Stop Neck Pain Naturally

Neck Pain UnPlugged

The Complete, Step-by-step Self-assessment/self-treatment System For Neck Pain Sufferers. Neck Pain UnPlugged is a simple-to-use, step-by-step system that is full of life changing benefits. Finally understand the underlying cause of your neck pain. Learn simple to follow steps for improving your neck pain. Save Time and $: Drastically reduce or eliminate your need for dangerous medications and endless trips for treatment. Changes that give you the long term neck pain relief that you deserve. Customized to You: No More generic stretches and exercises. Everyone is different. Only do what Your body needs to feel great. Wake up feeling great. Do the thing You want to do. Get your life back!

Neck Pain UnPlugged Summary


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What is the treatment of whiplash injury

Whiplash injury is a term used to describe an acute cervical sprain or strain that results from acceleration and deceleration motion without direct application of force to the head or neck. Whiplash commonly affects the cervical facet joints and related musculature (trapezius, levator scapulae, scalene, sternocleidomastoid, and paraspinals). Although the symptoms of nonradicular neck and shoulder pain are often self-limiting (6-12 months), many people continue to experience more chronic symptoms. Treatment options include cervical traction, massage, heat, ice, ultrasound, isometric neck exercises, a soft cervical collar, and NSAIDs and or short-term analgesic use. Patients with persistent pain may have annular tears, coexisting degenerative joint and disc pathology, nerve root entrapment, spinal stenosis, or myelopathy. Neurologic symptoms or intractable pain symptoms that are not responsive to treatment indicate the need for further evaluation.

Prevalence of mechanical syndromes in neck pain patients

Two surveys have been conducted of consecutive patients seen by McKenzie educational faculty (May 2004a, 2004b). In total, details of over one thousand patients were included in the two surveys from nearly eighty contributing faculty members, which included 256 patients with neck pain. The results were similar in the two studies, with most neck pain patients being classified as derangement (80 ), fewer numbers in other mechanical syndromes (8 , mostly dysfunction) and some classified as non-mechanical syndrome (12 ). The minority of patients not receiving mechanical classification were mostly classified as mechanically inconclusive (4 ), trauma (4 ) and chronic pain state (3 ). Figure 7.5 Classification of 256 consecutive neck pain patients

Is surgery indicated for chronic neck pain

Indications for surgical treatment of patients with axial neck pain are uncommon. Surgery may be indicated for conditions such as instability, posttraumatic facet injuries, and C1-C2 osteoarthritis. Patients with discogenic-mediated neck pain secondary to degenerative disc disease can occasionally be treated surgically. Whitecloud has shown that 60 to 70 of patients improve following anterior discectomy and fusion. Before surgery, patients are evaluated by provocative cervical discography to confirm the source of pain. Poorer results are seen in litigation cases and cases involving more than two cervical levels.


Was the neck forced into back bend- The athlete is hit from behind the head remains still while ing then forward bending (whiplash) the body accelerates forward. The cervical spine is forced into (Fig. 2-10) excessive back bending that can be coupled with rotation The whiplash mechanism can subject the brain to a contrecoup phenomenon (the brain moves forward and backward in the cranium and trauma to the cortex or cerebellum can result). A full concussion evaluation should be done if a whiplash mechanism occurs. Fig. 2-10 Whiplash mechanism. Cervical back bending then forward bending. Fig. 2-10 Whiplash mechanism. Cervical back bending then forward bending.

Is whiplash real

There is controversy within the medical literature between those who believe in the validity of WAD and those who claim it to be a myth. It has been argued that 'whiplash syndrome', as opposed to brief and insignificant neck pain, is no more than a cultural construct within a biopsychosocial model of pain (Ferrari and Russell 1997, 1999). It is suggested that WAD exists only in cultures in which pain following RTA is expected, bred in an environment in which anxiety and fears are nurtured by health professionals, lawyers and patients alike. These authors believe that the 'whiplash syndrome' is an example of illness actually induced by society, in general, and by physicians in particular (Ferrari and Russell 1997). the lack of neck pain in those who crash cars for fun, or let themselves be involved in 'crashes' for the sake of experiment They attempt to show that reporting 'injuries' in part reflects compensation systems, and that the prevalence of chronic symptoms varies in different...

Neck pain

Neck pain is a commonly occurring complaint. Its yearly prevalence is comparable with low back pain and is about 50 in the adult population. Neck pain is the main complaint in about 3 of those who consult a physician. The yearly prevalence of cervical radicu-lopathy is 40-80 per 100000 12 . Repeated collision injuries in contact sports not resulting in fractures or spinal cord injuries are associated with neck pain and paresthesia. The symptoms are commonly recurrent, existing just for seconds during a match, and result from traction of the brachial plexus or nerve root irritation. In a large Finnish survey the neck and head accounted for 9 of all soccer injuries 13 . A heading in soccer involves hyperextension and compression of the cervical spine and may affect the vertebrae, intervertebral joints, disks, ligaments and muscles. Chronic complaints of pain and limited range of motion of the cervical spine were found in about 30 of former players from the Norwegian national soccer team...

Whiplash Injuries

The term whiplash refers to the mechanism of the neck injury, which can result from hyperextension followed by flexion that occurs when an occupant of a motor vehicle is hit from behind by another vehicle. Some clinicians use the term to also describe other types of collisions wherein the neck is subjected to different sequences and combinations of flexion, extension, and lateral motion. The term was first used in 1928. Other terms used include cervical sprain, cervical myofascial pain syndrome, acceleration-deceleration injury, and hyperextension injury. y Epidemiology and Risk Factors. In 1994, there were 11,200,000 motor vehicle accidents including 2,600,000 rear-end collisions in the United States. Although neck injuries can commonly occur after side or front impact collisions, rear-end collisions are responsible for about 85 percent of all whiplash injuries. Although only rough estimates exist, perhaps 1 million people sustain whiplash-type injuries per year in the United States....

What is whiplash

Whiplash is a familiar term to patients and clinicians. It generally denotes neck symptomatology that has commenced during or shortly after a motor accident. Strictly, the causal event for a true 'whiplash' injury is said to be a rear-end collision at a modest speed into a stationary vehicle in which the victim is facing forwards (Bogduk 1986). In practice, anyone involved in a car accident that develops symptoms is likely to be considered to have 'whiplash'. Neck pain that develops after a diving incident or some other high-velocity impact to the neck is also often included in the term. A major review (Spitzer et al. 1995) of the topic gave the following definition Whiplash is an acceleration-deceleration mechanism of energy transfer to the neck. It may result from rear-end or side-impact motor vehicle collisions, but can also occur during diving or other mishaps. The impact may result in bony or soft-tissue injuries (whiplash injury), which in tum may lead to a variety of clinical...

Diagnosis Using the ICHD2

Location is not included in the diagnostic criteria. For example, neck pain, often thought to suggest TTH, is present in at least 75 of migraine patients. Forty percent of migraine is bilateral. Bilateral maxillary pain, often thought to suggest sinus headache, is a nonspecific symptom. In other words, do not make a diagnosis by location of pain alone. a. Neck pain in migraine is very common


Unlike other joints of the body, there is rarely a singular mechanism of injury. Only occasionally does injury occur as one traumatic incident (i.e., a direct blow or whiplash). Usually there are multiple factors that cause low-grade microtrauma over a long period of time. The multiple causes of temporomandibular joint dysfunction are usually a combination of the following

Treatment effectiveness

As with lumbar back pain, a wide range of treatment interventions are offered to patients with neck pain. These interventions have not appeared to affect the underlying prevalence or recurrence rates. A number of systematic reviews have been undertaken to evaluate the treatment effectiveness of interventions for neck pain, and their conclusions are summarised here. Evidence does not support the use of acupuncture for chronic neck pain of eight high-quality trials, five were negative (Kjellman et al. 1999 White and Ernst 1999). Subsequent trials have demonstrated short-term changes in pain, but outcomes no better than sham treatment (Irnich et al. 2001, 2002) or not clinically significantly better than placebo (White et al. 2004). High-quality studies demonstrated lack of effect for traction (Kjellman et al. 1999 Philadelphia Several reviews have provided limited to moderate support in favour of the short-term benefits of mobilisation and or manipulation for some types of neck pain and...

