From: J Rehabil Res Dev. 2009;46(4):499-514
For conventional motor vehicle seats, a head restrainteffectively reduces whiplash injuries to the neck in rear impact collisions, because it substantially reduces relative motion between the occupant’s head and chest. For wheelchair occupants traveling in adapted vehicles, a risk of whiplash injuries also exists, either for forward facing wheelchairs in a rear impact collision or for rearward facing wheelchairs in a frontal collision. However, unlike for motor vehicle seats, the provision of wheelchair head restraints is unregulated and testing of wheelchair head restraints in the mid-1990s indicated that commercial products failed in static tests through plastic bending of the vertical adjuster or pullout forces on the attachment bracket. Recent sled testing of head restraints for child wheelchair users showed that their presence significantly reduced a head restraint head fracture, concussion, and serious neck injury risk for rear impacts. However, how these findingsapply to AIS1 neck injury risk for adults in lower velocity rear impact whiplash cases is unclear. To address this problem, the authors performed a series of nine adult wheelchair occupant rear impact sled tests, where the BioRID-II was seated in a surrogate wheelchair. Tests were performed with and without a head restraint, and a new prototype and anexisting commercial head restraint were used.
Many wheelchair users remain in their wheelchairs during transit. Safety research for wheelchair users has focused mainly on frontal impact. However, although they are generally less severe, rear impact injuries are expensive and difficult to treat and whiplash injury protection for adult wheelchair users remains poorly understood. In this article, rear impact sled tests conducted with the Biofidelic Rear Impact Dummy II or BioRID-II seated in a rigid wheelchair with no head restraint showed that Abbreviated Injury Scale-score 1 neck injury risk evaluated with the neck injury criterion (NIC) and Nkm criterion is substantially above proposed threshold levels. A prototype wheelchair head restraint was developed and tested together with an existing commercial head restraint in the same rear impact. Both head restraints reduced the injury scores substantially. NIC test scores for the head restraints with no gap ranged from 18 to 24 (approximately 20%-30% chance of neck injury symptoms of duration >1 month) compared with test scores for no head restraints that ranged from 34 to 37 (approximately 95% chance of neck injury). The corresponding extension-posterior Nkm scores with no gap ranged from 0.30 to 0.35 (approximately 5% chance of neck injury) compared with no head restraint of 1.16 (approximately 45% chance of neck injury symptoms). However, the number of sled tests performed was small (three with no head restraint and six with a head restraint), and these results should be considered mainly trends. Preliminary results also showed that the horizontal gap between the head and the wheelchair head restraint cushion should be as small possible.
]]>From: Ann Fam Med. 2009 Sep-Oct;7(5):446-54
Complaints of arm, neck, and shoulder pain are very common in Western societies. In the Netherlands the estimated 12-month prevalence in the general population was 31% for neck pain, 30% for shoulder pain, 11% for elbow pain, and 18% for wrist or hand pain. Studies have reported that of the respondents with noninflammatory musculoskeletal pain, about 30% to 45% contacted their general practitioner. In Dutch general practice, incidence data for patients with nontraumatic arm, neck, or shoulder complaints show 97 consultations per 1,000 registered persons annually.
Common management options for patients with nontraumatic arm, neck, and shoulder complaints are watchful waiting, additional diagnostic tests, prescription of medication, referral for physiotherapy, a corticosteroid injection, and referral for medical specialist care. Use of these 6 management options shows wide variation, however, both between and within diagnostic groups. Until now, no studies have evaluated the determinants that contribute to variation in the management of these complaints. Part of this variation may be explained by the diagnosis, which, because of its natural course and available treatment, usually guides management. Also, patient and complaint characteristics may influence management. In the Netherlands guidelines issued by the Dutch College of General Practitioners are available for epicondylitis and shoulder complaints; in both guidelines, management advice is partly based on differences in the levels of hindrance (pain severity and functional limitations). In other study populations, patient and complaint characteristics reported to be associated with management options are distress, poor perceived health, age, and sex. Additionally, indicators of poor prognosis can play a role in management decisions. In our earlier study in this population, indicators of poor prognosis were long duration of the complaints at baseline, having musculoskeletal comorbidity, recurrent complaint, low social support, and a high somatization level.
