Neck Solutions

Vestibular evoked myogenic potentials (VEMPs) in whiplash injury: a prospective study

From: Acta Otolaryngol. 2008 Nov 13;:1-6 [Epub ahead of print]

Patients affected by whiplash associated disorder presented alterations of vestibular evoked myogenic potentials. Vestibular evoked myogenic potentials testing may be an important ‘forensic’ diagnostic tool in the assessment of cervical spine injury. The purpose of this prospective study was to evaluate changes in vestibular evoked myogenic potentials in the assessment of whiplash injuries. Patients and methods. Fourteen patients complaining of whiplash injury were examined and compared with 15 controls. All patients underwent vestibular evoked myogenic potential testing within 7 days from the injury and 90 days after whiplash injury. Beside vestibular evoked myogenic potentials, standard investigation consisted of pure-tone and speech audiometry, impedance audiometry and evaluation of the vestibular system. Results. All subjects presented normal hearing, normal impedence audiometry findings, and normal vestibular function. Vestibular evoked myogenic potentials were present both in patients affected by whiplash injury and in the control group at time 0. At 90 days vestibular evoked myogenic potentials were absent in two cases (14.3%). Statistical analysis showed that at time 0 and at time 90 days p1 latency was significantly higher in whiplash patients compared with healthy subjects on both sides. The amplitude of p1-n1 was significantly lower in whiplash patients, but not at 90 days.

Intervertebral neural foramina deformation due to two types of repetitive combined loading

From: Clin Biomech (Bristol, Avon). 2008 Nov 11; [Epub ahead of print]

Tissue compression and noxious stimuli are known to elicit pain from neural tissues in the spine. Compression of nerve roots due to decreases in the intervertebral foramina may be caused by posture, sustained loading and disc height loss, herniation, or altered mechanics. It has been established that non-neutral postures combined with repeated loading can cause disc herniations, however information regarding the effect of repetitive axial twist loading is limited. The objectives of this study were twofold; to measure the occlusion of the foramina due to two types of repetitive loading and to investigate whether repetitive combined axial twist loading can contribute to disc injury.

Sixteen porcine cervical spine segments (C5/6) were subjected to 1500N of compression combined with either repetitive flexion-extension motions or 16.4 degrees (Standard Deviation 2.1) of static flexion with repetitive axial twist motions. The foramina pressure was measured bilaterally using plastic tubing and a custom pressure monitoring system. Specimens were loaded until 10,000 cycles were reached or disc herniation occurred.

Significantly larger pressure (pre-post difference) developed in the intervertebral foramina of specimens that were repetitively flexed-extended compared to those that were repetitively twisted. All of the flexed-extended specimens herniated, whereas in the twisted specimens five (62.5%) had incomplete herniations, one (12.5%) sustained a facet fracture, and two (25%) had no damage. There was no difference between the loading groups for vertical height loss.

Repetitive loading of flexion-extension motions are a viable pain generating pathway in absence of distinguishing height loss. This information may be useful to consider for the diagnosis and treatment of nerve root compression.

Sustained effects of comprehensive inpatient rehabilitative treatment and sleeping neck support in patients with chronic cervicobrachialgia

From: Int J Rehabil Res. 2008 Dec;31(4):342-6

Clinical experience shows that the intensity of cervical syndrome patients’ complaints is affected by the nighttime sleeping posture, as any long-lasting inappropriate posture of the spine can irritate the capsular ligaments of the motor segments. These patients’ complaints revolve mostly around pain sensations that appear primarily during the night and in the morning, and frequently cause sleep disturbances. It is difficult to alleviate such symptoms by physical therapy and postural exercises. Therefore, the night-time sleeping position must be changed to achieve physiological positioning of the spine. In addition to adequate mattresses, sleeping neck supports (special neck pillows) can optimize the sleeping position.

The aim of this study was to determine whether inpatient rehabilitative treatment along with sleeping neck supports has long-term benefits in patients suffering from chronic cervicobrachialgia (neck and arm pain).

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The Nordic back pain subpopulation program: predicting outcome among chiropractic patients in Finland

From: Chiropr Osteopat. 2008 Nov 7;16(1):13 [Epub ahead of print]

The causes of non specific low back pain are largely unknown. Obviously, this is a hindrance to a rational approach to both prevention and treatment. In general, both etiologic studies and randomized controlled clinical trials are based on the concept that non specific low back pain is one single entity. However, most clinicians with an interest in back pain probably consider it to consist of several specific conditions, which have not been properly recognized, understood and described.

Chiropractors in the Nordic countries use predominantly spinal manipulative therapy in their treatment of back problems, frequently in combination with soft tissue therapy, advice on exercise, ergonomic precautions, and lifestyle changes. Randomized controlled clinical trials have shown that spinal manipulative therapy has a positive effect on low back pain. However, overall, the magnitude of the effect seems to be relatively small. Those, who believe that back pain consists of several specific but (as yet) undefined subgroups, obviously think that the recognition of these would improve the quality of care and that the selection of homogeneous study populations in etiological studies and clinical trials would improve the quality of research.