Defining traumatic brain injury TBI

Whiplash is a term first used in 1928 (Crowe, 1964a, 1964b) that describes the typical hyperextension followed by flexion of the neck that occurs when the occupant of a motor vehicle is struck from behind by another vehicle (Evans, Evans, & Sharp, 1994). Although neck injuries do occur following side or head-on collisions, approximately 85 of whiplash injuries occur as a result of rear-end impacts (Deans, McGalliard, & Rutherford, 1986).

Pain from the Neck Up

Some days, when the pain of a headache gets bad, do you feel like unscrewing your head and asking for a refund Hopefully you won't need to do that after reading this chapter on pain from the neck up. We'll be discussing some of the most common pains that occur above the neck, and then look at the ways that oriental medicine identifies what's going on and treats it. Headaches, dental and neck pain, and fibromyalgia are open for your examination. So hold onto your hat (and your head) while you learn valuable tips for taking the dread out of your head.

Factors that affect the range of movement

Various factors can affect the cervical range of movement. Some of these are temporary whilst others can be structural and lead to permanent changes in range if no effort is made to prevent this from happening. Age, degenerative changes, posture and the advent of neck pain may all produce a temporary or permanent change in available range of movement. Another cause of temporary loss of range of movement is an episode of neck pain. Several studies have compared neck pain subjects with asymptomatic controls and found significant differences in range of movement, as well as the presence of pain on movement (Hagen et al. 1997b Jordan et al. 1997 Hanten et al 2000, Lee et al. 2003, 2005 Norlander and Nordgren 1998). One study found that in particular limited flexion and rotation, and pain on flexion, extension and rotation, were correlated with severity of pain and significantly different between symptomatic and asymptomatic groups (Hagen et al. 1997b). Also, significant reductions in...

Seeking pathoanatomical diagnoses

In a group of patients increasing levels of spinal degeneration shown on x-ray were related to increasing chronicity of complaint however, there was no simple relationship between degeneration and pain (Marchiori and Henderson 1996). Findings of degeneration on x-ray lack sensitivity, as degenerative changes are common in the asymptomatic population (Gore et al. 1986 Teresi et al. 1987 Matsumoto et al. 1998). Radiological changes increase with age (Friedenberg and Miller 1963 van der Donk et al. 1991 Matsumoto et al. 1998 Gore et al. 1986) as does neck pain it could be speculated whether this is causal or merely incidental. The increase in neck symptoms stabilises around the fifth to sixth decade. However, the prevalence of degenerative changes continues to increase. By age 60 to 65, 95 of men and 70 of women in a sample of two hundred without neck pain had at least one degenerative change on x-ray (Gore et al. 1986). Significant disc space narrowing was reported by magnetic resonance...

Classification systems

The proposal that matching sub-groups of non-specific spinal pain to specific interventions will lead to improved outcomes, although logical, has until lately been hypothetical only. However, two recent studies, which both use the concept of mechanically determined directional preference either wholly or as part of the classification system, have demonstrated that patients treated according to classification do better than if treated in a non-specific, even if best practice, way (Long et al. 2004 Fritz et al. 2003) Further studies also suggest that sub-groups respond better to one type of intervention than another (Childs et al. 2003, 2004b Haldorsen et al. 2002). These studies involve lumbar spine patients the same evidence is not available relating to cervical spine patients. However, there is every reason to believe that management could equally be improved using a classification system for patients with neck pain (Childs et al. 2004a). and the more recent triage classification...

Fibromyalgia Tired of Being Sick and Tired

Now that youVe got the top part of your body in better shape let's move on to the rest. I have always felt it's better to have options in treating conditions such as headaches, dental, and neck pain. Fibromyalgia has also responded so favorably to treatment that I had to include it in the text. Go ahead to the next chapter to begin experiencing the relief for some of the most common shoulder and joint pains. V Say no way to neck pain through acupressure.

What are the pain generators of the spine

Soft tissue sprain or strain (muscle, tendon, ligament) is the most common disorder responsible for low back and neck pain. This diagnosis is generally based on clinical assessment without the need for interventional procedures. Frequently, the diagnosis of soft tissue sprain or strain is made by exclusion of more serious pathology and may alternately be described as nonspecific back pain syndrome. Facet joints (zygapophyseal joints or z-jointS) are paired synovial joints in the posterior column of the spine, which are innervated by medial branches of primary dorsal rami. Lumbar facet pathology may result in referred pain involving the buttock, groin, hip, or thigh. Cervical facet joint pathology can manifest as neck pain, referred pain involving the scapular area or headaches.

Rheumatoid arthritis RA

If patients develop neck pain as a result of one of the systemic arthropathies such as RA or AS, they will generally have had symptoms for many years (Maghraoui et al. 2003). The cervical spine is an unlikely site for onset of symptoms, and the patient will generally be aware of the diagnosis. In patients with RA, neck pain has been reported in 40 - 88 cervical subluxations have been observed in 43 - 86 and neurologic deficit hasbeen reported in only 7 - 34 (Pellicci et al. 1981).

Extreme dizzinessvertigo

For dizziness to be deemed cervicogenic in origin, the onset and duration must parallel the neck pain and must be associated with neck movements. If with further questioning any of the symptoms listed in Table 8.4 are reported, pathology of the central nervous system should be suspected, further treatment is contraindicated and the patient should be referred to the appropriate specialist. See next section for fuller discussion about dizziness.

What injection techniques can help differentiate other pain generators that mimic cervical and lumbar pathology

Shoulder pain can frequently mimic cervical disorders. Careful examination of the shoulder joint should always be performed in a patient presenting with neck pain. Diagnostic injection into the subacromial space and the acromioclavicular joint can differentiate pain originating from the shoulder region from pain originating in the cervical spine. 4. Carragee EJ, Hurwitz EL, Cheng I, et al. Treatment of neck pain injections and surgical interventions Results of the Bone and Joint Decade 2000-2010 Task Force on neck pain and its associated disorders. Spine 2008 33 S153-S169.

Cervical spondylosisstenosis

An important clinical point is that these changes, demonstrated on x-ray, can exist in a symptom-free population. Narrowing of joint space, disc herniation, anterior and posterior osteophytes, bony hypertrophy, foraminaI stenosis and even spinal cord compression are found in the asymptomatic population (Gore et al 1986 Friedenberg and Miller 1963 Teresi et al. 1987 Matsumoto et al 1998). Some of these changes are present in about 20 of individuals with no neck pain in their 30s, about 75 in their 50s and over 80 in their 60s (Gore et al 1986 Matsumoto et al 1998). No difference has been found in pain and disability levels between those with or without evidence of cervical spine degeneration (Peterson et al 2003). Thus, the same radiographic presentation can be found in a symptomatic or asymptomatic individual - this issue is discussed at more length in Chapter 5. Some individuals who have these radiographic changes also present with symptoms. Although cervical spondylosis may be a...

Acute Cervical Strain Syndrome

At this time the soft cervical orthosis can be removed and gentle active ROM initiated. Cervical isometric neck strengthening exercises may also be started. With continued clinical improvement, functional and sports-specific exercises are introduced. Although commonly prescribed, the use of a soft foam cervical orthosis is controversial. In 2000 and 2003, Rosenfeld et al. published two articles that compared active neck exercises without cervical orthosis with a protocol involving rest, soft collar use, and self-mobilization these studies were performed in persons who had suffered whiplash injuries. The authors found that the patients whose clinical course did not involve orthosis use had less pain and fewer lost days from work.

Patient demographics

Patients are more susceptible to certain problems at different times of life. Postural syndrome is more likely to be present in the young, whilst young to old adults have derangements and dysfunctions. Osteoporosis is generally only relevant in the elderly, esperially postmenopausal women, although there are exceptions. With increasing age spinal degeneration is more likely to be present, the intervertebral disc becomes dehydrated and fibrosed, and osteophytes and other bony changes can occur around the zygapophyseal and uncovertebral joints and vertebral bodies (Taylor and Twomey 2002). Such changes may predispose to spinal stenosis affecting nerve roots or the spinal cord. MalignanCies are also more common in the older age group. Completely new onset of headache or neck pain in older patients who have never experienced this before is also a possible warning symptom. Equally we should be aware of any normal sporting or recreational activities that they have stopped because of neck...

