Correlation between MR imaging and discography with provocative concordant pain in patients with low back pain.
From: Clin J Pain. 2011 Feb;27(2):125-30
The objective of this study aimed to correlate magnetic resonance findings and discography with pain response at provocative discography in patients with low back pain. Ninety-three patients who underwent magnetic resonance imaging of the lumbar spine and subsequent provocation discography as part of a clinical evaluation of low back pain were enrolled in the study.
Magnetic resonance images were evaluated for disc degeneration, high-intensity zone, and endplate abnormalities. In the procedure of discography, concordant pain was denoted as positive, whereas discordant pain and no pain were denoted as negative. Finally, magnetic resonance and discographic findings were analyzed by w2 test based on results of concordant pain.
Discography was conducted on 256 discs successfully, 116 discs of which presented with concordant pain, and the others presented with discordant pain. There were 141 discs we reevaluated as Grade I-III on magnetic resonance images, 17 of which presented with concordant pain; 115 were evaluated as Grade IV-V, 99 of which presented with concordant pain. High-intensity zone was found in 60 discs, 52 of which had concordant pain. The endplate abnormalities we reobserved in 58 discs, 51 of which manifested concordant pain. Concordant pain was significant correlated with Type IV-V discs on discography, Grade IV-V disc degeneration on magnetic resonance image, the presence of high-intensity zone, and endplate abnormalities.
Disc degeneration grades on magnetic resonance imaging showed an association with discographic grades. Type IV-V discs on discography, Grade IV-V disc on magnetic resonance images, the presence of high-intensity zone, and endplate abnormalities might indicate discogenic pain inpatients with chronic low back pain.
The effect of neck torsion on postural stability in subjects with persistent whiplash
From: Man Ther. 2011 Jan 19. [Epub ahead of print]
Loss of balance and sensations of dizziness and unsteadiness are symptoms commonly reported by patients with persistent neck pain. Research has shown that deficits in standing balance can be present in both traumatic and non-traumatic neck disorders, although these impairments seem to be more pronounced following a whiplash injury where such disturbances may be caused by damage to the neck receptors, vestibular receptors or the central nervous system.
Nevertheless, cervical afferent input is considered to be an important contributor to balance and previous studies have demonstrated an association between postural disturbances and deficits in neck proprioceptive acuity. Balance impairments in whiplash appear to be consistent with abnormal cervical afferent input at the neck joint and muscle receptors, although damage to the vestibular apparatus is possible. Even with recent evidence showing significant differences in balance responses between subjects with whiplash and those with vestibular pathology, current clinical measures used in the assessment of postural stability are not able to specifically differentiate between the two causes. Thus it would be useful to determine whether modifying existing tests of static balance might be helpful in determining the primary origin of sensorimotor impairments in whiplash associated disorders.
The Smooth Pursuit Neck Torsion test is a measure considered to be specific for differentiating between eye movement disturbances caused by altered cervical afferent input and abnormalities arising from the vestibular or the central nervous system. Difference in eye movement control with the head and trunk in a neutral forward facing position compared to when the trunk is rotated beneath the head. The latter neck torsion position acts to stimulate the cervical receptors but not the vestibular receptors. This technique has been shown to distinguish between subjects with vestibular pathology and those with neck pain in two previous studies where a torsion difference is only seen in those with neck pain and not in those with vestibular pathology. It would be an advantage to determine whether the use of the torsion position could be useful in the assessment of the causes of balance disturbances in those with neck pain.
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Evidence of an Inherited Predisposition for Cervical Spondylotic Myelopathy.
From: Spine (Phila Pa 1976). 2011 Jan 19. [Epub ahead of print]
This was a retrospective population based study cross referencing a genealogic database of over 2 million Utah residents with 10 years of clinical diagnosis data from a large tertiary hospital. The objective of this study is to determine the presence or absence of an inherited predisposition to the development of cervical spondylotic myelopathy.
A genetic predisposition for the development of cervical spondylosis has been discussed in the literature with low quality evidence. Families with a high incidence of disease or early onset disease in monozygotic twins have both been reported. However, these suggestions of an inherited predisposition for disease have never been rigorously studied. The purpose of this study is to determine a genetic predisposition among patients diagnosed with cervical spondylotic myelopathy.
The Utah Population Database (UPDB) combines health and genealogic data on over 2 million Utah residents. ICD-9 codes were used to identify 486 patients in the database with a diagnosis of cervical spondylosis with myelopathy (ICD9 code 721.1). The hypothesis of excessive familial clustering was tested using the Genealogical Index of Familiality and Relative risks in relatives were estimated by comparing rates of disease in relatives with rates estimated in the relatives of 5 matched controls for each case. This methodology has been previously reported and validated for other disease conditions but not for cervical spondylotic myelopathy.
The Genealogical Index of Familiality analysis for patients with cervical spondylotic myelopathy showed significant excess relatedness for disease. Relative risks were significantly elevated in both first and third-degree relatives. Excess relatedness of cases and significantly elevated relative risks to both close and distant relatives supports an inherited predisposition to cervical spondylosis with myelopathy.
