Alternative positions for Procedure 2 Retraction and extension

Retraction and extension with rotation in supine The patient should be instructed to lie supine over the end of the treatment table so that the head, neck and shoulders are unsupported down to the level of the third or fourth thoracic vertebra. The patient places one hand under the occiput to provide assurance and stability (Photo 44). The patient then fully retracts the head (Photo 45) and is instructed to continue the movement by slowly and steadily tilting the head backwards as far as...

Ankylosing spondylitis

Ankylosing spondylitis is an inflammatory systemic disease that can affect the whole spine. It usually commences with sacral and lumbar pain, but may involve the thoracolumbar spine early on (Singer 2000). Once the thoracic spine is involved, due to involvement of the costal joints, respiration may become impaired. Later on the disease causes ankylosis of joints and ossification of ligaments leading to an immobile, fused spine and structural deformity, such as a fixed thoracic kyphosis....

Application

Slouch-overcorrect is used to educate patients how to attain correct posture and demonstrates to them the difference between good and bad postures. Patients are often unaware of their body posture, and this procedure, practised regularly, helps them to become conscious of their poor sitting habits. Once the patient is able to attain the correct posture, they are then able to maintain the correction for increasing periods of time. As well as using slouch-overcorrect to retrain postural 'habit',...

Cervical anatomy

Cervical anatomy is described in detail elsewhere (for instance, Taylor and Twomey 2002 Oliver and Middleditch 1991 Bland 1998), and it is not the intention to replicate that material in this text however, it is important to note certain key features. Between the occiput and first thoracic vertebra there are eight cervical motion segments. Cervical motion segments are not simply smaller versions of lumbar motion segments. Anatomical differences include the absence of intervertebral discs at...

Differential diagnosis

The prevalence figures suggest that the differentiation between the different headache types is straightforward, uncontroversial and simple to make, but this is not the case. One problem is the use of different diagnostic criteria. For instance, Haldemann and Dagenais (2001) list five different criteria for cervicogenic headache, which have certain consistent features, but each includes distinctive characteristics. The most extensive classification criteria produced by IHS has been criticised...

Health careseeking

As with those who have lumbar back pain, not everyone with neck pain seeks health care. In the Netherlands, just over 50 of those with neck-shoulder-upper back pain had contact with a Gp, specialist or physiotherapist (Picavet and Schouten 2003). In the US, in two studies with a mixed population of neck and or back pain, 25 to 66 had sought health care from a complementary or conventional provider (Cote et al. 2001 Wolsko et al. 2003). In the UK, 69 consulted a health professional, mostly their...

History

Taking a history from patients with headache is much the same as patients with other symptoms. The site of symptoms is recorded, the initial onset, history this episode, aggravating and relieving factors, frequency, history of headache, and history and effect of medication. It is important to have a clear understanding of the frequency history, how often and for how long the headaches last, as this may help in evaluating clinical response. As in other parts of the spine, the aggravating and...

Introduction

Headache is a commonly reported symptom with a variety of causes, both serious and benign. Some headaches arise secondary to a neck problem with the primary complaint in the neck - such patients should be classified with one of the mechanical syndromes and managed in the same way as described elsewhere in the book. Some patients attend primarily with the complaint of headache, although there may be some secondary neckache - this chapter addresses this group. Headache means pain anywhere in the...

Natural history

A number of studies suggest that, like lumbar back pain, the natural history of neck pain is frequently protracted and episodic. In two long-term follow-ups of over 250 patients with neck pain, nearly 60 reported on-going or recurrent problems (Lees and Turner 1963 Gore et al. 1987). In those who had on-going symptoms, just over half reported them to be moderate or severe (Gore et al. 1987). Retrospectively, 42 of a general population sample of nearly four thousand reported an episodic history...

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...

Procedure 2 Posture correction

Photos 108, 109, 110 From slouched position (108), gentle pressure at spine and sternum restores the lordosis (109). Gentle pressure at chin and thoracic spine corrects the head posture (110). Symptom response is monitored before and after. Photos 108, 109, 110 From slouched position (108), gentle pressure at spine and sternum restores the lordosis (109). Gentle pressure at chin and thoracic spine corrects the head posture (110). Symptom response is monitored before and after....

Procedure 2 Retraction and extension

Can be performed in sitting, supine or prone. Retraction and extension in sitting Head and neck retraction and extension are the movements of retraction, followed immediately by movement of the head and neck into the fully extended position. Although there are two movements involved, they should appear to blend smoothly into one continuous motion until finally the neck is fully extended. This procedure can be commenced once the patient is proficient in performingbasic retraction and a good...