Cervical Cord Neurapraxia with Transient Tetraplegia

Transient tetraplegia most often results after an impact forcing the cervical spine into hyperextension, hyperflexion, or axial loading. Affected athletes experience tetraplegic symptoms of relatively short duration that include dysesthesias, and or weakness in both arms, both legs, or all four extremities. Individuals do not generally complain of neck pain. The clinical symptoms last for as short as 10-15 minutes and as long as 48 hours. The patient regains full function and ROM and radiographs show no evidence of fracture, but these players often have cervical canal stenosis. In individuals with a narrowed canal in the AP diameter, the pathophysiology is thought to be as follows. Hyperextension or hyperflexion of the cervical spine causes further narrowing of the canal with compression of the cord against adjacent bony or ligamentous structures. Torg et al. found the incidence of transient cervical cord neurapraxia with transient tetraplegia to be 7 per 10,000 football athletes.

What do you do now

Pain in the posterior neck or occiput is common, as is generalized headache. Pain often precedes neurological symptoms by hours, days, and, rarely, weeks. Many patients with vertebral artery dissections have only neck pain and do not develop neurological symptoms or signs. Transient ischemic attacks (TIAs), when they do occur, are most often characterized by dizziness, diplopia, veering, staggering, and dysarthria. TIAs are less common in patients with vertebral artery neck dissections compared to internal carotid artery dissections. Infarcts usually cause symptoms and signs that begin suddenly. The commonest locations of ischemic brain damage are the portion of the

Prevention of recurrence

Advice concerning neck care in the future is always given to the patient during the treatment episode and prior to discharge. This should include discussion of the following aspects recurrent nature of neck pain, avoiding prolonged aggravating postures, practice of prophylactic exercises and importance of general fitness. use of exercises if neck pain re-occurs.

Occipital Condyle Syndrome

Metastasis to the area of the occipital condyle is more common than to the jugular foramen. The clinical picture is uniform. This syndrome is characterized by continuous, severe, localized, unilateral occipital pain that worsens upon neck flexion. The pain sometimes radiates toward the ipsilateral temporal area or eye and is often associated with a stiff neck. Approximately half of the patients will complain of dysarthria, dys-phagia, or both, specifically related to difficulty in moving the tongue. The ipsilateral tongue is atrophic, and fasciculations may be noted.15,53 Seven of nine patients with the occipital condyle syndrome in Greenberg's series had the typical occipital pain, four had dysarthria, and two had dysphagia all had ipsilateral tongue weakness.28 Carcinoma of the breast in women and prostate carcinoma in men were the most common metastatic sites of origin in the 11 patients reported by Capobianco et al.15

Neck Back and Myofascial Pain

Recent randomized trials with good designs add to the potential armamentarium of interventions, although all of these results require confirmation by additional trials. For low back pain, osteopathic manual care and standard medical care produce equivalent results 140 bipolar magnets were no better than sham magnets 141 low energy laser treatment 3 times per week for 4 weeks is modestly better than sham treatment 142 40 units of botulinum toxin injected into 5 paralumbar sites is better than placebo for up to 8 weeks of less pain 143 neuromuscular electrical stimulation and TENS for 5 hours per day at 2-day intervals is better than placebo stimulation 144 percutaneous electrical nerve stimulation with acupuncturelike needles in the paraspinal muscles reduces the need for opioid analgesics more than sham treatment, TENS, or exercise 145 and facet injections with methylprednisolone are no better than placebo in patients who reported less pain after the facet was injected with local...

Experimental Case Studies

While driving on a freeway, an elderly couple was suddenly confronted by an 18 wheeler truck that plowed into the road divider and toppled onto the roof of their car. The wife dropped below the level of the window, but the husband felt the roof of the car collapsing on his head. The roof partially held, but they could not get out of the car. All was quiet for moments, then the roof and truck groaned and compressed the roof to the level of the bottom of the window before stopping again. He heard the voices of several men trying to figure out how to get to the car under the long cargo container that completely obscured it. One voice said, Nobody can be alive in there. The couple was pulled out several hours later by a crew of fireman and rescue workers. He had neck pain and arm weakness that led to the removal of a centrally herniated cervical disk. During the acute hospital stay, he seemed very anxious and detached from his wife, who had no injuries. He recalled little about the...

Stenosis in the Cervical Spine

A 63-year-old female presented to clinic with an 8-year history of worsening neck pain radiating to her bilateral shoulders and scapulae. The pain radiated primarily down her bilateral biceps and radial forearms into the thumb and index fingers of both hands. Additionally, she had noted a gradually worsening weakness in her legs, with loss of balance, worsening handwriting, and difficulty buttoning buttons and manipulating small objects with her hands. She had no bowel or bladder dysfunction. Despite nonoperative management that included activity modification, physical therapy, and nerve root and trigger point injections, her symptoms persisted and seemed to be worsening.

Clinical picture Onset

When severe neck pain or Significant trauma marked the onset of this episode some time will have elapsed at least six to eight weeks is probably necessary to allow dysfunction to develop. They may report involvement in a road traffic accident in the past. Since the onset the pain has eased considerably, but is now unchanging. When the onset has been insidious, the patient will be older, poor posture will be obvious, there may be an episodic history of neck pain in the past, and symptoms and functional impairment may well be worsening gradually over time. one exception, all dysfunctions present with local neck pain only this may be symmetrical, unilateral or asymmetrical.

Clinical Manifestations

Stage II of Lyme borreliosis may involve the neurological system. Of patients, 10 to 15 percent may have this involvement and present with a meningitis-type picture or have cranial nerve palsies. The most commonly involved cranial nerve is the seventh (facial) nerve, which results in an inability to control properly the facial musculature. In individuals with meningeal irritation, episodic headaches, neck pain, and stiffness may occur. Cerebrospinal fluid analysis frequently shows a predominance of mononuclear white blood cells. Occasional patients with stroke syndromes including hemiparesis as well as cases mimicking multiple sclerosis or encephalitis have been reported. Individuals may have associated confusion, agitation and disorientation, and memory loss. The symptoms and signs may wax and wane over weeks and months.

Clinical Features and Associated Findings

Patients who developed paralytic poliomyelitis may initially have had clinical symptoms of fever, malaise, headache, and gastrointestinal or upper respiratory tract symptoms. These symptoms subsided, only to recur after several days in association with increasing signs of meningeal irritation, headache, and stiff neck. When the illness progressed to the paralytic form, muscle soreness was prominent, particularly in the back and neck. Patients who developed paralysis usually did so on the second to fifth day after meningeal signs and fever became evident. Once weakness began, it typically progressed for only the first few days after its onset. The fever persisted for several days but often subsided before the paralysis was complete. Patients complained of severe muscle pain and spasms with asymmetrical flaccid muscle weakness that usually affected a lower extremity. Severe bulbar weakness occurred in 10 to 15 percent of patients with paralysis. The disease was most common in...

Cervicogenic headache

The first description of cervicogenic headache was in 1983 (Sjaastad ei al. 1983), and the IHS classification was amended in 1988 to include headaches related to neck problems. Since then several groups have published diagnostic criteria or amended earlier ones (Sjaastad ei al. 1990, 1998 Merskey and Bogduk 1994 Meloche ei al. 1993 Jull 2002). Although these contain certain common features, they also contain many inconsistencies. Differences include the location of pain, whether it is unilateral or bilateral, and whether it can change sides or not. Some include a positive response to nerve blocks, one included radiographic criteria, some stipulated neck trauma, one focussed on abnormalities in local muscles and one included additional symptoms. Most agree that pain starts around the occipital area and can be aggravated by neck movement. Some state aggravation by posture as well, most note a decrease in cervical range of movement and most include neck tenderness to palpation or...

Signs And Symptoms

Children with cervicomedullary tumors often develop symptoms and signs that can occur for several months or years before discovery of the tumor.25 Signs and symptoms generally fall into one of three major syndromes medullary dysfunction, spinal cord dysfunction,24 and hydrocephalus.25 Medullary dysfunction can lead to symptoms attributable to cranial nerve dysfunction such as facial nerve palsy or weakness,25 dysphonia, dysarthria, dysphagia, palatal deviation, and recurrent aspira-tion.21 Children may also complain of facial pain19 and torticollis.9 Severe neck pain may be a child's only complaint.7,21 The respiratory centers in the medulla may also be affected, causing apnea, or irregular nocturnal breathing patterns19 pulmonary edema and hiccups.25

Neurological examination

Neck pain may be the first clinical symptom of a slowly growing acusticus neurinoma, with absent corneal reflex being the first sign. Patients with referred pain in the region of trigeminus nerve pain commonly present an underlying pathology of the upper cervical spine, often observed in at-lanto-axial instability due to rheumatoid arthritis 38, 42 .

