocortical pathway, including brainstem trigeminal sensory nuclei, the thalamus, and the primary somatosensory cortex. In addition, myofascial temporomandibular pain individuals showed increased gray matter volume compared to controls in limbic regions such as the posterior putamen, globus pallidus, and anterior insula. Within the myofascial temporomandibular pain group, jaw pain, pain tolerance, and pain duration were differentially associated with brain and brainstem gray matter volume. Self-reported pain severity was associated with increased gray matter in the rostral anterior cingulate cortex and posterior cingulate. Sensitivity to pressure algometry was associated with decreased gray matter in the pons, corresponding to the trigeminal sensory nuclei. Longer pain duration was associated with greater gray matter in the posterior cingulate, hippocampus, midbrain, and cerebellum. The pattern of gray matter abnormality found in myofascial temporomandibular pain individuals suggests the involvement of trigeminal and limbic system dysregulation, as well as potential somatotopic reorganization in the putamen, thalamus, and somatosensory cortex.

From: Man Ther. 2010 Aug 4. [Epub ahead of print]

This study investigated effectiveness of manual therapy with transcutaneous electrical nerve stimulation (TENS) to reduce pain intensity in patients with mechanical neck disorder. A randomized multi-centered controlled clinical trial was performed in 12 Primary Care Physiotherapy Units in Madrid Region. Ninety patients were included with diagnoses of subacute or chronic mechanical neck disorder without neurological damage, 47 patients received manual therapy and 43 TENS. The primary outcome was pain intensity measured in millimeters using the Visual Analogue Scale (VAS). Also disability, quality of life, adverse effects and sociodemographic and prognosis variables were measured. Three evaluations were performed (before, when the procedure finished and six months after). Seventy-one patients (79%) completed the follow-up measurement at six months. In more than half of the treated patients the procedure had a clinically relevant “short term” result after having ended the intervention, when either manual therapy or TENS was used. The success rate decreased to one-third of the patients 6 months after the intervention. No differences can be found in the reduction of pain, in the decrease of disability nor in the quality of life between both therapies. Both analyzed physiotherapy techniques produce a short-term pain reduction that is clinically relevant.

From: Injury. 2010 Jul 31. [Epub ahead of print]

People with Whiplash Associated Disorder often experience pain and disability for extended periods of time. A large proportion of these people will seek treatment through a compensation process. Rarely is data related to people’s health collected within the compensation process making it difficult to identify those that are at risk of delayed recovery and appropriately direct interventions.

To compare people with whiplash associated disorder who have recovered with those that have not, within 3 months of injury and identify potential predictors of poorer health and non-recovery to inform claim screening processes. People who sustained a whiplash associated disorder and claimed compensation within an Australian Motor Accidents Compensation Scheme between November 2007 and June 2009 participated in the study.

Recovery indicated by Functional Rating Index score less than or equal to 25. Outcome measures were Short Form 36 (SF36), FRI, and the Pain Catastrophising Scale. 246 people who had lodged a claim for compensation were enrolled in the Whiplash Outcome Study within 3 months of sustaining a whiplash associated disorder injury. Participants were assigned to a recovered or non-recovered group and analysed for differences between the two groups. Multiple linear regression models were used to identify potential predictors of poorer health and non-recovery.

Overall 23% of the study population had recovered within 3 months of sustaining a whiplash associated disorder, while only 9% had finalized their insurance claim. The recovered group had significantly better scores on all health outcome measures; SF36 Physical Component Score, SF36 Mental Component Score and the Pain Catastrophising Scale. The significant independent predictors of poorer health and non-recovery were helplessness, older age and pre-injury work status being affected. Regardless of the health outcome measure used, helplessness was significantly associated with poorer reported health.

Including additional information at claim notification, specifically the Pain Catastrophising Scale and information on the effect the injury has on the working population could significantly improve claim screening processes, identifying those with poorer health and risk of non-recovery.

Related Sources:

Physical and psychological factors maintain long-term predictive capacity post-whiplash injury

A prospective cohort study of health outcomes following whiplash associated disorders in an Australian population

From: Am J Med. 2010 Aug;123(8):711-8

Tinnitus, derived from the Latin word tinnire meaning “to ring,” is the perception of noise in the absence of an acoustic stimulus. It is a common condition that is usually subjective, perceived only by the patient, and therefore diagnosis and monitoring rely on self-report. Data from the 1996 National Health Interview Survey (NHIS) showed tinnitus was experienced by approximately 35-50 million adults in the US, with 12 million seeking medical care, and 2-3 million reporting symptoms that were severely debilitating. Cases and proposed etiologies of tinnitus are clinically heterogeneous and, although several treatment options have been tried, no single cure exists for the condition.

Patients who experience tinnitus often report significant associated morbidities. Lifestyle detriment, emotional difficulties, sleep deprivation, work hindrance, interference with social interaction, and decreased overall health have been attributed to tinnitus. Although causative relations are yet unknown, patients with tinnitus can have increased risk for depression, anxiety, and insomnia.