Repeated test movements Protrusion sitting

The patient is reminded to remain sitting upright with their bottom to the back of the chair. Prior to test movements the patient is asked to report the location of any present pain, especially the most distal. The patient is then instructed to extend their chin as far forward as possible, so the neck is outstretched, with the head remaining horizontal and not inclining up or down. Then they return to the neutral sitting position, and the effect this has on their symptoms is recorded. The...

Symptomatic presentation

Pain is usually the main complaint of patients with musculoskeletal problems, although paraesthesia, numbness or weakness may also be relevant. Pain as an outcome measure is criticised as 'soft' data, which lacks objectivity. However, whilst pain is by its very nature a subjective experience, it can be recorded and assessed in a reliable way, especially when using serial measurements of pain taken from a single individual (Sim and Waterfield 1997). For any therapeutic intervention whose goal is...

Thoracic Outlet Syndrome

There is still controversy about the existence of Thoracic Outlet Syndrome (TOS), mainly because of the lack of reliable and valid diagnostic criteria (Rayan 1998 Huang and Zager 2004). Part of the controversy lies in the fact that it is detected and treated by surgeons more often in some countries than in others (Lindgren 1993). Whilst not uncommon in the US, it is reported to be unknown in Australia and seldom diagnosed in England and Europe (Lindgren 1993 Schenker and Kay 2001). Reported...

Types of pain

One proposed pain classification system has suggested the following broad categories of pain (Woolf et al. 1998) transient pain, which is of brief duration and little consequence. Tissue injury pain relates to somatic structures, whilst nervous system injury pain includes neurogenic or radicular, as well as pain generated within the central nervous system. An example of transient pain is that produced in postural syndrome. The other source of pain that occasionally must be considered in the...

Upper cervical instability

A generally accepted definition of instability does not exist (Swinkels and Oostendorp 1996). Concerns about instability at upper cervical levels relate to systemic conditions, such as rheumatoid arthritis (RA) or cervical trauma (Aspinall 1990 Bland 1994). There may be a discrepancy between the degree of destruction or instability and the symptoms. Patients with slight instability may have major neurological problems, whereas others may have significant laxity without neurological symptoms...

Epidemiology of headache

Headaches are extremely common in the general population and a very common reason for seeking health care. The literature on the prevalence of headache in forty-four studies was summarised in 1999 (Scher et al. 1999). At age 40 there was an estimated prevalence in males of 25 in Europe and just over 60 in North America, and in females of 70 - 80 in both these areas (Scher et al. 1999). It is unclear why there is such a marked difference between European and North American males. Lifetime...

Surgery for cervical and thoracic problems

Indications for cervical surgery are said to be instability, often secondary to rheumatoid arthritis or trauma, radiculopathy, myelopathy and tumour Qones 1998). In the thoracic spine, thoracic disc herniations causing progressive myelopathy, trauma that may cause spinal cord lesions, and progressive deformity that fails to respond to conservative measures are said to be indications for surgery (Findlay and Eisenstein 2000). If treatment is considered for thoracic scoliosis deformity, this may...

Management of dysfunction syndrome

The treatment of adhesions, contractures or adaptive shortening as in an articular dysfunction essentially requires the application of movements that encourage the process of remodelling. Only with the application of such loading strategies will normal tissue function be re-established. Ideally such movements commence during the stages of repair and remodelling in the weeks after an injury (Evans 1980 Hardy 1989 Hunter 1994 Barlow and Willoughby 1992). If appropriate and graded tension is...

Stephen may

THE CERVICAL & THORACIC SPINE MECHANICAL DIAGNOSIS & THERAPY This book is essential reading for any health professional involved in the management of patients with cervical or thoracic pain. Described within are the mechanical measures required for the diagnosis and treatment of these common problems. The precise identification and management of subgroups in the spectrum of mechanical cervical and thoracic disorders has been said to be a priority if we are to improve our methods of...

Instructions to all patients with dysfunction syndrome

Patients will be attending the clinic with pain. To be told that they must go away and regularly cause the pain that they are complaining about needs a very good explanation to gain their adherence to the programme. As long as patients are given a good justification for performing the exercises, most will follow the advice that is given. Most will understand the idea of scar tissue that needs to be 'stretched' to recover full movement that stretching the scar hurts, and on releasing the stretch...

Treatment pathways in derangement

Description of the management of derangement is based on two considerations. The numbering system is no longer used, but the management is based on familiar concepts. The first consideration is the location of pain the next is the extent of distal symptoms. These issues are decided by the patient's report of present symptoms, which is defined as the pain that is their present problem. This applies to all symptoms being experienced even if not actually present at the time of assessment....