Management of WAD literature

Several systematic reviews of conservative treatments for acute whiplash have recently been conducted. The general conclusions of all are similar - early activity is best, and the use of collars or rest leads to poorer outcomes. Peeters et al. (2001) concluded that active treatments show a beneficial long-term effect, and that 'rest makes rusty'. Bogduk (2000) found a home exercise programme better than rest, and stated that traction, electromagnetic therapy, collars, TENS, ultrasound, spray and stretch and laser should not be used. Magee et al. (2000) found studies indicated a weak-to-moderate positive effect for exercise, educational advice on posture and manual therapy. The QTF supported the use of exercises, advice on posture and mobilisation to help promote activation (Spitzer et al. 1995). Guidelines for physiotherapy management of whiplash derived from the available evidence recommended active interventions such as education, exercise therapy and training of functions and...

Advanced Trauma and Life Support ATLS

ATLS also calls for flexion projections of the cervical spine under supervision of an experienced doctor, prior to full 'clearance' of the spine in patients who are alert and neurologically normal but suffering neck pain. Flexion of the spine in an injured patient should be undertaken only under medical supervision.

Clinical presentation and Imaging

In elderly patients who complain of slowly increasing pain which occurs also during sleeping in the low back region, gluteal region, groin, knee, or generally in the lower extremity, may have a hip or knee problem, however, remain suspicious for a metastatic bone cancer, specifically if they have a tumor history or clinical signs of a consuming disorder. Also newly appearing neck pain in an elderly person should be taken seriously by the first consulted physician and not just automatically considered as an expression of a degenerative cervical spine disease.

Syndromes of Lesions Involving Peripheral Branches of Cranial Nerve V

Crescendo orbital pain or frontal headache can herald impending internal carotid artery occlusion presumably from irritation or ischemia to peripheral trigeminal branches. Similarly, a cluster of symptoms including facial, orbital, or neck pain or facial paresthesias in association with an ipsilateral Horner's syndrome may reflect dissection of the cervical portion of the internal carotid artery. y These symptoms may also be prodromal. Excruciating pain in the supraorbital headache in association with a pupil involving third nerve palsy is almost pathognomonic for an intracranial (especially posterior communicating artery) aneurysm. Ipsilateral orbital or ocular pain has also been reported in association with posterior cerebral artery occlusion, which may reflect ischemic damage to regions of the tentorium adjacent to the occipital lobes that are innervated by V1.

Other Headache Syndromes

Thunderclap headache is defined as the sudden onset of a severe headache that reaches maximum intensity within 1 minute. It can be further defined by the absence of a subarachnoid hemorrhage. This can be due to acute onset migraine and is very difficult to differentiate from a sub- arachnoid hemorrhage. y , y An extensive neurological evaluation, including CT and lumbar puncture, is indicated in patients presenting with their first or worst headache, particularly one associated with focal neurological signs, stiff neck, or changes in cognition. CT can miss subarachnoid blood in as many as 25 percent of cases, particularly if it is not performed until days after the onset of headache.y MRI is unreliable in detecting an acute subarachnoid hemorrhage. Only with a lumbar puncture can one unerringly diagnose subarachnoid hemorrhage. Day and Raskin' have stated that all patients presenting with severe,

Degenerative Mechanics

The atlantoaxial junction is a common site for arthritic changes, most commonly seen in rheumatoid arthritis. Although classically not associated with osteoarthritis, atlantoaxial osteoarthritis has been reported to have a prevalence ranging between 5 and 18 of patients with spinal osteoarthritis.6 True symptomatic prevalence is probably much smaller. Arthritic changes can affect the lateral mass articulations and the atlantodens articulation. Degeneration at the atlantodens articulation can produce a pannus, similar to that seen in rheumatoid arthritis, causing myelopathic symptoms due to cord compression. More commonly, osteoarthritis at the atlantoaxial junction results in neck pain. This pain generally originates in the suboccipital region. It can radiate both cranially and caudally and can present with severe occipital pain. In general, occipital pain or subaxial neck pain without a suboccipital component most likely does not represent pain from atlanto-axial osteoarthritis, and...

Painful de Quervains Thyroiditis

Painful thyroiditis occurs more commonly in women (malefemale ratio of 1 3 to 1 6) between 30 and 40 years of age. It is characterized by the sudden or gradual onset of unilateral or bilateral pain in the neck, which may radiate toward the mandible or ear and is exacerbated by swallowing or neck movement. Many patients report a preceding upper respiratory tract infection with low-grade fever, neck pain, dysphagia, and flu-like symptoms with malaise and myalgias.

Drug Therapy of Chronic Migraine CM

Dose or for acute exacerbations May be given intravenously as a loading dose or for acute exacerbations Effective with or without fluoxetine for CDH in one study anxiolytic and sleep promoting. Other antidepressants (nortriptyline, protriptyline, doxepin, or imipramine) have been used in our clinic and are most effective when utilizing their assets to treat comorbid conditions insomnia, anxiety, and or depression, muscle and neck pain, fibromyalgia, etc. Effective for CDH in one controlled blinded study

Acute Suppurative Thyroiditis

Gastrografin Swallow

Acute suppurative thyroiditis is more common in children and young adults and occurs equally in both sexes. The disease is often preceded by an upper respiratory tract infection or otitis media. It is characterized by severe neck pain radiating to the jaws or ear, fever, chills, odynophagia, and dysphonia. Infants may present with respiratory distress and stridor secondary to tracheal compression caused by a thyroid abscess.12 Rarely, acute suppurative thyroiditis may cause transient vocal cord palsy.13

Cervical radiculopathy

Cervical radiculopathy is a specific lesion affecting the cervical nerve roots in which neck pain is accompanied by upper limb pain and possibly neurological symptoms and signs (Radhakrishnan et al. 1994). This section presents some details about the epidemiology, pathology and recognition of cervical radiculopathy. For its management refer to Chapter 20, where it is included in the derangement category with referred arm pain below the elbow. The radiculopathy is most often attributed to cervical disc herniation or spondylosis, classified often as soft or hard discs respectively (Wainner and Gill 2000 Radhakrishnan et al. 1994). However, it should be noted that a number of case studies mention less common causes that include serious spinal pathology, such as tumour and arteritis (Vargo and Flood 1990 Sanchez et al. 1983 Wainner and Gill 2000). Clinical recognition of cervical radiculopathy has been made traditionally by pain pattern and accompanying paraesthesia or muscle weakness...

Differential diagnosis

Two items of history are important in helping to determine the source duration of episode and frequency of symptoms. If neck and arm pain are of recent onset, only derangement or stenosis need be included in the differential diagnosis. An adherent nerve root is a secondary product of derangement or some other trauma and takes time to form. Dysfunction of adherent nerve root is unlikely unless two to three months have passed since the beginning of the episode. Onset of the episode is from the time arm symptoms started, not simply neck pain. neck pain only.

Accreditation Commission for Acupuncture and Oriental Medicine AGAOM

Neck pain, 64-65 neck pain, 64-65 new mothers infertility, 157-158 insomnia, 227 insurance, 261-262 magnetics, 9 menopause, 171-172 migraine headaches, 61 nasal congestion, 126-127 nausea, 152 neck pain, 64-65 Oriental Medicine, 94-96 palm pressure, 30 postpartum depression, 163-164 pressure types, 32-34 Q , 8 literature, 257-258 magnetics, 9, 40-41, 74 migraine headaches, 61 morning sickness, 158-159 moxibustion, 41-42 MS, 106-107 nausea, 149-152 neck pain, 64 needles, 38-41 new mothers, 162-163 Oriental Medicine, 94-96 ovarian cysts, 179-181 PMS, 166-167 backlash, whiplash, 94-96 back pain, 82 bursitis, 70-71 neck pain, 64 ovarian cysts, 179-180 sciatica, 86 tennis elbow, 71-72 uterine fibroids, 180

Overview of Treatment for Ossification of the Longitudinal Ligament and the Ligamentum Flavum

Opll Operation

With regard to medication, NSAIDs and muscle relaxants are considered effective for local pain and stiffness. However, the only medication available for OPLL and OLF is bisphosphonate 9 , which is believed to prevent OPLL progression after surgery. In practice, when symptoms and signs of myelopathy are absent or are slight and do not limit activities of daily life, conservative treatment is indicated. In particular, when patients with cervical OPLL complain mainly of neck pain, radicular pain, or both, physicians should select conservative treatment. It is important to advise patients with OPLL not to hyperextend the neck and to be vigilant regarding trauma and falls due to sports activities or excessive alcohol intake. 5. Birch S, Jamison RN (1998) Controlled trial of Japanese acupuncture for chronic myofascial neck pain assessment of specific and nonspecific effects of treatment. Clin J Pain 14 248-255

Section Iv Painful Conditions

Neck pain and headaches associated with tightness in the posterior neck muscles are most often found in patients with a forward head and a round upper back. As shown on pages 152 and 153, the compensatory head position associated with a slumped, round upper back results in extension of the cervical spine.