The authors wanted to evaluate associations between diagnosis and characteristics of the patient, complaint, and general practitioner, as well as 6 common management decisions, in patients with nontraumatic arm, neck, and shoulder complaints at the time of the first consultation with their physician. They undertook an observational cohort study set in 21 Dutch general practices, including 682 patients with nontraumatic complaints of arm, neck, and shoulder. The outcome measure was application (yes/no) of a specific management option: watchful waiting, additional diagnostic tests, prescription of medication, corticosteroid injection, referral for physiotherapy, and referral for medical specialist care. Separate multilevel analyses showed that overall, the diagnostic category, having long duration of complaints, and reporting many functional limitations were most frequently associated with the choice of a management option. For watchful waiting, only complaint variables played a role (long duration of complaints, high complaint severity, many functional limitations, recurrent complaint). All these variables were negatively associated with watchful waiting. When opting for 1 of the 5 other management options, several physician characteristics played a role as well. Less clinical experience was associated with additional diagnostic tests and referral to a medical specialist. General practitioners working in a solo practice more frequently referred to a medical specialist. General practitioners working in a rural area more frequently referred for physiotherapy. Female General practitioners prescribed medication less frequently. Physicians with special interest in musculoskeletal complaints gave corticosteroid injections more frequently.
Diagnostic category, long duration of complaints, and high functional limitations were key variables in management decisions with arm, neck, and shoulder complaints complaints. In addition, several physician characteristics played a role as well.
]]>From: Man Ther. 2009 Oct;14(5):475-9
The cranio-cervical flexion test tests the coordination of the deep and superficial cervical flexor muscles during a cranio-cervical flexion task. The test has revealed impairments in muscle function in younger/middle aged patients with various neck pain disorders. Neck pain and headache are common in elders but it is unknown if age alone affects performance in the cranio-cervical flexion test. This study compared performance in the cranio-cervical flexion test between healthy asymptomatic elderly and younger subjects. Electromyographic (EMG) amplitude in the sternocleidomastoid, angle of cranio-cervical flexion and ability to target the pressure levels of each test stage were examined in 44 elderly and 39 young participants.
The results indicated that the elderly group had higher measures of normalized EMG signal amplitude in the sternocleidomastoid during the test, greater shortfalls from the target pressures of all stages of the test, except for the 22 mm Hg stage, and larger variability of the cranio-cervical flexion range of motion for the five successive stages of the test (particularly at 26, 28 and 30 mm Hg stages) compared to young subjects. Clinicians must be aware of this occurrence when assessing performance in the cranio-cervical flexion test in elders with neck pain.
]]>From: Ann Phys Rehabil Med. 2009 Oct 8.
The objective of this study was to assess the effect of mechanical and manual intermittent cervical traction on pain, use of analgesics and disability during the recent cervical radiculopathy. The authors made a prospective randomized study including patients sent for rehabilitation between April 2005 and October 2006. Thirty-nine patients were divided into three groups of 13 patients each. A group (A) treated by conventional rehabilitation with manual traction, a group (B) treated with conventional rehabilitation with intermittent mechanical traction and a third group (C) treated with conventional rehabilitation alone. The authors evaluated cervical pain, radicular pain, disability and the use of analgesics at baseline, at the end and at 1, 3 and 6 months after treatment.
At the end of treatment improving of cervical pain, radicular pain and disability is significantly better in groups A and B compared to group C. The decrease in consumption of analgesics is comparable in the three groups. At 6 months improving of cervical and radicular pain and disability is still significant compared to baseline in both groups A and B. The gain in consumption of analgesics is significant in the three groups: A, B and C. Manual or mechanical cervical traction appears to be a major contribution in the rehabilitation of cervical radiculopathy particularly if it is included in a multimodal approach of rehabilitation.
]]>From: Spine (Phila Pa 1976). 2009 Oct 16
The effect of postural change on degenerative lumbar discs was quantified using novel kinematic magnetic resonance imaging. The purpose is to describe the bulging of degenerative intervertebral lumbar discs in vivo subjected to different postural loads using a novel kinematic magnetic resonance imaging.
Symptomatic lumbar disc degeneration is a leading cause of pain and disability throughout the world. Over 70% of US citizens will experience a debilitating episode of low back pain. Earlier reports of degenerative disc changes are cadaver studies or are performed with recumbent MRI that eliminates the functional effects of gravity and muscle power. Little data are available on the behavior of degenerative intervertebral discs in vivo under physiologic loads.
A total of 513 patients obtained kMRI. Disc bulging beyond the intervertebral space was quantified during upright neutral, flexion, and extension imaging. The degree of intervertebral disc degeneration was correlated using the Pfirrmann Classification. Moderately degenerated intervertebral discs (grade III and IV) demonstrated greater bulging than mildly degenerated discs (grade II). Severely degenerated discs (grade V) also showed a trend toward greater bulging, but this was not significant. Grade I discs at all levels moved posteriorly in flexion and anteriorly in extension when compared to neutral posture. However, mild to severe (grade II-V) degenerative discs behaved differently in response to postural loads. Extension resulted in significant posterior bulging, while flexion did not demonstrate obvious anterior derangement.
