Neck Solutions Blog

November 12, 2011

Unpacking the burden: Understanding the relationships between chronic pain and comorbidity in the general population

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Unpacking the burden: Understanding the relationships between chronic pain and comorbidity in the general population

From: Pain. 2011 Nov 7. [Epub ahead of print]

The authors investigated the association of chronic pain with physical and mental comorbidity in the New Zealand population by measuring chronic pain status separate from comorbid conditions. Models of allostatic load provided a conceptual basis for considering multi-morbidity as accumulated comorbid load and for using both discrete conditions and cumulative measures in analyses. The nationally representative cross-sectional survey data included self-reported doctor-diagnosed chronic physical and mental health conditions, Kessler 10-item scale scores, an independent measure of chronic pain, and sociodemographic characteristics.

The population prevalence of chronic pain is 16.9%, and a quarter (26%) of the population report 2 or more comorbid physical conditions statistically associated with chronic pain. Results indicate that accumulated comorbid load is independently associated with chronic pain. Six physical conditions independently associated with chronic pain increase the risk of chronic pain in an additive manner, and residual accumulated load further increases risk for 2 or more conditions.

Anxiety and depression interacts synergistically with arthritis and neck and back disorders to increase the odds of reporting chronic pain beyond an additive model. This synergistic effect is not apparent for other conditions or for additional comorbid load. Results imply that measurement of chronic pain independent of comorbid conditions and adjustment for comorbid conditions is important for more accurate prevalence estimates and understanding relationships between conditions. Future epidemiological research might usefully incorporate independent measurement of chronic pain alongside adjustment for specific physical and mental health conditions as well as accumulated comorbid load.

September 6, 2011

Treatment of Patients With Degenerative Cervical Radiculopathy Using a Multi-Modal Conservative Approach in a Geriatric Population

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Treatment of Patients With Degenerative Cervical Radiculopathy Using a Multi-Modal Conservative Approach in a Geriatric Population: A Case Series.

From: J Orthop Sports Phys Ther. 2011 Sep 4. [Epub ahead of print]

To describe the management of 10 patients with advanced cervical spondyloarthrosis with radiculopathy using manual therapy, intermittent mechanical cervical traction, and home exercises. Predictors and short-term outcomes of cervical radiculopathy have been published. These predictors have not been developed for or applied to geriatric patients with spondylitic radiculopathy.

A series of 10 patients (ages of 67-82) with medically pre-diagnosed cervical spondyloarthrosis and radiculopathy (magnetic resonance imaging) were referred to a physical therapist. Neck Disability Index, numeric pain rating scale, upper limb tension testing, Spurling’s test, and the cervical distraction test were all completed on each patient at initial examination, and at discharge. Neck Disability Index and numeric pain rating scale data were also collected at 6 months post-treatment. Intervention included manual therapy (including high velocity low amplitude thrust manipulation) of the upper thoracic and cervical spine, intermittent mechanical cervical traction, and a home program (including deep cervical flexor strengthening) for 6 to 12 sessions over a period of 3 to 6 weeks.

All 10 patients had substantial improvement in numeric pain rating scale and Neck Disability Index scores. Mean numeric pain rating scale score was less than 1, and mean Neck Disability Index score was 6 at discharge, compared to the original mean numeric pain rating scale and Neck Disability Index scores of 5.7 and 27.4, respectively. All patients reported maintaining those gains for 6 months.

A multi-modal approach for patients with diagnosed cervical spondyloarthrosis with radicular symptoms was useful in this geriatric population in reducing pain, minimizing radicular symptoms, and improving functional outcomes.

August 25, 2011

Prevalence of facet joint degeneration in association with intervertebral joint degeneration in a sample of organ donors

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Prevalence of facet joint degeneration in association with intervertebral joint degeneration in a sample of organ donors

From: J Orthop Res. 2011 Aug;29(8):1267-74

Among the most common causes of low back pain are strain on the muscles and ligaments associated with the spine, degeneration of the intervertebral discs, and osteoarthritis of the facet joints. It is not clear, however, how these latter two conditions are related to each other in terms of their development during a patient’s lifetime. The facet joint is the sole synovial joint of the spine but because it is difficult to image its degenerative history as well as its relationship to other degenerative factors within the spine remain elusive.

The authors compared the gross and histologic characteristics of the lumbar spine from a sample of organ donors to the integrity of their associated intervertebral discs as assessed through magnetic resonance imaging. In this study sample, they found that facet joint degeneration was common, occurring as early as 15 years of age, while the intervertebral disc could still remain intact. Facet degeneration was more severe at the L4/5 level and progressed along with intervertebral disc degeneration with age. Because such early degenerative changes in the facet joint are somewhat surprising, degeneration of this joint should not be overlooked when assessing osteoarthritis of the spine and causes of lower back pain.