PCS Organic or functional

The whiplash shake syndrome that occurs in abused children is considered to be a prototypical demonstration of the phenomena associated with head trauma and an illustration of the fact that central nervous system injury can occur even in the absence of direct head injury (Carter & McCormick, 1983). In most cases of this syndrome, there is a history of a minor accident or shaking of the child. The syndrome is characterised by respiratory depression secondary to the trauma. Physical findings include gastrointestinal symptoms including reduction in appetite, vomiting, and constipation as well as bulging of the fontanelle, a head circumference that exceeds the 90 percentile, and retinal haemorrhage. Subdural or lumbar puncture often reveals blood in the cerebral spinal fluid (CSF), and CT can show subarachnoid haemorrhage and cerebral contusion. The median age of children suffering from the syndrome is 5.8 months, mortality is 15 , and morbidity 50 (Mandel, 1989). Adherents of the...

Cervical Spine Injuries In Athletesi

The most common sports-related injury of the cervical spine is a muscle strain. Direct trauma to the head or neck leads to eccentric contraction and muscle stretch injury. Sprains of the facet joint capsular ligaments may also occur. Patients report neck pain, muscle spasm, and limited cervical motion. Initial radiographs are obtained to rule out significant injury. The neck is immobilized, and symptoms are treated with nonsteroidal antiinflammatory drugs (NSAIDs), analgesics, and immobilization. In patients with persistent symptoms, magnetic resonance imaging (MRI) is performed to rule out a traumatic disc herniation or major ligamentous injury. The clinical presentation of a traumatic cervical disc herniation is variable. Patients may present with isolated neck pain, radiculopathy, or an anterior cord syndrome with paralysis of the upper and lower extremities. In contrast to adults, immature athletes most commonly develop disc herniations at C3-C4 and C4-C5. Disc injury is...

Assessment of the mechanical presentation

Neck pain has traditionally and anecdotally been viewed as being less dramatic in its effect on function thanback pain. Nonetheless, restrictions in normal function and range of movement are common in neck pain patients, especially if acute. Decreased movement compared to healthy controls and interference with usual activities of living and working are commonly reported in neck pain patients (Jordan et al. 1997 Hermann and Reese 2001 Hagen et al. 1997b Chiu and Lo 2002). Changes in these aspects of the clinical presentation can be used to monitor progress. Loss of movement occurs most dramatically in the derangement syndrome, when, with the onset of pain, all movements can be dramatically reduced. Equally, with derangements there can be rapid improvements in range of movement. In the dysfunction syndrome, the affected movement displays a marked loss of mobility. This will have been present for some time and will only gradually improve. In patients with dysfunction from a whiplash...

By Robin McKenzie And Stephen May

This second edition of The Cervical Thoracic Spine Mechanical Diagnosis Therapy parallels the changes in the updated Lumbar Spine text. It has been thoroughly levised and considerably expanded and explores in depth the literature relating to mechanical syndromes and neck and trunk pain in general. Theie are descriptions of the management of the three mechanical syndromes - derangement, dysfunction, and postural syndrome - as applied to neck, thoracic and headache problems. There is in-depth consideration of the literature relating to a number of issues, such a the epidemiology of neck pain, headaches, serious spinal pathology and whiplash. Operational definitions, descriptions and numerous tables provide clinical signs and symptoms to recognise or suspect mechanical syndromes or other diagnoses.

Chronic pain interpretation of symptomatic responses

Of symptom response needs to be different. Under these circumstances normal mechanical stimuli can produce pain, repeated movements may have a 'wind up' effect on pain production, there may be a spread of painful areas, and there may be ectopic nociceptive signals (Dubner 1991 Johnson 1997). These changes make the interpretation of mechanically produced symptom responses difficult and invalidate diagnostic labels applied to particular responses (Zusman 1992, 1994) . Psychosocial elements that have been identified as factors in chronic spinal pain and disability are passive coping strategies, fear-avoidance behaviour, lack of self-efficacy and depression (Linton 2000). These characteristics may make patients overly anxious and fearful about pain responses, which they consequently exaggerate. These examples suggest that we should interpret the behaviour of chronic pain to repeated movements somewhat less rigidly. Although most of this work to date has been conducted with low back...

Aims advantages and disadvantages of laminoplasty

The incidence of neck pain after lamino-plasty is reported to be high, and this is one of the most discouraging complications 11 . The pathomechanism of postoperative neck discomfort has not yet been clarified, although several hypotheses have been advocated such as prolonged neck immobilization, facet joint damage, and nuchal muscle damage.

Posttraumatic Movement Disorders

Contralateral dystonia can be due to a lesion in the striatum, particularly the putamen. Causes include perinatal trauma, closed head injury (severe much more often than mild), and thalamotomy. The onset of dystonia may have a latency period from 1 month to 9 years. Spastic dystonia due to pyramidal and extrapyramidal injury and paroxysmal nocturnal dystonia are variants of post-traumatic dystonia. Often patients develop post-traumatic dystonia as a delayed sequela of severe head injury, initially characterized by coma and quadriplegia. After the patient awakens and the plegia improves, severe action dystonia develops. Minor or moderate local peripheral trauma can be associated with focal dystonia, sometimes in patients with reflex sympathetic dystrophy. Examples of peripherally induced dystonia include the following blepharospasm after surgery on the eyelids oromandibular dystonia after dental procedures spasmodic dysphonia after facial injuries cervical dystonia after neck injuries...

Techniques of laminoplasty and supplementary procedures

Double Door Laminoplasty

A couple of days after surgery, patients are allowed to leave bed without wearing a collar. When a patient complains of neck pain, a collar is recommended until the patient can stand the pain. If a patient does not feel pain, a gentle active ROM exercise of the neck is recommended. Three weeks after surgery, isometric neck muscle exercises are started. When spinal fusion is required, immobilization of the neck with the collar should last until consolidation of the graft is confirmed roentgenographically.

Mechanical diagnosis and therapy and headaches

Patients who attend musculoskeletal specialists with a primary complaint of headaches may be suitable for mechanical diagnosis and therapy. Patients who have a secondary complaint of headache, but a primary complaint of neck pain, are managed as explained in other parts of the book. Amongst those with primary headache it must be remembered that the symptom can indicate serious pathology, although rare, and such patients must always be screened for the existence of other 'red flag' features (Table 24.2). Furthermore, headache may be due to migraine or other conditions that may not be amenable to mechanical therapy. Because of problems with the validity and reliability of diagnostic classifications, the proportion of headache patients that belong in each category is as yet unclear. It may in the future be revealed that far more patients with headache are in fact amenable to mechanical therapy than traditionally thought. Hopefully also in the future clinical features of those who do and...

Cervical Spine Assessment

Examining the cervical spine requires a thorough neurological and a rthrological scan of the spine and entire upper quadrant. The temporomandibular joint, upper thoracic spine, costovertebral joints, costotransverse joints, first rib, rib cage, and shoulder complex also have a large influence on the cervical spine and should be ruled out when assessing cervical pathologic conditions. Because of the frequent occurrence of motor vehicle accidents, the athlete must always be questioned regarding a previous accident or whiplash injury. If there has been a previous whiplash to the cervical spine, there is usually scar tissue and dysfunction that will affect the testing. It is also important to determine the emotional status of the athlete in the general history because stress or increased muscle tension can make testing more difficult and may alter the results. localized neck pain and muscle spasm Resisted tests require a fine orchestration of muscle work between you and the athlete....