Disc bulging increases with the severity of disc degeneration. Grade I discs demonstrate the expected sagittal migration in response to postural load. However, more degenerative discs behave less predictably, and spine extension may result in significant posterior disc bulging. Degenerative changes in the intervertebral disc significantly affect the kinematic patterns under postural load in vivo. Kinematic magnetic resonance imaging is a useful tool to quantify the kinematic behavior of degenerative intervertertebral discs.
]]>From: Spine (Phila Pa 1976). 2009 Oct 15;34(22):2389-94
This article investigates the effects of cervical disc herniation on kinematics at adjacent vertebral motion segments. Kinetic magnetic resonance imaging is an alternative method to conventional MRI, which allows evaluation of the cervical spine in a more physiologic, weight-bearing position, and acquisition of images in flexion, extension, and neutral alignment. Kinetic magnetic resonance imaging has previously been used to evaluate the effects of disc degeneration on cervical kinematics. A total of 407 patients with neck pain without prior history of surgery were evaluated using kinetic magnetic resonance imaging. Translational motion, angular variation, and disc height were measured at each segment from C2-C3 through C7-T1. Other factors including the degree of disc degeneration, age, gender, and vertebral segment location were analyzed in order to determine any predisposing risk factors for segmental instability adjacent to disc herniations.
Spinal levels above the disc herniation exhibited, on average, a 7.2% decrease in translational motion per mm of disc herniation, without significant change in angular motion. Levels below the herniation demonstrated a 5.2% decrease in angular motion per mm of disc herniation without significant change in translational motion. The degree of disc degeneration had no significant effect on adjacent level motion. Disc herniation had no significant impact on disc height at adjacent levels, although disc degeneration correlated with decreased disc height above and increased disc height below.
Although disc height, translational motion, and angular variation are significantly affected at the level of a disc herniation, no significant changes are apparent in adjacent segments. This study indicates that herniated discs have no effect on ROM at adjacent levels regardless of the degree of disc degeneration or the size of disc herniation, suggesting that the natural progression of disc degeneration and adjacent segment disease may be separate, unrelated processes within the cervical spine.
]]>From: Exp Brain Res. 2009 Oct 10
Chronic neck pain has been associated with disturbances in the sensorimotor control system in both non traumatic and whiplash related neck pain, such as postural stability disturbances, head and eye movement disturbances, erratic and irregular cervical motion patterns and stiffer, less flexible movement patterns. This points to centrally mediated somatosensory alterations with neck pain that may contribute to ongoing symptoms. Some motor impairments seem to particularly associate with a traumatic origin of the pain. Greater deficits in tests of head and eye movement control and decreased postural stability seem to distinguish whiplash associated disorder patients. Some of these deficits appear in association with the complaint of dizziness and neck pain intensity.
Patients with whiplash associated disorders have shown less accuracy in trajectory head motion compared to asymptomatic controls, which comply with clinical observations. The aim of this study was to investigate whether a trajectory head movement task can differ between whiplash associated disorders patients, chronic non traumatic neck pain patients and asymptomatic controls. Study groups included subjects with whiplash associated disorders (n = 35) with persistent neck pain after a car accident, chronic non traumatic neck pain (n = 45), and asymptomatic controls (n = 48). Head motion was recorded from an unsupported standing position using a 3D Fastrak device. A laser pointer was attached to the head and by moving the head the subjects were asked to trace a figure of eight displayed on the wall at three different paces (slow, moderate and fast). The motion signal was decomposed into 1 Hz frequency bands and angular velocity (deg/s) within each frequency band was calculated. Significantly higher angular RMS velocity was found in the whiplash associated disorders group compared to the two other groups for the slow paced test (3-4 and 4-5 Hz frequency bands) and the moderate paced test (3-4 Hz frequency band) indicating irregular and uncoordinated movements. Angular RMS velocity was associated with pain and dizziness, but only with severe symptom levels. In conclusion, irregular head movements during a complex task were found in the whiplash associated disorders group, indicating altered central sensorimotor processing. The irregularities were found within frequency levels observable to clinicians.