Effectiveness of an educational and physical program in reducing accompanying symptoms in subjects with head and neck pain: a workplace controlled trial
From: J Headache Pain. 2011 Jan 20. [Epub ahead of print]
The objective of this study is to evaluate the effectiveness of an educational and physical program in reducing behavioral or somatic symptoms along with headache, neck and shoulder pain in a working community. A controlled, non-randomized trial was carried out in a working community and 384 employees were enrolled and divided into a study group (Group 1) and a control group (Group 2). The Group 1 received a physical and educational intervention, consisting of relaxation and posture exercises and the use of visual feedback. After 6 months, the intervention was administered to the Group 2. Both groups were then followed for an additional 6 months until the end of the trial. The presence of accompanying symptoms was investigated with a semi-structured interview using a checklist of 20 items, along with headache, neck, and shoulder pain parameters and the prevalence of generalized anxiety disorder and depression, in three clinical examinations at baseline, after 6 months and after 12 months. For each symptom, as well as the presence of any type of symptom, the differences between groups in the prevalence at the clinical examinations following the baseline were evaluated by applying logistic models.
After 6 months, the probability of the presence of any type of symptom was significantly lower in the Group 1 with respect to the Group 2. After 12 months, the pooled estimation did not show any significant difference of symptom prevalence between groups. In conclusion, this is the first longitudinal study relative to accompanying symptoms. Its results suggest the effectiveness of this cognitive program in reducing the burden of physical and psychiatric complaints in a large, working population.
Treating tension-type headache – an expert opinion
From: Expert Opin Pharmacother. 2011 Jan 20. [Epub ahead of print]
Tension type headache is a highly prevalent disorder with enormous costs for the individual and the society. Nonpharmacological and pharmacological treatments are reviewed. Electromyographic (EMG) biofeedback has a documented effect in tension type headache, while cognitive-behavioral therapy and relaxation training are most likely to be effective. Physical therapy and acupuncture may be valuable options for patients with frequent tension type headache. Simple analgesics and nonsteroidal anti-inflammatory drugs are recommended for treatment of episodic tension type headache. Combination analgesics containing caffeine are drugs of second choice. Triptans, muscle relaxants and opioids should not be used. It is crucial to avoid frequent and excessive use of analgesics to prevent the development of medication-overuse headache. The tricyclic antidepressant amitriptyline is the drug of first choice for the prophylactic treatment of chronic tension type headache. Mirtazapine and venlafaxine are second-choice drugs.
There is an urgent need for more research in nonpharmacological as well as pharmacological treatment possibilities of tension type headache. Future studies should examine the relative efficacy of the various treatment modalities and clarify how treatment programs can be optimized and combined to best suit the individual patient. Frequent tension type headache may be difficult to treat, but an acceptable result can usually be obtained by a combination of nonpharmacological and pharmacological treatments.
Effects of three different conservative treatments on pain, disability, quality of life, and mood in patients with cervical spondylosis
From: Rheumatol Int. 2011 Jan 19. [Epub ahead of print]
This aim of this study was to determine the effect of different conservative treatment methods on pain intensity, disability, quality of life, and mood in patients with cervical spondylosis during a 6-month period. The patients were randomized into three groups. The 1st group (n = 20) was treated with active and passive physiotherapy methods, the 2nd group (n = 20) with active treatment methods, and the 3rd group (n = 20) with medication, including nonsteroid anti-inflammatory and muscle relaxing medicines. The 1st and 2nd groups received individual exercise treatment according to their current problems as determined by the assessment.
Pain recovery was found to be statistically significant after treatment and long-term follow-up for all three groups. Disability improvement was significant in all groups after treatment and 3rd months and only in 1st group after 6 months. Quality of life improvement was significant in all groups after treatment, at 3 months, and in the 1st and 2nd groups at 6 months. Psychological recovery was significant in all groups after treatment and in the 1st and 2nd groups during long-term follow-up. It was determined that patient satisfaction did not change in the 1st and 2nd group, but decreased in the 3rd group during long-term follow-up. There was more improvement in the two groups receiving exercise treatment than the group receiving medical treatment. The article concluded, exercise treatment has an important role in achieving long-term recovery of problems occurring with cervical spondylosis.
Simulated malingering in the testing of cervical muscle isometric strength
From: J Back Musculoskelet Rehabil. 2010;23(3):117-27
Malingering is a DSM IV diagnosis and defined as an intentional production of falsely or grossly exaggerated physical or psychological symptoms. Determination of sincerity of effort in cervical strength testing is difficult, especially since there is a lack of a gold standard with which to compare clinical subjects’ performances. The authors sought to determine if simulated malingering trials of isometric cervical muscular strength in flexion, extension and right/left bending are substantially different from maximum effort trials in young, healthy subjects.
A convenience sample of healthy, young adult subjects was used (M=9, F=9) who were free of neck pain. A uniaxial load cell was used to measure forces (N) produced by three trials of isometric flexion, extension and bilateral bending contractions of the head/neck muscles in two modes: comfortable maximum and simulated insincere malingering. An ANOVA model was created and tested post-hoc for paired differences within and between modes and genders. A separate ANOVA was conducted to test for differences in the ratio between flexion and extension.