Identification of serious spinal pathology

It is recommended that the same 'red flags' used to provide clues as to the existence of serious spinal pathology in patients with back problems be applied to patients with neck pain (Nachemson and Vingard 2000 Honet and Ellenberg, 2003). The recommendation Rather than seeking to identify specific pathology through individual items of history or physical examination, an alternative approach has been to predict serious spinal pathology in general from these items (Waddell 2004). When diagnostic triaging is involved, the key distinction is between a patient with serious spinal pathology, who should be referred for further investigations, and a patient with mechanical neck pain, who should be treated. Determining exactly which pathology is involved is less important at this stage. Bisschop (2003) and Ombregt (2003) produced a list of warning signs for the cervical and thoracic spine without indicating specific pathologies. This included items such as progressivelyincreasing pain,...

Invasive Therapies For The Control Of Chronic Pain

Nerve blocks with local anesthetic or neurolytic agents are helpful in managing intractable pain. It is generally agreed that 50 to 80 of patients receive benefit from single or repetitive blocks. Nerve blocks for pain may be used diagnostically to determine the pain generator, prognostically as outcome indicators of neurolytic procedures, or therapeutically for peripheral or central blockade. Blocks used by anesthesiologists for the relief of pain include blocks of the trigeminal system for relief of head and neck pain blocks of the cervical, thoracic, lumbar, and pelvic sympathetic nervous systems blocks of spinal nerve roots, and nerve plexus blockade.

Fractures and dislocations

Not everybody involved in an accident to the neck needs an x-ray for instance, patients at the minor end of the traumatic continuum. Following a whiplash-type injury, it is suggested that certain factors indicate the need for radiological investigation (see Table 8.3 Figure 8.1). 4. delayed onset neck pain These are not absolute variables, however, and clinicians' clinical reasoning must be used to determine the potential value of an x-ray. Obviously the greater the traumatic impact, the more useful radiography is to reassure both clinician and patient. Most of those who need an x-ray will have received the investigation at the time of the accident. However, if concern persists in the presence of one or more of these criteria, further investigation may be warranted. Initially clear x-rays do not always guarantee individuals have avoided significant damage. Six patients with normal radiographs, including flexion-extension views and normal neurology, were found to have zygapophyseal...

Expansive Laminoplasty

Radiografia Cervical

Ossification of the posterior longitudinal ligament (OPLL), considered to be one of the clinical manifestations of a generalized disease, diffuse idiopathic skeletal hyperostosis (DISH), appears as an abnormal radiopacity along the posterior margins of the vertebral bodies on lateral-view radiographs 1 . Most patients with OPLL have only mild, subjective complaints such as neck pain and numbness in their hands. However, some patients develop myelopathy, including gait disturbance and clumsiness of the fingers and they undergo surgery when their symptoms are aggravated.

Treatment of Cervically Mediated Dizziness

Further understanding of cervicogenic dizziness comes from treating dizzy patients without headache and cervicogenic headache patients without dizziness. The disorder is suggested by not meeting IHS criteria for either cervicogenic headache or migraine. A spectrum of improvement was seen with greater occipital nerve injections for patients with dizziness and headache, including relief of symptoms of ear discomfort, tinnitus, and neck pain, along with improvements in the headache and dizziness.

Sustained loading and creep

The study of Harms-Ringdahl (1986) has shown in the cervical spine the effect of sustained loading in healthy volunteers. They maintained a protruded head posture and began to feel pain within two to fifteen minutes, which increased with time until they were eventually forced to discontinue the posture. Abdulwahab and Sabbahi (2000) looked at the effect of sustained neck flexion for twenty minutes in patients with cervical radiculopathy and in controls. This had the effect of significantly increasing the radicular pain in the patient group, but also producing discomfort in some of the control group who were without prior neck symptoms. Gooch et al. (1991) studied in vivo creep of the cervical spine in sustained flexion in a mixed group of patients and controls. Over the ten-minute period, creep occurred in those who were able to sustain the position, with the effect of increasing the angle of cervical flexion. A third of the forty-seven individuals were unable to sustain the original...

Brachial And Lumbosacral Plexopathies

Repetitive activity such as working at a keyboard or playing a musical instrument and single injuries such as a fall or whiplash-type injury commonly result in the non-neurogenic type of thoracic outlet syndrome. Patients may complain of aching of the shoulder and arm with paresthesias going down the arm into the fourth and fifth fingers. The symptoms may be worse at night, with repetitive activity, and or with use of the arm overhead. Although they are nonspecific causes, medial supraclavicular palpation and the exaggerated military posture may reproduce the symptoms. Most of the patients are women long necks, droopy shoulders, and pendulous breasts may be contributing factors. No objective findings appear on examination or electrodiagnostic studies. y

Compressive Neuropathies

Cervical radiculopathy is a common diagnostic issue when the diagnosis of CTS is under consideration. Patients with radiculopathy are more likely to report neck pain, radiating pain with coughing or sneezing, and daytime (as opposed to nocturnal) paresthesias. With C6 or C7 radiculopathy, the biceps or triceps tendon reflex may disappear. Sensory loss proximal to the wrist is not characteristic of median neuropathy. A theory that proximal compression of a nerve root will worsen distal entrapment by impairing axonal transport (the so-called double-crush syndrome) has not been proved. y Most investigators believe that in patients with two sites of compression, for instance, C6 radiculopathy plus CTS, the disabilities are purely additive.

Acupuncture Yoga and Homeopathic Remedies

Although challenging to research, trials have shown acupuncture efficacious as an adjunctive therapy in osteoarthritis of the knee (Berman et al., 2004) and as a complement to standard therapy for the debilitating effect of pelvic girdle pain during pregnancy (Elden et al., 2005). Cochrane reviews have shown that acupuncture benefits patients with chronic low back pain, neck pain, and headache (migraine

Degenerative Disc Disease

Compression of the C6 root typically causes numbness in the thumb and index finger, and compression of the C7 root typically involves the index and middle fingers. When compression is severe, myotomal weakness, reflex loss, and, with time, fasciculations and atrophy may ensue. With C6 compression, the biceps, brachioradialis, pronator teres, and radial wrist extensors may be weak, and the brachioradialis and biceps reflexes may be diminished or lost. With C7 weakness, the wrist and finger extensors and the triceps are typically weak. The triceps reflex may also be diminished or lost. With C8 compression, there is often interscapular pain and pain in the medial aspect of the arm and hand with weakness of the hand intrinsic muscles. The finger flexor reflex may be lost. Lesions above C6 are less common and are associated with correspondingly more proximal sensory symptoms and weakness. Lesions of the C5 root may cause shoulder pain and pain and numbness...

Headache Due to Head or Neck Trauma

Posttraumatic headache (PTHA), by ICHD-2 criteria, occurs within 7 days following head injury or whiplash injury. PTHA may be acute, with resolution within 3 months following injury, or chronic, with symptoms persisting for greater than 3 months. The symptoms of PTHA are non-specific, often resembling those of primary headache disorders, and treatment follows the recommended guidelines for those disorders. Opioid analgesics should be avoided due to the risk of dependency and overuse. Physical therapy is useful to treat underlying muscle spasms and improve restricted cervical range of motion. Some clinical pearls in the management of PTHA are included in Table 14.1. Seizure Neck pain

Treatment Options Nonoperative Care

The key to safe strengthening is the ability to maintain the spine in a safe, neutral position during the strengthening exercises. For upper body strengthening, the spine must be well aligned with the chest-out chin-tucked posture. Doing isometric trunk exercises and upper body exercises emphasizing this chest-out chin-tucked posture will strengthen the support of the cervical spine, strengthen the postural muscles necessary for maintaining proper body alignment, and prevent neck pain due to athletic activity.

Acute Bacterial Meningitis

Clinical Features and Differential Diagnosis. The classic presentation of bacterial meningitis is headache, fever, stiff neck, and an altered level of consciousness, but may also be ataxic as a result of labyrinthine dysfunction or vestibular neuronitis. In adults, an upper respiratory tract infection frequently precedes the development of meningeal symptoms, and its presence should be sought in the history. 7 , y Adults typically complain of headache, photophobia, and stiff neck, and they may have a rapid progression from lethargy to stupor and coma. The clinical presentation of meningitis in an older adult consists of fever and confusion, stupor, or coma. Cranial nerve palsies, and most notably sensorineural hearing loss, are a common complication of bacterial meningitis and may be present early in the course of the illness. A stiff neck is the pathognomonic sign of meningeal irritation, resulting from a purulent exudate or hemorrhage in the subarachnoid space. Nuchal rigidity or...