Cervical and thoracic zygapophyseal joint pain

Zygapophyseal or facet joint pain somatic dysfunction is a common diagnostic label used by manual therapists (Maitland 1986 Trott 2002 Gatterman 1998 McClune et al. 1998). This section explores what is documented, rather than speculated, about this syndrome in terms of diagnosis and treatment. Zygapophyseal joints are involved in the normal ageing process of cervical spondylosis, but changes such as anterior and posterior osteophytes, bony hypertrophy and foraminal stenosis are commonly found...

Consequences of postural neglect

The effects of postural habits have long-term implications on the human shape (McKenzie 1981, 1990). The commonly observed posture of protruded head, rounded shoulders and flattened spine may become habitual. As age advances, permanent postural 'set' may occur - head protruded, shoulders rounded, dowager's hump, loss of lumbar lordosis and the erect posture replaced by a slight stoop. This is likely to be accompanied by considerable soft tissue adaptations. Positions that are frequently...

Contents

CHAPTER Management of Derangement - Principles 289 Stages of Management Treatment pathways in CHAPTER Management of Derangement - Central and Symmetrical EIGHTEEN Symptoms (previously Derangements 1,2 and 7) 311 Extension Deformity of kyphosis (previously Derangement 2) 316 Flexion principle (previously Derangement 7) 318 CHAPTER Management of Derangement - Unilateral and NINETEEN Asymmetrical Symptoms to Elbow (previously Derangements 3, 4 and Assessment - determining the appropriate strategy...

Classification

Mechanical headaches are classified as derangement, dysfunction or postural syndrome. It should be recognised that mechanical syndromes may behave atypically when symptoms are primarily headache, which may be due to the unique anatomy of the upper cervical region. For instance, with derangement headache symptoms can be abolished, but not always easily reproduced. For this reason the original description involved a separate headache syndrome (McKenzie 1990). However, despite atypicality, certain...

Nineteenasymmetrical Symptoms to Elbow

(previously Derangements 3, 4 and Assessment - determining the appropriate strategy 322 Identification of lateral Management - lateral component, no lateral deviation 329 Management - lateral component, with lateral deviation, wry neck or acute Flexion CHAPTER Management of Derangements - Unilateral or TWENTY Asymmetrical Symptoms Below the Elbow (previously Derangements 5 and Differential Determining the appropriate loading Management when deformity is Non-responders to mechanical diagnosis...

Postural syndrome aggravating factor sitting

Sitting is the most common cause of pain in the posture syndrome. The individual with posture syndrome is exposed to long hours of sitting due to occupation, study, unemployment or hobby The postural habit when sitting for a period of time, and the effect this may have on symptoms, is best observed if the patient is seated without a back support as on the examination couch, rather than in a chair. Posture in sitting is often slumped, with no attempt to maintain an upright position actively The...

Effect of posture on symptoms in normal population

Harms-Ringdahl (1986) explored the effects of sustained slumped postures in volunteers without current or past neck symptoms. They maintained a posture of lower cervical and thoracic flexion and extreme upper cervical extension that is seen in a typical protruded head posture. All ten volunteers began to perceive pain within two to fifteen minutes, which increased with time, eventually forcing them to discontinue the posture after sixteen to fifty-seven minutes. Once they discontinued the...

Failure to remodel repair tissue

Following tissue damage, an important factor in the physiology of repair is the phenomenon of contracture of connective tissues. A characteristic of collagen repair is that it contracts over time. Recently formed scar tissue always shortens unless it is repeatedly stretched, this contracture occurring from the third week to the sixth month after the beginning of the inflammation stage. Contracture of old scar tissue may in fact occur for years after the problem originated (Evans 1980 Hunter...

Example of clinical reasoning process

In the following illustration some examples of the clinical reasoning process are given in italics. In this clinical example not all possibilities are explored the main emphasis is on trying to establish a mechanical diagnosis and appropriate management. The data gathered was relevant to this end and another clinician with an alternative perspective could have focussed on other aspects of the case. It should also be noted that the patient initially displayed a number of poor coping responses to...

Osteoporosis

Osteoporosis is the most common metabolic disorder affecting the spine. The suggested World Health Organisation definition is bone mineral density more than 2.5 standard deviations below the mean of normal young people (Melton 1997). According to this definition, approximately 30 ofpost-menopausal white women in the USA have the condition, and 16 have osteoporosis of the spine. Prevalence is less in non-white populations. Bone density decline begins in both sexes around 40 years of age, but...