July 26, 2011

Is greater lumbar vertebral bone mineral density associated with more disc degeneration

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Is greater lumbar vertebral bone mineral density associated with more disc degeneration? A study using micro-CT and discography.

From: J Bone Miner Res. 2011 Jul 22.

It is well documented that osteoarthritis is associated with greater bone mineral density in peripheral extremities. Yet, the relationship between vertebral bone mineral density and disc degeneration remains controversial in the lumbar spine, which may be due largely to the inadequacies of bone mineral density and disc degeneration measures. Aiming to clarify the association between vertebral bone mineral density and adjacent disc degeneration, we studied 137 cadaveric lumbar vertebrae and 209 corresponding intervertebral discs from the spines of 48 Caucasian men, aged 21 to 64 years. disc degeneration was evaluated using discography. The vertebrae were scanned using a micro-CT system to obtain volumetric bone mineral density for the whole vertebra, the vertebral body, the vertebral body excluding osteophytes, and the vertebral body excluding osteophytes and endplates. A random effect model was used to examine the association between the different definitions of vertebral bone mineral density and adjacent disc degeneration.

No significant association was found between the bone mineral density of the whole vertebra and adjacent disc degeneration. However, when the posterior elements were excluded, there was a significant association between greater vertebral body bone mineral density and more severe degeneration in the disc cranial to the vertebra. This association remained after further excluding osteophytes and endplates from the vertebral body bone mineral density measurements. Also, a trend of greater bone mineral density of the vertebral body associated with more adjacent disc degeneration was evident. These results clarify the association between vertebral bone mineral density and disc degeneration, and specifically identified that it is higher bone mineral density of the vertebral body, not the entire vertebra, that is associated with more severe adjacent disc degeneration. This association may be obscured by the posterior elements, and is not confounded by osteophytes and endplate sclerosis

April 12, 2011

Distinguishing fibromyalgia from rheumatoid arthritis and systemic lupus in clinical questionnaires

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Distinguishing fibromyalgia from rheumatoid arthritis and systemic lupus in clinical questionnaires: an analysis of the revised Fibromyalgia Impact Questionnaire and its variant the Symptom Impact Questionnaire along with pain locations.

From: Arthritis Res Ther. 2011 Apr 8;13(2):R58. [Epub ahead of print]

The purpose of this study was to explore a dataset of subjects with fibromyalgia, rheumatoid arthritis and systemic lupus erythematosus, who had completed the Revised Fibromyalgia Impact Questionnaire and its variant the Symptom Impact Questionnaire, for discriminating features that could be used to differentiate fibromyalgia from rheumatoid arthritis and systemic lupus erythematosus in clinical surveys.

The frequency and means comparing fibromyalgia, rheumatoid arthritis, and systemic lupus erythematosus participants on all pain sites and Symptom Impact Questionnaire variables were calculated. A multiple regression was then conducted to identify the significant pain site and Symptom Impact Questionnaire predictors of group membership. Thereafter a stepwise multiple regression identified the order of variables in predicting their maximal statistical contribution into group membership. Partial correlations assessed their unique contribution, and lastly a two-group discriminant analysis provided a classification table.

The dataset contained information on the Symptom Impact Questionnaire and also pain locations in 202 fibromyalgia, 31 rheumatoid arthritis and 20 systemic lupus erythematosus subjects. As the Symptom Impact Questionnaire and pain locations did not differ much between the rheumatoid arthritis and systemic lupus erythematosus patients they were grouped (rheumatoid arthritis/systemic lupus erythematosus) to provide a more robust analysis. The combination of 8 Symptom Impact Questionnaire items and 7 pain sites correctly classified 99% of fibromyalgia and 90% of rheumatoid arthritis/systemic lupus erythematosus subjects in a two group discriminant analysis.

The largest reported Symptom Impact Questionnaire differences (fibromyalgia minus rheumatoid arthritis/systemic lupus erythematosus) were seen for “tenderness to touch”, “difficulty cleaning floors” and “discomfort on sitting for 45 minutes”. Combining the Symptom Impact Questionnaire and pain locations in a stepwise multiple regression analysis revealed that the 7 most important predictors of group membership were: mid lower back pain, tenderness to touch, neck pain, hand pain, arm pain, outer lower back pain, and sitting for 45 minutes.