A limited number of risk factors for tinnitus have been suggested, the best described of which include increasing age, hearing loss, and loud noise exposure. These associations merit further exploration in a large cohort. Furthermore, the relations between tinnitus and other demographic and health factors are minimally characterized in the current literature. Therefore, the authors examined the relation between tinnitus and several potential risk factors using data from the National Health and Nutrition Examination Survey (NHANES), a large nationally representative survey.

The overall prevalence of tinnitus in the US was 25.3%, corresponding to a national estimate of 50 million adults. This prevalence is consistent with the upper range of the overall estimate previously reported from the NHIS (35-50 million). Similar to data from the Beaver Dam cohort, the prevalence of tinnitus in our study increased with age until the age of 60-69 years, after which it decreased with increasing age. This inverse relationship between age and tinnitus in older age groups has been demonstrated in several previous studies. One possible mechanism for this observation is that tinnitus may be associated with other conditions that confer a selective mortality disadvantage among individuals with tinnitus. The possibility also exists, however, that late symptomatic improvement may be part of the natural history of tinnitus.

The results of this study showed that non-Hispanic blacks and Hispanics had lower prevalence of any and frequent tinnitus than non-Hispanic whites. Although decreased prevalence in hearing loss has been reported previously in non-Hispanic blacks and Hispanics compared with non-Hispanic whites, this study is the first to report this association between race/ethnicity and tinnitus. The fact that significant associations between race/ethnicity and tinnitus were maintained in participants without hearing impairment suggests a mechanism for tinnitus that is independent of hearing impairment.

The significant associations between tinnitus and smoking and hypertension in this study suggest that vascular disease might have a greater contribution to the etiology of tinnitus than previously reported. Associations between cigarette smoking and hearing loss have previously been suggested, but data on the association between smoking and tinnitus remains scant. The data from the authors showed that current and past smoking confer increased odds of experiencing tinnitus. Although multiple past studies have analyzed the relation between cardiovascular disease and tinnitus, information on the association between hypertension and tinnitus has, up to now, been limited to cases of pulsatile tinnitus from vascular etiologies. These cases likely represent a minority of patients with tinnitus, as most patients with tinnitus present with subjective, sensorineural tinnitus.

Loud noise exposure is generally considered an important risk factor for developing tinnitus. In this study, history of leisure-time, occupational, and firearm noise exposure were all associated with increased odds of tinnitus. The relation between noise exposure and frequent tinnitus, however, differed depending on the presence or absence of hearing impairment. Occupational noise exposure was associated with increased odds of frequent tinnitus in participants with hearing impairment, while leisure-time noise exposure was associated with increased odds of frequent tinnitus in participants without hearing impairment. Occupational noise exposure has been reported to be strongly associated with both tinnitus and hearing loss, possibly due to its chronic effects on inner hair cell, outer hair cell, and acoustic nerve function. However, after an acute acoustic trauma, tinnitus is reported in the initial stages in 90% of the cases, and often persists even when the hearing loss is temporary. The differential vulnerability of cochlear and central components to duration and intensity of noise exposure may explain the variability between tinnitus and hearing loss in noise-exposed subjects.

These results demonstrate an important relation between tinnitus and mental health, as both anxiety and major depressive disorder were associated with increased odds of tinnitus. Participants with a history of either major depressive disorder or generalized anxiety disorder had greater than twice the odds of reporting any tinnitus compared with those not affected by these disorders. In addition, participants with a history of generalized anxiety disorder had >6 times the odds of reporting tinnitus compared with unaffected participants. Although this study is the first nationally representative study to find an association between tinnitus and mental health disorders, numerous smaller studies have reported similar associations. The cause for these associations is not yet known. Tinnitus can result in sleep deprivation, decreased work productivity, and overall lifestyle detriment. These factors might cause psychological distress and bring about or worsen symptoms of anxiety and depression. Major depressive disorder and generalized anxiety disorder, on the other hand, may exacerbate tinnitus, and their treatment might alleviate tinnitus.

Several strengths and limitations of this study should be considered. Data from NHANES is comprehensive and nationally representative, drawing from a large and diverse sample of participants. The study is, however, cross-sectional, making causative relationships impossible to determine. Tinnitus is most often a subjective complaint without a means of objective diagnosis. Therefore, comparisons between participants and studies are difficult. But, during the period of this study, consistency was maintained in assessing the presence and quality of tinnitus among participants.

In conclusion, these results offer insight into the prevalence of tinnitus and identify potentially vulnerable groups. We have demonstrated that, although the prevalence of tinnitus is generally higher at older ages, it also is frequently reported in young adults. Likewise, the potential risk factors for developing tinnitus are significant even in the younger adults. Therefore, opportunities may exist to prevent tinnitus, starting at a younger age. As no known cure exists for tinnitus, it is important to investigate potentially modifiable risk factors for tinnitus. Future research should examine the prospective relations between smoking, hypertension, noise exposure, and mental health conditions and tinnitus.

Clinical Significance:
•Tinnitus is a very common and potentially disabling condition, but few risk factors for its development are currently known.
•The relations between tinnitus and other demographic and health factors are minimally characterized in the current literature.
•Because tinnitus currently has no known cure, identifying potentially vulnerable groups and establishing potential risk factors in a large, nationally representative study is important for decreasing the burden of this condition.