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...

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...

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...

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...

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...