In comfortable maximum mode, males were stronger in all ranges vs females; the expected flexion and extension ratio and bilateral ratios were demonstrated and good consistency of effort within and between trials was demonstrated by low CV’s and high ICC’s, respectively. In simulated insincere malingering mode, all mean peak values were significantly lower in both genders; however, the difference between genders disappeared. Within-trial consistency was much poorer with significantly higher CV’s while between-trial variability was good as demonstrated by high ICC’s. The flexion/extension ratio was increased in simulated insincere malingering vs comfortable maximum, with no difference between genders. It appears that simulated malingering trials produced consistent patterns of deviation from maximal effort trials: reduced peak values, increased flexion/extension ratio and increased variability of within-trial effort. These findings may provide a basis for valid indicators of insincere effort in neck pain and/or whiplash patients.
Synovial folds – A pain in the neck?
From: Man Ther. 2011 Jan 7. [Epub ahead of print]
The synovial folds of the cervical spine are regarded as a potential source of neck pain and headache, especially following whiplash injury. Damage to the synovial folds following motor vehicle trauma has been well documented in post-mortem studies. However, methods of identifying injury to the synovial folds in the survivors of motor vehicle trauma have proven elusive to date. Recently, it has been made possible to image the synovial folds in vivo using magnetic resonance imaging. This now makes it feasible to investigate the potential involvement of synovial folds in the generation of neck pain and headache and its relief using spinal manipulation. This paper reviews critically the morphology of the synovial folds of the cervical spine that underpins the hypotheses proposed to explain their functional and clinical significance and a new system of naming and classifying the synovial folds is presented. Although there is some evidence to support the contribution of the synovial folds to neck pain, several theories have little or no support and require investigation and further evaluation. These findings have implications for understanding the anatomical basis of neck pain and headache and the rationale for the use of spinal manipulation in their management.
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Cooling the neck region during exercise in the heat
From: J Athl Train. 2011 Jan-Feb;46(1):61-8.
Cooling the neck region can improve the ability to exercise in a hot environment. It might improve performance by dampening the perceived level of thermal strain, allowing individuals to override inhibitory signals. The objective of this study was to investigate whether the enhanced ability to exercise in a hot environment observed when cooling the neck region occurs because of dampening the perceived level of thermal strain experienced and the subsequent overriding of inhibitory signals. This was a crossover study in a walk-in environmental chamber of eight endurance-trained, nonacclimated men.
Intervention(s): Participants completed 4 running tests at approximately 70% V˙O(2max) to volitional exhaustion: 2 familiarization trials followed by 2 experimental trials (cooling collar [CC] and no collar. Trials were separated by 7 days. Familiarization and no collar trials were performed without a collar and used to assess the test variability.
Main Outcome Measure(s): Time to volitional exhaustion, heart rate, rectal temperature, neck skin temperature, rating of perceived exertion, thermal sensation, and feeling scale (pleasure/displeasure) were measured. Results: Time to volitional exhaustion was increased by 13.5% ± 3.8% (cooling collar = 43.15 ± 12.82 minutes, no collar = 38.20 ± 11.70 minutes; t(7) = 9.923, P < .001) with the cooling collar, which reduced mean neck skin temperature throughout the test (P < .001). Participants terminated exercise at identical levels of perceived exertion, thermal sensation, and feeling scale, but the cooling collar enabled participants to tolerate higher rectal temperatures (CC = 39.61°C ± 0.45°C, no collar = 39.18°C ± 0.7°C; t(7) = -3.217, P = .02) and heart rates (CC = 181 ± 6 beats/min, no collar = 178 ± 9 beats/min; t(7) = -2.664, P = .03) at the point of termination.
Conclusions: Cooling the neck increased the time taken to reach volitional exhaustion by dampening the perceived levels of thermal strain. There was no indication that neck pain was correlated with thermal strain.
Whiplash-associated disorders and temporomandibular symptoms following motor-vehicle collisions
From: Quintessence Int. 2011 Jan;42(1):e1-e14.
Recent research has shown that temporomandibular symptoms may be associated with or occur independently of whiplash associated disorders related to motor-vehicle collisions. A PubMed/Medline search was conducted using the terms “temporomandibular disorders,” “orofacial pain,” “temporomandibular joint,” “whiplash,” and “whiplash associated disorders and motor vehicle accidents and motor vehicle collisions” for the years 1995 to 2009. Systematic reviews, meta-analyses, and clinical studies were included if they addressed temporomandibular disorders, whiplash epidemiology, diagnosis, and prognosis. References in the selected articles were also reviewed (including those prior to 1995) if the articles specifically addressed the topic. An evidence base was established for general outcomes using the Oxford Centre for Evidence-Based Medicine Levels of Evidence. Temporomandibular symptoms may develop following motor vehicle collisions and be more complex, representing a component of a symptom cluster of potentially regional and widespread pain impacted by psychosocial factors. Oral health care providers must be aware of the relationship between temporomandibular symptoms, whiplash-associated disorders, and trauma and the more complex nature of the symptoms for appropriate diagnosis and management.