Until recently it has not been documented which patients with low back pain are most likely to benefit from the chiropractic approach. However, the predictive value of a set of clinical observations has been previously studied in patients with low back pain receiving chiropractic care. This research, conducted in Norway and Sweden under the Nordic Back Pain Subpopulation Program, has been running over the past years, in which specific subgroups of patients with low back pain are systematically studied. For instance, it was shown that it is possible to predict which chiropractic patients with persistent low back pain will not report definite improvement early in the course of treatment, making it possible to exclude from treatment those who are unlikely to become low back pain free. Furthermore, early recovery at the 4th visit was noted to be a predictor for outcome 3 and 12 months later and the status already by the second visit predicted status at the fourth visit.

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A comparison of functional assessment instruments and work status in chronic back pain

From: Eur J Phys Rehabil Med. 2008 Nov 4; [Epub ahead of print]

The aim of this cross sectional study was to analyse whether low back pain functional assessment instruments correlate well with work status measures. This study was a cross sectional study that enrolled 375 patients with chronic low back pain attending back pain outpatient clinics of a University Hospital and a specialist rehabilitation centre over a period of one year. The outcome scores measured were Oswestry Disability Index, Roland Morris Disability Questionnaire and Orebro Musculoskeletal Pain Questionnaire. The effect of back pain on their work status was also recorded and correlated to the above instrument values.

There was a only a modest correlation between work status and the three measured outcome scores, with the Spearman rank correlation being 0.47 for OMPQ, 0.43 for ODI and 0.39 for RMQ. The studied standard low back pain outcome measures and work status are not interchangeable. The impact on work status should not be assumed based on the severity of these outcome measures and should be recorded as a separate outcome measure in chronic low back pain.

Does Continuing Education Improve Physical Therapists’ Effectiveness in Treating Neck Pain?

From: Phys Ther. 2008 Nov 6; [Epub ahead of print]

Physical therapists often attend continuing education courses to improve their overall clinical performance and patient outcomes. However, evidence suggests that continuing education courses may not improve the outcomes for patients receiving physical therapy for the management of neck pain. The purpose of this study was to investigate the effectiveness of an ongoing educational intervention for improving the outcomes for patients with neck pain. Participants The study participants were 19 physical therapists who attended a 2-day continuing education course focusing on the management of neck pain. All patients treated by the therapists in this study completed the Neck Disability Index and a pain rating scale at the initial examination and at their final visit.

Therapists from 11 clinics were invited to attend a 2-day continuing education course on the management of neck pain. After the continuing education course, the therapists were randomly assigned to receive either ongoing education consisting of small group sessions and an educational outreach session or no further education. Clinical outcomes achieved by therapists who received ongoing education and therapists who did not were compared for both pretraining and posttraining periods. The effects of receiving ongoing education were examined by use of linear mixed-model analyses with time period and group as fixed factors; improvements in disability and pain as dependent variables; and age, sex, and the patient’s initial Neck Disability Index and pain rating scores as covariates.

Patients treated by therapists who received ongoing education experienced significantly greater reductions in disability during the study period (pretraining to posttraining) than those treated by therapists who did not receive ongoing training. Changes in pain did not differ for patients treated by the 2 groups of therapists during the study period. Therapists in the ongoing education group also used fewer visits during the posttraining period. The results of this study demonstrated that ongoing education for the management of neck pain was beneficial in reducing disability for patients with neck pain while reducing the number of physical therapy visits. However, changes in pain did not differ for patients treated by the 2 groups of therapists. Although it appears that a typical continuing education course does not improve the overall outcomes for patients treated by therapists attending that course, more research is needed to evaluate other educational strategies to determine the most clinically effective and cost-effective interventions.

Simplified form of tinnitus retraining therapy in adults: a retrospective study

From: BMC Ear Nose Throat Disord. 2008 Nov 3;8(1):7 [Epub ahead of print]

Tinnitus retraining therapy is aimed at removing negative associations of the tinnitus signal to enable the natural habituation process to occur. The goal is to achieve this through retraining counseling and sound therapy. Retraining counseling is a crucial part of tinnitus retraining therapy; it teaches patients the components of the neurophysiological model of tinnitus and encourages them to reclassify their tinnitus as a neutral signal. Sound therapy is assumed to facilitate tinnitus habituation by decreasing the strength of tinnitus signal. The tinnitus retraining therapy protocol requires that the patient adheres to the regimen for 12-24 months (typically attending for seven sessions over that time), except for patients experiencing weak tinnitus, which hearing aids little impact on everyday life.