A combination of 2 Symptom Impact Questionnaire questions (“tenderness to touch” and “difficulty sitting for 45 minutes”) plus pain in the lower back, neck, hands and arms, may be useful in the construction of clinical questionnaires aimed at patients with musculoskeletal pain. This combination provided a correct diagnosis in 97% of subjects, with only 7 of 253 subjects misclassified.

Source: Distinguishing fibromyalgia from rheumatoid arthritis and systemic lupus in clinical questionnaires

March 28, 2011

The effects of disc degeneration and muscle dysfunction on cervical spine stability from a biomechanical study

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The effects of disc degeneration and muscle dysfunction on cervical spine stability from a biomechanical study

From: Proc Inst Mech Eng H. 2011 Feb;225(2):149-57

Disc degeneration and muscle dysfunction are common spinal degenerations in the elderly. This in vitro study was carried out to investigate the effects of these two degenerative changes on spinal stability. The stability of nine porcine cervical spines (C2-T1) with mechanically simulated cervical muscles (sternocleidomastoid, splenius capitis, semispinalis capitis) was tested before and after experiment-induced disc degeneration. The patterns of muscle recruitments included: no muscle recruitment, normal recruitment of sternocleidomastoid, splenius capitis, semispinalis capitis, and sternocleidomastoid, splenius capitis, semispinalis capitis muscle dysfunctions. The neutral zone and the range of motion in the sagittal plane were measured to determine spinal stability.

The results showed that the neutral zone and the range of motion of a degenerative spine were larger than those of an intact spine under no muscle recruitment, but not under muscle recruitments. For both intact and degenerative spines, the neutral zone and the range of motion were greatest under no muscle recruitment, followed by semispinalis capitis dysfunction, sternocleidomastoid dysfunction, and splenius capitis dysfunction, and smallest under normal muscle recruitment.

In conclusion, muscle recruitments stabilize both intact and degenerative cervical spines, while dysfunctional muscles do not maintain stability efficiently as normal muscles do. Thus, spinal stability is more significantly affected by muscle dysfunction than by disc degeneration. Muscle training is suggested for the elderly with spinal degeneration to improve stability.

January 20, 2011

Effects of three different conservative treatments on pain, disability, quality of life, and mood in patients with cervical spondylosis

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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.

December 26, 2010

The prevalence of vitamin D deficiency in consecutive new patients seen over a 6-month period in general rheumatology clinics

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The prevalence of vitamin D deficiency in consecutive new patients seen over a 6-month period in general rheumatology clinics

Clin Rheumatol. 2010 Dec 24. [Epub ahead of print]

The objectives of this study are to assess: (a) the prevalence of vitamin D deficiency among new patients attending rheumatology outpatient departments, (b) the age profile of these low vitamin D patients and (c) whether any diagnostic category had a particularly high number of vitamin D-deficient patients. All new patients seen consecutively in general rheumatology clinics between January to June 2007 inclusive were eligible to partake in this study, and 231 out of 264 consented to do so.

Parathyroid hormone, 25-hydroxyvitamin D, creatinine, calcium, phosphate, albumin and alkaline phosphatase levels were measured. The authors defined vitamin D deficiency as ≤53 nmol/l and severe deficiency as ≤25 nmol/l. Overall, 70% of 231 patients had vitamin D deficiency, and 26% had severe deficiency. Sixty-five percent of patients aged ≥65 and 78% of patients aged ≤30 years had low vitamin D levels. Vitamin D deficiency in each diagnostic category was as follows: (a) inflammatory joint diseases and connective tissue diseases, 69%; (b) soft tissue rheumatism, 77%; (c) osteoarthritis, 62%; (d) non-specific musculoskeletal back pain, 75% and (e) osteoporosis, 71%. Seasonal variation of vitamin D levels was noted in all diagnostic groups apart from inflammatory joint diseases and connective tissue diseases group, where the degree of vitamin D deficiency persisted from late winter to peak summer.

Very high prevalence of vitamin D deficiency was noted in all diagnostic categories, and it was independent of age. The results suggest vitamin D deficiency as a possible modifiable risk factor in different rheumatologic conditions, and its role in inflammatory joint diseases and connective tissue diseases warrants further attention

December 12, 2010

Clinical observation on improvement of motion range of cervical spine of patients with cervical spondylotic radiculopathy treated with rotation-traction manipulation and neck pain particles and cervical neck pain rehabilitation exercises

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Clinical observation on improvement of motion range of cervical spine of patients with cervical spondylotic radiculopathy treated with rotation-traction manipulation and neck pain particles and cervical neck pain rehabilitation exercises

From: Zhongguo Gu Shang. 2010 Oct;23(10):750-3.