]]>From: BMJ. 2009 Oct 7;339:b3883
Cervical radiculopathy is a common disorder characterised by neck pain radiating to the arm and fingers corresponding to the dermatome involved. On examination, diminished muscle tendon reflexes, sensory disturbances, or motor weakness with dermatomal/ myotomal distribution can be found. The diagnosis is determined primarily on clinical grounds. Magnetic resonance imaging of the cervical spine usually shows the cause of the radiculopathy, which is usually spondylarthrosis or a herniated disc. This is often referred to as a pinched nerve.
Generally, degenerative cervical radiculopathy with subacute onset has a favourable prognosis, allowing a wait and see policy during the first six weeks. However, as pain is often excruciating during the first weeks to months, treatment to accelerate the improvement of pain and function would be highly valuable. Unfortunately, evidence is lacking for the effectiveness of any non-surgical treatment, including a wait and see policy, cervical collar, or physiotherapy. Two randomised trials comparing different non-invasive treatment methods in chronic cervical radiculopathy showed no benefit for physiotherapy or a cervical collar. Treatment in acute or subacute cervical radiculopathy has not yet been studied. Therefore,we evaluated the effectiveness of a semi-hard cervical collar in combination with taking as much rest as possible or physiotherapy and home exercises compared with a wait and see policy in recent onset cervical radiculopathy. We hypothesised that a treatment policy (collar or physiotherapy) would result in a faster decline in pain and improvement in function than would a wait and see policy.
To evaluate the effectiveness of treatment with collar or physiotherapy compared with a wait and see policy in recent onset cervical radiculopathy, neurology outpatient clinics in three Dutch hospitals included 205 patients with symptoms and signs of cervical radiculopathy of less than one month’s duration. Treatment with a semi-hard collar and taking rest for three to six weeks; 12 twice weekly sessions of physiotherapy and home exercises for six weeks; or continuation of daily activities as much as possible without specific treatment (control group).
Time course of changes in pain scores for arm and neck pain on a 100 mm visual analogue scale and in the neck disability index during the first six weeks. In the wait and see group, arm pain diminished by 3 mm/week on the visual analogue scale and by 19 mm in total over six weeks. Patients who were treated with cervical collar or physiotherapy achieved additional pain reduction, resulting in an extra pain reduction compared with the control group of 12 mm after six weeks. In the wait and see group, neck pain did not decrease significantly in the first six weeks. Treatment with the collar resulted in a weekly reduction on the visual analogue scale of 2.8 mm, amounting to 17 mm in six weeks, whereas physiotherapy gave a weekly reduction of 2.4 mm resulting in a decrease of 14 mm after six weeks. Compared with a wait and see policy, the neck disability index showed a significant change with the use of the collar and rest and a non-significant effect with physiotherapy and home exercises.
A semi-hard cervical collar and rest for three to six weeks or physiotherapy accompanied by home exercises for six weeks reduced neck and arm pain substantially compared with a wait and see policy in the early phase of cervical radiculopathy.
In this randomised study of patients with recent onset cervical radiculopathy, the authors found that treatment with a semi-hard cervical collar in combination with taking as much rest as possible for three weeks, with a maximum of six weeks, or standardised physiotherapy and doing home exercises for six weeks resulted in a significant reduction in arm and neck pain compared with a wait and see policy. The differences in pain reduction between the treatment and control groups varied from 12 to17 mm on a 100 mm visual analogue scale in six weeks and were highly statistically significant. Studies on visual analogue scale scores consider this difference to be clinically meaningful. One such study in patients with acute pain, mainly in emergency departments, showed that the meaning of a difference in pain scores depends on the height of the scores. In patients with scores between 34 and 66 mm, as in our patients at three and six weeks, a difference of 17 (SD 10) mm was found to be clinically meaningful. However, the setting differed from this study in which patients with subacute onset cervical radiculopathy were treated, and this may limit the interpretation of these data for our study population.
Disability decreased 9 points on the neck disability index over six weeks in the control patients, with an additional 5 point decrease in both the collar and physiotherapy groups. The additional effect of the collar on disability was small but statistically significant. Although the additional effect of physiotherapy on disability was not significant, a favourable effect on disability occurred, presumably owing to reduction. The less prominent effect on the neck disability index compared with the pain scores may well be explained by the fact that the index predominantly measures the disability caused by neck pain, whereas arm pain scores were highest initially and showed the largest improvement. All differences between the groups on the visual analogue scale and the neck disability index scores were no longer present at the six month follow-up. Most patients had no or limited pain, confirming earlier reports of the favourable natural course of the disease. As the patients had arm and neck pain for a mean of three weeks before entering the study, and as they were treated for six weeks, the authors have shown that both the cervical collar and physiotherapy are efficacious within this time frame. Considering the degree of pain reduction obtained at six weeks, further interventions after this period are not likely to be of benefit in most patients.