Posterior Fossa Anomalies

The clinical spectrum associated with the Chiari I malformation has broadened in recent years with the increasing use of MRI, the imaging modality of choice for the diagnosis of this condition. As opposed to the Chiari II malformation (see the previous discussion of neural tube closure defects), the Chiari I malformation usually becomes symptomatic in teenage to early adult years, although the initial presentation can also be in an infant or older adult. The initial complaint is often neck pain, at times presenting with torticollis or retrocollis. If cervical spinal cord syringomyelia co-exists, symmetrical, asymmetrical, or even totally unilateral arm pain can be the initial complaint. Neurological symptoms and signs also are dependent on the neural structures involved. Predominant impairment of the brain stem and cerebellar tonsils by either compression at the level of the foramen magnum or by extension of the syrinx into the brain stem (syringobulbia) can lead to a variety of brain...

Nonorganic or behavioral signs

Neck pain Axial loading Apply a few pounds of pressure to the top of the patient's skull with your hands (Fig. 10.9). This often produces neck pain, which is physical, but to test the lower back you can then repeat the test on the shoulders. Low back pain on axial loading is surprisingly rare even in the presence of serious spinal pathology. If axial loading produces low back pain in a patient with ordinary backache or root pain, it is behavioral.

Example of clinical reasoning process

She reports occasionally feeling nauseous and dizzy when symptoms first got worse and spread down her arm, but not recently. She has had multiple previous episodes of neck pain she thinks more than ten but cannot be certain of the exact number. In the past these have History of previous neck pain, as here with multiple self-resolving episodes, is common amongst patients with derangement this is in accordance with the mechanical-sounding nature of the problem already explored. Her negative responses to various'red flag' questions further suggest a mechanical neck problem and absence of serious spinal pathology. The NSAIDs do not appear to have helped, and as she has conveniently stopped, at this point it is better to advise no additional tablets until mechanical therapy has beenfully explored. To an enquiry about present symptoms and changes during the interview, she reports that she initially had neck and shoulder pain, but over the last ten minutes this has spread gradually halfway...

Effect of posture on symptoms in normal population

Gooch et al. (1991) studied in vivo creep of the cervical spine in sustained flexion in a mixed group of patients and controls. Over the ten-minute period, creep occurred in those who were able to sustain the position with the effect of increasing the angle of cervical flexion. A third of the forty-seven individuals were unable to sustain the original position due to discomfort, but were able to remain in a less flexed posture. Twelve of the original experimental group withdrew before completing the full ten minutes due to pain most of these were in the 'neck pain' group, but one was in the control group. The study demonstrates that a sustained posture of cervical flexion can lead to an increase or production of neck pain. Other studies that have examined the relationship between cervical posture and neck pain have used cross-sectional study designs that have examined postures in symptomatic and non-symptomatic groups to determine if they differ. In this type of study design, a direct...

Irreducible derangement

In an audit of mechanical diagnosis that included seventy-eight neck pain patients, sixty-two were classified as derangement, of which less than 5 were deemed to be irreducible (May 2004a). These patients generally have symptoms of constant brachialgia accompanied by nerve root signs and symptoms - this group will not respond to mechanical therapy Again, aspects ofthe history and physical examination provide clues that a patient may have an irreducible derangement (see Table 17.12).

Posttraumatic stress disorder and its distinction from TBI

Blanchard and colleagues (Blanchard, Hickling, Taylor et al., 1996) noted in their study of 158 MVA victims assessed one to four months postinjury, 62 (39 ) met the DSM-III-R (APA, 1987) criteria for the diagnosis for PTSD. They found that 70 of the participants could be classified as PTSD sufferers (or not) based on four variables prior major depression, fear of dying in the MVA, the extent of the physical injury, and whether or not litigation had been initiated. Eight variables including the presence of litigation, prior mood disorder, fear of dying in the MVA, ethnicity, road conditions responsible for the MVA, extent of injury, prior history of PTSD, and the presence of a whiplash injury accounted for 38.1 of the variance observed on the clinician-administered PTSD Scale (Blake et al., 1990).

Cervical and thoracic zygapophyseal joint pain

Much of the work done on this topic has been on individuals with chronic whiplash symptoms, and mostly by the same team of researchers. Pain patterns from different levels (C2 - 3 to C6 - 7) were determined in five asymptomatic volunteers by distending the joint capsules under fluoroscopic control (Dwyer et al. 1990). Distinguishable and characteristic patterns from each joint space allowed the construction of a pain chart (Figure 9.1). A similar study undertaken at the atlanto-occipital and lateral atlanto-axial joints revealed a consistent pattern for the latter, but more variability for the atlanto-occipital joint (Figure 9.1) (Dreyfuss et al. 1994b). The validity of the first pain chart was tested in a group of ten consecutive patients with chronic cervical pain (Aprill et al. 1990). There was virtually complete agreement between two observers regarding which segmental level was involved from the patients' pain patterns, and in nine out of ten cases this was validated by a...

Treatment pathways in derangement

Derangement Thoracic Spine

Initially there will be two groups of patients those with central or symmetrical pain and those with unilateral or asymmetrical symptoms. In those with symmetrical symptoms there may also be referral of symptoms into the shoulders or arms - as long as these referred symptoms are reasonably equally distributed, they should still be considered in the symmetrical group. In those with asymmetrical or unilateral neck pain there may be referral of symptoms this will be as far as the elbow or below the elbow, and may include paraesthesia. Neck pain with Referred symptoms to elbow neck pain

Classification of WAD

As the identification of specific pathology without the use of intrusive injection technology is highly problematical, classification is usually based on symptomatology. Most commonly this is related to duration of symptoms, which are described as either acute or chronic. The Quebec Task Force (QTF) classification attempts to portray some level of the severity of symptoms resulting from a whiplash injury (Spitzer et al. 1995) . No neck pain Neck pain, stiffness or tenderness only Neck pain and Neck pain Neck pain and

Chromosomal Anomalies

The major neurological features of Down's syndrome are developmental delay and severe, diffuse muscular hypotonia, which affects most patients. Convulsive disorders are also more commonly present in these patients. The pathogenesis of the convulsive activity in this population is probably multifactorial and may result from a combination of medical risk factors and inherent neurological abnormalities. As individuals with Down's syndrome age, however, other neurological signs may appear. About 20 percent of patients complain of neck pain or discomfort, and they may demonstrate torticollis, gait impairment, or corticospinal tract dysfunction. These features are believed to be related to atlantoaxial subluxation and instability and result in compression of the medulla and spinal cord.

Facet Joint Procedures

Intraarticular steroid injections have been shown to be no more effective than saline injections into the facet joints.26,30 Unfortunately the only prospective, double-blind, randomized, placebo-controlled trial for intraarticular cervical facet injections was limited to MVC-related whiplash sufferers.30 The authors screened patients for facet-mediated pain with double blocks and found no benefit from intraarticular steroid versus anesthetic. Results of this study, however, should not be applied to degenerative cervical facetogenic pain, which should be studied separately. A study by Kim et al.31 evaluated intraarticular cervical facet injections in a variety of diagnoses and found that those with disc herniation responded better than those with myofascial or whiplash pain syndromes. Intraarticular hyaluronic acid injections were compared to lumbar facet joint steroid injections by Fuchs et al,32 and no difference in efficacy was noted. In the cervical spine, one prospective,...

Surgery for cervical and thoracic problems

The scientific literature on surgery for neck pain and radiculopathy consists mostly of uncontrolled case series with varying periods of follow-up time (Carlsson and Nachemson 2000). Cervical radiculopathy caused by nerve root compression from disc herniation or spondylosis has been considered an indication for surgery however, there is no clear validation for this assumption (Carlsson and Nachemson 2000). Several prospective studies have in fact demonstrated the resolution of cervical radiculopathy with time andJor conservative management (Bush et al 1997 Mochida et al 1998 Maigne and Deligne 1994 Saal et al. 1996). Regarding the value of surgery for other cervical spine conditions, there were no randomised controlled trials evaluating surgery for whiplash associated disorders (WAD) (Carlsson and Nachemson A Cochrane review on the role of surgery in cervical spondylotic radiculomyelopathy found that the evidence was inadequate to provide reliable conclusions on the balance of risk...