Yellow flags

Term used to describe psychosocial risk factors for developing or perpetuating long-term disability or sick leave as a consequence of musculoskeletal symptoms. They include factors such as the attitudes and beliefs of the patient about their problem, their behavioural responses to it, compensation issues, inappropriate health care advice, information or treatment, emotions such as depression, anxiety and fear of movement, and relations with family and work. Adherent nerve root classification...

Management of mechanical cervical headache

If it has been established that the headache is cervical in origin and mechanical in nature by the previous test movements, management usually consists of postural advice and an exercise component. The exercise involves the movement thathasbeenfound to abolish or decrease symptoms for derangement and reproduce symptoms for dysfunction, whilst for postural syndrome, posture correction is the key component. The sequence below describes the normal force alternatives and force progressions that may...

Sustained loading and creep

Mechanical diagnosis and therapy makes use of the concept that different sustained postures (and movements) cause symptoms to decrease, abolish, centralise, produce, worsen or peripheralise. Certain therapeutic loading has a favourable effect on symptoms and should be encouraged, whilst other loading has an unfavourable effect on symptoms and should be temporarily avoided. Clues about this are gained during the history-taking, and these provide important pointers to management. The...

Fractures and dislocations

Fractures of the cervical or thoracic spine or ligamentous instabilities of the upper cervical spine may be caused by a variety of traumatic events, such as motor vehicle accidents, diving into shallow water, falling from a high place or a number of athletic activities. The thoracolumbar junction is reported as the most common site for non-osteoporosis-related spinal column fractures (Huler 1997). Fractures ofthe ribs may be caused by repeated muscular contractions. There are more reports...

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 exists because there is a lack of evidence with regard to 'red flags' for the cervical spine (Nachemson and Vingard 2000 Honet and Ellenberg, 2003). Minimal work has been done to evaluate the diagnostic accuracy, incidence or...

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...

Chronic pain interpretation of symptomatic responses

With chronic pain, peripheral tissue and central nervous system elements may be sensitised and deconditioned to normal movement the criteria 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...

By Robin McKenzie And Stephen May

This book is essential leading for any health profesional involved in the management of patients with ceivical or thoracic pain. Described within are the mechanical measures required for the diagnosis and treatment of these common problems. The precise identification and management of subgroups in the spectrum of mechanical cervical and thoracic disorders has been said to be a priority if we are to improve our methods of management of back and neck problems. This latest book in the series by...

Tissue repair process

Following tissue injury, the process that in principle leads to recovery is divided into three overlapping phases inflammation, repair and remodeling (Evans 1980 Hardy 1989 Enwemeka 1989 Barlow and Willoughby 1992). No inflammation no repair is a valid dictum (Carrico et al. 1984). In fact, each part of this process is essential to the structure of the final result. Connective tissue and muscle do not regenerate if damaged, but are replaced by inferior fibrous scar tissue (Evans 1980 Hardy...

Dysfunction syndrome

In the dysfunction syndrome, pain is never constant and appears only as the affected structures are mechanically loaded. Pain stops almost immediately on cessation ofloading. When affecting articular structures, the dysfunction syndrome is always characterised by intermittent pain and a restriction of end-range movement. When affecting contractile structures, functional impairment is demonstrated when the muscle or tendon is loaded at any or certain points during the physiological range,...

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...

Cervical spine and vertebrobasilar insufficiency VBI Background

Traditionally a series of movements or positions thought to test the integrity of the vertebrobasilar arteries have been advocated prior to manipulation or mobilisation of the cervical spine (Maitland 1986 Grant 1994a McKenzie 1990). Such cervical procedures have sometimes been associated with complications, very rarely of a serious nature, such as death or cerebrovascular accident. The aim of the test movements and certain direct questions is to try to identify patients for whom this type of...

List of Figures

1.1 Severity and disability grading of neck pain (N l lOO) 9 2. 1 Patterns of referred pain produced by stimulating cervical zygapophyseal joints in normal 2.2 Patterns of referred pain produced by discography at symptomatic 2.3 Cervical dermatomes derived by symptom provocation 24 2.4 Matching the stage of the condition to management 37 3.1 Sketch of the adult cervical 5.1 Initial management pathway - key categories, estimated prevalence in neck pain 6.1 Classification algorithm for cervical...

Neuroanatomy of cervicogenic headache and experimental evidence

Ironically, despite remaining controversies regarding diagnosis, the neuroanatomical mechanism for cervicogenic headaches is one of the best understood (Bogduk 2001). Cervicogenic headache appears to be a form of referred pain from the upper three cervical segments (Bogduk 1994 Pollman et al. 1997) The mechanism for this is the 'trigeminocervical' nucleus in the upper part of the spinal cord (Bogduk 1994). Within this area, terminals from the trigeminal nerve and the upper three cervical nerves...