Little evidence exists on the mechanisms of collars and physiotherapy in giving pain relief, and the explanations provided in the literature are largely hypothetical. The collar probably reduces foraminal root compression and associated root inflammation by immobilising the neck, which might explain the larger reduction of arm pain compared with neck pain and neck disability as found in this study.
Physiotherapy aims at restoring range of motion and strengthening the neck musculature, probably diminishing secondary musculoskeletal problems, although the mechanism of pain reduction is unclear. Thirteen (6.3%) of the 205 patients, equally distributed over the three groups, were surgically treated during the six months of follow-up. Considerably higher percentages of surgery for cervical radiculopathy are reported in the literature. The authorsdiscussed surgical treatment options with patients who had persisting or intractable pain and referred them to their neurosurgical department. The low rate of surgery in this cohort may be due to the fact that their patients were included at an early stage, whereas previous studies including more chronic cases encompassed a larger number of patients who did not respond to non-surgical treatment. Furthermore, patients were possibly less inclined to have surgery because they participated in a study aimed at reducing signs and symptoms by non-surgical interventions.
The results of this randomised clinical trial show a clinically relevant short term reduction in pain in recent onset cervical radiculopathy with two therapeutic interventions—that is, a semi-hard cervical collar combined with taking rest and standardised physiotherapy accompanied by home exercises—compared with a wait and see policy. The authors recommend a semi-hard cervical collar and taking rest in recent onset cervical radiculopathy because the costs are lower than for physiotherapy, although physiotherapy is a good alternative with an almost similar efficacy.
]]>From: J Orthop Sci. 2009 Sep;14(5):602-10
The authors conducted a prospective long-term follow-up study to assess associations between magnetic resonance imaging (MRI) findings and changes in clinical symptoms, as well as factors relating to the prognosis of symptoms. A total of 133 patients with acute whiplash injury between 1993 and 1996 participated in this follow-up study. They underwent neurological examinations by spine surgeons and second MRI scans of the cervical spine were obtained. They also filled out a questionnaire regarding cervical symptoms and the accident details. The items evaluated by MRI were (1) a decrease in the signal intensity of the intervertebral disc; (2) anterior compression of the dura and the spinal cord; (3) posterior disc protrusion; (4) disc space narrowing; and (5) foraminal stenosis. Relations between the presence/absence of degenerative changes on MRI, accident details, and patients’ symptoms were assessed by calculating the adjusted odds ratio.
Progression of some degenerative changes was recognized on MRI in 98.5% of the 133 whiplash injury patients, and clinical symptoms diminished in more than a half of the 133 patients. There were no statistically significant associations between MRI findings and changes in clinical symptoms. The prognosis for neck pain tended to be poor after accidents with double collisions (rear-end collision followed by frontend collision) and accidents with serious car damage. The prognosis for stiff shoulders tended to be poor in women; and the prognosis for numbness in the upper extremities tended to be poor after accidents with serious car damage. This study demonstrated that progression of degenerative changes of the cervical spine on MRI was not associated with clinical symptoms during the 10-year period after whiplash injury.
]]>From: Clin Invest Med. 2009 Oct 1;32(5):E360-7
Chronic low back pain is one of the main causes of disability in the community. Although there have been studies suggesting an association between smoking and chronic low back pain, these studies were limited by the small numbers of patients, and they did not control for confounders. The objective of this study was to determine whether cigarette smoking is associated with an increased risk of chronic low back pain among adults.
Using Canadian Community Health Survey (cycle 3.1) data, 73,507 Canadians aged 20 to 59 yr were identified. Self-reported chronic low back pain status, smoking habits, sex, age, height, weight, level of activity and level of education were identified as well. Back pain secondary to fibromyalgia was excluded. Multivariate logistic regression analysis was used to detect effect modification and to adjust for covariates. Design effects associated with complex survey design were taken into consideration.
The prevalence of chronic low back pain was 23.3% in daily smokers and only 15.7% in non smokers. Age and sex were found to be effect modifiers, and the relationship between smoking and chronic low back pain risk was dependent on sex and age. The association between daily smoking and the risk of chronic low back pain was stronger among younger individuals. Occasional smoking slightly increased the odds of having chronic low back pain.
Daily smoking increases the risk of chronic low back pain among young adults, and this effect seems to be dose dependent. Back pain treatment programs may benefit from integrating smoking habit modification. Further research is required to develop effective prevention strategies.
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