Clinical Case 2 Degenerative Cervical Spondylosis

Figure 13-2 presents axial computed tomography (CT) myelogram images of a 79-year-old woman with moderate neck pain and progressive difficulty with ambulating during the past 4 years. At presentation, the patient was wheelchair bound with limited ability to transfer. Past medical history was significant for osteoarthritis, atrial fibrillation, and multiple peripheral neuropathies. Physical examination revealed gross lower extremity hyper-reflexia and weakness and was consistent with myelopathy. Her sensation was diffusely diminished in her hands and arms, but she did have normal sensation in the C4-C5 distribution. She did not have a Hoffman sign, but had extensive hand intrinsic muscle atrophy. She did have crossed adductor reflexes. She was able to flex and extend her neck to 35 degrees and laterally rotate to 40 degrees. The patient's CT myelogram demonstrated severe spinal cord compression at the C4-C5, C5-C6, and C6-C7 levels. There was anterolisthesis and osteophytic bulging,...

Clinical Case 3 Atlantoaxial Instability

Figure 13-3 presents images from a CT scan of an 85-year-old woman with severe neck pain and occipital neuralgia. The pain had been progressively worsening during the past 12-month period despite analgesia. Past medical history included hypertension, hypothyroidism, and osteoarthritis resulting in bilateral knee arthroplasties. On physical exam no weakness or evidence of myelopathy was detected. Dynamic imaging revealed a C1-C2 atlantodens interval of 4 mm in neutral, increasing to 5 mm in flexion and in extension. CT imaging (see Figure 13-3) demonstrated gross evidence of atlantoaxial instability including pannus. The patient received temporary relief with a greater occipital nerve block. Because of the overwhelming disability attributable to her neck pain and occipital neuralgia, the patient was considered for surgical intervention.

Cervicogenic Headache and Occipital Neuralgia

This is a controversial entity whose existence has been questioned. Pain from cervical structures is referred to the head through the C1 to C4 cervical roots. Accepted causes of head pain from the neck include developmental abnormalities, tumors, ankylosing spondylitis, rheumatoid arthritis, and osteomyelitis. Controversial causes include cervical disc herniations, degenerative disc disease, and whiplash injuries. y Occipital neuralgia is thought by some to occur as a result of an injury to the occipital nerve, which may be vulnerable to compression as it passes through the semispinalis capitis muscle. Referred pain of cervical origin has often been referred to as occipital neuralgia, modifying the definition of this disorder. The prevalence of cervicogenic headache and occipital neuralgia is unknown. Risk factors include whiplash injury.

Headache Attributed to Carotid or Vertebral Artery Pain

Spontaneous dissection of the vertebral or carotid artery may produce head pain. The diagnosis should be considered in individuals reporting new onset of head pain along with neck pain. Clinical suspicion should be raised if the patient endorses a recent history of known provocative factors such as chiropractic manipulation, severe vomiting, or neck trauma, including whiplash-type injuries. Patients with collagen vascular disease or fibromuscular dysplasia are at particular risk. The headache tends to be ipsilateral to the side of dissection.

Chronic Tension Type Headache CTTH

Clinically, CTTH is a featureless, low level headache that is never severe and generally lacks migrainous features. The ICHD-2 criteria do not call for neck pain as a criterion, a frequently mistaken quality ascribed to this diagnosis. Location does not define tension-type headache (TTH).

Upper cervical instability

Major trauma is the other possible cause of cervical instability. Radiography or imaging studies are not routinely needed for patients following whiplash or trauma, but it should be noted that a plain x-ray might miss significant bony injury (Barnsley et al. 2002). Serious injuries do occur during motor vehicle accidents, but these are rare and should be detected at the time of the accident (Robertson et al. 2002). Currently the most common way of investigating subluxation instability in the upper cervical region is by x-ray, with measurements taken of the atlas-dens interval in flexion, neutral and extension (Cattrysse ei al. 1997).

Subgroup identification indications and contraindications for MDT

The majority of neck pain patients, including those with neurological signs and symptoms indicating cervical radiculopathy, are thus suitable for a mechanical evaluation using repetitive end-range motion and or static loading. Most of these will be classified in one of the mechanical syndromes, predominantly derangement, and a few with dysfunction and postural syndrome. The effect of repeated or static end-range loading on pain patterns can determine, often on day one, the potential of that patient to respond to mechanical therapy. Treatment response indicators can also be observed during the mechanical evaluation when a mechanically determined directional preference or other consistent mechanical response is sought - thus indicating the presence of one of the three mechanical syndromes (derangement most commonly, followed by dysfunction and then postural syndrome). The majority of patients with non-specific spinal pain can be classified

Severity and disability

The last study also reported on symptom severity. In those with continuous or recurrent pain (84 ), 11 reported this to be severe, but a further 10 reported severe episodes against a background of mild continuous pain (Picavet and Schouten 2003). A minority (6 ) reported partial disability from work and work leave greater than four weeks due to neck symptoms however, while 29 reported some limitation of daily living, the majority (80 ) reported no or minimal work loss (Picavet and Schouten 2003). High disability attributed to neck pain appears to affect the minority (

Preventative strategies

It is reasonable to advise patients about aspects of the epidemiology of neck pain. Not everyone with neck pain has future episodes, but a considerable proportion have future or persistent episodes. Warnings regarding the natural history of neck pain, which is commonly episodic or persistent, thus represent a responsible aspect of management. Most patients are interested in prognosis and clinicians are responsible for providing this information. Two main aspects should be discussed what can be done to try to prevent an episode and what can be done should an episode occur. Physical work factors have been shown to have a relationship with neck pain, although not all studies are consistent in their findings (Ariens et al. 1999). Working in static postures, especially involving neck flexion, sitting or driving, are biomechanical loads that have been implicated as risk factors for neck pain in some studies (Grieco et al. 1998 Vingard and Nachemson 2000 Makela et al. 1991 Andersen et al....

Postural syndrome aggravating factor lying

Individuals frequently awake with neck pain, presumably arising from end-range or awkward positions of the head and neck assumed and maintained during sleep. Derangements can arise in this way and symptoms will persist for a few days or more and be accompanied by restricted painful movements. Pain from cervical postural syndrome fades away once the individual gets up, and there are no effects on movements. However, this may occur regularly if the person sleeps in an awkward position that sustains the neck in an end-range posture or uses unsuitable pillows.

Physical examination

Sitting is the most common cause of neck pain in the posture syndrome. It is also an extremely common cause of aggravation of pain in derangement, but pain behaviour in the two syndromes is distinctly different. If an individual is having neck pain that is due to postural syndrome that is caused by sitting, there will be a clear association between the posture, when sustained for a sufficient period, and their pain - as frequently occurs in derangement. Upon rising and moving the pain rapidly ceases, only re-occurring when they resume the Sitting pOSition for a sustained period, and when tested all movements are full and pain-free. Pain in derangement has a vastly more significant effect in terms of pain and function. Another key difference between the two is prevalence in those seeking health

Mechanically determined directional preference

Mechanically determined directional preference describes the situation when postures or movements in one direction centralise, abolish or decrease symptoms and lead to an improvement in mechanical presentation. Very often postures or movements in the opposite direction cause symptoms and signs to worsen, although in part this is a response to the length of exposure to the provocative loading. The phenomenon of mechanically determined directional preference is characteristic of derangement syndrome and helps to identify the specific directional exercise that will lead to the best management strategy (Long et al. 2004). This study only involved patients with back pain, but it is a key study in demonstrating the importance of mechanically determined directional preference. It is proposed that mechanically determined directional preference will present in a similar way in patients with neck pain, although currently the evidence is limited. At randomisation patients were allocated to...

Mechanical presentation

In patients with cervical spine disorders, pain, range of movement, disability and functional limitations have been found to correlate with each other (Hermann and Reese 2001). Although pain, impairment and disability are related to each other, there is not always a close correlation between these different aspects of a clinical presentation. In neck pain patients we cannot measure impairment or disability directly. Instead we get proxy measures of their neck problem by seeing what functional limitations patients report and demonstrate when we examine them. Current functional limitations associated with pain may be the result of an anatomical impairment. It should

Management principles

Treatment principles are not necessarily stable throughout the reduction of a derangement, although they may be. In one situation it may occur that a patient reduces and then resolves symptoms with a loading strategy entirely in one plane. However, situations may also arise in which initial loading in extension exposes a relevant lateral component with a worsening of peripheral symptoms. The introduction of a lateral force produces rapid centralisation. The patient then requires extension to abolish the remaining central neck pain. In a few minutes the patient has required extension, lateral and extension loading.