The purpose of this article was to observe the effects of two different therapies on patients whose cervical function were restricted due to cervical spondylotic radiculopathy.

Form April 2008 to October 2009, 71 cases with cervical spondylotic radiculopathy were divided into group A (36 cases) and group B (35 cases). Among them, 22 cases were male and 49 cases were female, ranging in age form 45 to 65 years with an average of 52.27 years, course of disease was from 3 days to 5 years. The patients in group A were treated with rotation-traction manipulation, neck pain particles and cervical rehabilitation exercises; and the patients in group B were treated with cervical traction, Diclofenac sodium sustained release tablets and wearing neck collar. Theapeutic time was two weeks. The cervical anteflexion, extension, left and right lateral bending, left and right rotative activity were measured by helmet-style activities instrument before and after treatment (at the 1, 3, 5, 7, 9, 11, 13 days and 1 month after treatment respectively).

There were no difference between two groups in cervical activity in all directions before treatment. Compared with the beginning, cervical anteflexion and extension showed significant difference at the 5th day after treatment in group A. In group B, cervical anteflexion showed significant difference at the 13th day after treatment, but at the 1 month after treatment, the significant difference disappeared; cervical extension showed significant difference at the 7th day after treatment compared with the beginning. Compared with the beginning, left lateral bending showed significant difference at the 1st day after treatment in group A and at the 5th day after treatment in group B. Both in group A or B, right lateral bending, left and right rotative activity showed significant difference at the same time after treatment, either the 3rd day or the 5th day. Compared between groups, cervical anteflexion, left and right lateral bending, left and right rotative activity showed significant difference at the 1 month after treatment.

The rotation-traction manipulation and neck pain particles and cervical rehabilitation exercises in treating cervical spondylotic radiculopathy have quick effect to improve the activities of cervical anteflexion, extension, left lateral bending, and have durable effect to improve the activities of cervical spine in all directions.

November 26, 2010

Reduction in segmental flexibility because of disc degeneration is accompanied by higher changes in facet loads than changes in disc pressure

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Reduction in segmental flexibility because of disc degeneration is accompanied by higher changes in facet loads than changes in disc pressure: a poroelastic C5-C6 finite element investigation.

From: Spine J. 2010 Dec;10(12):1069-77.

Nerve fiber growth inside the degenerative intervertebral discs and facets is thought to be a source of pain, although there may be several other pathological and clinical reasons for the neck pain. It, however, remains difficult to decipher how much disc and facet joints contribute to overall degenerative segmental responses. Although the biomechanical effects of disc degeneration on segmental flexibility and posterior facets have been reported in the lumbar spine, a clear understanding of the pathways of degenerative progression is still lacking in the cervical spine.

To test the hypothesis that after an occurrence of degenerative disease in a cervical disc, changes in the facet loads will be higher than changes in the disc pressure. To understand the biomechanical relationships between segmental flexibility, disc pressure, and facet loads when the C5-C6 disc degenerates.

METHODS: A poroelastic, three-dimensional finite element (FE) model of a normal C5-C6 segment was developed and validated. Two degenerated disc models (moderate and severe) were built from the normal disc model. Biomechanical responses of the three FE models (normal, moderate, and severe) were further studied under diurnal compression (at the end of the daytime activity period) and moment loads (at the end of 5 seconds) in terms of disc height loss, angular motions, disc pressure, and facet loads (average of right and left facets).

Disc deformation under compression and segmental rotational motions under moment loads for the normal disc model agreed well with the corresponding in vivo studies. A decrease in segmental flexibility because of disc degeneration is accompanied by a decrease in disc pressure and an increase in facet loads. Biomechanical effects of degenerative disc changes are least in flexion. Segmental flexibility changes are higher in extension, whereas changes in disc pressure and facet loads are higher in lateral bending and axial rotation, respectively.

The results of the present study confirmed the hypothesis of higher changes in facet loads than in disc pressure, suggesting posterior facets are more affected than discs because of a decrease in degenerative segmental flexibility. Therefore, a degenerated disc may increase the risk of overloading the posterior facet joints. It should be clearly noted that only after degeneration simulation in the disc, we recorded the biomechanical responses of the facets and disc. Therefore, our hypothesis does not suggest that facet joint osteoarthritis may occur before degeneration in the disc. Future cervical spine-based experiments are warranted to verify the conclusions presented in this study.

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