Since the first description of tinnitus retraining therapy in the 1990s, clinicians have modified and customised the method of tinnitus retraining therapy to suit their practice and their patients. A simplified form of tinnitus retraining therapy hearing aids been used at Ealing Primary Care Trust (PCT) Audiology Department since 2005. This is different from tinnitus retraining therapy in the type and (shorter) duration of retraining counseling. Although the counseling used in simplified tinnitus retraining therapy also aims to get the patient to reclassify tinnitus as a neutral stimulus, it is different from the counseling used in tinnitus retraining therapy in the following ways: (1) there is no teaching about basic functions of the auditory system; (2) there is no presentation of the basics of brain function and the interactions of various systems of the brain; (3) there is no explanation of the theoretical basis of habituation based on the Jastreboff neurophysiological model; and (4) the duration of the initial counseling of simplified tinnitus retraining therapy is 30 minutes in comparison to 90 minutes for the initial tinnitus retraining therapy counseling.

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Muscle disorders and dentition-related aspects in temporomandibular disorders: controversies in the most commonly used treatment modalities.

From: Int Arch Med. 2008 Oct 30;1(1):23 [Epub ahead of print]

This review explores the aetiology of temporomandibular disorders and discusses the controversies in variable treatment modalities. Pathologies of the temporomandibular joint (TMJ) and its’ associated muscles of mastication are jointly termed temporomandibular disorders (TMDs). TMDs present with a variety of symptoms which include pain in the joint and its surrounding area, jaw clicking, limited jaw opening and headaches. It is mainly reported by middle aged females who tend to recognize the symptoms more readily than males and therefore more commonly seek professional help. Several aetiological factors have been acknowledged including local trauma, bruxism, malocclusion, stress and psychiatric illnesses. The Research Diagnostic Criteria of the Temporomandibular Disorders (RDC/TMD) is advanced to other criteria as it takes into consideration the socio-psychological status of the patient. Several treatment modalities have been recommended including homecare practices, splint therapy, occlusal readjustment, analgesics and the use of psychotropic medication; as well as surgery, supplementary therapy and cognitive behavioural therapy. Although splint therapy and occlusal readjustment have been extensively used, there is no evidence to suggest that they can be curative; a number of evidence-based trials have concluded that these appliances should not be suggested as part of the routine care. Surgery, except in very rare cases, is discouraged since it is the most invasive alternative; recent studies have shown healthier outcome with cognitive behavioural therapy.

Torque - electromyography velocity relationship in female workers with chronic neck muscle pain

From: J Biomech. 2008;41(9):2029-35. Epub 2008 May 5

The present study investigated the effect of chronic neck muscle pain (defined as trapezius myalgia) on neck and shoulder muscle function during concentric, eccentric and static contraction. Forty-two female office workers with chronic neck muscle pain and 20 healthy matched controls participated. Isokinetic and static maximal voluntary shoulder abductions were performed in a Biodex dynamometer, and electromyography obtained in the trapezius and deltoideus muscles. Muscle thickness in the trapezius was measured with ultrasound. Pain and perceived exertion were registered before and after the dynamometer test. The main findings were that shoulder abduction torque and trapezius electromyography amplitude were significantly lower in chronic neck muscle pain compared with healthy matched controls. Deltoideus electromyography and trapezius muscle thickness were not significantly different between the groups. While perceived exertion increased in both groups in response to the test, pain increased in chronic neck muscle pain only. In conclusion, having trapezius myalgia was associated with decreased strength capacity and lowered activity of the painful trapezius muscle. The most consistent differences in terms of both torque and electromyography were found during slow concentric and eccentric contractions. Activity of the synergistic pain free deltoideus muscle was not significantly lower, indicating specific inhibitory feedback of the painful trapezius muscle only. Parallel increase in pain and perceived exertion among chronic neck muscle pain were observed in response to the maximal contractions, emphasizing that heavy physical exertion provokes pain increase only in conditions of myalgia.

Kinematic Analysis of the Relationship Between Sagittal Alignment and Disc Degeneration in the Cervical Spine

From: Spine. 2008 Nov 1;33(23):E870-E876;

The cervical spine withstands the axial load of the head and is the most mobile region of the spine. Normal lordotic alignment is one of the most important factors contributing to effective motion and function of the cervical spine. The discs degenerate with age, and degeneration may ultimately affect the mechanical properties of spinal motion. On the other hand, it was reported that severe degenerative changes tend to produce less cervical lordosis. The loss of normal lordotic alignment may induce pathologic changes in the kinematics and may accelerate degeneration of the functional motion unit. Furthermore, it is well known that sagittal malalignment in cervical degenerative disorders causes spinal morbidities such as neck pain and deterioration of neurologic deficit. However, the relationship of altered alignment on the kinematics and degeneration of the cervical spine has not been elucidated thus far.

Kinetic magnetic resonance imaging (MRI) allows us to obtain images of patients in weight-bearing and flexion-extension positions and eventually provides considerable information, which would have been unavailable if a conventional MRI were used. It may also help in understanding the true nature of spinal pathologies. In addition, it can demonstrate the mobility of each motion segment and finally, relate the mobility to the changes in sagittal alignment and disc degeneration.

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